Language Barriers Imperil COVID-19 Vaccine Access, Worsening Outcomes

For patients who speak languages other than English, including the millions of immigrants in the US, language barriers have hindered COVID-19 vaccine access. Consequently, these barriers impacted the risk for poor health outcomes, like hospitalization and death, which can be more than double in this population compared to English-speaking patients.

The study by the University of Minnesota and HealthPartners Institute researchers, published in JAMA Network Open, examined the association between a patient's language preference and clinical outcomes between December 15, 2020, and March 31, 2022.

The large-scale US study involved 851,410 individuals aged 18 or older within a multispecialty health system in Minnesota and western Wisconsin. Participants self-identified a language preference other than English and whether they had limited English proficiency, as determined by the need for an interpreter.

Primarily, the findings show that individuals with limited proficiency in English (LPOE) and limited English proficiency (LEP) encountered delays in obtaining their initial vaccine dose and experienced higher rates of COVID-19-related hospitalization and death.

From January to May 2021, the primary series of COVID-19 vaccines were rolled out alongside the emergence of the Alpha and Delta variants. Between October 2021 and March 2022, the booster vaccines were introduced as the Omicron variant surfaced. During both these periods, researchers observed delays in vaccination for both the primary series and booster uptake.

But by the end of the study period, researchers noticed the vaccine rates among most groups with LPOE and LEP did not differ significantly from English speakers.  

However, the delayed time to vaccination and worse health outcomes suggested that having LPOE or LEP is a critical risk factor contributing to health disparities.

Despite the eventual similarity in vaccine rates, LPOE and LEP patients experienced higher COVID-19 hospitalization and death rates. Patients with LPOE had approximately double the risk of hospitalization and 2.13 times the risk of death than English speakers.

Those with LEP faced even higher COVID-19 risks, with a 1.98 times greater likelihood of hospitalization and a 2.32 times greater likelihood of COVID-19-associated death compared to patients who did not require interpreters.

"This study suggests that routine data collection of a patient’s preferred language and interpreter needs should be standard of practice and could provide key information on improving health equity in the US,” William Stauffer, MD, a professor at the U of M Medical School and director of Human Migration and Health at the Center for Global Health and Social Responsibility, said in a statement.

While racial and ethnic classifications are often used to describe health disparities in the United States, they offer limited information for direct intervention. By further examining language preferences, stakeholders can enhance local knowledge and identify social groups that could benefit from engagement with trusted messengers, the establishment of community partnerships, and development of culturally tailored interventions.

This approach allows for the delivery of messages in a linguistically congruent manner, ultimately addressing the needs of diverse populations more effectively.

"In a healthcare setting, language is more than a communication tool. It conveys respect, upholds a patient’s dignity, and gives patients autonomy over their care,” said lead author Nasreen Quadri, MD, an adjunct assistant professor affiliated with the U of M Medical School and physician collaborator with the National Resource Center for Refugees, Immigrants, and Migrants.

Language discordance, which occurs when healthcare providers and patients do not speak the same language, is a prevalent issue in the United States. However, healthcare systems can benefit greatly from educating clinicians on effective communication with non-English-speaking patients.

According to the 2019 American Community Survey, out of the 65 million individuals in the US who speak a language other than English at home, 39 percent have limited English proficiency,

Notably, one-third of individuals who immigrated to the US when they were 12 years or older reported not being fluent in English. However, these rates varied depending on factors such as educational attainment, race and ethnicity, and age at immigration.

Language barriers pose a persistent obstacle to delivering quality healthcare in the United States, often resulting in preventable adverse health outcomes. A previous study revealed that Latina breast cancer survivors experiencing communication difficulties due to LEP had worse quality of life and received poorer quality of care.

Insufficient access to language interpreter services harms patients and creates challenges for the clinicians treating them, as highlighted by a separate study in JAMA Network Open.

The study's findings indicate that emergency medical services (EMS) workers, who are often the first responders to LEP patients, are also constrained by language barriers, cultural differences, and a lack of patient trust during care encounters reported by the patients themselves.

Notably, EMS workers suggested they need more staff who speak languages other than English. That will help not just with communication barriers but also with cultural and trust issues at the point of care. They said that boosting workforce diversity will be essential, as is language training.