Introduction
According to Hu et al. (2010), diabetes affects close to 2.5 million Hispanic Americans (10.4%) compared to 6.6% of their non-Hispanic counterparts. The Hispanic population continues to grow in the U.S. with language barriers being an issue of concern in healthcare service delivery. On the other hand, Mohan et al. (2012) indicate that a lack of understanding of prescription instructions among diabetic Latinos in the United States occurs due to a high number of Latinos with limited English proficiency (LEP). Further, Fernandez et al. (2010) show that many Latinos lack the necessary English Language skills because about 39% of the Latino population rarely speaks good English. Considering that effective communication is fundamental to the practice of medicine, language differences may have serious implications on the patients as well as healthcare providers (Timmins, 2002).
Fernandez et al. (2010) point out that Hispanic Latinos have poor glycemic control and suffer more complications related to diabetes compared to non-Latino diabetic patients. Additionally, about 21% of Latino patients with LEP have poor glycemic control compared to Latino English-speakers (18%). Moreover, only 10% of White patients have poor glycemic control compared to their Latino counterparts (Fernandez et al., 2010). The statistics clearly show that the major disparities in health care that affect Hispanics may be attributable to language barriers. Karliner and Mutha (2010) point out that quality health care is achievable among patients with LEP through organizational commitment, use of information technology, coordinated project management, and paying attention to the medical needs of the patients.
Diabetes affects many people in the United States. Once regarded as a single disease entity, diabetes now represents a diverse group of metabolic diseases characterized by hyperglycemia. Chronic hyperglycemia leads to multiple complications that include cardiovascular, renal, neurological, and ophthalmic disorders. With diabetes disproportionately affecting certain groups such as the Latinos, Pena-Purcell, Boggess, and Jimenez (2011) propose a Diabetes Self-Management Education (DSME) programs to address different needs of the affected people.
Current procedures and policies regarding language services for non-English speakers in different healthcare institutions are suboptimal and potentially dangerous. As a result, there is the need for health care providers to develop programs aimed at improving the use of suitable linguistic access services in the provision of healthcare services to LEP patients (Saha, Fernandez, & Perez-Stable, 2007). The purpose of this paper is to analyze and present findings of existing literature regarding the impact of language barriers on healthcare access among immigrant diabetic Latinos. Moreover, the paper seeks to find out whether language barriers affect healthcare access among diabetic Latinos. Therefore, the findings of this review are relevant to evidence-based practice because Hispanic Americans are disproportionately affected by different factors that influence healthcare accessibility, and therefore, there is the need to highlight these factors to help in tackling the issue of language barriers among the Latino population.
Search Strategy
In preparing for this review, the specific search terms used include language barriers, health care access, and diabetic patients in the United States. The search engines used include SAGE Journals, BMC Public Health, PMC-NCBI, ProQuest, and Springer (JGIM). The initial search using the search terms, language barriers, and health care access among diabetic patients, produced 322 articles for SAGE Journals, 17 articles for BMC Public Health, 37 articles for ProQuest, 179 for PMC-NCBI, and 77 for Springer (JGIM). To narrow down the number of articles selected for this review, the search included the search terms, diabetic Latinos in the United States. The advanced search produced five articles for SAGE Journals, one article for BMC Public Health, one article for ProQuest, one article for PMC-NCBI, and two articles for Springer (JGIM) depending on relevance and the date of publication.
Integrated Review of Studies
Major Purposes for Completing the Studies
The impact of language barriers on healthcare access among Latinos is widely established. Fernandez et al. (2010) sought to establish the relationship between LEP and glycemic control, and the impact of having a language-concordant physician in the relationship. Specifically, this study is useful for the current review because it shows how language barriers affect health care access among the Latino population in the U.S. Further, Garcia and Duckett (2009) contribute to this discussion by showing the healthcare disparities experienced by immigrant Latino adolescents seeking healthcare services in the U.S. However, the findings of this study may not apply to adult Latino populations, particularly persons suffering from diabetes, which is the subject matter of this review. Considering the implications of language barriers on healthcare access, Mauldon, Melkus, and Cagganello (2006), examine the possibility, acceptability, and effectiveness of a culturally suitable Spanish-language diabetes-self care program to mitigate the effects of type-2 diabetes mellitus among Hispanic Americans. However, this feasibility study fails to acknowledge the effect of language barriers on healthcare access among the participants.
Moreover, Pena-Purcell and Jimenez (2011) sought to examine the effects of a culturally sensitive empowerment-based program focused on Latinos. The study is useful to this review because it focuses on diabetes intervention measures, but it fails to factor in the effect of language barriers. Perhaps a more relevant study entails the investigation conducted by Diamond et al. (2011) to examine how physicians and nurses use the Spanish language and interpreters in various clinical scenarios. Specifically, the study focuses on language barriers and recommends the development of relevant policies to enhance language skills in healthcare. Additionally, Mohan et al. (2012) sought to outline ways that can enhance medication-taking practices among diabetic Latinos. Further, the study considers the implications of incorporating patient cultures in prescribing medications, specifically, to Latinos. However, the findings may not apply to other groups of Latinos because the study involves low-income earners from Mexico. Further, Karliner and Mutha (2010) describe the steps required to implement and accomplish a hospital-wide language services program. This study shows the importance of effective communication in healthcare, but it does not show how this applies to Latinos.
On the other hand, Herrera et al. (2011) sought to examine the factors related to the provision of diabetes monitoring examination among older Latinos with type-2 diabetes. Accordingly, the study highlights the importance of effective communication in meeting the needs of Latino patients owing to their limited English skills, but it concentrates on older populations of Latinos, hence, its generalizability is in question. Further, Hu et al. (2010) explore the impact of different demographic data of adult diabetic Hispanics in the development and progression of diabetes. The study shows disparities in health access among Latinos, but it fails to handle language barriers as a major concern. Lastly, Zheng et al. (2012) explore how English proficiency relates to type-2 diabetes and diabetic retinopathy in Asians residing in Singapore. The study shows how language disparities affect healthcare access, but it may not apply to the Latino population.
Major Sample Characteristics
The studies under review involved participants from different geographic regions, but most of them targeted immigrant Latinos in the U.S. Most of the studies recruited adults aged 20 years and above drawn from the Latino/Hispanic population who were suffering from type-2 diabetes mellitus. However, Zheng et al. (2012) recruited Asians. Only one study by Garcia and Duckett (2009) involves adolescents aged 15-20 years. On the other hand, Diamond et al. (2011) recruited physicians and nurses with most of them being white Americans. The sample characteristics in the studies reviewed are important because they allow researchers to apply outcome measures to the target population. A major weakness of the sample characteristics used in the studies is that a few participants were recruited, and therefore, this diminishes the chances of generalization to the wider Latino population.
Research Designs
The studies under review employed different methods to collect information regarding the target population. The majority of the studies used one-on-one interviews (Hu et al., 2010; Garcia & Duckett, 2009; Mohan et al., 2012) while the other studies engaged respondents in structured interviews (Karliner & Mutha, 2010). The studies under review also include two surveys (Diamond et al., 2011; Fernandez et al., 2010); two cross-sectional studies (Herrera et al., 2011; Zheng et al., 2012); a quasi-experimental repeated measures design (Pena-Purcell et al., 2011); and a one-group pretest-posttest pilot study (Mauldon et al., 2006). These studies used the most effective and appropriate research methodologies in answering the research questions because about 40% of the studies involved face-to-face interviews.
Theoretical Frameworks
Hu et al. (2010) based their study on the Precede-Proceed planning model. The model describes the major factors influencing health outcomes besides providing a framework for need assessment and the process of developing, implementing, and evaluating health promotion programs. This model is appropriate in terms of examining the quality of life of Hispanics.
On the other hand, Herrera et al. (2011) used Andersen’s model of health service use. Andersen’s framework finds application in studies involving older adults, and it identifies three primary factors that affect the need to seek healthcare services. These include need factors such as functional impairment; enabling factors such as health insurance; and predisposing characteristics such as age, sex, and education. This model is useful to the current review because it informs the understanding of different factors that affect healthcare access.
Further, Garcia and Duckett (2009) employed the symbolic interactionalism framework in their study. This model helps researchers to understand the meaning of raw data from the participants’ perspective. It focuses on the argument that every individual has unique experiences, which when repeated can be of use as a combination to create a qualitative argument. This model is the basis of many studies, and it applies to the current review. Pena-Purcell et al. (2011) used the Yo Puedo framework that revolves around social modeling, self-efficacy, and behavioral competency. The study uses this model to show that the improvement of self-care and self-efficiency is fundamental in the management of diabetes. The other studies do not base their cases on any theoretical framework, but their respective approaches meet the criteria for inclusion in this review.
Major Components of Intervention
Hu et al. (2010) propose a patient-centered care program that addresses the cultural issues facing Hispanics through the inclusion of culture-specific health knowledge in the formal education programs for healthcare professionals. This measure is relevant since it seeks to enhance healthcare access, but it fails to address the issue of language barriers. On the other hand, Karliner and Mutha (2010) recommend the use of organizational culture in the efforts aimed at improving language services, particularly by bridging communication. Moreover, Mauldon et al. (2006) propose a culturally sensitive educational program for diabetic Latinos to address their learning needs and styles. This intervention is appropriate considering that it seeks to improve different factors including language barriers, which affect healthcare access among the Latino population.
Major Outcome Measures
Diamond et al. (2011) propose the teaching of Spanish vocabulary in health care courses as a measure to improve communication between clinicians and patients with LEP. However, this measure is not cost-effective because there is a need for additional funds to implement Spanish courses in medical schools. On the other hand, Fernandez et al. (2010) note that LEP compares with other risk factors such as race, ethnicity, and gender, which influence healthcare access, and hence, it is important to include language as part of the quality improvement measures. Lastly, Karliner and Mutha (2010) propose the incorporation of organizational commitment, attention to clinical needs, information technology, coordinated project development, and involvement of major stakeholders in the efforts aimed at achieving quality language services.
Major Findings
The studies under review show that language disparities affect health access among immigrant Latinos (Fernandez et al., 2010; Diamond et al., 2011; Herrera et al., 2011; Garcia & Duckett, 2009; Mohan et al., 2012). Additionally, Pena-Purcell et al. (2011) show that the use of self-management diabetes programs for Latinos improves health outcomes and self-efficacy. Furthermore, Mauldon et al. (2006) support these findings and recommend a culturally relevant intervention program for Hispanic Americans with type-2 diabetes. As a result, the study shows the need to implement culturally competent practices to address healthcare disparities; however, it fails to address the issue of language barriers. Further, Karliner and Mutha (2010) demonstrate that it is possible to provide quality services in an organization with financial problems through implementing changes in organizational skills, will, and culture. The study tackles the issue of language barriers but fails to acknowledge the plight of diabetic Latinos.
On the other hand, Zheng et al. (2012) sought to examine how language disparities affect health care access among Tamil-speaking Indians with type-2 diabetes and limited English proficiency in a society with many English speakers. The study findings show that Tamil-speaking Indians have a higher prevalence of diabetes type-2 compared to their English-speaking counterparts. This study is useful because it shows that the issue of language disparities is a major impediment to the accessibility of healthcare services, but it fails to meet the objectives of the current review since it does not involve the Latino population. Nonetheless, the findings of this study have a wider degree of generalizability because they support the findings of the other studies reviewed in the foregoing discussions in that language barriers affect access to healthcare services among different people who have limited English proficiency.
Other Findings/Unexpected Findings
According to Hu et al. (2010), obesity is a weak predictor of quality of life (QOL) unlike other studies, which indicate that obesity is inversely associated with health-related QOL in the general population of the United States. On the other hand, Mohan et al. (2012) assert that communication differences among patients and clinicians contribute to medication errors because the patients fail to comprehend the instructions. This is an unexpected finding because other studies show the use of illustrated medication instructions, which can be used by anyone.
Discussion
The studies reviewed in the discussions above establish the impact of language barriers on healthcare access among populations with limited English proficiency (LEP). All the studies except one examine the impact of having limited English skills on healthcare access among the Latino population. According to Karliner and Mutha (2010), the quality of healthcare is achievable through language access services. Here, note that the researchers sought to evaluate the effectiveness of a language service program in the delivery of safe and high-quality services to LEP patients in a public hospital. Their findings show that an organization’s commitment toward providing effective language services is central to the delivery of high-quality healthcare services to LEP patients.
Along with the same perspective, Mohan et al. (2012) illustrate the importance of using effective language services to meet the needs of LEP patients. In their study, Mohan and his colleagues found out that the use of illustrated medication instructions improved compliance among Latino patients with diabetes. Here, note that most LEP patients encounter difficulties in understanding the instructions provided by their physicians regarding medication management. However, with illustrated medication instructions, the patients expressed confidence in complying with the physician’s instructions. The other studies (Garcia & Duckett, 2009; Herrera et al., 2011; 2006; Pena-Purcell et al., 2011; Fernandez et al., 2010; Diamond et al., 2011; Hu et al., 2010) also establish the implications of language barriers on health care access among the Latino population. Although these studies employ different approaches, they all conclude that language barrier are part of the key factors influencing the equity, safety, and quality of healthcare services available to LEP patients, especially Latinos with diabetes.
Hu et al. (2010) further assert that there is a need for the implementation of culturally competent interventions in primary healthcare institutions to address language barriers and other factors influencing healthcare access among low-income Latinos with type-2 diabetes. In their study, Hu and her colleagues illustrate that culture plays a central role in determining whether Latinos with diabetes will comply with different interventions such as involvement in physical activity and adopting nutritional advice. However, with culturally competent strategies, there is a high probability of Latino patients adopting the interventions recommended by their physicians. From these findings and the other major findings from the rest of the studies, it is evident that language barriers play a pivotal role in influencing the safety and quality of healthcare services accessed by diabetic Latinos in the U.S. As a result, there is the need for healthcare providers to adopt various language services and culturally competent programs to ensure that their services meet the needs and preferences of the Latino clients.
Conclusion
The foregoing integrative review shows a common trend in the relationship between language barriers and healthcare access, particularly in populations with limited English proficiency (LEP). Although the studies employ different research approaches and methodologies, there is a consensus that language barriers affect healthcare access in the Latino population owing to the prevalence of limited English skills among a sizeable percentage of this particular population. Along with this perspective, note that the issue of language diversity presents special challenges to the U.S. healthcare sector due to limited access to health services by some racial and ethnic minority groups such as immigrant Latinos. Most importantly, this review shows that language barriers affect healthcare access in Latinos with diabetes. What does this mean to the major stakeholders in the healthcare sector? It means that health care providers should embrace the need to address this problem by developing and implementing culturally sensitive programs and practices that will ensure equity, safety, and quality of service provision to patients with LEP. Moreover, there is the need to analyze language proficiency among clinicians and nurses to come up with policies aimed at tackling the issue of language barriers in healthcare access. Finally, the administration of diabetes self-care education programs is necessary for diabetic Latinos.
References
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