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Glycemic Control in English- vs Spanish-Speaking Hispanic Patients With Type 2 Diabetes Mellitus
Laura M. Lasater, MD;
Arthur J. Davidson, MD, MSPH;
John F. Steiner, MD, MPH;
Philip S. Mehler, MD
Arch Intern Med. 2001;161:77-82.
ABSTRACT
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Background Hispanic individuals compose the fastest growing minority group in the
United States, yet little is known about how language impacts their health
care. The primary objective of this study was to determine whether the inability
to speak English adversely affected glycemic control in Hispanic patients
with type 2 diabetes mellitus.
Methods This retrospective cohort study selected 183 Hispanic patients with
type 2 diabetes mellitus aged 35 to 70 years from a public health care system;
patients were Spanish-speaking (SS) only, and control patients were English-speaking
(ES) or bilingual. Clinical information was collected via telephone survey,
and data on health care use, diagnosis, and glycosylated hemoglobin A1c (HbA1c) values were obtained from administrative and laboratory
information systems.
Results Values of HbA1c for SS (mean, 9.1%; range, 5.0%-15.3%) and
ES (mean, 9.0%; range, 4.9%-16.2%) patients with diabetes mellitus and the
total number of hospitalizations related and unrelated to diabetes mellitus
did not differ (P = .86). Spanish-speaking patients
had a diagnosis of diabetes mellitus for fewer years than ES patients (8.2
and 11.2 years, respectively; P = .01). Spanish-speaking
patients were less likely to understand their prescriptions; 22% of SS patients
reported no comprehension vs 3% of ES patients (P
= .001). There was a trend toward decreased prevalence of insulin use among
SS patients compared with ES patients (30% vs 42%, respectively; P = .07).
Conclusions Glycemic control in Hispanic patients was not related to their ability
to speak English. This finding may be explained by a high degree of language
concordance between patients and providers.
INTRODUCTION
THE ROLE that English fluency and proficiency play in the health care
of Hispanic patients with diabetes mellitus in the United States is not completely
understood. Language barriers to care may have important health and medical
economic implications since Hispanic individuals compose the fastest growing
minority group in the United States,1 and Hispanic
individuals have higher rates of mortality due to diabetes mellitus and complications,
such as peripheral vascular disease, amputations, and end-stage renal disease,
than whites.2, 3, 4
Spanish-speaking (SS) adults are more likely to be older, to live in urban
areas, to be less well educated, to be unemployed, to lack medical insurance,
to report poorer health status, and to score lower on measures of self-determination
than English-speaking (ES) adults.5, 6 Self-determination is a construct that refers to individuals'
perception of the degree to which their behavior is responsible for their
health. Schur et al5, 6 measured
self-determination using several health belief statements rated by patients
according to how strongly they agreed or disagreed with each. For example,
SS patients were more likely than ES patients to attribute a large role in
the recovery from an illness to luck. Studies7, 8
have shown that SS Hispanic patients are less likely than ES Hispanic patients
to have a regular source of medical care, to undergo screening, to use preventive
services, and/or to be referred to a specialist. In other studies,5, 9 SS was not significantly associated
with limited access to health care services after controlling for socioeconomic
and cultural factors known to decrease use of health care services. Language
acculturation that is, learning to speak English, among Hispanic individuals
has been found to predict use of preventive screening in some studies.10, 11 Although the negative impact of the
inability to speak English fluently on access to health care has been fairly
well characterized, its impact on other aspects of health care has received
less scrutiny.
For patients who are able to successfully surmount barriers to access,
language concordance, namely the patient's and provider's ability to speak
the same language, may still affect both the process of care and patients'
perceptions of their health status. A study12
on language concordance suggested that patients' adherence to their health
care plan and appointment-keeping behavior, 2 markers of effectiveness of
medical care, were associated with the ability of medical care providers to
speak the same language as their patients. Spanish-speaking patients with
SS providers had better recall of recommendations made during a visit and
asked more questions.13 Patients reported significantly
better health status when their provider spoke the same language as they did.14 The role language concordance plays in patient satisfaction
has not been extensively evaluated, and, despite the potential negative impact
of language barriers on medical outcomes, there is a paucity of research in
this area.
We chose to use diabetes mellitus as a disease model for studying how
medical care provided to Hispanic patients varies as a function of the patients'
primary language because of the high prevalence and complication rates of
diabetes mellitus in the Hispanic population. In addition, the value of glycosylated
hemoglobin A1c (HbA1c) serves as a useful marker for
disease management and outcomes.15 The primary
hypothesis was that glycemic control in SS patients with diabetes mellitus
would be worse than it is in ES patients with diabetes mellitus.
METHODS
PATIENT POPULATION
Patients in this study received their health care through Denver Health,
a vertically integrated public health care system that includes Denver Health
Medical Center, an urban hospital and ambulatory care center, and 10 community
health centers, serving primarily minority, low-income patients in Denver,
Colo. Approximately 130 000 patients are treated annually at Denver Health.
Of those, approximately 49% of the patients are Hispanic; 27%, white; and
17%, black. Almost half of the patients lack any form of medical insurance,
and the majority of the remaining patients receive health insurance through
Medicaid or Medicare. However, in our system, low income does not preclude
the ability to afford care because the Colorado Indigent Care Plan, a state-funded
program for adults who are ineligible for Medicaid and lack private health
insurance, uses an income-based sliding scale to determine patients' copay
requirements and prescription costs.
There is no uniform way patients are taught about diabetes mellitus
or the use of insulin in our system. Education is determined by provider discretion,
and the following methods are used: patients are referred to a series of free
classes; they are referred to an endocrine specialist; or they are taught
how to use insulin by either a nurse or the provider. Educational videotapes
are available in Spanish and English, but not all providers use this resource.
The availability of bilingual staff differs by clinic location; as a result,
the use of interpreters is highly variable.
Subjects were identified through a computer search of administrative
databases with the following selection criteria: age between 35 and 70 years,
recorded Hispanic ethnicity, diagnosis of type 2 diabetes mellitus or related
complications (International Classification of Diseases,
Ninth Revision, Clinical Modification16
codes 250.00-250.50), with at least 2 visits to Denver Health between January
1, 1995, and December 31, 1997, and a minimum of 1 HbA1c test performed
between June 1, 1997, and December 31, 1997. We chose this more recent period
to minimize recall bias. Seeing patients at least twice in the outpatient
setting ensured inclusion of established, not newly enrolled, patients. The
primary care provider for each patient was determined either by patient report
or through a review of the administrative database to identify the predominant
family practice or internal medicine provider who treated the patient during
the year preceding the study period. Exclusionary criteria were a diagnosis
of type 1 diabetes mellitus recorded in the administrative database, corticosteroid-induced
hyperglycemia, and no available HbA1c value from June 1, 1997,
to December 31, 1997. Patients younger than 35 years were excluded to avoid
potential misclassification of type 1 diabetes mellitus, and those older than
70 years were excluded as their level of optimal glycemic control might be
defined differently.
STUDY DESIGN
This was a retrospective cohort study. Patients who fulfilled inclusion
criteria were divided into 2 groups, ES or SS, based on language ability as
recorded in the administrative database. A random number generator ordered
the 2 groups; patients were then contacted sequentially by a bilingual research
assistant to participate in a telephone survey between June 9, 1998, and July
29, 1998. Those who were successfully contacted were asked for informed consent
to participate. The study was approved by the Colorado Multiple Institutional
Review Board.
Additional information was obtained from administrative and laboratory
databases and a health care provider written questionnaire. Laboratory databases
provided HbA1c test results (normal range, 4.0%-6.0%), while administrative
data sets provided patient demographics and visit-specific information (date,
clinic site, frequency, provider, and diagnoses).
MEASURES
The telephone survey, conducted by a trained bilingual interviewer,
initially confirmed Hispanic ethnicity to meet inclusion criteria, followed
by language fluency to ensure that the correct language version of the survey
was used for each participant and that the patient was assigned to the correct
cohort. The Spanish translation of the survey had been reviewed by 2 native
Spanish speakers before its final implementation. Hispanic ethnicity was self-reported.
Of the approximate 65 000 Hispanic patients, more than 90% were Mexican
American, and we did not determine the country of origin for the remainder.
The patients' language fluency was operationally rather than subjectively
defined as this method has greater validity.12
Subjects were asked, "How would you describe your ability to speak English?"
and chose 1 of 4 possible responses: (1) not at all; (2) basic communication
is difficult; (3) everyday conversation is possible; and (4) as well as a
native speaker. The patient survey collected the following information: age;
sex; weight; height; years with a diagnosis of type 2 diabetes mellitus; years
of residency in the United States; household income; education level; name
and type (either family practice or internal medicine) of primary care provider;
use of an interpreter (either professional or family member) during clinic
visits; use of insulin; whether written information (including prescriptions)
was provided in English, Spanish, or a combination; whether the provider spoke
Spanish; quality of communication between patient and provider; and number
of admissions to the hospital and visits to the emergency department during
the past year.
To assess each provider's ability to speak Spanish, a questionnaire
was circulated to 58 primary care providers at Denver Health identified through
patient surveys. Providers were asked to "place a check mark next to the statement
below that best describes your ability to speak Spanish," and there were 4
possible responses: (1) not at all; (2) even basic communication is difficult
and/or usually need an interpreter; (3) able to provide routine care comfortably
and/or only need interpreter for complex discussions (ie, psychiatric or end-of-life
issues); and (4) as well as a native speaker. In addition, providers were
asked for their country of origin and whether they considered themselves to
be Latino and/or Hispanic. For purposes of the analysis, providers selecting
either of the first 2 responses were categorized as non-SS, and providers
who selected the third or fourth response were categorized as SS. Overall,
40 (69%) of the 58 providers responded. For providers who could not be contacted,
we used the results of a different administrative survey as a proxy. One question
on this survey asked the participant to list any languages in which they were
fluent but did not ask for an estimation of degree of fluency. The 2 surveys
were concordant for responders.
STATISTICAL ANALYSIS
Data entry and statistical analysis were performed using SAS statistical
software (version 6.12; SAS Institute Inc, Cary, NC). The primary analysis
compared glycemic control between SS and ES patients with diabetes mellitus.
The null hypothesis would have suggested no difference between the SS and
ES groups. To compare bivariate relationships (between patient groups) for
continuous variables (ie, HbA1c value, age, and weight) a 2-sample t test was used, and Wilcoxon rank sum test was used for
nonparametric data.  2 Analyses were used for categorical variables,
and Fisher exact test was used for small cell sizes. Two-sided P .05 was considered statistically significant.
Sample size calculations were performed using Epi Info (USD Inc, Stone
Mountain, Ga). To estimate the sample required, we used the distribution of
HbA1c test results (N = 22 093) from Denver Health in 1997.
An independent estimate of the distribution would take only 1 value (eg, the
lowest) for each patient (n = 3228). Forty-five percent of the patients had
a value of 7.5% or less. The detection of a 1.5% (eg, 7.5%-9.0%) mean difference
in HbA1c values between groups ( = .05 and ß = .20)
would require a total sample size of 178 (89 patients per group).
RESULTS
We attempted to contact 327 (82%) of the 399 patients who met the inclusion
criteria. We were unable to contact 81 (25%) of these patients after 3 telephone
attempts. An additional 55 patients (17%) could not be reached because of
a disconnected telephone, an incorrect telephone number, or a changed address.
Of 191 patients contacted, 183 agreed to participate; of those, there were
79 SS and 104 ES patients.
Baseline data characteristics of the study sample are presented in Table 1, with significant differences between
ES and SS patients noted on most measures. Spanish-speaking patients had completed
a mean of only 3.4 years of school, whereas ES patients had completed a mean
of 9.3. In addition, SS patients were more likely to be immigrants, to have
a more recent diagnosis of diabetes mellitus, and to be receiving care at
Denver Health for fewer years.
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Table 1. Characteristics of 183 Hispanic Patients With Diabetes Mellitus*
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The main outcome measure, mean HbA1c values, did not differ
significantly between the ES and SS groups (9.0% vs 9.1%; P = .86; Table 2). We analyzed
the following patient characteristics to determine whether any characteristic
distinguished patients with better glycemic control (HbA1cvalue
< 8.0%) from those with less glycemic control (HbA1cvalue 
8.0%): age, sex, income, use of insulin, years with a diagnosis of diabetes
mellitus, years receiving care at Denver Health, number of hospitalizations,
number of visits to the emergency department, years of school completed, body
mass index, and language concordance with the provider. The only characteristics
that approached statistical significance were the use of insulin (P = .08) and language concordance (P = .12).
Insulin use correlated with poorer glycemic control (P
= .08), and this finding remained after adjusting for the number of years
with diabetes mellitus and age. Spanish-speaking patients with SS providers
tended to have better glycemic control (HbA1c value < 8.0%)
than SS patients with ES providers (41% vs 12%, respectively; P = .12). This difference, although clinically important, was not statistically
significant given our sample size. Spanish-speaking patients were no less
likely to have an established primary care provider (P
= .12) but were more likely to have a Hispanic and/or SS provider than ES
patients (P<.05; Table 2). The mean number of hospitalizations in the past year and
emergency department visits in the past 2 years did not differ significantly
between the 2 groups.
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Table 2. Differences in the Outcomes and Process of Care Measures in
183 Hispanic Patients With Diabetes Mellitus*
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There were significant differences in the process of care between the
2 groups: SS patients were less likely than ES patients to receive written
educational materials (P = .05), and a trend was
evident among SS patients toward less insulin use (P
= .07). Subgroup analysis showed that SS patients with an SS provider were
more likely to be taking insulin than SS patients with an ES provider (odds
ratio, 1.4; 95% confidence interval, 0.25-7.55). However, this association
was not statistically significant (P = .72) because
of the small sample size and resulting limited power to detect a difference.
Only 51 (66%) of the 77 SS patients received prescriptions with labels written
in Spanish.
COMMENT
We found no difference in the main outcome measure, glycemic control,
in SS vs ES Hispanic patients with diabetes mellitus; however, the results
of this study suggest that some potentially important processes of care for
Hispanic patients with type 2 diabetes mellitus differ based on English fluency.
First, SS patients were less likely than ES patients to be taking insulin.
We were not able to determine whether this finding was due to different provider
prescribing practices or patient preference. Health care providers identified
Hispanic patients with diabetes mellitus, in general, as having a greater
fear of insulin and a reluctance to use it compared with white patients.17 The fact that SS patients were less likely than ES
patients to receive written materials may reflect the providers' recognition
or assumption of lower reading ability or may relate to lack of availability
of translated materials. We do not know how many of the ES or SS patients
in the present study were unable to read; however, based on published data
from similar populations, we estimated that the prevalence of inadequate or
marginal functional health literacy was 35% in the 106 ES patients and 62%
in the 77 SS patients.18 A study19
in the United States established that the number of years of school completed
overestimates actual reading level by 4 to 5 grade levels. Whether this discrepancy
applies to individuals educated outside the United States, as a large number
of the SS patients in our study were, is not clear. While some patient educational
materials in Spanish are available at our institution, not all materials are
culturally sensitive or written at an appropriate reading level. Two studies20, 21 showed that patient educational materials
are often written at an inappropriately high level and cannot be understood
by the target population. With an average of 3.4 years of school, the SS patients
in our study undoubtedly would have difficulty understanding written educational
materials found in most hospitals.
Language discordance between providers and patients may also impact
the process of patient education. Providers who do not speak Spanish fluently
may spend less time on educational efforts that depend on communication with
the patient. This hypothesis has never been tested formally; however, one
study22 used physician self-assessment and
observers with stopwatches to demonstrate no difference in the total amount
of time an ES provider spent with non-ES patients vs ES patients. In the present
study, despite a high rate of language concordance, SS patients tended to
rate communication with their providers less favorably than ES patients. This
dissatisfaction, which has been noted in another study23
of primary care in Hispanic ethnic groups, may reflect language barriers imposed
by the high prevalence of illiteracy among the SS patients or overrating of
SS skills by ES providers. Alternatively, despite good SS skills, cultural
barriers between Hispanic patients and non-Hispanic providers could adversely
affect communication. A recent survey-based study24
also demonstrated decreased satisfaction with communication among SS Hispanic
patients vs ES Hispanic patients. However, this study made no attempt to account
for the degree of language concordance between patients and providers. Using
family members and friends as interpreters for SS patients has been proposed
as a viable method to improve satisfaction.25
Our study corroborated the findings of Tocher and Larson26
in the only other published study that addressed whether glycemic control
is compromised in SS patients. They found that the quality of care for diabetes
mellitus in terms of several medical outcomes for non-ES patients with established
primary care providers and consistent use of professional interpreters was
equal to that for ES patients. In the present study, interpreters were not
consistently provided, but language barriers had been largely circumvented
through a process of selection of SS providers by SS patients. We believe
that this situation more closely approximates the actual experience (ie, effectiveness
study) of most health care providers and patients, whereas the results of
the study by Tocher and Larson seem to apply only in ideal conditions (ie,
efficacy study), in which a professionally trained interpreter is always available.
Of the 77 SS patients in our study, 64 (83%) had SS providers. The provision
of education about diabetes mellitus in Spanish may have played a large beneficial
role in the equivalent degree of glycemic control seen; this impact is similar
to the previously observed impact of language-appropriate education on influenza
vaccination rates among SS patients.27 Spanish-speaking
Hispanic patients may be able to overcome potential language barriers when
care is provided in a more culturally and linguistically congruent setting.
To our knowledge, no studies have compared how the content and outcomes of
a clinical encounter differ when communication is mediated by an interpreter
as opposed to a bilingual primary care provider.
Although glycemic control did not differ based on the primary language
spoken by patients, it was suboptimal overall in both study groups. This finding
alone should warrant a greater focus on Hispanic health issues, since poor
glycemic control in patients with type 2 diabetes mellitus has been linked
to a greater incidence of many microvascular and macrovascular diabetic complications
and an increased cost of health care for this population.28
Even a 1% improvement in the HbA1c value can result in a 10% reduction
in the risk for coronary artery disease.29, 30
Of 183 patients, 168 (92%) reported having a regular medical care provider,
and 64 (83%) of the 77 SS patients reported having an SS or Hispanic provider.
These health care system results contrast markedly with those obtained in
the 1997 population-based National Medical Expenditure Survey,31
which showed that only 51% of Hispanic adults had a regular physician, and
among the SS adults with a physician, 29% had a Hispanic physician. The SS
population in the present study appeared to more often have a primary care
provider, which reflects the study inclusion design that stipulated that patients
must have at least 2 outpatient visits. In addition, patients needed an HbA1c value for study inclusion. Thus, all these patients had providers
who were attempting to take clinical responsibility for their care. Simply
having a regular clinician has been shown to result in a linear trend in increasing
health care use.32, 33 The present
findings demonstrate that a well-integrated health care system may overcome
potential barriers to receiving comparable care in SS and ES Hispanic patients
with diabetes mellitus.
Our study has several limitations. First, the sample was small, which
might jeopardize the generalizability of the results. We tried to circumvent
this problem by selecting replacements sequentially from the 2 lists of patients
that had been generated previously. Second, we relied on patient reporting
for most of our data. Such retrospective accounts are subject to recall bias,
but we have no reason to believe that the potential for bias would differ
between the 2 cohorts. Finally, results of subset analyses of the process
of care for SS patients based on the degree of language concordance with their
providers had limited statistical power because of the small sample size and
were, therefore, inconclusive.
In summary, this study shows that glycemic control is no worse in SS
Hispanic patients compared with ES Hispanic patients with type 2 diabetes
mellitus, perhaps because of language concordance in the patient-physician
partnership. However, overall control was suboptimal in both groups according
to current guidelines.34 A provider's ability
to speak Spanish as fluently as a native speaker does not appear to be mandatory
to confer the metabolic benefit observed in this study. Even with those providers
who ranked their SS ability as able to provide routine care comfortably in
Spanish and/or only need interpreter for complex discussions (ie, psychiatric
or end-of-life issues), the benefit was seen. This finding should prompt additional
initiatives to teach cultural and communication competence to health care
providers of ethnically and culturally diverse populations, starting early
in the educational process. Although glycemic control did not differ between
ES and SS patients, we found several discrepancies in the care provided, particularly
around patient education. Because most SS patients had less schooling, the
challenge is how to effectively educate that population. New methods that
rely less on written materials need to be investigated.
Additional studies are needed to investigate in more depth how patient
satisfaction, the quality and process of a medical visit, adherence to the
treatment plan, and medical outcomes, including cost of care, differ based
on the degree of language concordance between patient and provider. An overriding
goal of future studies should be to optimize health care delivery to the rapidly
growing, underserved Hispanic segment of the population by finding ways to
bridge cultural and language differences between health care providers and
patients. Non-ES individuals already compose 30% of the population in urban
areas, and the number is likely to increase even further given the projected
demographic trends.35 Barriers that may prevent
optimal use of our health care system by ethnic minorities should be identified
and addressed to ensure that quality primary care is provided in all settings
and to individuals of all colors.
AUTHOR INFORMATION
Accepted for publication June 30, 2000.
From the Division of General Internal Medicine, Denver Health, Denver,
Colo (Drs Lasater and Mehler); the Departments of Preventive Medicine and
Biometrics and Family Medicine (Dr Davidson) and the Division of General Internal
Medicine, Department of Medicine (Dr Steiner), University of Colorado Health
Sciences Center, Denver.
Corresponding author and reprints: Laura M. Lasater, MD, Denver Health,
777 Bannock St, Mail Code 0148, Denver, CO 80204 (e-mail: LLasater{at}dhha.org).
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Texas-Mexico Border Intervention by Promotores for Patients With Type 2 Diabetes
Sixta and Ostwald
The Diabetes Educator 2008;34:299-309.
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Language and other factors associated with foot self-management among puerto ricans with diabetes in new york city.
Hosler and Melnik
Diabetes Care 2006;29:704-706.
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Ethnic Disparities: Control of Glycemia, Blood Pressure, and LDL Cholesterol Among US Adults with Type 2 Diabetes
Kirk et al.
The Annals of Pharmacotherapy 2005;39:1489-1501.
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Population-Based Assessment of Diabetes Care and Self-management Among Puerto Rican Adults in New York City
Hosler and Melnik
The Diabetes Educator 2005;31:418-426.
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Socioeconomic Position and Health among Persons with Diabetes Mellitus: A Conceptual Framework and Review of the Literature
Brown et al.
Epidemiol Rev 2004;26:63-77.
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Health Behaviors and Quality of Care Among Latinos With Diabetes in Managed Care
Brown et al.
AJPH 2003;93:1694-1698.
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The Case for "Outsourcing" Diabetes Care
Davidson
Diabetes Care 2003;26:1608-1612.
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