Patient-physician language concordance and primary care screening among spanish-speaking patients

Is Primary Care Patient Experience Associated with Provider-Patient Language Concordance and Use of Interpreters for Spanish-preferring Patients: A Systematic Literature Review

BACKGROUND

Healthcare provided by a bilingual provider or with the assistance of an interpreter improves care quality; however, their associations with patient experience are unknown. We reviewed associations of patient experience with provider-patient language concordance (LC) and use of interpreters for Spanish-preferring patients.

METHOD

We reviewed articles from academic databases 2005-2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Joanna Briggs Institute Checklists to rate study quality. We reviewed 217 (of 2193) articles, yielding 17 for inclusion.

RESULTS

Of the 17 included articles, most articles focused on primary (n = 6 studies) or pediatric care (n = 5). All were cross-sectional, collecting data by self-administered surveys (n = 7) or interviews (n = 4). Most assessed the relationship between LC or interpreter use and patient experience by cross-sectional associations (n = 13). Two compared subgroups, and two provided descriptive insights into the conversational content (provider-interpreter-patient). None evaluated interventions, so evidence on effective strategies is lacking. LC for Spanish-preferring patients was a mix of null findings (n = 4) and associations with better patient experience (n = 3) (e.g., receiving diet/exercise counseling and better provider communication). Evidence on interpreter use indicated better (n = 2), worse (n = 2), and no association (n = 2) with patient experience. Associations between Spanish-language preference and patient experience were not significant (n = 5) or indicated worse experience (n = 4) (e.g., long waits, problems getting appointments, and not understanding nurses).

CONCLUSION

LC is associated with better patient experience. Using interpreters is associated with better patient experience but only with high-quality interpreters. Strategies are needed to eliminate disparities and enhance communication for all Spanish-preferring primary care patients, whether with a bilingual provider or an interpreter.

Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021

Introduction

Substantial barriers to screening exist for medically underserved populations, especially adults with limited English proficiency (LEP). We examined the proportion of US adults aged 45-75 up-to-date with colorectal cancer (CRC) screening by LEP after 2018. The American Cancer Society began recommending CRC screening for adults 45-49 in 2018.

Methods

We analyzed cross-sectional data of adults 45-75 years old participating in the 2019 or 2021 National Health Interview Survey (N = 25,611). Adults were considered up-to-date with screening if they reported any stool test within 1 year, stool-DNA testing within 3 years, or colonoscopy within 10 years. Adults who interviewed in a language other than English were considered to have LEP. Adults not up-to-date with screening were asked if a healthcare professional (HCP) recommended screening, and if so which test(s). Regression models conducted in 2022-2023 evaluated receipt of screening, adjusting for sociodemographics, year, and healthcare access.

Results

Overall, 54.0 % (95 % CI 53.1-54.9 %) of participants were up-to-date with screening (9.4 % aged 45-49 vs 75.5 % aged 65-75); prevalence increased from 2019 (52.9 %) to 2021(55.2 %). Adults with LEP (vs English proficiency) were less likely to be up-to-date with screening (31.6 % vs. 56.8 %, [aPR 0.86 (0.77-0.96)]). Among adults not up-to-date, 15.0 % reported their HCP recommended screening (8.4 % among adults with LEP).

Conclusions

Nearly half of US adults were not up-to-date with CRC screening in 2019 and 2021 and few reported being recommended screening. Adults with LEP and those 45-49 were least likely to be screened suggesting targeted interventions are needed for these populations.

Limited English Proficiency and Screening for Cervical, Breast, and Colorectal Cancers among Asian American Adults

BACKGROUND

Literature shows that limited English proficiency (LEP) influences individual healthcare-seeking behaviors. The Asian population is the fastest-growing racial/ethnic group in the US, and approximately 50% of foreign-born Asians are estimated to live with LEP.

OBJECTIVE

To examine associations of LEP and patient-provider language concordance (PPLC) with evidence-based cancer screening utilization for cervical, breast, and colorectal cancers among Asian American adults.

METHODS

We obtained LEP, PPLC, and up-to-date status on the three types of cancer screening from a nationally representative sample of Asian Americans aged ≥ 18 years in the 2010-2016 and 2018 Medical Expenditure Panel Surveys. We used multivariable logistic regression models with recommended survey weighting to examine associations of LEP and PPLC with the cancer screening uptake based on USPSTF guidelines.

RESULTS

The study population comprised 8953 respondents, representing 8.17 million Asian American adults. Overall, 11.9% of respondents experienced LEP; of those with LEP, 20% were with PPLC. In multivariable models, compared to respondents without LEP, respondents with LEP and without PPLC were significantly less likely to report up-to-date status on breast (OR = 0.44; 95% CI: 0.26-0.76), cervical (OR = 0.44; 95% CI: 0.26-0.75), or colorectal cancer screening (OR = 0.46; 95% CI: 0.26-0.80). However, these differences were not detected in respondents with LEP and with PPLC.

CONCLUSION

LEP is associated with lower up-to-date status on cancer screening among Asian Americans, while PPLC seems to moderate this association. These findings suggest the enhancement for language-appropriate and culturally competent healthcare for Asian Americans with LEP, which helps accommodate their communication needs and promotes cancer screening.

Culturally Competent Care in the Breast Imaging Clinic: Hispanic/Latino Patients

Hispanic/Latino people represent 19% of the U.S. population, and this proportion is expected to increase to 26% by 2050. Hispanic/Latino people comprise a diverse ethnic group that includes individuals from all races, religions, languages, cultural identities, and nationalities. Barriers to health care that have created significant disparities in this community include language, low socioeconomic status, and inability to afford health insurance. Health coverage for Hispanic/Latino people has been a longstanding problem in the U.S., stopping many of these patients from seeking preventive care such as screening mammography. Breast cancer is the most common cancer among Hispanic/Latino women in the U.S. and the leading cause of cancer death in this group. Five-year breast cancer survival in Hispanic/Latino women is slightly lower than that in non-Hispanic White women. Some of the factors that account for the ethnic disparities in breast cancer include lower levels of adherence to screening mammography of Hispanic/Latino women as a consequence of inadequate insurance coverage, language barriers, lack of transportation, being unable to leave work, and lack of childcare. By promoting a culturally sensitive clinical environment, breast radiologists can increase patient engagement, utilization of preventive services, treatment adherence rates, and overall health status.

Access to Care Among Adults with Limited English Proficiency

BACKGROUND

There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing.

OBJECTIVE

Investigate associations between LEP and access to care in adults.

DESIGN

Cross-sectional nationally representative survey.

PARTICIPANTS

Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014-2018 Medical Expenditure Panel Survey MAIN MEASURES: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18-64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening.

KEY RESULTS

Adults aged 18-64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27-2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89-2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79-2.23), cholesterol check (aOR = 1.22; CI = 1.03-1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37-1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years.

CONCLUSIONS

Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care.

Colorectal cancer screening in a safety-net health system: The intersectional impact of race, ethnicity, language, and mental health

Though rates of colorectal cancer (CRC) screening continue to improve with increased advocacy and awareness, there are numerous disparities that continue to be defined within different health systems and populations. We aimed to define associations between patients' socio-demographic characteristics and CRC screening in a well-resourced safety-net health system. A retrospective review was performed from 2018 to 2019 of patients between 50 and 75-years-old who had a primary care visit within the last two years. Numerous patient characteristics were extracted from the medical record, including self-reported race, self-reported ethnicity, insurance, preferred language, severe mental health diagnoses (SMHD), and substance use disorder (SUD). Multivariate logistic regression assessed characteristics associated with CRC screening. Of 22,145 included patients, 16,065 (72.5%) underwent CRC screening. <40% of the population was White or of North American/European ethnicity and 38% had limited English proficiency. Hispanic patients had the highest screening rate while White patients had the lowest among races (78.1% vs 68.5%, respectively). White patients had higher rates of SMHD and SUD (p < 0.001). In multivariable analysis, most other races (Black, Asian, and Hispanic), ethnicities, and languages had significantly higher odds of screening, ranging from 20% to 55% higher, when White, North American/European, English-speakers are used as reference. In a well-resourced safety-net health system, patients who were non-White, non-North American/European, and non-English-speaking, had higher odds of CRC screening. This data from a unique health system may better guide screening outreach and implementation strategies in historically under-resourced communities, leading to strategies for equitable colorectal cancer screening.

Physician-Patient Language Discordance and Poor Health Outcomes: A Systematic Scoping Review

Objective: This systematic review assessed whether physician-patient language concordance, compared with discordance, is associated with better health outcomes. Methods: A systematic literature search was conducted, without language restrictions, using PubMed, EMBASE, Web of Science, and PsycINFO, from inception to July 2020. We included studies that evaluated the effects of physician-patient language concordance on health outcomes. Articles were screened, selected, and data-extracted in duplicate. Review protocol was prospectively registered (PROSPERO, CRD42020157229). Results: There were 541 citations identified through databases and eight citations through reverse search and Google Scholar. A total of 15 articles (84,750 participants) were included reporting outcomes within five domains: diabetes care (four studies), inpatient care (five studies), cancer screening (three studies), healthcare counseling (two studies), and mental health care (one study). Ten studies were of good quality, four were fair, and one was poor, according to the modified Newcastle-Ottawa Scale. Eight studies (53%) showed a significant negative association between language discordance and at least one clinical outcome. Five studies (33%) found no association. Conclusion: Over half the evidence collated showed that physician-patient language concordance was associated with better health clinical outcomes.

Scoping review: Definitions and outcomes of patient-provider language concordance in healthcare

OBJECTIVE

To conduct a scoping literature review to understand the conceptualization and nature of the research on patient-provider language concordance (LC) in health care.

METHODS

We searched PubMed, EMBASE, CINAHL, PsycINFO, and Scopus to identify peer-reviewed articles between January 1961 and August 2018. We extracted study characteristics, content, definitions, and findings.

RESULTS

Fifty studies were included. Forty studies were quantitative, seven were qualitative, and three were mixed methods. Overall, the studies revealed inconsistent definitions and measures of patient-provider LC. Outcomes studied in connection to LC included: (1) interpersonal relationships, (2) access to health information, (3) access to care, (4) satisfaction and health-care experience, and (5) patient-related health outcomes. While four studies found that LC care had a negative or no impact on health outcomes, 46 studies reported positive outcomes associated with LC care.

CONCLUSIONS

The study findings highlight the need for more research on LC care and a consistent definition of LC using multiple measures of LC to capture the complex and multidimensional nature of language in social interaction.

PRACTICAL IMPLICATIONS

The study findings highlight the importance of how ideologies of language shape the perceptions of language and LC, thereby influence resource allocation and priorities.

A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes

BACKGROUND

Approximately 25 million people in the USA are limited English proficient (LEP). When LEP patients receive care from physicians who are truly language concordant, some evidence show that language disparities are reduced, but others demonstrate worse outcomes. We conducted a systematic review of the literature to compare the impact of language-concordant care for LEP patients with that of other interventions, including professional and ad hoc interpreters.

METHODS

Data was collected through a systematic review of the literature using PubMed, PsycINFO, Web of Science, Cochrane Library, and EMBASE in October 2017. The literature search strategy had three main components, which were immigrant/minority status, language barrier/proficiency, and healthcare provider/patient relationship. The quality of the articles was appraised using the Downs and Black checklist.

RESULTS

The 33 studies were grouped by the outcome measure studied, including quality of care (subdivided into primary care, diabetes, pain management, cancer, and inpatient), satisfaction with care/communication, medical understanding, and mental health. Of the 33, 4 (6.9%) were randomized controlled trials and the remaining 29 (87.9%) were cross-sectional studies. Seventy-six percent (25/33) of the studies demonstrated that at least one of the outcomes assessed was better for patients receiving language-concordant care, while 15% (5/33) of studies demonstrated no difference in outcomes, and 9% (3/33) studies demonstrated worse outcomes in patients receiving language-concordant care.

DISCUSSION

The findings of this review indicate that, in the majority of situations, language-concordant care improves outcomes. Although most studies included were of good quality, none provided a standardized assessment of provider language skills. To systematically evaluate the impact of truly language-concordant care on outcomes and draw meaningful conclusions, future studies must include an assessment of clinician language proficiency. Language-concordant care offers an important way for physicians to meet the unique needs of their LEP patients.

Patient-Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient-provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples.

Communication pitfalls in interpreted genetic counseling sessions

The impact of language interpretation on interactive communication in genetic counseling sessions is not well studied. We sought to determine whether interpretation affects communication in genetic counseling sessions using communication analysis. With a sample of pregnant patients of advanced maternal age, we audiotaped, analyzed, and compared seven Spanish-speaking patients with limited-English proficiency to seven English-speaking patients on length of session, English words spoken, and number of questions asked. An analysis of verbal listening cues, including back-channels and questions asked was performed to evaluate the level of engagement by both provider and patient. Session length did not differ between groups (p > 0.05), however, English-speaking sessions involved significantly more words (mean: 4,798 vs. 2,524) exchanged over the course of the conversation than interpreter-mediated sessions (p < 0.001). The number of back-channeling responses was significantly greater in English-speaking compared to Spanish-speaking sessions. We found the same information was covered, but there was less provider-patient interaction when the session was interpreter-mediated. The patient asked fewer questions and the genetic counselor spoke in condensed ideas. Overall, our observations suggest diminished levels of interactive communication in interpreter-mediated sessions. Our work highlights the need for further evaluation in how genetic counselors communicate during interpreter-mediated sessions.

Effects of Perceived Discrimination and Trust on Breast Cancer Screening among Korean American Women

OBJECTIVE

Korean American (KA) women continue to have lower breast cancer screening rates than other racial groups. Perceived discrimination and trust have been associated with breast cancer screening adherence, but little is known about the associations in KA women.

METHODS

Surveys were completed by 196 KA women in the Chicago metropolitan area. Multiple and Firth logistic regression analyses were performed to identify factors (perceived discrimination, trust, acculturation, cultural beliefs, health care access) influencing breast cancer screening adherence (mammogram). In addition, SPSS macro PROCESS was used to examine the mediating role of trust between perceived discrimination and breast cancer screening adherence.

RESULTS

Ninety-three percent of the women surveyed had health insurance and 54% reported having a mammogram in the past 2 years. Predictors of having a mammogram were knowing where to go for a mammogram, having a regular doctor or usual place for health care, greater trust in health care providers, and lower distrust in the health care system. Perceived discrimination had an indirect effect on breast cancer screening through trust.

CONCLUSIONS

The breast cancer screening rate among KA women is low. Perceived discrimination in health care, trust in health care providers, and distrust in the health care system directly or indirectly influenced breast cancer screening adherence in KA women. Trust is a factor that can be strengthened with educational interventions.

Impact of Patient-Provider Race, Ethnicity, and Gender Concordance on Cancer Screening: Findings from Medical Expenditure Panel Survey

Background: Racial and ethnic minorities experience lower rates of cancer screening compared with non-Hispanic whites (NHWs). Previous studies evaluating the role of patient-provider race, ethnicity, or gender concordance in cancer screening have been inconclusive.Methods: In a cross-sectional analysis using the Medical Expenditure Panel Survey (MEPS), data from 2003 to 2010 were assessed for associations between patient-provider race, ethnicity, and/or gender concordance and, screening (American Cancer Society guidelines) for breast, cervical, and colorectal cancer. Multivariable logistic analyses were conducted to examine associations of interest.Results: Of the 32,041 patient-provider pairs in our analysis, more than 60% of the patients were NHW, 15% were non-Hispanic black (NHB), and 15% were Hispanic. Overall, patients adherent to cancer screening were more likely to be non-Hispanic, better educated, married, wealthier, and privately insured. Patient-provider gender discordance was associated with lower rates of breast [OR, 0.83; 95% confidence interval (CI), 0.76-0.90], cervical (OR, 0.83; 95% CI, 0.76-0.91), and colorectal cancer (OR, 0.84; 95% CI, 0.79-0.90) screening in all patients. This association was also significant after adjusting for racial and/or ethnic concordance. Conversely, among NHWs and NHBs, patient-provider racial and/or ethnic concordance was not associated with screening. Among Hispanics, patient-provider ethnic discordant pairs had higher breast (58% vs. 52%) and colorectal cancer (45% vs. 39%) screening rates compared with concordant pairs.Conclusions: Patient-provider gender concordance positively affected cancer screening. Patient-provider ethnic concordance was inversely associated with receipt of cancer screening among Hispanics. This counter-intuitive finding requires further study.Impact: Our findings highlight the importance of gender concordance in improving cancer screening rates. Cancer Epidemiol Biomarkers Prev; 26(12); 1804-11. ©2017 AACR.

Preparedness of small animal veterinary practices to communicate with Spanish-speaking pet owners with limited proficiency in English

OBJECTIVE

To investigate the preparedness of small animal veterinary personnel to communicate with Spanish-speaking pet owners with limited English-language proficiency (LEP).

DESIGN

Cross-sectional telephone survey.

SAMPLE

Data from 383 small animal veterinary practices.

PROCEDURES

Telephone surveys were conducted with veterinarians and office or practice managers from a random sample of US small animal veterinary practices in 10 states to estimate the number of Spanish-speaking pet owners with LEP visiting these practices, proportion of practices that used services to facilitate communication with Spanish-speaking clients with LEP, and degree of veterinarian satisfaction with their communication with those clients.

RESULTS

Responses were obtained from 383 of 1,245 (31%) eligible practices, of which 340 (89%) had Spanish-speaking clients with LEP and 200 (52%) had such clients on a weekly basis. Eight percent of practices had veterinary personnel who were conversant or fluent in spoken Spanish. Veterinarians who depended on clients' friends or family to translate were significantly less satisfied with client communication than were those who could converse in Spanish with clients directly. Availability of Spanish-speaking staff and offering of Spanish-language resources were associated with an increase in the number of Spanish-speaking clients with LEP seen on a weekly basis. Industry- and practice-generated Spanish-language materials were offered at 32% (124/383) and 21% (81/383) of practices, respectively; 329 (86%) practices had no Spanish-language marketing.

CONCLUSIONS AND CLINICAL RELEVANCE

Opportunities were identified for improving communication with pet owners with LEP in the veterinary clinical setting, which could ultimately positively impact patient well-being and client compliance.

Patient-physician language concordance and use of preventive care services among limited English proficient Latinos and Asians

OBJECTIVES

Patient-physician language concordance among limited English proficient (LEP) patients is associated with better outcomes for specific clinical conditions. Whether or not language concordance contributes to use of specific preventive care services is unclear.

METHODS

We pooled data from the 2007 and 2009 California Health Interview Surveys to examine mammography, colorectal cancer (CRC) screening, and influenza vaccination use among self-identified LEP Latino and Asian (i.e., Chinese, Korean, and Vietnamese) immigrants. We defined language concordance by respondents reporting that their physician spoke their non-English language. Analyses were completed in 2013-2014.

RESULTS

Language concordance did not appear to facilitate mammography use among Latinas (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI] 0.72, 1.45). Among Asian women, we could not definitively exclude a negative association of language concordance with mammography (AOR=0.55, 95% CI 0.27, 1.09). Patient-physician language concordance was associated with lower odds of CRC screening among Asians but not Latinos (Asian AOR=0.50, 95% CI 0.29, 0.86; Latino AOR=0.85, 95% CI 0.56, 1.28). Influenza vaccination did not differ by physician language use among either Latinos or Asians.

CONCLUSIONS

Patient-physician language concordance was not associated with higher use of mammography, CRC screening, or influenza vaccination. Language concordance was negatively associated with CRC screening among Asians for reasons that require further research. Future research should isolate the impact of language concordance on the use of preventive care services from health system factors.

Impact of patient and navigator race and language concordance on care after cancer screening abnormalities

BACKGROUND

Patient navigation improves the timely diagnosis of cancer among minorities, but little is known about the effects of patient and navigator race and language concordance on health outcomes.

METHODS

The authors investigated the effects of patient and navigator race and language concordance on the time to diagnosis of cancer screening abnormalities among participants in the Boston Patient Navigation Research Program, a clinical effectiveness trial for women who had breast or cervical cancer screening abnormalities identified from January 1, 2007 to December 31, 2008. Hazard ratios and 95% confidence intervals were estimated using proportional hazards regression adjusting for clinical and demographic factors.

RESULTS

In total, 1257 women had breast cancer screening abnormalities (n = 655) or cervical cancer screening abnormalities (n = 602) identified, and 56% were nonwhite. Language concordance was associated with timelier resolution for all patients in the cervical cancer screening abnormalities group during the first 90 days (adjusted hazard ratio, 1.46; 95% confidence interval, 1.18-1.80), and specifically for Spanish speakers during the first 90 days (adjusted hazard ratio, 1.43; 95% confidence interval, 1.10-1.84), but no difference was observed after 90 days for women who had cervical cancer screening abnormalities or at any time for those who had breast cancer screening abnormalities. Race concordance was associated with significant decreases in the time to diagnosis for minority women with breast and cervical cancer screening abnormalities in analyses stratified by race, but no differences were observed in analyses that included all women.

CONCLUSIONS

Patient navigator race and language concordance improved the timeliness of care in a minority population. Patient navigators who are racially/ethnically diverse and multilingual may help address barriers to care and improve cancer outcomes for low-income minorities.

Low health literacy and cancer screening among Chinese Americans in California: a cross-sectional analysis

OBJECTIVES

Cancer is the leading cause of death among Asian Americans. Chinese Americans comprise the largest Asian American ethnic group. Low health literacy (LHL) is associated with lower cancer screening rates, but this association has not been studied in Chinese Americans. We examined the relationship between LHL and meeting US Preventive Service Task Force (USPSTF) guidelines for cervical, colorectal and breast cancer screening among Chinese Americans.

DESIGN

Observational study of Chinese respondents in the 2007 California Health Interview Survey, a population-based survey. Interview languages included English, Cantonese and Mandarin.

SETTING

California, USA PARTICIPANTS: Chinese respondents in age/gender groupings appropriate for USPSTF cancer screening guidelines (cervical: women ages 21-65, n=632; colorectal: men or women ages 50-75, n=488; and breast: women ages 50-74, n=326).

OUTCOMES

Relationships were tested using multivariable logistic regression models controlling for healthcare access and demographic factors, including limited English proficiency (LEP). The combined effects of having both LHL and LEP were specifically examined. LHL was measured by 2-items on perceived ease-of-use of written medical materials. All study variables were self-reported.

RESULTS

Cancer screening percentages among Chinese Americans were 77.8% for cervical, 50.9% for colorectal (47.9% for women and 54.2% for men), and 85.5% for breast. LHL was associated with lower odds of meeting breast cancer screening guidelines (OR 0.41; 95% CI 0.20 to 0.82). Respondents with both LHL and LEP were significantly less likely to have up-to-date colorectal (OR 0.49; 95% CI 0.25 to 0.97) and breast cancer screening (OR 0.21; 95% CI 0.08 to 0.54) than those with neither health communication barrier. In all multivariable models, having seen a physician in the past year was a significant predictor of an up-to-date screening.

CONCLUSIONS

In Chinese Americans, LHL and LEP were negatively associated with up-to-date breast and colorectal cancer screening, independent of a recent physician visit. Efforts to promote cancer screening among Chinese Americans should consider and address LHL, LEP and physician access barriers.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

HIV testing during the Canadian immigration medical examination: a national survey of designated medical practitioners

HIV testing is mandatory for individuals wishing to immigrate to Canada. Since the Designated Medical Practitioners (DMPs) who perform these tests may have varying experience in HIV and time constraints in their clinical practices, there may be variability in the quality of pre- and posttest counseling provided. We surveyed DMPs regarding HIV testing, counseling, and immigration inadmissibility. A 16-item survey was mailed to all DMPs across Canada (N = 203). The survey inquired about DMP characteristics, knowledge of HIV, attitudes and practices regarding inadmissibility and counseling, and interest in continuing medical education. There were a total of 83 respondents (41%). Participants frequently rated their knowledge of HIV diagnostics, cultural competency, and HIV/AIDS service organizations as "fair" (40%, 43%, and 44%, respectively). About 25%, 46%, and 11% of the respondents agreed/strongly agreed with the statements "HIV infected individuals pose a danger to public health and safety," "HIV-positive immigrants cause excessive demand on the healthcare system," and "HIV seropositivity is a reasonable ground for denial into Canada," respectively. Language was cited as a barrier to counseling, which focused on transmission risks (46% discussed this as "always" or "often") more than coping and social support (37%). There was a high level of interest (47%) in continuing medical education in this area. There are areas for improvement regarding DMPs' knowledge, attitudes, and practices about HIV infection, counseling, and immigration criteria. Continuing medical education and support for DMPs to facilitate practice changes could benefit newcomers who test positive through the immigration process.

Relationship between self-assessed and tested non-English-language proficiency among primary care providers

BACKGROUND

Individuals with limited English proficiency experience poor patient-clinician communication. Most studies of language concordance have not measured clinician non-English-language proficiency.

OBJECTIVES

To evaluate the accuracy of the self-assessment of non-English-language proficiency by clinicians compared with an oral proficiency interview.

SUBJECTS

Primary care providers (PCPs) in California and Massachusetts.

MEASURES

PCPs first completed a self-assessment of non-English-language proficiency using a version of the Interagency Language Roundtable (ILR) Scale, followed by the Clinician Cultural and Linguistic Assessment (CCLA), a validated oral proficiency interview. We used nonparametric approaches to analyze CCLA scores at each ILR scale level and the correlation between CCLA and ILR scale scores.

RESULTS

Sixteen PCPs in California and 51 in Massachusetts participated (n=67). Participants spoke Spanish (79%), followed by Cantonese, Mandarin, French, Portuguese, and Vietnamese. The respondents self-assessed as having "excellent" proficiency 9% of the time, "very good" proficiency 24% of the time, "good" proficiency 46% of the time, "fair" proficiency 18% of the time, and "poor" proficiency 3% of the time. The average CCLA score was 76/100. There was a positive correlation between self-reported ILR scale and CCLA score (σ=0.49, P<0.001). The variance in CCLA scores was wider in the middle categories than in the low or high ILR categories (P=0.003).

CONCLUSIONS

Self-assessment of non-English-language proficiency using the ILR correlates to tested language proficiency, particularly on the low and high ends of the scale. Participants who self-assess in the middle of the scale may require additional testing. Further research needs to be conducted to identify the characteristics of PCP whose self-assessments are inaccurate and, thus, require proficiency testing.

Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care

BACKGROUND

Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups.

PURPOSE

To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers.

METHODS

Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities.

RESULTS

Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders.

CONCLUSIONS

Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

Colorectal cancer screening: low health literacy and limited English proficiency among Asians and Whites in California

The authors examined the relationship between low health literacy (LHL), limited English proficiency (LEP), and meeting current U.S. Preventive Service Task Force colorectal cancer (CRC) screening guidelines for Asians and Whites in California. For 1,478 Asian and 14,410 White respondents 50-75 years of age in the 2007 California Health Interview Survey, the authors examined meeting CRC screening guidelines using multivariable logistic models by LEP and LHL separately and in combination. Analyses were run with the full sample, then separately for Whites and Asians controlling for demographics and insurance. For those with LEP, patient-provider language concordance and CRC screening was examined. Overall, respondents with LEP and LHL were the least likely to meet CRC screening guidelines (36%) followed by LEP-only (45%), LHL-only (51%), and those with neither LHL nor LEP (59%), a hierarchy that remained significant in multivariable models. For Whites, LHL-only was associated with screening, whereas LEP-only and LEP and LHL were significant for Asians. Having a language concordant provider was not significantly associated with CRC screening among those with LEP. Health literacy is associated with CRC screening, but English proficiency is also critical to consider. Asians with both LEP and LHL appear particularly vulnerable to cancer screening disparities.