From the University of Texas at El Paso, El Paso, TX.
Abstract
- Objective: To demonstrate the applied use of recommended cultural competency communication tools.
- Methods: An overview of several cultural competency tools is presented and vignettes are used to demonstrate the use of these tools with Hispanic patients with diabetes.
- Results: Three communication mnemonic instruments, ie, BELIEF, ETHNIC, and BATHE, may be useful for engaging health professionals in patient-centered communication with their Hispanic patients and shared decision making. Health professionals can also employ nonjudgmental probing as part of engaging patients in setting diabetes treatment goals.
- Conclusion: Health professionals are in an influential position to leverage a patient- and culture-centered communication style to improve communication with Hispanic patients. Using mnemonic tools can help facilitate this communication and improve health professionals’ understanding on how cultural and social factors influence diabetes management in this population.
Key words: Hispanic/Latino; diabetes; patient-centered communication; cultural-competency.
The 2017 American Diabetes Association (ADA) Standards of Medical Care recommend that health professionals engage in a patient-centered communication style with patient to facilitate shared decision-making and improve diabetes outcomes. The ADA defines patient-centered communication as “a style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care” [1]. One of the main goals of using patient-centered communication is to create a collaborative, personal, and non-judgmental relationship with patients. These guidelines, however, provide less direction on the type of communication skills training that would facilitate this type of communication, particularly as it relates to ethnic/racial minority groups most at risk for diabetes and related complications.
The US Hispanic/Latino population, in particular, is a group that is burdened by the diabetes epidemic, with a prevalence that is 130% higher than non-Hispanic whites [2]. It is widely known that certain social determinants of health, like socioeconomic status, social injustices, poor access to health care, food insecurity, or living in environments that do not support health behaviors, all contribute to health disparities for Hispanics/Latinos [3]. Understanding how Hispanics/Latinos cope with these social determinants of health is important for health care professionals, and a patient-centered communication style is an ideal approach for active listening and eliciting information about the social barriers/challenges that may influence diabetes self-care. However, there is some evidence that suggests this approach is not fully used by health care professionals when communicating with Hispanics/Latinos with diabetes, and Hispanics/Latinos continue to be more likely to experience disparities in the quality of diabetes care they receive compared to non-Hispanic whites [4–9]. One of the identified contributors to these disparities is the poor communication between physicians and Hispanic/Latino patients [10–16]. Given that health care professionals are the primary source of health care and diabetes information for Hispanics/Latinos, it is important for health professionals to enhance their patient-centered communications skills to improve the quality of care that is provided to this population [12].
Cultural Competence and Patient-Centered Communication
Not all health professional communication skills are perceived as unsatisfactory by Hispanic/Latino patients with diabetes. In fact, Hispanics/Latinos report a positive provider-patient clinical interaction when health professionals display cultural competency skills [15,17–20]. Moreover, evidence suggest that Hispanic/Latino patients with diabetes reported better quality of care and improved self-management behaviors with a culturally competent provider [18–20]. Cultural competency is described as “understanding and responding effectively to the cultural and linguistic needs brought by the patient to the health care encounter” and “valuing diversity, provider self-assessment, managing dynamics of differences, acquiring and institutionalizing knowledge, and adapting to diversity and the cultural context of individuals served” [9,11,12]. One approach for gaining cultural competency skills is to understand how the disease process is conceptualized within a culture and how that influences a patient’s own theory about their disease etiology, prognosis, and outcome [21]. This approach is known as culture-centered in the health communications literature and may be useful when communicating with Hispanic/Latino patients with diabetes because there is extensive literature describing unique indigenous Latin American explanatory models for diabetes [22–26].
Language Discordance in Physician-Patient Communication
The process of patient-physician communication includes “attending to one another and begin interpreting one another’s verbal and nonverbal” interactions [9]. A conventional assumption regarding the disparities in diabetes care quality for Hispanic/Latino patients is that it stems from language discordant patient-physician interactions, which result in errors in the provision of diabetes information and treatment instructions regarding medications and self-care behaviors [9]. While language is a contributing factor, the US Census reports that over half of US Hispanics/Latinos are bilingual and speak English “very well” [27]. Thus, other underlying mechanisms must be contributing to patient-physician miscommunication and suboptimal diabetes outcomes. Moreover, the findings from studies of patient-physician language concordance and diabetes management are inconsistent. For example, language concordance between Hispanic/Latino patients and physicians is associated with improvement in HbA1c but not self-care behaviors (ie, healthy eating, self-monitoring, medicine adherence, exercise) [20]. Thus, there is need to move beyond spoken language to address elements of interpersonal communication around diabetes care through addressing cultural health beliefs and explanatory models of diabetes.
Cultural Explanatory Models of Diabetes
Explanatory models for diabetes among Hispanics/Latinos are diverse and often include a biomedical framework (eg, obesity, unhealthy eating, sedentary lifestyle, genetics); however, there is one unique indigenous belief that continues to be held within this population. Specifically, there is a cultural belief that diabetes is caused by strong or negative emotions, like fright sickness (susto), stress (estres), anger (coraje), or nerves (nervios) [22–26]. Although this cultural belief has been in existence long before scientific evidence has shown the bi-directional relationship between stress/depression and diabetes, the integration of emotions in diabetes self-management in patient-provider communication has not been standardized [28–31]. Health professionals’ interest in how patients view their own disease process may help build rapport with patients. Enhancing health professionals’ cultural competency skills can be a critical first step for improving patient-provider communication. For instance, it can (1) present an opportunity to integrate cultural belief systems into diabetes care for Hispanics/Latinos, (2) open the door for other important conversations about Hispanic/Latino patients’ psychosocial and familial environment and identify barriers or motivators in diabetes self-management, and (3) build rapport and trust between the health professional and patient.
Additionally, inquiring about emotional beliefs or emotions about diabetes in general can help improve the patient-provider relationship, giving Hispanic/Latino patients a sense that their provider cares about their feelings and emotional well-being. For example, in a study conducted by Concha et al, a Hispanic/Latino male patient with diabetes expresses his appreciation of his doctor for attending to his emotional problems and suggests that his diabetes is in control because of the encouragement he receives from the doctor [22].
…I believe the doctors..can encourage one with ..diabetes… I am very grateful to God before anything that till today I have my sugar controlled. I am a diabetic, but controlled. And Dr. [name omitted], he’s a blessing from God. He knows my body like my mother….Because whatever little thing, he attends to me, he gives me a lot of encouragement with my emotional problems. He sent me to a counselor, I have a specialist for my problem with my urinary tracts. I have attention, I have all the attention from the doctor…
Inquiring about emotional well-being may also be beneficial because Hispanics/Latinos with diabetes have reported that they would feel more comfortable talking to a professional about personal problems compared to Hispanics/Latinos without diabetes [32]. Having a physical illness may provide an opportunity for these patients to discuss stress or depression in tandem with diabetes to diminish any possible stigma or shame associated with having a mental health problem. It is important for health care providers to be aware of emotional or social problems that may be negatively influencing diabetes self-care behaviors.
Models of Effective Cross-Cultural Communication
Cultural competency training for health professionals is one strategy for reducing health disparities and ensuring that racial/ethnic populations receive “equitable, effective, and culturally appropriate clinical care” [9,11,12,33]. The Association of American Medical Colleges’ guide for cultural competence education in medical school cites several models of effective cross-cultural communication for physicians and/or physician assistants [34]. I describe 3 communication tools below that may help health care professionals initiate conversations and aid them in understanding how to better manage sociocultural and environmental issues that may impede patients’ ability to manage diabetes. For each tool, a vignette is offered that illustrates how the tool may be used in communicating with Hispanic/Latino patients.
BELIEF
The BELIEF instrument (Dobbie 2003) is a teaching tool designed to elicit patients’ health beliefs and to assist preclinical medical students or medical professionals in understanding how explanatory models of a disease influence patient engagement in care. The BELIEF instrument is straightforward and can be easily implemented into clinical case vignettes and or role-play as part of cultural competency training [35]. The specific questions corresponding to the BELIEF prompts are
- B: Beliefs about health (What caused your illness/problem?)
- E: Explanation (Why did it happen at this time?)
- L: Learn (Help me understand your belief/opinion)
- I: Impact (How is this illness/problem impacting your life?)
- E: Empathy (This must be very hard for you)
- F: Feelings (How are you feeling about it?)
Vignette 1
The following vignette is a conversation between a Spanish-speaking Hispanic women, a language interpreter, and medical professional. The patient, Mrs. Chavez, has come into the clinic for the third time after experiencing symptoms due to hypoglycemia. Mrs. Chavez believes stress may have something to do with her hypoglycemia but is not quite sure how. By using the BELIEF mnemonic, the medical professional is able to ask more about the stress that led into a discussion about how stress actually influenced her eating and medication intake behaviors. Through this probing, the medical professional was able to identify the possible cause of her hypoglycemia and work with Mrs. Chavez on finding a solution every time she experiences the stressful event. The vignette also demonstrates how interpreters may share cultural information that may clarify problems.