Enhancing Language Access: A Pilot Study to Examine the Importance of Understanding the Language Preference and Acculturalization Level in the ...
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MILITARY MEDICINE, 186, S1:572, 2021
Enhancing Language Access: A Pilot Study to Examine the
Importance of Understanding the Language Preference and
Acculturalization Level in the Provision of Healthcare for
Hispanics Veterans With Traumatic Brain Injury
Irma L. Molina-Vicenty, MD*,‡,§ ; Isabel C. Borrás-Fernandez, MD* ; Charlene Pope, PhD† ;
Boyd Davis, PhD† ; Martha Alemán-Del Toro, SLPD* ; Irma Maldonado-Sánchez, SLP, CCC* ;
Lillian Arroyo, MD* ; Gerardo Jovet-Toledo, MS* ; Clara E. Dismuke, PhD† ; Alexandra Roque, MD* ;
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Yahaira Díaz, MD* ; Milagros Resto, MSN, RN† ; Alexandra Rincones, BS*,∥ ; Cecilia Soler-Llompart,
BS*,‡ ; Neishaliz-Díaz Acevedo, Undergraduate*,‡ ; Gabriela S. Betances-Arroyo, Undergraduate*,‡
ABSTRACT
Introduction:
The purpose of this pilot study was to obtain preliminary data to culturally adapt the Veteran Health Administration Trau-
matic Brain Injury (TBI) assessment instruments for the Hispanic Veteran population. A qualitative analysis explored
the cognitive processes used by Hispanic Veterans whose preferred language was Spanish to understand a specific set of
screening questions within the Initial TBI Screening, the Comprehensive TBI Evaluation, the Neurobehavioral Symptom
Inventory (NSI), and the La Trobe Communication Questionnaire (LTCQ).
Materials and Methods:
A certified translator completed translation of the TBI instruments, an expert panel resolved inadequate expressions of
the translations, and translated instruments were back translated. Male and female Hispanic Veterans with a positive
TBI screening underwent a recorded administration of the TBI instruments, including LTCQ, followed by systematic
debriefing using semi-structured cognitive interviews which then underwent qualitative analysis. The Marin’s Short
Acculturation Scale for Hispanics, the Tropp’s Psychological Acculturation Scale, the English-Language Proficiency
Test Series, and the TBI Demographic and Language Preference interview were administered to the subjects.
Results:
Fifteen subjects were enrolled for the TBI instruments intervention; 11 of them completed all the additional procedures.
The TBI instruments intervention seemed to produce very few variations, indicating adequate cultural equivalence.
However, the LTCQ instrument showed suggested cultural variations, but did not suggest a lack of understanding or
misinterpretation. The population studied displayed preferential connectedness to the Hispanic/Latino culture and to
the Spanish language. The LTCQ indicated that subjects perceived themselves as having a worse execution in terms
of communication skills than historical control and TBI groups. English-Language Proficiency Test Series found that
most of the subject population did not demonstrate mastery of grade-appropriate basic social and academic vocabulary
in English.
Conclusion:
Current findings highlight the importance of using linguistically and culturally appropriate materials upon evaluating
Hispanic Veterans with a suspected TBI who have Spanish as their primary or preferred language.
INTRODUCTION
* ACOS/Research and Development Service, Nuclear Medicine & Molec- Recovery of function from Traumatic Brain Injury (TBI) is of
ular Imaging Service, Physical Medicine & Rehabilitation Service, Audiol- great importance to patients and families. It is unclear how
ogy and Speech Pathology Service, and Psychiatry Service, VA Caribbean providing health services in English, without taking into con-
Healthcare System, San Juan, PR 00921, USA sideration well-adapted linguistic and cultural interventions,
† Charleston Health Equity and Rural Outreach Innovation Center, Nurs-
impacts the recovery trajectory of Veteran patients with TBI
ing and Patient Care Services, Ralph H. Johnson VA Medical Center,
Charleston, SC 29401, USA
‡ Department of Molecular Biology, University of Puerto Rico, Rio
Piedras Campus, San Juan, PR 00931, USA
§ Radiological Sciences Department, University of Puerto Rico, Medical
The contents of this article do not represent the views of the VA Caribbean
Healthcare System, the Department of Veterans Affairs or the United States
Sciences Campus, San Juan, PR 00921, USA Government.
∥ Department of Biomedical Sciences, San Juan Bautista School of
doi:10.1093/milmed/usaa256
Medicine, Caguas, PR 00725, USA Published by Oxford University Press on behalf of the Association of
Presented as an oral presentation at the 2019 Military Health System Military Surgeons of the United States 2021. This work is written by (a) US
Research Symposium, Kissimmee, FL; (MHSRS-19-00419). Government employee(s) and is in the public domain in the US.
572 MILITARY MEDICINE, Vol. 186, January/February Supplement 2021Enhancing Language Access in Veterans with TBI
whose primary language is Spanish. It is the second pre- tools could also extend access, accuracy, and acceptability for
dominant language in the USA; almost 38 million people other Hispanic Veterans whose primary language is Spanish.
over age of 5 years speak Spanish at home.1 Speaking a lan-
guage other than English at home has been associated with METHODS
disparities in receiving recommended health services, though The target population was Hispanic male and female Veter-
the mechanisms for those disparities are not clear.2 ans with a positive TBI screening, referred to the Veterans
Before this study, the official instruments used to assess Affairs Caribbean Healthcare System (VACHS) Polytrauma
and confirm TBI diagnosis in the Veteran Health Administra- Clinic Level II, who were ≥21 years of age, Operation Iraqi
tion (VHA) had not been officially translated or validated in Freedom/Operation Enduring Freedom/Operation New Dawn
Spanish. The process of Veteran TBI screening did not con- (OIF/OEF/OND) returning-soldiers, with Spanish as their
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sider that people whose primary language is not English may preferred language as documented in the subject’s electronic
turn to their first language in conditions of high stress and medical record or verbally indicated by the subject in person,
injury. Because of the lack of official translated or validated that could provide informed consent. Subjects that were ≤21
VHA instruments in Spanish, physicians in Puerto Rico trans- years of age, not categorized as an OIF/OEF/OND returning
lated the instruments or tools in the midst of screening, a prac- soldiers, did not prefer to receive care in the Spanish language,
tice which may have interfered with health care, prolonged and that were not able to provide informed consent were
visits, possibly altered responses, and potentially contributed excluded from participating. The instruments that underwent
to delays in access. Subtle differences in social cognition and Spanish translations were the VHA Initial TBI Screening, the
communication may have been missed or prompted. Access Neurobehavioral Symptoms Inventory (NSI), and the VHA
to TBI screening tools that are linguistically and culturally CTBIE. The translations were done using the World Health
appropriate may improve care. Organization guidelines and the recommended guideline of
This study intended to address the problem that the Ini- Sousa and Rojjanasrirat for translation, adaptation and vali-
tial TBI screening and the Comprehensive TBI Evaluation dation of screening tools for cross-cultural purposes in health-
(CTBIE) in the Spanish language were not accessible at the care.3,4 A previously adapted Spanish version of the La Trobe
VHA for the Hispanic Veteran population with a Spanish lan- Communication Questionnaire (LTCQ) was added to the anal-
guage preference who may have limited English proficiency. ysis to adapt it to the cultural context of Puerto Rico. The
The Initial TBI Screening instrument helps identify Veterans LTCQ was also compared to the original English version.5
who may be suffering from TBI. It consists of a four questions The LTCQ is a self-administered 30-item questionnaire that
screen that identifies Veterans who were exposed to events assesses perceived communication quality in TBI survivors.
that increase the risk of TBI and who experience symptoms Subjects respond the 30-item survey using a four-point scale
that can be related to that specific event(s). The patient must that ranges from 1 to 4 depending on the frequency with which
answer “yes” to at least one of the four questions to have a they experience a given symptom or behavior (1 = never or
positive TBI screening. A positive screening does not diag- rarely and 4 = usually or always). Respondents also select
nose TBI; it only indicates the need for further evaluation whether such symptom or behavior has occurred more, less
for possible TBI. Veterans with a positive TBI screening are or hasn’t changed since the lesion.
offered further evaluation using the CTBIE performed by a The officially translated instruments and newly adapted
specialty provider who can really determine whether the Vet- LTCQ were tested in the target population using a represen-
eran has suffered or not a TBI. The CTBIE is an instrument tative sample of the overall distribution of TBI patients in
that includes the origin or etiology of the patient’s injury, VACHS, taking into consideration gender, age, and socioeco-
assessment for neurobehavioral symptoms using the Neu- nomic status. The VHA TBI instruments (Initial TBI Screen-
robehavioral Symptom Inventory (NSI), a targeted physical ing, NSI, and CTBIE) and the LTCQ, along with the additional
examination, and a follow up treatment plan. For each item, profile assessments (Marin’s Short Acculturation Scale for
the patient chooses one option from the multiple choices. Hispanics (Marin’s SASH), Tropp’s Psychological Accultur-
The instrument includes very few open questions. The NSI ation Scale (PAS), English-Language Proficiency Test Series
included in the CTBIE is a 22-question inventory that mea- (LPTS), and TBI Demographic and Language Preference),
sures postconcussive symptoms. The NSI respondents rate were administered to the subjects in two separate visits. Fif-
the degree of symptom severity on a 5-point scale that ranges teen (n = 15) Hispanic Veterans with suspected TBI under-
from 0 to 4 (0 = none; meaning that the symptom is rarely went Part 1, a recorded administration of the TBI instru-
ever present/not a problem at all and 4 = very severe; meaning ments, and only 11 of those 15 underwent Part 2, a recorded
that the symptom is almost always present and impairs per- administration of the LTCQ and the additional profile assess-
formance at work, school, or home; the individual probably ments (two subjects moved to the USA before scheduling
cannot function without some kind of help). Part 2 and two (2) subjects were lost for follow up). The
The goal of this study was to produce linguistically and administrations of the TBI instruments and LTCQ (pretests)
culturally appropriate TBI screening and evaluation tools for were followed by systematic debriefing, conducted by physi-
Puerto Rican Hispanic Veterans. Potential adaptation of these cians, using semi-structured cognitive interviews (debriefing,
MILITARY MEDICINE, Vol. 186, January/February Supplement 2021 573Enhancing Language Access in Veterans with TBI
TABLE I. Description of the Acculturation Tests Used in This Study
Instrument Description Score
MARIN—Short Acculturation Scale A short (12 item) acculturation scale for Hispanics that Respondents answer the 12 items
for Hispanics (SASH) English evaluates language and social preferences. using a 5-point scale. For language
preferences, 1 = Only Spanish,
MARIN—Short Acculturation Scale 2 = Spanish better than English,
for Hispanics (SASH) Spanish 3 = Both Equally, 4 = English
better than Spanish, and 5 = Only
English.
For social preferences, 1 = All
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Spanish/Hispanics, 2 = More
Hispanics than Non-Hispanics,
3 = About Half & Half, 4 More
non-Hispanic than Hispanics, and
5 = All Non-Hispanics
An average score is calculated.
Average 1-2.5 = Connectedness
to Spanish or to Hispanic Latino,
2.5-4 = Same connectedness
to both languages or Bicul-
tural, Spanish and English, and
4-5 = Connectedness to English or
Connectedness to Anglos
TROPP Psychological Acculturation Consists of 10 items regarding the individuals’ psychological The subject answers the 10 items
Scale (PAS) English) responses to different cultural contexts. It emphasizes on the with a scale that ranges from 1 to 9
psychological aspects of acculturation rather than behavioral (1 = only with Hispanics/Latinos;
TROPP Psychological Acculturation or “attitudinal manifestations of acculturation.” Studies 5 = with Hispanics/Latinos and
Scale (PAS) (Spanish) suggest that this instrument can be a useful in understanding Anglos (Americans); 9 = only with
the psychological impact of a subject’s exposure to different Anglos (Americans)).
cultures. An average score is calculated.
Average 1-2-3 = Connectedness
to Hispanic Latino,
4-5-6 = Bicultural, and
7-8-9 = Connectedness to Anglos
SASH - Short Acculturation Scale for Hispanics
PAS - Psychological Acculturation Scale
*MARIN and TROPP are the names of the instrument creators*
re-test, respondents’ feedback assessment). In the debriefing Investigators conducted additional assessments to supple-
portion, subjects were asked the following: what they thought ment the validated instruments and have a better profile of
the question/item was asking, whether they could repeat the the target population in terms of English proficiency, accul-
question/item in their own words, what came into their minds turalization, and sociodemographic analysis. The English-
when they heard a particular phrase or term used in the ques- LPTS was administered by the Speech Pathologist to assess
tion/item, and how they chose their answer. For re-testing, the English language proficiency level of the subjects. This
the Initial TBI Screening, CTBIE, NSI, and LTCQ were test assesses English language proficiency in the areas of
re-administered immediately after the debriefing session to reading, writing, listening, and speaking. The administrator
explore if any differences arose between the participant’s instructed the participant to choose the answer they thought
understanding of the items before and after discussing the was correct based on the vocabulary word or the definition
details of each with the research staff during the debrief- that they were given (in English). They were later asked to
ing. In the participant’s feedback, the respondents were asked verbally answer a series of questions to the administrator to
if any of the words were not understood, unacceptable, or further assess their English proficiency. The administrator
offensive. When alternative words or expressions existed graded them using a 6-point scale that ranges from 0 to 5.
for one item or expression, the respondent was asked to The two self-administered acculturalization instruments, the
choose which of the alternatives conformed better to their Tropp’s PAS and the Marin’s SASH, were administered to
usual language. The cognitive interviews provided feedback evaluate the subject’s level of psychological and linguistic
from participants about what they were thinking and feeling acculturalization, respectively: see Table I. Selected demo-
while they were answering the questions, and elicited insight graphic data and the subject’s preferred language were exam-
about the words or phrases that might trigger inferences or ined using the Demographic and Language Preference Data
reactions. interview.
574 MILITARY MEDICINE, Vol. 186, January/February Supplement 2021Enhancing Language Access in Veterans with TBI
A qualitative analysis explored the cognitive processes TABLE II. Sociodemographic Characteristics of Veterans that
Hispanic Veterans used to understand a specific set of Underwent Additional Acculturation, Language Proficiency, and
screening questions within the Initial TBI Screening, the Language Preference Assessment (N = 11). (OIF = Operation Iraqi
CTBIE and the NSI (included in the CTBIE) resulting from Freedom, OEF = Operation Enduring Freedom)
the translation from English to Spanish, given the specific n %
language and cultural context of Puerto Rico. This analysis
was also applied to a Spanish version of the LTCQ. Gender
Male 10 90.9
Quantitative data analysis used descriptive statistics where
Female 1 9.1
the continuous and categorical variables were summarized Age
using the mean, standard deviation and proportions. Signif- 21-41 6 54.5
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icant statistical evaluation was evaluated and a significance 42-61 5 45.5
level of 0.05 was used for all statistical analyses. Distribution 62-81 0 0.0
81+ 0 0.0
was examined by t-test, analysis of variance, and correla-
Marital Status
tion analyses. The pretest and re-test results of the Initial Single 1 9.1
TBI Screening, CTBIE and LTCQ were compared. Paired t Married 5 45.5
and McNemar tests were used in this statistical analysis. For Divorced 5 45.5
the LTCQ, a per-item and global score assessment were both Education
Some college years 3 27.3
performed.
Associate’s 3 27.3
This study was revised and approved by the VACHS Insti- Bachelor’s 4 36.4
tutional Review Board and Research and Development Com- Postgrad 1 9.1
mittee at San Juan, Puerto Rico. There are no conflicts of Employment (can chose more than 1)
interest of any member of the research team. Full-time 3 27.3
Student 2 18.2
Unemployed 4 36.4
RESULTS Disability 3 27.3
Fifteen subjects were enrolled for the VHA TBI instruments Retired 1 9.1
and 11 of them completed all the other additional procedures Annual Income
including the LTCQ, the Marin’s SASH, the PAS, the LPTS, 0.05). In the NSI part of item assessment, a difference was observed in the “habla
the CTBIE questionnaire, differences were observed in only demasiado rápido”/speak too quickly item (p = 0.025).
4 of the 22 symptomatology items, specifically, “sensibil- The panel of experts’ review confirmed that the trans-
idad al ruido”/sensitivity to noise (p = 0.009); “pérdida o lated and original versions achieved semantic, idiomatic,
aumento de apetito”/loss of appetite or increase of appetite experiential, and conceptual equivalence. The qualitative
(p = 0.019); “Lentitud al pensar, dificultad para organizarse, analysis used discourse analysis incorporating techniques
no puedo terminar las cosas”/Slowed thinking, difficulty get- emphasizing social factors as opposed to focusing on gram-
ting organized, can’t finish things (p = 0.026); and “poca mar, to examine interactions between the Veterans and inter-
tolerancia a la frustración, sentirse abrumado por las cosas viewers.6 Even with the limited sample size, responses
fácilmente”/Poor frustration tolerance, feeling easily over- were fairly consistent and patterns evident. Most responses
whelmed by things (p = 0.029). Finally, no differences were appeared to be equivalent in content between the English
MILITARY MEDICINE, Vol. 186, January/February Supplement 2021 575Enhancing Language Access in Veterans with TBI
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FIGURE 1. The Psychological Acculturation Scale (PAS) showed that 5 subjects were bicultural, 5 were connected only to Hispanic/Latino culture, and 1
was connected to Anglo culture.
and Spanish versions. This study used the concept of target- were more likely to repeat what the interviewer said during
oriented equivalence that views the source document as the the cognitive interview explorations. Prompted by more open-
departure point, while focusing on the cultural and contextual ended cues, Veterans produced more narrative descriptions
factors in the communication process and end results.7 of their experiences in combat or the noncombat situations
Particular phrases were suggestive of cultural variation, that produced their TBI. As an example, one Veteran reported
though they should not create difficulty in use of the headaches and pressure in his ear on the TBI Initial screening
translations. The following examples highlight words or tool and then described when he got the TBI from a rocket
phrases of interest. For the LTCQ, the phrase “empty words” that landed nearby and his Land Rover turned over in a ditch;
in Question #2 elicited responses that it might mean pauses though he hit his head, he did not lose consciousness. The
or repetition of what the interviewer said. The concept varies demographic prompts elicit that he lives with someone, works
from the original. This phrase also appears to differ with as a mailman, considers himself single, has some university,
other Veterans in the sample. A professional Spanish lan- but is a full-time worker. Most other Veterans responded with
guage interpreter from Pacific Interpreters agreed that the similar narratives.
phrase “empty words” may be less meaningful in Spanish.8 On average, the LTCQ score was 72, suggesting that sub-
When Question #10 asked “Hesitate, pause and/or repeat jects perceive their communication skills to be worse than that
him/herself?”, it prompted reference to time rather than hes- of historical controls (48.51) and other TBI groups (51.89).9
itation. The word “hesitate” prompted variations from Veter- As measured by the LPTS, seven (n = 7; 64%) of the sub-
ans, though their concept, “Do I take time to express what jects did not demonstrate complete mastery of basic social and
I want to say?”, is linguistically equivalent. Question #12’s academic vocabulary in the English language.
query about “Get side-tracked by irrelevant parts of con- Cultural connectedness was assessed using the PAS scale
versations?” produced a response of “Do I get distracted?” (Fig. 1). The same proportion (n = 5; 45.5%) was observed
The word “side-tracked” produced hesitation in Veterans, but for connectedness only to Hispanic/Latino culture and bicul-
the word “distracted” is in the dictionary definition, so can tural connectedness. Only one subject reported connectedness
be considered equivalent. Question #16 “Make a few false to the Anglo culture. Marin’s SASH scale was used to further
starts before getting his/her message across?” produced the explore cultural connectedness, as well as language connect-
response “Do I pause before I express what I want to say?” edness (Fig. 2). The observed results of the Marin’s SASH
as a variation of the “false start” concept. The intent is simi- scale suggest that six (n = 6; 54.5%) were bicultural, whereas
lar. Question #29 asked “Lose track of conversations in noisy five (n = 5; 45.5%) were connected only to Hispanic/Latino
places?”: the Veteran responded: “Do I forget what I’m talk- culture. In terms of language, seven (n = 7; 63.6%) were con-
ing about in noisy places?” The variation between “losing nected to both English and Spanish language and four (n = 4;
track” versus “forgetting” may be either linguistic or cultural. 36.4%) were connected only to Spanish language. No subject
In contrast, the Initial TBI Screening and the CTBIE reported being connected exclusively to either Anglo culture
(includes NSI) produced fewer variations because Veterans or English language.
576 MILITARY MEDICINE, Vol. 186, January/February Supplement 2021Enhancing Language Access in Veterans with TBI
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FIGURE 2. Marin’s Short Acculturation Scale for Hispanics (Marin’s SASH) indicated that 7 subjects showed connectedness to both languages, 4 to Spanish
only and none to English only. It also showed that 6 subjects were bicultural, 5 were connected only to Hispanic/Latino culture, and none were connected
only to Anglo culture.
Instruction manuals consisting of the validated Spanish described in the LTCQ findings should not affect the use
TBI assessment were developed for VHA nationwide use. of the Spanish translation in clinical practice, though the
These instruments may now be available for the first time small sample size makes it difficult to draw broader or more
to each Veteran Healthcare System nationwide. With the generalizable inferences. The specific phrases empty words,
manuals, the TBI screening and evaluation process may not side-tracked, false start, and losing track suggested cultural
only be standardized amongst Spanish-speaking populations variations that might benefit from confirmation during ini-
within the VHA, but also simplified because of the widespread tial use of the LTCQ translation, however, did not suggest
availability of these assessments. a lack of understanding or misinterpretation. The Initial TBI
Screening and CTBIE (includes NSI) seemed to produce
DISCUSSION fewer variations. The absence of major differences between
The purpose of this study was to produce linguistically and the pretest and the re-test results for the Initial TBI Screening,
culturally appropriate VHA Initial TBI screening and VHA CTBIE, and LTCQ was indicative of a clear understanding of
CTBIE for Hispanic Veterans. The project also evaluated the items as initially presented to the subjects.
the subjects’ language preference and level of psychologi- The average score of 72 for the LTCQ indicated that the
cal and linguistic acculturalization. The research team was subjects saw themselves having fewer communication skills
able to produce Spanish versions of the Initial TBI Screening, than historical control and TBI groups. According to the LPTS
CTBIE, NSI, and LTCQ with adequate cultural equivalence results, most of the subject population did not demonstrate
for the Puerto Rico Veteran population. complete mastery of grade-appropriate basic social and aca-
As the Agency for Healthcare Research and Quality rec- demic vocabulary in the English language. As anticipated,
ommends, the translations were examined for linguistic and the outcome of Marin’s SASH revealed that the participants
cultural relevance in assessing variations and communicative with a possible mild TBI showed a connectedness to both
equivalence with similarly expressed or understood mean- languages (English and Spanish) or to the Spanish language
ings.10 This type of evaluation differs from the more struc- alone; however, none of the subjects showed connectedness
tured process for the initial translation, which often involves to the English language only. The results of both the PAS
multiple translators in forward and back translations and and Marin’s SASH showed that all subjects were either con-
quantitative ratings.11 The identification of most variations nected to both Hispanic/Latino and Anglo cultures or were
MILITARY MEDICINE, Vol. 186, January/February Supplement 2021 577Enhancing Language Access in Veterans with TBI
connected only to the Hispanic/Latino culture; however, none of Connected Care. Ultimately, the data collected supports
of the subjects showed exclusive connectedness to the Anglo evaluation of health disparities related to TBI care in future
culture. As predicted, assessment of the representative sam- studies.
ple of Puerto Rican Hispanic Veterans with a possible TBI
revealed that their language of preference is Spanish. ACKNOWLEDGMENTS
The authors acknowledge the sample size as a limitation We thank the contribution of the VACHS Telehealth Program, the VACHS
in this preliminary pilot, precluding analysis for internal con- Medical Media Production Service, Sergio Romero, PhD as member of the
expert panel, Denisse V Santiago, PT DPT CBIS who referred patients for this
sistency and construct validity. Future studies should assess
research, and our previous research assistants Maria Frontera, BS, Gerardo
these parameters. In addition, the study considered only Cintrón, BS, Pedro López, BS, and Joyce Hernández Maldonado1, BS.
the cultural context of Puerto Rico Veterans. The Veteran
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Hispanic population is diverse and shows different cultural FUNDING
backgrounds, economic profiles, health literacy levels, and This material is based upon work supported by the Charleston Health Equity
demographics. It is unclear at this moment if the results of this and Rural Outreach Innovation Center (HEROIC) at Charleston, SC, with
study can be generalized to Hispanic Veterans of other origins. resources and the use of facilities at the VA Caribbean Healthcare System at
Therefore, the investigators will expand the research project San Juan, PR. The grant number is CIN 13-3-418.
to Hispanic Veterans of other ethnic origins by establishing
partnerships with VA sites in California, Florida and Texas. REFERENCES
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