Limited English Proficiency Families Research Articles

Caregivers with limited English proficiency: Satisfaction with primary pediatric healthcare.

With a growing 25.5 million people in the United States experiencing limited-English proficiency (LEP), there is a concern over these individuals' experiences in healthcare. Health outcomes of LEP status are well-documented for adults in hospitals; however, less is known about patient experience, pediatric populations, and primary care settings. This study investigated differences in caregiver satisfaction between families with and without LEP receiving healthcare for their child. A sample of 25,118 caregivers whose children from birth to 17years had met with any healthcare providers in the past year was used. Analyses consisted of unpaired t-tests comparing mean satisfaction of LEP and English-proficient (EP) caregivers in the domains of how often primary healthcare providers spent enough time with the child, listened, provided specific information, demonstrated sensitivity to the family's values, and made the respondent feel like a partner. In all aspects of caregiver satisfaction, mean satisfaction scores were significantly lower for LEP caregivers than EP caregivers. The largest drops were seen in perceived time and sensitivity. These results highlight a need to ensure LEP families receive equitable and high-quality primary care services, ultimately building trust in the healthcare system and improving children's health and well-being.

Limited English Proficiency can Negatively Impact Disease/Treatment in Children With Cancer Compared to Those Who are English Proficient-an Institutional Study

BackgroundIn 2013, 25.5 million people in the United States self-identified as having limited English proficiency (LEP). LEP in adults has been associated with longer hospital stays, increased adverse events, increased emergency room visits, and decreased understanding of medications prescribed. This study aims to define the relationship between LEP and outcomes in a pediatric oncologic population. MethodsWe performed a matched case-control study utilizing data from our institutional cancer database (children </ = 18, 2012-2021). LEP families were matched by disease and stage with English proficient (EP) families. Descriptive, univariate, and bivariate analysis were performed. ResultsTwenty-four LEP children were identified and matched with 77 EP children. LEP children represented 11 languages, with the most common being Spanish (42%). Statistical regression demonstrated a clinically significant trend for LEP children to have an increased mean number of unexpected hospital admissions (p = 0.04), increased number of clinic cancellations (n = 0.003), and increased emergency department visits (p = 0.05). LEP children were more likely to have Medicaid than commercial insurance (p < 0.001). There was no difference in 2-year event free or overall survival. ConclusionIn our study cohort, LEP families are at risk for more negative treatment experiences than EP families. Further studies are needed to delineate specific causes and interventions. Type of StudyRetrospective comparative cohort study. Level of EvidenceLevel III.

Genetic counselling resources in non-english languages: A scoping review.

Genetic counselling is essential for individuals seeking genetic or genomic testing. Whereas innovative strategies for GC delivery are being explored to meet the growing demand on the clinical genetics workforce, it is essential to consider the unique needs of culturally and linguistically diverse populations. We conducted a scoping review to examine the extent, range, and gaps in the body of non-English, patient-facing educational resources available for Limited English Proficient (LEP) patients accessing clinical genetics and genomics services. The literature search returned 246 unique resources, most available in several languages. Forty-six languages were represented, with Spanish, Russian, and French being the most common. Resources were in various formats and were of varying quality. There is a lack of high-quality supplementary genetics education material available in languages other than English, which limits the quality-of-care that LEP families may receive compared to their English-speaking counterparts. Of equal concern is the difficulty in finding existing resources and in determining their quality. This research highlights the important need for genetics education material that is of good quality in languages other than English and the challenges associated with identifying this material. A central, curated repository, perhaps sponsored by a genetic counselling organization, would be of great benefit to help genetic counsellors meet the needs of their culturally and linguistically diverse patients.

Results of a Multidisciplinary Workshop to Reduce Bias and Improve Health Equity for Patients With Limited English Proficiency [ID: 1375774

INTRODUCTION: Birthing people with limited English proficiency (LEP) often face systemic limitations to care and are at increased risk for disparate birth outcomes due to barriers in patient–provider communication. Patients with LEP are particularly vulnerable to biases and microaggressions that can limit timely health care delivery and the quality of services received. We developed a multidisciplinary curriculum to educate providers about 1) unconscious bias (UCB), 2) barriers to equitable health care delivery for patients with LEP, and 3) use of trained interpreter services to promote patient–provider communication. METHODS: We developed a 60-minute workshop for physicians/midwives/nurses (n=75). Surveys were used to assess change in knowledge. Results were evaluated by descriptive statistics, t tests for significance, and thematic analysis. Institutional review board approval was obtained. RESULTS: Approximately 75 participants attended the workshop. Thirty-three percent of pre-workshop survey respondents (13/39) had not received cultural competency training within the last 3 years. Approximately 1 in 5 (22%) pre-workshop respondents were unaware of their hospital's interpreter services policy. After a brief didactic presentation, participants identified common microaggressions and barriers to care for patients with LEP. They also developed 15 unique strategies to promote communication via use of trained interpreters when the patient/family initially opt for ad hoc interpretation instead. At workshop completion, 97.1% of participants reported that they will adopt or modify an existing strategy when communicating with LEP patients and families. CONCLUSION: Post-workshop survey results suggest that continuing education can be used to address UCB for patients with LEP and promote use of interpreter services to improve patient–provider communication.

Increasing Language Interpreter Services Use and Documentation: A Quality Improvement Project.

Based on the Civil Rights Act of 1964, hospitals receiving funding from the Department of Human and Health Services must ensure adequate language assistance via a qualified interpreter for Limited English Proficiency (LEP) patients. Despite availability at our institution, official interpreter services were underutilized with inconsistent documentation of use. Baseline data over a 6-week period revealed a median of 43% of LEP parents reported use of official interpreter services, with a median of 0% documentation of use. We aimed to improve both over a 3-month period. This quality improvement project was conducted at a children's hospital between April and August 2020. Surveys were provided to inpatient LEP families. Four intervention periods were implemented with ongoing data collection for 12 weeks. Interventions included developing best practices, incorporating language identification into daily workflow, empowering families, and standardizing documentation. Data were analyzed by run chart and descriptive statistics. After interventions and several plan-do-study-act cycles, a median of 73% reported use of official interpreter services, and a median of 59% were documented. After multiple interventions, specifically noted after intervention period #2, improvement of official interpreter service use and documentation were identified in all inpatient units.

Association Between English Proficiency and Timing of Analgesia Administration After Surgery.

Pediatric patients from families with limited English proficiency (LEP) are at risk for health care disparities. We examined timeliness of analgesic administration in pediatric postoperative patients with a limb fracture from LEP versus non-LEP families. This was a retrospective cohort study of children aged 1 year to <18 years of age, hospitalized to the general inpatient floor after surgical correction of single limb fractures between July 2016 and July 2019 were eligible. Patients whose consent was in a non-English language or for whom an interpreter was used were classified as from LEP families. The primary outcome was time to first analgesia. Secondary outcomes included time to first opioid, proportion with any analgesia and opioid analgesia, and number of pain assessments. Associations between LEP and outcomes were tested by using χ2 tests, Kaplan-Meier plots, and Cox proportional hazards models. We examined 306 patients, of whom 59 (19%) were from LEP families. Children in LEP families were significantly less likely to receive any analgesia (86.4% vs 96.8%, P ≤ .01) and experienced longer time to first analgesia in unadjusted (hazard ratio = 0.68, 95% confidence interval: 0.50-0.92) and adjusted analyses (hazard ratio = 0.68, 95% confidence interval: 0.50-0.94). There was no significant association between LEP and time to first opioid, proportion given opioid analgesia, or number of pain assessments. Hospitalized children from LEP families experience a longer time to analgesia administration after surgery. The mechanisms that lead to these differences in care must be identified so that interventions can be designed to address them.

Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency.

Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%. Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish. During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months. Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

The Parent's Perspective: A Focus Group Study on Spanish Interpreter Services for Hospitalized Children

BackgroundThe US Census confirms a rise in Spanish-speakers, many of whom have limited English proficiency (LEP) and require interpreters. Parent perceptions of interpreter services throughout hospitalization are unknown. ObjectiveTo explore Spanish-speaking LEP parents’ views regarding roles of interpreters and providers (attending, resident, or nurse) during a hospital encounter, optimal modalities of interpretation, and barriers to services. MethodsSpanish-speaking LEP parents of children discharged from the hospital medicine service participated in focus groups. Sessions were audio-recorded and transcribed in Spanish, translated into English, and verified for translation accuracy. Qualitative methods were used for thematic analysis. ResultsFour sessions (n = 23 participants representing 15 families) were held. Parents felt the interpreter's primary role was to act as a conduit for word-for-word interpretation. They desired kind and trustworthy interpreters with medical knowledge. They saw providers as leaders of the encounter who should allot enough time for interpretation, not use Spanish unless they were fluent, and give frequent medical updates. In-person interpreters were preferred over telephone and video for their ability to convey body language and build relationships. Barriers to requesting interpreters included embarrassment and inability to directly request services, which resulted in using family members as interpreters. On family-centered rounds, parents preferred professional interpreters over bilingual providers. ConclusionsModifications are required to improve interpreter services to meet the needs of LEP families. Parents emphasized in-person interpreters’ social skills, frequent provider updates, and additional navigation support as essential components of effective care. Next steps include implementing guidelines and interventions to optimize interpreter services.

SAFER Care: Improving Caregiver Comprehension of Discharge Instructions.

One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.

PO504a / #1986: IMPROVING COMMUNICATION WITH LIMITED ENGLISH PROFICIENCY FAMILIES IN THE PICU

AIMS & OBJECTIVES: Children and families with Limited English Proficiency (LEP) have been reported to have worse healthcare outcomes as a result of communication barriers. The objective of this quality improvement study was to increase the frequency and quality of communication with LEP families in the PICU through improved access and functionality of video interpreters. METHODS: Interpretation data from our tertiary PICU were obtained and monitored starting in 2019. A key driver diagram was utilized to develop potential interventions. Multiple PDSA cycles were completed to evaluate interventions including providing written instructions on video interpreter use, obtaining new standardized video interpreter devices, designating standard locations and staff education around effective interpretation. Statistical process control was employed to analyze the number of interpretations per LEP patient per day based on hospital billing data. RESULTS: There were 82 encounters requiring interpretation during the study period, with an average of seven LEP families in the PICU on any given day. During the preimplementation phase (September-December 2019), LEP families received an average of 1.5 interpretations per patient day. After implementation (January-May 2020), LEP families received an average of 2.1 interpretations per patient day. CONCLUSIONS: Targeted efforts towards using interpretation services with LEP families can be an effective way to increase frequency of communication. Technology standardization alone did not increase interpreter use, however standardization along with improved accessibility correlated with an increase in interpreter use. This project was limited by a delay in data of interpretations due to billing processing, and disruption of overall patient census during the COVID19 pandemic.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency.

Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families. In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings. We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters. Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Patterns and Predictors of Professional Interpreter Use in the Pediatric Emergency Department.

Professional interpretation for patients with limited English proficiency remains underused. Understanding predictors of use is crucial for intervention. We sought to identify factors associated with professional interpreter use during pediatric emergency department (ED) visits. We video recorded ED visits for a subset of participants (n = 50; 20% of the total sample) in a randomized trial of telephone versus video interpretation for Spanish-speaking limited English proficiency families. Medical communication events were coded for duration, health professional type, interpreter (none, ad hoc, or professional), and content. With communication event as the unit of analysis, associations between professional interpreter use and assigned interpreter modality, health professional type, and communication content were assessed with multivariate random-effects logistic regression, clustered on the patient. We analyzed 312 communication events from 50 ED visits (28 telephone arm, 22 video arm). Professional interpretation was used for 36% of communications overall, most often for detailed histories (89%) and least often for procedures (11%) and medication administrations (8%). Speaker type, communication content, and duration were all significantly associated with professional interpreter use. Assignment to video interpretation was associated with significantly increased use of professional interpretation for communication with providers (adjusted odds ratio 2.7; 95% confidence interval: 1.1-7.0). Professional interpreter use was inconsistent over the course of an ED visit, even for patients enrolled in an interpretation study. Assignment to video rather than telephone interpretation led to greater use of professional interpretation among physicians and nurse practitioners but not nurses and other staff.

Health Care Provider Practices and Perceptions During Family-Centered Rounds With Limited English-Proficient Families.

To increase understanding of current practices and perceptions of family-centered rounds (FCR) by providers for limited English-proficient (LEP) families relative to English-proficient families. Using grounded theory methodology, we conducted ethnographic observations of FCR for LEP and English-proficient families on the pediatric wards at an urban teaching hospital. Focused coding of observation fieldnotes was performed independently, followed by regular group meetings to discuss discrepancies, refine codes, and identify theoretical direction. Data informed development of an interview guide used to conduct interviews with pediatric physicians, nurses, and interpreters. The iterative analysis process continued with interview transcriptions. FCR of 36 unique patient families were observed, of which 10 were LEP families. We conducted 20 interviews with 7 residents, 3 attendings, 5 nurses, and 5 interpreters. Major themes included: 1) standardization of FCR is needed to address equity issues for LEP families, 2) redefining the roles of medical interpreters would enhance the interpersonal interactions and relationships between families and health care providers, and 3) improving resources to allow interpreters to be used consistently will increase equity for LEP families. Many differences exist in FCR for LEP versus English-proficient families. FCR for LEP families may be optimized with standardization and training, redefining the interpreters' roles, and improving access to interpreters.

98. LOST IN TRANSLATION: SIMULTANEOUS SPANISH MEDICAL INTERPRETATION DURING FAMILY CENTERED ROUNDS FOR IMPROVED RESIDENT AND FAMILY ENGAGEMENT

Background Language barriers significantly contribute to medical errors compromising patient safety, quality of care, and resident engagement with patients. Spanish speakers account for the fastest growing population of patients within US pediatric hospitals. However, the communication needs of limited English proficiency (LEP) patients frequently remain unmet. PURPOSE: The purpose of this study is to implement equipment assisted simultaneous medical interpretation (EASMI) for Spanish speaking families on family centered bedside rounds (FCR) and determine family and trainee provider satisfaction. Methods In-person interpreters joined FCR at a tertiary care academic children's hospital. All medical discussion on FCR was interpreted simultaneously from English to Spanish. Interpreters wore a noise-cancelling microphone connected to a transmitter and family members were given a receiver with an earpiece. Qualitative interviews were performed with family members on their experience (N=25). Online qualitative and quantitative surveys were completed by medical students, residents, fellows, attendings, and nurses (N= 136). Results Surveys demonstrated 94% of physicians and 100% of nurses were “very satisfied” with EASMI. Common themes from the resident and fellow survey were improved efficiency of rounds, increased family engagement, improved understanding of the care plan, decreased communication errors and improving patient safety. After the intervention Spanish speaking families reported an increase in the domains of communication with physicians and nurses on the Child HCAHPS survey. Conclusion Medical interpretation for LEP patients and families is critical for improved healthcare and reduction in health disparities. Overall, EASMI is both an efficient and effective patient-centered intervention during pediatric FCR for increased trainee engagement with patients.

Deficiencies in Provider-Reported Interpreter Use in a Clinical Trial Comparing Telephonic and Video Interpretation in a Pediatric Emergency Department

Professional interpretation improves health care quality and outcomes for limited English proficient (LEP) patients, yet interpreter use remains low even when interpretation is available remotely. The researchers analyzed the effect of remote interpretation (telephone or video) on pediatric emergency provider attitudes and behaviors around professional interpretation. A cross-sectional questionnaire of pediatric emergency providers was conducted as part of a randomized trial of telephone vs. video interpretation with Spanish speaking LEP families. Providers recalled lapses of professional interpretation for medical communication (use of an ad hoc or no interpreter), if they had delayed or deferred communication due to the need for professional interpretation, and were asked about their satisfaction with the interpretation modality. Bivariate and multivariate analysis of professional interpreter use and communication behaviors were analyzed by self-report of study group assignment. One third of providers reported lapses of professional interpretation and many reported less frequent (45.6%) and deferred (34.6%) communication due to the need for interpretation. There was no significant difference in these outcomes between telephone and video assignment. Interpreter skill and technical difficulties were similar between groups. Providers assigned to telephone, compared to video, were more likely to be dissatisfied (p < 0.001) and to report that interpretation was ineffective (p = 0.002). Despite access to interpretation, providers caring for patients enrolled in a study of professional interpreter modalities reported frequent lapses in professional interpretation and deferring or delaying communication because an interpreter was needed. Addressing barriers to remote interpreter use will improve quality of care and health equity for LEP patients.

Sheltering in Place in a Xenophobic Climate: COVID-19 and Children in Immigrant Families.

* Abbreviations: CIF — : children in immigrant families COVID-19 — : coronavirus disease DACA — : Deferred Action for Childhood Arrivals ICE — : Immigration and Customs Enforcement LEP — : limited English proficiency SDH — : social determinant of health TPS — : temporary protected status WIC — : Women, Infants, and Children Program Like many health conditions that disproportionately impact vulnerable populations of color, we expect that the coronavirus disease (COVID-19) pandemic will inequitably affect the health and livelihoods of immigrant families. One in 4 children (>18 million) in the United States lives in an immigrant family, in which the child or ≥1 parent was born outside the United States.1 Among children in immigrant families (CIF), >7 million live in “mixed-status” families, meaning ≥1 parent is not a US citizen.2 Before the COVID-19 pandemic, immigrant families faced increasingly restrictive policies and discrimination. Regardless of legal status, CIF experience increased health and social risks compared with peers in nonimmigrant families, including lower rates of health insurance coverage and higher poverty levels.3 The COVID-19 pandemic amplifies existing inequities and introduces new ones as immigrant families navigate school closures, lack of health insurance and paid leave, and decisions to seek medical care or public services amid ongoing immigration enforcement. Additionally, immigrant families are more likely to live in multigenerational households,4 heightening the risk of COVID-19 for multiple family members. Families with limited English proficiency (LEP) must decipher rapidly evolving public health directives, such as “shelter-in-place” orders and recommendations for mask-wearing, without multilingual and culturally relevant messaging. Underlying these challenges is the implicit presumption of a safe place in shelter-in-place and social distancing directives. For immigrant families seeking safe haven in the United States, “place” may include violence and abject poverty, both in home countries and at the US border. For CIF in US communities coping with persistent fears of immigration enforcement and family separation, … Address correspondence to Rushina Cholera, Duke University School of Medicine, 200 Morris St, 3rd Floor, Durham, NC 27701. E-mail: rushina.cholera{at}duke.edu

The Effect of Limited-English Proficiency on Hematopoietic Stem Cell Transplantation Outcomes: A Retrospective Cohort Study of Hispanic Pediatric Transplant Patients at a Single Institution.

<h3>Background</h3> More than 25 million Americans have limited English proficiency (LEP) and are more likely than English-proficient (EP) patients to have poor health literacy, not understand their diagnosis, or experience complications from adverse drug effects. Hematopoietic stem cell transplantation (HSCT) is a potentially curative procedure for a variety of malignant and non-malignant diseases. However, HSCT requires prolonged hospitalization and excellent medication adherence to achieve good outcomes. Communication barriers between providers and LEP families of pediatric HSCT patients may further complicate this process and negatively affect clinical outcomes. <h3>Objectives</h3> The objectives of this study were to compare HSCT outcomes of Hispanic pediatric patients with LEP and EP families. Outcomes included overall survival, relapse, length of hospitalization, frequency of re-hospitalization and post-transplant complications including infections and graft-versus-host disease (GVHD). We hypothesized that LEP would be associated with worse outcomes. <h3>Methods</h3> We conducted a retrospective review of Hispanic or Latino pediatric patients receiving HSCT at Duke University from January 1, 2000 through March 15, 2019. Patients and families were identified as LEP or EP based on clinicians' notes, social work documentation or the signature of a Spanish interpreter on treatment consents. <h3>Results</h3> A total of 84 Hispanic/Latino patients were identified with 53 (63.1%) having LEP. There were no significant differences in age at transplant, sex, and race between these groups. Donor types, graft sources, and diagnoses were similar with the exception of more genetic diagnoses in the EP group (32%) than LEP (13%). The cumulative incidence of relapse, neutrophil engraftment, and acute GVHD were similar in both groups, as were the frequency of post-transplant infection and readmission. LEP patients were hospitalized on average 13 days longer than EP patients (Figure 1, p=0.06) and were more likely to have pre-transplant CMV reactivity (66%) than EP patients (30%, Figure 2, p=0.001). Overall survival was lower in LEP than EP but was not statistically significant (Figure 3). Multivariable Cox modeling suggested a potentially higher risk of death in LEP vs EP (hazard ratio=1.56, 95% CI: 0.38, 6.23). <h3>Conclusion</h3> Spanish-speaking patients with LEP undergoing HSCT may be at risk for prolonged hospitalization and are more likely to have pre-transplant CMV reactivity. These factors are known to be associated with post-transplant complications and death. Our results suggest LEP families are at higher risk for poor HSCT outcomes. Further study is warranted in a larger cohort.

Text Message Quality Improvement Project for Influenza Vaccine in a Low-Resource Largely Latino Pediatric Population.

Children with asthma are targeted for influenza vaccine because of their vulnerability to complications, particularly those with low income or family preference for Spanish language. We used text messaging to encourage caregivers to vaccinate. Participants were children (aged >6 months), predominantly low income and Latino, with an asthma diagnosis attending a pediatric clinic. Interactive text messages that described the vaccine and how to make an appointment were sent to parents in English or Spanish, January 2016 to April 2017. Year 1 messages were evaluated by the investigators considering vaccination results and evidence in the literature. Improvements for Year 2 included timing of message, clarity of message, and using the family language of preference. Messages went to 398 (Year 1) and 485 (Year 2) families. Sixty-four percent of families preferred English; 35% preferred Spanish. Children in Spanish-speaking families were significantly more likely than children in English-speaking families to be vaccinated, 66% versus 46%. Text messaging is a straightforward, low-cost health promotion strategy with potential to improve child health. Quality improvement efforts in outpatient settings with low-income and limited English proficiency families are needed. mHealth strategies may help address the needs of vulnerable populations. SQUIRE V.2.0 guidelines were used for manuscript writing and reporting.

Spanish Interpreter Services for the Hospitalized Pediatric Patient: Provider and Interpreter Perceptions

BackgroundMany Americans have limited English proficiency (LEP) and difficulty communicating with health care providers, creating inequitable health care delivery. Despite widespread interpreter availability in hospitals, perceptions of interpreter services in the pediatric inpatient setting are largely unknown. ObjectiveTo investigate staff perspectives regarding: 1) roles of the interpreter and provider (attending, resident, and nurse) during an encounter, 2) modalities of interpretation, and 3) barriers to services. MethodsFocus groups were conducted with: 1) hospital-employed Spanish interpreters, 2) Pediatric Hospital Medicine attendings, 3) pediatric and internal medicine-pediatric residents, and 4) medical unit nurses. Sessions were audio-recorded and transcribed. Using Atlas.ti, 2 investigators created the coding scheme, independently coded the data, and achieved consensus. Qualitative methods were used for thematic analysis. ResultsFourteen groups (n = 59 participants) were held: 3 interpreter groups (n = 10), 3 attending groups (n = 14), 2 resident groups (n = 17), and 6 nurse groups (n = 18). Most believed the interpreter's role was to serve as a conduit (provide word-for-word interpretation), act as a cultural broker, and maintain transparency (not withhold information). All groups felt providers should interact with families as they would with English-speaking families. In-person interpreters were preferred over telephone and video for being more accurate, efficient, and personable. Barriers to accessing services included time needed for interpretation, overconfidence in language skills, variable family dynamics, and identification of LEP families. ConclusionsIn-person interpreters are highly valued, fulfilling complex roles. However, operational and human factors limit access to services in the hospital. These findings, along with family perspectives, can be used to optimize interpretation experiences.

The Use and Impact of Professional Interpretation in a Pediatric Emergency Department

Background and ObjectivePatients with limited English proficiency (LEP) experience worse health care outcomes compared to English proficient (EP) patients, and professional interpretation is underutilized in clinical settings. The objectives of this study were to describe patterns of interpreter use in a pediatric emergency department (ED), to determine factors associated with its use, and to examine differences in outcomes between EP families and those with LEP. MethodsED encounters for LEP and EP patients were reviewed in a retrospective cohort study design over a 15 month period. Generalized estimating equations were used to compare patient encounters and factors associated with interpreter use. ResultsInterpreter use for families who preferred a non-English language was 45.4%. Use of interpretation was less likely during busier times of day (odds ratio [OR] 0.85, confidence interval [CI] 0.78–0.93), with a lower triage acuity (OR 0.66, CI 0.62–0.70), and with each increasing year of patient age (OR 0.97, CI 0.96–0.98). LEP patients who did not receive interpretation were less likely to be admitted than EP patients (OR 0.69, 0.62–0.78). Patients of LEP families, with or without interpretation, were more likely to be transferred to the ICU within 24 hours of admission than patients of EP families (OR 1.76, 1.07–2.90; 1.85, 1.08–3.18) suggesting that an aspect of clinical severity may have been missed in the ED. ConclusionsProfessional interpretation is currently underutilized in this ED for patients with LEP, and important differences in outcomes exist between LEP and EP patients. Factors associated with interpreter use will inform ongoing improvement efforts.