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Approaches to Enhancing Patient-Centered Communication In Caring For Hispanic/Latino Patients With Diabetes
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.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
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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.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
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.
Medical Professional: Mrs. Chavez, I see you are here again for hypoglycemia. Can you tell me what has happened? Do you have your medications with you today?
Interpreter: Sra. Chavez, entiendo que está aquí nuevamente por hipoglucemia. ¿Puedes decirme qué ha pasado? ¿Tiene sus medicamentos con usted hoy?
Mrs. Chavez: Si, me ha sentido débil y mareado.
Interpreter: Yes I have felt faint and dizzy?
Medical Professional: Have you been taking your metformin as prescribed?
Interpreter: ¿Ha estado tomando su metformin según lo recetado?
Mrs. Chavez: Si (YES).
Medical Professional: We might have to consider adjusting your dosage.
Interpreter: Es posible que tengamos que considerar ajustar su dosis.
Mrs. Chavez privately to the Interpreter: ¿no es posible que las emociones o nervios puedan causar algo? He escuchado que este puede ser el problema?
Interpreter to Mrs. Chavez: Déjame preguntarle al doctor, si?
Let me ask the doctor, yes? (Mrs. Chavez, nods in agreement)
Interpreter to Medical Professional: She is asking if emotions or nervousness could be the cause. She has heard that this could be the problem.
Medical Profesional to Interpreter: What does she mean?
Interpreter: There is a cultural belief that stress or nerves can cause diabetes or affect diabetes. You may want to ask about this.
Medical Professional: Yes emotions like stress can cause changes in you glucose. (Beliefs) Do you believe that some emotions are causing your hypoglycemia?
Interpreter: Sí, las emociones como el estrés pueden provocar cambios en la glucosa. ¿Crees que algunas emociones están causando tu hipoglucemia?
Mrs. Chavez: (Shrugs shoulders).
Medical Professional: I see here in your records, that the other two times you had hypoglycemica were 1 month and 3 months ago. (Beliefs) What do you think caused these events and (Explanation) why do you think it happened during these times?
Interpreter: Veo aquí en sus registros que las otras dos veces que tuvo hipoglucemia fueron hace 1 mes y 3 meses. ¿Qué crees que causó estos eventos y por qué crees que sucedió durante estos tiempos?
Mrs. Chavez: Pues, no sé.
Interpreter: Well I don’t know.
Medical Professional: (Learn) Help me understand what you think happened 3 and 1 month ago and this month that may have caused your glucose to drop. What was happening emotionally during these times? Do you remember?
Interpreter: Ayúdame a entender lo que piensas que sucedió hace 3 y 1 meses y este mes, puede haber causado que tu glucosa baje. ¿Qué estaba pasando emocionalmente durante este tiempo? ¿Te acuerdas?
Mrs. Chavez: Hmm. Pues, hace 3 meses fui a visitar a mi madre y hace 1 meses fui a visitar a mi hermano al norte.
Interpreter: Hmm. Well 3 months ago I went to visit my mother and 1 months ago I went to visit my brother up north.
Medical Professional: (Learn) How were those trips for you. Did you have fun? What types of emotions were you feeling during these trips?
Interpreter: ¿Cómo fueron esos viajes para ti? ¿Te divertiste? ¿Qué tipo de emociones sentías durante estos viajes?
Mrs. Chavez: Pues, yo estaba muy estresado durante mis viajes.
Interpreter: Well, I was very stressed during my trips.
Medical Professional: (Learn) Would you like to share why you were stressed? What was happening for you to feel so stressed?
Interpreter: ¿Te gustaría compartir por qué estabas estresado? ¿Qué estaba pasando para que te sientas tan estresado?
Mrs. Chavez: Bueno, tenemos muchos problemas familiares y conflictos. Hay muchos argumentos familiares y se vuelve estresante.
Interpreter: Well we have a lot of family problems and conflict. There are a lot of family arguments and it gets stressful.
Medical Professional: (Impact) How do you think this has affected your glucose?
Interpreter: ¿Cómo crees que esto ha afectado tu glucosa?
Mrs. Chavez: No lo sé.
Interpreter: I don’t know.
Medical Professional: (Learn) Do you think the stress maybe led you to forget to take your medication or affected your eating?
Interprter: ¿Crees que el estrés puede llevarte a olvidarte de tomar tu medicación o afectó su alimentación?
Mrs. Chavez: Pues si y no comí. Estaba demasiado estresado para comer. Raramente comí mientras estaba allí. Estaba tan estresado que no tenía apetito.
Interpreter: Well yes and I didn’t eat. I was too stressed to eat. I rarely ate while I was there. I was so stressed i did not have an appetite.
Medical Professional: (Empathy) Mrs. Chavez, that must have been very hard for you. I’m sorry you have had to feel this way. (Feelings) Is this how you feel everytime you visit your family?
Interpreter: Sra. Chávez, eso debe haber sido muy difícil para usted. Lamento que hayas tenido que sentirte de esta manera. ¿Es así como te sientes cada vez que visitas a tu familia?
Mrs. Chavez: Sí, todos se involucran en los problemas familiares y es muy estresante visitarlos, pero tengo que ir a ayudar a mi madre porque mi hermano está enfermo y no puede ayudarla. Soy el único que está cerca y mis otros hermanos discuten sobre lo que debería hacer. Tengo que estar ahí. Tengo que visitar.
Interpreter: Yes, everyone gets involved in the family problems and it is very stressful to visit but I have to go to help my mom because my brother is sick and can’t help her. I’m the only one close by and my other siblings argue about what I should do. I have to be there. I have to visit.
Medical Profesional: (Empathy) Yes, that must be very difficult for you. Okay, now I understand what is happening. Your visits are necessary but it seems like the stress is affecting your eating patterns and whether you remember to take your metformin. How do you feel if we come up with a plan for when you visit your family now that we know what might be causing your hypoglycemia? Do you think it is a good idea to take high glucose snacks or candy and have them with you on the trip so when you feel dizzy or faint you can eat them?
Interpreter: Sí, eso debe ser muy difícil para ti. De acuerdo, ahora entiendo lo que está pasando. Sus visitas son necesarias, pero parece que el estrés está afectando sus patrones de alimentación y si recuerda tomar su metformina. ¿Cómo se siente si elaboramos un plan para su familia ahora que sabemos lo que podría estar causando su hipoglucemia? ¿Cree que es una buena idea tomar refrigerios con alto contenido de glucosa o dulces y llevarlos consigo durante el viaje para que cuando se sienta mareado o desmayado pueda comerlos?
Mrs. Chavez: Sí, por supuesto. Ni siquiera me di cuenta de eso hasta ahora que hablamos sobre eso. Tienes razón, no he estado comiendo bien cuando lo visito. Me siento terrible cuando estoy allí como si quisiera desmayarme.
Interpreter: Yes of course. I didn’t even really realize that until now that we talked about it. You are right, I haven’t been eating right when I visit. I feel terrible when I am there like I want to faint.
Medical Professional: Mrs. Chavez, sometimes it is helpful to talk about our stress and problems we encournter in life, just to talk through it. Is this something you would be interested in? If so, we can arrange for you to come talk to the social worker.
Interpreter: Sra. Chavez, a veces es útil hablar sobre nuestro estrés y los problemas que alegramos en la vida, solo para hablar sobre ello. ¿Esto es algo que te interesaría? Si tu quieres, podemos hacer arreglos para que vengas a hablar con el trabajador social.
Mrs. Chavez: Tal vez, no estoy seguro, pero tal vez
Interpreter: Maybe, I’m not sure but maybe.
Medical Professional: Okay, you let me know if this is something you would like to do. You can call and let us know and I’ll ask again during our next visit and see how you are dealing with the stress when you visit your family.
Interpreter: De acuerdo, dime si esto es algo que te gustaría hacer. Puede llamar y dejarnos saber, y volveré a preguntar durante nuestra próxima visita y verá cómo lidia con el estrés cuando visita a su familia.
ETHNIC
The ETHNIC interviewing tool (Levin SJ 2000) can be used to explore cross cultural issues and facilitate collaboration during clinical encounters and is designed for clinical students or health professionals permitted to diagnose and provide therapeutic interventions [36]. The specific questions corresponding to the ETHNIC prompts:
- E: Explanation (How do you explain your illness?)
- T: Treatment (What treatment have you tried?)
- H: Healers (Have you sought any advice from folk healers?)
- N: Negotiate (mutually acceptable options)
- I: Intervention (agreed on)
- C: Collaboration (with patient, family, and healers)
Vignette 2
The second vignette is a discussion between a conscientious patient, Mrs. Rodriguez, and her doctor. Mrs. Rodriguez is determined to keep her glucose levels within optimal range by eating healthy and living a natural lifestyle. Included in her natural lifestyle is the use of herbs from her garden and herbal supplements sold to her by her neighbor. Because her numbers have been in the normal range she discontinues her prescribed medication to rely on natural products. However, a trip with family members interrupts her daily routine, which is replaced with fast foods and little rest. Upon returning from her trip her glucose levels increase and she cannot decrease her glucose numbers.
Medical Professional: Good morning Mrs. Rodriguez. I see you are here today for high blood sugar because of your diabetes. (Explanation) Can you share why you think you have recently had higher numbers than normal?
Mrs. Rodriguez: Good morning Doctor. Yes, I am usually very good with my numbers but lately they have gone up and I know why.
Medical Professional: Yes, that is good that you have had your glucose managed. (Explanation) What has caused your numbers to go up Mrs. Rodriguez?
Mrs. Rodriguez: All this American food. I went on a trip to visit my daughter and all we did was eat out, hamburgers, fast food restaurants. They do not cook at home and we were always doing something so I could not cook. It was terrible, all we did was keep busy out and about, I was tired. I spent so much money on food that has chemicals. Look at me now. I can’t seem to get my numbers down.
Medical Professional: Oh, I understand. Yes, a trip can sometimes mess with our routine. (Treatment) Since you have been good at managing your glucose in the past what have you been doing now to get your glucose in normal range?
Mrs. Rodriguez: Well I have been doing the same thing I have always been doing. Eating healthy, resting, gardening, and praying.
Medical Professional: Gardening? That’s really nice. What do you garden?
Mrs. Rodriguez: Oh I love gardening. I plant all types of herbs, vegetables, flowers.
Medical Professional: That is so good Mrs. Rodriguez. I wish I had more time to garden. Do you use your own vegetable and herbs when you cook?
Mrs. Rodriguez: Haha. Yes of course. That is why my sugar was fine before I went on this trip. I rely on my garden to keep me healthy.
Medical Professional: There are so many herbs that are helpful for diabetes. (Treatment) Do you use any to help with your diabetes?
Mrs. Rodriguez: Well yes, in fact, I do. I know you doctors don’t like us to use our herbs but I do. And that was what keeps my sugars normal.
Medical Professional: Oh Mrs. Rodriguez, yes sometimes you hear doctors say this but some herbs are helpful. We just like to know what other things our patients do so we know how to make sure your medications work with certain herbs. (Treatment) I know many people use nopal (cactus), do you eat nopal?
Mrs. Rodriguez: ¿Como no? (of course). I eat them all the time. I make my morning licuado (drink); a little bit of parsley, oregano, oatmeal, lemon, nopal mixed with milk and yogurt.
Medical Professional: (Treatment) Sounds good, what else do you use?
Mrs. Rodriguez: Oh you know other things. Apple cider, cinnamon, cayenne.
Medical Professional: All from your garden?
Mrs. Rodriguez: Yes.
Medical Professional: (Treatment) Do you use any type of herbal supplements from stores or online?
Mrs. Rodriguez: My neighbor sells supplements specifically for diabetes. I started to use a natural supplement with cinnamon, vitamin D, and fish oil. All very natural.
Medical Professional: (Healer) Oh does your neighbor also have diabetes?
Mrs. Rodriguez: No, she sells products. But she sells to many people with diabetes and the supplement works. We get together and she tells us about how they work.
Medical Professional: Do you know the name of this supplement Mrs. Rodriguez?
Mrs. Rodriguez: Oh, gluco…something, it has a heart in the name. But I read the ingredients and it has only natural ingredients. (An FDA banned supplement for false claims)
Medical Professional: Oh I see. I may be familiar with that. Can you bring the supplement along with the medications I have prescribed? I just want to make sure there is not interaction between the two. To get your glucose back to normal I want to make sure we think of every possible situation that could be causing your high numbers. (Treatment) How have you been taking the supplement and the prescribed medications?
Mrs. Rodriguez: Well, I have not refilled your prescription. I was doing so well with my numbers, I’d rather go natural than take all those chemicals.
Medical Professional: Oh, I see Mrs. Rodriguez. Okay, you have done so well controlling your glucose before your trip and now we are in a situation where your numbers are not coming down so let’s try to figure this out. I’d like to learn more about this supplement, so for our next visit can you bring in your supplements so I can take a look at it? (Negotiate) We can then talk about the benefits or cautions. But in the meantime I’d like you to refill your medication and take as followed to see if that helps your sugars. (Negotiate) What do you think? Is this possible?
Mrs. Rodriguez: Oh Doctor, I just don’t like taking chemicals.
Medical Professional: I understand Mrs. Rodriguez. You did take them to start when you first came in for diabetes, is this correct?
Mrs. Rodriguez: Well yes but, I slowly got off them.
Medical Professional: I know it’s difficult to take medications every day but they can help in addition to your healthy eating. I know you are concerned about medications but for now we have to focus on getting your numbers down or your diabetes could become worse and we don’t want you to get there. Do you agree? (Negotiating process)
Mrs. Rodriguez: Well, I am concerned about my numbers.
Medical Professional: (Intervention) Okay well let’s try to get back to where you were before the trip. Let’s get you back on the medication and let’s see if this helps. (Negotiate) For the next visit would you be willing to bring any supplements you are taking along with the medication? (Collaboration) We can talk about the benefits and cautions for the medications and supplements. How does this sound?
Mrs. Rodriguez: Well, I am here to fix my numbers. I have everything I take in a box so I can bring that.
Medical Professional: Yes that would be great. (Collaboration) We can both talk about your daily routine and what have you learned about the supplement, any information or papers that you have, in addition to the medication I prescribed.
Mrs. Rodriguez: Yes I can do that.
Medical Professional: Thank you Mrs. Rodriguez. (Intervention) Also, I’ll have the nurse call you today or tomorrow and you can give her the name of the supplement and she’ll make sure the drug store has a refill for you. Would this work for you Mrs. Rodriguez?
Mrs. Rodriguez: Yes Doctor. You can call me. I’ll have the list ready.
BATHE
Unlike the BELIEF and ETHNIC instruments, the BATHE mnemonic (Lieberman 1999)
- B: Background (What is going on in your life?)
- A: Affect (How do you feel about what is going on?)
- T: Trouble (What troubles you most?)
- H: Handling (How are you handling that?)
- E: Empathy (This must be very difficult for you)
Vignette 3
The last vignette features Mr. Gonzalez, who typically shows a positive outlook on life when visiting his doctor. He is a patient who would not necessarily discuss his emotions if not asked specific questions about his emotional well-being.
Medical Professional: Hello Mr. Gonzalez. (Background) How are you doing today? What’s new? What’s going on in your life lately?
Mr. Gonzalez: Hey, Doctor! I’m good you know just living day to day.
Medical Professional: Good. (Affect) So how is your diabetes treating you day to day? How are you feeling with life and managing your diabetes?
Mr. Gonzalez: Ah well you know, just dealing with it as best as I can.
Medical Professional: Ah okay. As best as you can. (Troubles) What troubles you the most about managing diabetes?
Mr. Gonzalez: Well you know the aches and pains. But what can I do.
Medical Professional: (Affect) How do you feel about those aches and pains?
Mr. Gonzalez: Well it does limit me. I can’t move as well as I use to.
Medical Professional: (Handling) Hmm. I see. How are you handling those aches and pains? What are you doing to relieve it?
Mr. Gonzalez: I do my best with pain cream.
Medical Professional: (Empathy) Pains and aches, that must be difficult. (Affect) How do the aches and pains make you feel?
Mr. Gonzalez: Ahh, Doc, it’s not the same. You know I can’t do the same things anymore.
Medical Professional: (Background) What do you mean? What is not the same anymore?
Mr. Gonzalez: This diabetes, I’m not the same person. I use to be able to be there for my family and community and now I feel like I can’t be there for them the way I use to. I use to be the strong one for my family, helping those in need, and now I’m limited, my body is limited.
Medical Professional: (Affect) How do you feel about that? How does it make you feel emotionally and physically?
Mr. Gonzalez: Bad. I feel bad about it.
Medical Professional: Bad emotionally or physically?
Mr. Gonzalez: Both
Medical Professional: I see. (Handling) How are you dealing with the emotional part of it?
Mr. Gonzalez: I don’t know. I don’t know how.
Medical Professional: (Empathy) Dealing with diabetes and how it makes your body feel can be very emotionally distressing. It is common to feel this way but I want to make sure we also work on how you feel emotionally or how your emotions is affecting your diabetes.
Conclusion
Three mnemonic tools have been suggested to initiate patient-centered and culture-centered communication with patients. Beyond the use of these instruments, there are 2 key skills that are essential for engaging a Hispanic/Latino patient. The first is a non-judgmental, warm communication approach, and the second is astute probing. Once when I was interpreting for a Spanish-speaking Hispanic/Latino patient and English-speaking doctor, the patient expressed to me that she felt that the medical professionals “tienen una cultura fría” (“have a cold culture”), and she did not feel comfortable sharing more about herself because of it. It is also important for medical professionals to be aware of a patient’s doublespeak as a way to share enough information but not all information to keep from being judged by medical professionals. Thus, non-judgmental probing can uncover important information that may be useful for collaborative goal setting and treatment decisions.
The management of diabetes is multifaceted and complex, particularly for populations who face social barriers and challenges. The Hispanic/Latino population is more likely to encounter disparities in access to quality health care and disparities in social determinants of health compared to non-Hispanic whites [4–9]. Therefore, it is important for health professionals to engage Hispanic/Latino patients in self-care by eliciting information that best facilitates collaborative goal setting. Health professionals are in an influential position to leverage a communication style that is empathetic, trusting, and open, setting the tone for a positive patient-physician encounter and, in turn, positive patient outcomes [18–20].
Corresponding author: Jeannie Belinda Concha, PhD, MPH, Dept. of Public Health Sciences, The University of Texas at El Paso, 500 W. University Ave., El Paso, TX 79968, jeannie@utep.edu.
Funding support: Support for this research was provided by the Office of Research and Sponsored Projects at The University of Texas at El Paso.
Financial disclosures: None.
1. American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care 2017; 40: Suppl 1.
2. Dominguez K, Penman-Aguilar A, Chang MH, et al. Vital signs: Leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States, 2009–2013. MMWR 2015;64:1–10.
3. Commission on Social Determinants of Heath. Closing the gap in a generation: health equity through action on the social determinants of health. Final report on the Commission on Social Determinants of Health. Geneva, World Health Organization. Accessed 10 Sept 2017 at http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf.
4. Laiterapong N, Fairchild PC, Chou CH, et al. Revisiting disparities in quality of care among US adults with diabetes in the era of individualized care, NHANES 2007-2010. Med Care 2015;53:25–31.
5. Vaccaro JA, Feaster DJ, Lobar SL, et al. Medical advice and diabetes self-management reported by Mexican-American, Black, and White-non-Hispanic adults across the United States. BMC Public Health 2012;12:185.
6. Correa-de-Araujo R, McDermott K, Moy E. Gender differences across racial and ethnic groups in quality of care for diabetes. Women Health Iss 2006;16:56–65.
7. Chawla N, Rodriguez MA, Babey SH, Brown ER. Health policy fact sheet: diabetes among Latinos in California; disparities in access and management. UCLA Center for Health Policy Research. Accessed 1 Aug 2017 at http://healthpolicy.ucla.edu/publications/Documents/PDF/Diabetes%20among%20Latinos%20in%20California%20Disparities%20in%20Access%20and%20Management.pdf.
8. Pu J, Chewning B. Racial differences in diabetes preventive care. Res Social Adm Pharm 2013;9:790–6.
9. Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press; 2003.
10. Saha S, Arbeaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of care. Am J Public Health 2003;93:1713–9.
11. What is cultural and linguistic competence?: Definitions, February 2003. Agency for Healthcare Research and Quality, Rockville, MD. Accessed 28 Aug 2017 at http://www.ahrq.gov/pprofessionals/systems/primary -care/cultural-competence-mco/cultcompdef.html.
12. U.S. Department of Health and Human Services, Office of Minority Health. 2000. Assuring cultural competence in health care: Recommendations for National Standards and an outcomes-focused research agenda. Accessed 17 August 2017 at http://www.omhrc.gov/clas/finalpo.htm.
13. Zhao X. Relationships between sources of health information and diabetes knowledge in the US Hispanic population. Health Commun 2014;29:574–85.
14. Perchman ML, Flannagan D, Ferrer RL, Matamoras M. Communication compete c e, self-care behaviors, and glucose control in patients with type 2 diabetes. Patient Educ Couns 2009;77:55–9.
15. Reimann JOF, Talavera GA, Salmon M, et al. Cultural competence among physicians treating Mexican Americans who have diabetes: a structural model. Soc Sci Med 2004;59:2195–205.
16. Gordon HS, Gerber BS. What we’ve got here is a failure to communication. J Gen Intern Med 2011;26:104–6.
17. Gonzalez A, Salas D, Umpierrez GE. Special considerations on the management of Latino patients with type 2 diabetes mellitus. Curr Med Res Opin 2011;27:969–79.
18. Peek ME, Cargill A, Juang ES. Diabetes health disparities: A systematic review of health care interventions. Med Care Res Rev 2007;64(5 Supp):101S–156S.
19. Kutob RM, Bormanis J, Crago M, et al. Assessing culturally competent diabetes care with unannounced standardized patients. Fam Med 2013;45:400–8.
20. Weller SC, Baer RD, Garcia de Alba Garcia J, Salcedo Rocha AL. Are differences between patient and provider explanatory models of diabetes associated with patient self-management and glycemic control? J Health Care Poor Underserved 2013:24;1498–510.
21. Duta MJ. Communicating about culture and health: Theorizing culture-centered and cultural sensitivity approaches. Commun Theory 2007;17:304–28.
22. Concha JB, Mayer SD, Mezuk B, Avula D. Diabetes causation beliefs among Spanish speaking patients. Diabetes Educ 2015:42:116–25.
23. Arcury TA, Skelly AH, Gesler WM, et al. Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59:2183–3.
24. Daniulaityte R. Making sense of diabetes: cultural models, gender and individual adjustment to type 2 diabetes in a Mexican community. Soc Sci Med 2004;59:1899–912.
25. Poss J, Jezewski MA. The role and meaning of susto in Mexican American’s explanatory model of type 2 diabetes. Med Anthropol Q 2002;16:360–77.
26. Weller SC, Baer RD, Pachter LM, et al. Latino beliefs about diabetes. Diabetes Care 1999;22:722–8.
27. United States Census Bureau. Language use. Accessed Sept 2017 at https://www.census.gov/topics/population/language-use/about.html.
28. Mezuk B, Albrecht S, Eaton WW, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31:2383–90.
29. Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among US adults with diabetes. Diabetes Care 2007;31:105–7.
30. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2006;24:1069–78.
31. Li C, Barker L, Ford ES, et al. Diabetes and anxiety In US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabetes Med 2008;25:878–81.
32. Concha JB, Mezuk B, Duran B. Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes. BMJ Open Diab Res Care 2015;3.
33. Bentancourt JR, Green AR, Carillo Je, Park ER. Cultural competence and health care: Key perspectives and trends. Health Affairs 2015;24:499–506.
34. Association of American Medical Colleges. Cultural Competence Education 2005. Accessed Feb 2016 at https://www.aamc.org/download/54338/data/.
35. Dobbie AE, Medrano M, Tysinger J, Olney C. The BELIEF Instrument: A preclinical teaching tool to elicit patients’ health beliefs. Family Med 2003;35:316–9.
36. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent ethical practice. Patient Care 2003;34:188–9.
37. Stuart MR, Leibermann JR. The fifteen-minute hour: applied psychotherapy for the primary care physician. New York: Praeger.
38. Pace EJ, Somerville NJ, Enyoha C, et al. Effects of a brief psychosocial intervention on inpatient satisfaction: a randomized control trial. Fam Med 2017;49:675–8.
1. American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes. Diabetes Care 2017; 40: Suppl 1.
2. Dominguez K, Penman-Aguilar A, Chang MH, et al. Vital signs: Leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States, 2009–2013. MMWR 2015;64:1–10.
3. Commission on Social Determinants of Heath. Closing the gap in a generation: health equity through action on the social determinants of health. Final report on the Commission on Social Determinants of Health. Geneva, World Health Organization. Accessed 10 Sept 2017 at http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf.
4. Laiterapong N, Fairchild PC, Chou CH, et al. Revisiting disparities in quality of care among US adults with diabetes in the era of individualized care, NHANES 2007-2010. Med Care 2015;53:25–31.
5. Vaccaro JA, Feaster DJ, Lobar SL, et al. Medical advice and diabetes self-management reported by Mexican-American, Black, and White-non-Hispanic adults across the United States. BMC Public Health 2012;12:185.
6. Correa-de-Araujo R, McDermott K, Moy E. Gender differences across racial and ethnic groups in quality of care for diabetes. Women Health Iss 2006;16:56–65.
7. Chawla N, Rodriguez MA, Babey SH, Brown ER. Health policy fact sheet: diabetes among Latinos in California; disparities in access and management. UCLA Center for Health Policy Research. Accessed 1 Aug 2017 at http://healthpolicy.ucla.edu/publications/Documents/PDF/Diabetes%20among%20Latinos%20in%20California%20Disparities%20in%20Access%20and%20Management.pdf.
8. Pu J, Chewning B. Racial differences in diabetes preventive care. Res Social Adm Pharm 2013;9:790–6.
9. Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press; 2003.
10. Saha S, Arbeaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of care. Am J Public Health 2003;93:1713–9.
11. What is cultural and linguistic competence?: Definitions, February 2003. Agency for Healthcare Research and Quality, Rockville, MD. Accessed 28 Aug 2017 at http://www.ahrq.gov/pprofessionals/systems/primary -care/cultural-competence-mco/cultcompdef.html.
12. U.S. Department of Health and Human Services, Office of Minority Health. 2000. Assuring cultural competence in health care: Recommendations for National Standards and an outcomes-focused research agenda. Accessed 17 August 2017 at http://www.omhrc.gov/clas/finalpo.htm.
13. Zhao X. Relationships between sources of health information and diabetes knowledge in the US Hispanic population. Health Commun 2014;29:574–85.
14. Perchman ML, Flannagan D, Ferrer RL, Matamoras M. Communication compete c e, self-care behaviors, and glucose control in patients with type 2 diabetes. Patient Educ Couns 2009;77:55–9.
15. Reimann JOF, Talavera GA, Salmon M, et al. Cultural competence among physicians treating Mexican Americans who have diabetes: a structural model. Soc Sci Med 2004;59:2195–205.
16. Gordon HS, Gerber BS. What we’ve got here is a failure to communication. J Gen Intern Med 2011;26:104–6.
17. Gonzalez A, Salas D, Umpierrez GE. Special considerations on the management of Latino patients with type 2 diabetes mellitus. Curr Med Res Opin 2011;27:969–79.
18. Peek ME, Cargill A, Juang ES. Diabetes health disparities: A systematic review of health care interventions. Med Care Res Rev 2007;64(5 Supp):101S–156S.
19. Kutob RM, Bormanis J, Crago M, et al. Assessing culturally competent diabetes care with unannounced standardized patients. Fam Med 2013;45:400–8.
20. Weller SC, Baer RD, Garcia de Alba Garcia J, Salcedo Rocha AL. Are differences between patient and provider explanatory models of diabetes associated with patient self-management and glycemic control? J Health Care Poor Underserved 2013:24;1498–510.
21. Duta MJ. Communicating about culture and health: Theorizing culture-centered and cultural sensitivity approaches. Commun Theory 2007;17:304–28.
22. Concha JB, Mayer SD, Mezuk B, Avula D. Diabetes causation beliefs among Spanish speaking patients. Diabetes Educ 2015:42:116–25.
23. Arcury TA, Skelly AH, Gesler WM, et al. Diabetes meanings among those without diabetes: explanatory models of immigrant Latinos in rural North Carolina. Soc Sci Med 2004;59:2183–3.
24. Daniulaityte R. Making sense of diabetes: cultural models, gender and individual adjustment to type 2 diabetes in a Mexican community. Soc Sci Med 2004;59:1899–912.
25. Poss J, Jezewski MA. The role and meaning of susto in Mexican American’s explanatory model of type 2 diabetes. Med Anthropol Q 2002;16:360–77.
26. Weller SC, Baer RD, Pachter LM, et al. Latino beliefs about diabetes. Diabetes Care 1999;22:722–8.
27. United States Census Bureau. Language use. Accessed Sept 2017 at https://www.census.gov/topics/population/language-use/about.html.
28. Mezuk B, Albrecht S, Eaton WW, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31:2383–90.
29. Li C, Ford ES, Strine TW, Mokdad AH. Prevalence of depression among US adults with diabetes. Diabetes Care 2007;31:105–7.
30. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2006;24:1069–78.
31. Li C, Barker L, Ford ES, et al. Diabetes and anxiety In US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabetes Med 2008;25:878–81.
32. Concha JB, Mezuk B, Duran B. Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes. BMJ Open Diab Res Care 2015;3.
33. Bentancourt JR, Green AR, Carillo Je, Park ER. Cultural competence and health care: Key perspectives and trends. Health Affairs 2015;24:499–506.
34. Association of American Medical Colleges. Cultural Competence Education 2005. Accessed Feb 2016 at https://www.aamc.org/download/54338/data/.
35. Dobbie AE, Medrano M, Tysinger J, Olney C. The BELIEF Instrument: A preclinical teaching tool to elicit patients’ health beliefs. Family Med 2003;35:316–9.
36. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent ethical practice. Patient Care 2003;34:188–9.
37. Stuart MR, Leibermann JR. The fifteen-minute hour: applied psychotherapy for the primary care physician. New York: Praeger.
38. Pace EJ, Somerville NJ, Enyoha C, et al. Effects of a brief psychosocial intervention on inpatient satisfaction: a randomized control trial. Fam Med 2017;49:675–8.