Baig AA, Locklin CA, Foley E, et al. The association of English ability and glycemic control among Latinos with diabetes. Ethn Dis 2014 Winter;24:28–34.
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Objective. To determine if there is an association between self-reported English language ability and glycemic control in Latinos with type 2 diabetes.
Design. Descriptive correlational study using data from a larger cross-sectional study.
Setting and participants. 167 adults with diabetes who self-identified as Latino or Hispanic recruited at clinics in the Chicago area from May 2004 to May 2006. The dataset was collected using face-to-face interviews with diabetic patients aged ≥ 18 years. All participants attended clinics affiliated with an academic medical center or physician offices affiliated with a suburban hospital. Patients with type 1 diabetes and those with < 17 points on the Mini-Mental State Examination were excluded. English speaking ability was categorized as speaking English “not at all,” “not well,” “well,” or “very well” based on patient self-report. A multivariable logistic regression model was used to examine the predictive relationship between English language skills and HbA1c levels, with covariates selected if they were significantly correlated with English language ability. The final regression model accounted for age, sex, education, annual income, health insurance status, duration of diabetes, birth in the United States, and years in the United States.
Main outcome measure. HbA1c ≥ 7.0% as captured by chart review.
Main results. Of the 167 patients, 38% reported speaking English very well, 21% reported speaking well, 26% reported speaking not very well, and 14% did not speak English at all. Reflecting immigration-sensitive patterns, patients who spoke English very well were younger and more likely to have graduated high school and have an annual income over $25,000 per year. Comorbidities and complications did not differ by English speaking ability except for diabetic eye disease, which was was more prevalent among those who did not speak English at all (42%, p = 0.04). Whether speaking ability was treated as a continuous or dichotomous variable, HbA1c levels formed a U-shaped curve: those who spoke English very well (odds ratio [OR] 2.32, 95% CI, 1.00–5.41) or not at all (OR 4.11, 95% CI 1.35–12.54) had higher odds of having an elevated HbA1c than those who spoke English well, although this was only statistically significant for those who spoke no English. In adjusted analyses, the U-shaped curve persisted with the highest odds among those who spoke English very well (OR 3.20, 95% CI 1.05–9.79) or not at all (OR 4.95, 95% CI 1.29–18.92).
Conclusion. The relationship between English speaking ability and diabetes management is more complex than previously described. Interventions aimed at improving diabetes outcomes may need to be tailored to specific subgroups within the Latino population.
Immigrant health is complex and language is an understudied factor in health transitions of those who migrate for new lives or temporary work. For Latinos, migration abroad was once thought to improve health, but a recent systematic review by Teruya et al  suggests that the migration experience has a wide variety of effects on health, many of which can be negative.
The notion that English fluency confers health care benefits is questionable, as the authors state. Those unfamiliar with the acculturation literature might think that English speaking ability is a good marker of acculturation, but recent research on the subject suggests otherwise. Acculturation is a complex phenomenon that cannot be measured or gauged by a single variable [2–5]. Among the many factors influencing acculturation, the migration experience and country of origin will play a major role in acculturation and how it occurs in the arrival country. Health care providers seeking to understand the complexity of acculturation better to improve care for their immigrant patients would benefit from examining the extensive social science literature on the subject. The results of this study suggest that providers should not take for granted someone’s English speaking ability as a marker of acculturation and thus assume that their health outcomes would be equivalent to native born populations.
This study has number of weaknesses. The main concern is that the study did not consider a number of important health service delivery factors. The researchers did not assess for the number of visits the patient had with appropriate interpretation services, whether or not there were language concordant visits between patients and providers (limited English proficiency patients are more likely to form consistent service relationships with language concordant providers [6–10]), or whether the patient had diabetes education classes or individual counseling sessions to facilitate self-management. These service-based factors could potentially explain some of the results seen. The small sample size, age of the data in the study, and failure to distinguish the country of origin of the Latino patients are other weaknesses.
Applications for Clinical Practice
Providers can improve their clinical practice with limited English proficiency Latino patients with diabetes by being more sensitive to the potential effects of language on diabetes outcomes in this population. The results suggest that providers should not assume that a Latino patient’s English language skills mean that they are better at self-managing their diabetes and will have better outcomes. Asking patients about their country of origin and migration experiences may help differentiate the effects of language in concert with other potentially confounding variables that can help elucidate the effects of language on diabetes related outcomes.
—Allison Squires, PhD, RN
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