Limited English Proficiency, Other Language Preference Associated With Increased COVID-19 Hospitalization Rates

Delayed time to first-dose vaccine in patients who had limited English proficiency (LEP) or had a language preference other than English (LPOE) was associated with increased rates of hospitalization and death from COVID-19, according to a study published in JAMA Network Open.

The authors noted that fundamental right of all people to communicate in their preferred language is encompassed in the concept of language justice. In the United States, 39% of the 65 million people who speak a language other than English at home have reported that they have LEP. Due to a lack of previous literature on the effect of linguistic disparities on COVID-19 vaccine uptake, this study aimed to evaluate COVID-19 vaccine uptake rates and the associated hospitalizations and deaths from December 15, 2020, to March 31, 2022, in a health care system in Minnesota and Wisconsin.

Data for this study came from patients who sought out care from a HealthPartners facility between January 1, 2019, and March 31, 2022. To be included, a patient had to have sought care in 2019 or 2020 and another time between December 15, 2020, and March 31, 2022. The patient also had to be 18 years or older on December 15, 2020. Electronic health records were used to obtain vaccination records.

Race and ethnicity, preferred language, country of birth, and need for interpreter were self-reported by all patients. American Indian or Alaskan Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Pacific Islander, White, and other were used to categorize race and ethnicity. All patients were asked what language they preferred to use when talking to a health care professional.

There were 851,410 participants in this study, 58.0% of whom were women and with a median (IQR) age of 29 (35-64) years. People who self-identified as Asian (20.3%), Black (8.7%), and Hispanic (21.0%) were the most common LEP groups who needed an interpreter. Spanish (27.0%), Somali (19.3%), and Vietnamese (10.3%) were the most common languages spoken outside of English.

A total of 19.3% of the participants never received a dose of the COVID-19 vaccine. Both the LPOE and LEP groups had a delay in vaccination, which led to more frequent hospitalizations and deaths across these groups.

Vaccine rates did not vary greatly by LPOE and LEP by the end of the observation period compared with the reference group (rate ratio [RR], 0.96; 95% CI, 0.95-0.96) but delayed uptake was more likely in patients reporting LPOE (HR, 0.83; 95% CI, 0.82-0.84) and LEP (HR, 0.81; 95% CI, 0.80-0.82). Patients in the LPOE group had nearly twice the risk of hospitalization (RR, 1.85; 95% CI, 1.63-2.08) and death (RR, 2.13; 95% CI, 1.65-2.69). Patients in the LEP group had a higher risk of hospitalization (RR, 1.98; 95% CI, 1.73-2.25) and death associated with COVID-19 (RR, 2.32; 95% CI, 1.79-2.95) compared with patients who did not need interpreters.

Black (HR, 0.71; 95% CI, 0.70-0.71), Hispanic (HR, 0.88; 95% CI, 0.87-0.89), Native American (HR, 0.92; 95% CI, 0.88-0.96), Native Hawaiian/Pacific Islander (HR, 0.94; 95% CI, 0.87-1.01), other (HR, 0.90; 95% CI, 0.88-0.92), and multiracial (HR, 0.97; 95% CI, 0.95-1.00) patients had delayed vaccine uptake. However, Asian patients had a faster vaccine uptake (HR, 1.22; 95% CI, 1.21-1.23).

Hospitalizations were higher in most groups compared with White patients: 2.6 times higher in Black patients, 2.1 times higher in Hispanic patients, 2.2 times higher for Native American patients, and 2 times higher in Native Hawaiian/Pacific Islander patients. Deaths had a similar pattern, with Asian, Black, and Hispanic patients all having 2 times higher risk of death, the multiracial patients having nearly 3 times higher risk, and Native American patients having a risk 4 times higher.

Languages also contributed to delays in vaccination uptake, with Eastern European languages associated with delayed uptake (HR, 0.43; 95% CI, 0.40-0.46), a decreased vaccination rate (RR, 0.68; 95% CI, 0.65-0.71), and increased hospitalization (RR, 2.76; 95% CI, 1.72-4.17) and death (RR, 3.51; 95% CI, 1.68-6.37). Similarly, patients who spoke Somali had delayed vaccination uptake (HR, 0.58; 95% CI, 0.57-0.60), a decreased vaccination rate (RR, 0.72; 95% CI, 0.71-0.74), and increased hospitalization (RR, 2.12; 95% CI, 1.60-2.75) and death (RR, 1.31; 95% CI, 0.52-2.67). Lastly, Spanish speakers had delayed vaccine uptake (HR, 0.85; 95% CI, 0.83-0.87), a decreased vaccination rate (RR, 0.97; 95% CI, 0.96-0.99), and increased hospitalization (RR, 1.99; 95% CI, 1.55-2.50) and death (RR, 1.87; 95% CI, 0.97-3.23).

In discussing the limitations, the study authors noted that Wisconsin death records could not be accessed and were therefore not represented. The results may not be generalizable to the entire US population. Certain groups were eligible for the vaccine before others, which could have affected the results. Finally, hospitalizations outside of the health system could have been undercounted.

The researchers concluded that LPOE and LEP groups had higher rates of COVID-19–associated hospitalization and death compared with the English-language reference group.

Reference

Quadri NS, Knowlton G, Vazquez Benitez G, et al. Evaluation of preferred language and timing of COVID-19 vaccine uptake and disease outcomes. JAMA Netw Open. 2023;6(4):e237877. Doi:10.1001/jamanetworkopen.2023.7877