While US health systems are implementing language proficiency assessments to verify skills needed to ensure meaningful language access for patients, there is no consensus on best practices for multilingual medical students who want to demonstrate language proficiency for direct patient care. Many medical students who report non-English language skills face challenges navigating when and how to appropriately use those skills in clinical interactions. We used a modified Delphi process to seek consensus from an expert panel through the National Association of Medical Spanish (NAMS) for a Qualified Multilingual Assessment (QMA) policy for medical students. The survey included five topics related to QMA logistics and five topics related to QMA implementation guidance for clinical affiliates: QMA purpose, language access standards, responsibilities of supervising physicians, guarding against implicit bias, and monitoring learning opportunities. We set 80% as the threshold for consensus and revised topics that yielded <80% consensus. We circulated the revised topics in a second survey to establish consensus. Following two rounds of surveys among expert stakeholders, we reached consensus across all topics, yielding a first-of-its-kind QMA policy that administrators may adapt for clinical learning environments and institutions with health professional trainees. This policy includes key QMA policy recommendations for medical students: selecting a QMA, QMA logistics, and QMA implementation guidance for clinical affiliates.
OBJECTIVES: While some medical indications for cesarean delivery are clear, subjective provider and patient factors contribute to the rising cesarean delivery rates and marked disparities between racial/ethnic groups. We aimed to determine the association between language preference and risk of primary cesarean delivery.
METHODS: We conducted a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) deliveries of patients over 18 years old from 2011-2016 at an academic medical center, supplemented with data from the Massachusetts Department of Public Health. We used modified Poisson regression with robust error variance to calculate risk ratios for cesarean delivery between patients with English language preference and other language preference, with secondary outcomes of Apgar score, maternal readmission, blood transfusion, and NICU admission.
RESULTS: Of the 11,298 patients included, 10.3% reported a preferred language other than English, including Mandarin and Cantonese (61.7%), Portuguese (9.7%), and Spanish (7.5%). The adjusted risk ratio for cesarean delivery among patients with a language preference other than English was 0.85 (95% CI 0.72-0.997; p = 0.046) compared to patients with English language preference. No significant differences in risk of secondary outcomes between English and other language preference were found.
DISCUSSION: After adjusting for confounders, this analysis demonstrates a decreased risk of cesarean delivery among women who do not have an English language preference at one institution. This disparity in cesarean delivery rates in an NTSV population warrants future research, raising the question of what clinical and social factors may be contributing to these lower cesarean delivery rates.
BACKGROUND: We assessed understanding of the obstetric consent form between patients with English and Spanish language preference.
METHODS: This observational study included pregnant patients who identified as Hispanic/Latinx with English or Spanish language preference (defined as what language the patient prefers to receive healthcare information) and prenatal care providers at a large academic medical center from 2018 to 2021. Patient demographics, language preference, literacy, numeracy, acculturation, comprehension of the obstetric consent, and provider explanations were collected.
RESULTS: We report descriptive statistics and thematic analysis with an inductive approach from 30 patients with English preference, 10 with Spanish preference, and 23 providers. The English group demonstrated 72% median correct responses about the consent form; the Spanish group demonstrated 61% median correct responses. Regardless of language, the participants demonstrated limited understanding of certain topics, such as risks of cesarean birth.
DISCUSSION: Overall comprehension of key information in an obstetric consent form was low, with differences in language groups, which highlights opportunities for improvements in communication across language barriers. Innovations in the communication of critical pregnancy information for patients with limited English proficiency need to be developed and tested.
There is growing evidence that language discordance between patients and their health care teams negatively affects quality of care, experience of care, and health outcomes, yet there is limited guidance on best practices for advancing equitable care for patients who have language barriers within obstetrics and gynecology. In this commentary, we present two cases of language-discordant care and a framework for addressing language as a critical lens for health inequities in obstetrics and gynecology, which includes a variety of clinical settings such as labor and delivery, perioperative care, outpatient clinics, and inpatient services, as well as sensitivity around reproductive health topics. The proposed framework explores drivers of language-related inequities at the clinician, health system, and societal level. We end with actionable recommendations for enhancing equitable care for patients experiencing language barriers. Because language and communication barriers undergird other structural drivers of inequities in reproductive health outcomes, we urge obstetrician-gynecologists to prioritize improving care for patients experiencing language barriers.
BACKGROUND: Qualified language service providers (QLSPs)-professional interpreters or multilingual clinicians certified to provide care in another language-are critical to ensuring meaningful language access for patients. Designing patient-centered systems for language access could improve quality of pregnancy care.
OBJECTIVE: We synthesized and identified gaps in knowledge about communication preferences during pregnancy care among patients with Spanish primary language.
METHODS: We performed a scoping review of original research studies published between 2000 and 2022 that assessed communication preferences in Spanish-speaking populations during pregnancy care. Studies underwent title, abstract, and full-text review by three investigators. Data were extracted for synthesis and thematic analysis.
RESULTS: We retrieved 1,539 studies. After title/abstract screening, 36 studies underwent full-text review, and 13 of them met inclusion criteria. Two additional studies were included after reference tracing. This yielded a total of 15 studies comprising qualitative (n = 7), quantitative (n = 4), and mixed-methods (n = 4) studies. Three communication preference themes were identified: language access through QLSPs (n = 7); interpersonal dynamics and perceptions of quality of care (n = 9); and information provision and shared decision-making (n = 8). Although seven studies reported a strong patient preference to receive prenatal care from Spanish-speaking clinicians, none of the included studies assessed clinician Spanish language proficiency or QLSP categorization.
CONCLUSIONS: Few studies have assessed communication preferences during pregnancy care among patients with primary Spanish language. Future studies to improve communication during pregnancy care for patients with primary Spanish language require intentional analysis of their communication preferences, including precision regarding language proficiency among clinicians.
OBJECTIVE: To explore Spanish-speaking patients' experiences and preferences regarding communication during pregnancy care with specific attention to language barriers.
METHODS: Patients with a Spanish language preference who gave birth between July 2022 and February 2023 at an academic medical center were invited to participate in focus groups. Focus groups were held over Zoom, audio-recorded, transcribed in Spanish, translated into English, and reviewed for translation accuracy. Thematic analysis was conducted with deductive and inductive approaches. Three investigators double-coded all transcripts, and discrepancies were resolved through team consensus.
RESULTS: Seven focus groups (27 total participants, range 2-6 per group) were held. Three key themes emerged regarding patient experiences and communication preferences when seeking pregnancy care: 1) language concordance and discordance between patients and clinicians are not binary-they exist on a continuum; 2) language-discordant care is common and presents communication challenges, even with qualified interpreters present; and 3) language discordance can be overcome with positive interpersonal dynamics between clinicians and patients.
CONCLUSION: Our findings highlight the importance of relationship to overcome language discordance among patients with limited English proficiency during pregnancy care. These findings inform potential structural change and patient-clinician dyad interventions to better meet the communication needs of patients with limited English proficiency.
OBJECTIVE: To measure what patients with Spanish language preference and limited English proficiency value most when selecting a prenatal care clinician.
METHODS: A discrete choice experiment was administered at two large academic medical centers in Boston, Massachusetts. Participants were identified by electronic medical record, had preferred Spanish language and self-identified limited English proficiency, and either were pregnant with a completed fetal anatomy scan or had given birth within the past 12 months at the time of the study. The discrete choice experiment consisted of eight attributes to consider when selecting a prenatal care clinician: clinician Spanish proficiency, type of interpreter used, interpersonal dynamics (ie, making patients feel seen, heard, and cared for), cultural concordance, continuity of care, shared decision making, distance from home, and wait times for appointments. Descriptive statistics of demographic variables were calculated. Hierarchical Bayesian models were used to analyze discrete choice experiment data.
RESULTS: The attributes that were most important to 166 participants when choosing their prenatal care clinician were interpersonal dynamics within the patient-clinician dyad and clinician Spanish language proficiency (average importance 21.4/100 and 20.8/100, respectively). Of lowest importance were wait time to receive an appointment and continuity of care (average importance 5.1 and 6.1, respectively). Although participants highly preferred that their clinician be "fluent or near fluent in Spanish," the second most preferred option was having a clinician with only basic Spanish proficiency rather than a more advanced level of Spanish proficiency with some misunderstandings.
CONCLUSION: Our study demonstrates the importance of positive clinician-patient interpersonal dynamics and language-concordant care for patients with Spanish language preference in prenatal care. Promoting equitable patient-centered care for patients with limited English proficiency requires responding to preferences regarding clinician language proficiency and demonstrating attentiveness, empathy, and concern for prenatal care experiences.
BACKGROUND: Engaging patients in quality improvement and innovation projects is increasingly important, yet challenges persist with involving patients who speak languages other than English. This article presents design activities our team used to engage Spanish-speaking patients and cultural brokers.
OBJECTIVE: To develop a clinician communication tool to enhance patient trust in pregnancy care clinicians, especially among minoritized populations who face language and cultural barriers, using human-centered design (HCD).
PATIENT INVOLVEMENT AND INNOVATION: We centered end-user experiences, including clinicians, Spanish-speaking patients, and Spanish-speaking cultural brokers, in our design process through multiple feedback sessions and modalities.
METHODS: We used a HCD process to understand the problem, co-design a tool, and prepare for testing of a clinician tool. Design activities included a critical literature review, user interviews, design principles, solution sketching, rapid cycle feedback with subject matter experts, and field experience with pregnancy clinicians.
RESULTS: We innovated on a widely used clinical communication tool, the Four Habits Model, and developed the Five Habits for Pregnancy Care to support pregnancy care clinicians in building trust by bridging cultural and language differences. We added an equity-focused habit "Pause and Reflect" to bookend the Four Habits. We refined the tool to meet different needs across pregnancy care visits based on feedback from 7 clinicians.
DISCUSSION: We applied equity principles in a HCD process to understand a problem, co-design a tool, and prepare for testing by engaging with patients and cultural brokers in Spanish. Balancing the differing approaches for designers and researchers yielded important insights for enhancing equitable processes and outcomes in healthcare improvement.
PRACTICAL VALUE: Communication tools designed with and for minoritized populations are critical for improving trust in all patient-clinician dyads during pregnancy care.
