2023 Namey/Burnett Preventive Medicine Writing Award author Mitchell Schwocho, OMS-II, shares the current disparities contributing to disadvantages towards Hispanic Americans in healthcare and how progression is possible.
Mitchell Schwocho, OMS-II
2023 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
US Census data estimates that 18.9% of the current population in the United States is Hispanic, a percentage that continues to rise each year.1 As defined by the US Census Bureau’s Office of Management and Budget, a Hispanic person is “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish origin regardless of race”.2 Moreover, Spanish is the second most commonly spoken language in the United States, with over 41 million people identifying as Spanish speakers.1,3 Despite these numbers, there continue to be many challenges and barriers that Hispanic patients face when seeking healthcare. These obstacles can range from linguistic barriers to cultural misinterpretations and can further complicate care for a population of patients who are already at increased risk for diseases such as diabetes, obesity, and liver disease.4 The coronavirus pandemic has only magnified these issues, as studies have additionally shown worse outcomes for Hispanic patients diagnosed with the COVID-19 virus. A retrospective study from Rhode Island reported that in comparison to non-Hispanic white patients, Hispanic patients were significantly more likely to require ICU admission as well as ventilator use.5 As these disparate outcomes have continued, the importance of careful causal analysis has been magnified. The root cause for these outcomes for Hispanic patients is likely due to a complex interplay of socioeconomic status, limited access to care, the language barrier, and cultural differences amongst the population. As more is learned about these issues, efforts to eliminate the existing disparities will become more focused and ideally, effective.
As the importance of preventative care has continued to grow, so with it has the role of the primary care physician. In a survey conducted by Pew Research Center in 2021, only 48% of recent (living in the United States for less than 10 years) Hispanic immigrants indicated that they had a primary care physician.6 Many factors might contribute to this number, but more recent immigrants may be less likely to speak English or have access to health insurance. While many communities have programs in place to assure care for the uninsured population, these would-be patients still need to be made aware of the available options. By extrapolating the data collected from this survey, it makes sense why diseases that are amenable to preventative care such as diabetes and metabolic syndrome, tend to disproportionately affect the Hispanic population.
Even after gaining access to healthcare, Hispanic patients still face an uphill battle to receive equitable care. Much of this imbalance lies in the most apparent difference in care for Hispanic patients: the language barrier. Navigating the healthcare system can be a challenge for most, but the language barrier adds stress, confusion, and decreased satisfaction for Spanish-speaking patients. Communication is such an important part of patient care, so its nuances must not be overlooked when analyzing the disparities in outcomes. In a large survey in 2021, 44% of Hispanic patients cited communication problems from language and cultural differences as major reasons for health disparities.6 By 2045, the US Census estimates that nearly 25% of the US population will be Hispanic, but the availability of Spanish-speaking physicians is limited, as data from the AAMC in 2018 identified that 5.8% of practicing physicians identified as Hispanic.7,8 This means, in the absence of concomitant numerical growth of Hispanic physicians, the percentage of Hispanic patients may be more than 4 times the percentage of Hispanic physicians by 2045. While these percentages will likely never perfectly match, increased representation is an important and sensible starting point. This stresses the importance of community outreach and recruiting programs that target Hispanic youth intending to inform and guide them toward a career in medicine.
Language barriers also come to the forefront when considering the use of medical interpreters. With the time crunch that many physicians face, the added minutes that come with the use of a medical interpreter can often be seen as a nuisance, even when translation services are available. This leads to many physicians side-stepping the need for interpreters and oftentimes using their own sub-par Spanish abilities.9 While this may seem innocuous in the moment, it can lead to unclear communication and predispose patients to have more questions than answers after an encounter with their physician.
A study published in the Journal of Pediatric Surgery serves as an excellent example of the profound impact of eliminating the language barrier on patient satisfaction. This study examined the outcomes of families who were treated with Spanish-speaking medical staff (language-concordant care) and compared it to a group where a medical translator was used and a control group of English-speaking families interacting with English-speaking medical staff. Spanish-speaking families who interacted with all Spanish-speaking medical staff had higher levels of satisfaction and higher rating of the quality of the information received than the control group, as well as the separate experimental group who only used a medical translator.10,11 Similarly designed studies have been repeated and continue to show that language-concordant care leads to significantly higher levels of patient satisfaction and technical quality of care.12
Thankfully, the elucidation of these issues for the Hispanic population in the medical literature has led to efforts for change. Many strategies for improvement have been studied and have shown promise. The American Diabetes Association published a review article in 2019 highlighting many different modalities that have been used to improve clinical outcomes for Hispanic patients with diabetes.13 One study in this review showed significant improvements in A1C values for Hispanic patients with type 2 diabetes who were assigned community health workers in comparison with control groups.14 The community health workers in this study had been language and culturally trained specifically for Hispanic patients.13,14 As studies such as these continue to be replicated, new standards of care for Hispanic patients with chronic disease will hopefully narrow the gap in outcomes.
There are over 20 countries of origin that comprise the United States Hispanic population, and each of them celebrates its culture in different ways. As cultural competency becomes more ingrained into medical training and curriculum, the generations of coming physicians must strive to carry out their role as beacons of comfort for patients from all backgrounds. Future measures can also be made to recognize that even within the United States Hispanic population there are cultural differences based on country of origin. If the medical theme of being a lifelong learner should become a metaphorical tree, then its roots would permeate the foundations of science, its trunk would bear the quality of patient care, and its branches would extend to appreciating the culture of all the people we treat.
Table 1: Demographic Data of US Population and US Physician Workforce
- U.S. Census Bureau quickfacts: United States. US Census Bureau. https://www.census.gov/quickfacts/fact/table/US/RHI725221
- About the Hispanic population and its origin. Census.gov. https://www.census.gov/topics/population/hispanic-origin/about.html. Published April 15, 2022.
- Fernández A, Pérez-Stable EJ. ¿Doctor, Habla Español? increasing the supply and quality of language-concordant physicians for Spanish-speaking patients. Journal of general internal medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579210/. Published October 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579210/
- Velasco-Mondragon E, Jimenez A, Palladino-Davis AG, Davis D, Escamilla-Cejudo JA. Hispanic Health in the USA: A scoping review of the literature – public health reviews. BioMed Central. https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-016-0043-2. Published December 7, 2016. https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-016-0043-2
- Macias Gil R, Touzard-Romo F, Sanchez MC, et al. Characteristics and outcomes of Hispanic/Latinx patients with coronavirus disease 19 (COVID-19) requiring hospitalization in Rhode Island: a retrospective cohort study. Ann Epidemiol. 2021;58:64-68. doi:10.1016/j.annepidem.2021.03.003 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962584/
- Nadeem R. Hispanic Americans’ experiences with Health Care. Pew Research Center Science & Society. https://www.pewresearch.org/science/2022/06/14/hispanic-americans-experiences-with-health-care/. Published June 16, 2022.
- Frey WH. The US will become ‘minority White’ in 2045, Census Projects. Brookings. https://www.brookings.edu/blog/the-avenue/2018/03/14/the-us-will-become-minority-white-in-2045-census-projects/. Published March 9, 2022.
- Figure 18. percentage of all active physicians by Race/ethnicity, 2018. AAMC. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
- Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-262. doi:10.1007/s11606-008-0875-7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628994/
- Digitale E. Spanish-speaking families prefer native language when discussing surgical care. Stanford Medicine News Center. https://med.stanford.edu/news/all-news/2015/09/spanish-speaking-families-prefer-native-language-when-discussing.html#:~:text=Spanish%2Dspeaking%20families%20prefer%20native%20language%20when%20discussing%20surgical%20care,-share&text=A%20study%20has%20found%20higher,care%20in%20their%20native%20language. Published September 2, 2015.
- Dunlap JL, Jaramillo JD, Koppolu R, Wright R, Mendoza F, Bruzoni M. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015;50(9):1586-1589. doi:10.1016/j.jpedsurg.2014.12.020 https://pubmed.ncbi.nlm.nih.gov/25783324/
- Seible DM, Kundu S, Azuara A, et al. The Influence of Patient-Provider Language Concordance in Cancer Care: Results of the Hispanic Outcomes by Language Approach (HOLA) Randomized Trial. Int J Radiat Oncol Biol Phys. 2021;111(4):856-864. doi:10.1016/j.ijrobp.2021.05.122 https://pubmed.ncbi.nlm.nih.gov/34058256/
- Fortmann AL, Savin KL, Clark TL, Philis-Tsimikas A, Gallo LC. Innovative diabetes interventions in the U.S. Hispanic population. American Diabetes Association. https://diabetesjournals.org/spectrum/article/32/4/295/32396/Innovative-Diabetes-Interventions-in-the-U-S. Published November 1, 2019. https://diabetesjournals.org/spectrum/article/32/4/295/32396/Innovative-Diabetes-Interventions-in-the-U-S
- Babamoto KS, Sey KA, Camilleri AJ, Karlan VJ, Catalasan J, Morisky DE. Improving diabetes care and health measures among hispanics using community health workers: results from a randomized controlled trial. Health Educ Behav. 2009;36(1):113-126. doi:10.1177/1090198108325911 https://pubmed.ncbi.nlm.nih.gov/19188371/