INTRODUCTION
Language Barriers in Health Care Settings: A Searchable Annotated Bibliography of the Research Literature
This project was made possible through a grant from The California Endowment. The original document on which this searchable version is based is available from
The California Endowment's website: http://www.calendow.org. Indexing data of the original document is:
Jacobs, E. A., Agger-Gupta, N., Chen, A. H., Piotrowski, A., & Hardt, E. (2003). Language barriers in health care settings: An annotated bibliography of the research literature. Woodland Hills, California: The California Endowment.
Contents:
Background
Goals
of this Initiative
Limitations
Compilation
Sources
How
To Use the Bibliography
Over the past four decades, the United States has attracted immigrants from all
around the world, with the majority emigrating from Latin America, Asia, and
Europe.
The resulting increase in ethnic, cultural, and linguistic diversity has
been accompanied by a great – and growing – need for language access services in
health care settings. According to
the 2000 Census, nearly 47 million U.S. residents aged 5 or older speak
a language other than English at home, and more than 21 million have English
proficiency self-rated less than “very well.” California is arguably the most
ethnically and linguistically diverse state in the country: 39.5% of Californians speak a language
other than English at home, and one in five Californians has a level of English
proficiency that suggests s/he would benefit from language assistance when
accessing the health care system.
The issue of language barriers in health care settings has
received significant attention in recent years, in large part due to a series of
federal policies, including Executive Order 13166, which mandated that all
federal agencies review their own policies and procedures to ensure equal access
for limited English proficient (LEP) clients; the ensuing Department of Health
and Human Service’s (DHHS) Office of Civil Rights Policy Guidance on Title VI
and language access; and the DHHS Office of Minority Health’s release of the
National Standards on Culturally and Linguistically Appropriate Services in
Health Care. These and other
developments, such as the Institute of Medicine’s report “Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care,” have generated
substantial debate on the extent and effects of language barriers in health care
and the role of health care providers, institutions, and government in providing
language access for LEP patients.
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To better inform this discussion, The California Endowment
commissioned an annotated bibliography of the research on the prevalence, role,
and effects of language barriers in health care. The goal of this publication is to
provide a comprehensive – but given the extent and pace of research, not
exhaustive – review of the research literature in this area. Our hope is that this bibliography will
provide an empirical basis for future discussions about the need for and impact
of language access services in the provision of health care.
While the annotations are not meant to be a rigorous or
detailed critique of methodology, we attempted to include pertinent information
to allow readers to draw their own conclusions about the limitations and
validity of the studies (e.g. methodological considerations such as appropriate
statistical analysis, adequacy of sample size, and the consideration of possible
confounding variables). We also tried to make the Annotated Bibliography more
reader-friendly by adding a “summary statement” that highlights the crux of each
article’s findings.
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The annotation process was complicated by the fact that the
terminology in this area is not yet standardized, so that terms such as
“language barrier,” “limited English proficient,” and “interpreter” have different meanings in different articles. For example, many articles use the term
“interpreter” for any bilingual person who assisted during the clinical
encounter, whereas others limit the term to trained medical interpreters; the
findings attributed to these two different groups of “interpreters” are not
likely to be comparable. On the
other hand, in a given article, different terms may be used for the same
concept. For example, the terms
“limited English proficient,” “primary language not English,” and
“non-English-speaking” are sometimes used interchangeably. Finally, the articles vary tremendously
in how the researchers identified people who face language barriers – from
asking the treating provider if s/he felt there was a language barrier, to
having the admitting clerk decide if a patient was LEP, to asking the patient if
s/he needed an interpreter. In a
few instances, the article did not actually describe how the study group was
identified (for example “Spanish speakers”). In the text of the annotations, we
generally use each study’s own terminology, but also try to be explicit about
how the researchers defined their terms and study groups. To assist the reader, we have included a
short glossary that defines some of the common terms used in the field (Appendix
C).
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The California Endowment’s Language Access Annotated
Bibliography builds on references originally compiled by Eric Hardt, M.D., of the National Council on Interpretation in
Health Care. We also benefited from
the work of Jean Gilbert, Ph.D., who graciously shared her own bibliography with
us. These lists were supplemented
by MEDLINE (National Library of Medicine), PsycINFO
(American Psychological Association), Sociological Abstracts (Cambridge
Scientific Abstracts), Periodical Abstracts (Bell & Howell), ArticleFirst, Social Sciences Abstracts (H. W. Wilson
Company), and Digital Dissertations (ProQuest/UMI)
searches using the Medical Subject Heading terms, “language,” “communication
barrier,” “multilingual,” and
“translation” as well as text words such as “interpreter,”
“non-English-speaking,” and “limited English proficient.” Additional articles were identified from
the reference lists of key articles.
The articles included are intentionally multidisciplinary,
and include quantitative and qualitative data, international studies, studies
from the United
States, and a diversity of language
groups. In our search we
encountered a myriad of valuable publications, including review articles,
commentaries, editorials, and dissertations, but decided to limit the
annotations on the basis of three selection criteria:
(1) the article was
published in peer reviewed journal;
(2) a primary focus or finding of the
article was specific to language barriers; and
(3) the article contained
original research.
Publications that did not meet the first criteria but that we
thought would be of interest to the reader are referenced in Appendix A.
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How To Use the Bibliography
The annotations may be sorted and searched by a variety of
approaches:
(1) Alphabetically by
a.
last name of the first author;
b.
title of article
c.
journal name in which the article was published
d.
year of publication
(2) Key words – which highlight the study’s
areas of investigation (e.g. adherence, asthma, etc.), health care setting (e.g.
Emergency medicine), languages (e.g. Spanish), and geographic region (e.g.
California). A reader interested in studies that
measure costs related to language access can sort the bibliography for all
annotations with the key word “cost.”
The key words and our operational definitions are listed in Appendix
B.
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