Spanish Speakers Face Bias When Seeking Mental Health Care

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Seeking and obtaining mental health care can be difficult for anyone needing help, but the challenges for Spanish-speaking individuals with limited English proficiency often start the moment they make the first phone call for an appointment.

Those difficulties are highlighted in a recent study by RAND Corporation researchers using a secret-shopper design in which callers posed as Spanish- and English-speaking Medi-Cal beneficiaries seeking medication treatment for depression.

To compare the experiences of English speakers and individuals with limited English proficiency, the simulated patients contacted 386 Federally Qualified Health Centers (FQHCs) and behavioral health clinics serving Medi-Cal enrollees in February and March 2023. The clinics contacted had specialty behavioral providers on staff, such as psychiatrists and psychiatric nurse practitioners, who were able to prescribe medications.

Among the clinics reached in one or both languages, English-speaking callers were more likely to speak with a live person (90% vs. 72%) and more likely than Spanish-speaking callers to reach the point in the scheduling process when they would be able to obtain appointment information in their preferred language (62% vs. 41%).

Supported by the California Health Care Foundation, the researchers observed clear evidence of discrimination during the scheduling process; nearly one in five Spanish-language calls ended with the scheduler hanging up on the caller or informing them that no one was available to assist them in Spanish.

The use of telehealth, which reached its peak early in the COVID-19 pandemic, remains strong in behavioral health care while it has declined in many other clinical areas. A study on telehealth trends found that in the summer of 2022, 63% of specialty behavioral health visits in California’s FQHCs were delivered via telehealth. The RAND researchers sought to assess how this dramatic change in behavioral health care delivery affects patients with limited English proficiency in accessing care. The study focused on how the experiences of these patients differed from those of English speakers when seeking mental health care via telephone.

Although barriers encountered by patients with limited proficiency in English can be seen at every level of care, the study indicates that more resources are needed to support these patients at the critical point when they interact with schedulers.

Only a handful of secret-shopper studies have described the process of obtaining appointments among Spanish-speaking patients, and no published research to date has focused on behavioral health services.

Contrasting Experiences

Samantha Perez Dávila, a graduate student at RAND, conducted secret-shopper calls in both Spanish and English — and supervised others making similar calls — to compare how the groups were treated. “Some of the people answering the calls were good and professional, and some were rude and unfriendly,” she said. “It was a mixed bag.”

“I didn’t expect the energy and the time required to make an appointment” when she posed as a patient with limited proficiency in English, she said. When contacting the clinic as a Spanish speaker, Perez Dávila said the calls were much longer, roughly 30 minutes compared with 5–10 minutes when she and her colleagues called as English speakers. While part of this was due to the lack of Spanish-speaking staff in some clinics and the need to bring in interpreters, most calls as patients with limited English proficiency took longer because they were asked many more questions than English speakers got. “It was a frustrating experience,” said Perez Dávila.

“They would ask me many questions about insurance — the specific type of insurance I had and if I had gotten it from the county or from my family. They asked for my date of birth, and sometimes they wouldn’t give me any information if I didn’t give them my insurance number,” Perez Dávila said. “In some calls, they would even tell me they didn’t accept Medi-Cal or Medicare.” She was never asked so many questions when calling as an English speaker. Perez Dávila’s experience reflects findings in recent studies that identified perceived discrimination, mistrust, and privacy concerns as factors contributing to inequities.

In the RAND study, 22% of Spanish-speaking callers who reached a scheduler discovered that the person would not engage with them and either abruptly ended the call or declared that nobody could speak with them in Spanish. This was less likely to occur in FQHCs (8%), which have traditionally served large percentages of Latinos/x and patients with limited English proficiency (53% and 36% of total FQHC patients, respectively).

In one instance, a caller reached an English-speaking scheduler at a group practice in Los Angeles. When the caller asked in Spanish if the clinic was taking new patients, the scheduler repeated several times in English that they didn’t speak Spanish. When asked if someone else at the clinic spoke Spanish, the scheduler said no and hung up.

Perez Dávila, a PhD student at Pardee RAND Graduate School with a master’s degree in applied economics from Johns Hopkins University, is a native of Mexico and bilingual. She grew up with parents who spoke Spanish and had limited English proficiency.

The study found that most callers who obtained appointment details (64% of Spanish-speaking and 70% of English-speaking callers) were subject to one or more required steps before obtaining care, such as an intake visit or being assigned to a particular clinic, but there were no significant differences by language. Spanish-speaking callers were more likely to be placed on hold for five or more minutes (48% vs. 28%) but were also significantly more likely to be told that they had a choice of telehealth or in-person visits (71% vs. 48%). The mean wait time across all callers for an appointment to obtain a prescription medication was more than one month and not significantly different for Spanish and English speakers, which demonstrates that once Spanish speakers are in the door, they may not face differential treatment.

Calling Salud Para La Gente

According to US Census data, almost 17 million Spanish speakers in the US have limited proficiency in English. While health care organizations receiving federal funding are legally required to ensure these patients have access to care, many lack the resources to deliver it. As a result, studies on barriers faced by Latino/x patients show that, compared to English-proficient patients, individuals with limited English proficiency receive fewer health care services, have greater unmet mental health needs, and get poorer-quality care.

Salud Para La Gente, a nonprofit health care organization providing affordable, high-quality care in California’s Central Coast region, is tackling the problem to ease the way for patients with limited English proficiency to make an appointment. The process seems to work for everyone. “Our staff speak English and Spanish, and they understand the importance of language for people to access services,” said Amy Ross, the health center’s director of patient services.

Since it opened in 1978 as a free clinic for farmworkers and their families, Salud has become an FQHC and grown to five clinics and four school-based health centers in Santa Cruz and Monterey Counties, serving nearly 30,000 patients a year. Most speak Spanish, others English, and a few Mixtec.

For patients telephoning Salud Para La Gente, “Press ‘1’ for Spanish” is not just a menu option but a key to connect with bilingual and bicultural staff. Of the 450 staff members at Salud, nearly all in-clinic positions require bilingual and bicultural qualifications, which help patients access services seamlessly in a language they understand.

It all starts at the call center, where patients make phone, video, or in-person appointments. Ross monitors the operation closely to ensure all patients have equal access to the FQHC’s services.

For Mai-Khanh Bui-Duy, MD, director of health information and population health at Salud Para La Gente, the staff is key. “Many of the men and women working at Salud come from the same community we serve, which builds trust and makes a huge difference,” she said.

However, when it comes to behavioral health, many patients with limited English proficiency may experience some waits before they can make an appointment, Bui-Duy said. “The major challenge is the high demand we have for mental health services from a population where the majority of patients speak Spanish,” she said. While stigma has kept many in Latino/x communities from seeking mental health care, Bui-Duy said there has been a shift, and younger generations now are not only seeking help for themselves but also encouraging their parents to do so.

The first point of contact for these patients when they call Salud Para La Gente is a team of four bilingual behavioral health coordinators who serve as the connection with the 20 clinicians on the mental health team, including counselors, therapists, and social workers. Except for a few part-time contract psychiatrists, everybody on the mental health team is bilingual. When the behavioral health coordinators send a message to the psychiatric team to schedule an appointment after a patient calls, the staff must reply within 24 hours.

“This is what it takes,” said Ross, who took the job eight years ago. “The leadership has to be committed to it.”

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