Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California

The effect of language discordance on the experience of palliative care: A scoping review

BACKGROUND

Internationally, research demonstrates consistent disparities in access to palliative care services for those in underserved communities with life-limiting conditions.

OBJECTIVES

This outcomes-oriented scoping review examines the impact of language discordance on palliative care (PC) experiences. It seeks to answer the question: what are the PC experiences of individuals who do not speak the same language as their care provider? The review explored the range and depth of existing research and synthesizing trends across studies.

DESIGN

Online databases were used to find articles published in English or French, from January 1, 2010, to February 5, 2024. Inclusion criteria included studies that explored the relationship between palliative, end-of-life or hospice care, as well as advance care planning in the context of language discordance between individual and health care provider. This scoping review was originally designed to explore Canadian official language minority communities, but was broadened to an international search for a more robust dataset.

RESULTS

A total of 39 articles were included in the review, 23 qualitative studies, nine quantitative studies and seven mixed-methods studies. The following elements were extracted from eligible articles: country, study design, target population and definitions, participant characteristics, definitions of PC, outcomes studied, findings related to the study aims, as well as author-defined study limitations and next steps. Areas for further research were identified, as were areas for policy and practice change. Studies used various perspectives of PC, often synonymizing it with end-of-life and hospice care, as well as advanced care planning. There was no contextual definition of language barriers in the studies and no studies that explored the PC in any Canadian official language minority communities. The importance of in-language resources, accessibility of skilled interpreters, education in cross-cultural care were all common themes in the literature.

CONCLUSIONS

From a variety of perspectives, studies generally found that language discordance has a negative impact on the quality of accessibility of palliative, end-of-life and hospice care, as well as advanced care planning. Given that Canada's population is becoming increasingly linguistically diverse, there is a need to better understand the impact of receiving PC from individuals who speak another language on both the quality of PC and quality of life at the end of life.

Patient Activation and Shared Decision-Making Among Hispanics/Latinos With Metastatic Cancer: A Qualitative Study

BACKGROUND

Patient activation is established when patients are equipped with the necessary knowledge, skills, and motivation to meaningfully participate in managing their health and, along with shared decision-making, improves clinical outcomes like treatment adherence. Little is known regarding patient activation among Hispanics/Latinos with metastatic cancer, who report worse quality of life and symptom burden compared to non-Hispanic/Latino Whites.

AIMS

This study aimed to characterize barriers and facilitators to patient activation and shared decision-making among English- and Spanish-speaking Hispanics/Latinos with metastatic cancer.

METHODS

Three, 2-h focus groups with Hispanics/Latinos with metastatic solid tumors (N = 22) were audio-recorded and transcribed. Semi-structured interviews addressed experiences living with metastatic cancer, palliative care beliefs, and communication with healthcare team. Barriers and facilitators were identified through secondary analysis of interviews.

RESULTS

Barriers included: (a) feeling overwhelmed by treatment decision-making; (b) lack of clarity regarding treatment and diagnosis; (c) lack of symptom management resources; and (d) concerns regarding English fluency and medical terminology. Facilitators included: (a) self-advocacy for treatment options and quality of life resources; (b) feeling comfortable asking care team questions; (c) having a skilled support system; and (d) avoiding unhelpful medical information. Patient activation levels varied, but all participants expressed a desire to be proactively included in decisions throughout care.

CONCLUSIONS

Results suggest that patient activation may be promoted in this population through the provision of information/resources that are timely, accessible, and relevant to their care needs and active inclusion of patients in decision-making. Findings will guide culturally-adapted interventions that increase patient activation and shared decision-making.

Quality of Virtual vs. In-Person Outpatient Palliative Care: Disparities by Language and Race

CONTEXT

Virtual visits have increased in outpatient, clinic-based palliative care (OPC). The association between virtual visits and OPC outcomes is largely unknown.

OBJECTIVES

(1) Examine the association between visit type (virtual vs. in-person) and screening (yes/no) for psychosocial, spiritual, and goals of care needs. (2) Assess effect modification by language.

METHODS

We used data from the Palliative Care Quality Network (01/2017-03/2021). We conducted multivariable analyses adjusting for age, sex, diagnosis, self-reported race-ethnicity, and language, clustered by site, and included an interaction term to assess effect modification by language.

RESULTS

Among 2684 patients, 29% had a virtual visit; 50% were ≥65 years old, 24% non-English preferred languages; 18% identified as Hispanic, 9% Black, 17% Asian, 6% Native Hawaiian/Pacific Islander. There were no differences by visit type in screening for psychosocial (aOR 0.87 vs. in-person visits, 95% CI 0.60-1.25), spiritual (aOR 0.81, 95% CI 0.57-1.15), or goals of care needs (aOR 1.05, 95% CI 0.85-1.31). Patients with non-English preferred languages (vs. English-speaking) had significantly lower odds of screening regardless of visit type. Patients identifying as Black (vs. White) also had significantly lower odds of screening.

CONCLUSIONS

There were no differences by visit type in screening for psychosocial, spiritual, and goals of care needs. Patients with preferred languages other than English were significantly less likely to be screened than English speakers, though there was no further difference by visit type. Patients identifying as Black were also significantly less likely to be screened. Addressing these disparities in core OPC elements is essential in providing equitable, high-quality OPC.

Latine Patients' Beliefs, Attitudes, and Experience With Psoriasis

Importance

In the US, Latine patients disproportionately experience severe psoriasis, limited access to care, and poor disease-related quality of life. However, little is known about psoriasis in this growing US population.

Objectives

To explore Latine patients' perception of their illness and their attitudes toward and experiences with the health care system, treatment, and research.

Design, Setting, and Participants

In this qualitative study, a thematic analysis was performed of in-depth, semistructured interviews of 30 Latine adults with moderate to severe psoriasis at an outpatient dermatology clinic in an urban safety-net hospital. All patients included had psoriasis diagnosed by a dermatologist and were defined as having moderate to severe psoriasis if systemic treatment was offered at any time during their disease course. Interviews were held between July 7 and August 3, 2022. Data saturation was used to determine sample size.

Main Outcomes and Measures

Interviews were conducted in English or Spanish, audio recorded, transcribed verbatim, and translated. Transcripts were then coded through an iterative process, and themes were identified through thematic analysis.

Results

Among 30 participants included, the mean (SD) age was 50 (11) years, 20 (67%) were male, and 22 (73%) preferred Spanish. Among 15 participants who disclosed their country of origin or ancestry, 7 (23%) were from Mexico; 4 (13%), Guatemala; 2 (7%), El Salvador; 1 (3%), Honduras; 1 (3%), Nicaragua; and 1 (3%), Peru. Six interrelated themes describing participant experiences were identified: (1) illness perception of psoriasis, (2) reliance on sociofamilial connections for medical decision-making, (3) impact of psoriasis on work life, (4) barriers to accessing quality dermatologic care, (5) receptiveness to prescription and nonprescription treatments, and (6) positive perception and interest toward research.

Conclusions and Relevance

The findings of this study highlight the impact of psoriasis on Latine individuals, the efforts made by this population to overcome health disparities, their positive perception toward biologic medications, and their interest in participating in biomedical research. Future investigations should assess educational interventions and further explore the preferences of Latine patients toward biologic medications and biomedical research.

Making end-of-life health disparities in the U.S. visible through family bereavement narratives

Objective

End-of-life experiences can have important implications for the meaning-making and communication of bereaved family members, particularly due to (in)access to formal healthcare services (i.e., palliative care and hospice). Grounded in Communicated Narrative Sense-Making theory, this study extends knowledge about how the stories told about end-of-life by bereaved family members affect and reflect their sense-making, well-being and importantly, potential disparities in end-of-life care.

Methods

Semi-structured interviews with 25 bereaved individuals were conducted regarding their experiences with the terminal illness and death of an immediate family member. Using a framework of family bereavement narratives, a cross-case data analysis demonstrated qualitative patterns between (in)access to end-of-life care and how participants framed bereavement stories.

Results

Four themes illustrated the continuum of communication that families engaged in when making sense of end-of-life experiences, including reflections on silence, tempered frustrations, comfort with care, and support from beyond.

Innovation

This innovative qualitative connection between family members' bereavement stories and end-of-life care emphasizes the importance of employing a health equity lens within hospice and palliative care, especially in addressing the important aim of comprehensively supporting families even when illness ends. This study demonstrates that access to, quality of, and imagining beyond current structures for EOL may be vital factors for facilitating effective sense-making for the dying and their family systems.

Conclusion

These findings illustrate the potential interconnections between (in)access to end-of-life care, sense-making, and communication for individuals and families experiencing terminal illness and bereavement.

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Pilot Testing Transcreated Spanish-Language Study Materials for Symptom Research With Infants and Parents in the Neonatal Intensive Care Unit

BACKGROUND

Rising admission rates of Hispanic/Latinx families to the neonatal intensive care unit (NICU) have increased the number of non-English-speaking individuals who may wish to participate in research studies. However, a lack of appropriately translated research study materials may limit the opportunity for these families to be involved in research that could impact the care that infants and families receive in the NICU.

PURPOSE

The primary purpose was to pilot test study materials that were transcreated from English to Spanish with the assistance of a bilingual community advisory board with Spanish-speaking parents of NICU infants.

METHODS

A total of 19 Spanish-speaking parents (15 mothers and 4 fathers) who were representative of the population of interest completed paper-and-pencil surveys, along with a cognitive interview. Preliminary data related to decision-making and goals of care, infant symptoms, and their experiences in the NICU were also collected.

RESULTS

The internal reliability of the transcreated study instruments ranged from good to excellent (α= 0.82-0.99). Participants reported that study materials were not offensive and did not make them feel uncomfortable; however, they found some words/phrases to be confusing. Parents had the opportunity to provide suggested wording changes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Language barriers and a lack of cultural responsiveness can affect the care that infants and their families receive. More accurate and culturally appropriate transcreation of study materials can remove barriers to research participation and facilitate better communication with non-English-speaking families, which may lead to the development of better-informed evidence-based interventions and clinical practices in the NICU.

Spanish Translation and Dissemination of EMPOWER Materials to Address Barriers to Pain Management at the End of Life

Introduction

The Effective Management of Pain by Overcoming Worries to Enable Relief (EMPOWER) intervention is an evidence-supported approach for addressing barriers to pain management (e.g., patient/family concerns about addiction) at the end of life. Such barriers appear more pronounced among Spanish-speaking individuals. This study aimed to (1) translate EMPOWER materials into Spanish, (2) disseminate materials to hospices with ≥25% Hispanic patients, and (3) survey hospices about the use and usefulness of materials.

Methods

We back translated EMPOWER materials with harmonization, then disseminated materials to 242 hospices. Thereafter, we used a semistructured survey to assess use and usefulness of EMPOWER materials using univariate statistics and content analysis.

Results

Thirty-eight hospice representatives responded (participation rate = 15.7%). Respondents were primarily non-White (55.3%) and Hispanic (60.5%). Nealy half (47.4%) were nurses. A majority (81.6%) indicated they currently employ ≥1 full-time English-Spanish bilingual team member. Among those who reported receiving the EMPOWER materials (n = 29), 58.6% indicated they-or another staff member-used them with patients or families. Using a single-item rating (0 = not useful to 10 = very useful), respondents evaluated the English EMPOWER materials' usefulness as 7.6 (standard deviation [SD] = 1.4) and Spanish materials as 8.4 (SD = 1.4). Most (62.1%) indicated they would likely use EMPOWER materials in the future.

Conclusion

Thematic findings suggest EMPOWER reinforces clinical education, promotes discussion about pain management, and helps address culturally specific barriers to care. EMPOWER appears to be a useful, easy to use, and promising intervention that can be implemented among both English- and Spanish-speaking populations.