Designing Online Cultural Resources to Support Ezidi Refugee Parents of Young Children / Diseño de recursos culturales en línea para apoyar a las familias yazidíes refugiadas con niños pequeños

Initiation and Use of Public Mental Health Services by Persons With Severe Mental Illness and Limited English Proficiency

Stories Blossom:Boundaries Can Blur between Literature and English Teaching and Learning in English as a Foreign Language Eun Young Yeom (bio) The Potential of Children's and Young Adult Literature in English as a Foreign Language During my twelve years of teaching as an in-service teacher of English as a foreign language (EFL) at middle schools and high schools in South Korea, I witnessed that children's and young adult literature written in English was rarely incorporated into South Korean secondary EFL classrooms, mainly because of the college-bound, grammar-focused English teaching curriculum. Also, secondary EFL emergent bilingual students' full linguistic (i.e., both their home languages and English), cultural, and semiotic repertoires are often dismissed in South Korean curriculum; the most common home language, Korean, is regarded as a deficit to acquire higher English proficiency (Turnbull). Secondary EFL emergent bilingual students are often deemed as English learners with limited English proficiency, hence implying that they might not be proficient enough to decode the meanings of literary texts written in English (Harfitt and Chu). In an environment where their home language(s) and other semiotic repertoires are dismissed as deficits to make meaning of children's and young adult literature written in English (CYAL hereafter), secondary EFL emergent bilinguals' active meaning-making through CYAL cannot take place as often as it is supposed to. It must be noted here that EFL emergent bilinguals are making meanings with their full linguistic, cultural, and semiotic repertoires, which is called translanguaging (García and Li Wei). Their home linguistic, cultural, and semiotic resources can be an asset to make meanings of literary texts written in English. While mixing their home language(s), different modes for meaning, and even their feelings and histories (Li Wei and Lin), EFL emergent bilinguals are indeed able to decode meanings written in English and encode new meanings out of literary texts. That is, CYAL is not mere English tutorials to teach grammar, but "literature" that invites EFL emergent bilinguals to add their interpretations onto the text. To decode and encode the meanings inherent in CYAL, EFL emergent bilinguals fuse themselves into the text written in English; incorporate their full linguistic, cultural, and semiotic resources; and create new meanings of their own based on the text (Rosenblatt). In addition to [End Page 84] reading and learning authentic English through CYAL, EFL emergent bilinguals can become active readers whose inner worlds are not governed by teacher-centered lectures and explanations. The Potential of Multicultural Picturebooks Written in English in EFL Among children's and young adult literature, picturebooks can reap benefits in EFL contexts thanks to their comprehensible texts and visual appeal. Between EFL emergent bilingual readers and picturebooks, the boundary between the readers' "inner and outer world breaks down, and the literary work of art, so often remarked, leads us into a new world" (Rosenblatt 21). The new world might include experiencing alternative possibilities of lives, which the reader might have not been exposed to. For example, growing up in a racially and linguistically homogenous country such as South Korea, EFL emergent bilingual middle school students could not have a chance to live through the experience of being newly arrived immigrants with racial and linguistic minority backgrounds. The intersectionality of migration, race, and language could be lived through literature such as multicultural picturebooks regarding Korean immigrants in the United States. Korean EFL emergent bilingual readers might attend to certain elements of a multicultural picturebook and their past experiences, while incorporating their linguistic, cultural, and semiotic repertoires to make meanings, along with the feelings and thoughts evoked by the stories of newly arrived immigrants. New meanings, including insights concerning multiculturalism, could also be generated through book club discussions where active meaning-making through EFL emergent bilinguals' home languages and English uses are simultaneously integrated. If book club discussions are applied in EFL classrooms, EFL emergent bilinguals can imagine, vicariously experience, and critically think about multiculturalism thanks to teachers' and peers' facilitations during meaning-making processes. With the help of translanguaging, EFL emergent bilinguals do not stop at decoding English sentences but can reach into their "social imagination" (Wissman 18) regarding diversity through transacting with multicultural picturebooks. Stories...

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

In the USA, people with limited English proficiency (LEP) disproportionately experience gaps in health insurance coverage and access to care. The Patient Protection and Affordable Care Act (ACA) of 2010 included reforms that could improve these outcomes. To describe changes in insurance coverage and access to health care by English language proficiency over 2006-2016. We used regression models to estimate changes in coverage and access after 2010 for adults with high vs. limited English proficiency, adjusting for socio-economic status, demographic characteristics, and health care needs. We used difference-in-differences models to assess adjusted changes in disparities by English proficiency after 2010. Supplemental analyses used nearest-neighbor propensity score matching to balance the characteristics of respondents. Respondents aged 18-64 in the Medical Expenditure Panel Survey over 2006-2016, with high (n = 174,214) or limited (n = 16,484) English language proficiency. Insurance coverage was a binary variable indicating any health insurance coverage during the past 12months. Access to care was measured using binary variables indicating whether the respondent had a usual source of care and received necessary medical, dental, and preventive care. Gains in health insurance coverage after 2010 were significant for adults with high English proficiency (1.7 percentage points, p < 0.001) and adults with limited English proficiency (4.6 percentage points, p = 0.007); gains did not significantly vary by English proficiency. Adults with LEP showed larger improvements than adults with high English proficiency in having a usual source of care (5 percentage points, p = 0.007) and receiving needed medical care and dental care (1.4 percentage points, p = 0.013, and 2.8 percentage points, p = 0.009, respectively). Findings remained similar when matching was used to balance the measured characteristics of respondents with high vs. limited English proficiency. Disparities in health care access by English proficiency narrowed after 2010, the year of passage of the ACA.

99 Background: More than a quarter of people living in British Columbia, Canada speak languages other than English in their homes. Immigrants often encounter communication challenges with their health care providers (HCPs), have poor health literacy, and have a limited understanding on navigating the health care system. NSCLC patients with limited English proficiency (LEP) may receive less palliative care services despite high symptom burden and significant needs due to these factors. The study goals were to observe the difference in access to community palliative home care (CPHC) and rate of completing a Do Not Resuscitate (DNR) form between NSCLC patients who are English proficient (EP) and LEP. Methods: All patients with advanced NSCLC referred to BC Cancer–Vancouver Centre in 2016 and received medical care were included (N=176). Patients seen with a medical interpreter were considered to be LEP. Demographics and clinical information were collected retrospectively. UVA using X2 test and Fisher’s exact test were used to compare EP and LEP patients. Mann-Whitney test was used to compare the median time from CPHC referral and signed DNR to death between EP and LEP patients. Results: Language of communication: English 65%, Cantonese 22%, Mandarin 6%, Korean 1%, Tagalog 1%, and other 5%. Baseline characteristics: median age 69 EP vs 76 LEP, female 44% EP vs 65% LEP, non-squamous 68% EP vs 72% LEP and squamous 14% EP vs 6% LEP. There was no difference in the rate of CPHC referral (87% EP vs 80% LEP, p=0.342) and signed DNR form (92% EP vs 89% LEP, p=0.549). The median time from CPHC referral to death was 10 weeks EP vs 15 weeks LEP (p=0.039). The median time from signed DNR to death was 5 weeks EP vs 6 weeks LEP (p=0.806). There was no statistically significant difference in location of death between the two groups: acute care 20% EP vs 24% LEP, home 27% EP vs 13% LEP, hospice 36% EP vs 39% LEP, and tertiary palliative care unit 17% EP vs 24% LEP (p=0.251). Conclusions: EP and LEP patients with NSCLC had similar rates of CPHC service referrals and end of life planning. This suggests assistance of medical interpreters at the time of oncology visits help message delivery between LEP patients and HCPs. LEP patients had earlier referrals to CPHC prior to death which may reflect an enhanced awareness and effort by HCPs to have earlier conversations with patients who may have language and cultural barriers with discussing goals of care. Good communication improves patients and their family’s understanding of the goals and scope of palliative care services and allow HCPs to better understand the patients’ wishes.

Biliteracy and Second-Language Learners

Theories of change and outcomes in home-based Early Head Start programs

COVID-19-Related Care for Hispanic Elderly Adults With Limited English Proficiency.

BACKGROUND: Health disparities among patients with limited English -proficiency (LEP) are well documented in the literature. Barriers to communication for LEP patients affect quality of care, length of stay and readmission rates. Our aim is to increase the frequency of interpretations on the pediatric inpatient floors from 1.7 interpretations per patient per day (baseline) to 2.5 interpretations per day by 12/31/2018. METHODS: A 2016 needs assessment was conducted to identify opportunities to improve care for patients and families with LEP. One of …

The South African national curriculum mandates that all learners study at least one home language, selected from the country’s 11 official languages. The policy is intended to promote linguistic equity and affirm cultural identity in the post-apartheid era by supporting a language that learners speak regularly at home. However, in practice, some students opt to study English as their home language, even though it is not the primary language spoken in their homes. This creates a paradoxical situation where the label "home language" inaccurately represents their actual linguistic environment culminating in students being taught and assessed at a level intended for first-language speakers, despite having only limited proficiency in English. Therefore, in this paper I reflect on the pedagogical difficulties and successes that I have encountered as an educator for English Home language in Mthatha in the Eastern Cape province of South Africa. This I do by employing a decolonial framework underpinned by decolonial love as decoloniality, and a living theory methodology with action-reflection cycles. One key finding is the difficulty of reconciling the demands of a standardised curriculum with the linguistic diversity of South African students. Ultimately, the paper advocates for a shift away from uncritically imposed Western models toward more adaptive, context-sensitive practices to improve educational outcomes in South Africa’s heterogeneous classrooms. The argument challenges the continued dominance of Eurocentric methodologies which were developed for monolingual Western contexts and often prove mismatched with South Africa's complex multilingual classrooms.

Persons with limited English proficiency (LEP) can face barriers when seeking health care. Rural communities often have reduced access to some health resources. However, little is known about how rural communities meet the language needs of their LEP populations. A cross-sectional survey and interview were designed and sent to managerial staff in rural health centers around the state of Oregon. During the months of January – March 2020, survey and interview data were collected to assess the relationship between frequency of LEP patient visits and available language resources in rural Oregon. The study also investigated staff perceptions when working with patients with LEP. Data responses came from centers in mainly northern, northeastern, and coastal regions of the state. Data suggested that clinics that see higher numbers of patients with LEP have more onsite bilingual staff and interpreter resources available than health centers with less regular LEP patient visits. Clinics preferred the use of bilingual staff during visits, rather than relying on remote interpreting services, and preferred onsite interpretation, instead of remote interpretation. Further, clinics perceived that the population of LEP patients was growing across the state. One promising method for meeting demands of language resources is implementing certification courses for bilingual care staff and community members. State-subsidized certification courses could increase the availability of certified bilingual health workers trained in medical interpretation, as well as provide opportunities for bilingual community members to become trained as certified medical interpreters.

BackgroundHealth care systems are rapidly deploying digital tools for disease management; however, few studies have evaluated their usability by vulnerable populations. To understand the barriers to app usage among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app.ObjectiveThe study aimed to describe variations in patients’ engagement in the app design process, focusing on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL).MethodsWe conducted 20 in-depth semistructured interviews with primary care patients at a public health care system, used open-ended discussions and card sorting tasks to seek input about mobile phones and text messaging, and used open coding to categorize the patterns of mobile phone usage and to evaluate engagement in the card sorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content and calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy.ResultsThe average age of the 20 participants was 59 (SD 8) years; 13 (65%) were female, 18 (90%) were nonwhite, 16 (80%) had LHL, and 13 (65%) had LEP. All had depression, and 14 (70%) had diabetes. Most participants had smartphones (18/20, 90%) and regularly used text messaging (15/20, 75%), but 14 (70%) of them reported having difficulty texting because of inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP, and all 10 had LHL. Half of the participants required a modification of the card sorting activity owing to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (4/13, 30% vs 5/7, 71%), limited versus adequate health literacy (7/16, 44% vs 3/4, 75%), and limited versus adequate digital literacy (4/10, 40% vs 6/10, 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (8/16, 50% vs 4/4, 100%); there were no statistical differences by any subgroup.ConclusionsDespite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the card sorting activity varied among participants and appeared to be lower among those with LHL, LEP, and LDL. Researchers employing traditional UCD methods should routinely measure these communication domains among their end-user samples. Future work is needed to replicate our findings in larger samples, but augmentation of card sorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.

e18533 Background: Prior studies have shown that when patients with cancer engage with social media, they have positive outcomes, including clinical trial participation, volunteerism and advocacy, and diminished levels of anxiety. However, active users of social media tend to be white, well-educated, and of higher socioeconomic status. Little is known about the use of technology and social media by underserved oncology populations, particularly patients with limited English proficiency (LEP). We sought to characterize current technology use by patients at Olive View—UCLA Medical Center (OVMC), a safety net hospital in Los Angeles County. Methods: We developed an anonymous online survey (Qualtrics, Provo, UT) comprised of 39 questions. The survey was administered, via touchscreen tablets from January 2020 through January 2021, to a convenience sample of patients seen in OVMC’s outpatient medical oncology clinic. The survey was available in English and Spanish, and we excluded patients who were not fluent in either language. Patients were categorized as having LEP versus English proficiency (EP) by self-assessment, on a 5-point Likert scale, of their comfort in speaking English. Differences between the LEP and EP groups were assessed using Pearson’s chi-squared test and Fisher’s exact test. Results: Of 113 patients who were offered the survey, 10 (9%) declined participation because of illiteracy in their primary language or inability to use a tablet. Reponses were recorded for 50 patients with LEP and 53 with EP. The LEP and EP groups, respectively, were similar in their representation of women (62% and 64%) and mean age (58 years and 51 years). High school completion rates were 32% for the LEP group and 70% for the EP group. A higher proportion of the LEP group identified as Hispanic/Latinx (84%) compared to the EP group (58%). The LEP group was less likely than the EP group to have internet access (63% vs. 98%, P&lt; 0.01). However, among patients with internet access, social media use was similar in the LEP and EP groups (65% vs. 71%, P= 0.7). Facebook was the most used platform by the LEP (22%) and EP (32%) groups; other platforms (e.g., Twitter, Instagram) were used by very few respondents. The LEP group was less likely than the EP group to have activated the OVMC online patient portal (19% vs. 47%, P&lt; 0.01) and less likely to perceive websites as helpful for learning about clinical trials (30% vs. 53%, P= 0.03). Conclusions: A notable proportion of safety net oncology patients at OVMC do not engage with tablet technology because of illiteracy or lack of comfort with touchscreens. Patients with LEP are less likely to have internet access, but those with access use social media about as often as patients with EP, and prefer Facebook over other platforms. For patients with LEP, engagement efforts, including clinical trial outreach, should continue to include non–internet-based resources in patients’ native languages.

Individuals with limited English proficiency (LEP) are a growing population 1. Patients with LEP are at high risk for lower quality care, including higher rates of misdiagnoses, medical errors, and serious adverse events 2-4. Language barriers and underuse of medical interpreters have been widely identified as obstacles to equitable and quality care 2, 4; however, the rate of professional interpreter use remains unknown. Further, no known study has explored patients' reasons for refusing interpreter assistance, rather, existing studies have largely focused on physician and parental barriers 3. Patients with LEP diagnosed with cancer may be particularly susceptible to adverse outcomes as a result of communication barriers. Conversations in cancer care often involve complex, confusing, and emotionally laden discussions. In fact, English proficient patients have been shown to have difficulty understanding cancer-related discussions yet are reluctant to ask questions 5. In effect, poor communication in cancer care may exacerbate a patient's feelings of helplessness and distrust, which may manifest in treatment nonadherence and care dissatisfaction. Although language barriers have been shown to impact care delivery among populations with LEP, little is known about additional factors that may influence the provision of quality care for patients with LEP and cancer, particularly from the perspective of medical interpreters. Medical interpreters are trained specialists who bridge communication between a patient and their provider. Given their position as medical liaison and cultural broker, interpreters offer a unique outlook of patient experiences that can inform and equip cancer centers with tools to manage the complexities of a linguistically and culturally diverse medical population. Given their distinct position, a number of studies led by Hsieh and colleagues have qualitatively explored interpreters' perspectives by tapping into their personal challenges and experiences with navigating their role as cultural advocate and medical conduit, particularly as it relates to care delivery 6, 7. However, this is one of the first studies to specifically explore professional interpreters' perceptions of the potential mechanisms underlying disparities in the care of patients with LEP and cancer. Moreover, this is among the first studies to solicit interpreters' recommendations for improving cancer care for patients with LEP. As such, this study aims to understand interpreters' perceptions of factors that impact the quality of cancer care receipt. Secondary aims include exploring interpreters' recommendations for improving overall cancer care delivery for patients with LEP. This qualitative study was part of a larger study which developed and evaluated the effects of a mind-body program, Project CARE (Coping and Enhancing Resiliency), for professional medical interpreters working at three Boston-based hospitals serving a diverse community of patients with cancer 8. It was approved by the MGH/Partners HealthCare Institutional Review Board. In brief, interested interpreters who worked >20 h per week at one of the participating hospitals and who had experience working in oncology departments were screened, consented, and scheduled to partake in one of five focus groups. After the group, the participants completed 30-min individual interviews using a semi-structured interview guide that elicited the interpreters' perceptions of factors that reduce patients with LEP's quality of care and strategies to enhance patient satisfaction and quality care, specifically in the cancer care context. Audiorecordings were transcribed and entered into NVivo10. Two study staff (GKP and MSY) reviewed each transcript to identify themes and develop a coding framework using a framework approach, independently coding all data. Coders met on a regular basis to compare coding schemes. Discrepancies were resolved with comparisons to raw data and through discussions with the PI. A coding comparison query showed acceptable level of coding reliability (Kappa = 0.91). Approximately 29 interpreters participated in the study. A majority were women (69%), 30.8% were White, and 53.8% were Hispanic. About half had more than 10 years of interpreting experience, and all interpreted for an average of six encounters with cancer patients daily. Three themes emerged related to the interpreters' perceptions of factors that interfere with the provision of quality cancer care for patients with LEP: (a) system-level factors; (b) underutilization of trained interpreters; and (c) gaps in patient understanding and interactions with the US medical system. Following are a summary of the major themes with corresponding quotes listed in Table 1. System-wide limitations in access to care, including limited access to language-specific informational resources (e.g., discharge paperwork or treatment instructions), insurance-related barriers to supportive care (e.g., visiting nurses or hospice care) or medical treatment, longer wait times, and shorter medical encounters as a result of staff shortages were commonly identified sources believed to impact the quality of cancer care that the patients with LEP received. Underutilization of professional interpretation services was unanimously introduced as a principal factor impacting the provision of quality patient care. Specifically, the participants observed that patients who procured the help of trained interpreters were more satisfied and comfortable with their care, were more apt to express their concerns and to ask questions, and were more likely to know how to access patient advocacy when needed. Yet, the participants acknowledged that patients did not effectively access professional interpreter services. When prompted for reasons for underuse, the participants discussed a blending of patient and provider themes: (a) patient-level factors, including lack of knowledge regarding free interpreter services, culturally laden expectations, privacy concerns, and familial barriers; and (b) provider-specific factors, including a desire to save time and perceived language mastery. Generally, the interpreters found that patients struggled with understanding and engaging with the US medical system. The interpreters noticed that patients were unaware of the emphasis placed on patient care involvement in decisions about prescriptions, tests, or treatments. They observed that patients did not comprehend the differences across specialties and practices. In conjunction with communication difficulties, this often resulted in patients 'bouncing' from physician to physician prior to connecting with the appropriate provider. In addition, the interpreters felt that patients had difficulty fully understanding information exchanged during medical encounters, especially when it was replete with medical terminology. Consequently, this left patients unequipped to ask questions and compromised in their ability to participate in treatment decisions, thus contributing to treatment nonadherence. Altogether, the participants felt that this broadened the patient-provider divide and contributed to patient dissatisfaction, because patients often felt rushed, misunderstood, and unattended. The participants offered many strategies to improve care quality for patients with LEP (refer to Figure 1). Themes primarily centered on empowering the patient while reinforcing the foundation of a medical system that serves a culturally and linguistically diverse population. The participants thought that hospital-wide efforts should be made to increase patients' knowledge and awareness of free and confidential interpreter services. Specifically, they recommended that at first entry into a clinic, patients should receive language-concordant visual aids highlighting their rights to free interpreters, defining the role of interpreters (e.g., voice vs. friend), describing methods for requesting interpreter services, and summarizing ways to effectively utilize an interpreter. The participants imparted the need to educate patients about the US medical system, including informing patients of their right to ask questions and to inform their physician of any discomforts. Suggestions included the creation of language-concordant materials that provide treatment-specific information and that describe the differing roles of their medical team; additionally, they recommended booklets wherein patients can maintain a list of medications, treatment history, questions regarding their cancer care, and provider names and contact information. Suggested communication improvements included instructing patients to be on time to appointments and to schedule an interpreter prior to their visit as well as using diagrams to reinforce patients' understanding of their diagnosis and treatment. The participants recommended regular, hospital-wide trainings to increase staff and provider awareness of the utility of medical interpreters as well as strategies to integrate them into their practice. Further, the participants felt that it was important to increase providers' awareness of cultural norms and their potential impact on patients' diagnostic awareness and decision-making processes; particularly, efforts should be made to prioritize the need of patients while being mindful of familial roles, values, and preferences. Interpreters underscored the value of empowering the patient, which they defined as bestowing patients with the knowledge, skills, and resources necessary to become more active and effective players in their own health care. Specifically, the participants believed that patients should be informed of their right to ask questions. Patients with LEP are highly susceptible to poorer quality care as a result of language barriers; however, there is little information regarding factors that may influence their cancer experience and the nature of cancer care delivery. Consistent with what has been documented in the literature 4, 9, our sample of medical interpreters echoed similar themes they believed may impact the quality of care that patients with LEP receive in the cancer context, including system-level obstacles to service access, underuse of medical interpreters, and lack of patient understanding of the medical system and their cancer care. These themes both substantiate and build on existing findings by explaining, from the interpreter perspective, how these separate yet interrelated pathways may contribute to some of the disparities in cancer care for patients with LEP. Collectively, the participants speculated that these factors increased the risk of communication errors and reduced patients' capacity to engage in their cancer treatment. In essence, interpreters have the potential to strengthen the patient-provider dyad by providing patients with a medium to convey health concerns, symptoms, side effects, and treatment preferences. However, these findings suggest that the provision of interpreter services alone may be limited by deficits in patients' understanding and involvement in their care. It is possible that although interpreters may offer linguistic support, perceived gaps in patients' knowledge and awareness of important health care management processes might preclude patients from fully comprehending medical transactions; in effect, patients may receive but be unable to adequately process and respond to the information provided. These results lend support for the development of interventions that target both language and knowledge barriers to improve the provision of equitable and quality cancer care for patients with LEP. In light of these reports, the interpreters offered a number of strategies to mitigate these challenges, and thus, optimize cancer care for patients with LEP. Specifically, they stressed the need to educate patients by incorporating accessible resources, such as language-concordant informational aids (e.g., booklets and visual aids), into cancer clinics and patient encounters to increase patients' awareness and use of trained interpreters, promote their understanding of their diagnosis and treatment, and facilitate their ability to actively engage in their cancer care. These interpreter-driven solutions slightly diverge from typical recommendations to address quality care barriers in that they are patient-centric. Specifically, although the interpreters acknowledged system-level obstacles to quality care delivery, these efforts center on activating patients and empowering them to overcome the linguistic divide and become more engaged in their treatment, which may help support the assimilation of Western medical practices into their own cultural framework. Despite the novelty of these findings, this study has several limitations. Because this study recruited from a convenience sample of interpreters working in Boston academic medical centers, findings are limited in generalizability and may not reflect the opinions of interpreters beyond this sample. Further, although interpreters work closely with patients, patients may have alternate accounts of factors impacting their use of interpreters and their care during cancer treatment. As such, future research should be undertaken with patients to evaluate their reasons for declining interpreter services as well as assess their programmatic and care needs. Lastly, these findings highlight patient-empowering strategies to increase the quality of cancer care for patients with LEP; however, it is important to acknowledge the role that the physician and medical establishment have in ensuring equitable and quality cancer care delivery across all patients. As such, this is only one facet of a multilayered approach that would be strengthened by integrating systemic and provider-level interventions to improve patient quality care.

The aim of this study was to determine whether there has been a change in access to private dental services in regional and remote areas of Australia by comparing the distribution of private dental practices and dentists in 2011 to the distribution in 2018 according to state and territory and the Accessibility/Remoteness Index of Australia Plus. A database of dental practices and dentists in Australia was compiled from open-access sources for 2011 and 2018; dental practices were mapped by state, Accessibility/Remoteness Index of Australia Plus and Statistical Area 2 census district and linked to population data. Change in number of private dental practices, mean number of dentists per private practice, population per dental practice and mean number of dentists per population by geographic location from 2011 to 2018. There were more dental practices in rural and remote areas in 2018 than in 2011. The percentage of Statistical Area 2s without a private dental practice was lower in 2018 but remained high in rural areas and increased with remoteness-inner regional 23.1%; outer regional 31.6%; and remote and very remote 48%. Growth in registered dentist numbers did not match population growth, and on average, there were less dentists per practice in inner regional and remote and very remote areas by the end of the study. There has been an improvement in spatial access to private dental services in regional areas of Australia, but slower rate of growth of dentist numbers compared to population growth resulted in poorer access to dental services and large population numbers must still travel outside their local Statistical Area 2 census district to access dental care.