Eunice Lam
ELECTRONIC SUBMISSION
FOR CONSIDERATION IN THE
UNIVERSITY OF TORONTO MEDICAL JOURNAL
Title: Linguistic and cultural barriers to health care among Chinese patients at the
Toronto Western Hospital
Authors:
Eunice Lam*, BHSc 1
E.J. Heathcote, MBBS, MD, FRCP, FRCPC 2
Author affiliations:
1
Faculty of Medicine(1T2), University of Toronto
2
Toronto Western Hospital, University Health Network, University of Toronto
Correspondence:
Eunice Lam: eunicehy.lam@utoronto.ca
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Abstract
Objective: Patient satisfaction surveys are primarily conducted in English and thus
exclude respondents who cannot read or are not proficient in the English language.
This study used a language and culture-specific questionnaire to explore potential
barriers to health care among Chinese patients and to determine their satisfaction with
health care services received at their visit to the Toronto Western Hospital (TWH),
University Health Network.
Methods: A cross-sectional survey design was used. Patients were recruited from the
General Internal Medicine inpatient ward and Tuberculosis, Liver and Angiography
ambulatory care clinics at TWH. A questionnaire was administered by an interviewer to
patients who self-identified as Chinese. The interviewer administered the questionnaire
in English, Cantonese and Mandarin. The questionnaire explored three main topics
which included language barriers, cultural barriers and patient satisfaction.
Results: A total of 138 patients were approached to participate in the study over a six
week period. There was a 97.1% response rate. Of the 134 patients who participated
in the study, 52% reported having difficulty speaking English but only 25% of the
patients requiring translational help utilized the hospital’s interpretation services.
Barriers to health care identified by patients included: limited discussion of use of
Chinese medical therapies with physicians, difficulty understanding explanations
provided by physicians and nurses, and difficulty finding a hospital staff member who
could talk with them about their illness in their preferred language.
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Conclusion: Language and culture-specific questionnaires revealed barriers to health
care in patients with limited English proficiency. These barriers need to be addressed to
ensure delivery of quality health care in a culturally responsive manner. Specifically, the
issue of inadequate utilization of trained medical interpreters needs to be explored for
optimal planning of interpretation services at the hospital.
Keywords: Linguistic and cultural barriers to health care, Chinese patients,
professional interpretation services
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Introduction
Quality of health care can be negatively impacted when health care professionals do not
speak the same language as their patients or are insensitive to cultural differences, and
when patients do not understand instructions and explanations provided by physicians
and nurses. The impact of communication barriers and the co-existing cultural barriers
on the quality of patient care has been well documented in several studies. 1-3 The TWH
is located in Chinatown in Toronto, Ontario which is densely populated with immigrants
of Chinese descent. As a multi-cultural centre, it is especially important for the TWH
health care team to determine how to meet the needs of this diverse population and to
deliver services in a culturally responsive manner.
However, most patient satisfaction surveys are developed for a target population that is
English-proficient. Thus we are only aware of the perception of acute hospital and
ambulatory care among English speaking patients and know little about the non-English
speaking patient population at TWH. To address the need to provide culturally
appropriate services, language and culture-specific surveys investigating issues faced
by this particular subgroup is worthy of study.
This study used a questionnaire written in Chinese and English specifically designed for
Chinese patients to examine the issues they faced, and to determine whether this
patient subgroup was satisfied with the services provided to them. The findings of this
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study may contribute to the planning and development of a Multicultural Health Program
at TWH, particularly the need for hospital professional interpretation services.
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Method
Study Design: A cross-sectional observational study design was used. A cultural and
linguistic assessment questionnaire was developed and administered by an interviewer
to self-identified Chinese patients in the General Internal Medicine inpatient ward and
Tuberculosis, Liver, and Angiography ambulatory care clinics at TWH. The daily patient
rosters from the aforementioned wards and clinics were screened for potential Chinese
patients based on surnames. The researcher approached patients when they
registered for their appointments at the reception desk. Exclusion criteria included
patients under the age of 18 and those unable to communicate with the interviewer due
to physical or cognitive impairment. Of the 138 that were approached, 134 agreed to
participate. Eligible patients who agreed to participate were interviewed in their
preferred language (English, Cantonese or Mandarin). The questionnaire included 28
questions which covered three main topic areas: linguistic barriers, cultural barriers, and
patient satisfaction. The questions were derived from previous studies in Chinese
patients and using the UHN inpatient satisfaction survey developed by NRC Picker. 4,5
The final version was approved by the Multicultural Health Program Committee of TWH.
Data that was collected was tabulated in Microsoft Excel and analyzed using descriptive
statistics.
Results
The demographic characteristics of the participants are shown in Table 1. Patients
ranged in age from 19 to 98 and was a mean of 52.6 (SD 17.2) years. Fifty-five per
cent of the sample was male. Most respondents (78%) were recruited from the TWH
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Liver Clinic. Thirteen percent were recruited from the General Internal Medicine
inpatient ward, 2% from the Angiography clinic, and 7% from the Tuberculosis clinic.
Sixty-four percent of respondents identified Cantonese as their first language, 28%
Mandarin, 4% English, and 4% another language. Only 3% of respondents reported
being born in Canada. Seventy-seven percent had been living in Canada for more than
a decade.
Table 1. Characteristics of 134 self-identified Chinese patients at the Toronto Western
Hospital
Characteristics
Sex, male, no. (%)
74 (55)
Age, yr, mean (SD)
52.6 (17.2)
Place of birth, no. (%)
China
108 (81)
Vietnam
15 (11)
Others
7 (5)
Canada
4 (3)
First language, no. (%)
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Cantonese
84 (63)
Mandarin
38 (28)
English
5 (4)
Other Chinese dialect
4 (3)
Vietnamese
2 (1)
French
1 (1)
No. of years living in Canada (%)
<1
6 (4)
1-9
25 (19)
10-19
41 (31)
20-29
30 (22)
30-39
20 (15)
≥40
8 (6)
Life
4 (3)
When asked about language barriers, 52% admitted to having difficulty speaking
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English and 48% to having difficulty reading English. Only 25% of the patients who
needed linguistic help in communicating with their health care providers utilized the
hospital’s interpretation services. Overall, only 10% of all respondents used the hospital
interpretation services during their hospital stay or clinic visit, whereas 27% brought
along a family member or friend to help translate (see Figure 1). When asked about
cultural medical practice, Chinese medical therapies were used by 51% of the patients,
but only 45% of these users had discussed their use of alternative therapy with their
health care providers. With regards to patient satisfaction, 46% found it difficult to find a
hospital staff member to whom they could talk in their preferred language, and 11%
stated they did not receive answers they could understand from their health care
providers.
Figure 1.
Can't find translator
3%
Translator
10%
Family / friend
27%
Self
51%
Chinese speaking
staff
9%
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Discussion
These results provide insight into the issues faced by Chinese patients at the TWH. A
third of the respondents received information about their condition through family
members or social contacts (i.e. not directly from the health care team). This may lead
to communication of false information (e.g. withholding unpleasant news) and invasion
of patient privacy. Although this survey did not ask whether there were exchanges of
inaccurate information or whether the lack of professional interpreters led to poorer
medical decision-making, studies in the literature have shown that patients who are not
proficient in English have greater difficulty understanding instructions on how to take
their medications.6 These findings indicate the importance of providing an easily
accessible program which will allow all monolingual Chinese patients to have their
health issues translated to them directly by professional interpreters. The use of
hospital interpretation services may have a beneficial impact on the delivery of quality
health care. The role of such individuals who are trained to translate information in the
medical environment has been shown to provide benefits as a result of improved
communication (reduced errors and increased comprehension), utilization, clinical
outcomes and satisfaction with care.7 Despite the well acknowledged benefits of
professional interpretation services, the utilization by their target patients have not been
well examined. Even with an established professional interpretation service at TWH,
the challenges faced by Chinese patients remained since not all patients who claimed to
have limited English proficiency were receiving the interpretation services they needed.
This could be due to logistical reasons or personal choice. Further investigation is
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needed to explore why barriers to access a readily available service exist for Chinese
patients. Once these barriers are explored, programs may be developed to educate
ethnic communities about language access issues, thereby reducing the need to use
untrained translators, and finally to increase funding of professional interpreter services.
The limited communication regarding the use of Chinese medical therapies may
negatively affect patients’ health care. One study documented that almost one third of
current users of herbal medicines were at risk of a herb-drug interaction.8 The lack of
discussion regarding herbal use may promote the likelihood of an adverse event related
to herb-drug interactions. Trying to persuade a patient with strong cultural heritage to
change their medical regime and stop taking Chinese herbs may be difficult. 2 There is a
need when serving a diverse population to promote cultural competency when
delivering care.
This study suggested that linguistic and cultural issues impacted patient satisfaction
such as patients’ difficulties with finding a hospital staff member to talk to in their
preferred language, and the inabilities to communicate with full understanding with their
health care providers. The use of a language and culture-specific questionnaire was
helpful in eliciting the barriers to health care in patients with difficulty comprehending
English, whereas the use of standard hospital patient satisfaction questionnaires may
not be able to explore such findings. The results of this study shed light on the need to
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provide adequate services to Chinese speaking patients. Our findings will be used by
the Multicultural Health Program Committee at TWH to implement quality improvement
and patient safety initiatives directed at the culturally diverse patient population served
by the hospital.
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Acknowledgements
We are most grateful to Dr. Richard Reznick (Vice President of Education, UHN) at the
University of Toronto and to the administration department of the Toronto Western
Hospital for financially supporting Eunice Lam during the summer of 2009.
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References
1. Andrulis D. Reducing racial and ethnic disparities in disease management to
improve health outcomes. Dis Manag and Health Outcomes. 2003; 11:789-800.
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the perspectives of small group practitioners. J Gen Intern Med. 2007; 22:341-346.
3. Anderson LM, Scrimshaw SC, Fullilove MMT, Fielding JE, Normand J; Task Force
on Community Preventive Services. Culturally competent healthcare systems: a
systematic review. Am J Prev Med. 2003; 24:68-79.
4. Kwong K, Mak Agnes. Health care and cancer screening experience of Chinese
immigrants in New York City: a qualitative study. Soc Work in Health Care. 2009;
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5. Ma GX. Between two worlds: the use of traditional and Western health services by
Chinese immigrants. J of Community Health. 1999; 24; 421-437.
6. Andrulis D, Goodman N, Pryor C. What a difference an interpreter can make.
Boston: The Access Project. 2002.
7. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve
clinical care for patients with limited English proficiency? Health Serv Res. 2007;
42:727-754.
8. Dergal JM, Gold L, Laxer DA, Lee MSW, Binns MA, Lanctot KL, Freedman M,
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Rochon PA. Potential Interactions between herbal medicines and conventional drug
therapies used by older adults attending a memory clinic. Drugs & Aging. 2002;
19:879-886.
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Table Title
Table 1: Characteristics of 134 self-identified Chinese patients at the Toronto Western
Hospital
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Figure Caption
Figure 1: Result – Methods of translation used by self-identified Chinese patients at
the Toronto Western Hospital
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