Families with limited English proficiency are less likely to question their child's hospital care

Communication failures are a known source of medical errors and are especially likely to occur when there are language barriers. A new study at 21 children's hospitals throughout the U.S., led by Alisa Khan, MD, MPH, at Boston Children's Hospital, surveyed patients and family caregivers and found that many who lack proficiency in English feel less safe asking questions and speaking up during their hospital stay. Findings were published June 13 in JAMA Pediatrics.

"As providers and hospitals, we must do a better job of partnering with families with language barriers," says Khan. "We should encourage families to ask questions and speak up and make it safe for them to do so. Families know their child best and their observations are valuable. We must also use certified interpreters with every interaction. These investments may take more time but can pay dividends in terms of patient safety, quality, and equity."

The researchers approached 813 randomly selected Arabic-, Chinese-, Spanish-, and English-speaking hospitalized pediatric patients and families. With the assistance of interpreters, investigators invited them to complete a survey also in their own language. Adolescent patients aged 13 and older were invited to complete their own surveys.

Of the 608 patients and caregivers who agreed to participate, 75 (14 percent) had limited English proficiency based on their survey responses, and 132 (25 percent) had limited health literacy.

All 21 hospitals had interpreters available in-person, on video, or by telephone to varying degrees. Nonetheless, survey respondents with limited English proficiency were:

• less likely to strongly agree that they would "freely speak up if I see something that may negatively affect my/my child's care" than respondents who were proficient in English (57 vs. 82 percent).
• less likely to strongly agree that they would "feel free to question the decisions or actions of health care providers" (37 vs. 71.5 percent).
• less likely to strongly disagree that they would be "afraid to ask questions when something does not seem right" (39 vs. 64 percent).

"We know that our hospital systems aren't always set up to proactively encourage patients to speak up, but we were surprised by the magnitude of the difference based on language proficiency," says Khan. "This difference can have safety implications, since when families speak up, it can greatly improve care."

Participants with limited health literacy and a lower level of education were also less likely to question decisions. However, when the researchers adjusted for these and other factors—relationship to the patient, age, gender, race, ethnicity, and income level—participants with limited English proficiency:

• were one-fourth as likely as English-proficient participants to say they would freely speak up about something that may adversely affect the child's care
• were one-fifth as likely to say they would question providers' decisions or actions
• were less than half as likely to say they would be unafraid to ask questions when something does not seem right.

Language barriers and medical errors

In a prior 2020 study, which informed the current research, Khan and colleagues found that hospitalized children whose families had limited comfort with English were twice as likely to experience adverse events (harm due to medical care). Based on their new findings, Khan calls on hospitals to:

• invest in additional interpreter resources (including video and in-person interpreters)
• create policies that require the use of certified interpreters for every encounter
• encourage clinicians to build rapport with non-English-proficient families, to invite families to speak up and ask questions, and to solicit their expertise about their child's condition
• create a culture that allows more time for encounters with non-English-proficient families
• hire more bilingual staff (beyond just interpreters)
• invest in implicit bias and cultural humility training.

"Starting from admission, every interaction is an opportunity for families to speak up and potentially intercept a medical error," says Khan. "We must ensure that families who speak languages other than English have an equal opportunity to speak up."

Christopher P. Landrigan, MD, MPH, chief of the Division of General Pediatrics at Boston Children's, was senior investigator on the study, conducted in collaboration with the Patient and Family Centered I-PASS Safer Communication on Rounds (SCORE) Study Group.

"Families are crucial partners in everything we do in health care," Landrigan says. "Health systems must find ways to ensure that the voices of all patients and families—regardless of language, literacy, education, or race—are heard and acted upon."