Implications of Language Barriers for Healthcare: A Systematic Review
Hilal Al Shamsi Abdullah G. Almutairi Sulaiman Al Mashrafi Talib Al Kalbani
Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high- quality healthcare and maintaining patient safety. To address these challenges, many larger healthcare institutions ...
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PubMed Central (PMC)
Introduction

Language barriers have a major impact on the cost and quality of healthcare. They commonly occur between healthcare providers and patients when the two groups do not share a native language.1 Regardless of language barriers, healthcare providers are required to deliver high-quality healthcare that adheres to the principles of human rights and equity to all their patients.2

Health disparities such as unequal treatment related to language barriers are associated with unequal access to healthcare and unequal health outcomes.3 For instance, a recent study demonstrated that patients who do not speak the local language are disadvantaged in terms of access to healthcare services.4 Similarly, several studies have shown that patients who face language barriers have poorer health outcomes compared with patients who speak the local language.5,6

Growing evidence documents the fact that language barriers indirectly impact the quality of the healthcare that patients receive. Language barriers contribute to reducing both patient and medical provider satisfaction, as well as communication between medical providers and patients. Patients who face language barriers are more likely to consume more healthcare services2 and experience more adverse events.7 A recent study conducted in six hospitals in the US found that adverse events occurred more frequently among patients with limited proficiency in English than among those who were proficient in English.

This review investigates the impact of language barriers on healthcare and suggests solutions to address the challenges.

Results

shows the researcher’s method of selecting eligible studies for this review. Initially, the researcher’s search of the PubMed and Medline databases returned 2569 articles. After removing the duplicate articles, 1211 remained. Next, the researcher excluded the articles that were not mainly about language barriers (n = 605) and the non-peer-reviewed articles (n = 532). Then the researcher excluded those studies that were not primarily conducted in healthcare organizations (n = 60), leaving 14 articles to be included in this systematic review.

presents a summary of the general characteristics of the 14 studies arranged by the authors’ names. Nine studies used a cross-sectional design, two used a prospective design, two used qualitative research, and one was a report. Five studies collected data from an interview survey, three used questionnaires, one used both an interview survey and questionnaires, three used hospital databases, and two used telephone and mail surveys. Five of the studies were conducted in the US, two in Saudi Arabia, two in Switzerland, and one each in Canada, Germany, England, Norway, and South Africa. The total number of participants in the 14 studies was 300 918, with the number of participants in each study ranging from 21 to 22 353.

presents the most important findings of the 14 studies in this review. Seven of the studies focused on language barriers and patient satisfaction, two on the impact of language barriers on healthcare provider satisfaction, one on the impact of language barriers on both healthcare providers and patient satisfaction, two on the cost of interpretation services, one on the quality of interpretation services, and one on online translation tools. The findings of studies can be divided into three categories: the impact of language barriers on medical providers (such as physicians and nurses), patients, and the cost and quality of healthcare services.

Communication between patients and medical providers is at the heart of effective healthcare. In Pytel,17 94.3% of nurses reported that it was very important for their work environment and communication to understand the language of their patients. Physicians also have difficulty understanding patients who do not speak their language, leading to wrong diagnosis and medications.18 In Norway, medical providers reported that they had trouble understanding between 36% and 43% of the patients who do not speak the local language, necessitating interpreters.15 Indeed, 37% of physicians indicated that they felt that patients hide some information because of language barriers.15 In addition, all South African nurses in Saudi Arabia had difficulty communicating with patients and their family members, as well as nurses from other countries, because of language barriers.19

Language barriers have negative implications for the delivery of healthcare and patient satisfaction. One study showed that among patients who received treatment from nurses who did not speak the local language, 30% had difficulty understanding medical instructions, 30% had a problem with the reliability of information, and 50% believed that the language barrier contributed to errors.10 Other studies found that among patients who did not speak the local language, 49% had trouble understanding a medical situation, 34.7% were confused about how to use medication, 41.8% had trouble understanding a label on medication, 15.8% had a bad reaction to medication due to a problem understanding their healthcare provider’s instructions,20 66.7% faced a barrier when accessing healthcare, and 20% did not seek healthcare services if these were not readily available for fear of not understanding their healthcare provider.14 Furthermore, many patients with limited local language proﬁciency experienced adverse health events that resulted in detectable physical harm (49.1% of patients) or moderate temporary harm (46.8%) or experienced some failure in communication with medical providers (52.4%).5 Patients with limited local language proficiency are also likely to miss medical appointments and have difficulties arranging appointments due to the language barrier.9 Therefore, these patients have a poor level of satisfaction with their healthcare.14,18

To increase patient satisfaction with healthcare, it is necessary to provide interpreter services. Two studies pointed out that medical providers needed interpreter services for 43.2% of their patients, and 21–76% of medical providers stated they had poor access to these services.12,15 Moreover, 70.7% of limited English proficiency patients (LEPPs) reported limited availability of interpreter services,13,14 and 26.4% reported that there were no interpreters in their healthcare institutions.2 LEPPs also indirectly raise the cost of health services when they use interpreter services.12 LEPPs who used interpreter services received more inpatient services and attended more office visits than those who did not.11 The authors of this study estimated that interpreter services for Medicaid recipients at about $4.7 million annually. Some healthcare organizations use online translation tools such as Google Translate and MediBabble to address the challenges of language barriers. These tools are free and easy to access, and they contribute to improving healthcare delivery, patient safety, and increased (up to 92%) the satisfaction of both medical professionals and patients.8

Discussion

This review investigates the impact of language barriers on the delivery of healthcare and identifies possible solutions to the challenges posed by these language barriers. The first impact of language barriers is miscommunication between medical providers (physicians and nurses) and patients [ ]. This miscommunication contributes to a reduction in the satisfaction of both medical providers and patients, the quality of healthcare delivery, and patient safety. The second impact is an increase in indirect healthcare costs. The final impact is the application of online translation tools to healthcare organizations, which improves the quality of healthcare delivery and patient safety and increases the satisfaction of both medical professionals and patients.

Language barriers are a key cause of miscommunication between medical providers and patients, and negatively affect the quality of healthcare services and patient satisfaction. Hospital medical professionals perceive language barriers to be a source of workplace stress and an impediment to the delivery of high-quality healthcare.21 Much evidence shows a significant association between workplace stress and lower satisfaction among medical providers.22-24 In addition, studies indicate that language barriers contribute to medical professionals’ incomplete understanding of patients’ situations, delayed treatment or misdiagnoses, poor patient assessment and incomplete prescribed treatment.14,25

We also found that patients who do not speak the local language will have less satisfaction with their healthcare and less access to usual sources of healthcare. Even when patients with language barriers have access to healthcare, they have decreased satisfaction with that healthcare, decreased understanding of their diagnoses, and increased medication complications.25,26 A study conducted in Saudi Arabia showed that 25% of foreign patients reported that they had difficulty communicating with medical professionals and decreased satisfaction with their healthcare; 20% of medical professionals reported that health outcomes (i.e., healthcare errors, understanding patient needs, feeling satisfaction, and trust in nursing care needs) were always affected by language barriers.27 Interpreter services are necessary to solve the problem of language barriers in healthcare institutions and to increase the satisfaction of both medical professionals and patients.

To overcome language barriers, some healthcare institutions provide interpreter services; however, these services pose critical challenges in terms of access and financial burden. Previous studies have shown that most healthcare institutions have poor access to interpreter services or no services at all.12,14 The use of interpreter services contributes to increased patient satisfaction and improved patient care among patients with language barriers.28 Interpreter services have a significant association with increased physician visits, prescription drugs by physicians, and receipt of preventative services among patients.29 However, providing interpreter services also increases the length and cost of physician visits.

MediBabble is an application created by medical students at the University of California, San Francisco, and released in 2011. Using advanced voice recognition software, it offers translations for thousands of medical instructions, as well as the questions for a standard medical history.30,31 The application contains thousands of instructions and translated questions, organized by symptom. Most questions can be answered with ‘yes’ or ‘no’ gestures.32 MediBabble can be used online or offline, and it allows physicians to take patient histories and make diagnoses when a language barrier exists.32 However, the application translates only six languages: English, Spanish, Russian, Cantonese, Haitian Creole, and Mandarin.32

A case study showed that medical professionals and patients were highly satisfied with MediBabble; they reported that the application was fast and easy in terms of translating and collecting information.33 In a study done in Canada, MediBabble was used as one strategy to improve the delivery of healthcare for resettled Syrian refugees. It allowed medical professionals to take the refugees’ histories and also make diagnoses.30 In brief, MediBabble shows success as a medical translator. Using both interpreter services and online translation tools may offer more opportunities to improve healthcare delivery and patient safety.

This review has some limitations. First, there are few existing studies on the application of online translation tools in healthcare to address the problem of language barriers. Second, there are few studies evaluating the challenges of language barriers in private healthcare organizations. The impact of language barriers must be evaluated in both the public and the private sectors to address this problem.

This review also has several strengths. First, studies included in the review were conducted in both developing and developed countries. Second, the response rate was 100% in six of the studies. Third, the studies focused on various aspects of language barriers in healthcare, which helped the researchers to evaluate the challenges from multiple angles and determine solutions.