Dara H. Sorkin

Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use

BackgroundProvider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.ObjectiveWe examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes.DesignCross-sectional survey, response rate 74%.ParticipantsA total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities.MeasurementsProvider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding.ResultsPatients with language-discordant providers reported receiving less health education (β = 0.17, p < 0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β = 0.28, p < 0.05), and were more likely to give low ratings to their providers (odds ratio [OR] = 1.61; CI = 0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers.ConclusionLanguage barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

Loneliness, lack of emotional support, lack of companionship, and the likelihood of having a heart condition in an elderly sample

Social isolation has been linked to a variety of adverse health outcomes, including cardiovascular disease. Researchers have attributed this association to the feelings of loneliness that accompany social isolation, but they have rarely assessed loneliness directly. In a sample of 180 older adults, feelings of loneliness and two kinds of social deficits that underlie loneliness& limited emotional support and limited companionship&were examined in relation to the likelihood of having a coronary condition. Potential physiological, behavioral, and affective mediators were examined as well. Greater loneliness was found to be associated with an increased probability of having a coronary condition, as were low levels of both emotional support and companionship. Mediators of these links were not identified, however, in this sample. These results underscore the value of examining the specific social deficits that underlie loneliness in investigations of the relation between loneliness and cardiovascular health in later life.

Racial/ethnic discrimination in health care: impact on perceived quality of care.

BackgroundRacial/ethnic minorities are more likely to report receipt of lower quality of health care; however, the mediators of such patient reports are not known.ObjectivesTo determine (1) whether racial disparities in perceptions of quality of health care are mediated by perceptions of being discriminated against while receiving medical care and (2) whether this association is further mediated by patient sociodemographic characteristics, access to care, and patient satisfaction across racial/ethnic groups.Research DesignA cross-sectional analysis of a population-based sample of California adults responding to the 2003 California Health Interview Survey. Multivariable logistic regression was used to examine the relationship between perceived discrimination and perceived quality of health care after adjusting for patient characteristics and reports of access to care.Main ResultsA total of 36,831 respondents were included. African Americans (68.7%) and Asian/Pacific Islanders (64.5%) were less likely than non-Hispanic whites (72.8%) and Hispanics (74.9%) to rate their health care quality highly. African Americans (13.1%) and Hispanics (13.4%) were the most likely to report discrimination, followed by Asian/Pacific Islanders (7.3%) and non-Hispanic whites (2.6%). Racial/ethnic discrimination in health care was negatively associated with ratings of health care quality within each racial/ethnic group, even after adjusting for sociodemographic variables and other indicators of access and satisfaction. Feeling discriminated against fully accounted for the difference in low ratings of quality care between African Americans and whites, but not for other racial/ethnic minorities.ConclusionsPatient perceptions of discrimination may play an important, yet variable role in ratings of health care quality across racial/ethnic minority groups. Health care institutions should consider how to address this patient concern as a part of routine quality improvement.

Self‐Reported Health Status of Vietnamese and Non‐Hispanic White Older Adults in California

Vietnamese Americans are a rapidly growing minority group in the United States, yet little is known about their health status. Chronic medical conditions and self‐rated health of older Vietnamese Americans were compared with those of non‐Hispanic white adults living in California using the 2001 and 2003 California Health Interview Surveys (CHISs). The CHIS employed a random‐digit‐dial telephone survey, and its sample is representative of Californias noninstitutionalized population. The sample included 359 Vietnamese and 25,177 non‐Hispanic white adults aged 55 and older. Vietnamese and non‐Hispanic white adults were compared in terms of limitations in activities of daily living, chronic medical conditions (diabetes mellitus, hypertension, heart disease, asthma), mental health care, and self‐reported health, adjusting for age, sex, and education. Vietnamese were more likely than white participants to report needing help for mental health problems (adjusted odds ratio (aOR)=2.1, 95% confidence interval (CI)=1.4–3.1) but less likely to have had their medical providers discuss their mental health problems with them (aOR=0.3, 95% CI=0.1–0.5). In addition, Vietnamese participants reported significantly worse health than white adults on five of eight domains of the Medical Outcomes Survery 12‐item Short Form survey (P<.006). Clinicians caring for older Vietnamese individuals should be aware of the high risk for mental health needs in this population and should initiate discussions about mental health with their patients. Further research is needed to better understand why older Vietnamese Americans are at higher risk for worse self‐reported health than older white adults.

Assessing the mental health needs and barriers to care among a diverse sample of Asian American older adults.

ABSTRACTBACKGROUNDAsian Americans represent a mix of cultures and immigration experiences, which may put them differentially at risk for mental health problems. Yet, little is known about the mental health needs of older adults from various Asian subgroups compared to non-Hispanic whites.OBJECTIVESTo compare the prevalence rates of mental distress of Chinese, Filipino, South Asian, Japanese, Korean, and Vietnamese older adults (aged 55 and older) to that of non-Hispanic whites; and to examine subgroup differences in utilization of mental health services.METHODSA cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression analysis was used to examine subgroup differences in mental health status and use of mental health services among the six different Asian subgroups and non-Hispanic whites, adjusting for respondents’ demographic and health characteristics, socioeconomic status, and English-language proficiency.RESULTSA total of 20,712 respondents were included. Filipino [aOR=2.25; 95% CI=1.14-4.47] and Korean Americans [aOR=2.10; 95% CI=1.06-4.17] were more likely to report symptoms indicative of mental distress compared to non-Hispanic whites, yet were less likely to have seen a primary care provider [Filipino: aOR=0.41; 95% CI=0.18-0.90; Korean: aOR=0.24; 95% CI = 0.08-0.69] or have taken a prescription medication [Filipino: aOR=0.20; 95% CI=0.10-0.40; Korean: aOR=0.15; 95% CI=0.05-0.40], even after adjusting for indicators of respondents’ demographic and health characteristics, socioeconomic status, and English-language proficiency. In contrast, Japanese Americans were less likely to report symptoms indicative of mental distress [aOR=0.43; 95% CI=0.21-0.90], and were less likely to make use of mental health services compared to non-Hispanic whites.DISCUSSION/CONCLUSIONSThe findings from this study not only highlight the unmet mental health needs among older Asian Americans, but also illustrate significant variations among the various Asian subgroups. Clinicians who work closely with these patients should regularly screen and assess older Asian adults for symptoms related to their mental health needs.

Evaluating the SF-36 Health Survey (Version 2) in Older Vietnamese Americans.

Objectives: The SF-36® Health Survey (Version 2; SF-36) was evaluated among older Vietnamese Americans to determine whether underlying dimensions of physical and mental health were similar to those of other groups in the United States. Method: Field testing of participants from senior centers. Results: The study provided support for the reliability and validity of the SF-36. Structural equation modeling provided confirmation of physical and mental health factors. However, the factor loadings for the SF-36 scales were more consistent with previous results from Asian countries than the typical pattern observed in the United States. Discussion: As the older populations in the United States become more diverse, it is important to have standardized health-related quality of life measures. However, the conceptualization of physical and mental health and associations among different scales may be different for Asian immigrants than for other groups. Thus, the interpretation of the SF-36 scores needs to account for cultural differences.

Racial and ethnic disparities in healthcare use, delayed care, and management of diabetes mellitus in older adults in California.

This study examined racial and ethnic differences in healthcare use, delayed care, and management of care of older adults with a self‐reported diagnosis of diabetes mellitus. Drawing on the 2009 California Health Interview Survey (CHIS), the sample included 3,003 adults (representative of N = 998,795) aged 60 and older from five racial and ethnic groups: non‐Hispanic white (n = 2,153), African American (n = 213), Hispanic (n = 336), Asian (n = 306), and American Indian and Alaska Native (AI/AN) (n = 59). All self‐reported a diagnosis of diabetes mellitus. Descriptive statistics and logistic regression analyses were conducted using weighted data. Results from adjusted logistic regressions indicated significant racial and ethnic differences between non‐Hispanic white elderly and the other groups examined. Specifically, African Americans were significantly less likely than whites to see a doctor and to have a usual source of care, and were more likely to visit the emergency department (ED) for diabetes mellitus and to have their feet examined by a provider. Hispanics were significantly less likely to take medicine to lower cholesterol but were more likely to test their blood glucose regularly (following ADA guidelines). Asians were significantly less likely than whites to test their blood glucose regularly or have a foot examination. AI/ANs were significantly less likely than whites to see a doctor, visit an ED, and take medication to reduce heart attack risk but were more likely to use insulin, oral diabetic medication, or both. The findings suggest the need for racial‐ and ethnic‐specific interventions for managing diabetes mellitus to help reduce existing racial and ethnic disparities among elderly adults.

Underdiagnosed and Undertreated Depression Among Racially/Ethnically Diverse Patients With Type 2 Diabetes

OBJECTIVE To examine racial/ethnic differences in the prevalence of depressive symptoms and in provider recognition of depression among Latino, Asian, and non-Hispanic white patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Patients (n = 1,209) with type 2 diabetes were recruited from five university-affiliated primary care clinics for an observational study. RESULTS Vietnamese American (133, 59.4%) and Mexican American (351, 50.2%) patients were more likely to report symptoms consistent with clinical depression (Center for Epidemiological Studies Depression [CES-D] scale score ≥22) than non-Hispanic whites (119, 41.6%; F [2, 1206] = 8.05, P < 0.001). Despite comparable diabetes care, Vietnamese and Mexican patients with high depressive symptoms were less likely to be diagnosed and treated than non-Hispanic whites (all P values < 0.001). Minority patients who reported low levels of trust in their provider were less likely to have been diagnosed or treated for depression (adjusted odds ratio 0.65, 95% CI 0.44–0.98, P < 0.05). CONCLUSIONS Innovative strategies are needed to improve recognition of depressive symptoms in minority patients.

Surveying minorities with limited-english proficiency: Does data collection method affect data quality among Asian Americans?

Background:Little is known about how modes of survey administration affect response rates and data quality among populations with limited-English proficiency (LEP). Asian Americans are a rapidly growing minority group with large numbers of LEP immigrants. Objective:We sought to compare the response rates and data quality of interviewer-administered telephone and self-administered mail surveys among LEP Asian Americans. Design:This was a randomized, cross-sectional study using a 78-item survey about quality of medical care that was given to Vietnamese, Mandarin, or Cantonese Chinese patients in their native language. Measures:We examined response rates and missing data by mode of survey and language groups. To examine nonresponse bias, we compared the sociodemographic characteristics of respondents and nonrespondents. To assess response patterns, we compared the internal-consistency reliability coefficients across modes and language groups. Results:We achieved an overall response rate of 67% (322 responses of 479 patients surveyed). A higher response rate was achieved by phone interviews (75%) as compared with mail surveys with telephone reminder calls (59%). There were no significant differences in response rates by language group. The mean number of missing item for the mail mode was 4.14 versus 1.67 for the phone mode (P ≤ 0.000). There were no significant differences in missing data among the language groups and no significant differences in scale reliability coefficients by modes or language groups. Conclusions:Telephone interviews and mail surveys with phone reminder calls are feasible options to survey LEP Chinese and Vietnamese Americans. These methods may be less costly and labor-intensive ways to include LEP minorities in research.

Racial and Ethnic Disparities in Indicators of Physical Health Status: Do They Still Exist Throughout Late Life?

Physical health problems become more common as people age and are associated with a great deal of disability. Although racial and ethnic disparities have been reported in physical health, little is known about whether these disparities remain in the latest part of older adulthood. Accordingly, the current study sought to examine racial and ethnic differences in the physical health status of three age groups of older adults, using the 2005 and 2007 California Health Interview Survey. The sample for the current study included 40,631 individuals aged 55 and older: 33,488 non‐Hispanic whites, 1,858 blacks, 2,872 Asians and Pacific Islanders, and 2,412 Latinos. Respondents were compared with regard to three indicators of physical health: four chronic health conditions, difficulties with activities of daily living, and self‐rated health. Analyses were conducted with and without adjustment for sex, marital status, education, English‐language proficiency, nativity, and insurance status. Results revealed that, in general, racial and ethnic disparities existed for physical health in late adulthood, with differences less pronounced for Asians and Pacific Islanders and Latinos aged 75 and older after multivariable adjustment. Disparities between blacks and non‐Hispanic whites and disparities across all racial and ethnic minorities in self‐rated health still existed. These findings suggest that, to reduce racial and ethnic disparities, clinicians need to address specific sociodemographic and lifestyle factors related to racial and ethnic differences in health before these conditions are manifested in late adulthood.