Language barriers have been found to adversely affect health care in multiple ways, including access to care, quality of care, medical errors, and reduced patient satisfaction.1 Oral communication barriers are only one aspect of a multifaceted problem when there is physician-patient language discordance.2 Efforts to improve office efficiency, reduce demands on physician time, and provide patient reminders often rely on written educational materials. Handouts are often translated directly from English to another language despite the possible limited health literacy of the patient. We examined Spanish-speaking adult preferences regarding health instruction materials.
This study was approved by the University of Illinois at Chicago institutional review board.
Spanish-speaking Hispanic adults (age, >18 years) requiring an interpreter during their office visit to an academic dermatology center were invited to participate in the study during a 4-month period (May through August) in 2009. Patients excluded were individuals with decisional and/or cognitive impairment, physical disabilities that would prevent effective communication, or the ability to speak, read, and/or understand English without the aid of an interpreter.
All new patients visiting our clinic are asked to complete the “Patient Education Self-Assessment” questionnaire (Figure), as mandated by the Joint Commission on Accreditation of Healthcare Organizations. This survey instrument has been in use at the University of Illinois Medical Center since 2000 and is designed to elicit patient information regarding language abilities, educational background, disabilities, and preferred learning methods. For the present study, completed questionnaires were reviewed by the research assistant for clarification and completion of items, as needed. The patients then reviewed 4 types of educational materials regarding nevi: (1) handouts of plain text only; (2) handouts combining text and color pictures; (3) oral explanations aided by pictures (no text handouts); and (4) oral explanations without pictures (no handouts of any kind). Patients were also asked if they had a DVD player, and if they did, they were asked if they would like to view an educational DVD at home. Similarly, patients were asked if they had access to a computer, and if they did, they were asked if they would like to view materials on the Web on their computer. Finally, patients were invited to make their own suggestions, and the responses were recorded by the research assistant.
Patient Education Self-Assessment questionnaire.
The 54 adults interviewed were primarily of Mexican heritage (50 Mexican, 2 Puerto Rican, 1 Columbian, and 1 from the Dominican Republic), with an average age of 47 years. Of the 54 adults interviewed, 3 had no formal education; 11 had a maximum education level between grades 1 and 5; 22, between grades 6 and 8; 12, between grades 9 and 12; and 6 reported an associate's degree or beyond. All individuals without formal education felt that they had no or poor Spanish language reading skills; approximately 54% of the individuals educated to a grade 1 to 5 level felt that they had poor reading skills (6 of 11); only 1 individual educated to grade 6 to 8 self-reported poor reading skills, while most claimed average Spanish-language reading skills (63%, 14 of 22). Two with high school level education felt that they had weak reading skills, and no patients educated at the college level felt that they had weaknesses in reading skills.
One individual had no intention to examine any handouts in the future. Only 25% felt comfortable reviewing handouts (14 of 54), and all of these were educated to the sixth grade level or higher. Most Hispanic patients (56%, 30 of 54), regardless of their education level, wanted the materials explained to them by their physician (oral explanation) prior to completion of their visit. The addition of photographs to materials did not have any effect: only 2 individuals expressed a preference for this type of educational material. Technology-driven educational materials such as DVDs and Web-based materials were the least preferred choice: not a single individual chose a Web-based review, and only 4 chose DVDs.
Individuals in the United States who speak only Spanish are predominantly first-generation immigrants and elderly Hispanic people.3- 4 Educational levels attained by immigrants are lower than those attained by US-born Hispanics. According to 2003 Pew Hispanic Center3 data, more than 50% of immigrants lacked a high school diploma. Valdez et al5 found that 5.2% of Hispanics 65 years or older reported no formal schooling; 61% of Hispanics aged 65 to 74 years reported only some elementary education; and only 68% of Hispanics 75 years or older reported some elementary education. Although educational levels vary widely, lower educational levels among first-generation immigrants and elderly Hispanics means many of these individuals cannot read well in either English or Spanish.5
While a minimum of a sixth grade reading level is recommended for patient education materials, this recommendation fails to recognize that educational levels do not accurately reflect health literacy. Some investigators report that reading levels average 4 grade levels below the number of years of education, and self-report of education is not always reliable.6 Frequently, Spanish-language health education materials are directly translated from English-language handouts. Our data suggest that even materials produced in Spanish at a sixth grade reading level may prove challenging to comprehend for 30% of those we interviewed. This study suggests that materials used for English-speaking populations, when directly translated without modifications, are written at a higher literacy level than many of the Spanish-speaking adult patients in this survey. Literacy levels must be considered in older or first-generation immigrants and may in part explain the desire to have materials orally explained. For physicians to successfully fulfill their role as health educators, we must have knowledge of health literacy levels and realize that a “one size fits all” mentality is not meaningful in terms of health education, especially as our nation becomes more linguistically and culturally diverse.
Correspondence: Dr Hernandez, Department of Dermatology, University of Illinois at Chicago, MC 624, 808 S Wood St, Room 376, CME, Chicago, IL 60612 (firstname.lastname@example.org).
Accepted for Publication: August 8, 2010.
Author Contributions: Dr Hernandez had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hernandez and Robinson. Acquisition of data: Cruz. Analysis and interpretation of data: Hernandez and Robinson. Drafting of the manuscript: Hernandez and Cruz. Critical revision of the manuscript for important intellectual content: Hernandez. Obtained funding: Hernandez. Administrative, technical, and material support: Cruz. Study supervision: Hernandez and Robinson.
Financial Disclosure: None reported.
Funding/Support: This research was supported in part by the Dermatology Foundation Women's Health Career Development Award (Dr Hernandez).
Previous Presentation: This article was presented as a poster at the American Academy of Dermatology Annual Meeting; March 2010; Miami, Florida.
Disclaimer: Dr Robinson is the Editor of the Archives and was not involved in the editorial evaluation or editorial decision to accept this work for publication.
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