Maria Canales was her family's English-to-Spanish translator growing up.
She began going with her parents to medical appointments when she was nine. Her family had recently moved to Connecticut from Puerto Rico and her parents struggled to learn English. In addition, Canales was "the baby" of the family, so she was always with one of her parents.
From filling out forms to explaining her parents’ ailments to the doctors, Canales said translating for people became an ingrained daily task. Simple things like acronyms were a challenge for her parents, she added.
“Tons of times they gave me this prescription [and said] 'can you read what it says on the bottle?' Something as simple as that,” Canales said.
Although Latinos are the second largest ethnic group in the U.S, only 7% of doctors identify as Latino nationwide, according to Pew Research Center. In addition, the American Board of Family Medicine estimates that 22% of family physicians were fluent in Spanish nationwide from 2013 to 2019.
The lack of bilingual providers causes language barriers across all medical fields and leads to poorer health outcomes.
“The person goes home [after an appointment], they’ve gotten a prescription, they have no clue how to take it,” Canales said. “They’ve gotten no directions, but whatever’s on the paper, and the pharmacy is not going to print it in Spanish.”Where are thebarriers?
Assistant executive director for the Spanish Community of Wallingford (SCOW), Lizandra Mejias, started translating for her non-English speaking parents when she was nine years old. Her parents would regularly bring her to doctor’s appointments to translate for them.
However, it wasn’t until she got her medical interpreting license did she realize the potential consequences of translating incorrectly.
Mejias described translating as getting “the gist of what a person is saying and [giving] your own kind of opinions on what you understood.” On the other hand, medical interpretation has to be “as exact as possible, leaving nothing out and not letting your own opinions or your own understanding get in the way of what the person is trying to transmit.”
“I had no idea I was doing it wrong…I was a child and I had to be the interpreter,” she said.
National studies show language barriers in a medical setting can lead to miscommunication, confusion, and poor health. According to the Pew Research Center, 44% of 3,716 Latinos who responsed to a 2021 survey said that language barriers are a main contributor to them having worse health outcomes than other U.S. adults. Under half of the respondents also said they have a close friend or family member who needs a Spanish-speaking healthcare provider or translator.
A JAMA Pediatrics Network survey found patients with limited English were less likely to advocate for themselves and ask questions at doctors’ appointments. As a result, they cannot fully communicate when they need clarifications or feel uncomfortable with the care offered.
“The language barrier, it’s like a vicious cycle and it doesn’t affect everybody the same,” Mejias said. “There are people who are indiscriminately affected by just the fact that they don’t have the same resources as everybody else.”
Mejias worked as a client services specialist for eight years at SCOW and is a trained medical interpreter. She has helped many clients by translating hospital documents, attending doctors’ appointments and providing over-the-phone translations.
Mejias saw many examples of language barriers in the medical field over her career. For example, some clients reported being asked by medical providers to bring their own translators. She said patients often rely on their English-speaking children to translate on their behalf. If they can’t bring someone to translate, the doctors may use any bilingual staff, regardless of medical specialty, during the appointment.
Similarly, Mejias said clients brought in several documents and forms full of grammar mistakes. She explained that documents from private practices were more likely to have errors since they couldn’t employ trained medical interpreters and typically use Google Translate instead.
“Some of these issues were life-and-death decisions that they had to make, but the information wasn’t provided to them in their native language,” she said.
Language barriers also often hinder patients from receiving proper follow-up care in many ways, Mejias added. She said language barriers often result in confusion with aftercare instructions, or the patient may not fully understand their diagnosis.
Meanwhile, patients who need to meet with specialists following a diagnosis might be unable to find a Spanish-speaking one. Even if they do find one, the specialist may not be available for several weeks or months, she said.
Mejias recalled attending a patient’s cardiology follow-up appointment to help translate. The doctor had diagnosed the patient in a previous visit but they didn’t fully understand the doctor. With Mejias’ help, the patient finally learned about her diagnosis and how to take her medications correctly.
“This person did not have the information that they needed in order to really make the appropriate changes in their lifestyle and prevent a future heart attack. It was that serious,” Mejias said.Quality of care
Language barriers may also result in lower quality of care and treatment during an appointment, said Canales, a Hispanic community educator for the Connecticut Alzheimer’s Association.
Canales remembered how doctors would provide almost no health education and used the language barrier as an excuse when she was a child.
They weren’t “really taking the time to say ‘this is the prescription. These are the potential side effects. Do you have questions?’” Canales said. “Back then it’s like ‘I’m a doctor, I’m giving you this, follow my directions, bye.’”
Although hospitals have improved care toward Spanish-speaking patients, Canales still sees room for growth.
Her mother learned enough English to hold her own in a doctor’s appointment. Over the years, however, Canales noticed her mother’s medical care was worsening. She said doctors wouldn’t listen to her mother as much due to the language barrier.
Her mother was hospitalized following a massive stroke that left her aphasic and was discharged a week later. During the discharge, medical staff brought a translator to let her know Canales’ mother was finally going home. Although excited to go home, she knew her daughters were at work, so there would be no one home to care for her, but she couldn’t communicate this to her medical team.
Canales and her sister would leave a paper with their information and schedules so doctors would know when to send her home. She added that her sister called the hospital to check in and was told her mom was already in the ambulance.
“They were going to send her home to an empty house and they would’ve gotten here, no one would have answered,” Canales said. “They thought it was an English-Spanish language barrier and it was completely bigger.”Mental health
A language barrier in a mental health setting can lead to a “complete breakdown” of the appointment, said Paul Shaker, a licensed clinical social worker for Rushford’s Latino mental health services.
At Rushford, Shaker said most staff, including the front desk and case managers, are bilingual. Case managers can help connect clients with free English classes too.
Shaker added that they also rely on the language lines to help translate in appointments. However, there are a few hindrances to using the line.
For example, one of his Spanish-speaking clients recently had surgery and couldn’t communicate clearly. The client needed to use a language line during an appointment, but the interpreter on the other end couldn’t fully understand him.
“Everybody got frustrated and we had to basically start from scratch,” Shaker said.
In addition, mental health services in Spanish are limited.
The Psychiatric Services Journal’s analysis of the National Mental Health Services survey found that mental health facilities offering treatment in Spanish have declined by 18% from 2014 to 2019 nationwide. Altogether, 44 states saw a decline in the availability of mental health treatment in Spanish despite increasing Hispanic populations, including Connecticut.
Shaker said Rushford had to close its Latino Intensive Outpatient Program several years ago because it was understaffed. As a result, Spanish-speaking patients only had access to outpatient services and support groups that met once or twice a week.
Once, Shaker needed to recommend his Spanish-speaking patient to Rushford’s regular IOP, which was in English. He explained that the patient required more care than the Latino outpatient program could provide and knew enough English to get by.
The patient transferred to the Latino IOP program when the program reopened earlier this year. Since moving, Shaker said his patient has been able to express himself more freely and with more vulnerability. In addition, the patient loves communicating in his native tongue with people from similar backgrounds.
“They speak the same language. They know the same culture. They use the same cultural expressions. [The patient] will feel much more engaged, at home and at ease,” Shaker said. “So that becomes a much better place for him. So, he is much more likely to continue in his treatment as a result.”Solutions
Chief of Diversity, Equity and Inclusion for the Middletown-based Moses/Weitzman Health System, Dr. Karoline Oliveira, said language barriers in the medical world must be addressed in a multifaceted and culturally humble way.
Resources such as language lines and trained medical interpreters can lessen the burden of language barriers.
Oliveira said the Moses/Weitzman Health System addresses language barriers in various ways. Connecticut’s health system provides primary care through the Community Health Center and ConferMED.
Their medical facilities use multi-language welcome kiosks and have pre-translated documents in multiple languages.
Many facilities also have trained medical interpreters who can provide accurate translations during appointments.
In addition, Oliveira said that they don’t rely on untrained bilingual staff to translate since that could lead to mistakes and misunderstandings. If a patient brings a friend or family member to translate, the provider will welcome them into the appointment but ask them to refrain from translating.
“Not everyone always understands the nuances of medical language and terminology. So we try to be really intentional about that, ” Oliveira said.
Oliveira said the best way to ensure patients fully understand what is going on medically is to have medical interpreters and providers that can speak Spanish and are culturally humble.
Cultural competency sets an expectation that providers must know and understand everything about their patients’ cultural backgrounds. Meanwhile, cultural humility recognizes that the medical provider is not an expert in a patient’s culture and relies on provider-patient communication to provide care in a sensitive manner.
Providing culturally humble care leads to a better understanding of the patient’s beliefs, builds trust and improves adherence to aftercare directions, Oliveira said.
“You’re more likely to have someone adhere to that plan if they feel like [the provider] heard them and they’ve taken their cultural concerns into consideration in the delivery of care,” Oliveira said.Trained medical interpreting
Two years ago, Eastern Connecticut State University launched its “Medical Interpreting in Spanish” minor to encourage more students to enter the public health workforce as trained translators.
Department Chair of Health Sciences Dr. Yaw Nsiah said the minor is a dual language program offered by his department and the department of world languages and culture. There are fewer than 10 people currently enrolled in the minor, with most of the students studying Spanish as a second language.
According to its website, the program aims to help students "develop critical skill sets that future healthcare providers can use to improve communication with Spanish-speaking patients."
Nsiah explained that medical interpretation is taught using grammatical Spanish so that they can connect with patients from all over Latin America. However, as the students enter the workforce, they'll build a specified but accurate translation style for the community they serve.
"The information you are trying to give to the patient or to the provider is very specific and it has consequences if it doesn't go according to what is meant or what is expected," he continued.
Nsiah added that Eastern is launching a new nursing program in the fall and hopes students will pick up the minor so that more medical providers learn to communicate with their patients without an interpreter. He noted that more trust could be built when a provider can speak with the patient directly, thus creating rapport and understanding.
Nationwide, about eight in 10 Spanish-language-dominant Hispanic adults prefer to see a Spanish-speaking healthcare provider, according to the Pew Research Center.
“[A patient] may not be able to say certain things in English to the provider who doesn’t understand Spanish. But if the provider understands Spanish then there is no barrier anymore. They both can actually communicate effectively and fluently,” Nsiah said. Lifelong educator
Although Canales speaks five languages, she said that the hardest one to learn was English. So, whenever she sees someone struggling to communicate because of a language barrier, she steps in.
In addition, her childhood experience inspired her to become a Spanish community educator for the Connecticut Alzheimer's Association to help other Latinos access the information they need in their native language.
"At the end of the day, they should be eligible to get the same kind of care that we all are. And they know that they won't," Canales said. "If we can give education in our language, then at least they're more empowered when they go to the doctor."
Editor’s Note: This story is part of “More than Words,” a Report for America initiative that brought together newsrooms covering Latino communities in eight states to examine the impact of language barriers on the social, economic and educational advancement of Latinos.
Health Equity reporter Cris Villalonga-Vivoni is a corps member with Report for America, a national service program that places journalists in local newsrooms. They can be reached at email@example.com and 203-317-2448. Support RFA reporters at the Record-Journal through a donation at https://bit.ly/3Pdb0re. To learn more about RFA, visit www.reportforamerica.org.