A recent study published in Health Affairs Scholar revealed significant challenges for Spanish speakers trying to access in-person or telehealth-based mental health services at California safety net clinics.
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 stated that they were Medicaid beneficiaries seeking medication for depression.
Among the findings:
- Nearly one in five of the Spanish-speaking callers spoke to someone who hung up on them or told them no one could help them in Spanish — even though an estimated 28.8% of California residents speak Spanish at home, and some 50% of clinicians at those offices spoke Spanish.
- English-speaking callers were more likely to talk to a live scheduler and get appointment information in their preferred language.
- The Spanish-speaking callers were much more likely to be on hold for five or more minutes.
- Spanish speakers were more likely than English speakers to be asked if they had insurance.
Like millions of other people who aren’t proficient in English, Spanish-speaking patients who don’t speak or read the language well face numerous barriers in navigating the health care system, the authors said. These barriers include receiving fewer health care services, having greater unmet mental health needs and receiving poorer quality care. Disparities can be exacerbated when patients with limited English skills can’t get seen by clinicians who speak their language, don’t have the assistance of qualified interpreters to communicate with doctors, nurses or intake staff or don’t get discharge papers and educational materials in their preferred language.
The study’s findings suggest that language-based discrimination may have serious implications on the mental health of Hispanic Americans. This is partly because it’s a population that is younger than the non-Hispanic white and Black populations but is aging faster, census data shows. Among the 39.7 million who speak Spanish, more than 9 million don’t speak English well or not at all, census data also shows.
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 much less likely to have received mental health services. CDC data shows that age-adjusted suicide rates increased between 2000 and 2020 for non-Hispanic Black and Hispanic people but declined for non-Hispanic white people for that same period.
‘Heterogeneous’ experiences for a study caller
During the study, which was conducted earlier this year, callers asked if they could make an appointment as a new patient to get medication treatment for depression. Each clinic was called by two different callers in Spanish and English within a 14-day period. Study coauthor Samantha Pérez-Dávila, Ph.D., a fellow at RAND and one of the Spanish-speaking callers, told AHCJ her experience was “very heterogeneous.”
“I had very good experiences where right away the receptionist spoke Spanish and she was able to give me information,” she said. But she also experienced some unique challenges. For example, Pérez-Dávila sometimes got a phone tree menu that didn’t provide an option in Spanish. At times, even if the phone tree did provide options in Spanish, an English-speaking receptionist would answer the call. Her experiences with Spanish speakers also ranged from native speakers to less confident speakers, and in some cases, she was hung up on.
Some clinics linked her with an interpreter, but she could tell the translation was not quite accurate. Other clinics transferred her to a clinic staff member who spoke Spanish but didn’t know about scheduling. And in one case, a receptionist linked her with an interpreter then disconnected, leaving Pérez-Dávila speaking with just the interpreter. When she called back, 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 brings up questions about how federal and state agencies ensure that clinics receiving taxpayer money are complying 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 of the RAND study hinted at that and said that “more attention and resources are needed to support patients with limited English proficiency at the critical point of scheduling.”
Of 239 clinics where callers were able to reach a scheduler in one or both languages, 90% of English speakers spoke with a live scheduler compared with 72% of Spanish speakers. English speakers also were more likely to reach a point in the scheduling process where they could obtain appointment information in their preferred language — a difference of 62% vs 41% for Spanish speakers.
And 42% of Spanish speakers who spoke with a scheduler reached someone who would not engage with them because of lack of language assistance (such as being hung up on or told no one on staff could speak with them in Spanish), whereas English speakers did not experience these issues.
What clinics can do
To reduce inequities in access to behavioral health care for patients with limited English proficiency, RAND study authors said health care organizations should:
- Implement and encourage the use of online scheduling systems designed to meet the digital and linguistic needs of patients. These efforts could be supplemented with interpretation or care navigation services at the county, regional or state level.
- Prioritize hiring bilingual staff in key positions such as receptionists and schedulers and promote high-quality medical language courses in areas with large populations of Spanish speakers.
- Include interpreters in scheduling discussions and improve workflow training.
Reporting ideas for journalists
Journalists looking to cover these issues might look into hiring challenges on the part of providers, Pérez-Dávila suggested. “There may be a demand problem with having bilingual receptionists, right now. Some of these clinics are very small, but they are also located in areas where the Hispanic population is high,” she said.
It might also be interesting to look at interpretation services and how clinics incorporate those services into workflows or vet services to ensure accuracy and confidentiality of protected health information. Some clinics told Pérez-Dávila they didn’t have a Spanish-speaking clinician on staff, so they would have a nurse or other bilingual staff member sit in on the appointment to translate. Or they recommended bringing an English-speaking relative – both of which bring up additional privacy concerns. That also raises questions about contract requirements, specifically whether federally funded clinics have to provide remote interpreting services in languages other than English. Clinics and federal agencies should provide those documents.
Reporters writing about mental health services offered in Spanish (or languages other than English) may also want to add context about trends in telehealth use. While many studies and reports about telehealth use break-down trends by race and ethnicity and not preferred language, they provide context applicable in stories about remote mental health services. Furthermore, 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 get their health care in a language other than English.
