English Language Learners Needs/Content

Literature Review for Staff Educational Plan Regarding Hispanic Limited English Speaking Patients and Language Needs

Introduction The Hispanic population in the United States (US) is the largest and fastest growing minority in the US. Approximately one out of every ten people in the US speaks Spanish at home and it has been reported that about half of these state they do not speak English well (Dubard & Gizlice, 2008). The Hispanic minority in the US has roots in Mexico, other central and southern American countries, Puerto Rico and Cuba. The continued growth of this minority is related to continued migration from these countries into the US as well as a high fertility or birth rate for those already residing in the US (Morales,Lara, Kington,Valdez, Escarce, 2002). Literature reviews have repeatedly reported that an inability to speak English well is a barrier to accessing and participating in healthcare activities (Collins et al, 2004; Dubard & Gizlice, 2008; Jacobs et al, 2004; Nailon, 2002).Language is repeatedly noted to be a barrier for this population in accessing healthcare. When Hispanic patients are admitted to a hospital or other healthcare facility, if there is an inability to speak English well it can impact their ability to fully understand and participate. There are also cultural issues which impact Hispanic patients’ response to care giving as well (Gordon,1994; Mayo,et al,2007) When patients are admitted to a hospital, a physical assessment is completed along with a history, which is usually provided verbally. However, if the patient experiences limited English proficiency (LEP), it is difficult for them to explain their problems and concerns as well as to respond to any questions. Although translation and interpreters are often available, they are not always available as one interpreter can be assigned to a whole hospital or clinic, or are only available at certain times. Sometimes, staff overestimate these patients ability to speak and understand English (Zun, Sadoun and Downey ,2006). Nurses and other healthcare providers are left to decide how best to handle these patients who cannot communicate fully.

This literature review has been undertaken to examine the issues of hospitalized Hispanic patients and language as a barrier to fully participating in one’s own healthcare.

This information will be used to support provision of an educational module for nurses and other healthcare providers to heighten their awareness of these issues and to equip them with tools to assist these patients by way of both a language assessment and access to appropriate expanded resources for language assistance.

Review of Literature To locate articles for this review CINAHL, Cochrane, Pubmed data bases were searched. The search terms used were: Hispanic, language assistance, interpreters, translation, and culture. Twelve articles were reviewed for this literature search. The dates of publication ranged from 1994 through 2008; however ten of these articles were published from 2004 thru 2008. Six articles were chosen for review. The article published in 1994 was included because it related to cultural and folk health beliefs, and was thought to be still pertinent. A recurrent theme throughout the literature reviewed was the issue of limited English proficiency (LEP) as a barrier to accessing healthcare. Another recurrent theme was the need for more research in all areas. The articles will be reviewed in a chronologic order.

Health care is sought after, experienced and interpreted through one’s own cultural orientation. The qualitative study conducted by Gordon (1994) used a focus group of 11 Hispanic women to conduct an interview regarding Hispanic folk treatments and healthcare beliefs. She sought to describe traditional Hispanic health care practices and cultural values. She noted Leininger’s theory of culture care as the theoretical framework. These participants were a convenience sample obtained from a class of adult education students who volunteered to participate. A 90 minute group interview was held. Four general questions were used to guide the semi-structured process conducted in Spanish. The interview was conducted in an informal manner and it was observed the participants took notes and shared information with each other. Data obtained was grouped into 75 statements about healthcare and treatments and then evaluated using qualitative analysis techniques. Gordon noted characteristics of Hispanic culture regarding the role of women and that medical information is transmitted from mother to daughter. She also noted that women are the primary caregivers and decision makers and that the family only becomes involved when the woman can no longer treat the problem. Critical decisions are made by the entire family. Care may be delayed as a family goes through this process.

Gordon believes negotiation is needed by western care providers to integrate their care with the more traditional Hispanic approaches. Gordon then goes on to describe a number of traditional folk remedies often using spices, herbs, ointments and other material found in most households as well as a few more unusual treatments. Gordon discusses the responsibility of nurses to increase their cultural awareness to provide culturally appropriate care; identifies the value of mutual respect in promoting understanding and acceptance of differing healthcare practices and identifies negotiation as central to caring for patients with a different cultural belief system. This study was included because it provided an extensive, thoughtful, well researched perspective regarding the balance and intermingling of Hispanic culture and healthcare practices. It is an older study, however, and these values may not be currently reflected in the general Hispanic population as much, due in no small part to the information age, use of computers, cell phones and television.

Noting the sizeable number of Americans who do not speak English as their primary language and that nearly half of these people report speaking English less than very well, Jacobs, Shepard, Suaya and Stone (2004) describe a situation where a limited ability to speak English is associated with a lack of access to healthcare. They note a lack of primary physician, less preventative care and a reported dissatisfaction with healthcare received; they also suggest there may be a safety risk as well. They go on to depict a situation where healthcare providers attempt to provide care to limited English speaking patents, experience a lack of translation services and may use family or friends even though this practice has been shown to have a negative effect. The lack of adequate translation services may be due to cost concerns. There is limited data available regarding the effect on overall cost and quality of care vs. the cost of increased translation services. Jacobs,et al. designed a 2 year study to investigate the costs and benefits of a comprehensive interpreter program for limited English speaking patients. The participants in this quantitative study were members of a large, well established Health Maintenance Organization (HMO). The study group or interpreter service group was comprised of 380 patients who had used the interpreter service at least once during the past year. Translation services were available 24 hours a day by phone or in person and at every encounter with the HMO. The comparison group was a randomly selected group of 4119 patients from all other eligible members. They received no additional services. Data was obtained from the electronic medical record regarding utilization of primary care, emergency care, preventive care services and the associated costs. Included in the costs for the study group was the expenditure for the increased interpreter services. The cost of clinical services was compared between the groups and the change in cost per person from year 1 to year 2. There was also a comparison of overall utilization of services between groups. The results of this study did not demonstrate a reduction in costs for the study group, but did demonstrate a significant increase in utilization of recommended primary care services, physician office visits and prescriptions filled for this group. There was a small but not significant reduction in emergency room visits for the study group, as well. The annual cost of interpreter service per person was $279 and this was approximately the amount of additional cost noted per person for this group as compared to the comparison group. These findings are significant believe Jacobs et al. because this demonstrates access to care can be greatly improved for minimal cost by providing adequate interpreter services. They also suggest that an increase in preventative and primary care services may lower costs in the future. Limitations of this study include the small size of the study group, that the data were obtained after only 1 year of implementation of the new interpreter services and that there may be other possible costs or cost savings not fully noticed due to the length of time of this study. The annual cost of an interpreter was higher than a national average. Despite the limitations, this study demonstrates that an increased language assistance or translation services leads to improved access to healthcare with better care for patients who have limited English proficiency.

Controlling pain for patients who have a limited ability to speak English is a challenge but not an unusual situation in many hospitals throughout the US. Noting that 35 million Hispanic people live in the US who cannot speak English or do not speak English very well, Collins, Gullette and Schneph (2004) in their descriptive study describe the barriers to providing care, especially pain management for these patients and identify possible solutions. The barriers include a lack of interpreter services, cultural interpretations of pain, and that the use of untrained interpreters can result in errors. They also note the Health Insurance Portability and Accountability Act (HIPPA) which prevents family members from acting as interpreters due to confidentiality concerns. The Americans with Disabilities Act stipulates that patients will have access to language assistance and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) addresses a patient’s right to pain management and effective communication (2008). This study primarily addresses pain management in the setting of a language barrier for a Hispanic patient. Collins et al. suggest health care providers learn basic Spanish in order to ask simple questions and be able to handle immediate issues such as pain control. They also suggest use of a translated words and phrases on cards, pain scales in Spanish and an audio recording produced by the university’s Spanish department. They recommend use of formal translators, education of more bilingual staff, and lobbying for more and reimbursable language assistance in an effort to provide culturally competent care. This study describes a common situation, where a language barrier impairs the ability to deliver care; the issues are clearly noted as well as some of the regulatory issues. But the solutions, though appropriate, are not innovative and for those facing this situation daily, there is little offered to help the nurse caring for this patient.

In an attempt to assess the true English language proficiency of Hispanic patients who report they are able to speak and understand English, Zun, Sadoun and Downey (2006) designed a quantitative study of adult patients in the emergency department (ED) of an urban trauma center. They hypothesized that many patients did not speak English as well as they initially reported. The purpose of this study was twofold; first, the study was designed to assess the English language proficiency of Hispanic patients who reported they spoke English. The second purpose of this study was to determine whether there was agreement between the patients’ tested level of English language proficiency and the informal appraisal of language proficiency by healthcare staff. Zun et al. note that the Hispanic population is the fastest growing minority in the US and postulate that with the rise of minority populations who may not always speak English; healthcare institutions must make accommodations to address their communication needs. The clinical consequences of inaccurate communication can lead to error or at best unnecessary testing. Also noted was dissatisfaction with care by Spanish speaking patients, and that physicians in the ED did not always fully recognize or understand the initial complaints. This was a convenience study undertaken in a large urban level-1 trauma center, also a teaching hospital. The subjects in the patient group were stable ED patients with Hispanic surnames who could speak some English and agreed to participate. There were 105 participants in this group. The 11 physicians in the ED were all board certified and all 45 ED nurses were Trauma Certified. A verbal test of competency was desired by the researchers but none could be found so two written language tests were used: the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Short Test of Functional Health Literacy in Adults (STOFHLA). Research assistants administered these tests by interview to each subject, followed by an 8 item questionnaire asked of each patient’s physician and nurse regarding their perception of the patients English language proficiency. The results of this study indicate that a majority of patients who state they can speak English, in fact can do so. However, there are is a significant proportion of these subjects who did not test as proficient, 28% to 33% depending on which test was used. Of note, both nurses and physicians overestimated the language proficiency for those patients who did not pass the test as proficient in English; they did however, accurately estimate the language proficiency for patients who passed the exam. Limitations of this study included the fact that the proficiency test could not be given orally. Another limitation was the inner-city sample used in this convenience study, rather than a consecutive sample. This was a thorough, relevant study regarding a frequent occurrence in an ED where patients when queried about their ability to speak English may report incorrectly and also that healthcare personnel may overestimate the ability of these patients to speak English. (Zun,et al. 2006)

In a comprehensive review, Mayo, Sherril, Sundareswaran and Crew (2007) surveyed the literature to examine the reported attitudes and perceptions of both patients and care providers in the treatment of Hispanic patients. Mayo et al. note themes of communication, attitudes and perceptions, cultural competence and type of illness for Hispanic patients. Whereas, for healthcare providers themes emerged regarding communication and language barriers, perceptions of care and differences in care and services provided. Recommendations for further study were made.

Again, the growth of the Hispanic minority in the US is noted along with mention that Hispanics are the largest minority in the US. However, they still face barriers as they attempt to access healthcare services; these barriers include insurance, financial, language and immigration status barriers as well as barriers related to healthcare provider practices, behaviors and cultural issues. In terms of providing culturally congruent care, the behaviors of respect, caring, understanding, patience and understanding were highly valued by this minority. Despite the fact that numerous studies have looked at the experience of Hispanics regarding healthcare, the intention of this survey was provide a thorough and exhaustive review of the literature regarding  the not only the experiences and perceptions of the Hispanic patient but also that of the treating health care provider. A broad search was initiated using a number of databases, 30 articles were reviewed regarding the Hispanic patients’ experiences and 20 articles were examined for the provider perspective and their perceptions of their own cultural interpretations. Inexperienced providers as well more experienced healthcare providers were studied. The inexperienced providers noted a lack of confidence in their own ability to provide culturally appropriate care but with more experience and education regarding these issues an increase in competence and ability was reported.

The design for these studies varied from survey to focus groups and interviews. Physicians reported less satisfaction providing care for Hispanic patients because of issues of non compliance, use of alternative therapies and excessive respect for medical personnel which resulted in less questions being asked; there was also a perception that these patients did not fully accept responsibility for their own care. Additionally, there were concerns surrounding financial, insurance and immigration issues. These physicians felt that developing a more personal relationship was beneficial in dealing with these patients. Another physician concern related to the use of interpreters; there was a concern regarding accuracy of interpretation and the increased time spent waiting for interpreters to arrive.

Emerging from the review of the 30 studies describing the Hispanic experience of healthcare were themes of communication and language barriers, perceptions of care and differences in care received from other patient populations. Language was noted to be a major barrier and use of an interpreter resulted in concern over accuracy of the interpretation and loss of control of the communication process. One study noted that despite the use of alternative therapies, conventional western medicine is considered superior. Four studies identified the importance of family in medical decision making and recommended healthcare providers be increasingly aware of this. These same studies revealed a preference on the part of Hispanic patients to develop a relationship of paternalistic dependence with their physicians with a kind and respectful attitude. Again, it was noted that healthcare providers who participated in education to increase their own cultural awareness experienced significant improvement in patients’ perception of them as well as a decrease in interpreter use.

To summarize this significant study, the themes that emerged seem familiar; but the differences between patients and providers should be noted. Language is the primary factor serving as a barrier, impacting both patient and provider. Patients report a preference for using family to translate whereas providers would prefer a professional translator. A lack of time is considered a barrier by providers. Patients report dissatisfaction with care provided that is different based on ethnicity. Limitation of this comprehensive review of qualitative studies is the lack of noting the many subgroups of the Hispanic population and that the results cannot be generalized to all these groups. Another limitation is that even though this review is designed to address both patient and provider issues they are not the same, cannot really be compared and no study looked at both. The authors of this review recommend further study to include both patients and providers; they also note the importance of education and training regarding cultural issues not only in medical schools but at all levels provider practice. Spanish-language preference is been associated with decreased access to care and decreased use of preventive health care services, Dubard,& Gizlice (2008). In what they believe to be the first in-depth, national, population-based assessment of the relationship between Spanish language preference and measures of access to healthcare and health status, Dubard and Gizlice examine data obtained from national telephone surveys conducted by the Centers for Disease Control (CDC) using the Behavioral Risk Factor Surveillance System (BRFSS) for the years 2003 to 2005. These surveys are used by the CDC to monitor progress toward meeting the goals and objectives of Healthy People 2010 Initiative; a primary goal of this initiative is to eliminate disparities in healthcare ( USDHHS, 2000). The BRFSS is a continuing, state by state, random dialed telephone survey of US households who have landline telephone service. There is an optional Spanish language portion of this survey which, though available since 1987, has only recently been used. The researchers report that this survey of 45076 Hispanic adults from 23 different states was representative of approximately 90% of the total US Hispanic populace. The purpose of this study and examination of data was threefold; first, to provide a comprehensive national picture of the state of health, access to healthcare and areas of health concern for Spanish speaking US Hispanics. The second purpose was to determine the association of language with the 25 indicators identified and the third purpose was to investigate regional differences in US Hispanic populations. This is an ambitious agenda.

The self-identified US Hispanics were divided into two groups, those who preferred to complete the survey in Spanish and those who preferred to complete the survey in English. There was also a further regional geographic grouping. The researchers identified 25 indicators from the survey to address the issues of access to care, current health status, use of preventive care and risk factors. Language was considered to be the primary independent variable. Covariables were identified as well to include age, gender and education. Data was analyzed using the x2 test and a multivariate logistic regression model was developed for each indicator along with adjusted odds ratios to compare English-speaking Hispanics with Spanish speaking Hispanics. The review of the published findings reveals a wealth of information has been obtained.

Language remains associated with disparities in health and especially access to healthcare services; however the overall health of the Spanish-speaking Hispanic population is not markedly worse than the English-speaking Hispanic population, though access to health care services and participation in preventive care and health maintenance activities is less. There was note of the phenomenon of a “healthy immigrant” effect whereby it is proposed that recent immigrants are healthier members of their population subgroup(Dubard & Gizlice). Limitations of this study relate to the complexity of the amount and types of data generated, many variables were identified needing further investigation. However, the need for a more standardized assessment of English language proficiency was noted. The surveying only of adults with telephone landlines is also a limitation as Spanish-speaking Hispanics are noted to be economically disadvantaged and may not have access to a landline. The issue of self-reporting may also be considered a limitation. The researchers conclude that the US Spanish-speaking population is a group at risk with lower income and education status, extremely limited access to healthcare and lower perceived health status.

Summary The preceding literature review has been conducted to provide an understanding of the background, identification of variables and current state of the issue of providing culturally appropriate healthcare services to the Hispanic limited English speaking population throughout the US. This review also serves as the information base for an educational module for healthcare personnel to heighten Hispanic cultural awareness and to perform a language assessment as early as possible in the healthcare encounter. However, after reviewing the literature which repeatedly describes the inability to speak English proficiently as a barrier or indicator of negative findings; and although it is still necessary to assess the language proficiency of Hispanic patients within the current health care system to adequately meet their needs; a consideration for the future is a commitment to the re-doubling of efforts to provide English language education and  making it available in a variety venues with an ultimate goal of eliminating this barrier to not only health but so much else.

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