2021 HEALTHCARE WORLD LANGUAGE INDEX - A National and State-by-State Listing of the Most Frequently Spoken Languages Other Than English in ...

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2021 HEALTHCARE WORLD LANGUAGE INDEX - A National and State-by-State Listing of the Most Frequently Spoken Languages Other Than English in ...
2021
HEALTHCARE WORLD
LANGUAGE INDEX
A National and State-by-State Listing of the Most Frequently Spoken
Languages Other Than English in Hospital, Medical Group and
Community Health Center-Based Patient Encounters
2021 HEALTHCARE WORLD LANGUAGE INDEX - A National and State-by-State Listing of the Most Frequently Spoken Languages Other Than English in ...
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    Executive Summary

    AMN Healthcare Language Services (formerly Stratus Video) is a leading provider of healthcare language
    interpretation services and is a division of AMN Healthcare (NYSE: AMN), the largest healthcare staffing
    organization in the U.S. and the innovator of healthcare workforce solutions.

    AMN Healthcare and its divisions produce a continuous series of surveys, white papers, educational
    presentations and reports that examine a wide range of healthcare staffing issues. Topics addressed by
    AMN Healthcare include healthcare professional supply and demand trends, health care professional practice
    patterns, morale levels, compensation metrics, recruiting and retention methods and a variety of others.

    An additional topic covered by AMN Healthcare is the delivery of medical interpretation services. AMN
    Healthcare Language Services partners with thousands of hospitals, medical groups, community health centers
    and other healthcare facilities nationwide to provide on-site and remote medical interpretation. These
    services help ensure patients and healthcare providers can fully and effectively communicate with one another
    regarding patient symptoms, diagnoses and treatment plans.

    In this, the inaugural edition of the Healthcare World Language Index, AMN Healthcare Language Services
    reports on the world languages other than English most commonly spoken in patient/provider encounters
    nationally and by state.

    The Index references data on 50 different languages other than English spoken throughout the U.S. in
    healthcare encounters based in a variety of settings. It lists the top ten languages other than English spoken in
    healthcare encounters nationally and by state. It also includes an analysis how increasing language diversity in
    the U.S. and the availability of interpretation services is affecting access to care and quality of care.

    The intent of the Index is to track the extent to which world languages are spoken in healthcare encounters,
    as well as the specific languages being used, and how these usage patterns may vary over time. Data included
    in the Index may be of use to health care providers, administrators and policy makers seeking to ensure that
    appropriate healthcare services are available to a linguistically and culturally diverse population. The Index
    may also be of interest to journalists, researchers and members of the public who follow trends in
    cultural diversity, particularly as they apply to the delivery of healthcare services.

    © Copyright AMN Healthcare 2021                                                      2021 Healthcare World Language Index
2021 HEALTHCARE WORLD LANGUAGE INDEX - A National and State-by-State Listing of the Most Frequently Spoken Languages Other Than English in ...
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    Methodology

    The Healthcare World Language Index uses internal data compiled by AMN Healthcare Language Services to
    determine which languages other than spoken English are used in patient encounters with physicians, nurses
    and other healthcare professionals at hospitals, medical groups, community health centers and other settings.

    The 2021 Healthcare World Language Index is based on 110,540,751 minutes (76,764 days) of interpretation
    services that AMN Healthcare Language Services provided to 3,239 healthcare facilities during the 12 months from
    January 1 of 2020 to January 1 of 2021. During these more than 110 million minutes, an on-site or remote AMN
    Healthcare Language Services interpreter provided interpretation services allowing healthcare professionals and
    patients to communicate with each other using a language other than spoken English, including American Sign
    Language (ASL).

    Approximately 80 percent of these encounters took place in acute care settings, 10 percent in community
    health centers, and the remaining ten percent in medical group or other non-acute care settings.

    Because this is the first time AMN Healthcare Language Services has compiled this information, no comparisons
    to previous years are provided. Data will be tracked over time and data comparisons will be included in future
    Healthcare World Language Indexes prepared by AMN Healthcare Language Services.

    © Copyright AMN Healthcare 2021                                                    2021 Healthcare World Language Index
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    Key Findings

    Following are some of the key findings revealed by the data.

    •   The top ten languages other than English used in      •    Vietnamese is the second most spoken world
        patient/healthcare provider encounters nationally          language other than English used in healthcare
        as tracked by minutes of medical interpretation            encounters nationally, and is used in 3.8% of
        services include:                                          encounters.

                                                              •    American Sign Language ranks third when
                       Language             Percent used
                                                                   considered as non-spoken English, used in 3.6% of
                      1. Spanish                74%                patient encounters.

                    2. Vietnamese              3.8%           •    Arabic ranks fourth, and is used in 3.5% patient
                                                                   encounters.
            3. American Sign Language          3.6%
                       4. Arabic               3.5%           •    Mandarin is the 5th most spoken world language
                                                                   other than English used in patient encounters
                     5. Mandarin               3.0%                and Cantonese is 7th. When combined, however,
                      6. Russian               1.8%                languages commonly spoken in China represent
                                                                   the second most spoken world language other
                    7. Cantonese               1.7%                than English, used in 4.7% of patient encounters.
                    8. Portuguese              1.2%
                                                              •    50 different languages are included in the top ten
                  9. Haitian Creole            1.0%                languages used in patient encounters by state.
                     10. Korean                0.9%           •    Mandarin is included in the top ten world
                                                                   languages other than English used in patient
    •   Spanish is by far the most frequently used world
                                                                   encounters in 47 states, the most among Far
        language other than English in patient/healthcare
                                                                   Eastern languages, followed by Vietnamese in
        provider encounters nationally. Spanish is spoke in
                                                                   38 states, Korean in 24 states and
        74% of such encounters nationwide, and in 47 out
                                                                   Cantonese in 15 states.
        of 50 states.

    •   Hawaii (Mandarin), Vermont (Nepali) and Maine
        (Arabic) are the only three states in which Spanish
        is not the most spoken world language other than
        English in patient/provider encounters.

    © Copyright AMN Healthcare 2021                                                      2021 Healthcare World Language Index
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    •     47 states include Arabic among their top ten most                   •    There are only 7 states where European languages
          spoken languages.                                                        make up two of the top three world languages
                                                                                   other than English used in patient/provider
    •     26 states include Sub-Saharan languages among                            encounters.
          their top ten. Swahili is the most common and is
          featured in the top ten in 17 states.                               •    One state (New Mexico) includes a Native
                                                                                   American language (Navajo) among its top ten.
    •     26 states include Russian among their top ten
          most spoken foreign languages. Russian makes the                    •    The language with the fewest native speakers to
          top three in one state (Oregon).                                         make any state’s top ten is Chuukese (also known
                                                                                   as Trukese), a language spoken by about 45,000
    •     20 states include languages spoken in India (Hindi,                      people in Micronesia, and among the top ten in
          Bengali, Punjabi, Gujarati) among their top ten.                         North Dakota.

    Top Ten World Languages Other Than English Used in Provider/Patient
    Encounters By State Based on Minutes of Medical Interpretation Services
    The Top Ten Languages Used Nationally Coded in Color. All Others in White.

                                                                          Language

        State      1           2            3            4            5               6              7             8              9             10
         AK     Spanish      Korean      Hmong          ASL        Tagalog          Somali        Russian      Mandarin         Swahili         Lao
                                                                                                              Portuguese
         AL     Spanish       ASL         Arabic     Vietnamese   Mandarin          Quiche        Swahili                     Cantonese       Korean
                                                                                                                (BRA)
         AR     Spanish       ASL         Arabic     Vietnamese   Mandarin        Marshallese     Korean         Hindi          Hmong        Burmese

         AZ     Spanish       ASL         Arabic     Vietnamese   Mandarin          Swahili     Cantonese       Russian         Somali      Kinyarwanda

         CA     Spanish     Mandarin    Cantonese    Vietnamese      ASL            Arabic        Russian       Korean           Farsi        Punjabi

         CO     Spanish    Vietnamese      ASL        Russian     Mandarin         Rohingya       Somali         Arabic       Cantonese       Korean
                                        Portuguese                                  Haitian                                                 Portuguese
         CT     Spanish      Arabic                     ASL       Mandarin                        Pashto         Polish       Vietnamese
                                          (BRA)                                     Creole                                                     (EU)
         DC     Spanish       ASL        Amharic       French       Arabic         Mandarin     Vietnamese      Bengali         Russian        Farsi
                                                      Haitian                                                                               Portuguese
         DE     Spanish       ASL         Arabic                  Mandarin        Vietnamese      Korean        Bengali         Turkish
                                                      Creole                                                                                  (BRA)
                             Haitian                              Portuguese
         FL     Spanish                    ASL       Vietnamese                     Russian      Mandarin        Arabic         Korean         Farsi
                             Creole                                 (BRA)
                                                                                  Portuguese
         GA     Spanish    Vietnamese      ASL       Mandarin      Korean                         Russian        Arabic         French      Cantonese
                                                                                    (BRA)
         HI     Mandarin     Spanish    Cantonese    Vietnamese    Korean          Japanese       Tagalog         ASL           Russian       Arabic

         IA     Spanish      French      Burmese      Swahili       Karen         Vietnamese      Arabic         Nepali          ASL        Hakha Chin

         ID     Spanish      Arabic      Swahili       Nepali      Russian           ASL        Vietnamese        Farsi        Mandarin     Kinyarwanda

         IL     Spanish       ASL         French       Arabic       Polish         Mandarin     Vietnamese      Russian       Cantonese       Korean
                             Haitian
         IN     Spanish                  Burmese       Arabic     Hakha Chin        French          ASL         Yoruba          Swahili     Kinyarwanda
                             Creole
         KS     Spanish    Vietnamese      ASL        Burmese      Swahili         Mandarin     Kinyarwanda      Arabic         Russian       Korean

         KY     Spanish      Swahili     Burmese       Zomi          ASL            Bosnian       Arabic        Karenni          Karen        Somali
                                                                                                Portuguese      Haitian
         LA     Spanish       ASL       Vietnamese     Arabic     Mandarin          Korean                                    Cantonese        Hindi
                                                                                                  (BRA)         Creole
                           Portuguese                             Portuguese        Haitian
         MA     Spanish                 Vietnamese     Arabic                                       ASL         Russian        Mandarin     Cantonese
                             (BRA)                                   (EU)           Creole
         MD     Spanish       ASL         Arabic      Burmese     Vietnamese        Korean       Mandarin        Nepali         Russian       French
                                                                                                                              Portuguese
         ME      Arabic      Spanish       ASL         French       Somali        Kinyarwanda Vietnamese        Lingala                      Mandarin
                                                                                                                                (BRA)
         MI     Spanish    Kinyarwanda Vietnamese       ASL         Arabic          Nepali       Burmese        Swahili       Hakha Chin     Mandarin
                                                                                                                                 Khmer
         MN     Spanish      Somali     Vietnamese    Hmong          ASL           Mandarin        Karen        Oromo                        Amharic
                                                                                                                              (Cambodian)
         MO     Spanish    Vietnamese      ASL         Arabic       Swahili        Burmese        Somali        Bosnian          Karen       Mandarin
                                                                                                                Kanjobal
         MS     Spanish      Arabic     Vietnamese      ASL       Mandarin           Chuj         Gujarati                      Punjabi      Akateko
                                                                                                              (Q'an jo'bal)
         MT     Spanish       ASL       Mandarin      Russian       Swahili       Vietnamese     Armenian      Japanese         Arabic        Tagalog

    © Copyright AMN Healthcare 2021                                                                              2021 Healthcare World Language Index
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                                                                          Language

     State       1            2           3             4             5              6          7             8            9           10
      NC       Spanish   Vietnamese      ASL          Arabic       Russian     Mandarin      Burmese        French       Nepali      Swahili
                                                                   Haitian                                 Chuukese
      ND       Spanish      Arabic      French         ASL                      Swahili     Vietnamese                 Mandarin      Kurdish
                                                                   Creole                                  (Trukese)
                                                                                                            Kurdish-
      NE       Spanish      Arabic      Karen        Kunama          ASL         Somali       Quiche                    Burmese       Nepali
                                                                                                           Kurmanji
                                                                                                          Portuguese
      NH       Spanish      Nepali      Arabic      Kinyarwanda    Swahili     Vietnamese      ASL                     Mandarin      Bosnian
                                                                                                             (BRA)
                                                                  Portuguese
       NJ      Spanish    Cantonese   Mandarin        Russian                     ASL         Arabic       Bengali      Korean        Polish
                                                                    (BRA)
      NM       Spanish       ASL        Arabic      Vietnamese    Mandarin      Rohingya      Karenni      Burmese      Tagalog       Navajo
                                                                                            Portuguese
      NV       Spanish       ASL       Korean        Mandarin     Vietnamese     Arabic                   Cantonese     Serbian        CDI
                                                                                              (BRA)
                                                                                                                        Haitian
      NY       Spanish    Mandarin      Arabic        Russian       Nepali     Cantonese      Bengali        ASL                      Karen
                                                                                                                        Creole
      OH       Spanish      Nepali      Arabic        Somali         ASL         French      Mandarin      Russian       Karen      Vietnamese

      OK       Spanish   Vietnamese      ASL         Mandarin      Burmese      Korean        Arabic        Zomi         French     Cantonese

      OR       Spanish   Vietnamese    Russian      Cantonese        ASL         Arabic      Mandarin      Korean        Somali      Burmese
                                                                                                           Haitian     Portuguese
      PA       Spanish      Arabic       ASL        Vietnamese    Mandarin      Russian       Nepali                                 Korean
                                                                                                           Creole        (BRA)
                                      Portuguese    Portuguese
       RI      Spanish       ASL                                  Cantonese    Mandarin       Korean        Arabic      Russian      Tagalog
                                        (BRA)          (EU)
                                                                                            Portuguese
      SC       Spanish   Vietnamese      ASL          Arabic       Russian     Mandarin                     Karen       Swahili       Chuj
                                                                                              (BRA)
      SD       Spanish      Arabic       ASL          Nepali        Karen       Kunama       Ukrainian    Mandarin      Tigrinya     Amharic

      TN       Spanish      Arabic       ASL        Vietnamese    Mandarin      Swahili     Kinyarwanda    Kurdish      Burmese        Farsi

      TX       Spanish   Vietnamese     Arabic         ASL        Mandarin       French      Burmese        Nepali      Korean       Swahili
                                                                  Portuguese
      UT       Spanish       ASL      Vietnamese     Mandarin                    Arabic     Cantonese      Russian      Bosnian      Korean
                                                                    (BRA)
      VA       Spanish   Vietnamese     Arabic        Korean         ASL       Mandarin        Farsi       Russian      Amharic       French

      VT       Nepali      Spanish     Swahili         ASL          Somali     Vietnamese     French        Arabic     Mandarin      Burmese

      WA       Spanish   Vietnamese   Cantonese       Russian     Mandarin       Arabic       Somali       Korean         ASL        Amharic

      WI       Spanish     Hmong         ASL          Somali      Vietnamese   Mandarin        Karen         Lao         Arabic      Russian
                                                                                Haitian
      WV       Spanish       ASL      Vietnamese     Mandarin       Arabic                    Russian       French        CDI        Korean
                                                                                Creole
      WY       Spanish     Japanese   Vietnamese     Mandarin

    Languages Included in the Top Ten for All 50 States
    Spanish                                      Burmese                             Bosnian
    Korean                                       Kinyarwanda                         Karrenni
    Hmong                                        Farsi                               Lingala
    American Sign Language                       Punjabi                             Oromo
    Tagalog                                      Rohingya                            Khmer
    Somali                                       Haitian Creole                      Chuj
    Russian                                      Pashto                              Gujarati
    Mandarin                                     Polish                              Kanjobal
    Swahili                                      Amharic                             Akateko
    Lao                                          French                              Chuukese
    Arabic                                       Bengali                             Kurdish
    Vietnamese                                   Turkish                             Kunama
    Quiche                                       Japanese                            Navajo
    Portuguese                                   Karen                               Certified Deaf Interpreting
    Cantonese                                    Hakha Chin                          Urkranian
    Marshallese                                  Yoruba                              Tigrinya
    Hindi                                        Zomi

    © Copyright AMN Healthcare 2021                                                                         2021 Healthcare World Language Index
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    Overview
    One Nation, Many Languages

    The United States is a nation of immigrants, many of whom do not speak English as their first language. Using
    Census Bureau data, the Center for Immigration Studies reports:1 2
    •   67.3 million residents in the United States, or 22 percent of the population, now speak a language other
        than English at home, a number equal to the entire population of France. The number has nearly tripled
        since 1980, and more than doubled since 1990. It includes native-born Americans, legal immigrants and
        undocumented immigrants.
    •   Since 1980, the number five-year-olds or above who speak a language other than English at home grew
        nearly seven times faster than the number who speak only English at home. Even since 2010, when the
        number speaking a language other than English at home was already very large, the number of non-English
        speakers increased more than twice as fast as that of English speakers.
    •   In nine states, more than one in four residents now speaks a language other than English at home. These
        nine states account for two-thirds of all non-English language speakers. In contrast, in 1980 non-English
        speakers comprised one in four residents in just two states (New Mexico and Hawaii) and these two states
        accounted for just 3 percent of all non-English language speakers.
    •   The states with the largest share of their populations speaking a language other than English at home in
        2018 were California (45 percent), Texas (36 percent), New Mexico (34 percent), New Jersey (32 percent),
        New York and Nevada (each 31 percent), Florida (30 percent), Arizona and Hawaii (each 28 percent), and
        Massachusetts (24 percent).
    •   In America’s five largest cities, just under half (48 percent) of residents now speak a language other than
        English at home. In New York City it is 49 percent; in Los Angeles it is 59 percent; in Chicago it is 36 percent;
        in Houston it is 50 percent; and in Phoenix it is 38 percent.
        •   There are now more people who speak Spanish at home in the United States than in any country in
            Latin America with the exceptions of Mexico, Colombia, and Argentina.
    •   Of those who speak a language other than English at home, 25.6 million (38 percent) told the
        Census Bureau that they speak English less than very well.

    In an increasingly diverse country, access to healthcare is not just determined by economic
    factors, geographic location, or health insurance coverage, it may also be determined
    by the ability of patients to communicate with their care givers.

    © Copyright AMN Healthcare 2021                                                        2021 Healthcare World Language Index
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    Language Barriers and Quality of Care
    Productive patient/provider encounters depend on how well providers and patients understand each other.
    Providers must follow patients closely enough to accurately diagnosis their complaints and communicate
    treatment plans. Patients must understand providers well enough to follow the care plans they are given.

    Language barriers, particularly those facing Limited English Proficiency (LEP) patients, can significantly erode
    patient/provider communication.

    LEP is an increasingly widespread healthcare challenge nationwide. Eight percent of Medicare beneficiaries are
    LEP, according to a 2017 brief from the Center for Medicare and Medicaid Services’ (CMS) Office of Minority
    Health.3

    Medicare beneficiaries in urban areas are four times as likely to face language barriers as beneficiaries living
    rural regions, with two percent of rural-dwelling patients having LEP compared to eight percent of urban
    beneficiaries.

    LEP is also pervasive outside of the Medicare population. As was referenced above, more than one-fifth of the
    population speaks a language other than English at home.

    Language barriers put about nine percent of the US population at risk for an adverse patient safety event,
    according to the Agency for Healthcare Research and Quality (AHRQ) report Improving Patient Safety Systems
    for Patients With Limited English Proficiency.

    Patients see language barriers as a significant hurdle to managing their health. The Robert Wood Johnson
    Foundation reports that half of Spanish-speaking patients cite language limitations as their biggest barrier to
    healthcare. Language barriers keep these patients from both engaging in seamless conversations with their
    doctors and interacting with the healthcare industry at large.4

    Health disparities such as unequal treatment related to language barriers are associated with unequal access to
    healthcare and unequal health outcomes.5

    Similarly, several studies have shown that patients who face language barriers have poorer health outcomes
    compared with patients who speak the local language.6 7

    Cultural Misunderstanding
    It is not just the ability to understand providers that can inhibit the healthcare experience for those who are not
    proficient in English. Patients who cannot understand billing forms may be inappropriately charged for services.
    In addition, patients given information about additional healthcare resources at their disposal may not use
    those resources if they do not understand the information.

    Cultural misunderstanding regarding gender roles, generational roles, body etiquette and other factors that are
    caused by language barriers also can erode quality of care and the patient/provider experience.

    Similarly, language barriers can adversely affect how providers deliver healthcare. Providers may abandon
    typical relationship building techniques they employ with English speakers and adopt a more paternalistic
    approach to those who are not proficient in English.

    Family members sometimes act as interpreters but may carry with them an implicit bias, potentially to guard the
    patient’s feelings or protect the patient from bad news. Family members, most notably children, also may not
    have a full understanding of the healthcare industry and healthcare terminology, leaving some concepts lost in
    translation.

    © Copyright AMN Healthcare 2021                                                       2021 Healthcare World Language Index
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    Healthcare Language Mandates
    For these reasons, the Joint Commission requires healthcare organizations to offer interpretive services at the
    point of care.

    In addition, various federal laws and policies require that LEP patients have a means to address language
    barriers in healthcare settings. These include:

    •   Title VI of the 1964 Civil Rights Act, which establishes that language access be provided to those with LEP in
        organizations that benefit from federal funding and other resources.

    •   Title III of the Americans with Disabilities Act provides for equal treatment for those with disabilities,
        including the Deaf community.

    •   Section 1557 of the Affordable Care Act which prohibits discrimination in certain health programs and
        requires qualified interpreters for LEP patients.

    © Copyright AMN Healthcare 2021                                                        2021 Healthcare World Language Index
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     Trends And Observations

     The 2021 Healthcare World Language Index offers a variety of insights into the use of languages other than
     English in patient/provider encounters within the context of an increasingly diverse society.

     Not surprisingly, Spanish is the dominant non-English language spoken in patient/provider encounters
     nationwide, and is used in 74 percent of encounters tracked by the Index. People of Hispanic/Latinx origin now
     represent 18 percent of the total U.S. population (approximately 60 million people) and have accounted for
     more than 50 percent of total U.S. population growth since 2010.8

     As of 2018, there were 44.8 million people in the U.S. who were born in another country, representing 14
     percent of the population. Spanish-speaking Mexico is the country of origin of 25 percent of all U.S. immigrants
     (see chart below):

                                           Country of Origin of U.S. Immigrants
                                                                In millions              % of All Immigrants
                     Mexico                                         11.2                         25
                      China                                          2.9                         6
                       India                                         2.6                         6
                  Philippines                                        2.0                         5
                  El Salvador                                        1.4                         4
     Source: Key Findings About U.S. Immigrants. Pew Research Center. August 20, 2020.

     As the chart above indicates, China is second behind Mexico as the country of origin of the most U.S.
     immigrants, and Chinese languages (Mandarin and Cantonese) when combined, are ranked as the second
     most spoken in patient/provider encounters by the Index.

     Though India ranks third as the country of origin of the most U.S. immigrants, languages
     commonly spoken in India are not ranked in the top ten by the Index. This is because a wide
     variety of languages are spoken in India, including Hindi, Punjabi, Gujarati and others, and
     also because English is widely spoken in India.

     © Copyright AMN Healthcare 2021                                                                           2021 Healthcare World Language Index
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     Similarly, though the Philippines ranks fourth as the country of origin of the most U.S. immigrants, no
     languages native to the Philippines are ranked in the top ten by the Index. Approximately 170 languages are
     spoken in the Philippines and English also is widely spoken, limiting the number Filipino immigrants likely to
     require language services.

     Niche Languages
     All the world languages ranked in the top ten nationally by the Index are spoken widely throughout the world,
     with the exception of Haitian Creole. The list of the most spoken languages in the world includes:

         Most Spoken Languages Worldwide by Total Speakers
                    Language                            Number of Speakers
                     English                                 1.132 billion
                   Mandarin                                  1.117 billion
                      Hindi                                   635 million
                     Spanish                                  534 million
                     French                                   280 million
                     Arabic                                   280 million
                     Bengali                                  265 million
                     Russian                                  258 million
                  Portuguese                                  234 million
                  Indonesian                                  199 million
     Source: The Ten Most Spoken Languages in the World. Babbel Magazine. June 2, 2021.

     In contrast to the large numbers above, only 10 million people speak Haitian Creole. Healthcare professionals
     can be particularly challenged when treating patients conversant with only one of a variety of niche languages
     that are included among the top ten used in patient encounters in various states as ranked by the Index.

     These niche languages include:

     •     Oromo – spoken in Northeast Africa by 30 million people

     •     Amharic – spoken in Ethiopia by 21 million people

     •     Yoruba – spoken in Southwest Nigeria by 20 million

     •     Lingala – spoken in the Congo by 10 million people

     •     Tigrinya – spoken in Eritrea by 7 million people

     •     Quiche (also known a K’iche) – spoken in the Central Highland of Guatemala by 1 million people

     •     Akateko – a in certain regions of Guatemala by 65,000 people

     •     Chuukese, (also known as Trukese) – spoken in Micronesia by 45,000 people

     A Linguistic Diaspora
     The Index suggests that niche languages now are among the most commonly spoken world
     languages in patient/provider encounters in a variety of states.

     For example, Hmong, Somali and Swahili are among the top ten world languages other than
     English spoken in patient/provider encounters in Alaska. Haitian Creole is the number two
     most spoken world language other than English in patient/provider

     © Copyright AMN Healthcare 2021                                                      2021 Healthcare World Language Index
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     encounters in Florida and Indiana. Arabic, Swahili and Nepali and two, three and four respectively in Idaho,
     while Nepali is second in New Hampshire and Ohio.

     Though not a niche language, Vietnamese is second after Spanish as the most commonly used language other
     than English used in patient/provider encounters in Colorado, Georgia, Kansas, Missouri North Carolina ,
     Oklahoma, Oregon, South Carolina, Texas, Virginia and Washington.

     Similarly, Arabic is either the second or third most commonly used language other than English after Spanish
     in patient/provider encounters in Alabama, Arkansas, Arizona, Connecticut, Idaho, Mississippi, North Dakota,
     Nebraska, New York, Ohio, Pennsylvania, South Dakota, Tennessee and Texas, and is ranked first in Maine.

     In total, 50 different languages are cited by the Index as being among the top ten spoken in patient/provider
     encounters throughout the 50 states and Washington, D.C.

     A Land of Asylum
     Several of the languages listed in the top ten in various states are spoken in countries which have experienced
     violence and other turmoil in recent years. These countries include Vietnam, Somalia, Myanmar, Democratic
     Republic of Congo, Eritrea, Ethiopia, Guatemala, El Salvador, Haiti, and others. Some of the citizens of these
     countries have come to the U.S. seeking asylum and may require translation services when they seek healthcare.
     The chart below lists the countries of origin of U.S. asylum seekers in 2019:

             Top 5 Countries of Origin/U.S. Asylum Seekers/2019
              Democratic Republic of Congo                                         43%
                       Myanmar (Burma)                                             16%
                               Ukraine                                             15%
                                Eritrea                                             6%
                            Afghanistan                                             4%
     Source: Key Findings About U.S. Immigrants. Pew Research Center. August 20, 2020.

     Continued international unrest is likely to add to the number of immigrants in the U.S. who will require
     translation services in healthcare settings.

     Few European Languages in the Top Ten
     Only two European languages other than Spanish (Russian and Portuguese) are ranked in the top ten languages
     other than English spoken in patient/provider encounters nationally, representing 3 percent of all encounters
     (It should be considered that the great majority of Spanish and Portuguese speakers in the U.S. are from Latin
     America, not Europe). By contrast, 9.6 percent of languages listed in the national top ten by the Index are
     spoken in the Far East, including Mandarin, Cantonese, Vietnamese and Korean.

     These numbers underscore the relative decline of immigration to the U.S. from Europe. From 1960 to 2016, only
     13 percent of U.S. immigrants came from Europe or Canada (see chart below).

                         Regions of Origin of U.S. Immigrants
          Mexico, Central and South America                                        40%
                                  Asia                                             28%
                          Europe/Canada                                            13%
                             Caribbean                                             10%
                       Sub-Saharan Africa                                           5%
               Middle East and North Africa                                         4%
     Source: Key Findings About U.S. Immigrants. Pew Research Center. August 20, 2020.

     © Copyright AMN Healthcare 2021                                                     2021 Healthcare World Language Index
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     The fastest growing number of immigrants to the U.S. are from Asia. The number of immigrants from China, for
     example, has increased seven-fold since 1980. In 2018, China surpassed Mexico as the country sending the most
     immigrants to the U.S., though China was not in the top ten in 1980.9 A growing number of patients requiring
     medical interpretation services in the future are likely to be from China and other Asian countries.

     A Sign of the Times
     Because it is non-spoken English and users may require medical interpretation, American Sign Language (ASL) is
     included in the Index among foreign languages used in patient/provider encounters.

     The Index suggests that the use of ASL in patient/provider encounters is relatively common. ASL ranked second
     behind Spanish as the most commonly used language other than English used in patient/provider encounters
     in 13 states and the District of Columbia. According to the Communication Services for the Deaf (CSD),
     approximately one million people in the U.S. now use ASL as their main way to communicate. It is used by the
     Deaf and Hard of Hearing as well as those with communications disorders.

     © Copyright AMN Healthcare 2021                                                  2021 Healthcare World Language Index
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     Conclusion

     With its longstanding tradition of immigration, the United States continues to be an ethnically, culturally
     and linguistically diverse nation. AMN Healthcare’s 2021 Healthcare World Language Index provides insights
     into how linguistical diversity manifests in patient/provider healthcare encounters both nationally and
     by state. While Spanish is the primary language other than English spoken in such encounters, 50 other
     languages are among the most commonly spoken, depending on the state. These languages include those
     generally spoken in Asia by hundreds of millions of people, but also may include niche languages spoken by
     fewer than 50,000 people. Because the quality of healthcare encounters depends on clear patient/provider
     communication, medical interpretation will be a continued key to healthcare access for a growing segment
     of the population.

     © Copyright AMN Healthcare 2021                                                   2021 Healthcare World Language Index
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     References

     1 American Community Survey. U.S. Census Bureau. September, 2019.
     2 67.3 Million People in the U.S. Spoke a Foreign Language at Home in 2018. Center for Immigration Studies. Cis.
     org/Report/67-million-united-states-spoke-foreign-language-2018
     3 Understanding National Patient Language Proficiency, Barriers. Patient Engagement HIT. May 4, 2017
     4 Addressing Language Barriers in Patient/Provider Communication. Patient Engagement HIT. September 26, 2017
     5 Hilfinger Messias DK, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives
     of formal and informal healthcare interpreters. ANS Adv Nurs Sci 2009. Apr-Jun;32(2):128-143. 10.1097/
     ANS.0b013e3181a3af97.
     6 Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int
     J Qual Health Care 2007. Apr;19(2):60-67. 10.1093/intqhc/mzl069
     7 Squires A. Evidence-based approaches to breaking down language barriers. Nursing2019 2017;47(9):34-40.
     8 Hispanics Have accounted for More Than Half of Total U.S. Population Growth since 2010. Pew Research Center.
     July 10, 2020
     9 Chinese Immigration to the U.S. Migration Policy Institute. January 15, 2020

     © Copyright AMN Healthcare 2021                                                       2021 Healthcare World Language Index
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