Should everyone have access to health care in a language they can understand? This is not a new question. In 2001, Health Canada released a report entitled ‘Language Barriers in Access to Health Care,’ calling for further research, including an exploration of the feasibility and cost of providing interpretation throughout the health care system. Since then, while interpretation programs have been expanded in some jurisdictions in Ontario, we are no closer to guaranteeing that every patient receives health care in a language they can understand. In fact, the conversations, policies and funding related to interpretation programs in Ontario largely seem to position it as a ‘nice to have,’ opt-in bonus, rather than an essential component of provider/patient interactions.
In terms of policy in Ontario, the current grab bag of approaches suggests there are no clear, binding provincial guidelines regarding health care language accessibility. Studies suggest, however, that when providers and patients can’t communicate in the same language – sometimes termed ‘language discordance’ – this results in poorer health outcomes, and even increased risk of death. A 2002 study of 1,800 people with active tuberculosis born outside of Canada and living in Ontario found an association between language discordance and increased risk of death. A 2004 study of three Toronto hospitals found that language discordance led to increased length of hospital stays, and a 1990 study of 22,448 women in Ontario suggested that women whose primary language was not English were less likely to receive some forms of cancer screening.
We also know there are many jurisdictions in Ontario where patients who do not speak English will be unable to find a primary care provider who speaks their language. A recent study from the Centre for Research on Inner City Health (CRICH) found several municipalities in need of Portuguese, Italian, Punjabi, Chinese and Spanish-speaking primary care physicians, although in some cases the population in need was small. Currently, CRICH is conducting an analysis for the Toronto Central Local Health Integration Network (TC LHIN) looking at the degree to which patients are able access care from a primary care physician who speaks their language in different areas of Toronto. The study is ongoing, but preliminary results suggest there are large gaps in different areas of the city.
When interpretation is offered, we see a clear improvement in the health care experience. In 2014, CRICH conducted an evaluation of the TC LHIN’s telephone interpretation program, Language Service Toronto (LST). Established in 2012, LST currently offers 25 participating hospitals and 18 community health organizations in or near central Toronto on-demand access to telephone interpreters speaking 170 languages, 24 hours a day, 7 days a week. Interpreters are available to health care workers for appointments and follow-up. They are also available to administrative workers for appointment booking and other interactions. Our evaluation found that relatively seamless access to telephone interpretation both improved the health care experience and allowed organizations to reach people they were not able to previously.
The positive impact of the right type of interpretation at the right time is clear. So is the fact that language discordance between health care organizations and patients can lead to negative impacts on health outcomes, and potentially unnecessary additional use of health care service (ie. lengthier hospital stays). While LST Toronto is an excellent start, it is a voluntary program. Organizations opt in – hospital and community-based health organizations are not required to offer professional interpretation. In addition, we don’t know the degree to which independent primary care providers, who are often the first point of contact to the health care system, are using professional interpretation. Even within organizations subscribed to LST, use may be uneven. It is unclear, for example, whether all providers (physicians, nurses, social workers, case coordinators, etc.) and support staff (receptionists) are trained on and offered the use of LST within every organization.
Access to telephone interpretation is one component of what could be a coordinated, multi-pronged approach to ensuring language concordance between health care organizations and patients in Ontario. Our evaluation of LST found that telephone interpretation should be supplemented with other forms of interpretation including in-person, adaptations for people who are hard-of-hearing, and video conferencing (for detailed findings, please visit www.crich.ca/reports). A previous study suggests additional strategies including increased recruitment of medical students who speak needed languages and a publicly-available database of physicians who speak a range of languages. Finally, when obtaining a license in Ontario, international medical graduates are required to practice in ‘underserved areas.’ The definition of ‘underserved’ could be broadened to include areas that require physicians who speak non-official languages.
There is no doubt that a coordinated health care language accessibility strategy is needed in Ontario and, likely, at a national level. The stated objective of the Canada Health Act is to ‘facilitate reasonable access to health services without financial or other barriers.’ We would argue that language discordance is a barrier that needs to be addressed, not based on the goodwill of individual providers and organizations, but at all levels of the health care system, and for everyone.