Mental Health Care Challenges and Barriers for Non-English-Speaking Trauma Survivors in the Era of COVID-19
By Claudia Orlas, MD and Juan P. Herrera-Escobar, MD, MPH with policy contributions by Esther Moberg, MPH and Amanda Reich, PhD, MPH
Part of the CSPH Series “What Comes Next: the Impact of COVID-19 on Surgery”
All individuals are at risk of suffering from poor mental health during the COVID-19 pandemic, however, individuals of racial and ethnic minority groups are more likely to face barriers to access effective mental health care.
Traumatic injury survivors are at higher risk of suffering from poorer mental health outcomes that can last long after their injury (1). Findings from the Functional Outcomes and Recovery after Trauma Emergencies (FORTE) research project at the Center for Surgery and Public Health (CSPH) at Brigham and Women’s Hospital (BWH) have shown that traumatic injury survivors experience higher rates of post-traumatic stress disorder (PTSD), depression, and anxiety at 6 and 12 months post-injury compared to the US population mean (2). Further, long-standing systemic health and social inequities have put trauma survivors from low socioeconomic status and members of racial and ethnic minority groups at increased risk of worse long-term mental health outcomes and decreased utilization of post-discharge health services (1,3,4).
The coronavirus (COVID-19) global outbreak has infected more than 7 million people and caused at least 206,221 deaths in the US at the time of this publication (5). It is safe to say that COVID-19 is one of the biggest public health issues of modern times. The “lockdowns” and stay-at-home orders instated as essential components of state governments’ responses to the pandemic, while necessary to control the spread of COVID-19, have resulted in an overlooked mental health crisis in the United States (U.S.) (6). Along with this outbreak, new traumatic injuries trends have emerged and even though during early stages, most trauma centers saw an overall reduction in trauma cases as a result of work closures and stay-at-home orders (7), the rates of intentional & accidental injuries have been raising at levels never seen before (8).
Among minority trauma survivors, non-English speaking patients are particularly vulnerable as the barriers they encounter go beyond accessing effective mental health care, they also face communication and translation barriers.
All individuals are at risk of suffering from poor mental health during the COVID-19 pandemic, however, individuals of racial and ethnic minority groups are more likely to face barriers to access effective mental health care. This issue of access is compounded when looking at a specific population: non-English speaking survivors of traumatic injury. As of 2016, 35 million U.S. citizens over the age of 18, or more than 15% of the adult population, spoke a language other than English at home, according to the U.S. Census (9,10).
Among minority trauma survivors, non-English speaking patients are particularly vulnerable as the barriers they encounter go beyond accessing effective mental health care, they also face communication and translation barriers. Non-English-speaking patients often have difficulty finding providers with awareness and training on culturally dexterous care who speak the language with which they are comfortable communicating (11,12). In response to the pandemic, hospitals and mental health clinics have adopted new strategies through technology platforms, among them telemedicine (13–15). However, this transition to tele-mental healthcare as opposed to in-person care, may disrupt access to health care, create additional barriers around interpersonal communication and impact the physician-patient relationship (16), especially for minority, non-English speaking patients. While telehealth decreases everyone’s risk of exposure to COVID-19, it has the potential to exacerbate health care disparities especially among minorities. Patients face three overlapping barriers to accessing telehealth: 1) the absence of technology at home, 2) digital literacy, and 3) reliable internet coverage. Together, these barriers comprise the “digital divide,” which disproportionately affects older people of color and those with low socioeconomic status (11).
TRANSFORMING POLICY & PRACTICE
There are currently no clear guidelines in response to the COVID-19 on how to adopt new strategies or revise the existing ones to guarantee continuous access to tele-mental health services for non-English speaking trauma survivors. In addition, there are no guidelines on how to properly scale in-person patient-provider relationships to telemedicine without disruption, delays, or decrease in the quality of all the clinical services that are part of the comprehensive care and management of mental health conditions. In an effort to reduce patient burden, and provide an acceptable virtual platform that accurately “translate” non-English speaking patients’ thoughts, feelings, fears, concerns, we recommend the following strategies:
- Haider AH, Herrera-Escobar JP, Al Rafai SS, Harlow AF, Apoj M, Nehra D, et al. Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study. Ann Surg [Internet]. 2020 Jun 1 [cited 2020 Aug 5];271(6):1165–73. Available from: https://pubmed.ncbi.nlm.nih.gov/30550382/
- Herrera-Escobar JP, Seshadri AJ, Stanek E, Lu K, Han K, Sanchez S, et al. Mental Health Burden After Injury. Ann Surg [Internet]. 2020;Publish Ah. Available from: https://pubmed.ncbi.nlm.nih.gov/32511129/
- Herrera-Escobar JP, Seshadri AJ, Rivero R, Toppo A, Al Rafai SS, Scott JW, et al. Lower education and income predict worse long-term outcomes after injury. J Trauma Acute Care Surg. 2019 Jul 1;87(1):104–10.
- Chun Fat S, Herrera-Escobar JP, Seshadri AJ, Al Rafai SS, Hashmi ZG, de Jager E, et al. Racial disparities in post-discharge healthcare utilization after trauma. In: American Journal of Surgery [Internet]. Elsevier Inc.; 2019 [cited 2020 Aug 20]. p. 842–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30954233/
- Coronavirus in the U.S.: Latest Map and Case Count – The New York Times [Internet]. [cited 2020 Jul 10]. Available from: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html?action=click&module=Top Stories&pgtype=Homepage
- Coronavirus is causing a historic rise in mental health problems, experts warn – The Washington Post [Internet]. [cited 2020 Jun 18]. Available from: https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/
- New injury trends emerge during COVID-19 pandemic | Trauma System News [Internet]. [cited 2020 Sep 30]. Available from: https://www.trauma-news.com/2020/07/new-injury-trends-emerge-during-covid-19-pandemic/
- Gun Violence Archive [Internet]. [cited 2020 Sep 30]. Available from: https://www.gunviolencearchive.org/
- Millions of U.S. citizens don’t speak English to one another. That’s not a problem. – The Washington Post [Internet]. [cited 2020 Aug 20]. Available from: https://www.washingtonpost.com/news/wonk/wp/2018/05/21/millions-of-u-s-citizens-dont-speak-english-to-each-other-thats-not-a-problem/
- United States Census Bureau [Internet]. [cited 2020 Aug 20]. Available from: https://data.census.gov/cedsci/
- Velasquez D, Mehrotra A. Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care. Health Affairs Blog. 2020.
- Haider A, Smink D. The Provider Awareness and Cultural Dexterity Toolkit for Surgeons Trial – Full Text View – ClinicalTrials.gov [Internet]. ClinicalTrials.gov. 2018 [cited 2020 Sep 25]. Available from: https://clinicaltrials.gov/ct2/show/NCT03576495
- Shore JH. Managing Virtual Hybrid Psychiatrist-Patient Relationships in a Digital World. Vol. 77, JAMA Psychiatry. American Medical Association; 2020. p. 541–2.
- Shore JH, Schneck CD, Mishkind MC. Telepsychiatry and the Coronavirus Disease 2019 Pandemic-Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care. JAMA Psychiatry. 2020;
- Blazer D. Social Isolation and Loneliness in Older Adults—A Mental Health/Public Health Challenge. JAMA Psychiatry. 2020 Jun 3;
- Telehealth wasn’t designed for non-English speakers – The Verge [Internet]. [cited 2020 Jun 18]. Available from: https://www.theverge.com/21277936/telehealth-english-systems-disparities-interpreters-online-doctor-appointments
- Castillo RC, Huang Y, Scharfstein D, Frey K, Bosse MJ, Pollak AN, et al. Association between 6-Week Postdischarge Risk Classification and 12-Month Outcomes after Orthopedic Trauma [Internet]. Vol. 154, JAMA Surgery. American Medical Association; 2019 [cited 2020 Sep 24]. p. 159–69. Available from: https://pubmed.ncbi.nlm.nih.gov/30566192/