In 1990 more than 10% of women in Ontario spoke a language other than English at home. Our study demonstrates that these women were less likely to receive important preventive services than women who spoke English at home.
Use of a language other than English may be related to the receipt of preventive services in four ways: (1) as a proxy for insurance status1
or for low socioeconomic status,5
a factor known to be related to less use of screening 6,7
even in the Canadian system13
; (2) as a barrier to contact with the health care system; (3) as a marker for culture differences about the value of screening; or (4) as a communication barrier.
In this study we attempted to isolate the communication aspect of language by adjusting for characteristics reflecting the first three possibilities. In our sample, English speakers had higher income and educational attainment, attributes that, consistent with previous work,5
were associated with increased use of preventive services. However, in our analysis, socioeconomic characteristics did not explain the association between language and use of preventive services. No relation was observed between language and contact with the health care system. Physician contact was high, most likely reflecting Canada’s policy of universal insurance. Thus, although doctor visits were independently related to receipt of preventive services, it is not surprising that controlling for physician visits did not change the effect of language. Finally, although language was related to both self-reported ethnicity and years in Canada, an important independent relation between language and use of preventive services persisted even after adding measures of cultural identification to the model.
The persistent association of language with the preventive services after adjusting for the aforementioned characteristics suggests that the language effect is attributable to a communication barrier. Although there is evidence that beliefs specific to certain ethnic groups (e.g., fatalismo
among certain Hispanic groups14
) may affect how health care is utilized, communication about the benefits or importance of screening has also been shown to be strongly related to patient compliance with screening recommendations.15,16
In the one study examining cervical cancer screening among Hispanics, most of the reasons cited for noncompliance with Pap testing related to poor provider communication.15
Similarly, Fox and Stein found that the strongest predictor of mammogram use was whether or not the doctor discussed mammography with the patient.17
Spanish-speaking women were significantly less likely to report that the doctor had discussed mammography.
Several aspects of our study merit comment. First, it is reasonable to question the validity of the variables used to measure culture. Self-reported ethnicity and immigration status are only proxies for cultural identification, and failure to adequately measure culture may limit our findings. It could be argued, for example, that language is a more powerful marker of cultural differences than either ethnic identification or immigration status, and that our results simply reflect greater accuracy in identifying the most “culturally” different women in Ontario (i.e., the least acculturated). Such an argument assumes that “less acculturated” uniformly means less interest in prevention. We are unaware of any empirical data to support this assumption. To the contrary, Fox and Stein found that regardless of spoken language, women were equally interested in mammography once the provider discussed the issue.17
It seems more likely that language measures what it implies—communication. Further research is needed, however, to understand when differences in health behaviors are informed (i.e., reflect real differences in values) or are the result of ineffective communication.
Next, we have no information about the extent to which patients and providers shared a common language. Ontario is a predominantly English-speaking province, and most doctors are primary English speakers. If patients and providers are sufficiently fluent in a common language, then language will not be a barrier to communication. Patients, however, may be fluent in English, despite speaking another language at home—or, some doctors may be fluent in languages other than English. Finally, the Ontario Health Survey excluded fully non-English-speaking or non-French-speaking households. About 2.4% of eligible households were excluded on the basis of a language barrier. The excluded households represent the most linguistically isolated persons, a group that is most likely to suffer the consequences of language barriers. Both the extent to which patients and providers shared a common language (i.e., unmeasured language concordance) and the exclusion of the most linguistically isolated persons would tend to minimize differences between language groups—the observed effect would underestimate the true effect.
In conclusion, women in this study who spoke a language other than English at home were less likely to receive important preventive services. The effect of language persisted after adjusting for variables reflecting socioeconomic factors, contact with the health care system, and culture, suggesting that observed differences across language groups may be attributable to a communication barrier. Improving communication with such patients may enhance participation in preventive health programs. Because most other health care involves issues at least as complex, they too are likely to be susceptible to the effects of communication barriers.
Our data suggest that those who live in developed, English-speaking countries, and who speak a language other than English at home may not receive the same level of care as persons speaking English. As ethnic minority populations grow in these countries, the number of persons with limited English will expand. In the United States, 32 million people speak a language other than English at home.18
Although communication barriers are remediable,19
solutions such as effective interpreter services may be costly. Recent work suggests that simply providing untrained interpreters may do little to improve communication.20
Making rational decisions about how to improve services to minority-language speakers will require understanding the public health costs of communication barriers.