Economic burden of limited English proficiency: A prevalence-based cost of illness study of its direct, indirect, and intangible costsS Karande1, NJ Gogtay2, T More1, RF Sholapurwala1, S Pandit2, S Waghmare1
1 Department of Pediatrics, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Clinical Pharmacology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.jpgm_445_22
Source of Support: None, Conflict of Interest: None
Keywords: Attention-deficit hyperactivity disorder, language barrier, social acceptance, surveys and questionnaires, underachievement
Many Indian parents who have studied in vernacular (non-English) medium prefer to send their children to English-medium schools, hoping that learning English would improve their children's social and economic future. Despite studying in English medium schools, many of these students have a limited ability to communicate with or understand English (”limited English proficiency” or “LEP”)., The term “limited language proficiency” refers to limited competencies in multiple domains (e.g., vocabulary, verbal analogies) and multiple modalities (e.g., expressive, receptive). Typically, these students have difficulties in reading, and writing and underperform in all school subjects., They are at an increased risk of chronic poor school performance (”PSP”) and its resultant sequelae, namely, anxiety, depression, becoming school dropouts, experiencing social isolation, and developing lowered self-esteem.,
From the societal perspective, it is important to evaluate the economic impacts ('cost of illness' [COI]) associated with LEP and identify interventions that can reduce the burden of this underreported condition. We conducted the present study with the primary objective of evaluating the economic burden of LEP imposed on families of afflicted students, healthcare providers, and society. A secondary objective was to assess the impact of variables on the economic burden imposed on families of afflicted students.
The present study was approved by the Institutional Ethics Committee [EC/100/2019] and was registered prospectively with the Clinical Trials Registry of India [CTRI/2020/03/024006]. The study was conducted following the ethical standards laid down in the 1964 Declaration of Helsinki and the 2017 guidelines laid down by the Indian Council of Medical Research. Accordingly, all parents signed an informed consent form before participating in the present study. Additionally, all school students either gave oral assent (≥8 to <12 years) or written assent (≥12 to ≤18 years) before parental enrolment. The parents and their children were assured that the answers to the questionnaire would be kept confidential.
Design, setting, and sample size calculation
The present cross-sectional single-arm questionnaire-based descriptive COI study was conducted at the learning disability clinic of a public medical college in Mumbai, a megacity in western India over 21 months, from March 2020 to November 2021. The prevalence of students with LEP in Indian schools is unknown. Hence in the present study, a convenience sample (n = 100) was decided upon.
Enrolment process, inclusion, and exclusion criteria
The study population (recruited by nonprobability sampling) comprised parents of students having LEP,,,, who were ≥8 to ≤18 years of age and who were studying in English-medium schools. A total of 100 parents were recruited. Only parents of students with LEP with co-morbid specific learning disabilities were excluded from the study.
Diagnosis of LEP
Each student had been referred to our clinic for PSP and had undergone clinical and psycho-educational evaluation before the diagnosis of LEP was confirmed. An otolaryngologist and an ophthalmologist documented that hearing or visual impairment was <40%, if any, respectively. The counselor ruled out that any environmental deprivation due to a poor home or school environment, or any emotional problem was not primarily responsible for a student's PSP. The pediatrician took a detailed clinical history and did a clinical examination. The clinical psychologist used the Wechsler Intelligence Scale for Children-Revised (M.C. Bhatt's Indian adaptation) or the Binet-Kamat Test of Intelligence to determine that the student's IQ score was ≥85; confirming average to above average intellectual functioning. Using a locally developed and validated English curriculum-based test, the special educator conducted an educational assessment in specific areas of learning, namely, basic learning skills, reading comprehension, oral expression, listening comprehension, written expression, mathematical calculation, and mathematical reasoning. Based on this test, an academic underachievement of beyond two years below the student's actual school grade placement or chronological age led to a diagnosis of LEP. For students studying in class standards XI and XII, the Woodcock-Johnson Test of Achievement, was used to diagnose LEP.
Using information from the student's parents and teachers, a diagnosis of co-occurring attention-deficit/hyperactivity disorder (ADHD), if present, was made by ascertaining that the student's specific behaviors met the required Diagnostic and Statistical Manual of Mental Disorders-5 criteria. ADHD is characterized by persistent hyperactivity, impulsivity, and inattention and is known to impair academic learning.
In our clinic and hospital, all consultations and tests were conducted free of cost. However, some parents who wished to do their child's audiometry and visual testing and occupational therapy assessment from a private clinic were allowed to do so.
In the present COI study, data collection of costs was carried out from the “societal” perspective, namely both from the “afflicted families” (viz. the parent) and from the “healthcare provider's” perspectives., To collect data, the present study followed the “prevalence-based retrospective” approach which measures the COI in the present and the past in a given year.,
Data collection of costs from the “afflicted families” perspective
To estimate the costs from the “afflicted families” perspective, the “bottom-up” approach (”person-based”) was followed which assigns costs to individuals with the health condition of interest., A structured questionnaire was used to interview the parent to collect data related to three types of treatment costs of the afflicted students, viz. (1) “direct costs (medical and non-medical)”,, (2) “indirect costs”,, and (3) “intangible losses.”, For documenting the “direct costs (medical and non-medical)” and “indirect costs” of individual students the parents were asked to state the costs incurred since the time their PSP had been noticed.
(1) “Direct costs”:
(a) “Direct medical costs”: The direct medical costs (defined as the medical care expenditures incurred for diagnosis, treatment, and rehabilitation), of the students included all out-of-pocket payments for: (i) out-patient registration paper of our clinic, (ii) audiometry (including otolaryngologist's consultation charges, travelling expenses for doing audiometry), (iii) vision testing (including ophthalmologist's consultation charges, travelling expenses for doing vision testing, cost of spectacles/contact lenses if prescribed), (iv) remedial education, if availed (including remedial teacher's charges and travelling expenses); one-to-one hourly remedial sessions with a remedial teacher twice or thrice weekly for a few years to achieve adequate English proficiency,; (v) occupational therapy, if availed, (including occupational therapist's consultation charges, travelling expenses), (vi) psychiatric evaluation, if done (including psychiatrist's consultation charges, travelling expenses), (vii) counseling, if availed, (including counselor's consultation charges, travelling expenses), (viii) medications (for PSP and co-occurring medical condition, if any, such as epilepsy), including complementary therapies such as Ayurveda, homeopathy, if availed, and (ix) other investigations (electroencephalogram, magnetic resonance imaging/computed tomography (CT) brain, blood tests (e.g., vitamin B12/folic acid/thyroid hormone levels), if done.
(b) “Direct non-medical costs”: The direct non-medical costs, of the students included all out-of-pocket payments for transportation costs for traveling to the learning disability clinic and school.
(2) “Indirect costs”:
Indirect costs included: (i) “loss of earnings” (average annual loss of wages due to absenteeism), (ii) “productivity losses” (average annual loss of income due to loss of job) for the parent, as valued by the human capital method,, and (iii) costs of “tuition classes,” including its traveling expenses. In our city, many parents due to their lack of knowledge of English prefer tuition, a form of additional individualized teaching, in school subjects taken from a private regular teacher which is not the therapy for their child's LEP, and (iv) costs of “academic enhancement measures,” namely, books/compact discs bought to improve student's scholastic performance or costs of recreational activities classes (e.g., dance/swimming/art/craft) to channelize the student's energies into academics.
(3) “Intangible costs”:
Intangible cost data was collected by documenting the willingness-to-pay (WTP) value using the contingent valuation technique, a recommended method in COI studies that adopt a societal perspective., The parent would be provided with an initial bid (namely, their per capita income to minimize the starting bid bias) and asked whether they would like to pay this amount of money as a one-time payment for a remedy that would cure their child's PSP. If the parent answered positively (negatively), then the amount was increased (decreased) (i.e., doubled or halved) until the parent declined (accepted) the specified amount.
Data related to 12 sociodemographic variables (”potential confounders”) were documented using a supplementary questionnaire. These included: (i) age, (ii) gender, (iii) religion, (iv) mother tongue of student, (v) number of sibling(s), (vi) intelligence quotient (IQ) score of the student, (vii) school class standard, (viii) school educational board, (ix) socioeconomic status, as determined by the Kuppuswamy's socioeconomic scale, (x) absence or presence of co-morbid ADHD, (xi) absence or presence of co-occurring chronic medical illness, and (xii) duration of PSP.
Data collection of costs from the “healthcare provider's” perspective
The direct medical costs from the “healthcare provider's” perspective,, i.e., the “learning disability clinic costs” was computed by calculating the expenditure to run it, namely; “overt expenditure”: (i) salaries paid to the secretaries, medical officer, counselor, clinical psychologist and special educator, (ii) clinic's mobile number expenses, stationery, and photocopying expenses for maintaining patient records and for psychological tests material; and the on-going “covert expenditure” (namely, electricity, water, and building maintenance expenses) during the period of study.
All the costs were documented in Indian Rupees (INR) (1 US$ = ~73.9 INR in 2021).
Estimation of the economic burden of LEP from the “afflicted families” perspective
First, the “direct costs” and “indirect costs” for every student were estimated as a simple sum of all their components under the individual costs. Second, every student's “total costs” was estimated by adding his/her “direct costs” and “indirect costs”. Third, the “direct costs”, “indirect costs” and “total costs” of all 100 students were estimated. Fourth, the “average annual total costs” of every student were computed by dividing his/her “total costs” by the number of years the PSP had been noticed. Fifth, the “average annual total costs” of all 100 students were added to estimate the “average annual total costs of LEP” for afflicted families. Sixth, the “intangible costs” of LEP were estimated from the data collected.
Estimation of the economic burden of LEP from the “healthcare provider's” perspective
By extrapolating the “learning disability clinic costs” calculated over the study period of 21 months to 12 months, the “average annual learning disability clinic costs” was estimated.
Estimation of the economic burden of LEP from the “societal” perspective
The “average annual total costs” for afflicted families were added to the “average annual learning disability clinic costs” to estimate the “average annual total costs of LEP” for society. The “average annual total costs of LEP” per student was calculated by dividing the “average annual total costs of LEP” for society by the number of participants (n = 100).
The data were analyzed using the Statistical Package for Social Sciences, Version 25.0 for Windows (Chicago, USA). Cost data were first assessed for normality using the Shapiro-Wilk test which indicated non-normal distributions. Initially, univariate regression analysis was carried out to evaluate the unadjusted impact of each of the 12 sociodemographic variables (”independent variables”) on the (”dependent”) variables [direct costs, indirect costs, total costs, and intangible costs]. For the mother tongue variable, binary classification of Marathi and Hindi versus all other languages [non-Marathi and non-Hindi] was made. Furthermore, a purposeful selection of variables (cut-off levels of P < 0.20 on the univariate analysis) was done; and a multivariate regression analysis was performed for determining the “independent” impact that these selected variables had on the (”dependent”) variables [direct costs, indirect costs, total costs, and intangible costs]. A two-tailed P value of < 0.05 was considered significant.
Characteristics of students with LEP
The median age of students was 166.5 months (min = 109, max = 210; IQR = 44.5). The boys': girls' ratio was 5.25:1. A majority (74%) of students had Marathi or Hindi as their mother tongue; 40 and 34, respectively. The remaining 26% of students had the following as their mother tongue: Gujarati (10), Telegu/Urdu (3 each), Kutchi/Malayalam/Sindhi (2 each), and Kannada/Konkani/Marwari/Tulu (1 each). Their median IQ score was 93.5 (min = 85, max = 125; IQR = 10). Only nine students had a co-occurring chronic medical illness (eight had epilepsy and one had asthma, respectively). Other details of the sociodemographic characteristics (variables) of the students are shown in [Table 1]. No parent or student declined consent/assent for participation in the study. Of the informants, 26 (26.0%) were the students' mothers, and 74 (74.0%) were the fathers.
Economic burden of LEP from the “afflicted families” perspective
“Direct costs” estimated for all 100 students was INR 826,736 [eight hundred twenty-six thousand, seven hundred thirty-six]; (median 3,245; IQR 8,180). The components of the “direct costs” are shown in [Table 2]a. None of the students had undergone any psychoeducational testing or counseling before being referred to our clinic. Also, both these services are conducted free of charge in our clinic. Expenditure availed on non-medical costs, remedial education, and audiometry comprised 52.81%, 14.08%, and 12.16% of the “direct costs”, respectively. Among the 100 students enrolled only two students had received remedial education, and both had discontinued it prematurely, after availing it for 10 months (spending INR 30,000 [thirty thousand]), and 12 months (spending INR 86,400 [eighty-six thousand, four hundred]), respectively.
“Indirect costs” estimated for all 100 students was INR 3,828,220 [three million, eight hundred twenty-eight thousand, two hundred twenty]; (median 20,000; IQR 34,000). The components of the “indirect costs” are shown in [Table 2]a. “Loss of earnings” comprised 60.14% of the “indirect costs”. There were no “productivity losses”, as no previously working parent had left his/her job to look after their child's studies, after their PSP had begun. Among the 100 students enrolled, 97 had received tuition, which comprised 39.86% of the “indirect costs”.
“Total costs” estimated of all 100 students was INR 4,654,956 [four million, six hundred fifty-four thousand, nine hundred fifty-six]; (median 30,605; IQR 36,910). “Indirect costs” comprised 82.2% of the “total costs”.
Average annual total costs
The duration of PSP noticed by parent in their children is shown in [Table 2]b. The median duration of PSP of students was three years (min = 1, max = 8, IQR = 1). Maximum students (28; 28.0%) had an “average annual total cost” in the range INR 5,001–10,000 [Table 2]c. The “average annual total costs” estimated was INR 2,041,013 [two million, forty-one thousand, thirteen]; (median 10,223; IQR 15,709).
All 100 parents participated to estimate the “intangible costs” of LEP. “Intangible costs” estimated for 100 students was INR 1,906,300 [one million, nine hundred six thousand, three hundred]; (median 10,000; IQR 15,000) as shown in [Table 2]d.
Economic burden of LEP from the “healthcare provider's” perspective
The “average annual learning disability clinic costs” were estimated to be INR 2,169,146 [two million, one hundred sixty-nine thousand, one hundred forty-six] as shown in [Table 2]d; of which the “overt expenditure” to run the clinic was found to be INR 729,146; 33.6%]; namely, (i) expenditure on salaries INR 698,689 [six hundred ninety-eight thousand, six hundred eighty-nine, 32.2%], and (ii) miscellaneous expenses, namely stationery and photocopying expenses and clinic mobile recharging expenses INR 30,457 [thirty thousand four hundred fifty-seven, 1.4%]. The “covert expenditure” (namely, electricity, water, and maintenance expenses calculated as INR 1,800 per square foot per year, as per hospital data) was INR 1,440,000 [one million, four hundred forty thousand; 66.4%].
Economic burden of LEP from the “societal” perspective
The “average annual total costs of LEP” were estimated to be INR 4,210,159 [four million, two hundred ten thousand, one hundred fifty-nine]; and the “average annual total costs per student with LEP” was estimated to be INR 42,102 [forty-two thousand, one hundred two] as shown in [Table 2]d.
Impact of variables on the economic burden of LEP
Impact on direct costs of LEP
As shown in [Table 3]a, only “age of student” and “duration of PSP” were the significant predictors of the “direct costs”. In other words: (i) for every monthly increase in age of the student, lower was the family expenditure by INR 169 [one hundred sixty-nine] on “direct costs” (P = 0.006); and, (ii) for every yearly increase in the duration of PSP, higher was the family expenditure by INR 214 [two hundred fourteen] on “direct costs” (P = 0.024).
Impact on indirect costs of LEP
As shown in [Table 3]b, only “mother tongue” and “socioeconomic status” were the significant predictors of the “indirect costs”. In other words: (i) families whose mother tongue was non-Marathi/non-Hindi had an increased expenditure by INR 27, 077 [twenty-seven thousand seventy-seven] (P = 0.018) on “indirect costs”, relative to those whose mother tongue was Marathi or Hindi; and, (ii) lower the “socioeconomic status” of the student's family, lower was the family expenditure by INR 22,926 (twenty-two thousand nine hundred twenty-six) (P < 0.01) on “indirect costs”.
Impact on total costs of LEP
As shown in [Table 3]c, only “mother tongue” and “socioeconomic status” were the significant predictors of the “total costs”. In other words: (i) families whose mother tongue was non-Marathi/non-Hindi had an increased expenditure by INR 32,612 [thirty-two thousand six hundred twelve] (P = 0.008) on “total costs”, relative to those whose mother tongue was Marathi or Hindi; and, (ii) lower the “socioeconomic status” of the student's family, lower was the family expenditure by INR 27,228 (twenty-seven thousand two hundred twenty-eight) (P < 0.01) on “total costs”.
Impact on intangible costs of LEP
As shown in [Table 3]d, only “mother tongue” and “socioeconomic status” were the significant predictors of the “intangible costs”. In other words: (i) families whose mother tongue was non-Marathi/non-Hindi had an increased expenditure by INR 18,251 [eighteen thousand two hundred fifty-one] (P = 0.001) on “intangible costs”, relative to those whose mother tongue was Marathi or Hindi; and, (ii) lower the “socioeconomic status” of the student's family, lower was the family expenditure by INR 13,901 (thirteen thousand nine hundred one) (P < 0.01) on “intangible costs”.
A COI study is useful to inform the economic burden of a condition and aid the decision-making for health resource allocation., The present study has documented that the economic burden of LEP in the city of Mumbai is huge for the afflicted families, the healthcare provider, and society at large. “Indirect costs” far outweighed “direct costs” of LEP (82.2% versus 17.8%). The hypothetical “intangible costs” of LEP are far from modest. Furthermore, multivariate regression analysis revealed that: (i) “younger age of student” and “longer duration of PSP” were the significant predictors of increased “direct costs”; (ii) “mother tongue being non-Marathi or non-Hindi” and “higher socioeconomic status” were the significant predictors of increased “indirect costs”, “total costs”, and “intangible costs.”
We cannot compare the present study with previous work because there isn't any. A PubMed search using the medical subject headings (MeSH) words “economic burden” and “limited English proficiency” did not reveal any study which has evaluated the economic burden of LEP in students.
What is the importance of the present study? First, this study shows that in our city LEP continues to be diagnosed late (median age 13.9 years, IQR 3.7). Ideally, LEP should be diagnosed when the afflicted student is in early primary school so that there is adequate time to avail adequate remedial education to achieve academic competence. Second, this study shows that almost all parents (97%) of students with LEP wastefully spend an enormous amount on private “tuition classes.” Third, this study shows that very few (2%) students with LEP avail remedial education and that too stop it prematurely; while an overwhelming majority (98%) does not undergo any remedial education. Likely, the high costs of remedial education (approximately INR 36,000–108,000 annually) in our city could be one of the main reasons for this poor compliance. Currently, very few schools have resource rooms for remedial education within their premises and most parents have to avail remedial education from private special educators. Fourth, 36% of parents reported a “loss of earnings” due to absenteeism from work due to their child's PSP resulting in a significant loss of income for their families. Fifth, parents are willing to pay high amounts (median, INR 10,000; IQR 15,000) for a hypothetical cure for their child's condition. “Intangible costs” reflect parental anguish in dealing with their child's condition and need to be documented for a comprehensive estimation of the economic burden of a condition., Sixth, we found out that the higher socioeconomic status of the family was predictive of higher intangible costs. Perhaps parents from high socioeconomic status were overwhelmed that their child's LEP would adversely impact their child's social and economic future.
What can be done to reduce the economic burden of LEP? All “regular” classroom teachers should be sensitized to suspect this condition early when the child is in early primary school. School principals too should similarly refer such students to a learning disability clinic early, for a timely diagnosis of LEP. School management should become proactive to set up resource rooms and employ remedial teachers to ensure that these children receive regular and affordable remedial education and gain academic competence. This would also help reduce parental anguish and the “intangible” costs of this condition. Counseling parents would help improve their understanding of LEP and reduce wasteful expenditures on tuition.
We have no proper explanation for why: (i) younger age of students was predictive of increased direct costs, or (ii) non-Marathi or non-Hindi speaking families had significantly higher “indirect costs”, “total costs”, and “intangible costs.” These aspects are beyond the scope of the present study. Future studies are required to evaluate the role of these sociodemographic factors in influencing these costs.
The strengths of this study include high participation and high response rates. This study has its limitations. First, the convenience sampling of this study restricts the generalization of its results to the population as a whole. Second, the nonprobability sampling of this study may have led to a recruitment bias in our findings. Third, the present study's results are subjected to recall bias of participating parents. Fourth, students with LEP from the lower socioeconomic strata of society were not represented in our study population. Very few students, hardly 4%, referred to our clinic belong to the lower socioeconomic strata of society. Most of them are studying in poor-quality schools and go undetected because either the school authorities do not refer or their parents do not bring them for assessment of their PSP. However, we do not believe that these limitations adversely affect the utility of our results. Due to the limitations outlined above and the general paucity of data on the economic burden of LEP, there is a need for such studies to be carried out in clinics situated all over the country/world.
LEP is a cost-intensive condition (indirect > intangible > direct costs). To reduce the enormous economic burden of LEP, all primary school students with PSP should be evaluated for LEP to aid in its early diagnosis. Afflicted students should be offered affordable remedial education within their schools. Parents should be counseled to reduce wasteful expenditures on tuition.
We thank all the parents and students who participated in the present study.
Financial support and sponsorship
The Learning Disability Clinic at our institute is partially funded by a research grant from MPS Interactive Systems, Mumbai, Maharashtra, India.
Conflict of interest
Dr. Sunil Karande is the Editor of the Journal of Postgraduate Medicine.
[Table 1], [Table 2], [Table 3]