English-Language Competency Using Written Tests of Health Literacy: DISCUSSION
This study demonstrates that most self-declared English-speaking patients of Hispanic heritage have English-language competency using written tests of health literacy as a surrogate of English-language ability. However, a significant number of patients who state that they speak English do not possess sufficient English-language skills to communicate effectively with respect to their medical care. The study also demonstrates that physicians and nurses had a higher assessment of English-language com petency than the results of health literacy testing. This study would suggest that there is a need for the more liberal use of interpreters.
Our study had a much smaller number of Hispanic patients with limited or no healthcare literacy, compared to other studies of language competency in the ED. In a study of public hospital patients presenting for acute care, 61.6% of the Spanish-speaking patients had inadequate or marginal functional health literacy, as measured by the STOFHLA. In a systematic review of U.S. studies examining the prevalence of health literacy, overall, 26% had low health literacy and 20% had marginal health literacy using either the REALM or the STOFHLA. The results of this study found a higher level of health literacy on both tests as compared to this systematic review. Those patients in our study who stated they spoke English were a self-selected group that may have represented a more intelligent segment of this population.
The importance of adequate communication between the healthcare providers and non-English-speaking patients cannot be overemphasized. The lack of health literacy has been correlated with the provision of inferior healthcare and an additional burden on healthcare resources. The lack of health literacy was found to be associated with a higher rate of hospitalization (31.5% vs. 14.9%) in a study at Grady Memorial Hospital. Williams found that 40% of the ED asthma English-speaking patients read at or below the sixth-grade level and that this inadequate literacy level was strongly correlated with poor knowledge of asthma and improper metered dose inhaler use. Schillinger and others have also found that poor health literacy has been associated with worse diabetic control.
the use of interpreters in the ED. There are also many concerns about the proper use of interpreters in the ED. The developers of the STOFHLA exam recommended, but did not test, bringing someone along who can read and interpret health texts, using other media to communicate health information and having the staff assist patients with low functioning literacy. Untrained interpreters were often noted to be inaccurate and misleading, due to omissions, additions, condensation, substitution and role exchange. Also, the practice of having minority clients provide their own interpreters as an alternative to using qualified interpreters may violate Title VI of the Civil Rights Act of 1964. A study of 530 ED patients found that 26% of Spanish-speaking patients used an interpreter. The most frequent interpreters were physicians and nurses (49%). In this study, professional interpreters were used for only 12%) of the patients. Putsch published a list of guidelines for use of interpreters, including avoiding the use of family members, learning basic words and sentences, using dictionaries, understanding special terminology and interpreter relations. The use of interpreters or interpreter phone services can be costly. Interpreters can range from $25,000-$32,000 per full-time equivalent plus benefits and phone services can range from $1.50-$2.50 per minute for an average of 10-15 minutes.
It is unreasonable to expect most healthcare providers to give patients such lengthy exams, as utilized in this study, to determine their English proficiency. Future studies would hinge on the development and validation of a short test of verbal English proficiency. These short verbal tests could be tested in various healthcare environments, languages and populations to determine when it is important to involve an interpreter in medical care provided to the patient.
This study found that a number of patients stated that they were competent in the English language but then failed to pass a test of English-language ability using tests of health literacy. It was concerning that both physicians and nurses tended to believe that patients with self-declared English-language ability that was not found by by formal testing. This study did not determine the best means to determine English-language competence or how to decide which patients need to have their competency assessed.
Tags: English-language competency, interpreters