The impact of limited English proficiency on asthma action plan use

The Child Opportunity Index and asthma morbidity among children younger than 5 years old in Washington, DC

BACKGROUND

Place-based social determinants of health are associated with pediatric asthma morbidity. However, there is little evidence on how social determinants of health correlate to the disproportionately high rates of asthma morbidity experienced by children <5 years old.

OBJECTIVES

This study sought to evaluate census tract associations between the Child Opportunity Index ±COI) and at-risk rates (ARRs) for pediatric asthma-related emergency department (ED) encounters and hospitalizations in Washington, DC.

METHODS

This was a cross-sectional study of children <5 years old with physician-diagnosed asthma included in the DC Asthma Registry between January 2018 and December 2019. Census tract COI score (1-100) and its 3 domains (social/economic, health/environmental, and educational) were the exposures (source: www.diversitydatakids.org). ED and hospitalization ARRs (outcomes) were created by dividing counts of ED encounters and hospitalizations by populations with asthma for each census tract and adjusted for population-level demographic (age, sex, insurance), clinical (asthma severity), and community (violent crime and limited English proficiency) covariates.

RESULTS

Within a study population of 3806 children with a mean age of 2.4 ± 1.4 years, 2132 (56%) had 5852 ED encounters, and 821 (22%) had 1418 hospitalizations. Greater census tract overall COI, social/economic COI, and educational COI were associated with fewer ED ARRs. There were no associations between the health/environmental COI and ED ARRs or between the COI and hospitalization ARRs.

CONCLUSION

Improving community-level social, economic, and educational opportunity within specific census tracts may reduce ED ARRs in this population.

Caregiver Language Preference and Health Care Utilization Among Children With Asthma

BACKGROUND AND OBJECTIVES

Asthma is a leading cause of health care utilization in children and disproportionately affects historically marginalized populations. Yet, limited data exist on the role of caregiver language preference on asthma morbidity. The study aim was to determine whether caregiver non-English language preference (NELP) is associated with unscheduled asthma-related health care utilization in pediatric patients.

METHODS

This was a retrospective cohort study using data from a population-level, disease-specific registry of pediatric patients with asthma living in the District of Columbia (DC). Patients aged 2 to 17 years were included and the study period was 2019. The primary exposure variable was language preference: English preferred (EP) or NELP by self-identified language preference. The primary outcome was unscheduled asthma-related health care utilization including emergency department visits, hospitalizations (ICU and non-ICU), and ICU visits alone. Logistic regression was used to calculate adjusted odds ratios (aORs).

RESULTS

Of the 14 431 patients included, 8.1% had NELP (1172 patients). In analyses adjusted for age, sex, ethnicity, insurance status, diagnosis of persistent asthma, controller prescription, and encounter with a primary care provider, caregiver NELP was associated with an increased odds of having an asthma-related emergency department visit (aOR, 1.37; 95% CI, 1.08-1.74), hospitalization (aOR, 1.79; 95% CI, 1.18-2.72), and ICU visit (aOR, 4.37; 95% CI, 1.93-9.92). In the Hispanic subgroup (n = 1555), caregiver NELP was associated with an increased odds of having an asthma-related hospitalization (aOR, 1.73; 95% CI, 1.02-2.93).

CONCLUSIONS

In the population of children in the District of Columbia with asthma, caregiver NELP was associated with increased odds of asthma-related health care utilization, suggesting that caregiver language preference is a significant determinant of asthma outcomes.

Hispanic/Latino Perspectives on Hearing Loss and Hearing Healthcare: Focus Group Results

OBJECTIVES

To better understand the hearing health learning needs of Hispanic/Latino adults by assessing hearing healthcare (HHC) knowledge, attitudes, and behaviors to inform the development of a culturally and linguistically appropriate self-management program. Through a series of focus groups with members of the target audience, this study explored knowledge about hearing loss and interventions, cultural facilitators and barriers to HHC utilization, and preferences for hearing health education and information delivery. Opinions were also received on patient education materials designed to increase self-efficacy for managing hearing loss in daily life.

DESIGN

This work was guided by a practical framework of culturally competent interventions for addressing disparities in health and healthcare, centered on structural, clinical, and organizational barriers to care. A hybrid individualistic social psychology and social constructionist approach was used to build programmatic theory related to the primary research objective. Focus group goals were to generate a combination of personal opinions and collective experiences from participants with an a priori plan to analyze data using combined content analysis/grounded theory methods. Purposive sampling was used to select 31 participants who were Spanish-speaking, identified as Hispanic/Latino, and who had normal hearing or self-reported hearing difficulties. Thirteen focus groups were conducted using Microsoft Teams, and each group was audio and video recorded for later off-line transcription, translation, and analysis. A constant comparison approach was used to systematically organize focus group data into a structured format for interpretation. Transcripts were coded independently by two investigators, and emergent themes were derived and interpreted from the coded data.

RESULTS

Major and minor themes tied to the framework for culturally competent interventions included those related to sociocultural barriers to care. Structural barriers, including inconsistent access to quality care, lack of culturally and linguistically appropriate patient education materials, appointment wait times and intake processes, and referrals to specialty care, were most frequently experienced by participants. Clinical barriers most frequently cited were a lack of culturally and linguistically congruent healthcare providers and lack of language access during healthcare visits. Other major themes included hearing loss lived experiences, family and familism, and hearing-related patient education needs and preferences.

CONCLUSIONS

Focus group results were integrated into a Spanish-language hearing loss self-management program that is currently being evaluated in a randomized controlled trial. The themes uncovered provided insight regarding the knowledge, attitudes, and beliefs about hearing loss and HHC, including hearing-related learning needs, of Hispanic/Latino adults in this sample.

Ethnic Differences in Severe Asthma Clinical Care and Outcomes: An Analysis of United Kingdom Primary and Specialist Care

BACKGROUND

Understanding the effects of ethnicity in severe asthma is important for optimal personalized patient care.

OBJECTIVE

To assess ethnic differences in disease control, exacerbations, biological phenotype, and treatment in severe asthma in the United Kingdom.

METHODS

We compared demographics, type 2 biomarkers, lung function, asthma control, medications, and health care use between White and underrepresented ethnic group patients in the UK Severe Asthma Registry (UKSAR) and Optimum Patient Care Research Database (OPCRD).

RESULTS

A total of 3637 patients (665 from the underrepresented ethnic group) were included from UKSAR and 10,549 (577 from the underrepresented ethnic group) from OPCRD. Patients in the underrepresented ethnic group had higher levels of uncontrolled disease when measurements were made using the asthma control questionnaire in UKSAR (odds ratio [OR] = 1.47; 95% confidence interval [CI], 1.12-1.93) and the Royal College of Physicians 3 Questions in OPCRD (OR = 1.82; 95% CI, 1.27-2.60). Although exacerbation rates were similar, patients in the underrepresented ethnic group were more likely to have recently attended the emergency department (OR = 1.55; 95% CI, 1.26-1.92) or to have been hospitalized (OR = 1.31; 95% CI, 1.07-1.59) owing to asthma. Inflammatory biomarkers were consistently higher in the underrepresented ethnic group, including blood eosinophils in OPCRD (ratio = 1.12; 95% CI, 1.05-1.20) and in UKSAR blood eosinophils (ratio = 1.16; 95% CI, 1.06-1.27), FeNO (ratio = 1.14; 95% CI, 1.04-1.26), and IgE (ratio = 1.70; 95% CI, 1.47-1.97). Patients in the underrepresented ethnic group were more likely to be atopic in the UKSAR (OR = 1.32; 95% CI, 1.07-1.63) and OPCRD (OR = 1.67; 95% CI, 1.26-2.21), and less likely to be using maintenance oral corticosteroids at referral (OR = 0.75; 95% CI, 0.61-0.92).

CONCLUSIONS

Severe asthma patients from underrepresented ethnic groups presented with a higher disease burden and were more likely to attend the emergency department. They had a distinct phenotypic presentation and differences in medicine use, with higher levels of type 2 biomarkers.

Social and Cultural Challenges in Caring for Latinx Individuals With Kidney Failure in Urban Settings

IMPORTANCE

Latinx individuals with end-stage kidney disease (ESKD) constitute 19% of US patients receiving in-center scheduled hemodialysis. Compared with non-Latinx White patients, Latinx individuals often face poor economic, environmental, and living circumstances. The challenges for health care professionals engendered by these circumstances when Latinx individuals present with ESKD and possible solutions have not been well described.

OBJECTIVE

To examine the perceptions of interdisciplinary health care professionals who work in dialysis centers in urban settings with large racial and ethnic minority populations about how social challenges affect the care of Latinx patients with ESKD.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study administered semistructured interviews of interdisciplinary health care professionals at 4 urban dialysis centers in Denver, Colorado, from April 1 to June 30, 2019. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

MAIN OUTCOMES AND MEASURES

Themes and subthemes of barriers to care.

RESULTS

Thirty interdisciplinary dialysis center health care professionals (23 [77%] female; mean [SD] age, 42.0 [11.6] years) participated. Four themes were identified. The first 3 themes and their respective subthemes (in parentheses) describe challenges to kidney care: compromised quality of care attributable to communication and cultural barriers (language interpretation by telephone, in-person language interpretation, burden of ad hoc interpretation, low-quality health care, lack of language- and culturally concordant materials, and health literacy levels), difficulty with health care access (unreliable transportation, economic instability, and loss of insurance benefits), and concerns about patient psychosocial well-being (social isolation, hopelessness, stigma of illness, and balancing personal social challenges). The fourth theme describes solutions to improve care (culturally responsive care, patient empowerment and activation, supporting primary caregivers, and peer support with navigation of the health care system).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that dialysis center policies are needed that require high-quality language interpretation and the availability of culturally concordant educational materials. Community-based interventions that improve patient activation and provide peer support as well as culturally responsive care may improve the care of Latinx patients with ESKD receiving in-center scheduled hemodialysis.

Length of Stay for Patients With Limited English Proficiency in Pediatric Urgent Care

This retrospective chart review compared the length of stay (LOS) of families with limited English proficiency (LEP) versus English-speaking families seen in 3 pediatric urgent care centers (PUCCs). Visits were included for patients aged 2 months to 17 years seen between January 1, 2016, and December 31, 2016, with 1 of 5 primary diagnoses. For each LEP encounter, we randomly selected 3 English-speaking encounters within the same PUCC and diagnosis class. We compared overall LOS between LEP and English-speaking encounters. Of our entire sample, 184 (1.03%) were LEP encounters, of which 145 (78.8%) preferred Spanish. Comparing the LEP visits to 552 matched English-speaking visits, we found a significant difference in average LOS (LEP 85.5 minutes; English-speaking 76.4 minutes) and in prescriptions provided (P = .005) but not in triaged acuity nor number of medications administered, laboratory or radiological studies, or suction treatments. This study serves as a starting point to better care for patients/families with LEP in PUCCs.

Spanish Speaking, Limited English Proficient Parents whose Children are Hospitalized: An Integrative Review

PROBLEM

Children of non-English speakers are at risk for health disparities. Little is known about the experiences of Spanish speaking parents with limited English proficiency (LEP) whose children are hospitalized. The purposes of this integrative review were to explore what is known and to identify gaps in the literature about the experiences of Spanish speaking parents with LEP whose children are hospitalized.

ELIGIBILITY CRITERIA

Whittemore and Knafl's (2005) integrative review method guided the process. Studies addressed Spanish speaking parents of hospitalized children in the United States.

SAMPLE

A final sample consisted of 36 quantitative and qualitative research studies published from 1994 to 2018; located through a search of CINAHL, Pubmed, and Scopus.

RESULTS

Language services were inconsistent although mandated by standards and laws. Parents experienced mixed emotions related to care. Emergency departments in large, urban cities were the most common care settings. Differences in care outcomes and safety risks for children of Spanish speaking parents existed; however, findings were inconsistent. Only three of the 36 studies addressed nursing care.

CONCLUSIONS

Research design and quality varied. Parents valued communication in their language. Nurses are the primary healthcare provider in the hospital setting but few studies explored parents' experiences associated with nursing care. No studies explored parents' experiences with their child's hospitalization in the context of culture.

IMPLICATIONS

Future research is needed to explore the cultural values, beliefs, and experiences of Spanish speaking parents with LEP and the role of nurses and to inform culturally congruent nursing care, research, and policy.

Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department

BACKGROUND

National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP.

OBJECTIVE

To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County.

METHODS

We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and t-tests.

RESULTS

90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (p < 0.05 for both comparisons).

CONCLUSION

Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

Spanish-Speaking Caregivers' Experience with an Emergency Department Pediatric Asthma-Care Bundle Quality Initiative

Most pediatric emergency departments' (ED) quality improvement (QI) initiatives for asthma aim to standardize care based on the priorities of healthcare providers. Perceptions and priorities of the caregiver rarely are addressed, especially in families with limited English-language proficiency. We explored Spanish-speaking caregivers' perceptions, understandings, and barriers with the care they received for asthma, after exposure to an ED asthma-care bundle. This qualitative study was part of a larger QI initiative on Spanish-speaking caregivers of patients presenting to a children's hospital ED with an asthma exacerbation. Patients were exposed to an asthma-care bundle, which included timely administration of medication, home dose of medications, an educational intervention, asthma action plans (AAPs), and discharge instructions. Through semi-structured interviews and qualitative analyses, we assessed the perceptions, understandings, and barriers caregivers reported during their ED experience. From January 2015 to October 2016, 492 patients received AAPs in the ED. Of 128 families that preferred Spanish, 88 (69%) received a Spanish AAP, 41 (32%) received Spanish discharge instructions, and 34 (27%) received discharge materials in both languages. Thirteen families were interviewed. Three themes emerged regarding the caregivers' perceived barriers: (1) need for improved accessibility to medication, primary care, and insurance; (2) communication barriers, such as timeliness, availability of interpreters, and need for resources in their preferred language; and (3) uncertainty about the child's diagnosis and acuity. Incorporating the caregivers' perspectives into QI projects may yield valuable information when developing new interventions. In the ED, improving accessibility to interpreters and providing discharge materials in their preferred language, as well as addressing misconceptions about asthma, may enhance caregivers' satisfaction.

Public Health Agency Responses and Opportunities to Protect Against Health Impacts of Climate Change Among US Populations with Multiple Vulnerabilities

During the past several decades, unprecedented global changes in climate have given rise to an increase in extreme weather and other climate events and their consequences such as heavy rainfall, hurricanes, flooding, heat waves, wildfires, and air pollution. These climate effects have direct impacts on human health such as premature death, injuries, exacerbation of health conditions, disruption of mental well-being, as well as indirect impacts through food- and water-related infections and illnesses. While all populations are at risk for these adverse health outcomes, some populations are at greater risk because of multiple vulnerabilities resulting from increased exposure to risk-prone areas, increased sensitivity due to underlying health conditions, and limited adaptive capacity primarily because of a lack of economic resources to respond adequately. We discuss current governmental public health responses and their future opportunities to improve resilience of special populations at greatest risk for adverse health outcomes. Vulnerability assessment, adaptation plans, public health emergency response, and public health agency accreditation are all current governmental public health actions. Governmental public health opportunities include integration of these current responses with health equity initiatives and programs in communities.

Association between pediatric asthma care quality and morbidity and English language proficiency in Ohio

OBJECTIVE

Limited English proficiency can be a barrier to asthma care and is associated with poor outcomes. This study examines whether pediatric patients in Ohio with limited English proficiency experience lower asthma care quality or higher morbidity.

METHODS

We used electronic health records for asthma patients aged 2-17 years from a regional, urban, children's hospital in Ohio during 2011-2015. Community-level demographics were included from U.S. Census data. By using chi-square and t-tests, patients with limited English proficiency and bilingual English-speaking patients were compared with English-only patients. Five asthma outcomes-two quality and three morbidity measures-were modeled using generalized estimating equations.

RESULTS

The study included 15 352 (84%) English-only patients, 1744 (10%) patients with limited English proficiency, and 1147 (6%) bilingual patients. Pulmonary function testing (quality measure) and multiple exacerbation visits (morbidity measure) did not differ by language group. Compared with English-only patients, bilingual patients had higher odds of ever having an exacerbation visit (morbidity measure) (adjusted odds ratio [aOR], 1.4; 95% confidence interval [CI], 1.2-1.6) but lower odds of admission to intensive care (morbidity measure) (aOR, 0.3; 95% CI, 0.2-0.7), while patients with limited English proficiency did not differ on either factor. Recommended follow-up after exacerbation (quality measure) was higher for limited English proficiency (aOR, 1.8; 95% CI, 1.4-2.3) and bilingual (aOR, 1.6; 95% CI, 1.3-2.1), compared with English-only patients.

CONCLUSIONS

In this urban, pediatric population with reliable interpreter services, limited English proficiency was not associated with worse asthma care quality or morbidity.

Working With Clients With Limited English Proficiency: Mapping Language Access in Occupational Therapy

Nearly one in ten US residents have difficulty speaking and understanding English and are deemed to have limited English proficiency (LEP). Despite federal mandates for provision of interpreters and other language access services, individuals with LEP experience notable health disparities. Occupational therapists must be prepared to equitably serve this population, however there is a dearth of research evidence and practical recommendations about our profession's readiness to serve this growing population. This paper maps the current healthcare policy environment and existing language access research relevant to occupational therapy. Implications for the future of occupational therapy research, education and practice are discussed.

A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers

OBJECTIVES

To evaluate limited English proficiency (LEP) Latino caregiver asthma knowledge after exposure to an educational video designed for this target group.

METHODS

A cross-sectional, interventional study was performed. We aimed to evaluate the post-test impact on asthma knowledge from baseline after exposure to a patient-centered, evidence-based, and professionally produced Spanish asthma educational video. Participants included LEP Latino caregivers of children 2-12 years old with persistent asthma. Enrollment was performed during ED encounters or scheduled through a local community organization. Asthma knowledge was measured with a validated Spanish parental asthma knowledge questionnaire. Differences in mean scores were calculated with a paired t-test.

RESULTS

Twenty caregivers were enrolled. Participants included mothers (100%) from Puerto Rico (75%), with a high-school diploma or higher (85%), with no written asthma action plan (65%), whose child's asthma diagnosis was present for at least 3 years (80%). Mean baseline asthma knowledge scores improved 8 points from 58.4 to 66.4 after watching the educational video (95% CI 5.3-10.7; t(19) = 6.21, p < 0.01). Knowledge improvements were similar across the ED and community groups. Knowledge gains were observed in the areas of ED utilization, medication usage, and activity limitations.

CONCLUSIONS

The developed educational video improved caregiver asthma knowledge for a Latino population facing communication barriers to quality asthma care. Dissemination of this educational resource to LEP caregivers has the potential to improve pediatric asthma care in the United States.

Latino caregiver experiences with asthma health communication

In this article, we analyze qualitative data from a purposeful sample of limited English proficiency (LEP) asthma health caregivers. We used ethnically concordant, semistructured, in-depth Spanish-language interviews and a follow-up focus group to explore issues related to communication during pediatric asthma encounters in medical settings. Inductive coding of Spanish transcripts by a bilingual research team was performed until thematic saturation was reached. Several key findings emerged. LEP caregivers encountered significant asthma burdens related to emotional stress, observed physical changes, and communication barriers. Language-discordant communication and the use of ad hoc interpreters were common. This finding is complex, and was influenced by perceptions of interpreter availability, delays in care, feelings of mistrust toward others, and individual emotional responses. Language-concordant education and suitable action plans were valued and desired. We discuss a revealing depiction of the LEP caregiver experience with asthma health communication and recommend areas for further inquiry.

Findings from a community-based asthma education fair for Latino caregivers

OBJECTIVE

To assess limited English proficiency (LEP) asthma caregiver quality of life (QoL), skills retention and healthcare utilization after an asthma education fair (AEF).

METHODS

A language concordant AEF was conducted at a Latino community center. LEP caregivers of children 1-12 years old and an established asthma diagnosis participated in three skill stations: (a) medication recognition and administration, (b) peak flow use (if child ≥ 5 years) and (c) action plan dissemination. Spacers, peak flow meters and individualized action plans were distributed. A validated, pediatric asthma caregiver quality of life questionnaire (PACQLQ-Spanish version) was administered. Baseline data was compared to follow-up interview data at three and six months after the AEF. Mean PACQLQ scores were analyzed with Wilcoxon signed-rank test and nominal paired data with McNemar's test.

RESULTS

We analyzed data from 18 caregivers able to speak English well (22%), not well (28%) or not at all (50%). After three months, improved caregiver QoL was experienced (51 vs. 72, p<0.01). No differences were observed in medication recognition, spacer and peak flow use or peak flow interpretation. After six months, mean school days missed due to asthma decreased (4.1 vs. 0.4, p<0.01). Mean clinic visits, emergency department visits and hospitalizations remained unchanged.

CONCLUSIONS

Implementation of a community-based AEF with action plan administration can be beneficial for LEP caregivers and their children. QoL improvements to emotional wellbeing and activity limitations were observed, and lower rates of school absenteeism were reported. Caregiver ability to accurately identify medications was not enhanced.