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PubMed1998

Non-compliance and professional power.

The non-compliance of patients with prescribed treatments is considered as a barrier to effective health care. Non-compliance has implications for the health of patients, effective use of resources and assessments of the clinical efficacy of treatments. Research into non-compliance has increased over the last 30 years. This seems to indicate that it is seen as an important area of concern for all health care professionals. Definitions of non-compliance are problematic, as are methods of assessment of its nature and frequency. Many factors which may account for non-compliance have been proposed, as well as methods to improve compliance. Research into these factors however, mainly based on a positivist epistemology, has failed to provide any conclusive answers to the problem. Sound clinical reasons are suggested as the basis for the increase in interest in non-compliance. It is contended, however, that it is not only these reasons that account for the identification of non-compliance as a problem. Non-compliant behaviour is seen as problematic, because it contravenes professional beliefs, norms and expectations regarding the 'proper' roles of patients and professionals. These have formed the basis of an ideology that views patients as passive recipients of health care. It has led to an inherent tendency to 'blame' the patient and view non-compliance as irrational and deviant. The professional view of non-compliance as irrational, is exemplified in the case of individuals with mental illness, where there are inherent assumptions that non-compliance can be seen primarily as a symptom of illness. This denies the legitimacy of patient choice, and has led to attempts to control compliance via suggested legislative measures. Serious moral and ethical problems arise from such measures, and can be seen as the ultimate legitimization of an ideology of non-compliance. The maintenance of professional power and control is suggested as central to the debates surrounding non-compliance. The ideological assumptions underpinning the concept of non-compliance need questioning, and a re-conceptualization of the roles of patients and professionals is required. This must involve a view of patients as active participators in their own health care. Research based on an interpretative epistemology, aimed at understanding individual action, rather than control, would seem a more appropriate model to pursue.

Communication Barriers↗
PubMed1999

Language barriers and resource utilization in a pediatric emergency department.

BACKGROUND: Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). OBJECTIVE: To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. DESIGN: Prospective cohort study. METHODS: This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature >/=38.5 degrees C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. RESULTS: Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay. CONCLUSION: Despite controlling for multiple factors, the presence of a physician-family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients.

Child, Preschool↗
PubMed2001

Health literacy and shared decision making for prostate cancer patients with low socioeconomic status.

Quality of life (QOL) considerations are important in the treatment decision making process for prostate cancer patients. Although patient involvement in the treatment decision process has been encouraged, low health literacy can limit patient understanding of the complex information about treatments and their probable QOL outcomes and is a barrier to patient participation in the decision-making process. The objectives of the study were to evaluate (i) knowledge, level of satisfaction, and treatment preferences and intentions of men newly diagnosed with prostate cancer after participation in a CD-ROM shared decision making program; and (ii) the relationship between prostate cancer knowledge and health literacy. Thirty newly diagnosed prostate cancer patients from two Veteran's Administration (VA) hospitals in Chicago completed a demographic questionnaire and participated in an interactive CD-ROM shared decision making program. Subsequently, knowledge of prostate cancer, satisfaction with the information in the computer CD-ROM program, treatment preferences, and likelihood of following treatment preferences were assessed using interviewer-administered questionnaires. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). The Pearson correlation test was used to assess the relationship between health literacy and prostate cancer knowledge. The chi2 test and the Fischer exact test were used to evaluate relationships between patient demographics and other variables. More than three-quarters of the patients rated the information in the CD-ROM as "very satisfactory" (highest possible rating). Two-thirds of the patients (21 of 30) selected a treatment after participation in the CD-ROM program and 90.5% of these patients stated that they were very or somewhat likely to adhere to their selection. However, prostate cancer knowledge was variable, with one-third of the patients scoring 69.9% or lower. Participants' health literacy was equivalent to a 7th-8th grade reading level (mean = 57.1+/-10.9), and more than one-third of participants (36.7%) had lower than 9th grade literacy levels. Participants' prostate cancer knowledge was correlated with health literacy (Pearson correlation rhor = 0.65, rhop = 0.0001). Patients were satisfied with the interactive shared decision making CD-ROM program, and two-thirds of patients were able to select a preferred treatment based on the information presented in the program that they intended to follow. However, prostate cancer knowledge scores varied among participants after participation in the CD-ROM program, raising doubts that patients were adequately informed to make appropriate choices regarding their treatment. Lower prostate cancer knowledge scores corresponded to lower literacy scores, indicating that low literacy may have hindered patient understanding of the shared decision making program. The development of shared decision making tools should include collaborative efforts with the target population to improve the success of shared decision making programs among patients with low health literacy.

Aged↗
PubMed2002

Working with interpreters: an interactive Web-based learning module.

OBJECTIVE: Medical students are presented with unique challenges when they care for patients with limited English proficiency. Students must learn a complex set of skills needed to care for patients across cultural and language barriers and to understand the impact of their own attitudes and beliefs about caring for these patients. We developed and piloted a multimedia interactive Web-based module aimed at teaching students effective strategies for working with interpreters and diverse patient populations, and at raising their awareness of important legal, ethical, and cultural issues. DESCRIPTION: First the learner completes a 37-multiple-choice-question (MCQ) pre-test that assesses attitudes, factual knowledge, and ability to analyze written clinical scenarios relevant to the module's content. Learners are then shown a series of professionally produced video vignettes, which reflect diverse patient populations, interpreters, and effectiveness of interpretation strategies (e.g., a Russian-speaking woman with chest pain whose daughter interprets, a medical student interpreting for a Chinese-speaking man using herbal medication, a Haitian woman told of an abnormal mammogram through a trained simultaneous interpreter). In each case, learners submit short answers to on-screen questions analyzing the effectiveness of the interpretation strategies demonstrated. Immediate feedback is given comparing student responses with those of experts. At any time during the module, the learners may view video commentary by legal, ethics, and cultural experts, or access a glossary and Web site links. Students conclude the module by again taking the MCQ test. A final screen compares their pre- and post-MCQ test responses and shows best answers, allowing them to assess their learning. The learners also complete a survey, providing personal cultural information and feedback on the module. DISCUSSION: All 160 first-year medical students completed the module and evaluated its effectiveness this year. On average, students improved by 20% on the MCQ post-test and 86% of the students were satisfied with the learning experience and acquired new knowledge. As a result of their participation in the module, students examined their own cultural and linguistic backgrounds and made the following comments: "I am interested in exploring the way my own culture and cultural biases could impact my working with patients from other cultures"; "This module has opened my eyes to the fears and concerns of immigrants who do not speak English." Therefore, this pilot of the module effectively imparted guidelines for, and raised awareness of, medical interpreting. The most common critique of the module was that as a result of technical difficulties, it was time-consuming. A more rigorous evaluation is planned for the next academic year. We are also working to enrich and enhance the module for more experienced clinicians (GME and CME). As a complementary educational tool, the Internet has the advantages of allowing students to work at their own paces, view engaging video clips, and participate in interactive learning with immediate feedback and self-assessment.

Communication Barriers↗
PubMed1993

Issues in the provision of health care to Soviet emigrants.

Political and economic unrest in the former Soviet Union has been associated with an influx of refugees to the United States. The medical staff at our health maintenance organization perceived health care provision to the Soviet refugees as a goodwill opportunity, but soon realized that providing health care to this subpopulation of patients was very difficult. This was often related to cross-cultural differences regarding disclosure of medical information to the patient, acute care provision, and payment systems. Immigrants' expectations of US medicine are incredibly high. The interpreter plays a key role in facilitating communication between the health care team and the immigrant, yet the use of an interpreter has several inherent problems. Recognition of the problems and knowledge of the cross-cultural differences will likely improve rapport between health care personnel and immigrants.

Communication Barriers↗
PubMed1993

The health status and health care utilization of deaf and hard-of-hearing persons.

OBJECTIVE: To evaluate whether health habits, self-reported health status, and communication with physicians play a role in the known altered health care utilization patterns of deaf and hard-of-hearing persons. DESIGN: A cross-sectional survey. Respondents were given the choice of completing either a self-administered written survey or an American Sign Language interview-administered survey. POPULATION: Eighty-seven deaf and hard-of-hearing members of various organizations serving this population in southeastern Michigan and 88 hearing patients from a family practice clinic in the same area. RESULTS: Deaf and hard-of-hearing persons visit physicians more frequently (P = .01), have a lower incidence of ever smoking tobacco (P < .0006) and of alcohol use (P = .04), have more difficulties communicating with physicians (P < .001), have trouble understanding physicians (P < .001), and feel less comfortable with physicians (P < .001). Lower current tobacco use among deaf and hard-of-hearing persons was only seen in persons who were not educated beyond high school. Increased frequency of physician visits for deaf and hard-of-hearing persons was especially noticeable in the group of persons 60 years of age and older. Our finding that use of interpreters is associated with increased utilization and decreased understanding suggests deaf and hard-of-hearing patients presenting with interpreters warrant more focused attention from physicians. Reasons for seeing physicians did not explain the difference in frequency of physician visits between the two groups. CONCLUSIONS: Deaf and hard-of-hearing persons report a lower subjective health status and higher physician utilization, as well as substantial communication difficulties with physicians. They also report better health-related behaviors, namely less use of tobacco and alcohol. The use of interpreters did not decrease physician utilization or improve the understanding of physicians by these persons. Overall, our results underscore the fact that deaf and hard-of-hearing persons constitute a minority population that experiences considerable difficulties in the patient-physician relationship.

Adult↗
PubMed1995

Communication between primary care physicians and consultants.

Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.

Adult↗
PubMed2001

Glycemic control in English- vs Spanish-speaking Hispanic patients with type 2 diabetes mellitus.

BACKGROUND: Hispanic individuals compose the fastest growing minority group in the United States, yet little is known about how language impacts their health care. The primary objective of this study was to determine whether the inability to speak English adversely affected glycemic control in Hispanic patients with type 2 diabetes mellitus. METHODS: This retrospective cohort study selected 183 Hispanic patients with type 2 diabetes mellitus aged 35 to 70 years from a public health care system; patients were Spanish-speaking (SS) only, and control patients were English-speaking (ES) or bilingual. Clinical information was collected via telephone survey, and data on health care use, diagnosis, and glycosylated hemoglobin A(1c) (HbA(1c)) values were obtained from administrative and laboratory information systems. RESULTS: Values of HbA(1c) for SS (mean, 9.1%; range, 5.0%-15.3%) and ES (mean, 9.0%; range, 4.9%-16.2%) patients with diabetes mellitus and the total number of hospitalizations related and unrelated to diabetes mellitus did not differ (P =.86). Spanish-speaking patients had a diagnosis of diabetes mellitus for fewer years than ES patients (8.2 and 11.2 years, respectively; P =. 01). Spanish-speaking patients were less likely to understand their prescriptions; 22% of SS patients reported no comprehension vs 3% of ES patients (P =.001). There was a trend toward decreased prevalence of insulin use among SS patients compared with ES patients (30% vs 42%, respectively; P =.07). CONCLUSIONS: Glycemic control in Hispanic patients was not related to their ability to speak English. This finding may be explained by a high degree of language concordance between patients and providers.

Adult↗
PubMed1991

Access to neurological care for minorities.

Minority groups comprise a major segment of the estimated more than 34 million Americans without insurance coverage and also the underinsured. Neurologic disease and neurologic complications of the major causes of morbidity and mortality affect minorities protracted by limited access to health care. Hypertension, a major cause of stroke in the black population, is just one example of the impact of accessibility to intervention in central nervous system disease. Health statistics note the persisting gap between minority groups and the nation's norms for life expectancy. Aging America and particularly black elderly women, combined with the lagging infant mortality among minority groups, demonstrate limited access issues beyond economics, reflecting inner city mores, cultural barriers, and communication delay limiting contact with the practicing neurologist. Awareness of such access limitations to neurological care for minorities demands the attention of the practicing neurologist and the neurological societies.

Black or African American↗
PubMed1999

Culture and the care of children with chronic conditions: their physicians' views.

BACKGROUND: Little is known about physicians' perceptions of the influence of culture on the health care of children with chronic and disabling conditions. OBJECTIVE: To identify physicians' perceptions of the impact of the family's ethnocultural background on the health care of school-aged children with chronic conditions and recommendations for improving care. DESIGN: Qualitative study in 2 midwestern metropolitan areas. SETTING: General community. PARTICIPANTS: Convenience sample of 52 physicians nominated by 60 African American, Hispanic, and European American families of school-aged children with chronic conditions. METHODS: In-depth interviews were conducted with the physicians. Content analytic techniques were used to analyze the data. RESULTS: In 44% of the responses, the physicians reported that ethnocultural background did not influence the care the child received, noting that comparable care was provided to all of their patients. In 14% of the responses, the effect was unknown. The overall effect was negative in 26% of the responses and positive in 16%. Physicians' recommendations focused on 4 topics: improving the training and education of health care professionals and families; ensuring good communication between the child, family, and health care professionals; supporting families; and improving the access and provision of services for children from diverse cultural backgrounds. CONCLUSION: Although the majority of participants reported that ethnocultural background did not affect the care the child received from the health care system, physicians' recommendations reflected awareness of the influence of culture on the care of children with chronic conditions and the need for further training on this issue.

Attitude of Health Personnel↗
PubMed2000

Minority and nonminority pediatricians' care of minority and poor children.

BACKGROUND: Although it has been established that minority physicians tend to see more minority and more poor or uninsured patients, pediatrics as a specialty has not been studied in this regard. OBJECTIVE: To determine if minority pediatricians disproportionately provide care to minority children and to poor and uninsured children, relative to nonminority pediatricians, while controlling for possible confounding variables (socioeconomic background, sex, use of non-English languages in practice, and subspecialty training). METHODS: In 1996, a stratified random sample of 1044 pediatricians, half of whom were underrepresented minorities (URMs) (African, Native, and Mexican Americans, mainland Puerto Ricans, and other Hispanics) and half of whom were Asian or Pacific Islanders, commonwealth Puerto Ricans, and whites (non-URMs), were surveyed about personal, practice, and patient characteristics. RESULTS: Multivariate analyses reveal that, independent of other variables, being a URM pediatrician is significantly (P = .001) and positively associated with caring for a greater proportion of minority and Medicaid-insured or uninsured patients. Underrepresented minority pediatricians saw 24 percentage points more minority patients and 13 percentage points more Medicaid-insured or uninsured patients than did non-URM pediatricians. CONCLUSIONS: Compared with what non-URM pediatricians report, URM pediatricians report caring for significantly (P =.001) more minority and poor and uninsured patients. Given the few pediatricians who are URM, non-URM pediatricians should be adequately prepared to provide care for minority patients, as the proportion of minority children is high and will be increasing significantly in the next several years. Most important, efforts to ensure a racially and ethnically diverse health care workforce should be greatly enhanced, as its diversity, and hence representativeness, will improve the health care system for all Americans.

Adult↗
PubMed2006

The interpreter as cultural educator of residents: improving communication for Latino parents.

OBJECTIVE: To determine whether augmentation of the Spanish interpreter's role to include cultural education of residents can improve the satisfaction of Latino patients. DESIGN: We assessed parent satisfaction during 4 sequential 2-month periods between June 1, 2004, and February 11, 2005, using different interpretation methods: telephone interpretation (n = 91 patient encounters), trained in-person interpretation (n = 49), in-person interpretation with cultural education of residents (n = 65), and postprogram telephone interpretation (n = 45). SETTING: General pediatric practice at a large teaching hospital. PARTICIPANTS: A total of 250 Spanish-speaking parents who were limited in English proficiency. INTERVENTIONS: The cultural education program included 3 brief preclinic conferences taught by an interpreter and one-on-one teaching of residents about language and cultural issues after each clinical encounter. MAIN OUTCOME MEASURES: Parent satisfaction was assessed using 8 questions that have previously been validated in Spanish. Lower scores indicated more satisfaction. RESULTS: Because they were limited in English proficiency, our Spanish-speaking patients were significantly more satisfied when an in-person interpreter was used compared with a telephone interpreter (mean total satisfaction score of 14.5 [in-person] vs 17.4 [telephone]; P = .006) but were even more satisfied when the interpreter educated residents in cultural and language issues (mean, 11.5 [in-person with education] vs 17.4 [telephone]; P<.001). CONCLUSION: Although use of an in-person interpreter can increase Latino parents' satisfaction, a program using an interpreter to educate residents in cultural and language issues can increase satisfaction further.

Acculturation↗