A recent study published in the journal Health Affairs Scholar revealed significant challenges faced by Spanish speakers trying to access in-person or telehealth-based mental health services at safety-net clinics in California.
In a secret shopper-type study, researchers from the nonprofit RAND Corporation posed as English- or Spanish-speaking patients and contacted 386 safety-net clinics in California. They reported that they were Medicaid beneficiaries seeking treatment for depression.
Among the results:
- Nearly one in five Spanish-speaking callers have spoken to someone who hung up on them or told them that no one could help them in Spanish — even though an estimated 28.8% of Californians speak Spanish at home, and about 50% of doctors in Home those offices speak Spanish.
- English-speaking callers were more likely to speak with the live scheduler and receive appointment information in their preferred language.
- Spanish-speaking callers were more likely to be on hold for five minutes or more.
- Spanish speakers were more likely to be asked whether they had insurance.
Spanish-speaking patients, who do not speak or read the language well, like millions of other people who are not proficient in English, face many barriers in navigating the health care system, the researchers said. These barriers include access to fewer health care services, increased unmet mental health needs, and receiving lower quality care. Disparities can be exacerbated when doctors who speak their language are unable to see patients with limited English skills, do not receive assistance from qualified interpreters to communicate with doctors, nurses or reception staff, or do not receive discharge papers and educational materials in their preferred language.
The study results suggest that discrimination based on language may have serious effects on the mental health of Hispanic Americans. That’s partly because the population is younger than that of non-Hispanic whites and blacks, but they are aging faster, Census data show. Of the 39.7 million people who speak Spanish, more than 9 million do not speak English well or at all, according to census data.
According to results from the 2021 National Survey on Drug Use and Health (NSDUH), Hispanic and Latino Americans were almost as likely as non-Hispanic white people to say they had a mental illness but were less likely to receive mental health services. CDC data show that age-adjusted suicide rates increased between 2000 and 2020 for black and non-Hispanic white people but decreased for non-Hispanic white people in the same period.
“Heterogeneous” experiences of the study contact
During the study, conducted earlier this year, callers asked if they could make an appointment as a new patient for drug treatment for depression. Each clinic was contacted by different callers in Spanish and English over a 14-day period. Her experience was “very heterogeneous,” study co-author Samantha Pérez Davila, Ph.D., a fellow at the RAND Corporation and one of the Spanish-speaking callers, told AHCJ.
“I’ve had very good experiences where the receptionist spoke right away in Spanish and was able to give me information,” she said. But she also faced some unique challenges. For example, Pérez-Dávila sometimes had a phone tree menu that did not provide a Spanish language option. Sometimes, even if the phone tree offers Spanish-language options, an English-speaking receptionist will answer the call. Her experiences with Spanish speakers also ranged from native speakers to less confident speakers and, in some cases, were suspended.
Some clinics connected her with an interpreter, but realized the translation wasn’t entirely accurate. Other clinics transferred her to a clinic employee who spoke Spanish but knew nothing about the schedule. In one case, the receptionist connected her with a translator and then the connection was cut off, leaving Pérez Davila speaking only with the translator. When I called again, the same thing happened.
While the study was conducted in California, it raises questions about the availability of Spanish-language psychotherapy and psychiatric care services in other states with large Hispanic populations. It also raises questions about how federal and state agencies ensure that clinics receiving taxpayer money comply with language access mandates under Title VI of the Civil Rights Act of 1964, Section 1557 of the Patient Protection and Affordable Care Act and state laws. The researchers in the RAND study alluded to this and said that “more attention and resources are needed to support patients with limited English proficiency in the critical phase of scheduling.”
Of the 239 clinics where callers had access to scheduling software in one or both languages, 90% of English speakers spoke using live scheduling software compared with 72% of Spanish speakers. English speakers were also more likely to reach a point in the scheduling process where they could get appointment information in their preferred language — a difference of 62% versus 41% for Spanish speakers.
And 42% of Spanish speakers who spoke with a scheduler reached out to someone not engaging with them due to a lack of language assistance (such as hanging up on the call or being told that no staff could speak to them in Spanish), while English speakers who did not experience this Issues.
What clinics can do
To reduce inequalities in access to behavioral health care for patients with limited English proficiency, the authors of the RAND study said health care organizations should:
- Implement and encourage the use of online scheduling systems designed to meet the digital and language needs of patients. These efforts can be supplemented with interpretation or care services at the county, district, or state level.
- Prioritize hiring bilingual staff in key positions such as receptionists and appointment organizers and promote high-quality medical language courses in areas with large numbers of Spanish speakers.
- Include interpreters in scheduling discussions and improving workflow training.
Providing ideas to journalists
Pérez Davila suggested that journalists looking to cover these issues might consider staffing challenges on the part of service providers. “There may be a demand issue with bilingual receptionists, right now. Some of these clinics are very small, but they are also located in areas with a large Hispanic population,” she said.
It may also be interesting to look at interpretation services and how clinics integrate these services into their workflow or veterinary services to ensure the accuracy and confidentiality of protected health information. Some clinics told Pérez Davila they don’t have a Spanish-speaking doctor on staff, so they’ll have a nurse or other bilingual staff attend the appointment to translate. Or they recommended bringing an English-speaking relative — both of which raise additional privacy concerns. This also raises questions about the requirements of the contract, specifically whether federally funded clinics are required to provide remote interpreting services in languages other than English. Clinics and federal agencies must provide that documentation.
Reporters writing about mental health services provided in Spanish (or in languages other than English) may want to add context about trends in telehealth use. While many studies and reports on telehealth use detailed trends by race and ethnicity and not preferred language, they provide applicable context in stories related to telemental health services. Moreover, the access problem faced by Spanish speakers may extend to the millions of Americans who speak Haitian Creole, Chinese, and other languages at home and may prefer to receive health care in a language other than English.
Language is a powerful tool that can either bridge barriers or create obstacles. A recent study has shed light on the fact that discrimination based on language can significantly limit access to mental health services. This revelation has important implications for the well-being of individuals who are not proficient in the dominant language of their community, as it suggests that they may face unnecessary challenges in seeking and receiving the care they need. In this essay, we will delve into the findings of this study and explore the implications of language-based discrimination on mental health access.