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1.  Pharmacists’ Provision of Information to Spanish-speaking Patients: A Social Cognitive Approach 
Background
Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients use medications safely and effectively, however scant research has explored factors that may impact pharmacists’ communication with Spanish-speaking patients (SSPs).
Objective
Guided by Social Cognitive Theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists’ cognition and pharmacists’ communication with SSPs.
Methods
A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to a SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of Spanish-speaking patients) and pharmacists’ cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition and pharmacists’ communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.
Results
Of the 183 respondents, the majority were white (91%) and male (63%) with a mean age of 47 years (SD=12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.
Conclusions
Study findings identify both environmental factors and cognition that could contribute to pharmacists’ communication behavior with SSPs. Thus, future interventions to improve pharmacists’ communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery, as well as strengthening pharmacists’ self-efficacy beliefs.
doi:10.1016/j.sapharm.2012.02.003
PMCID: PMC4441301  PMID: 22554399
Pharmacists; Communication; Spanish-speaking patients
2.  Access to Multilingual Medication Instructions at New York City Pharmacies 
An essential component of quality care for limited English proficient (LEP) patients is language access. Linguistically accessible medication instructions are particularly important, given the serious consequences of error and patient responsibility for managing often complex medication regimens on their own. Approximately 21 million people in the U.S. were LEP at the time of the 2000 census, representing a 50% increase since 1990. Little information is available on their access to comprehensible medication instructions. In an effort to address this knowledge gap, we conducted a telephone survey of 200 randomly selected NYC pharmacies. The primary focus of the survey was translation need, capacity, and practice. The majority of pharmacists reported that they had LEP patients daily (88.0%) and had the capacity to translate prescription labels (79.5%). Among pharmacies serving LEP patients on a daily basis, just 38.6% translated labels daily; 22.7% never translated. In multivariate analysis, pharmacy type (OR=4.08, 95%CI=1.55–10.74, independent versus chain pharmacies) and proportion of Spanish-speaking LEP persons in the pharmacy’s census tract (OR=1.09, 95%CI=1.05–1.13 for each 1% increase in Spanish LEP population) were associated with increased label translation. Although 88.5% of the pharmacies had bilingual staff, less than half were pharmacists or pharmacy interns and thus qualified to provide medication counseling. More than 80% of the pharmacies surveyed lacked systematic methods for identifying linguistic needs and for informing patients of translation capabilities. Consistent with efforts to improve language access in other health care settings, the critical gap in language appropriate pharmacy services must be addressed to meet the needs of the nation’s large and ever-growing immigrant communities. Pharmacists may require supplemental training on the need and resources for meeting the verbal and written language requirements of their LEP patients. Dispensing software with accurate translation capability and telephonic interpretation services should be utilized in pharmacies serving LEP patients. Pharmacists should post signs and make other efforts to inform patients about the language resources available to them.
doi:10.1007/s11524-007-9221-3
PMCID: PMC2232041  PMID: 17926130
LEP patients; Medical instructions; Pharmacists; Label translation;  Immigrants; Language access
3.  English-language competency of self-declared English-speaking Hispanic patients using written tests of health literacy. 
INTRODUCTION: Hispanic patients comprise the largest minority population in the United States. The federal government mandates that healthcare providers be able to communicate with those patients who have limited English ability. The primary purpose of this study was to assess the English-language proficiency of self-declared English-speaking Hispanic patients in the emergency department (ED). The secondary purpose was to determine concordance between patients' tested English proficiency and perceived proficiency by nurses and physicians. We hypothesized that many patients who state that they are able to speak English do not in fact possess sufficient ability to communicate in English. METHODS: A convenience study was conducted in an urban level-1 pediatrics and adult trauma center with 45,000 annual visits. Participants included adult patients and parents of pediatric patients, all of which spoke Spanish as their first language. Since there were no verbal tests of English-language ability used in medicine, two written tests were used as surrogates-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 to patients with Hispanic surnames to assess the English comprehension of patients who stated that they spoke English. Score of seventh grade or better on the REALM and > or = 23 on the STOFHLA was considered a level of English competency. Data was entered into SPSS and analyzed for correlations. This study was approved by the institutional review board as exempt. RESULTS: Three-hundred-fifty-four patients with Hispanic names were approached and asked if they spoke English, Spanish or both. One-hundred-five patients, all self-proclaimed English speakers, were enrolled in the study. Patients ranged from 18-89 years of age, with 37.1% (39/105) male and 62.9% (66/105) and female; 49% (50/102) patients had only completed grade school. Sixty-five of 98 (66.3%) of self-proclaimed English speakers scored at or above a seventh grade reading level on the REALM, and 72.0% (67/93) scored in the category of adequate or better on the STOFHLA. There was a significant difference between patients' tested level of English competency and the physicians' and nurses' assessments of the patients' language competency (p=0.002). CONCLUSION: This study demonstrated that a significant number of patients who report English proficiency have an inadequate level of English health literacy and therefore English-language ability. Furthermore, there was a discrepancy between level of English competency found in the study and in the perceived English competency of the patients in the judgment of the physicians and nurses in the ED. This study demonstrated that that there was significant lack of English-language ability of self-declared Hispanic patients, suggesting that a more liberal use of interpreters may be indicated.
PMCID: PMC2569412  PMID: 16775913
4.  Development and Evaluation of an Instrument to Measure Community Pharmacists' Self-Efficacy Beliefs about Communicating with Spanish-Speaking Patients 
Background
Hispanics are the largest growing population in the United States and their use of prescription medications can be influenced by the education and counseling they receive from pharmacists. However, little is known about pharmacists' communication with patients who speak Spanish or factors that can influence such communication.
Objectives
The objective of the study was to develop and validate an instrument to measure pharmacists' self-efficacy in communicating with Spanish-speaking patients.
Methods
An initial pool of 15 items developed from previous research and suggestions from communication experts and practicing pharmacists was subjected to cognitive interviewing. Nine retained items were administered to 1022 licensed pharmacists by mail survey. Summary statistics and exploratory factor analysis (EFA) were conducted. Retained factors were determined by the examination of eigenvalues and Scree test results. Cronbach's alpha coefficients were calculated to assess internal consistency.
Results
A total of 540 community pharmacists completed the survey. Item means ranged from 2.93(SD=1.47) to 1.58(SD=0.88) based on a 5-point scale (1-not at all confident to 5-extremely confident). EFA resulted in a 2-factor solution, accounting for 71% of the variance. The 2 factors consisted of Health and Drug Information (alpha = 0.92) and Opening the Encounter (alpha = 0.75). The alpha for the overall scale was 0.88.
Conclusions
We found evidence to support the reliability and validity of an instrument to measure pharmacists' self-efficacy beliefs about communicating with Spanish-speaking patients in community practice. Practitioners and researchers may use this instrument to inform pharmacy education, pharmacy practice improvement, and research efforts around communicating with Spanish-speaking clients.
doi:10.1016/j.sapharm.2010.08.003
PMCID: PMC4432470  PMID: 21272530
Self-efficacy; Pharmacists; Communication; Spanish-speaking patients
5.  Adherence: a review of education, research, practice and policy in Spain 
Pharmacy Practice  2009;7(3):125-138.
Aims:
To describe medication adherence education, practice, research and policy efforts carried out by pharmacists in Spain in the last decade.
Methods:
A literature review using Medline and Embase was conducted covering the last ten years. Additional pharmaceutical bibliographic sources in Spain were consulted to retrieve articles of interest from the last decade. Articles were included if a pharmacist was involved and if medication adherence was measured or there was any direct or indirect pharmacist intervention in monitoring and/or improving adherence. Articles focusing on the development of tools for adherence assessment were collected. Pre- and post-graduate pharmacy training programs were also reviewed through the Spanish Ministry of Education and Science website. Information regarding policy issues was gathered from the Spanish and Autonomous Communities of Education and Health Ministries websites.
Results:
Pharmacists receive no specific training focused on adherence. There is no specific government policies for pharmacists in Spain related to medication adherence regardless of their practice setting. A total of 24 research studies met our inclusion criteria. Of these, 10 involved pharmacist intervention in monitoring and/or improving adherence and 14 assessed only adherence. Ten studies involved hospital pharmacists working in collaboration with another healthcare professional.
Conclusions:
At present in Spain, the investigative role of the pharmacist is not well developed in the area of medication adherence. Adherence improvement services provided to patients by pharmacists are not implemented in a systematic way. However, recent efforts to implement new initiatives in this area may provide the basis for offering new cognitive services aimed at improving patient adherence in the near future.
PMCID: PMC4139043  PMID: 25143789
Medication Adherence; Pharmacists; Spain
6.  Language and Regional Differences in Evaluations of Medicare Managed Care by Hispanics 
Health Services Research  2008;43(2):552-568.
Objectives
This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country.
Data Sources
CAHPS 3.0 Medicare managed care survey data collected in 2002.
Study Design
The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health.
Data Collection/Extraction Methods
The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish.
Principal Findings
Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care.
Conclusions
Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.
doi:10.1111/j.1475-6773.2007.00796.x
PMCID: PMC2442381  PMID: 18370967
CAHPS; patient experiences; Medicare managed care; Hispanics; language; ethnic disparities; geographic variations
7.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
8.  Bilingual Text Messaging Translation: Translating Text Messages From English Into Spanish for the Text4Walking Program 
JMIR Research Protocols  2015;4(2):e51.
Background
Hispanic adults in the United States are at particular risk for diabetes and inadequate blood pressure control. Physical activity improves these health problems; however Hispanic adults also have a low rate of recommended aerobic physical activity. To address improving physical inactivity, one area of rapidly growing technology that can be utilized is text messaging (short message service, SMS). A physical activity research team, Text4Walking, had previously developed an initial database of motivational physical activity text messages in English that could be used for physical activity text messaging interventions. However, the team needed to translate these existing English physical activity text messages into Spanish in order to have culturally meaningful and useful text messages for those adults within the Hispanic population who would prefer to receive text messages in Spanish.
Objective
The aim of this study was to translate a database of English motivational physical activity messages into Spanish and review these text messages with a group of Spanish speaking adults to inform the use of these text messages in an intervention study.
Methods
The consent form and study documents, including the existing English physical activity text messages, were translated from English into Spanish, and received translation certification as well as Institutional Review Board approval. The translated text messages were placed into PowerPoint, accompanied by a set of culturally appropriate photos depicting barriers to walking, as well as walking scenarios. At the focus group, eligibility criteria for this study included being an adult between 30 to 65 years old who spoke Spanish as their primary language. After a general group introduction, participants were placed into smaller groups of two or three. Each small group was asked to review a segment of the translated text messages for accuracy and meaningfulness. After the break out, the group was brought back together to review the text messages.
Results
A translation confirmation group met at a church site in an urban community with a large population of Hispanics. Spanish speaking adults (N=8), with a mean age of 40 (SD 6.3), participated in the study. Participants were engaged in the group and viewed the text messages as culturally appropriate. They also thought that text messages could motivate them to walk more. Twenty-two new text messages were added to the original database of 246 translated text messages. While the text messages were generally understood, specific word preferences were seen related to personal preference, dialect, and level of formality which resulted in minor revisions to four text messages.
Conclusions
The English text messages were successfully translated into Spanish by a bilingual research staff and reviewed by Hispanic participants in order to inform the use of these text messages for future intervention studies. These Spanish text messages were recently used in a Text4Walking intervention study.
doi:10.2196/resprot.3984
PMCID: PMC4439522  PMID: 25947953
text messaging; mobile phone; translating; language; focus groups; exercise
9.  Uncovering Treatment Burden as a Key Concept for Stroke Care: A Systematic Review of Qualitative Research 
PLoS Medicine  2013;10(6):e1001473.
In a systematic review of qualitative research, Katie Gallacher and colleagues examine the evidence related to treatment burden after stroke from the patient perspective.
Please see later in the article for the Editors' Summary
Background
Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed ‘treatment burden’ and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.
Methods and Findings
The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.
Conclusions
Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.
Systematic Review Registration
International Prospective Register of Systematic Reviews CRD42011001123
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, 15 million people have a stroke. About 5 million of these people die within a few days, and another 5 million are left disabled. Stroke occurs when the blood supply of the brain is suddenly interrupted by a blood vessel in the brain being blocked by a blood clot (ischemic stroke) or bursting (hemorrhagic stroke). Deprived of the oxygen normally carried to them by the blood, the brain cells near the blockage die. The symptoms of stroke depend on which part of the brain is damaged but include sudden weakness or paralysis along one side of the body, vision loss in one or both eyes, and confusion or trouble speaking or understanding speech. Anyone experiencing these symptoms should seek immediate medical attention because prompt treatment can limit the damage to the brain. In the longer term, post-stroke rehabilitation can help individuals overcome the physical disabilities caused by stroke, and drugs that thin the blood, reduce blood pressure and reduce cholesterol (major risk factors for stroke) alongside behavioral counseling can reduce the risk of a second stroke.
Why Was This Study Done?
Treatment for, and rehabilitation from, stroke is a lengthy process that requires considerable personal investment from the patient. The term “treatment burden” describes the self-care practices that patients with stroke and other chronic diseases must perform to follow the complicated management strategies that have been developed for these conditions. Unfortunately, treatment burden can overwhelm patients. They may be unable to cope with the multiple demands placed on them by health-care providers and systems for their self-care, a situation that leads to poor adherence to therapies and poor outcomes. For example, patients may find it hard to complete all the exercises designed to help them regain full movement of their limbs after a stroke. Treatment burden has been poorly examined in relation to stroke. Here, the researchers identify and describe the treatment burden in stroke by undertaking a systematic review (a study that uses predefined criteria to identify all the literature on a given topic) of qualitative studies on the patient experience of stroke management. Qualitative studies collect non-quantitative data so, for example, a qualitative study on stroke treatment might ask people how the treatment made them feel whereas a quantitative study might compare clinical outcomes between those receiving and not receiving the treatment.
What Did the Researchers Do and Find?
The researchers identified 69 qualitative studies dealing with the experiences of stroke management of adult patients and analyzed the data in these papers using framework synthesis—an approach that divides data into thematic categories. Specifically, the researchers used a coding framework informed by normalization process theory, a sociological theory of the implementation, embedding and integration of tasks and practices; embedding is the process of making tasks and practices a routine part of everyday life and integration refers to sustaining these embedded practices. The researchers identified four main areas of treatment burden for stroke: making sense of stroke management and planning care; interacting with others, including health care professionals, family and other patients with stroke; enacting management strategies (including enduring institutional admissions, managing stroke in the community, reintegrating into society and adjusting to life after stroke); and reflecting on management to make decisions about self-care. Moreover, they identified problems in all these areas, including inadequate provision of information, poor communication with health-care providers, and unsatisfactory inpatient care.
What Do These Findings Mean?
These findings show that stroke management is extremely demanding for patients and is influenced by both the micro and macro organization of health services. At the micro organizational level, fragmented care and poor communication between patients and clinicians and between health-care providers can mean patients are ill equipped to organize their care and develop coping strategies, which makes adherence to management strategies less likely. At the macro organizational level, it can be hard for patients to obtain the practical and financial help they need to manage their stroke in the community. Overall, these findings suggest that care provision for stroke needs to be transformed so that the needs of patients rather than the needs of health-care systems are prioritized. Further work is required, however, to understand how the patient experience of treatment burden is affected by the clinical characteristics of stroke, by disability level, and by other co-existing diseases. By undertaking such work, it should be possible to generate a patient-reported outcome measure of treatment burden that, if used by policy makers and health-care providers, has the potential to improve the quality of stroke care.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001473.
The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); its Know Stroke site provides educational materials about stroke prevention, treatment, and rehabilitation including personal stories (in English and Spanish); the US National Institutes of Health SeniorHealth website has additional information about stroke
The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish)
The UK National Health Service Choices website also provides information about stroke for patients and their families, including personal stories
MedlinePlus has links to additional resources about stroke (in English and Spanish)
The UK not-for-profit website Healthtalkonline provides personal stories about stroke
Wikipedia provides information on the burden of treatment and on the normalization process theory (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001473
PMCID: PMC3692487  PMID: 23824703
10.  A Spanish Language Module in a First-Year Pharmaceutical Care Laboratory Course 
Objective. To assess the impact of incorporating Spanish language lectures and activities in a required Pharmaceutical Care Laboratory course on first-year doctor of pharmacy (PharmD) students’ perceptions of and comfort level with Spanish-speaking patients and basic knowledge of Spanish pharmacy terms.
Design. The 6-week module consisted of attendance at a 1-hour lecture on medical Spanish and Hispanic culture, and completion of 4 small-group activities: drug and product information, patient information, counseling and side effects, and a written scenario that involved filling a prescription for and counseling a Spanish-speaking patient.
Assessment. All students enrolled in the Pharmaceutical Care Laboratory course in fall 2008 (153) and fall 2009 (152) completed a pre- and post-intervention questionnaire (100% response rate). Less than 4% of students considered themselves fluent in Spanish prior to participating in the Spanish language module. Students agreed or strongly agreed that it was important for pharmacists to be able to translate common pharmacy label instructions from English to Spanish (89.8%) and Spanish to English (73.8%). Student-reported confidence in their ability to pronounce common pharmacy and medical terms in Spanish significantly increased, as did their ability to correctly interpret pharmacy label instructions.
Conclusions. While incorporation of a Spanish language module in a first-year Pharmaceutical Care Laboratory course did not result in students achieving fluency in Spanish, it was a beneficial method of exposing students to Spanish language and culture.
doi:10.5688/ajpe76470
PMCID: PMC3355290  PMID: 22611279
Spanish; pharmaceutical care laboratory; cultural competency
11.  A qualitative study exploring the impact and consequence of the medicines use review service on pharmacy support-staff 
Pharmacy Practice  2013;11(2):118-124.
Background
Pharmacy support-staff (pharmacy technicians, dispensers and Medicines Counter Assistants) support the delivery of pharmaceutical and retail functions of the pharmacy. Workflow is supervised and at times dependent upon the pharmacist’s presence. Policy makers and pharmacy’s representative bodies are seeking to extend the community pharmacist's role including requiring the pharmacist to undertake private consultations away from the dispensary and shop floor areas. However, support-staff voices are seldom heard and little is known about the impact such policies have on them.
Objective
The objective of this study is to explore the impact and consequences of the English Medicine Use Review (MUR) service on pharmacy support-staff.
Methods
Ten weeks of ethnographic-oriented observations in two English community pharmacies and interviews with 5 pharmacists and 12 support-staff. A thematic approach was used to analyse the data.
Results
Despite viewing MURs as a worthwhile activity, interviews with support-staff revealed that some felt frustrated when they were left to explain to patients why the pharmacist was not available when carrying out an MUR. Dependency on the pharmacist to complete professional and accuracy checks on prescriptions grieved dispensing staff because dispensing workflow was disrupted and they could not get their work done. Medicines Counter Assistants were observed to have less dependency when selling medicines but some still reported concerns over of customers and patients waiting for the pharmacist. A range of tacit and ad hoc strategies were consequently found to be deployed to handle situations when the pharmacist was absent performing an MUR.
Conclusions
Consideration should be given to support-staff and pharmacists’ existing work obligations when developing new pharmacy extended roles that require private consultations with patients. Understanding organisational culture and providing adequate resourcing for new services are needed to avoid improvisations or enactments by pharmacy support-staff and to allow successful innovation and policy implementation.
PMCID: PMC3798177  PMID: 24155859
Pharmacists' Aides; Pharmacists; Workflow; Community Pharmacy Services; Drug Utilization Review; Professional Practice; United Kingdom
12.  Preferences for Self-Management Support: Findings from a Survey of Diabetes Patients in Safety-Net Health Systems 
Patient education and counseling  2007;70(1):102-110.
Objectives
We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support.
Methods
Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (esponse rate 47%) recruited from 4 urban US public hospital systems. In multivariate models, we measured the association of race/ ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients’ interest in three self-management support strategies (telephone support, group medical visits, and internet -based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance.
Results
Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95%CI 1.97–6.05) and group medical visits (OR 2.45, 95%CI 1.49–4.02), but less interested in internet self-management support (OR 0.56, 95%CI 0.33–0.93). African-Americans were more interested than Whites in all 3 self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences.
Conclusion
Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy.
Practice Implications
Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.
doi:10.1016/j.pec.2007.09.008
PMCID: PMC2745943  PMID: 17997264
diabetes; communication; health literacy; telephone care; group medical visits; racial/ethnic minority; self-management; disparities
13.  Public health in community pharmacy: A systematic review of pharmacist and consumer views 
BMC Public Health  2011;11:582.
Background
The increasing involvement of pharmacists in public health will require changes in the behaviour of both pharmacists and the general public. A great deal of research has shown that attitudes and beliefs are important determinants of behaviour. This review aims to examine the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health in order to inform how best to support and improve this service.
Methods
Five electronic databases were searched for articles published in English between 2001 and 2010. Titles and abstracts were screened by one researcher according to the inclusion criteria. Papers were included if they assessed pharmacy staff or consumer attitudes towards pharmaceutical public health. Full papers identified for inclusion were assessed by a second researcher and data were extracted by one researcher.
Results
From the 5628 papers identified, 63 studies in 67 papers were included. Pharmacy staff: Most pharmacists viewed public health services as important and part of their role but secondary to medicine related roles. Pharmacists' confidence in providing public health services was on the whole average to low. Time was consistently identified as a barrier to providing public health services. Lack of an adequate counselling space, lack of demand and expectation of a negative reaction from customers were also reported by some pharmacists as barriers. A need for further training was identified in relation to a number of public health services. Consumers: Most pharmacy users had never been offered public health services by their pharmacist and did not expect to be offered. Consumers viewed pharmacists as appropriate providers of public health advice but had mixed views on the pharmacists' ability to do this. Satisfaction was found to be high in those that had experienced pharmaceutical public health
Conclusions
There has been little change in customer and pharmacist attitudes since reviews conducted nearly 10 years previously. In order to improve the public health services provided in community pharmacy, training must aim to increase pharmacists' confidence in providing these services. Confident, well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health.
doi:10.1186/1471-2458-11-582
PMCID: PMC3146877  PMID: 21777456
14.  Stakeholder experiences with general practice pharmacist services: a qualitative study 
BMJ Open  2013;3(9):e003214.
Objectives
To explore general practice staff, pharmacist and patient experiences with pharmacist services in Australian general practice clinics within the Pharmacists in Practice Study.
Design
Qualitative study.
Setting
Two general practice clinics in Melbourne, Australia, in which pharmacists provided medication reviews, patient and staff education, medicines information and quality assurance services over a 6-month period.
Participants
Patients, practice staff and pharmacists.
Method
Semi-structured telephone interviews with patients, focus groups with practice staff and semi-structured interviews and periodic narrative reports with practice pharmacists. Data were analysed thematically and theoretical frameworks used to explain the findings.
Results
34 participants were recruited: 18 patients, 14 practice staff (9 general practitioners, 4 practice nurses, 1 practice manager) and 2 practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits and logistical challenges. Participants reported that colocation and the interdisciplinary environment of general practice enabled better communication and collaboration compared to traditional community and consultant pharmacy services. Participants felt that pharmacists needed to possess certain attributes to ensure successful integration, including being personable and proactive. Attitudinal, professional and logistical barriers were identified but were able to be overcome. The findings were explained using D'Amour's structuration model of collaboration and Roger's diffusion of innovation theory.
Conclusions
This is the first qualitative study to explore the experiences of general practice staff, pharmacists and patients on their interactions within the Australian general practice environment. Participants were receptive of colocated pharmacist services, and various barriers and facilitators to integration were identified. Future research should investigate the feasibility and sustainability of general practice pharmacist roles.
doi:10.1136/bmjopen-2013-003214
PMCID: PMC3773653  PMID: 24030867
Primary Care; Qualitative Research; Health Services Administration & Management
15.  Improving access to shared decision-making for Hispanics/Latinos with inadequately controlled type 2 diabetes mellitus 
Purpose
To describe the cultural and linguistic adaptation and Spanish translation of an English-language patient decision aid (PDA) for use in supporting shared decision-making in Hispanics/Latinos with type 2 diabetes mellitus (T2DM), a group at a high risk for complications.
Patients and methods
A steering committee of endocrinologists, a primary care physician, a certified diabetes educator, and a dietician, each with extensive experience in providing care to Hispanics/Latinos was convened to assess a PDA developed for English-speaking patients with T2DM. English content was reviewed for cultural sensitivity and appropriateness for a Hispanic/Latino population. A consensus-building process and iterative version edits incorporated clinician perspectives. The content was adapted to be consistent with traditional Hispanic/Latino cultural communication precepts (eg, avoidance of hostile confrontation; value for warm interaction; respect for authority; value of family support for decisions). The PDA was translated by native-speaking individuals with diabetes expertise.
Results
The PDA underwent testing during cognitive interviews with ten Spanish-speaking Hispanics/Latinos with T2DM to ensure that the content is reflective of the experience, understanding, and language Hispanic/Latino patients use to describe diabetes and treatment. Content edits were made to assure a literacy level appropriate to the audience, and the PDA was produced for online video dissemination.
Conclusion
High-quality, well-developed tools to facilitate shared decision-making in populations with limited access to culturally sensitive information can narrow gaps and align care with individual patient preferences. A newly developed PDA is available for shared decision-making that provides culturally appropriate treatment information for inadequately controlled Hispanics/Latinos with T2DM. The impact on the overall health of patients and care management of T2DM requires further study.
doi:10.2147/PPA.S80552
PMCID: PMC4425339  PMID: 25995623
patient decision aid; language adaptation; Hispanic; decision making; type 2 diabetes
16.  The Use of Spanish Language Skills by Physicians and Nurses: Policy Implications for Teaching and Testing 
ABSTRACT
BACKGROUND
Language barriers present a substantial communication challenge in the hospital setting.
OBJECTIVE
To describe how clinicians with various levels of Spanish language proficiency work with interpreters or their own Spanish skills in common clinical scenarios.
DESIGN & PARTICIPANTS
Survey of physicians and nurses who report ever speaking Spanish with patients on a general medicine hospital floor.
MEASUREMENTS
Spanish proficiency rated on a 5-point scale, self-reported use of specific strategies (own Spanish skills, professional or ad-hoc interpreters) to overcome the language barrier.
RESULTS
Sixty-eight physicians and 65 nurses participated. Physicians with low-level Spanish proficiency reported frequent use of ad-hoc interpreters for all information-based scenarios, except pre-rounding in the morning when most reported using their own Spanish skills. For difficult conversations and procedural consent, most used professional interpreters. Comparatively, physicians with medium proficiency reported higher rates of using their own Spanish skills for information-based scenarios, lower rates of professional interpreter use, and little use of ad-hoc interpreters. They rarely used their own Spanish skills or ad-hoc interpreters for difficult conversations. Physicians with high-level Spanish proficiency almost uniformly reported using their own Spanish skills. The majority (82%) of nurses had low-level Spanish proficiency, and frequently worked with professional interpreters for educating patients, but more often used ad hoc interpreters and their own Spanish skills for information-based scenarios, including medication administration.
CONCLUSIONS
Physicians and nurses with limited Spanish proficiency use these skills, even in important clinical circumstances in the hospital. Health-care organizations should evaluate clinicians’ non-English language proficiency and set policies about use of language skills in clinical care.
doi:10.1007/s11606-011-1779-5
PMCID: PMC3250531  PMID: 21773850
physician-patient communication; interpreter; language barriers; nurses; inpatients
17.  Assessment of the Equivalence of the Spanish and English Versions of the CAHPS® Hospital Survey on the Quality of Inpatient Care 
Health Services Research  2005;40(6 Pt 2):2140-2161.
Objective
To describe translation and cultural adaptation procedures, and examine the degree of equivalence between the Spanish and English versions of the Agency for Healthcare Research and Quality's (AHRQ) Consumer Assessments of Healthcare Providers and Systems (CAHPS®) Hospital Survey (H-CAHPS®) of patient experiences with care.
Data Sources
Cognitive interviews on survey comprehension with 12 Spanish-speaking and 31 English-speaking subjects. Psychometric analyses of 586 responses to the Spanish version and 19,134 responses to the English version of the H-CAHPS survey tested in Arizona, Maryland, and New York in 2003.
Study Design
A forward/backward translation procedure followed by committee review and cognitive testing was used to ensure a translation that was both culturally and linguistically appropriate. Responses to the two language versions were compared to evaluate equivalence and assess the reliability and validity of both versions.
Data Collection/Extraction Methods
Comparative analyses were carried out on the 32 items of the shortened survey version, focusing on 16 items that comprise seven composites representing different aspects of hospital care quality (communication with nurses, communication with doctors, communication about medicines, nursing services, discharge information, pain control, and physical environment); three items that rate the quality of the nursing staff, physician staff, and the hospital overall; one item on intention to recommend the hospital. The other 12 items used in the analyses addressed mainly respondent characteristics. Analyses included item descriptives, correlations, internal consistency reliability of composites, factor analysis, and regression analysis to examine construct validity.
Principal Findings
Responses to both language versions exhibit similar patterns with respect to item–scale correlations, factor structure, content validity, and the association between each of the seven qualities of care composites with both the hospital rating and intention to recommend the hospital. Internal consistency reliability was slightly, yet significantly lower for the Spanish-language respondents for five of the seven composites, but overall the composites were generally equivalent across language versions.
Conclusions
The results provide preliminary evidence of the equivalence between the Spanish and English versions of H-CAHPS. The translated Spanish version can be used to assess hospital quality of care for Spanish speakers, and compare results across these two language groups.
doi:10.1111/j.1475-6773.2005.00469.x
PMCID: PMC1361240  PMID: 16316442
Survey translation and adaptation; patient survey; language equivalence; hospital care quality; Spanish-language survey
18.  Patient-Physician Language Concordance: A Strategy for Meeting the Needs of Spanish-Speaking Patients in Primary Care 
The Permanente Journal  2009;13(4):79-84.
The Hispanic/Latino community increased by 58% in the last decade (1990–2000) and it is estimated that Hispanics/Latinos will be 30% of the population by 2050. Many of the Hispanic/Latino households (40%) surveyed by the census bureau in 2000 spoke Spanish. Because of its location, the Southern California Permanente Medical Group, which provides the medical services for Kaiser Permanente Southern California (KPSC) serves a large and growing Hispanic/Latino community. It is estimated that by 2010, the KPSC region will be between 30–50% Hispanic/Latino. A Spanish language task force (the task force) was created in 2006 to address the needs of the KPSC Spanish-speaking membership using primary care services. This task force examined data from a variety of sources including electronic medical databases and focus group reports from Spanish-speaking members. Using the task force findings and the literature in this area, we make recommendations to increase patient-physician language concordance in other health care settings so that organizations can effectively serve a growing Hispanic/Latino, Spanish-speaking patient population.
PMCID: PMC2911827  PMID: 20740108
19.  Do Physicians with Self-Reported Non-English Fluency Practice in Linguistically Disadvantaged Communities? 
Background
Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP.
Objective
To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP.
Design
Cross-sectional cohort study.
Participants
A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001–2007.
Measures
Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households.
Methods
Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status.
Results
Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63–1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43–1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency.
Conclusions
Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.
doi:10.1007/s11606-010-1584-6
PMCID: PMC3077490  PMID: 21120633
workforce; language; Hispanic American; Asian American
20.  Patient-Physician Language Concordance and Primary Care Screening among Spanish-Speaking Patients 
Medical care  2011;49(7):668-672.
Background
Language discordance between patient and physician is associated with worse patient self-reported healthcare quality. As Hispanic patients have low rates of cardiovascular and cancer screening, we sought to determine whether patient-physician language concordance was associated with differences in rates of screening.
Methods
We performed a retrospective medical record review of 101 Spanish-speaking patients cared for by 6 Spanish-speaking PCPs (language concordant group) and 205 Spanish-speaking patients cared for by 44 non-Spanish-speaking PCPs (language discordant group). Patients were included in the study if they were age 35–75 and had utilized interpreter services 2001–2006 in two Boston-based primary care clinics. Our outcomes included screening for hyperlipidemia, diabetes, cervical cancer, breast cancer, and colorectal cancer with age- and sex-appropriate subgroups. Our main predictor of interest was patient-physician language concordance. In multivariable modeling, we adjusted for age, sex, insurance status, number of primary care visits, and comorbidities. We adjusted for clustering of patients within individual physicians and clinic sites using generalized estimating equations.
Results
Patients in the language discordant group tended to be female compared to patients in the language concordant group. There were no significant differences in age, insurance status, number of primary care visits, or Charlson comorbidity index between the two groups. Rates of screening for hyperlipidemia, diabetes, cervical cancer, and breast cancer were similar for both language concordant and discordant groups. However, patients in the language concordant group were less likely to be screened for colorectal cancer compared to the language discordant group RR 0.78 (95% CI 0.61–0.99) after multivariable adjustment.
Conclusions
This study finds that Spanish-speaking patients cared for by language-concordant PCPs were not more likely to receive recommended screening for cardiovascular risk factors and cancer. Furthermore, language concordance was associated with less colorectal cancer screening. Further research is needed to examine which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer which has a low rate of screening.
doi:10.1097/MLR.0b013e318215d803
PMCID: PMC3117916  PMID: 21478772
21.  Ductal carcinoma in situ: knowledge of associated risks and prognosis among Latina and non-Latina white women 
While not itself life-threatening, ductal carcinoma in situ (DCIS) can progress to invasive disease if untreated, and confers an increased risk of future breast cancer. We investigated knowledge of DCIS among a cohort of English- and Spanish-speaking Latina and English-speaking non-Latina white women previously treated for DCIS. We examined knowledge of DCIS with four true/false statements about risk of invasive disease, breast cancer recurrence, and prognosis. For each knowledge statement, we modeled the odds of a correct answer by language–ethnicity (English-speaking Latinas, Spanish-speaking Latinas, and English-speaking whites) adjusting for demographics, health history, and treatment factors. Of 710 participants, 52 % were English-speaking whites, 21 % English-speaking Latinas, and 27 % Spanish-speaking Latinas. Less than half (41 %) of participants were aware that DCIS is not life-threatening and only 32 % knew that surgical treatment choice does not impact mortality; whereas two-thirds (67 %) understood that DCIS confers increased risk of future breast cancer, and almost all (92 %) knew that DCIS, if untreated, could become invasive. Only three Spanish-speakers used professional interpreters during discussions with their physicians. In adjusted analyses, compared to English-speaking whites, both English- and Spanish-speaking Latinas had significantly lower odds of knowing that DCIS was not life-threatening (OR, 95 % CI 0.6, 0.4–0.9 and 0.5, 0.3–0.9, respectively). In contrast, Spanish-speaking Latinas had a twofold higher odds of knowing that DCIS increases risk of future breast cancer (OR, 95 % CI 2.6, 1.6–4.4), but English-speaking Latinas were no different from English-speaking whites. Our data suggest that physicians are more successful at conveying the risks conferred by DCIS than the nuances of DCIS as a non-life-threatening diagnosis. This uneven communication is most marked for Spanish-speaking Latinas. In addition to the use of professional interpreters, efforts to create culturally and linguistically standardized information could improve knowledge and engagement in informed decision making for all DCIS patients.
doi:10.1007/s10549-013-2676-x
PMCID: PMC4520413  PMID: 23996141
Ductal carcinoma in situ; Latino/Hispanic; Breast cancer; Language barriers; Healthcare disparities; Patient; physician communication
22.  Perceptions of Patient-Provider Communication in Breast and Cervical Cancer-Related Care: A Qualitative Study of Low-Income English- and Spanish-Speaking Women 
Journal of community health  2013;38(4):707-715.
To explore patient perceptions of patient-provider communication in breast and cervical cancer-related care among low-income English- and Spanish- speaking women, we examined communication barriers and facilitators reported by patients receiving care at safety net clinics. Participants were interviewed in English or Spanish after receiving an abnormal breast or cervical cancer screening test or cancer diagnosis. Following an inductive approach, interviews were coded and analyzed by the language spoken with providers and patient-provider language concordance status. Of 78 participants, 53% (n = 41) were English-speakers and 47% (n = 37) were Spanish-speakers. All English-speakers were language-concordant with providers. Of Spanish-speakers, 27% (n = 10) were Spanish-concordant; 38% (n = 14) were Spanish-discordant, requiring an interpreter; and 35% (n = 13) were Spanish mixed-concordant, experiencing both types of communication throughout the care continuum. English-speakers focused on communication barriers, and difficulty understanding jargon arose as a theme. Spanish-speakers emphasized communication facilitators related to Spanish language use. Themes among all Spanish-speaking sub-groups included appreciation for language support resources and preference for Spanish-speaking providers. Mixed-concordant participants accounted for the majority of Spanish-speakers who reported communication barriers. Our data suggest that, although perception of patient-provider communication may depend on the language spoken throughout the care continuum, jargon is lost when health information is communicated in Spanish. Further, the respective consistency of language concordance or interpretation may play a role in patient perception of patient-provider communication.
doi:10.1007/s10900-013-9668-y
PMCID: PMC3706461  PMID: 23553683
patient-provider communication; low-income women; cancer-related care; qualitative research
23.  Hablamos Juntos (Together We Speak): Interpreters, Provider Communication, and Satisfaction with Care 
Journal of General Internal Medicine  2010;25(12):1282-1288.
BACKGROUND
The Hablamos Juntos—Together We Speak (HJ)—national demonstration project targeted the improvement of language access for Spanish-speaking Latinos in areas with rapidly growing Latino populations. The objective of HJ was to improve doctor-patient communication by increasing access to and quality of interpreter services for Spanish-speaking patients.
OBJECTIVE
To investigate how access to interpreters for adult Spanish-speaking Latinos is associated with ratings of doctor/office staff communication and satisfaction with care.
DESIGN
Cross-sectional cohort study.
PATIENTS
A total of 1,590 Spanish-speaking Latino adults from eight sites across the United States who participated in the outpatient HJ evaluation.
MEASUREMENTS
We analyzed two multi-item measures of doctor communication (4 items) and office staff helpfulness (2 items), and one global item of satisfaction with care by interpreter use. We performed regression analyses to control for patient sociodemographic characteristics, survey year, and clustering at the site of care.
RESULTS
Ninety-five percent of participants were born outside the US, 81% were females, and survey response rates ranged from 45% to 85% across sites. In this cohort of Spanish-speaking patients, those who needed and always used interpreters reported better experiences with care than their counterparts who needed but had interpreters unavailable. Patients who always used an interpreter had better adjusted ratings of doctor communication [effect size (ES = 0.51)], office staff helpfulness (ES = 0.37), and satisfaction with care (ES = 0.37) than patients who needed but did not always use an interpreter. Patients who needed and always used interpreters also reported better experiences with care in all three domains measured [doctor communication (ES = 0.30), office staff helpfulness (ES = 0.21), and satisfaction with care (ES = 0.23)] than patients who did not need interpreters.
CONCLUSIONS
Among adult Spanish-speaking Latinos, interpreter use is independently associated with higher satisfaction with doctor communication, office staff helpfulness, and ambulatory care. Increased attention to the need for effective interpreter services is warranted in areas with rapidly growing Spanish-speaking populations.
doi:10.1007/s11606-010-1467-x
PMCID: PMC2988148  PMID: 20703951
doctor-patient communication; Latino population; interpreter services; immigrants; disparities; limited English proficient
24.  Palliative Care for Latino Patients and Their Families: “Whenever We Prayed, She Wept” 
Latinos account for 15% of the US population, a proportion projected to grow to 30% by the year 2050. Although there is tremendous diversity within this community, commonalities of language, beliefs, attitudes, and behaviors unite Latinos, making them more similar than different. For non-Latino and non-Spanish-speaking clinicians, communication barriers and cultural misunderstandings can impede the care of dying Latino patients and their families. We present the case of a young, pregnant, Spanish-speaking woman from Guatemala diagnosed with a fatal leukemia. As illustrated by this case, Latino immigrants face a number of external challenges to optimal end-of-life care: (1) geographic distance as well as political and economic realities often separate patients from their valued families; (2) undocumented immigrants are frequently uninsured, and fear of deportation may create a barrier to accessing health services; (3) language and literacy barriers; and (4) concerns about discrimination. Other Latino issues that may be more pronounced in end-of-life settings include cultural themes and religious and spiritual influences. We recommend that professional interpreters must be used for discussions about goals of care with Spanish-speaking patients and families, or when negotiating conflict between the patient, family, and the health care team. Concrete suggestions are provided for clinicians in working with interpreters, eliciting culturally-based attitudes and beliefs, and implementing universal strategies for clear health communication.
doi:10.1001/jama.2009.308
PMCID: PMC2782583  PMID: 19278947
25.  Unraveling the relationship between literacy, language proficiency, and patient–physician communication☆,☆☆ 
Patient education and counseling  2009;75(3):398-402.
Objective
To examine whether the effect of health literacy (HL) on patient–physician communication varies with patient–physician language concordance and communication type.
Methods
771 outpatients rated three types of patient–physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant).
Results
Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL.
Conclusion
Limited health literacy impedes patient–physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication.
Practice implications
Patient–physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.
doi:10.1016/j.pec.2009.02.019
PMCID: PMC4068007  PMID: 19442478
Communication; Health literacy; Limited English proficiency; Health disparities

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