Addressing Low Health Literacy and Limited English Proficiency

Effective communication is essential to providing high quality care to patients and their families. Low health literacy and Limited English Proficiency (LEP) can significantly impact communication and are associated with inappropriate testing, missed diagnosis, increased use of emergency services and poor patient adherence to recommended care.  

​Health Literacy

According to Healthy People 2030, health literacy is defined as the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Up to a quarter or third of adults are believed to have low health literacy.

This problem is often associated with low literacy, but even well-educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor's instructions about a drug or procedure. Below are some ways that pediatricians and their teams can help:

• Improve the practice environment. Use universal symbols instead of words on signs.
• Identify the problem. Patients/families with low health literacy look like any other patients/families and they may be pretty good at pretending that they understand. Behaviors that you might see include: incompletely or inaccurately completed patient registration forms; frequently missed appointments; non-adherence with prescribed medication regimen; and not following through on orders for laboratory tests, imaging tests, or referrals to consultants.
• Offer Assistance in completing forms.
• Slow down. Speak slowly and appear unrushed. Focus on the patient and the parent. Sit rather than stand. Listen rather than speak.
• Use plain, non-medical language.
• Use visuals. Visual images can improve the patient/family’s understanding and recall of ideas. Consider using videos, models, or brochures with pictures or diagrams.
• Limit the amount of information provided and emphasize the most important points. Use orienting statements: "First I will ask you some questions and then I will listen to your heart." Watch for signs of "tracking", and deliver information in small, digestible bites. Organize the information so that the most important points stand out.
• Use the teach-back or show-me technique. Confirm that patients/families understand by asking them to repeat back the instructions or ask them, "how would you explain this to your spouse or a friend?" If the patient/parent does not explain it correctly, try again using another approach.
• Create a shame-free environment. Avoid asking, "Do you understand?" Patients/parents tend to say yes even when they don’t understand. Instead ask, "Do you have any concerns that I haven't addressed?" Encourage patients/families to ask questions.
• Build in safeguards. Make it clear to patients/families that if they get home and cannot remember exactly what to do, they can call the office for help.

Limited English Proficiency and Use of Translators

Limited English Proficiency (LEP) refers to someone whose primary language is not English and has difficulty communicating effectively in English. Patients and families who have LEP require additional support to be effective partners in health care conversations. Below are some factors to consider:

• Practices who received federal funding (eg. Medicaid) are subject to the Civil Rights Act of 1964. Failure to provide appropriate interpretation services can be considered discrimination. You may not refuse patients with LEP to avoid providing appropriate accommodations.
• Practices must take reasonable steps to ensure meaningful access. What is reasonable depends on the needs of the community where you practice, how often you see LEP in your office, how important the service is to the individual, and the availability and cost of interpretation services. For example, for a practice located in a community where a significant proportion are Spanish-speaking, it might be reasonable to hire bi-lingual staff and/or an on-staff interpreter and offer written materials in both English and Spanish.
• It is generally not best practice to utilize a family member to serve as an interpreter due to concerns about confidentiality, accurate interpretation of medical concepts and possible withholding of information. An adult family member should be used only in extraordinary circumstances; only when requested by the patient or family, and after they have been informed that a translator can be provided at no cost. A child should not be used to translate.
• While some state Medicaid and CHIP programs pay for or provide interpretive services, most payers do not pay pediatricians for this cost. This cost cannot be passed on to the patient/family.
• Pediatricians should be aware that the use of interpreters is likely to increase the total time of the visit. This should be considered in scheduling.

Potential options for interpretation services as well as the pros and cons include:

• Language lines are traditionally audio based and charged by the minute, which can be costly. The lack of physical presence or video feed of the interpreter can be challenging for some. Language lines work well if the anticipated need for interpretation is brief and if the language is uncommon.
• Video conferencing interpretation are similar to language lines with the addition of a video component.
• Trained independent interpreters typically charge by the hour, so are more cost effective if several patients needing interpretation services are scheduled in a block.
• On-site interpreters can either be individuals specifically hired to provide interpretation servicesin the practice or bi-lingual staff who may be certified as medical interpreters.

Tips to working with interpreters:

• Provide a brief summary of what will be covered during the visit to the interpreter. Invite the interpreter to provide their insights on cultural practices or challenges that may arise during the visit.
• Maintain eye contact with the patient/family as opposed to making eye contact with the interpreter.
• Speak slowly and use easy to understand words as opposed to medical jargon.
• The Office for Civil Rights recommends practices have a written language policy and provides guidance here.
• Document your use of an interpreter in the medical record.
• Remember, state or local law may impose greater requirements than federal law.