THE INTERNATIONAL JOURNAL OF COMMUNICATION AND HEALTH 2013 / No. 1 Vital Signs: A photovoice assessment of the linguistic landscape in Spanish in healthcare facilities along the U.S.-Mexico border Glenn A. Martínez Professor of Hispanic Linguistics Department of Spanish and Portuguese and The James Comprehensive Cancer Center The Ohio State University [email protected] Abstract The intersection of health literacy and limited English proficiency is a concern of increasing importance. While there is considerable overlap between populations with limited English proficient and low health literacy, there may also be interaction effects in which low health literacy is exacerbated by unequal access to and differential presentation of information. In this study, interaction effects are explored by examining the linguistic landscape of healthcare facilities using a photovoice approach. A sample of 32 young Spanish-speakers residing in the U.S.- Mexico border region participated in the study. Youngsters went to healthcare facilities normally visited by family members and took pictures of publicly displayed signs and written materials. They wrote captions for each photograph and presented their photographs in a critical dialogue session. The results of the study indicated that participants perceive significant differences in the presence of English and Spanish on the linguistic landscape in healthcare facilities. Signs in English were more numerous than signs in Spanish. Spanish signs, furthermore, were plagued with spelling errors, grammatical errors, and unintelligible translations and were less likely than English signs to convey information about salient health concerns. Participants interpreted these patterns as indexical of the inequities faced by Spanish speakers in the health delivery system. This study demonstrates that care should be taken to create a health literacy environment that provides adequate information and that makes non-English speaking patients feel welcome. Key words: CLAS Standard 7; Linguistic Landscape; Photovoice; U.S.-Mexico Border the web site and think “Man, they really don’t care about Introduction us” (Associated Press 2014). This article showcases how The intersection between health literacy and the unequal access to texts and information in the health limited English proficiency has been identified as a literacy environment can place limited English proficient serious and understudied area of concern within the populations at a disadvantage. Concern over the health health literacy literature (McKee & Paasche-Orlow literacy environment for non-English speaking populations, 2012). On the one hand, there may be significant however, is not new in the research on limited English overlap between the populations at risk for low health proficiency. literacy and limited English proficiency which can The 2001 National Standards for Culturally and magnify poor health outcomes (Sudore 2009). On the Linguistically Appropriate Care (CLAS) issued by the Office other hand, there may also be interaction effects that of Minority Health (OMH) in response to Executive Order create unique and insurmountable barriers to 13166 (Spolsky 2004), for example, identified the health obtaining and processing health information for limited literacy environment as a significant part of language English proficient populations (Egede 2006). This access policy. CLAS standard 7 states that “health care later concern has recently garnered national attention organizations must make available easily understood through a syndicated Associated Press news piece patient-related materials and post signage in the languages entitled “Health care website frustrates Spanish of the commonly encountered group and/or groups speakers” that criticized the Spanish version of the represented in the service area” (U.S. Department of federal health insurance exchange website Health and Human Services 2001). Through this standard www.cuidadodesalud.gov. In addition to complaints the OMH sought to improve access for LEP populations by about the late launch and technical glitches on the educating patients on the availability of health care site similar to those surrounding the English version, resources, indicating how to access those resources, and the article points out that “a web page with Spanish identifying patient rights (American Institutes for Research instructions linked users to an English form” and that 2005). The Enhanced CLAS standards of 2013 further “translations were so clunky and full of grammatical underscore the relationship between health literacy and the mistakes that critics say they must have been standards related to health-related materials and signage in computer-generated.”The article concludes by quoting languages other than English. The OMH states that the a political science professor from the University of purpose of this standard is to “ensure that readers of other New Mexico who said Spanish-speakers will look at languages and individuals with various health literacy levels THE INTERNATIONAL JOURNAL OF COMMUNICATION AND HEALTH 2014 / No. 4 are able to access care and services, to provide The Linguistic Landscape access to health-related information and facilitate The concept of the “linguistic landscape” (LL) was comprehension of, and adherence to, instructions and developed in order to describe the conflicting and health plan requirements, to enable all individuals to complementary relationships that emerge between multiple make informed decisions regarding their health and languages that coexist in a single community. The first their care and services options” (U.S. Department of definition of the term referred to LL as “the language of Health and Human Services 2013, 93). public road signs, advertising billboards, street names, Research on the implementation of CLAS place names, commercial shop signs, and public signs on standards has uncovered ongoing barriers to full government buildings within a given territory, region, or compliance with standard 7, however. In a national urban agglomeration” (Landry & Bourhis 1997, 25). In this survey of 202 hospitals, for example, only 51% of the definition, LL served as a visual representation of patterns sample provided hospital signage in the language of of language choice. It was assumed that a direct the most commonly encountered group in the correspondence existed between the language heard in hospital’s service area. The same study found that public places and the languages seen on billboards, road only 57% of the sample reported availability of signs, commercial signs, etc. informed consent and hospital discharge instructions More recent definitions, however, have challenged in a language other than English (Diamond, et. al. this somewhat static and passive conceptualization of the 2010). A cross-sectional telephone survey of 162 LL. They have viewed LL, instead, as a symbolic pharmacies in New York City, furthermore, found that construction of public space (Ben Rafael 2006), as a while 69% of the pharmacies surveyed reported the strategic tool wielded in local politics, power struggles and ability to provide drug labels in Spanish, a full 86% competing claims to space (Leeman and Modan 2009), and reported that they used a computer-generated as a mechanism in determining and sustaining unequal translation to do so. Furthermore, only one pharmacy power relations between hegemonic and subordinate in the sample reported to have a Spanish-speaking groups (Pavlenko 2009). This amplified perspective has pharmacist on staff who could verify and correct allowed researchers to approach LL as a spatial practice computer translations (Sharif, et. al. 2006). that constitutes social relations and creates social Notwithstanding claims that “standard 7’s requirement inequalities. Following the work of critical geographer Henri of providing written materials and signage in Lefebvre (1992), sociolinguists have argued that the LL is languages common in the service area should not not a neutral container of multilingual expressions, but provide a particular burden on providers,” full rather that the LL constructs and shapes the type and compliance with this standard has proven to be character of the relations that exist between expressions in elusive in many health delivery settings (Hoffman multiple languages. The LL should thus be evaluated not as 2011, 50). an objective physical environment but as the subjective While previous research has identified representation of those who inhabit the environment barriers to the implementation of CLAS standard 7, it (Leeman & Modan 2009). LL within this view may be more has not ascertained the impact of these barriers on properly described as a process of “linguistic landscaping” LEP users of health care services. In fact, the lack of where linguistic resources are deployed to achieve social measures and methodologies to assess the health ends (Pennycook 2010). literacy environment and its impact on LEP users This approach has unearthed novel methods for presents a fundamental gap in our understanding of studying and comprehending the LL within its social the relationship between health literacy and limited context. Ethnographic accounts of spatial inhabitance English proficiency. In this paper, I draw on theoretical (Curtin 2007; Shohamy 2012), historical accounts of the insights from contemporary sociolinguistics and planning processes that construct the LL (Leeman & methodological trends within the framework of Modan 2009), and formal accounts