Vol. 12 •Issue 1 • Page 35
Speaking the Language of Asthma
Clinicians Take a Multicultural Approach to Care
When educating and treating asthma patients of other cultures, health care workers could face many barriers other than language. A new immigrant with asthma, for instance, may not only speak a foreign language, she also may be wary of Western medicine, live in a crowded apartment building full of asthma triggers, work a low-paying job that doesn’t offer health benefits, and be scared of anyone “official-looking,” like a doctor or respiratory therapist.
Still, these obstacles can be overcome. Clinicians can gain the trust of different populations by showing respect for their belief systems. And if doctors can’t relate to a particular culture, they need to find someone who can.
“When you can’t breathe, nothing else really matters,” said Garaudy Antoine, MD, CPFT, CRT, director of the respiratory therapy department of the Wyckoff Heights Medical Center in Brooklyn, New York. “That’s the universal language right there.”
In her work on asthma interventions involving Hispanic children, Pamela R. Wood, MD, professor of pediatrics, University of Texas Health Science Center at San Antonio, has come to recognize a number of Hispanic beliefs, behaviors and ways of life that clinicians need to keep in mind.
Family is a priority, she said. Unlike in some inner city populations, where an asthma educator may be dealing with many single-mother households, Hispanic families are often large and more inclusive. More than just the parents may be involved in decision-making. A grandmother, for instance, may have a strong voice in the household.
As with other cultures, respect is also important. When dealing with Hispanic families, make sure to introduce yourself, shake hands, greet individuals by their last names, and talk formally.
With Mexican-Americans, it’s important to touch children when talking to them. This comes from the folk myth that if you compliment children, you could give them the evil eye, causing them to cry and be irritable.
Another Mexican-American belief is that the Chihuahua can take away asthma. As children grow, they find that their asthma often improves while the dogs many times develop lung disease. So, families may own the dogs to try to cure their children with asthma. “That can be a problem if the child is allergic to dogs,” Dr. Wood said.
In Asian cultures, the care of small children is regarded highly, which may partially explain why this population usually recognizes the benefits and importance of asthma interventions, said Margo Sidener, MS, CHES, executive director of the American Lung Association of Santa Clara-San Benito Counties, San Jose, Calif.
“The different Asian groups embrace our programs more than other cultural groups,” Sidener said. They usually participate in large numbers in the association’s in-school education initiative and summer camps, an interesting phenomenon, considering that Asians haven’t been as accepting of other medical issues.
For example, smoking cessation programs aren’t very successful because smoking is so ingrained in the culture. “You’re thought to be rude if you don’t accept tobacco offered to you,” Sidener said.
Many cultures rely on folk medicine, and patients may refuse to replace this with more conventional methods. “Many of them are afraid of Western medicine because of side effects,” said Jose Calderon, MD, assistant professor of pediatrics, Yale University School of Medicine, New Haven, Conn., who attends at the Pediatric Asthma and Allergy Clinic, which serves the minority population of the New Haven area.
In this matter, it’s important to be sensitive and compromise, Dr. Calderon said. If the folk medicine poses no harm, let the patient continue to use it, rather than being critical and trying to impose modern medicine above all else.
At the New York City Childhood Asthma Initiative, formed in 1997 in response to rising asthma hospitalization rates, health care workers are encouraged to be very specific when asking about the various asthma medications a patient may be taking.
“New York City is a cultural epicenter,” said Lorna E. Davis, MS, the initiative’s director. “Asking about folk medication had to become standard.”
Of course, asking is easy if you speak the patient’s language. But many times, a bilingual doctor is unavailable, and hospitals have to rely on whomever they can find to do translating.
“Once you have someone who speaks the language, they (patients) automatically warm up to that person,” said Dr. Antoine, director of the Wyckoff Heights Medical Center’s Asthma Awareness Program, which treats a number of patients from different ethnic groups.
Wyckoff has advertised in Spanish newspapers for bilingual RTs, nurses and doctors, and it has a pool that lists staff members who speak other languages — Spanish, Turkish, German, Hindu, Haitian Creole — so if a patient comes in speaking a language on the list, that staff member is sent for.
Some hospitals use on-staff translators, though this situation raises confidentiality issues because a nonmedical professional is hearing about a patient’s private business, Dr. Calderon said. At his clinic, a nurse’s aid is frequently called on to translate, and as a result, many of the patients have become familiar with her.
In the Southwest, finding someone who can speak Spanish isn’t difficult because many nurses and doctors are bilingual, Dr. Wood said. But locating staff members who can translate any of the numerous languages that can walk through the door is hard.
Sometimes, the hospital might luck out, like at the University of Texas Health Science Center, when a resident fortunately knew German and could communicate with an Eastern European family. Other times, it might have to resort to using family members or friends who patients bring along as translators, which isn’t the best situation because they may editorialize the translation, adding words or leaving them out.
As a last option, AT&T offers a language line, Dr. Wood said. Calling the number, a translator can be put on speakerphone so doctor and patient can communicate through him. With the translator unseen and far removed from what’s going on in the hospital, it’s an impersonal way to go, though essential if nothing else is available.
Even if translation can be accomplished, other issues can arise. For starters, medical terms can mean different things in different languages. At the Texas Health Science Center, Dr. Wood and colleagues made sure they were using the right lingo for asthma terms.
For instance, the word in Spanish that comes closest in meaning to “spacer” is “c‡mara,” which means, “compartment,” but that word’s pronunciation is too similar to the English word “camera,” so it wasn’t used.
For wheezing, the Spanish word usually used in the medical community is “silbido,” which conveys the idea of a whistle. But the center instead used “pillido,” which means, “squeak,” because that’s the word commonly used in the Southwest, Dr. Wood said.
When educating and promoting the importance of asthma care, health care workers won’t get anywhere if they’re not trusted, and unfortunately, gaining the trust of ethnic populations usually isn’t easy.
“If they’re not afraid of the immigration people, they’re afraid of the welfare people,” said Robert J. Ledogar, D Theol, MCP, associate executive director of Community Information and Epidemiological Technologies, or CIET, an international organization based in New York City that’s committed to bringing scientific research and its benefits to local communities. “There is a kind of general reticence to deal with anything official. You knock on doors, and people won’t answer. They’re very guarded. People are very polite É but that doesn’t mean you’ll get a straight answer.”
As part of CIET, Dr. Ledogar has given technical support to El Puente, a community organization located in the predominately Hispanic section of Williamsburg in Brooklyn, N.Y., that has done research and education in the community regarding asthma.
When encouraging asthma education in areas such as Williamsburg, Dr. Ledogar advocates recruiting neighborhood health promoters, people who are of the same background as those you’re trying to reach. The promoters are trained about asthma and triggers, though care is taken not to overwhelm them with technical medical terms. Then, they spread the word throughout the community.
Find people who ethnic populations trust, Dr. Ledogar said. “And the ones they’re most likely to trust are the ones like them.”
Unfortunately, while promoters can be effective and establish a great rapport with a community, they’re difficult to keep on staff. The job doesn’t pay well, and there’s not much opportunity for advancement. “It’s not a great career track, even though it should be,” Dr. Ledogar said.
In addition to employing residents, a health care organization can tap into other aspects of a community, such as setting up booths at street fairs or speaking at church events.
The New York City Childhood Asthma Initiative has learned the value of working with community organizations. They really had no choice. After all, New York is a big place full of many nationalities. To get an idea of the scope of the populations the initiative deals with, just consider the fact that its main .asthma brochure is translated into nine languages: English, Spanish, Chinese, Russian, Polish, French, Haitian Creole, Arabic and Urdu.
“We might not know these groups particularly well,” said Lorna E. Davis, MS, the initiative’s director. As a result, the initiative has made partnerships with community groups who are familiar with the ethnic populations’ cultural and linguistic needs.
The community groups are encouraged to come up with posters and local strategies for getting out the asthma message. For instance, large groups of Central and South American immigrants were concentrating in apartment buildings in Jamaica, Queens, so the initiative’s community partner spoke to tenant organizations, making them, in turn, pressure landlords to address indoor allergens.
Wyckoff Heights Medical Center’s Asthma Awareness Program uses a slew of methods to educate about asthma, its triggers and the proper use of medications: support groups, church presentations, a clinic, periodic surveys and mass mailings, work with community organizations and free peak flow meters for patients.
“We try to capture everybody,” Dr. Antoine said. “No one should die of a disease we can control.”
John Crawford is assistant editor of ADVANCE.
TIPS FOR TRANSLATING EDUCATIONAL TOOLS
Pamphlets may seem like a good way to educate patients, but many immigrants aren’t literate in their own language. So, it’s best to make sure the reading level isn’t too difficult.
For example, when dealing with a Hispanic population, use both Spanish and English for the written material. Several generations, from grandparents to children, may be reading it, and they may have varying degrees of proficiency in each language, said Pamela R. Wood, MD, professor of pediatrics, University of Texas Health Science Center at San Antonio.
Having both languages side by side can help with reading. Sometimes, patients may be unfamiliar with a word in one language and use the identical word in the other language to figure it out.
Pictures are also important. “A lot of people don’t know what a spacer is unless there’s a picture of it,” said Lorna E. Davis, MS, director of the New York City Childhood Asthma Initiative. Try to use either pictures or live demonstrations, such as acting out how to properly use a peak flow meter, in educational efforts.
Finally, make sure to have people familiar with the language check over any written materials. At the American Lung Association of Santa Clara-San Benito Counties in San Jose, Calif., potential pamphlets are sent to community groups, who then see how focus groups perceive the handouts.
“The only way to have it work is to actually try it out in the community,” said Margo Sidener, MS, CHES, the association’s executive director.