Communication Barriers in Hispanic Patients With Rheumatoid Arthritis

Effective communication between patients and their physicians is the foundation of quality care. A positive patient-physician relationship can be a source of motivation, reassurance, and support,¹ and the implementation of a shared-decision making process as part of a productive patient-physician relationship promotes a wider array of treatment strategies.¹ The facilitation of a shared-decision making approach by physicians is imperative among patients with rheumatoid arthritis (RA) from underserved backgrounds, especially those at high risk for poor outcomes.²

Social determinants of health have been suggested to affect patients with rheumatoid arthritis (RA).³ For instance, Hispanic patients present to physicians later and with more severe disease compared with White patients.⁴ Although some of these associations have been studied, the reasons for these disparities are not yet widely understood.

In a previous study, the researchers had 2 main objectives: to examine patient-physician concordance within a Spanish-language digital patient-provider questionnaire (PPQ), and to determine if this PPQ could serve as a proxy for patient impressions of a prospective clinical study.⁵

The study findings were notable in that the questionnaire responses from both patients and physicians showed high concordance and positivity regarding their interactions. This, the researchers suggested, was the result of social desirability bias, or the tendency to respond in a way that the respondent knows will be viewed favorably.

To further understand this research, we spoke with lead study author, Daniel Hernandez, MD. Dr Hernandez is the Director of Medical Affairs and Hispanic Outreach at CreakyJoints, part of the Global Healthy Living Foundation.

How can physicians help patients with RA better understand their disease and the available treatment options?

Dr Hernandez: Being diagnosed with a chronic disease, like arthritis, can be overwhelming for a patient, particularly at the beginning when there is so much to learn and understand about trialing medications, recommended exercise and diet plans, and other lifestyle changes. Therefore, physicians have an obligation to ensure that their patients — regardless of education level — understand why they may be experiencing symptoms and their management strategies. They should use easy-to-understand language and allow enough time in appointments for patients to ask questions. 

We often recommend that patients bring a family member or friend with them to their appointments so that 2 people can hear and digest the information, or so that a care partner can remind the patient of questions they meant to ask.

We also suggest that rheumatologists refer their patients to our websites (available in English and Spanish) where we have an immense amount of educational resources that are meant to guide the newly diagnosed as well as the experienced arthritis patient through living with the condition. Notably, we are working with the BMS Foundation to introduce a Spanish-language RA guide that is meant to teach the basics of living with RA and improving the discussions these patients are having with their rheumatologists. We are studying how people interact with and understand the website so that we can evolve it to be a valuable tool to this Spanish-speaking population, which is drastically underserved when it comes to in-language health education.

What steps can be taken to ensure physicians acknowledge and understand patient concerns?

Dr Hernandez: Rheumatologists should work with their patients to set pragmatic goals that they can work toward as a team. This also ensures that everyone understands symptoms and treatment options. Importantly, if a patient does not use English as their first language, the practice should make efforts to provide comprehensive translation services to ensure that vital information is not misunderstood.

In your experience, do cultural norms inform when patients seek care? For instance, do older adult Hispanic patients typically view the effects of RA and other joint issues as a normal part of aging rather than the result of a chronic disease that requires treatment?

Dr Hernandez: While health disparities can be directly linked to systemic racial, gender, or ethnic discrimination, it is also true that cultural norms inform how different patient populations seek out and use medical services. As you mentioned, the Hispanic community tends to wait much longer to seek care, often leading to higher disease activity and severity. 

However, it is not all bad news. Thanks to these cultural norms, there are some aspects that can be leveraged for better outcomes in these patients. We are currently focused on not only creating an outreach strategy for patients, but also encouraging family members and the Hispanic community to learn more about chronic diseases such as RA to motivate and support those who present with symptoms to seek diagnosis and early treatment. 

In this study, social desirability bias is cited as the major reason for the discrepancy between actual outcomes in Hispanic patients with RA and the highly positive survey responses. Why do you think patients may sometimes feel the need to over-report positive physician interactions over negative interactions?

Dr Hernandez: What might be happening is that patients and physicians are setting goals that are not attainable and are therefore ignored, or they are not setting goals at all, which causes an over-reporting of positive responses. The results from this study surprised us and we are closely looking into what actually causes this agreement between providers and patients.

It was concluded that the PPQ may not be a suitable proxy for patient-reported outcomes. What measures do you think could work for this patient population?

Dr Hernandez: Through our partnership with the BMS Foundation, we are testing a Spanish-language website that will help us to understand better how newly diagnosed patients who speak Spanish as their primary language interact with and understand introductory educational material about RA. This may suggest how we develop a measure that is specific to this patient population. Certainly, it is an area of research we want to explore in the future to improve health outcomes.

While we are working specifically with the Hispanic community in the US, it is worth pointing out that there are other large, non-English speaking communities in the US that would also benefit from culturally intelligent, in-language tools. It is an exciting time for research as it progresses beyond what had been the baseline for so long. 

Would you expect these study results to be generalizable to other patient populations?

Dr Hernandez: There are certainly parts of this study, especially the digital guide, which will be interesting to test and iterate on different disease states and patient populations, but we do not know if they are applicable to others until we try. It is important that we consider how language, cultural norms, and attitudes about medicine all contribute to how people from diverse communities interact with health care so that we can personalize medicine to each person’s experience. Our research and this study is specific to the US (and Puerto Rican) Hispanic community, which we recognize is incredibly heterogenetic when you consider a family’s heritage over time, so this is the first step in a vast unexplored space. We are definitely looking forward to the insights we gain as we continue studying and applying our learning into educational content for this community, and hopefully in time, to many others.  

References

1. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring;10(1):38-43. PMID: 21603354; PMCID: PMC3096184.

2. Barton JL, Décary S. New galaxies in the universe of shared decision-making and rheumatoid arthritis. Curr Opin Rheumatol. 2020 May;32(3):273-278. doi:10.1097/BOR.0000000000000699.

3. Safiri S, Kolahi AA, Hoy D, et al. Global, regional and national burden of rheumatoid arthritis 1990–2017: a systematic analysis of the Global Burden of Disease study 2017. Annals of the Rheumatic Diseases. 2019;78:1463-1471.

4. Riad M, Dunham DP, Chua JR, et al. Health disparities among hispanics with rheumatoid arthritis: delay in presentation to rheumatologists contributes to later diagnosis and treatment. J Clin Rheumatol. 2020 Oct;26(7):279-284. doi:10.1097/RHU.0000000000001085.

5. Hernandez D, Bravo J, Maya JJ, et al. Do patient and physician assessments of a health care visit match for hispanic/latinx patients with rheumatoid arthritis in the United States and Puerto Rico? Annals of the Rheumatic Diseases. 2022;81:1891.