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Lost in Translation Tackling the Barriers to Hispanic Good Health By Kim Ribbink The significance of the growing Hispanic market to pharmaceutical companies cannot be overemphasized. Hispanics are the fastest-growing multicultural group in the United States. According to U.S. Census Bureau statistics, by 2035 there will be 75 million Hispanic individuals, comprising 20% of the population, and by 2050 Hispanics will constitute about a quarter of the population. (Incomes of Hispanics are growing 60% to 70% faster than the general population.) But just as important are the disease disparities within Hispanic communities and the difficulty patients have accessing healthcare services and information that addresses their specific language and cultural needs. According to the National Council of La Raza’s Institute for Hispanic Health (IHH), Hispanics suffer a greater incidence of such diseases as HIV/AIDS, tuberculosis, diabetes, cardiovascular disease, and breast and cervical cancers than other U.S. patient populations. Moreover, traditionally Hispanics have been less likely to have access to health insurance. (Since 1998, Hispanic healthcare insurance coverage has increased 3%, more rapidly than for any other group.) The 1996 Welfare Reform Bill is another barrier to healthcare for recent immigrants. This law does not allow people who came to the United States after Aug. 22, 1996, to qualify for Medicaid for the first five years after entry into the country. Hispanics also lack access to adequate preventive medical care and public health-education materials. Making the Patient Connection To make the connection with Hispanic patients, some pharma companies are working with organizations that are deeply involved in the community, including grassroots community leaders and organizations such as the National Council of La Raza (NCLR), the National Alliance for Hispanic Health, and the National Hispanic Medical Association. “The first task is to educate Hispanic patients through simple messages, such as public-service announcements, that incorporate their values,” says Alejandra Cádiz-Gómez, director of Hispanic marketing at BLH Consulting Inc. “For the Hispanic community, family is important, so a message that encourages people to take care of themselves for the sake of their family will have an impact.” Recognizing the pressing need to provide culturally relevant and Spanish-language health information to Hispanic consumers, Pfizer launched a health-education campaign called Sana la Rana. The name of the program comes from a childhood rhyme known throughout Latin America, which conveys that if “you don’t get better today, you’ll get better tomorrow.” The program, which was created to educate Hispanics on diseases that disproportionately impact this group, with a focus on cardiovascular health and the dangers of high cholesterol, began in New York and has evolved into a more robust program in Miami and Houston. Sana La Rana includes advertisements designed to raise awareness about the risks of high cholesterol and includes a Website that provides information in Spanish about various disease categories. All materials include a toll-free telephone number through which pamphlets and patient-education materials in Spanish can be requested. “The goal has been to understand the barriers that exist and what needs to be done to motivate Hispanics to take better control of their health and become more engaged with their doctor,” says Michal Fishman, director, U.S. pharmaceutical public relations at Pfizer Inc. Pfizer worked with the NCLR to identify health promoters, or promotores de salud. “Our promotores de salud are lay health workers within the community who talk about the importance of healthcare and prescription drugs,” says Marcela Urrutia, senior health policy analyst at the NCLR. Pfizer says its Sana la Rana program already is starting to show results. For example, within the markets where the program has run, there has been a 20% increase in awareness of cholesterol, and 8% of people who have accessed the information say they intend to go to the doctor or will encourage someone to go to the doctor. “There is a huge prevalence for serious, chronic conditions in the Hispanic community,” Ms. Fishman says. “The actual diagnosis of these diseases is one of the greatest barriers to treatment.” In addition, Pfizer is working in partnership with a coalition of 19 organizations, including the NCLR and the National Hispanic Medical Association. The Partnership for Clear Health Communications was created to raise awareness about the role that understandable health information plays in improving health outcomes. The program includes materials written at the sixth-grade level. The materials also include clear diagrams to enhance understanding and improve the patient’s interaction with the doctor. “Also included in the program is a campaign called ‘Ask Me Three,'” says Dorothy Wetzel, VP for the consumer marketing group for Pfizer U.S. Pharmaceuticals. “This program encourages patients to ask, and doctors to answer, three basic questions: What is my main problem? What do I need to do about it? And, why is that so important? The program also encourages the doctor to be on the lookout for people who don’t always understand the questions.” The use of diagrams is a powerful and effective way to reach patients with low literacy levels or who speak little English, says Stephanie Mazzeo-Caputo, senior VP, operations and administration, at HealthEd. “Illustrations need to be positive and focus on what patients are meant to do, not what they’re not meant to do,” she says. “For example, a picture of a person sitting at a table with a physician or nurse having his or her blood pressure checked is much more powerful than a picture of a stethoscope.” Another example of an outreach program for Hispanic patients is GlaxoSmithKline’s “Take Diabetes to Heart” campaign, which was launched in 2002, in collaboration with the American Association of Diabetes Educators and the Association of Black Cardiologists. In 2003, the company built on the campaign by working with another third party, the Interamerican College of Physicians and Surgeons, a professional network of Hispanic physicians. “Working with Spanish-speaking physicians in a media-outreach program, we developed diabetes materials in Spanish, we provided a cookbook in Spanish with culturally relevant menus, and we provided a toll-free telephone number so that Spanish-speaking patients could call in,” says Bernadette King, product communications director at GlaxoSmithKline. “We have had more than 9,000 requests from Hispanic consumers for these materials.” Among Bristol-Myers Squibb’s efforts is a grassroots program for cancer patients in Florida. The program, the Individual Cancer Assistance Network, or ICAN, was designed to provide emotional and practical support through individual counseling sessions to treat cancer-related stress issues. ICAN is a philanthropic program of the Bristol-Myers Squibb Co., the Alliance for Children and Families, and Cancer Care. The Miami-Dade portion of the central and southern Florida program addressed Hispanic and Creole-speaking communities. For the Miami-Dade research, Bristol-Myers Squibb turned to Barreto & Brightwell Associates for assistance. To start with, program organizers met with caregivers running mental-health programs and social-support programs for cancer patients that included large Hispanic populations, such as the Sylvester Cancer Center at the University of Miami, the Liga Contra el Cancer, and the Haitian American Association Against Cancer. Bristol-Myers Squibb also tapped organizations that provide cancer-patient support, such as the Wellness Community. The first goal was to find bilingual counselors, which the program organizers were quickly able to do, uncovering more than 100 fully qualified counselors. “We trained the community-based counselors, who had experience in delivering mental health services, to address the specific needs of cancer patients and their families,” says Patricia Duquette, Ph.D., associate director for the Bristol-Myers Squibb Foundation. “An overall goal of the program has been to bring a means of total patient care that deals with both the medical side and the human side of cancer to those populations that have had poor access to psycho-social support.” “The program was culturally sensitive,” says Martin Barreto, president of Barreto & Brightwell Associates Inc. “For example, the Spanish materials excluded the word ‘psycho’ because research showed that Hispanics associate schizophrenia and craziness with this term.” Dr. Duquette says the feedback from counselors and patients has been very positive. “The mental-health professionals had not been active in the area of oncology before, so we were bringing them new skills, and they were very appreciative of that training,” she says. “For the patients, simply acknowledging that they were suffering from cancer-related distress was a significant benefit to them. The individualized support also allowed them to discuss many more personal issues that were challenging them.” Going forward, Bristol-Myers Squibb, working in partnership with CancerCare, the American Psycho Social Oncology Society, and the National Association of Social Workers, plans to make the training available nationally via online and in-person training formats. HealthMedia has assisted other pharmaceutical companies with developing patient materials for Hispanics, including one company that was interested in marketing oral contraceptives to Hispanic women. “The company understood that there were several issues it had to face in terms of marketing oral contraceptives to Hispanic women,” says Kevin Wildenhaus, Ph.D., director of behavioral science and chief product architect at HealthMedia Inc. “Research from the CDC showed that more than 50% of Hispanic high-school girls had been sexually active; about 40% were regularly sexually active; but only about one-third were using condoms, and only 9% were using oral contraceptives. Also, 12.8% of Hispanic high-school girls had been pregnant already. There’s also research that shows Hispanic women on birth control are the most inconsistent ethnic group in accurately using that medication.” To increase use of oral contraceptives as well as consistency of use, an effective campaign would need to address issues such as religious influence on birth control, a cultural tendency to live for the moment rather than plan ahead, as well as the particular barriers for both boys and girls in terms of their beliefs about birth control and use. The more companies become aware of the needs within the Hispanic community, the better the odds of reaching that community with information that resonates and that encourages patients to take control of their health. “The way we do business now in addressing the Hispanic-American community will not be what we do 10 years from now,” says Tamara Burkett, senior manager, multicultural marketing, U.S. Pharmaceuticals – RTP, at GlaxoSmithKline. “We have to ensure we’re keeping up with how all the different cultural groups within the United States are changing.” “It’s not enough for pharmaceutical companies to just make drugs,” Ms. Wetzel says. “We have to make sure people know how to use our products. We believe that we have to put as much effort into communicating to doctors and consumers as we do to making medicines and making sure they’re effective.” Speaking at Cross Purposes According to Global Insight, Hispanics represent a $12.2 billion marketplace, a figure that is expected to more than double by 2007. More than 10 million newly insured Hispanics will be entering the workforce in the next 10 years, which accounts for the increase in prescription spending, according to Global Insight. The Hispanic community is heterogeneous, made up of people from 22 countries. For marketing or outreach programs to hit their targets, there are some important considerations to bear in mind, including language, acculturation, and heritage. “A Spanish speaker from Mexico may use words to describe parts of the body or for how to take medicine that are very different from the words that a person from Chile would use,” says Elizabeth Elting, president and CEO of TransPerfect Translations. Mr. Barreto says a set of simple solutions can address the issue of different dialects within the Spanish-speaking community. “For example, using universal Spanish devoid of colloquialisms, providing information in English and Spanish, and developing programs that have a spectrum of approaches – from those that address the more acculturated, discerning professional Hispanics to those that target more recent immigrants,” he notes. Factors such as age, number of years in the United States, and socio-economic levels also are important to consider when addressing this patient population. A Hispanic patient’s level of English knowledge will vary significantly depending on acculturation. According to U.S. Census data, in 2002 40.2% of the Hispanic population in the United States was foreign born. Ms. Elting notes that only 28% of Hispanics born outside the United States are English dominant or bilingual, compared with 96% of those born in the United States. According to a TransPerfect survey, 33% of non-English speakers, across all groups, have left the doctor’s office without being fully clear about their medication. Among Spanish speakers: 57% said they found the information accompanying prescription drugs to be impossible to fully understand because of language difficulties; 47% have described a bad prescription experience they have encountered because of a language barrier problem; 44% said they have at one time taken the wrong dosage because they had trouble translating the instructions into Spanish; 29% know of elderly relatives who have taken their medication improperly because they didn’t understand the instructions; 12% said they drank alcohol while on their medication because they didn’t fully understand the instructions; and 8% said they had taken medication and driven a car when they did not understand the information accompanying the medication that cautioned against operating heavy machinery. “New immigrants have a high degree of reliance on Spanish-language materials,” Mr. Barreto says. “They also have a fear of or little knowledge of the healthcare system.” Ms. Burkett says, when it comes to healthcare, new immigrants face a two-fold barrier. “The first is an unfamiliarity with the American healthcare system,” she says. “Second, in many Hispanic countries and communities there is a greater reliance on self-medication with natural or herbal traditional remedies instead of prescription medications. There also is a greater reliance on nontraditional medical advice – from naturalists or pharmacists – rather than a medical doctor.” According to research from Barreto & Brightwell, Hispanics are nearly twice as likely as whites (30% vs. 16%) to use alternative therapies because they are a less expensive way of getting care. Balancing the needs of new immigrants with those of large populations of second- or third-generation Mexican Americans, Puerto Rican Americans, and Cuban Americans is complicated. Dr. Wildenhaus says research shows that some second- or third-generation Hispanics say they would be offended if material was automatically provided to them in Spanish because they feel acculturated and they don’t want to be seen as different. “On the other hand, Hispanics in their 40s, 50s, and 60s, who may be first generation, may be proud of their heritage and culture and would prefer a program in Spanish,” he says. Companies also need to understand that different groups view healthcare differently. “For example, Cubans in Miami tend to take a much more assertive and aggressive approach to healthcare, in contrast to Mexican Americans in California and Texas, who are much more likely to be passive and submissive about their healthcare, and Puerto Ricans in New York and Chicago, who tend to value the family strongly and have specific belief systems about healthcare,” Dr. Wildenhaus says. “Outreach initiatives by pharma companies often miss the mark because materials are translated literally without taking into account cultural nuances or literacy levels,” Ms. Urrutia says. Cultural nuances when providing instructions about medication usage need to be considered as well. “A simple instruction such as taking a medication three times a day with a meal can impact medical treatment,” Ms. Elting says. “In some Spanish-speaking countries, individuals might view lunch as the primary and only meal of the day, and therefore when they read the instructions, ‘take three times a day with a meal,’ they might think they can take it three times at lunch.” Cultural barriers extend beyond language and have an equal impact on a population’s adoption of healthcare. For example, experts say Hispanic patients tend to revere doctors as they would parish priests or other authority figures and are not comfortable engaging in conversations with physicians or questioning the physicians. This lack of interaction is exacerbated when dealing with conditions that are asymptomatic. “Culturally, Hispanic patients tend to take a medication only to treat symptoms and to stop taking medicines when the symptoms disappear,” Ms. Burkett says. Other challenges involve overcoming a profound fatalism where illness is often perceived as God’s will or as fate. According to Ms. Wetzel, Pfizer conducted an attitude and usage study with Hispanic consumers on a variety of diseases. “We found that only 69% of Hispanics were aware of high cholesterol as a problem, as compared with 94% of Caucasians,” she says. “For depression, 74% of Hispanics are aware of the condition versus 92% of Caucasians.” Another important consideration is religion, since about 70% of Hispanics practice a religious faith. Further, according to Dr. Wildenhaus, cultural taboos exist that may hinder how healthcare information is provided, and may also hinder discussions about issues such as safe sex, birth control, and depression. Healing the Physician Gap Equally as important as educating the patient are efforts to educate the healthcare professionals practicing in Hispanic communities. Pfizer launched Vida Sana as a companion program to Sana La Rana to help doctors understand the barriers that Hispanic patients face. “This is a training program for non-Hispanic doctors that gives them tools and resources to improve communications with their Hispanic patients,” Ms. Wetzel says. “We give them cultural competency training, such as making them aware of different belief systems and different eating habits and then provide them with communication tools.” Finding Spanish-speaking healthcare providers and linking them to the community is one way GlaxoSmithKline tries to bridge the gap between the physicians and their Hispanic patients. Another way is to ensure that sales representatives call on these physicians. “We train sales representatives to understand some of the different cultural nuances of the various ethnic and racial groups living in the United States so they can provide hints or tips to healthcare providers,” Ms. Burkett says. “We also have advisory boards – physicians and healthcare providers – who are members of different ethnic groups and who treat a large number of diverse patient populations. We meet with them to brainstorm on what we need to do next – from developing strategies to reviewing brochures.” Not having access to doctors who speak the language or understand the cultural backgrounds of the patient presents an additional challenge. According to the American Medical Association, 3.5% of doctors are Hispanic, compared with 54.6% of doctors who are white. “Often doctors and nurses at a practice don’t speak Spanish so they may be unable to provide accurate directions,” Ms. Cádiz-Gómez says. To assess the communications within the doctor’s office, Pfizer videotaped interactions between doctors, their Hispanic patients, and a translator. Pfizer found that up to 90% of the conversations between the doctor and patient were lost in translation. “In any doctor/patient communication, there’s probably some technical language that gets lost,” Ms. Wetzel says. “Take that to another level – translating the information – and the situation becomes even more difficult.” “In the case of a family who moved to the United States recently, the parents might not speak English, but their children do,” Ms. Cádiz-Gómez says. “Often those children, who might be very young, act as the translator.” There are signs, however, that efforts to reach out to the Hispanic community with information about healthcare issues are having an effect. A 2003 study, commissioned by The Commonwealth Fund, found that 27% of Hispanics have difficulty communicating with their doctor compared with 33% in 2001. In comparison, the 2003 study found that 23% of African Americans and 16% of Caucasians have difficulty communicating with physicians, the same as in the 2001 study. “The improvement in the Hispanic community might have something to do with the fact that more pharma companies are supplying Spanish-language materials,” says Debbie Regiaba, market development manager, media sales and marketing, at Time Inc. “Advertising and marketing also might be playing a role. If people are starting to understand what ailments they have, speaking to the doctor might be easier.” F PharmaVoice welcomes comments about this article. E-mail us at firstname.lastname@example.org. 57% of Hispanics say they have found prescription drugs impossible to fully understand because of language difficulties. Debbie Regiaba Efforts to reach out to the Hispanic community with healthcare information are having an effect. As people start to understand what ailments they have, speaking to the doctor might be easier. Alejandra Cádiz-Gómez The Hispanic community will pay attention to companies that care about their community. Even for people who speak English, knowing there is a Spanish-language Website with health information will make them feel as though the company does care. Tamara Burkett When working with Hispanic patients, it’s important to work with trusted figures within that community – doctors, community leaders, or religious leaders – and make sure they have the information they need to talk to patients. Stephanie Mazzeo-Caputo The pharmaceutical industry has a responsibility to provide educational materials in the primary language. The important thing is not to translate literally, but to translate using the phraseology used in that culture. Bernadette King For industry as a whole, there’s room for improvement, but we’re proud of what we’ve achieved so far to reach out to the Hispanic community. 27% of Hispanics have difficulty communicating with their doctor. HISPANIC diversity 10 Leading Causes of Death in the U.S. in 2000 for Hispanics or Latinos Heart disease Cancer Unintentional injuries Stroke Diabetes Chronic liver disease and Cirrhosis Homicide Chronic lower respiratory disease Pneumonia and Influenza Birth defects Pneumonia and Influenza Pharmaceutical Opportunity: Embracing the Hispanic Market Hispanics represent a $12.2 billion marketplace to the prescription drug industry. This figure is expected to more than double by 2007, According to Global Insight. Despite this figure, little ethnic marketing has occurred. Hispanic agencies see potential and expect direct-to-consumer advertising targeted to Latinos to increase significantly in the next five years. Many challenges face multicultural marketers: n Funding n Skeptical measurement of results n Lack of top management commitment n Scarcity of market research According to reports from Hispanic Business in December 2003, pharma companies Johnson & Johnson, Pfizer, Wyeth, and Bayer were among the top 60 advertisers in Hispanic media, spending more than $65 million in 2003, a 19% increase compared with 2002. Hispanics represent a $12.2 billion marketplace. Experts on this topic Martin Barreto. President and CEO, Barreto & Brightwell Associates Inc., New York; Barreto & Brightwell is a PR and marketing communications firm specializing in the U.S. Hispanic and Latin American healthcare markets. For more information, contact email@example.com. Tamara Burkett. Senior manager, multicultural marketing, U.S. Pharmaceuticals – RTP, GlaxoSmithKline, Research Triangle Park, N.C.; GlaxoSmithKline, with U.S. headquarters in Philadelphia, is a research-based pharmaceutical company. For more information, visit gsk.com. Alejandra Cádiz-Gómez. Director, Hispanic marketing, BLH Consulting Inc., Atlanta; BLH Consulting is a full-service PR firm that specializes in developing and implementing marketing-communications programs that are culturally sensitive and relevant to African-American and Hispanic consumers. For more information, visit blhconsulting.net. Patricia Duquette, Ph.D. Associate director, Bristol-Myers Squibb Foundation, New York; Bristol-Myers Squibb is a global pharmaceutical and healthcare company. For more information, visit bms.com. Elizabeth Elting. President and CEO, TransPerfect Translations, New York; TransPerfect provides translation, interpreting, multilanguage typesetting/graphic services, staffing solutions, Website globalization, software localization, subtitling, voice-overs, and multicultural marketing. For more information, visit transperfect.com. Michal Fishman. Director, U.S. pharmaceutical public relations, Pfizer Inc., New York; Pfizer is a global research-based pharmaceutical company. For more information, visit pfizer.com. bernadette king. Product communications director, GlaxoSmithKline, Philadelphia; GlaxoSmithKline is a research-based pharmaceutical company. For more information, visit gsk.com. Stephanie Mazzeo-Caputo. Senior VP, operations and administration, HealthEd, Westfield, N.J.; HealthEd is devoted to patient-centered health education and medical professional education. For more information, visit healthed.com. Debbie Regiaba. Market development manager, media sales and marketing, Time Inc., New York; Time is one of the largest magazine publishers in the world. For more information, visit timewarner.com. Marcela Urrutia. Senior health policy analyst, the National Council of La Raza, Washington, D.C.; NCLR is a nonprofit, nonpartisan organization dedicated to reducing poverty and discrimination, and improving life opportunities for Hispanic Americans. For more information, visit nclr.org. Dorothy Wetzel. VP consumer marketing group, Pfizer U.S. Pharmaceuticals, Pfizer Inc., New York; Pfizer is a global research-based pharmaceutical company. For more information, visit pfizer.com. Kevin Wildenhaus, Ph.D. Director of behavioral science and chief product architect, HealthMedia Inc., Ann Arbor, Mich.; HealthMedia blends behavioral science, tailoring technology, and creative marketing to produce programs for healthy lifestyle issues, diseases, and conditions. For more information, visit healthmedia.com. Dorothy Wetzel It’s important to delve into the information and emotional barriers that may be preventing Spanish-speaking patients from seeking and staying on treatment and to meet their needs through programs that resonate within the community. Dr. Patricia Duquette With community-based programs, an effort won’t be successful unless the company is deeply involved in the community and has buy-in from the community as a partner in addressing the major health challenges. Dr. Kevin Wildenhaus There is some resistance to certain preventive medications because there’s a belief among some Hispanics that they’re almost tempting fate by using a medication. Elizabeth Elting Language and culture cannot be separated when reaching out to people from different ethnic communities.