Book announced at https://linguistlist.org/issues/35.1457

EDITOR: Glenn Martinez
EDITOR: Pilar Ortega
EDITOR: Maichou Lor
EDITOR: A. Susana Ramirez
TITLE: The Handbook of Language in Public Health and Healthcare
SERIES TITLE: Blackwell Handbooks in Linguistics
PUBLISHER: Wiley
YEAR: 2024

REVIEWER: Laura Callahan

SUMMARY

The Handbook of Language in Public Health and Healthcare brings together four editors and 49 contributors from various research, educational, and medical settings. The volume is divided into five sections, each with a brief introduction. Each of the 26 chapters has its own list of references. There is also a preface, glossary, and index.

Part I. Theory, History, and Context: Language in Public Health and Healthcare

In Chapter 1, “Are We Overlooking Language? An Applied Linguistics Perspective on the Role of Language as a Social Determinant of Health”, Stephanie Harsch and Maricel G. Santos advocate for an approach to health literacy that integrates consideration of social practice. They dissect six myths around language in healthcare, and criticize an over-reliance on English reading ability as a measure of people’s skills in navigating medical systems. Health literacy is socially situated and cannot be measured with simple print language assessments, which tend to be based on a monolingual norm.

In Chapter 2, “Sociolinguistics, Public Health, and Healthcare”, Dalia Magaña emphasizes the importance of using local language varieties and choosing communication styles and even metaphors that are consonant with cultural preferences and community values. Magaña contrasts the sociolinguistics of mobility—which privilege standard, translocal varieties—with “‘scaling down’ and prioritizing the local” (p. 31).

In Chapter 3, “A Critical Overview of Language Narratives: Sociolinguistic, Literary, and Graphic Perspectives”, Roxana Delbene introduces us to illness narratives, in particular “graphic pathographies” (Green & Myers 2010). Delbene traces the existence of medical narratives from their origins, noting a movement away from narratives focused on patient-as-subject to their current form focused on patient-as-agent.

In Chapter 4, “Anthropological Linguistics, Health, and Healthcare”, Milena A. Melo, Carla Pezzia, William J. Robertson, and K. Jill Fleuriet center the theory of bordering to examine three case studies.
The case studies focus on undocumented immigrant patients in Texas in dire need of dialysis, indigenous Maya in Guatemala suffering from alcoholism, “and LGBTQI+ patients at an anal cancer research clinic in Chicago” (p. 59). The authors find that attitudes toward which patients deserve care can influence the quality of that care.

In Chapter 5, “Applied Linguistics, Public Health, and Healthcare”, Holly E. Jacobson offers a review of studies from various disciplines that aim to eliminate patient/provider communication barriers. Earlier research comes from the fields of Communication, Public Health, and Psychology, and focuses on improving patients’ health literacy. Only later does Applied Linguistics enter the scene. One finding that might be expected but is nevertheless startling concerns resuscitation decisions.

Part II. Language Interpretation and Translation in Public Health and Healthcare

In Chapter 6, “Recognizing and Addressing Language Discordance” Allison Squires begins with a scenario of what it means to be unable to communicate directly with healthcare providers in one’s preferred language. A historical overview of language access legislation follows. Squires maintains that the lack of a common measure of translation quality affects the rigor and reliability of research studies in which survey instruments had to be translated.

In Chapter 7, “The Role of Healthcare Interpreters”, Elaine Hsieh traces the healthcare interpreter’s transformation from neutral conduit to active participant in patient-provider interactions (Loach 2019). Hsieh details the typologies and challenges of interpreter roles, including those of dual-role interpreters, e.g., a nurse who speaks the patient’s language (Chang et al. 2021). Hsieh also reviews the problems of using nonprofessional interpreters, including clinical consequences, but nevertheless finds that family member interpreters may have more value than previously believed.

In Chapter 8, “Healthcare Translation for Patients”, Wioleta Karwacka outlines various modes and criteria for judging translations. Karwacka notes that drug information often emphasizes risks rather than benefits; this is a problem even without language discordance. In a similar vein, confusing informed consent forms can lead to under enrollment of less represented populations in drug research trials, and this lack of representation exacerbates health disparities.

In Chapter 9, “Health Literacy and Plain Language”, Suad Ghaddar reviews health literacy initiatives, the role of plain language, and the relationship between health literacy and health outcomes. Ghaddar also addresses the issue of how to assess health literacy; a major impediment is the sheer number of models and measures of health literacy.

Part III. Language Concordance in Public Health and Healthcare

In Chapter 10, “Language Concordance in Clinical Care”, Alicia Fernández and Francine Ríos-Fetchko review work on language concordance as a factor in clinical outcomes and patient satisfaction. While the number of healthcare providers who speak a non-English language has risen, those languages are not always the same ones that patients need. Having an interpreter is not the same as having provider-patient concordance. Research indicates that “even high-quality medical interpretation does not provide patients as a group the same level of comprehension as language-concordant care does” (p. 182; italicized in the original).

In Chapter 11, “Language Concordance as Interactional Concordance in Multilingual Clinical Consultations”, Caroline H. Vickers and Ryan A. Goble focus on interactional achievement. For example, do providers orient to topics raised by patients, align to information presented by patients, and follow patients’ cues to translanguage? This chapter includes three transcriptions of provider-patient consultations, two in which there is alignment and one in which there is not. Interestingly, in the consultation lacking alignment, the provider and patient are both native speakers of Spanish.

In Chapter 12, “Assessing Clinician Language Skills”, Ute Knoch and Jason Fan continue with the issue of how to assess healthcare providers’ language proficiency, and specifically how to assess their language skills for the professional setting. This differs from the more general assessments that might be given at the end of a typical college language course. Language assessments for professional purposes are most available for English.

In Chapter 13, “Setting Standards for Clinician Language Use in Patient Care”, John D. Cowden makes the case for treating the use of non-dominant languages by medical providers the same way that English skills are measured and regulated as part of the professional certification for clinicians who were educated in country in which English is not the dominant language. Cowden argues that “[a]pplying regulatory and professional standards only to dominant language proficiency among healthcare professionals creates a two-tiered system, where some patients (i.e., dominant language speakers) are treated to a different level of communication competence than others (i.e., speakers of nondominant languages)” (p. 233).

In Chapter 14, “Current Gaps and Future Directions in Language Concordance Research and Policy”, George S. Corpuz, David A. Chirikian, and Lisa C. Diamond highlight an issue raised in several of the preceding chapters in this volume, the lack of consensus on what it means to be proficient: “Research in language concordance must coalesce around a common definition and measure for language proficiency so that findings from studies across various fields can be compared” (p. 272). The authors also emphasize the importance of considering not just the physician but rather the entire team of people with whom patients interact in the healthcare system, from the person who schedules appointments to interpreters to nurses.

Part IV. Pedagogy of Medical Language Education

In Chapter 15, “Second Language Acquisition for Healthcare Purposes”, Karol J. Hardin offers a review of second language acquisition (SLA) theories and pedagogical practices in language instruction over the years, followed by an exposé of the current state of teaching language for healthcare purposes (LHP) in the United States. A key recommendation is that “[l]anguage for healthcare courses […] target intermediate proficiency or higher, focus on oral/aural interaction with patients and cross-cultural communication, and emphasize conversation over memorizing lists of vocabulary” (p. 298).

In Chapter 16, “Centering Translanguaging for Inclusive Health Communication: Implications for Healthcare Professional Education”, Josh Prada and Robin Woodward-Kron call for curricular innovations that center the expertise and lived experience of heritage speakers and local community members, as a part of Value-Added Medical Education (VAME). Prada and Woodward-Kron state that “[f]or us, the education of healthcare professionals must incorporate spaces for critical reflection about the life histories, historical formations, and linguistic and cultural practices of the populations they serve” (pp. 313-314).

In Chapter 17, “Dedicated Medical Spanish Courses and Crosslinguistic Healthcare Communication Skills”, Marco A. Alemán and Alejandra Zapién-Hidalgo note the inconsistencies in medical Spanish program evaluation. This chapter offers detailed practical suggestions for such courses, including the use of trained actors in role-play scenarios “to expose medical Spanish learners to cultural issues affecting Spanish-speaking populations” (p. 338).

In Chapter 18, “Medical Language Programs to Enhance Engagement with Diverse Communities in the United States and Around the World”, Rose L. Molina and Jennifer Kasper present a case study of the Medical Language Program at HMS (Harvard Medical School). Its global health focus means that students can apply their language skills in other countries. The authors discuss steps taken to avoid the reproduction of colonial structures and to elevate the authority of local personnel and perspectives, and to do so in the local language.

In Chapter 19, “Clinical Communication Skills Training in Minoritized Languages”, Carmen Pérez-Muñoz and Tiffany M. Shinn note the place of medical Spanish courses in Language for Specific Purposes (LSP), but warn that it does not suffice to model medical Spanish courses after English for Specific Purposes (ESP) (Trace et al. 2015, cited on p. 369).

In Chapter 20, “Faculty Development in Medical Language Education”, Mónica B. Vela and Adriana C. Black Morocoima urge the training of medical school faculty in health equity, and denounce the power imbalances that allow the persistence of “poorer standards of care for linguistically diverse populations” (p. 388). Vela and Black Morocoima advocate for seeking more medical students and healthcare workers who have intersecting, minoritized identities.

Part V. Mass Communication and Health: Theory, Research, and Applications with and for Linguistically Diverse Populations

In Chapter 21, “Mass Media and Health Research in, with, and for Linguistically Diverse Populations”, Katharine J. Head and Katherine E. Ridley-Merriweather delve into research methodologies and theoretical frameworks used to study mass media and its effects on health behaviors. Of particular note is the shift to messages that ordinary individuals can both create and disseminate to mass audiences. This contrasts with just a couple of decades ago, when authorship would have been limited to governmental or commercial entities.

In Chapter 22, “Health Information Seeking among Linguistically Diverse Populations in the United States”, Christine Swoboda, Priti Singh, A. Susana Ramírez, and Naleef Fareed discuss intersecting factors that can hinder linguistic minorities’ access to useful health information. Such factors include general mistrust, lack of accurate and comprehensible information in the non-English language, and barriers to accessing online information. This latter has become especially acute with the increase in insurance and healthcare system information being available exclusively online.

In Chapter 23, “Entertainment-Education as Linguistic Duality in Practice”, Suruchi Sood and Rachael HaileSelasse present numerous examples of entertainment designed to educate, appearing in various media. Television, posters, and social media—in local languages around the world—are some of the channels through which campaigns have been made to influence behaviors. These public education efforts often deal with culturally stigmatized topics. Sood and Rachael HaileSelasse argue that using linguistic features from local languages can increase the effectiveness of the message.

In Chapter 24, “Graphic Medicine and Visual Communication Techniques for Public Health and Healthcare in Linguistically Diverse Settings”, MK Czerwiec, Q. Jane Zhao, Isa Álvarez, and Pilar Ortega trace the history of graphic medicine and the humanization of medicine. Graphic medicine has obvious applications for patient and public education, especially when images may compensate where not every viewer’s language can be included. But graphic medicine also has valuable applications for medical students and practitioners, such as to develop empathy and to foster self-care.

In Chapter 25, “Social Media and Health in Linguistically Diverse Communities: An Examination of Overlooked Populations and Understudied Platforms”, Anna Gaysynsky, Kathryn Heley, and Wen-Ying Sylvia Chou highlight successes in communicating with hard-to-reach populations using various social media platforms. The authors acknowledge the social media dangers of mis- or disinformation and of hate speech and discriminatory language, due to “inadequate moderation efforts in languages other than English” (p. 505).

In Chapter 26, “Urgent Communication During Public Health Crises: Reaching Linguistically Diverse Populations”, Victoria Ledford, A. Susana Ramírez, and Xiaoli Nan focus on the COVID-19 pandemic and the successes and failures of public health messaging during this time. In addition, the chapter explains the application of communication and behavior theories to public health campaigns, and how to tailor such campaigns for specific populations.

EVALUATION

The Handbook of Language in Public Health and Healthcare is a well-edited and comprehensive contribution to multiple disciplines. It will be of interest to students, scholars, practitioners, and administrators in medicine, public health, communication, and applied linguistics.

The book’s organization adds to its effectiveness. Individual chapters end with a list of highlights, helpful for returning readers to refresh their memory. There is ample repetition of key information across chapters within each of the five sections, and across the volume as a whole. Thus, later chapters reinforce concepts from earlier ones, which helps maintain cohesiveness in this 26-chapter collection. This also makes each chapter comprehensive enough to read alone.

A very minor criticism would be the occasional overuse of abbreviations for the names of concepts, theories, or disciplines. Using the full form might add a little to the total word count, but would save readers the distraction of having to refer back to previous pages in a chapter. As an alternative, a future edition could include a list of abbreviations for the entire volume. This would help users who may not always read pages in a strictly linear fashion.

Topics of particular interest to applied linguists and language educators include plain language, proficiency levels and measures, and medical language courses and curricula.

On the topic of plain language, while some authors in this volume advocate for its use (e.g., Chapters 2, 8, 9), others view it more as a tool whose usefulness is unproven (Chapter 5), and/or even problematic (e.g., Chapter 1). While the use of plain language to facilitate comprehension might seem at first to be a matter of social justice, Harsch and Santos (Chapter 1) argue that this strategy can have the opposite result. Plain language may help solve an immediate, surface level problem but at the same time obscure a structural issue. Harsch and Santos advocate instead for empowering people to develop critical health literacy (HL), “[…] to express their healthcare needs and desires and to advocate for themselves” (p. 15). These authors continue, “[a]s applied linguists, we would like to see more research and interventions that link linguistic simplifications to patient empowerment outcomes, not only indicators of patient compliance (e.g., following instructions, accepting medical advice) typically reflected [in] functional HL definitions” (p. 15).

Healthcare providers’ proficiency in the languages spoken by their patients is an issue of great relevance, although there are varied opinions on the level of linguistic abilities required and on what assessment practices are adequate. Fernández & Ríos-Fetchko (Chapter 10) discuss the pros and cons of self-reporting proficiency versus formal testing. Self-reporting can be fairly accurate for distinguishing between providers who have little to no ability and those who are highly proficient, but is much less reliable when it comes to the broad range of skills that characterize the intermediate level.

Providers may report the ability to speak another language, but their estimations of personal fluency may be unreliable. Fernández and Ríos-Fetchko (Chapter 10) explain why this matters:
“For example, someone who speaks fluent conversational Spanish, learned at home or in school, may not have the medical vocabulary required to say ‘your spleen is swollen,’ as they do not know the words for either spleen or swelling. Conversely, someone who knows the words for spleen or swelling because they learned a list of vocabulary may not necessarily have the Spanish language level to spontaneously produce an explanation about what the medical terms mean, why it is significant to the patient’s health, and what the next steps in treatment are” (p. 180).

A recommendation that arises more than once in this volume is that medical Spanish courses be aimed at intermediate and advanced level learners (e.g., Chapters 15, 16), as this level of proficiency is needed to communicate with patients. Molina and Kasper (Chapter 18) however, defend offering some courses at the beginner level; they cite the proficiency gains students in these courses can achieve, as well as the demand for courses to prepare students for an intermediate level course. Pérez-Muñoz and Shinn (Chapter 19) suggest offering beginning level courses for clinicians to learn greetings and informal conversation skills, to build rapport and trust with patients. These authors, as do others in this volume, also recommend giving training on how to work with professional interpreters, and caution that “students must understand that calling in an interpreter should not be viewed as a failure” (p. 375).

A call for standardized curricula is a common refrain in education, and the field of medical language education is no exception. While standardization might be optimal for the purposes of conducting research in this area, to have every program to follow the same curriculum is not necessarily the best option for programs, students, or patients. Rather, as Pérez-Muñoz and Shinn (Chapter 19) state “[f]rom curriculum design to teaching tools and methods of evaluation, LSP [Language for Specific Purposes] courses must be intentional in content, learning objectives, teaching methodologies, and student assessments” (p. 370). Intentional is not the same as standardized, and as these same authors later affirm, “[t]here is not a ‘one size fits all’ approach to medical language education; courses and programs must be tailored to the specific level, institution, and context in which they take place” (p. 383).

Pérez-Muñoz and Shinn (Chapter 19) give recommendations for specific types of programs: from undergraduate programs, graduate programs in healthcare, medical school programs, resident physician training programs, programs for physicians-in-practice, to programs for non-physician healthcare professionals. Each program can focus on particular needs of its students. The first type of program, general undergraduate, has broad ramifications. This is because many Modern/World Language departments at U.S. universities are currently looking to develop medical Spanish and other LSP courses to counter dwindling enrollments. Indeed, at some institutions the very survival of such departments is at stake (e.g., Bauer-Wolf 2023; West Virginia University). Hardin (Chapter 15) makes the important point that since medical students have very little time to spend on language acquisition once they are in medical school, there should be more emphasis on learning languages earlier in their academic careers.

Finally, another issue of perennial importance to language educators is how to help students acquire cultural competence. The definition of cultural competence has evolved over the years, and the term cultural humility is becoming more and more frequent instead. Contributors to this volume make some salient observations. For example, Alemán and Zapién-Hidalgo (Chapter 17) state that “[s]tudents must learn that culture is complex and dynamic, affects all people, does not determine behavior and cannot be distilled into a body of traits that is used as a checklist, implied by the term cultural competence (Hunt 2019)” (p. 337). Pérez-Muñoz and Shinn (Chapter 19) also recommend teaching cultural humility, making the important point that “[i]nstructors may have difficulties selecting cultural content while avoiding stereotyping patients given the many cultures, traditions, and perspectives that often reside within a single language” (p. 371).

REFERENCES

Bauer-Wolf, Jeremy. 2023. West Virginia University no longer plans to completely eliminate world languages. Higher Ed Dive. 29 August.

Chang, Heesun, Claire Hutchinson, and Janice Gullick. 2021. Pulled away: The experience of bilingual nurses as ad hoc interpreters in the emergency department. Ethnicity and Health. 27(7). 1045-1064.

Green, Michael J. & Kimberly R. Meyers. 2010. Graphic medicine: Use of comics in medical education and patient care. BMJ. 340. 574-577.
Hunt, Linda M. 2019. Beyond cultural competence: Applying humility to clinical settings. In The Social Medicine Reader, Volume II, Third Edition, eds. J. Oberlander, M. Buchbinder, L.R. Churchill, S.E. Estroff, N.M.P. King, B.F. Saunders, R.P. Strauss & R.L. Walker. 127-131. Durham, North Carolina: Duke University Press.

Loach, Barbara L. 2019. A time to speak and a time to keep silent: Professional ethics, conscience, and the medical interpreter. Ethics, Medicine, Public Health. 11. 52-59.

Trace, Jonathan, Thom Hudson, & James Dean Brown. 2015. An overview of Language for Specific Purposes. In Developing Courses in Language for Specific Purposes, eds. J. Trace, T. Hudson & J.D. Brown. 1-22. University of Hawaii at Manoa: National Foreign Language Resource Center.

ABOUT THE REVIEWER

Laura Callahan has taught courses in Spanish language and linguistics in California, Michigan, and New York, at Ohlone and Mission Colleges, San José State University, Santa Clara University, the University of California at Berkeley, Michigan State University, and the City College and Graduate Center of the City University of New York. Her principal area of research has been Spanish in the United States. Her publications include work on code switching, intercultural communication, heritage language maintenance, and linguistic landscapes. Prior to her academic career she worked in food service and healthcare, where she served as an ad hoc and dual role interpreter.