Language Interpreter Services Key for Overcoming LEP Barriers

Poor access to language interpreter services isn’t just harmful to the patient with limited English proficiency at the center of care; it also makes things more difficult for the clinicians treating them, according to a new JAMA Network Open study.

The data found that emergency medical services (EMS) workers who are the first to arrive to treat an LEP patient are also hamstrung by the language barriers, cultural differences, and lack of patient trust during the care encounter that patients themselves report.

Between 2014 and 2018, around 8.5 percent of the US population spoke English “less than well,” and another fifth spoke a language other than English at home. Previous studies have indicated that language barriers can impact the overall patient experience, care access, and even outcomes.

This latest study, published by researchers from the University of California Davis, found that those language barriers are also salient for clinicians providing care. The researchers spoke to 39 EMS workers, including 26 firefighters/EMTs and 13 paramedics, about the challenges they face when responding to emergencies and giving care to LEP patients.

The challenges that EMS workers reported were similar to those that LEP patients have reported in separate studies. Notably, language barriers hampered patient-provider communication, which made it hard for EMS workers to assess the acuity of a patient’s condition.

It also impacted the relationship between the patient and provider, EMS workers said. Cultural differences were rampant, and EMS workers reported issues related to implicit bias and patient distrust of EMS.

Those barriers usually have a direct link to the quality of care EMS can provide. While in some cases, EMS might administer some services and manage to keep the patient out of the hospital, EMS workers told the researchers that they usually have to transport LEP patients.

That is because they cannot meaningfully communicate with these patients and therefore cannot clearly assess the acuity of patient conditions. EMS workers transport most LEP patients regardless of illness severity to “play it safe” out of fear they have had a miscommunication with the patient.

That kind of conservative decision-making, although likely necessary, could result in duplicative or unnecessary care for the patient, as well as a high medical bill.

Respondents said they can sometimes use certain context clues, like objective clinical findings or observing an obviously high-acuity patient, to make clinical decisions. Some have also worked to build rapport and trust regardless of language barriers.

However, EMS workers did note that access to language interpretive services is helpful when treating patients with LEP. EMS workers told the researchers that better access to interpretative services, even via digital technologies, will be necessary to improve pre-hospital care in the future.

Even still, those interpretive services, even when they are available, can lead to delays in care.

“The time from initial call to connection with the interpreter was the primary delay, and a previous study demonstrated that telephonic interpreting during 911 calls led to increased time to dispatch of paramedics and increased time to initiation of bystander cardiopulmonary resuscitation,” the researchers explained. “While some providers in our study preferred automated translation via a telephone app to telephonic interpreting, this is a less effective form of interpretation.”

Some EMS workers said they do not use digital interpreters and instead resort to gathering only essential medical history from patients, the researchers said.

It will be key to improve these digital interpretation services, EMS workers said, but also ensure there are other ways of communicating with patients.

Particularly, EMS workers suggested that 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. Boosting workforce diversity will be essential, they said, as is language training.

“The EMS workforce is also mostly composed of White males,21,22,36 and diversification would improve prehospital care through improved communication, trust, and interpersonal interactions,” the researchers added. “Participants also suggested EMS-community interactions outside emergencies to build trust, cultural familiarity, and relationships.”

Perhaps their most notable finding, the researchers emphasized that EMS workers’ assertion that they provide high-quality care to all was in conflict with the reality that barriers to high-quality care afflict patients with LEP. The researchers indicated that EMS workers certainly desire to provide high-quality care to all, but that both individual and system factors make that equity impossible.

“Still, like other health care settings, both individual (eg, preference for noncertified interpreters, subconscious bias) and system factors (eg, lack of integrated interpretation services, lack of workforce diversity, prevalent stereotypes, and systemic racism)40 contributed to the lower quality of care described in this study,” the researchers wrote.

“While the underlying causes for these problems are multifactorial and complex, the first step in working toward equitable high-quality care is recognition that this problem exists.”