Bridging Literacy and Language Differences for Better Health Outcomes: Characterizing a Bilingual Health Specialist

Background: The following research study addresses the current needs of community health workers and employers, future health professionals and patients in response to the increase in populations that are culturally and linguistically diverse. Methods: Perspectives of each of these stakeholders (n=22) were developed through the use of focus groups in order to develop the pedagogical principles that lead to an innovative approach in the development of a bilingual health specialist. Results: The findings indicate that language is an important tool that assists patients in understanding how to better manage their health as well as informing health care workers and employers of best practices in health. Discussion: Language was identified as an important theme along with the need for cultural competency, access to preventative and urgent care, as well as service learning for future health professionals in order to serve patients in more comprehensive ways that lead to better health outcomes.


Introduction Background
As the proportion of Latinos living in the United States grows from 17% in 2012 to 25% in 2030 [1], so does the number of individuals who primarily speak a language other than English. The health of Spanish-speaking Latinos continues to be of national concern due to the many complexities of accessing health information that is often not provided in Spanish. As a result there is an immediate need to find real solutions that eliminate health disparities among this population, such as with language and literacy.

Spanish speaking Latinos and poor health literacy
In the US, Latinos who are learning English as a Second Language make up as much as 20 percent of the patient populations [2]. Spanishspeaking Latinos are a growing and thriving population that faces issues such as less access to quality health care and health education due to being uninsured and confronting language barriers [3]. These issues become barriers that create an unequal health disparity among Latinos, who are considered to have the highest rates of obesity and chronic disease [4]. Along with the rapid growth of people who speak a language other than English is the complexity of poor health literacy. Currently, 65% of Hispanics adults are considered to be at basic or below basic level of health literacy [5]. Research suggests that "poor health literacy is a stronger predictor of a person's health than age, income, employment status, education level, and race" [6].

Bilingual health communication
With the rise in Spanish-speaking Latinos, it is no surprise that more employers are seeking bilingual health professionals. In a recent job search for bilingual healthcare professionals, "All Bilingual Jobs" [7] website listed over 200 possible jobs and 1,591 on CareerBuilder [8].
Though most job descriptions classify this need as a "preferred qualification" and not required, it seems to suggest that there is a growing need for a bilingual health professional.
Despite the apparent employment needs, bilingualism historically has been in existence for centuries. According to Baker [9], bilingualism is difficult to define in a single phrase but rather can be conceptualized as an individual's ability to use two languages in different contexts with a degree of proficiency in the four basic dimensions of language (listening, speaking, reading and writing). From the German settlements in the US to the linguistic diversity found in all parts of the world, the ability to develop multiple languages and skills in that language has been constant and thriving. However, in the US, the linguistic policies and language ideologies have posed barriers for those individuals wanting to develop their bilingualism.
Sherill et al. [10] explored the factors that become barriers for health communities, such as language barriers, lack of insurance and cultural differences. Researchers found that socio-economic status and the access to health services particularly for Latinos was intertwined with the cultural health practices found in the communities and familial households. These cultural health practices were supported by the language and used during the interactions with health professionals and patients. However, a challenge presented in this study was the difficulty in finding bilingual health professionals. The researchers encourage language training however; many health professionals were not proficient to meet linguistic and cultural needs of the patients. Researchers suggested the use of the Promotora or health promoter's model to meet the needs of the patients.
Drolet et al. [11] also found that health professionals faced challenges when working with culturally and linguistically diverse patients. The authors identified that the basis of patient health care is primarily supported by verbal communication. When patients engage in health services in a language they have limited proficiency in, they will more than likely not consistently follow the recommended preventative treatments. In addition, health professionals who were bilingual reported a challenge based on their degree of proficiency in their language skills in both languages and the patients' expectations of their ability to communicate proficiently with them. Even though, there were challenges that had been identified by the bilingual patients and health professionals, the study still highlighted the lack of professionals who were available to work with culturally and linguistically diverse patients. As a result, the need for these types of professionals limited the full range of health services that could be offered to the patient who were in desperate need of them.
To address the needs of a more diverse population and meet the growing trend of employers requesting bilingual health professional candidates, universities need to explore formal bilingual instruction, particularly in the allied health fields. Though numerous universities offer various degree plans in nursing, nutrition, health education or public/community health; most do not require formal training in language proficiency. At most, a course in medical Spanish might be listed as a possible elective. Moreover, the need for a bilingual health professional has not thoroughly been explored extensively. Therefore, the purpose of the study was 1) to explore perceptions about bilingual health professionals among key stakeholders and individuals impacted by health disparities 2) to identify essential characteristics of bilingual health specialists and 3) to provide recommendations for curriculum design, and experiential learning considerations necessary for education and training programs to prepare the next generation of bilingual health specialists.

Methods
A qualitative approach was taken using focus group data collection techniques to explore perceptions about bilingual health professionals, to identify essential characteristics of bilingual health specialists and to provide learning considerations. The research questions were the following: (1) What knowledge, attitudes, and beliefs do students and community health workers have about the needs of bilingual patients and clients? (2). What language and communication barriers do patients/clients experience when provided health related instructions or health education? and (3) What do employers in the field perceive to be the essential competencies of bilingual health professionals prepared by college/university preparatory programs?

Participants and site selection
Four focus groups were created with 22 participants. Institutional review board approved the study and a consent form was provided to all participants in the study so that they could understand the nature of the research and provide their signed consent. Following consent, four focus groups were divided by the nature of their involvement in their respective categories: 4 -employers, 3 -community health workers, 3students and 12 -patients. The demographics demonstrated that 77.3% (n=17) were female and 22.7% (n=5) male. The participants were between the ages of 30-65 years of age. The participants were predominately Latino/Hispanic 93.3% (n=14).
Initial contacts were made with agencies serving primarily lowincome minority patients (health agencies and medical clinics in the southernmost part of the US), through a snowball sampling technique that involved attaining participants through referrals based on years of networking and building relationships with local agencies. Community health workers and employers from the same agencies were also selected using the same sampling technique. Students were selected by open invitation via email and through class announcements. Flyers were distributed to all groups. Employers and community health workers were interviewed in their respective workplace. Students were interviewed on the university campus and patients were interviewed at their physician's clinic community gym.

Focus group process
Focus groups were conducted during the fall 2015. Each focus group was approximately 90 minutes long. To provide consistency, the same two researchers facilitated all groups. Standard procedures were employed for obtaining informed consent. All focus group interviews were conducted in English with the exception of the patient focus group, which was primarily conducted in Spanish. Seven open-ended guiding questions were used during the interview to discuss issues and concerns without prompting.

Data collection and analysis
The audio of each focus group was recorded and transcribed. To maintain transcription quality and standards, facilitators verified the accuracy of the transcripts by cross-checking them against the audio recordings of the interview. Deductive analysis was conducted to identify preliminary trends and a code template was created based on data themes. "Deductive reasoning is a theory testing process which commences with an established theory or generalization, and seeks to see if the theory applies to specific instances" [12]. In phase one of the data analysis, transcriptions and field notes were analyzed to find the overarching themes. In phase 2, the list of themes served as a coding template. The themes that were identified in the final phase of analysis were then summarized into tables and Figure 1 with participant quotes used to illustrate the themes as issues, barriers and recommendations.

Results
The focus groups revealed numerous themes related to the barriers and challenges regarding the health care of bilingual patients particularly Spanish speaking individuals. Four focus groups included: Community health workers (CHW), kinesiology/health students (KHS), bilingual patients (BP) and community health employers (CHE). Thus, the findings reveal the perspectives of each of the focus groups respectively and address the research questions for this study.

Community health workers (CHW)
RQ1 what knowledge, attitudes, and beliefs do students and community health workers have about the needs of bilingual patients and clients?
From the interviews conducted with community health workers, some of the health needs identified were poor nutrition education, obesity, language proficiency, diabetes, lack of community infrastructure, and financial resources. Many of the CHW stated that many of their patients get discouraged because of all the "red tape" (CHW focus interview) or difficulty navigating the health care system to address their needs. Coupled with difficulty navigating the health system, the CHW indicated that many of the patients have mentioned to them that they feel demeaned because they don't speak English. For example, a CHW stated "They get embarrassed when they don't understand instructions. Professionals can talk down to the patients. I don't trust them enough to provide them with more information after that" (CHW focus interview). Also from a CHW perspective "Medical professionals can be mean and demeaning to non-[English] speaking patients, which the patient will just leave" (CHW focus interview).
An interesting belief pointed out by CHWs is that the students who are studying health professional occupations are not being prepared as they should to meet the needs of culturally diverse populations. For example, translation as a need for many of the CHWs' patients and sensitivity with the patients was absent from the care provided by the student in the health professional field. Not only were students demonstrating this lack of knowledge for bilingual patients, a CHW who has years of experience working in a local state hospital stated "Non-Hispanic nurses would not be very receptive and [I] can tell they give a lower level of care because they just don't want to bother, they would say "its America they should learn to speak English" (CHW focused interview). The type of care provided by these future and current health professional results in discriminatory treatment and would more likely lead to the least quality care for these patients due their limited proficiency in English.

Kinesiology/health student (KHS)
The Kinesiology/Health (KHS) student as well indicated similar beliefs in reference to health needs and barriers to quality health care as CHWs. Moreover, the KHS state "Students are not prepared at all" and "Students will place the responsibility on the patient to know English" or "Will ask some to translate in the field" (KHS focused interview). They also assume that "[Spanish speaking] parents do not teach Spanish to their children due to the shame associated with it". Some of these assumptions are not comprehensively founded because of lack of information or course study for KHS students, but these important theoretical conceptualizations have been widely studied by many scholars and future professionals in other fields [9,13,14].
An important finding is that many of the KHS's have positive attitudes and beliefs of what quality health care should entail. For example, a KHS student stated in regards to the importance of being bilingual as a health professional "Yes, because you will not get the same cooperation, unless you can communicate. Patients would feel more comfortable, not be scared and because there will not always be a [need for a] translator". One student stated that she had an experience where the patient indicated that they didn't speak English but Chinese. She described what she experienced "[The] healthcare provider depended on the patient's daughter to translate. Translating instructions were different and the outcome was not optimal" (KHS focused interview). Finally, in reference to cultural competence, the KHS stated the belief that "You have to be sensitive" and "Need to know certain cultural traditions" (KHS focused interview) to better serve the needs of the patient. (Table 1) summarizes the main issues expressed by community health workers and students in terms of the needs and barriers to address health among minority individuals.

Focus Group Questions Typical Quotes
What are the health needs in Texas (South Texas)? "People lack nutrition education." "Obesity is an issue." "There is a lack of walkable areas, lighted sidewalk and parks." "People lack the financial resources for healthier food." "Diabetes" "Lack of education" What are the barriers and challenges faced by your patients/clients? "Navigating systems is challenging." "They get embarrassed when they don't understand instructions. Professionals can talk down to the patients. Don't trust them enough to provide them with more information after that." "They lack health insurance." "Language barriers" "Medical professionals can be mean and demeaning to non-speaking patients, which the patient will just leave." What knowledge, attitudes, and beliefs do students and community health workers have about the needs of bilingual patients and clients?
"Students are not prepared at all." "Students will place the responsibility on the patient to know English." "Will ask some to translate in the field." "Assumption that Hispanics can speak Spanish." Do you feel that being bilingual is important in working with bilingual patients and clients? Do you feel that being culturally competent is important in working with bilingual patients and clients?
"Yes, but parents do not teach Spanish to their children due to shame associated with it." "Yes, because you will not get the same cooperation, unless you can communicate" "Patients would feel more comfortable, not be scared." "Yes, because there will not always be a translator" "You have to be sensitive." "Need to know certain cultural traditions." Describe an experience where you worked with bilingual patients and clients. "Healthcare provider asked on patient's daughter to translate exam instructions. Daughter did not speak English very well. Outcome of medical test was not optimal." Table 1: Community health workers/students typical quotes.

Bilingual patients (BP)
RQ2 what language and communication barriers do patients/clients experience when provided health related instructions or health education?
The bilingual patients (BP) (who were at varying degrees of Spanish proficiency) indicated the following as their health needs in their local area. The discussion began with the topic of their children's' needs. Moreover, the mothers wanted for their children to grow up in a healthy environment and develop a healthy lifestyle for their future survival. Many of the patients were mothers of young children. Some of the challenges indicated included the lack of preventative care and urgent care for their children. Many stated "We lack access to places that promote healthy lifestyles (parks, education centers)" and "The cost of the medical services is high" (BPs focused interview).
In regards to language, the participants stated that they felt "There is no urgency to provide health treatment for Spanish Speakers". For example, one BP stated in Spanish "Aunque hablo los dos idiomas prefiero discutir mi concernimientos de salud en Español pero es difícil encontrar una persona bilingüe que puede asistirme aunque este en una región donde hay una gran población de Latinos o Hispanos. Even though I speak both languages, I prefer to discuss my health concerns in Spanish but it is difficult to find a person who is bilingual who can assist me, even though in this region where there is a large population of Latino o Hispanics" (BP focused interview). Another BP stated "Cuando pides una cita con un doctor que hable Español te cuelgan o te dejan esperando por mucho tiempo. When I ask for an appointment with the doctor and I speak to them Spanish, they hang up the phone or they leave you waiting a long time to be attended to" (BP focused interview). A BP stated "Existe una ausencia de profesionales bilingües en la salud en Tejas y la disposición de los doctores es que aprenda el idioma Inglés. There exists an absence of bilingual professionals in Health in Texas and the Doctor's [Health Professional] disposition is that you learn English". This is in light that learning a first language takes up to 10 years to establish and acquiring and learning a second language as well can take up to additionally 10 years as well [15][16][17]. In response to the health educators sent by the community health employers (CHE), a BP stated "Las personas de nutrición que mandan para educarnos no hablan el idioma y no podemos hacer preguntas y a veces nos llaman la atención cuando nos están enseñando. The people or dieticians that they send to educate us don't speak our language and we can ask questions and sometimes they call our attention [in a demeaning way] when they are teaching us" (BP focused interviews).
Health professionals are also described by the BP as seemingly difficult to understand or care using deficit approaches to working with BP. This is an interesting finding identified as a challenge because deficit perspectives are developed over time. Due to this deficit perspective, the BP finds it difficult to manage their health needs because they are unable to comprehend the treatment or preventative health suggestions presented by the health professionals or health educator. According to the BP, "When the bilingual health provider or presenter provides the opportunity to learn the information in either language nobody leaves with doubts and confusion" (BP focused interview).
Many of the BP indicated, for example, when they cook they can infuse healthier practices into their traditional dishes that they were raised with from their home country or culture. One BP stated "When they send someone who speaks the language [Spanish] like the representative from the food bank, I like it. Learning about how to eat has benefited our family because we know not to eat meat all week but  Table 2 summaries the main issues expressed by bilingual patients in regards to accessing preventative healthcare for themselves as well as for their children.

Focus Group Questions Typical Quotes
What are the health needs in Texas (South Texas)? What are the barriers and challenges faced by your patients/clients? "We don't have access to preventative care and urgent care particularly for our children." "We lack access to places that promote healthy lifestyles (parks, education centers)." "The cost of the medical services is high." What language and communication barriers do patients/clients experience when provided nutrition and health related instructions or education? Tell me about a typical time when you met with a nutrition and health educator to discuss a personal health related issue.
"Lack of importance regarding health care treatment." "There is no urgency to provide health treatment for Spanish speakers." What part of the instruction did you feel went well? What areas could be improved? Explain why? What difficulties have you encountered receiving nutrition and health related instructions?
"When the bilingual health provider or presenter provides the opportunity to learn the information in either language nobody leaves with doubts or confusion." What concerns do you have about your own personal health that you feel may not be properly communicated from a nutrition/health professional? Explain why?
"Difficult to manage health needs and comprehend treatment."

Community health employers (CHE)
RQ3) what do employers in the field perceive to be the essential competencies of bilingual health professionals prepared by college/ university preparatory programs?
Community Health Employers began the interviews by identifying the current needs of the population adjacent to their organization's location. An important health need presented by CHE was identification and management of diabetes. Each of the CHE primarily serve large populations of Latinos who are primarily Spanish speaking who identified that their great health need for their communities is diabetes.
However, CHE also indicated that language barriers existed for patients and they may encounter this in relation to their health education. CHE stated that to improve the language barrier, they try to offer Spanish translation services for their patients. One employer, a former medical doctor in his home country, stated that "Well I speak Spanish but I can't be with them all the time translating for every patient they see because I have things to do or some other staff member [to supervise]". Moreover, this employer indicated that he is unable to continuously translate for KHS's who are needing to complete their service learning projects or his employees who service their Spanish or bilingual patients. Therefore, employers also indicated their preference when hiring future health professionals. One employer stated that one of the competencies is hiring health professionals who were bilingual. This employer stated "Currently our job description for hiring a bilingual community health worker or professional is preferred; however, we will be moving towards it being required" (Interview Focus Group CHE). Moreover, when we have student interns, this same employer stated "Student interns not able to communicate with patients due to being only English speaking, it's hard because they don't obtain the same experience. Sometimes there is no one to translate for the students" (Interview Focus Group CHE).
In addition, as a bilingual, another competency CHE are interested in is the biliteracy skills of the health professional. The employer also stated when they have health education presentations at their organization "Patients at times not willing to stay and participate if the student presenting will not be able to speak Spanish" (Interview Focus Group CHE). Another CHE stated on this same topic "You know I just feel really bad because we tell them she's here [Student Nutrition or Health Educator] and our patients ask "habla en Español" No, [patients] van does she speak Spanish. No, oh and they [patients] leave. And the poor student didn't get the opportunity [and they (patients)] both missed out" (Interview Focus Group CHE).
Being bilingual assists with another competency identified by CHE. This competency is cultural competence. Another important finding from CHE was the need for cultural competence. Employers indicated that they are interested in hiring student health professionals who have the following qualities, "Important for future students to be sensitive, have compassion for the person and understand what the person may be going through especially if you have had a similar experience.
Willingness to establish a relationship, being open-minded, respectful; learn from experience and how you can use it after that" (Interview Focus Group CHE). Cultural proficiency is considered the ability to respond and assist individuals in culturally specific ways to addresses needs [18]. Table 3 summarizes the main issues expressed by community health employers in terms of the health needs and barriers among minority individuals and describes the competencies needed of a bilingual health professional.
What are the barriers and challenges faced by your patients/clients? "They lack transportation (public transportation, bus) etc." "There is a lack of infrastructure in the community (sidewalks, parks etc)." "Some people live in conditions with no electricity, potable water, paved roads, sewage and storm drainage." "They lack of access to medical services." "Lack of consistent attendance for specific services offered, for example, our ladies not consistently attending exercise class due to leaving to California or Mexico for certain months-they also have family obligations, attend ESL classes and job opportunities." What language and communication barriers do patients/clients experience when provided nutrition and health related instructions or education? "Language-"the whole aspect of communication is more of the issue, such as reading, writing difficulties, need to provide information in a meaningful wayculturally sensitive." "Spanish translation is offered at a much higher level of literacy." What is the role and responsibilities of a nutrition/health professional in your work setting and tell me about the process of hiring nutrition/health professional? "Currently our job description for hiring a bilingual community health worker or professional is preferred; however, we will be moving towards it being required." "Student interns not able to communicate with patients due to being only English speaking, it's hard because they don't obtain the same experience. Sometimes there is no one to translate for the students. Patients at times not willing to stay and participate if the student presenting will not be able to speak Spanish." What is the need for a bilingual nutrition/health professional?
"Yes, take learning courses about language, but not using medical jargon." "Writing pamphlets when it came to Spanish there was so many different terms." "Yes, because I can't help them all the way, I refer them to someone who knows Spanish." "Working with patients, it can be comforting to them if they know you speak Spanish".
"Providing a presentation in English is not as effectiveness with someone not able to speak Spanish, but need to have the best translator or best interpreter present while everyone else can wear earphones or equipment to interact in real time." What skills and/or competencies are required for a bilingual nutrition/health professional?
"Important for future students to be sensitive, have compassion for the person and understand what the person may be going through (esp. if you have had similar experience)." "Willingness to establish a relationship, being open minded, respectful, learn from experience and how you can use it after that." "Need for service learning and firsthand experience." "Approachable" "Friendly"

Discussion
Though there are a multitude of factors that influences a person's life such as the environment, eating habits, biological inherited traits and access to quality health care, Spanish-speaking patients might experience even greater challenges to maintain their health from a health professional that does not communicate in their primary language. Many participants in this study, from employers to bilingual patients, indicated their belief that the Spanish speaking patient is fearful of visiting their physician. Bilingual patients (BP) in this study indicated similar barriers to health care access that are well documented in the literature such as "longer wait times for physician visits, lack of transportation, high cost of services, lack of Spanish speaking providers, high cost of medical services and lack of limited health facilities" [3].
The BP also previously noted that "Existe una ausencia de profesionales bilingües en la salud en Tejas y la disposición de los doctores es que aprenda el idioma Ingles. There exists an absence of bilingual professionals in Health in Texas and the Doctor's [Health Professional] disposition is that you learn English". Moreover, Latinos, the largest growing ethnic minority in the US, are in need of comprehensive health care that affirms and acknowledges their language(s) and cultural knowledge. From the perspectives of all the participants in this study, this is still an unmet area.
To develop future health professionals that can meet the needs of patients, it is imperative that universities develop programs that infuse training in language proficiency and cultural competency. Future health professionals in this study indicated that they come with initial assumptions that need to be discussed and approached through pedagogical approaches inherent of a course of study. Each of the KHS's indicated the importance of having proficiency in the patients' native language and that through future coursework development this can be integrated in a course of studies that leads to the production of a bilingual health specialist. Moreover, a medical professional that is knowledgeable in medicine and health education that can provide this knowledge in multiple languages; bilingual or multilingual would be ideal. In summary, participant findings indicate the three overarching components that should be considered as part of a Bilingual Health Specialist Certification Program: 1) Language Proficiency 2) Cultural Competency and 3) Experiential Learning. Moreover, employers identified the following characteristics that a Bilingual Health Specialist should strive for in meeting the needs of patients/clients: (a) language proficiency in two languages (b) cultural sensitivity (c) compassion for the person (d) establish a rapport and build relationship (e) open mindedness (f) respectful of patients (g) approachable and friendly and (h) learning from experiential opportunities.

Limitations
A few limitations are associated with this study. Though participants were randomly selected and chose to participate, the sample size was relatively small and may be difficult to generalize. Lastly, the study did not include the perspective of a large number of health professionals, which could have provided valuable insights to the barriers and challenges faced in the workforce.

Future Implications for Study
A goal of this study, although preliminary in scope, will be to use focus group perspectives to design a health professional curriculumcourse that leads to a Bilingual Health Specialist Certification Program. First, focus group findings noted that learning the language, such as Spanish, should be part of the instruction and curriculum design of a certification program; however, it should include cultural competency training to create a holistic approach and a more knowledgeable and skilled future health professional.
Secondly, the need for service learning and firsthand experience was a common theme among CHE and CHW in the field. Further, researchers could use the findings of this study to explore the need for a Multilingual Health Specialist as the population grows and becomes more diverse.