Limited English Proficiency as a Consideration When Designing Health and Risk Messages
Summary and Keywords
For many decades, the field of risk messaging design, situated within a broader sphere of public health communication efforts, has endeavored to improve its response to the needs of U.S. immigrant and refugee populations who are not proficient speakers of English, often referred to as limited English proficient (LEP) populations. Research and intervention work in this area has sought to align risk messaging design models and strategies with the needs of linguistically diverse patient populations, in an effort to improve patient comprehension of health messages, promote informed decision-making, and ensure patient safety. As the public health field has shifted from person-centered approaches to systems-centered thinking in public health outreach and communication, the focus in risk messaging design, in turn, has moved from a focus on the effects of individual patient misunderstanding and individual patient error on health outcomes, to structural and institutional barriers that contribute to breakdown in communication between patients and healthcare providers.
While the impact of limited proficiency in English has been widely documented in multiple spheres of risk messaging communication research, the processes by which members of immigrant and refugee communities actually come to understand sources of risk and act on risk messaging information remain poorly researched and understood. Advances in risk messaging efforts are constrained by outdated views of language and communication in healthcare contexts: well-established lines of thinking in sociolinguistics and language education provide the basis for critical reflection on enduring biases in public health about languages other than English and the people who speak them. By drawing on important findings about language ideologies and language learning, an alternative approach would be to cultivate a deeper appreciation for the linguistic diversity already shaping our everyday lives and the competing views on this diversity that constrain our risk messaging efforts.
The discourse surrounding the relationship between LEP and risk messaging often omits a critical examination of the deficit-based narrative that tends to infuse many risk messaging design efforts in the United States. Sociolinguists and language education specialists have documented the enduring struggle against a monolingual bias in U.S. education and healthcare policy that often privileges proficiency in English, and systematically impedes and discriminates against emerging bilingualism and multilingualism. The English-only bias tends to preclude the possibility that risk messaging comprehension for many immigrant and refugee communities may represent a multilingual capacity, as patients make use of multiple linguistic and cultural resources to make sense of healthcare messages. Research in sociolinguistics and immigration studies have established that movement across languages and cultures—a translingual, transcultural competence—is a normative component of the immigrant acculturation process, but these research findings have yet to be fully integrated into risk messaging theory and design efforts. Ultimately, critical examination of the role of language and linguistic identity (not merely a focus on proficiency in English) in risk messaging design should provide a richer, more nuanced picture of the ways that patients engage with health promotion initiatives, at diverse levels of English competence.
Keywords: linguistic diversity, cultural diversity, limited English proficient (LEP), immigrant and refugee communities, language ideologies, risk communication, health communication, language brokering
Although there is no standardized definition of the term limited English proficient (LEP), the U.S. Census Bureau considers anyone older than age 5 who reports speaking English “not well,” or “not at all,” as LEP. Those who answer “well,” or “very well” are considered English proficient (Zong & Batalova, 2015). Based on this operationalization, approximately 9%, or 25.9 million, of the total U.S. population in 2015 was deemed LEP. While great numbers of LEP individuals are foreign-born, nearly 18% (4.7 million) are U.S. born. Spanish is the language most commonly spoken by LEP-designated individuals (64%), with Chinese, including Mandarin and Cantonese (5%), and Tagalog (3%) as the next two most commonly spoken languages (Zong & Batalova, 2017).
In healthcare settings, LEP status can be determined in multiple ways. For example, it is sometimes based on a patient’s self-reported proficiency in English (e.g., the patient marks “not well” on a questionnaire about speaking English). In other cases, during patient intake, the patient is asked to state his or her preferred (dominant) spoken language or primary language spoken at home, or both. Sometimes patients are asked whether they prefer to have an interpreter present, and this is used as an indicator of language proficiency. However measured, LEP status remains the most widely used variable for examining the effect of language barriers on health outcomes. Its function as the default index for language barriers has largely gone unchallenged in public health since the label was officially introduced into U.S. educational policy in the 1970s. The LEP label continues to be widely used in U.S. federal policies, although the term has not been without controversy among critics in education, who have abandoned the label in favor of descriptors less deficit-oriented: English language learner (ELL or EL), translingual, bilingual, emergent bilingual, multilingual, linguistically and culturally diverse learners, or learners with English language communication barriers, language minority, or English-as-a-second-language learner. While it is preferable and more accurate to use terms that recognize patients’ full linguistic repertoire (e.g., multilinguals or linguistically diverse patients), in this article the terms LEP patients and patients of LEP status are used interchangeably, because this terminology continues to be used in public health policy and practitioner discourse.
Brief History of the LEP Marker
To understand the future of LEP-based accommodations in health communication, it is useful to review the historical roots of the label in U.S. public and institutional discourse. In 1974, the U.S. Supreme Court ruled in Lau v. Nichols that English-only practices excluded children from their rightful educational experience, and thus, public schools were required to “provide affirmative remedial efforts” (p. 5) to linguistically disadvantaged students, or as they came to be termed, limited English proficient (LEP) students. Linguistic accommodations, as set forth in Lau v. Nichols, are a civil right; the denial of necessary accommodations (e.g., in-language interpreter services) thus is considered linguistic discrimination and a civil rights violation under Title VI of the Civil Rights Act of 1964.
Section 504 of the Rehabilitation Act of 1973 extended the principle of language access in healthcare by establishing the concept of communication-related rights. Ensuring LEP patients understand their health conditions, treatment plans, and communications with healthcare providers becomes a matter of informed consent, and therefore essential to the quality of healthcare delivery (Germaine-McDaniel, 2010; Teitelbaum, Cartwright-Smith, & Rosenbaum, 2012). This safeguard mentality was a key factor behind Executive Order 13166, signed in 2000 by President Bill Clinton. The order served as an impetus to identify and serve vulnerable, at-risk populations, including LEP communities, in the United States, by (a) reinforcing existing policy, and (b) imposing a new obligation for all federal agencies to meet nondiscrimination standards, or what Martinez (2008) termed the nation’s first official “language-in-healthcare” policy. At the time, President Clinton expressed his “concern that language barriers are preventing the federal government and recipients of federal financial assistance from effectively serving a large number of people in the country who are eligible to participate in their programs” (The White House, 2000).
Thirty-one states have active Official English legislation (often referred to as “English-only” legislation), which means that official state business is conducted solely in English, which includes public records, hearings, public meetings, and official ceremonies. However, because federal law supersedes state law, Title VI cannot be overridden by a state’s Official English legislation.
Clinton’s 2000 order led to the creation of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, which set forth 14 mandates, recommendations, and implementation guidelines geared toward hospitals, healthcare organizations and hospital-accrediting offices that receive federal funds. Five of the 14 mandated standards (see Table 1) specifically addressed access and provision of language assistance services for LEP populations, in clear recognition that addressing linguistic and cultural barriers was central to the reduction of health disparities within diverse, vulnerable populations. Respectively, the five mandates, all of which fall under the CLAS communication and language assistance clause, offer no-cost language assistance to LEP individuals; inform all individuals of language-assistance services available to them in their preferred language, orally and in writing; ensure interpreter’s competence in language assistance; and provide print and multimedia materials in commonly used languages in the area. In the years following the passage of the policy, 20 states enacted their own legislation that either required or strongly recommended training in the implementation of CLAS standards.
Table 1. Five of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care that address access and provision of language assistance services for LEP populations
1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Communication and Language-Assistance Standards
2. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
3. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
4. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
5. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Source: U.S. Department of Health and Human Services Office of Minority Health.
In 2010, the CLAS Standards Enhancement Initiative was established, partly in response to broader understanding of diversity in healthcare (to account for differences in socioeconomic status, gender identity, sexual orientation, or disability) and changing demographics in the United States, which, as former Assistant Secretary of Health Howard Koh observed, is on track to becoming a “majority minority” nation (Koh, Gracia, & Alvarez, 2014). Of particular relevance to the discussion of LEP needs is the expanded view on culture in the revised 2010 CLAS standards beyond the conventional markers of individual race and ethnicity, as reflected in official interpretations of the revamped CLAS standards, such as: “Every healthcare encounter is a cross-cultural interaction: you should consider not only the patient’s culture, but your culture as a health professional and the culture of your organization” (National CLAS Standards, Health Literacy, and Communication, n.d.).
In addition, the view on language and communication in the revised 2010 CLAS Standards Enhancement Initiative has also broadened beyond the provisional issue of language choice, which is significant for evaluating the impact of CLAS standards in mitigating health disparities. The phrase “linguistically appropriate services” is meant to take into account patients’ “preferred languages, health literacy levels, and communication needs,” as expressed in the Principal Standard. The HSS website on the national CLAS standards offers the following systems-level view on communication in healthcare:
The “linguistically appropriate” part of CLAS actually has to do with communication in a broad sense, including language(s) spoken, written, or signed; dialects or regional variants; literacy levels; and other related communication needs. What this means is that, ultimately, CLAS helps us de-jargonize the health system and healthcare encounters so everyone involved is on the same page. There’s often a disconnect between the communication style, language ability, and literacy level of a health professional and a patient. This has to do with differences in communication skills of lay people and health professionals, as well as differences in their knowledge of the health topics being discussed.
(National CLAS Standards, Health Literacy, and Communication, n.d.).
As noted in this paragraph, the CLAS standards, at least in principle, seek to emphasize the contributions to meaningful communication by both patient and provider, and not to focus narrowly on the patient’s deficiencies in English.
In a review of literature related to the CLAS standards and their implementation published between 2001 and 2014, Estrada and Messias (2015) addressed the ongoing challenges of fulfilling the promise of the CLAS standards regarding the reduction of health disparities for vulnerable populations. Their review cited persistent organizational constraints, such as (a) insufficient funding to provide the recommended level of translation and interpreting services; (b) inconsistency in the professionalism of interpreting services; (c) insufficient training of interpreters; and (d) the selective application of only the translation and interpreting guidelines to the neglect of the standards’ broader goals for culturally responsive healthcare.
An extensive and growing body of research points to numerous disparities in health communication outcomes as a function of LEP status, as traditionally measured by the U.S. Census. Patients who are designated LEP have been found to be less likely to access routine primary or preventive care, are more likely to score lower on assessment of health knowledge and understanding of diagnosis or treatment, and are more likely to suffer from medical errors than those who speak English well. Patients labeled LEP have been shown to experience longer hospital stays and are subsequently at greater risk of line infections, surgical infections, falls, and pressure ulcers than English-speaking patients with the same clinical conditions (Betancourt & Tan-McGrory, 2014; Germaine-McDaniel, 2010; Jacobs et al., 2006). Studies also have shown that patients with LEP status are less likely to comprehend patient–doctor communication, to understand consent procedures, to adhere to treatment instructions, and to report positive levels of patient satisfaction (Aspden, Wolcott, Bootman, & Cronenwett, 2007; Patel et al., 2016). The Health Research and Educational Trust (HRET) has reported that 80% of hospitals encounter LEP-designated patients “frequently” (meaning at least monthly), which reflects an increasing strain on the healthcare system’s resources (Germaine-McDaniel, 2010).
Studies point to a direct relationship between patients’ linguistic needs and their safety and health outcomes (Ashton, 2012; van Rosse, de Bruijne, Suurmond, Essink-Bot, & Wagner, 2016). Many hospitals, nationally and internationally, also recognize this as a risk and concern, yet few monitor their patient safety data by language. Errors related to LEP are not disaggregated from general communication errors as the cause, which makes it hard to understand the needs of LEP patients in different subgroups (Wasserman et al., 2014). In addition, multilingualism is a highly complex phenomenon: the language use of patients and providers in a cross-linguistic, cross-cultural context reflects a constellation of variables, making it difficult to tease apart contributors to miscommunication. Limited English proficiency, as defined by the U.S. Census or determined using health literacy measurement tools, does not take into account this complexity.
LEP as an Outdated Label in Today’s Globalizing World
The unquestioned acceptance of limited English proficiency as the measure of linguistic barriers is hardly surprising, given the enduring struggle to shed an English-only bias in U.S. education, healthcare, and the workplace, a bias that privileges English proficiency over an emerging multilingualism. However, sociolinguists, such as François Grosjean (2010), point out that multilinguals—referring to people who go about their lives using two or more languages—are the norm in many parts of the world, including among the approximately 50 million bi/multilinguals living in the United States today. Another outdated assumption is that bi/multilingualism is a phenomenon that begins in childhood. In fact, because of dynamic shifts in migration and human mobility, there are increasing numbers of adults and adolescents who develop their multilingualism later in life. This multilingualism is a result of many forces, including immigration (by choice, forced circumstances, or some combination thereof), marriage, work, education, or contact with diverse linguistic and cultural communities. In light of these trends, there is increasing attention in sociolinguistics and immigration studies on movement across languages (including, but not limited to, English) as a normative component of the acculturation and social integration process of linguistically diverse communities (Portes, Guarnizo, & Landolt, 1999; Risager, 2007). However, these theoretical and research insights have yet to be fully integrated into health communication theory and risk messaging design efforts.
While the negative effects of limited proficiency in English have been widely documented in risk messaging and health communication research, the processes by which LEP patients actually come to understand risk messages, seeking out health information from different social networks and resources in different languages, remain poorly researched and understood. As a result, the English-only bias tends to disqualify the possibility that, for many LEP-designated populations, health communication represents a multilingual, multimodal capacity, as patients may make use of multiple linguistic resources, multiple platforms (e.g., clinical interactions, personal and professional connections, social media), and multiple sociocultural cues to seek out health information, interpret risk messages, and make informed healthcare decisions.
Consider that, in many regions of the United States, over the course of a single medical visit, a first-generation LEP patient from a Guatemalan Spanish-speaking background may interact with a second-generation Spanish-speaking receptionist of Puerto Rican descent, and then with a monolingual English-speaking doctor and a Filipino nurse who developed medical Spanish skills through a bilingual training program at work. This scenario suggests that the linguistic repertoire of an LEP patient reflects new concepts and expressions they acquire through interactions in English, which adds to what they already know how to communicate about health in other languages.
Arguing against the tendency to conflate LEP status with immigration history, Kagawa-Singer and Kassim-Lahka (2003, cited in Koehn & Swick, 2006, p. 2) challenged essentializing assumptions about linguistically and culturally diverse patients in this way:
What information does “Chinese” convey? This man could have been born in Hong Kong, be a college professor who speaks five languages including English, and lives six months of the year in the United States and six months in Hong Kong. This man could also be a monolingual Chinese gentleman, born in the United States, unmarried, and living alone in Chinatown in New York, with little education and very poor.
In this light, the reliance on the traditional LEP label hardly reveals the multilingual practices that LEP individuals use to seek out health communication. The rate of development of an LEP patient’s linguistic repertoire, and the functionality of that repertoire, will depend on any number of factors (e.g., patient age, degree of autonomy in the healthcare environment, frequency of access to healthcare interactions, etc.). An important consideration here is whether and how linguistic assistance encounters provide meaningful opportunities for LEP patients to demonstrate their full linguistic repertoire, and ideally even develop new areas of competence as their healthcare needs evolve over time. Will the “majority-minority” phenomenon prompt changes in the way languages other than English are regarded in risk communication efforts?
LEP Patients Lost in Translation?
The quality of adequate, accurate translation for LEP patients is critical. However, it is also equally important that care providers and language-support staff reach LEP patients not only linguistically, but also cognitively and culturally, to ensure that the message, and the associated risks, are fully received and understood. Hospitals and clinicians may look to bilingual staff members to intercede after other options have proven unsuccessful (Bischoff & Hudelson, 2010; Dubus, 2015). Even when interpreters are available, providers will often forgo their use, and attempt an ad hoc approach to communication (Martinez, 2008). One approach involves providers’ depending on their own limited language skills, sometimes obtained through short-term foreign language education, such as taking courses in “medical Spanish.” A number of studies suggest that this approach often impedes effective communication and results in the underuse of available trained interpreters (Burbano O’Leary, Federico, & Hampers, 2003; Diamond, Shenker, Curry, Bradley, & Fernandez, 2009; Hsieh, 2006a, 2006b; Lion et al., 2012; Prince & Nelson, 1995). The conflicts that emerge when a provider takes on the role of interpreter, especially when the provider has no formal interpreter training, can adversely affect, rather than facilitate, provider–patient communication (Hsieh, 2006a, 2006b, 2007). Another barrier to the use of interpreting services is provider perception that time spent on language mediation creates inefficiencies and compromises time that might otherwise be used for treatment and instruction (Hammersmith & Lee, 2009).
Two relatively recent systematic reviews (Flores, 2005; Karliner, Jacobs, Chen, & Mutha, 2007) suggest that, overall, the use of trained interpreters is associated with improved quality of care for LEP patients and is of greater benefit than use of ad hoc interpreters (e.g., family members or untrained staff who speak the patient’s first language). However, Flores (2005) called for future studies involving more rigorous design and control for confounding variables, such as type of interpreter (for example, trained or untrained). According to Karliner et al. (2007) the positive impact of interpreting has not been consistent. For example, in psychiatric interviews employing a professional interpreter, patients received the same mental status exam score as they did without a language-concordant psychiatrist, which suggests the need to look at other contextual and structural factors that may constrain the positive effects of language assistance, including language proficiency, interpreter training, dedicated vs. dual-role interpreting, and other confounding factors not related to interpreter use that may be more systemic or cultural. Estrada and Messias (2015) observed that the conflation of language assistance with the provision of culturally competent care also has hampered effective implementation of the CLAS standards. Estrada and Messias cited studies that showed that providers without adequate training may overestimate their own cultural and linguistic competence in their efforts to accommodate their patients’ language needs.
The term language brokering (Tse, 1995) is used in the literature to refer to children’s translating and interpreting for their LEP parents or other extended family in many different contexts, including healthcare. Language brokering is a common phenomenon among immigrant families who are dealing with the challenges and stresses of acculturation, including adapting to mainstream, English-dominant systems: education, immigration, banking, healthcare, and others. Studies have shown that patients may refuse interpreter language support because they are confused or embarrassed to seek help; in other cases, patients may also deem their children’s English proficiency and maturity sufficient to allow them to interpret (Krugman, 2014). According to a literature review conducted by Morales and Hanson (2005), the majority of immigrant children in the United States translate documents and orally interpret for family members. Given that children often acculturate more quickly than their parents, especially in terms of acquiring English language skills, the opportunities for them to serve as language brokers may emerge quite frequently and naturally. Morales and Hanson’s review indicates that children are often called on to interpret and translate in contexts that require the cognitive abilities of adults, and that their experiences as language brokers may have a positive effect on their English acquisition and understanding of the various U.S. systems. According to Morales and Hanson, it is not clear how language brokering affects the parent–child relationship or the emotional well-being of children. More recent studies (Corona et al., 2012; Kam, 2011) suggested that children and their families have both positive and negative feelings and experiences with respect to language brokering: for both adults and children, it is sometimes considered a necessary and expected part of contributing to the family; for others, language brokering is embarrassing and stressful. According to Corona et al., children report healthcare as being the most difficult language-brokering experience. Kam’s (2011) research suggested a possible indirect relationship between negative feelings about language brokering and alcohol abuse and risky behaviors among youth. It is clear that more research is needed to better understand the impact of language brokering on families, children, and on the healthcare quality and access of LEP patients.
As noted earlier, a conflation of culture and language can hamper the efficacy of linguistic accommodation efforts. Because LEP groups may also be unfamiliar with the expectations of the U.S. healthcare system (what is expected of patients in terms of how they should contribute to and participate in discussions of their own healthcare), public health professionals and care providers should take care to recognize their own style of communication, and to approach communication with sensitivity. Furthermore, LEP groups also may differ from mainstream, English-dominant groups in their communication of pain and symptoms, their beliefs about the cause of their illness, and their understanding of risk (Bruhn, 2014; Koehn & Swick, 2006; Lucey et al., 2000).
The lack of linguistically and culturally appropriate interpreting and translation has led to an increase in malpractice lawsuits due to miscommunication of diagnosis, prescriptions, and treatment. In Boston, Massachusetts, for example, measurements for taking medication needed to be clarified for some Chinese patients. A basic example is how the word teaspoon translates from English to Chinese—the Chinese teaspoon is larger than the American teaspoon (Germaine-McDaniel, 2010)—and therefore it may be more appropriate to use a different type of measurement, such as milliliters. Other examples include LEP patients who have mistaken pain medication for birth control and who have perceived general anesthesia as being put to sleep permanently (Morris et al., 2009).
Additionally, in more extreme cases, LEP patients have suffered from severe, but easily preventable, medical complications. For example, in Ann Fadiman’s (1998) The Spirit Catches You and You Fall Down, Lia Lee, the newborn daughter of Hmong refugees living in central California, is diagnosed with epilepsy. Fluent only in Hmong and unable to read or write, Lia’s parents receive only literal translations concerning their daughter’s medications. On multiple occasions, however, her parents exhibit misunderstanding because communication is attempted with a focus on literal, lexical accuracy in translation, rather than considering the Hmong cultural perspective on the family versus outside role in illness, or the cause and meaning of illness. Culturally, Lia’s parents do not recognize the value and gravity of administering prescription medication to their ailing daughter, and instead adhere to traditional customs, such as herbal baths. While medical and public health curricula have advanced since Fadiman’s book was written, cultural insensitivity and related patient–provider miscommunications remain. In addition to use of unqualified interpreters, or relying on “getting by,” ignorance about cultural beliefs and traditions constitutes a significant contributing factor to poor patient health outcomes (Surbone & Rowe, 2015).
Such communication misfires inevitably translate into financial losses and burden healthcare systems and taxpayers. One American hospital insurance company covering four states paid $2,289,000 in damages or settlements and $2,793,800 in legal fees. This was specific to 35 claims, or 2.5% of the carrier’s total claims reviewed. These claims raised several points related to the failure to provide appropriate language services. For example, in 32 of the 35 cases, healthcare providers did not use competent interpreters, and 12 of the claims involved failure to translate important documents, including informed consent forms and discharge instructions. Nearly all of the cases demonstrated poor documentation of a patient’s limited English proficiency or the need for an interpreter (Betancourt & Tan-McCrory, 2014).
Language-Assistance Interactions as Ideological and Implementation Spaces
Although the impact of linguistic and cultural competence on the reduction of health disparities seems to lie at the core of the social justice ideals set forth in the CLAS standards, equally serious attention must be directed toward a critical examination of language use in translation and interpreting interactions, in particular the persistent role of English as an institutional gatekeeper in LEP patients’ efforts to access healthcare information, even in situations when assistance in other languages is offered. In many areas of public health practice, such as in the assessment of patients’ health literacy or in patient intake processes, differentiation is rarely made between English proficiency and literacy level: literacy is generally regarded as equivalent to literacy in English. Similarly, as reflected in the Census-based operationalization of LEP, the default view of proficiency is spoken English proficiency. Only when these hidden language practices in healthcare are critically examined can the promise of language assistance be fully realized; the development of effective language-assistance measures arguably depends on an expanded understanding of the rich linguistic repertoire that LEP patients bring to healthcare interactions.
Educational linguist Nancy Hornberger’s (2005; Hornberger & Johnson, 2007) distinction between ideological spaces and implementational spaces provides a theoretical framework for examining the language practices and language-in-healthcare policies (Martinez, 2008), like the CLAS standards, that officially support the use of languages other than English in healthcare contexts. The concept of language ideology derives primarily from work in linguistic anthropology. It is defined by Woolard (1998) as “representations, whether explicit or implicit, that construe the intersection of language and human beings in a social world” (p. 3). Under this definition, language ideologies are beliefs about language that people in a community share. For example, the belief that the use of only one language in any public official capacity—such as in government, schools, and healthcare—is beneficial to society, while multilingualism is harmful, is an example of a “one nation–one language” ideology (cf. Hornberger, 2002). According to Woolard’s definition, language ideology also refers to how people interpret particular linguistic patterns. For example, people make inferences about the identity of others based on their language use, as when they draw conclusions about socioeconomic status or educational level of based on the way a person speaks. The concept of ideological spaces was defined by Hornberger (2005, cited in Flores & Schissel, 2014) as “the dominant ways of understanding language in local settings, while implementational spaces are the ways that these understandings are enacted” (p. 455) in a particular context. Language policies and legislation have the potential to “open up” or “close down” ideological spaces, which, in turn, leads to the filling up or emptying of implementational spaces (e.g., implementation or eradication of bilingual practices in the school classroom). In the context of bilingual and multilingual education, Hornberger was concerned with the ways that implementational spaces open up new possibilities for speakers of nondominant languages to participate meaningfully in classrooms. In applying Hornberger’s framework to the context of healthcare communication, a central task becomes identifying ways that encounters involving language mediation open up opportunities for patients from minority linguistic backgrounds to participate in everyday interactions in clinics and hospitals, and the healthcare system more broadly. Moreover, an examination of implementational spaces would promote a deeper appreciation of the interactional work of patients and interpreters/translators, whose contributions to language-assistance encounters remain relatively undocumented in evaluation research (Estrada & Messias, 2015; McDowell, Messias, & Estrada, 2011).
Similar to the way the ecological approach is used to account for population-level and individual-level determinants of health (McLeroy, Bibeau, Steckler, & Glanz, 1988), Hornberger (2002) viewed language planning efforts through the ecology metaphor to place “emphasis on language rights and on connecting macro sociopolitical processes with micro level patterns of language use” (p. 35). An examination of “micro level patterns of language use” in language-assistance encounters draws attention to what all individual participants (the patient, the interpreter, the healthcare provider, and other individuals who may be present, such as family members) contribute to the interaction, the agency that each exhibits, and their “acts” and “choices” that shape what gets communicated, in what language, and in what form (oral, written, paralinguistic).
A study by Martinez (2008) of LEP patient perceptions of language-assistance services in healthcare contexts near the U.S.–Mexico border providesd compelling evidence of what Hornberger (2002) viewed as the tension between “opening up” and “closing down” of implementation spaces when language planning policies are put into practice. Based on interviews with 34 Spanish-speaking LEP patients, all of whom were managing a chronic disease, Martinez (2008) found that, in the course of interactions with providers, patients cited frequent barriers to getting information about their own disease management, even when support in Spanish was offered. For example, Martinez observed that, by default, healthcare interactions often begin in English, which tends to reinforce the ideology of English as the more privileged, dominant language. Although it is the provider’s responsibility to notify patients of their right to language assistance, Martinez’s study found that patients’ disclosure, such as when a patient finds herself needing to say “‘¿me lo puedes decir en español?’ (“Would you say it to me in Spanish?”; p. 353), more frequently signals the need for linguistic support (see also Diamond, Wilson-Stronks, & Jacobs, 2010). Patient self-initiated disclosure may need to occur multiple times in one appointment—at the reception desk, with a nurse, and then again in the examination room with a doctor. Martinez’s study characterized this phenomenon as the “repeated enactment of the performative elevation of English” (p. 353), which reinforces the normalization of English and the ancillary treatment of Spanish.
Another example of the “closing down” of implementation spaces is evident in Martinez’s findings regarding the “deliteracization of Spanish,” which refers to the way that healthcare information exchanges in Spanish were confined to the oral mode, whereas information in English was routinely conveyed through the oral mode and official written documents, providing evidence for an ideological space in which English was promoted as the official language of healthcare. Sometimes, patients were provided instructions orally in Spanish along with literature in English, or nothing written at all if translated Spanish print documents were not available, which contributed to LEP patients’ sense that “Spanish orality [is] a surrogate for English literacy” (p. 356). For example, Martinez cited a case of an LEP patient who was seeking information about a scheduled laparoscopic procedure. The patient was given a brochure in English with lots of pictures, and was offered an oral explanation in Spanish about the procedure. Unfortunately, the patient experienced an allergic reaction to the plastic tubing used in the procedure and became quite ill. The patient’s sense was that the oral explanation in Spanish provided only a partial representation of what was available in the English-print brochure, including the information about possible allergic reactions. As Martinez’s findings demonstrate, while the CLAS policies are designed to “open up” opportunities for LEP patients to participate in healthcare encounters, in practice, the language ideologies and practices that privilege English use end up “closing down” the implementation spaces, resulting in uneven transmission of vital healthcare information.
The educational field has a long history of debate between competing monolingual and multilingual ideologies, and a track record of reform efforts around the marginalization of LEP children that spans over one hundred years (García, 2009). Investment in cross-disciplinary collaboration between public health and language education can revitalize commitment in both fields to language assistance as a civil right. Such collaboration is vital to the opening up of implementational spaces where healthcare providers can improve their own responsiveness to LEP patients by building on evidence-based strategies for supporting the participation of multilinguals in healthcare settings.
LEP as a Marker of Patient Identity
Central to an expanded sociolinguistic understanding of the LEP experience is the concept of investment, which, in language education, is used to “signal the socially and historically constructed relationship of learners to the target language, and their often ambivalent desire to learn and practice it” (Norton, 2013, p. 6). In other words, changes in one’s proficiency and confidence in a target language go hand in hand with changes in investment in one’s identity in that language. Norton’s (2013) research over nearly 20 years demonstrated that, for many LEP individuals, the struggle to be recognized as legitimate English-speaking participants in school, workplaces, and the community is also a struggle to free oneself from categories like “immigrant” or “LEP” or “non-native speaker of English.” Learners’ investment in a new language reflects their hopes and expectations about the range of “profits”—material, political, social, cultural, symbolic—that learning and using the new language might yield.
Even though Norton (2013) focused on language learners in English-as-a-second-language education contexts, her theory provides a valuable lens on language choice in language-assistance encounters that goes beyond a provisionary or instrumental view on language. Norton’s theory may be refreshing to healthcare providers who know from personal experience that there is a strong link between language and identity but don’t know how to use these insights to improve interactions with their LEP patients. Within the investment framework, the question, To what extent are LEP patients motivated to use English in their healthcare interactions? is fair and important, and consonant with Estrada and Messias’ (2015) concerns about how little discussion is directed toward patient responsibility in the implementation of the CLAS standards. Equally essential is the question, What is the patient’s investment in the communication practices of the language-assistance encounter? In the context of Norton’s (2013) line of argumentation about healthcare communication, patients may be highly motivated to understand what is being communicated in both English and their native language, but the language practices of their healthcare interactions may diminish their investment in the language-assistance encounter as a meaningful source of reliable healthcare information.
To illustrate the relationship between language choice, investment, and patient identity, consider the following LEP patient perspectives, drawn from several qualitative studies on language-assistance encounters. While none of the original studies explicitly invoked Norton’s theory on investment, these qualitative excerpts can be used to highlight the relevance of the investment construct for examining patients’ language choices as struggles to be recognized as “good” patients:
In a study of 24 LEP patients from the Dominican Republic, Colombia, Guatemala, and Puerto Rico, one patient commented:
I asked for an interpreter and the interpreter never showed up. So [the doctor] asked me if it was OK like that and you know, you think you can defend yourself. But that’s the mistake, to agree knowing that you’re not going to understand 100%, that you’re going to be limited in the questions you can ask . . . You end up lost.
(English translation of Spanish in original, Brooks et al., 2016, p. 31)
The patient describes the pressure to decide between waiting for the interpreter and proceeding with treatment. The interpreter’s failure to show up seems to constrain the patient’s ability to comprehend adequately, to ask questions, and to speak up for herself. However, the patient does not seem to locate the “mistake” with the healthcare provider, but instead she attributes the “mistake” to her own complicity in accepting less-than-ideal conditions (“that’s the mistake, to agree knowing that you’re not going to understand 100%”). Her diminished investment in this healthcare interaction is reflected in her own feelings of ownership over the “mistake” and the recognition that her ability to ask questions will be compromised. From the perspective of investment theory, the patient’s lack of investment in this healthcare interaction reflects a struggle to be recognized as a patient who can “defend” herself; this view on investment stands in contrast to what could be more narrowly viewed as a struggle to communicate in English.
Another example from Brooks et al. (2016) demonstrated that an LEP patient’s use of English, even when she or he has only limited command of English, can reflect investment in the language-assistance encounter, or possibly a struggle to participate meaningfully in the interaction. One patient commented:
One does not get to express everything that one feels. No, not everything, only the basics. . . . I feel like the same happens to all of us. We want to say more [during the appointment]. But to avoid being excessive or because we are afraid of making mistakes and making things worse, we thus only talk about: “How are you?”—“Good”; “Are you walking?”—“Yes.”
(Brooks et al., 2016, p. 31)
The patient’s relatively simple utterances in English (small-talk language, one-word perfunctory responses to yes/no questions) may on the surface seem to contribute relatively little to the substance of a healthcare visit. However, the patient also seems to suggest that this use of English helps to project an identity of a patient who is sensitive to the doctor’s time (“avoid being excessive”) and cooperative (avoid “making mistakes and making things worse”). Through Norton’s investment lens, we can surmise that, although the patient was far more proficient in Spanish than in English, she chose to use English to assert a “good patient” identity. The patient further seemed to recognize that, even with language assistance, she was unable to “express everything that one feels” but “only the basics,” perhaps a sign of the patient’s ambivalence about the material value of her healthcare interactions.
The implications of investment theory for improvements in language-assistance services starts with ongoing, critical reflection on the elevated risk that stems, not solely from a patient’s limited English proficiency, but from the “asymmetry in linguistic repertoires” (Lüdi, Asensio, & Longhi, 2016, p. 139) between healthcare providers and their LEP patients. In this regard, if the goal is to integrate a multilingual perspective into assistance measures, greater interchange between public health providers, applied linguists, educational leaders, and classroom teachers arguably is perhaps one of the most immediate, yet underutilized, strategies to promote professional training and capacity building in healthcare organizations.
Less Visible, Less Understood LEP Groups
In the context of today’s immigration climate, the language assistance needs and sources of resilience of three subgroups in the LEP population remain poorly understood. These groups include:
1. Adolescent English language learners, who may be newcomers to the United States or may have been schooled exclusively in the United States
2. Immigrant and refugee elders
3. Recently arrived immigrant and refugee adults with limited prior schooling and/or literacy skills (in English or perhaps even their mother tongue).
The rising number of LEP-designated adolescents in the United States provides clear evidence of a shifting immigration narrative. The LEP numbers reflect recent increases in immigrant and refugee children enrolling in U.S. schools as older children; at the same time, 57% of LEP adolescents are U.S.-born, suggesting that a large proportion of adolescents struggle to function well in English, despite having been schooled in the United States (Batalova, Fix, & Murray, 2007).
Compared to the level of attention paid in health disparities research to LEP adults and young children (ages 0 to 5 years) of LEP parents, the attention devoted to adolescents, much less LEP adolescents, has been historically minimal. However, priorities are shifting in response to strong socioepidemiological evidence that links exposure to risk factors during adolescence (e.g., the stressors associated with poverty) to alarming disparities in the incidence of chronic disease in adulthood (Araújo-Dawson & Williams, 2008).
Because the negative effects of initial exposure to risk may not be evident for several years, there is an urgent need to raise awareness and promote positive behavioral change in LEP youth, who may not yet fathom the significance of recent epidemiological trends. Current research already points to the multiple risks associated with LEP status. For example, children of LEP parents are more likely to be uninsured, to have worse access to healthcare, to receive less preventative care, and to have higher unmet behavioral health needs (Becker-Herbst et al., 2016). Children with LEP status are at higher risk than their English-proficient peers of internalizing stigma-driven symptoms, including stress, anxiety, and depression, and of externalizing behaviors, such as aggression and acting out. Such behavior problems presenting at an early age have been associated with behavioral disorders as children mature and enter adulthood (Araújo-Dawson & Williams, 2008). Studies also show that language proficiency, more than ethnicity, influences teacher perceptions that LEP children, more so than their English-proficient peers, are at risk for both behavioral and emotional problems (Dowdy, Dever, DiStefano, & Chin, 2011).
There is also an urgent need to recognize that LEP adolescents themselves are a vital and underutilized resource in the development of risk messages and health communication strategies, particularly in light of (a) the relative dearth of health communication initiatives and informational campaigns that engage LEP youth in the development and dissemination of risk messages (Rogers et al., 2014), and (b) the increasingly ubiquitous reliance on digital media for health information among adolescents, which in many respects outpaces the digital habits of adults (Wartella, Rideout, Montague, Beaudoin-Ryan, & Lauricella, 2016). Rather than solely emphasizing translation and the adolescents’ command of English, new areas of health communication research are showing how this population can be engaged and informed through social media platforms and digital tools (cf. Akom, Cammarota, & Ginwright, 2008; Lam, 2014).
The rising number of unaccompanied immigrant adolescents entering the United States also has implications for the provision of culturally and linguistically appropriate services to LEP adolescents. In 2015, nearly 60,000 unaccompanied minors were taken into federal custody, compared to only about 13,500 in 2011; 75% of the minors are 14 to 18 years old (Sugarman, 2015). Recruiting and training qualified providers to address the needs of LEP newcomers remain difficult, particularly in situations where the child’s home language (for example, Burmese or Nepali) is not one of the more commonly requested languages. Of particularly urgent concern is communication around the mental healthcare of unaccompanied adolescents placed into foster care, notably those from war-torn countries, such as Sudan, Cambodia, and most recently Syria, who must make the transition into adulthood relatively quickly and under incredibly stressful circumstances (Capps et al., 2016). As this diverse cohort of LEP adolescents moves into adulthood and takes on increasing responsibility for their own healthcare decisions, their health futures are undoubtedly linked to the effectiveness of risk communication efforts in the United States.
LEP Immigrant and Refugee Elders
Among the most vulnerable groups at risk of increased negative health outcomes and health disparities are immigrant and refugee elders. Approximately half of the nation’s immigrant elders in 2010 (56%) reported speaking English less than “very well,” with Spanish as the primary language for 45% of immigrant elders (Batalova, 2012). Approximately half of U.S. elders from Mexico and one-third of elders of Asian backgrounds have less than a high school education (Yeo, 2009).
Studies have shown that LEP older patients and LEP patients’ caregivers are less likely to receive appropriate information necessary for their continued recovery, home care, and other resources compared to English-dominant groups. A California study of LEP immigrant and minority older adults and their caregivers found that hopsital discharge information was available only in English; for example, a Spanish-speaking stroke patient received discharge instructions in English, but could not read them. Her caregiver, also a Spanish speaker who was unable to read the discharge instructions, drew on her personal experience with rehabilitation from a knee injury to guide her client’s stroke care (Graham, Ivey, & Neuhauser, 2009). For older adult stroke patients, LEP status often has been associated with increased length of hospital stay and underutilization of anticoagulants. Once released from hospital care, this population is less likely to follow treatment recommendations and to engage in physical exercise. LEP status may also have an effect on fall risk and health service use after stroke for older adults at risk of recurrent falls. Finally, the finding that many LEP individuals utilize fewer in-home health services and live with extended family members suggests that LEP elders have informal caregivers to “fill in gaps” in the healthcare system (Fryer et al., 2012).
Although the CLAS standards caution against ad-hoc interpreting, elderly patients often prefer to use family members or friends rather than a trained interpreter. The participation of a family member or a friend in a language-assistance encounter may encourage the LEP elder to trust the information provided by the professional translator (Edwards, Alexander, & Temple, 2006, as cited in Fryer, Mackintosh, Stanley, & Crichton, 2013). Graham, Ivey, & Neuhauser (2009) found that family and friends, not healthcare providers, were the most common source of postdischarge care for LEP elders. In a related study, Thomson and Hoffman-Goetz (2011) found that acculturation levels and language proficiency only partly accounted for differences in cancer screening comprehension among older immigrant women: the researchers surmised that, in the women’s real-world healthcare activities, the elders relied on oral advice from informal networks to augment written screening information (whether in Spanish or English), a resourcefulness that would not manifest on measures of the women’s reading comprehension of written cancer materials. In some cultures, the family, not the individual elder, assumes responsibility for the elder’s healthcare, which may create challenges for healthcare providers who presume they can manage heathcare communication with the elder directly (Yeo, 2009). Together, these studies suggest that language-assistance support services must come to an improved understanding of the most judicious and appropriate ways to integrate an LEP elder’s social networks in healthcare decisions. The evaluation of language-assistance services must also be able to account for the role that social networks play in multilingual service encounters (Gracie, Moon, & Basham, 2012).
LEP Adults with Limited Schooling and/or Minimal Literacy Skills in English or Their Native Language
Another overlooked and poorly understood subgroup within the LEP population are adults with limited or interrupted schooling experiences and/or who are not able to read and write in either their first language or English. This group of LEP adults comprises a rising proportion of the adult learner enrollment in federally funded adult ESL programs (U.S. Department of Education, 2015). Adults of Latino and Asian/Pacific Islander background are disproportionately represented in the lowest literacy levels (Capps et al., 2015).
Multiple factors—personal, economic, political, institutional—may explain why adults have limited or interrupted schooling and have never learned to read and write. For example, it is common for many refugee adults to experience multiple interruptions and delays over the course of the resettlement process, limiting educational and workforce training opportunities; by the time many refugees are able to settle in the United States, many may be beyond the age for compulsory public school enrollment and need to enroll in adult basic skills programs for instruction (Bigelow & Schwarz, 2010). Although this LEP group is commonly referred to as “illiterate” or “nonliterate” in popular discourse, these descriptors are highly stigmatizing terms that often tend to be conflated with lack of intelligence; instead, a better descriptor is the term LESLLA, which stands for Literacy Education and Second Language Learning for Adults (formerly Low Educated Second Language and Literacy Acquisition), a descriptor first coined in 2005 by an international group of educators and researchers devoted to the study of this adult learner population (www.leslla.org).
Research on LESLLA adults, who, by definition, are learning to communicate and read/write in English without or with limited print-based literacy, is a relatively new domain of study in adult education (with a publishing record only about 10 years old; e.g., Bigelow & Tarone, 2004; Bigelow & Tarone, 2011), and is a largely uncharted area in U.S. health communication. Particularly relevant to the design and use of risk messaging brochures or other communication tools are findings that LEP adults with limited print literacy bring a different kind of awareness about written text and language than adults who already are print-literate. When discussing information in a text, learners without print literacy tend to rely on their own personal experience rather than referring to the text for answers. For example, in a study of LESLLA learners predominantly from Morocco, Turkey, and Somalia in The Netherlands (Kurvers, Hout, & Vallen, 2006), the learners were given a prompt All stones on the moon are blue. A man goes to the moon and takes a stone. What color is that stone?, to which the LESLLA learners responded with comments like “Surely there are no stones on the moon” or “I have to see it first.” In the same study, researchers found that abstract words like empty perplexed the LESLLA learners because they could not understand how something could be a word, “when there is nothing” (Kurvers, Hout, & Vallen, 2006, p. 85).
The use of pictures, rather than prose, is often incorporated into health materials in an effort to boost comprehension of medical instructions or preventive health messages. Studies show that two-dimensional representations are often confusing to LESLLA learners, who are not accustomed to “seeing” the world via illustrations and photographs on paper. In a study of visual literacy, Bruski (2012) found that LESLLA earners often failed to interpret the symbolic meaning of seemingly universal graphic devices: for example, when presented with a picture illustrating “headache,” with lightning bolts drawn next to a picture of a person’s head, some learners thought the person was “worried” or “busy,” while other learners thought that something might be entering or leaving the person’s ear; in another example, a speech bubble was confused with a mirror and a “rain cloud.”
LESLLA studies also emphasize that oral interaction, rather than relying solely on print materials, is essential for enhancing comprehension and improving confidence in written information in the target language (Bigelow, Delmas, Hansen, & Tarone, 2006). Oral interactions that focus on extending meaning from the learners’ real-life experience or their transactions with the physical world (the “here and now,” such as through concrete realia or photographs) make it more likely that a LESLLA learner will be able to digest information presented in the “imagined space” of written texts (Whiteside, 2008). As noted with LEP elders, there also appear to be important buffering effects associated with social support, which likely provides LESLLA patients with nonthreatening opportunities for meaningful exchange and deliberation of healthcare information (Wångdahl, Lytsy, Mårtensson, & Westerling, 2014).
With increasing numbers of patients from LESLLA backgrounds in the healthcare system, there is an urgent need for research and innovative interventions that balance meaningful oral interactions with providers/interpreters and the routine provision of print materials. Research has shown that high-quality engagement with health communication, whether mediated in spoken or written form, can benefit patients, regardless of language background (cf., Garcia-Retamero & Dhami, 2011; Germaine-McDaniel, 2010), but it’s highly likely that patients from LESLLA backgrounds may require more frequent opportunities to engage with health communication initiatives, given that they are working to digest health content (e.g., personal risk information) at the same time that they are developing new skills for navigating the “print environment” of our healthcare system. More research and intervention work are needed to determine whether and how routine health communication practices (e.g., translated written brochures, visual supports) are useful to patients from LESLLA backgrounds. Greater investment in this area will undoubtedly prompt the public health field to examine some of its most deep-seated assumptions and expectations about the role of reading and writing in English in the U.S. healthcare system.
As a whole, greater attention in health communication research to the language-assistance needs and experiences of the neglected LEP subpopulations will reveal a far more complex picture of the role of spoken interaction, information technologies, and social support in today’s healthcare system for an increasingly diverse swath of LEP patients.
Language Assistance that Supports-up LEP Patients
In response to the myriad challenges that surround the public education of LEP children in the United States, educational researchers and bilingualism advocates, such as Walqui (2006), argue that a “pedagogy of hope and rigor” is urgently needed—a pedagogy that simultaneously supports language learning and content learning (of math, science, history, etc.), without losing sight of the multilingual, multicultural beings the children are becoming. Likewise, to appropriate Walqui’s perspective in the context of public health, healthcare communication structured around “hope and rigor” would remain resolute that LEP patients are able to develop knowledge of health, personal risk, and well-being, and that language-assistance encounters are prime opportunities to engage LEP patients in knowledge and capacity building. Healthcare providers need to know how to tap into the linguistic repertoire that LEP patients bring to the healthcare setting.
As illustrated by the findings related to language practices in LEP patient–provider interactions in Brooks et al. (2016) and Martinez (2008), LEP patients are often not able to access healthcare information or to ask questions, even if language assistance is available. Pauline Gibbons’ concept of message abundancy offers a useful framework that builds on a patient’s linguistic repertoire and enables providers to gauge the effectiveness of a language-assistance encounter. Walqui (2006) summarized Gibbons’ message abundancy construct:
Rather than simplifying the tasks or the language, teaching subject matter content to English learners requires amplifying and enriching the linguistic and extralinguistic context, so that students do not get just one opportunity to come to terms with the concepts involved, but in fact may construct their understanding on the basis of multiple clues and perspectives encountered in a variety of class activities.
(p. 169, italics added)
The goal of message-abundant instruction in the language classroom is to use communication and learner engagement strategies that “support-up” the learners’ comprehension and engagement with the new material, and to avoid “dumbing-down” the instruction (Hammond & Gibbons, 2005).
This goal reflects a similar conviction in health communication that “plain language” efforts should not result in the omission of important health information or distortion of the message (Andrulis & Brach, 2007; Aranguri, Davidson, & Ramirez, 2006). The message-abundancy framework is also consonant with efforts in risk communication to attend to the quality of patient–provider conversations as meaning-making exchanges of which the choice of language is only one part (Candlin & Candlin, 2002; Sarkar et al., 2011; Schenker et al., 2010), and efforts to optimize the complementary use of linguistic and nonlinguistic strategies to promote communication with patients in several domains, including the patient’s attention to salient information, comprehension of complex information, recall of that information, and adherence to healthcare guidelines (Houts, Doak, Doak, & Loscalzo, 2006). An area for the development of new message-abundant strategies is the integration of information and communication technologies (e.g., text messaging and interactive screens on hand-held devices) that enable the patient to encounter healthcare information in multiple, customizable iterations. A promising example of a message-abundant model is the STAR-MAMA project, which aims to provide information about gestational diabetes to Latina women through (a) multiple social interactions in which the women are provided information about diabetes risk (interactions with the doctor, interactions with a peer coach); (b) multiple modalities (orally, via follow-up phone conversations, and in text messages); and (c) a choice of genres for explaining risk (the personal story of a Latina woman, or a medical explanation of risk (Handley et al., 2016).
The application of message abundancy in language-assistance interactions heightens the relevance of (a) the “amplification and enrichment of the linguistic and extralinguistic context” (Gibbons’ words) in which healthcare information is shared, and (b) the number of different, meaningful opportunities that the patient has to encounter new healthcare information. The framework prompts a number of questions about the purpose and nature of specific language practices that structure the patient–provider interaction and the extent to which they offer patients multiple points of access to health information (Wong-Fillmore, 1985):
• How much of the health information will be presented orally in the patient’s preferred language?
• Does the patient also encounter the same information in the preferred language in written form?
• How does the spoken information complement or differ from what is presented in written form? Is the patient directed to notice the complementarity or difference?
• How many opportunities does an LEP patient have to “check” his or her understanding of new information with multiple individuals—including real-time opportunities to confer with a trained translator and an informal interpreter, such as a family member, as well as after an appointment, perhaps through live follow-up interactions or email/text communication from hospital staff?
• To what extent are visual supports (e.g., the use of realia, pictures, illustrations), paralinguistic cues (e.g., gestures), and written texts made available to amplify the patient’s uptake of new information?
• What purpose and degree of authority are assigned to the use of particular languages (e.g., everyday English, medical English, the Spanish used by the translator, the Spanish used by the patient) and the modalities used in the interaction (spoken versus written)?
The integration of message-abundancy principles into language assistance should not be interpreted as an effort to make clinical spaces feel more like language classrooms, whereby the provider must act as a language teacher. Rather, from a language-as-identity and language-as-ideology perspective, a deeper appreciation for patterns of patient talk and participation (across languages, not only in English) is essential to any assessment of what patients know and want to know, what they understand, and what language-assistance measures are most relevant. The provider focus shifts from asking “Does the LEP patient understand me?” to “What number of steps have I taken to make myself understood?” At a minimum, the message-abundancy framework points to the value of investing in professional training models that develop bilingual proficiency in healthcare providers, and more broadly, cultivate greater language awareness in the healthcare profession (Roberts et al., 2007), as a necessary condition for successful implementation of the CLAS standards.
Engagement with Community Members in Risk Messaging Efforts: What Language and Which Public Guide Risk Messaging Design?
As called for in the CLAS standards, improved risk messaging efforts will require collaborations with the community “to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness” (Standard 13). Collaboration among applied linguistics professionals, language educators, immigration scholars, and public health practitioners will go a long way in advancing our understanding of what constitutes the “LEP experience” in healthcare in today’s changing times.
Community-based participatory research (CBPR) models, whereby community members and academic researchers work in an equitable, collaborative partnership through all phases of the research, hold great promise for working with LEP populations as well as other historically marginalized, at-risk populations. CBPR approaches also provide key insights into how communities negatively impacted by health disparities can contribute their experience and expertise to better address multiple levels of health. Furthermore, by utilizing CBPR to research and address health issues, community members have gained valuable skills, such as interpreting and analyzing data, interviewing, and presenting at conferences (Cashman et al., 2008; Trickett et al., 2011).
For example, Bopp et al. (2012) described a multiphase partnership between the Mayo Clinic and Hawthorne Education Center, which began with a survey of 78 Spanish- or Somali-speaking LEP individuals with type II diabetes about their diabetes and health knowledge, as well as barriers to disease management. Their feedback informed subsequent phases, which included community-led focus groups and a digital story-telling project in which participants shared their struggles and accomplishments with diabetes self-management in their native Spanish or Somali. These stories in turn became available to other community members as health resources. This project demonstrated how community involvement promoted meaningful access to preventive health information.
As another example, Njeru et al. (2015) highlighted an obesity-prevention curriculum developed for members of a Latino community in Southwest Kansas (see also Bopp et al., 2012). This community was experiencing higher rates of obesity than the national ethnic group average (60.7% vs. 57.6%) and higher rates of diabetes than the state ethnic group average (8.8 vs. 8.1%). Through a broad partnership involving Kansas State University and the county health department, a community safety-net clinic, local hospitals, community colleges, local coalitions, local foundations, and faith organizations, the stakeholders worked together to develop a bilingual, culturally sensitive physical activity and nutrition guidebook addressing obesity and chronic disease prevention programs. Although less than half of the community in total (43%) reported seeing and referring to this book, most (99%) reported that the information was relevant and useful (Bopp et al., 2012).
These projects underscore the promise of keeping the community of interest’s voice at the center of risk communication efforts. In this spirit, the words of Charles Briggs (2003) are worth repeating:
Why not include people who are ‘experts’ in reading how information is interpolated within their own communities? In doing so, we might learn a lot more about the full range of publics that emerge as discourse about health circulates. Nevertheless, inviting popular participation in shaping how health-related public discourse is disseminated should form part of efforts to break the hold of hegemonic models and practices—not to make them more effective.
To close, the future of LEP-oriented advances in health communication must engage members of an increasingly diverse and varied community whose healthcare needs and priorities include, but also transcend, their limitations in English. To advance innovation in science and fulfill the mandates of federal policies, community engagement merits more attention, given that LEP patients arguably are most qualified to explain the relationship between language choice and the desire for health information and, ultimately, the desire to direct one’s healthcare outcomes.
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