A Systematic Review of Asthma and Health Literacy: A Cultural-Ethnic Perspective in Canada

Abstract

Background

Asthma is one of the most common inflammatory lung diseases and its prevalence and incidence have increased in many developed and developing countries. Asthma places a heavy burden on healthcare expenditures and productivity, which in turn diminishes the quality of life of the individuals involved as well as their families. The goal of improving a patient's knowledge about asthma management should include the enhancement of the individual's skills with the hopeful outcome of improving how the individual manages the condition. However, when health professionals prepare a training program, they are faced with the challenging cosmopolitan reality of individuals with different ethnic backgrounds.

Methods

In order to find links between asthma and health literacy in a cultural/ethnicity perspective, we performed a systematic review of all publications on the topic of asthma, health, and literacy among cultural groups from 1980 to 2006 using the Internet and journals: Medline (Ovid), ERIC, EMBASE, PsycINFO, Google, Google Scholar, Sociological Abstracts, and Anthropology Plus. Key words included the following: “asthma,” “culture,” “ethnicity,” “literacy,” “health,” “health literacy,” “health beliefs,” “adults,” “disease management,” “chronic condition,” “ethnocultural groups,” “minority groups,” and “newcomers/immigrants.”

Results

More than 650 articles were initially identified in our review; 65 met our inclusion criteria. From these, we examined the factors related to asthma and literacy/health literacy with a cultural lens. All of these are categorized and summarized below. We chose what we considered to be the most relevant and important articles/documents in the research literature to date. Because many of the studies were qualitative, a formal meta-analytic review was not undertaken. We found that current asthma management techniques – including patient education – are not culturally sensitive, linguistically sensitive, or relevant, which creates further difficulties for ethnocultural communities and minority groups in many Western countries. In this systematic review, several themes were identified, including: approaches to language limitation and cultural barriers; the recognition of healthcare system bias (in terms of culturally competent care); and relationship-building to facilitate participatory decision-making by both provider and patient. This review provides further understanding and considerations regarding the beliefs and perspectives of care providers and populations in relation to health and illness, literacy and health literacy, and their association with asthma among ethnocultural communities.

Conclusions

There is an urgent need to better define the impact of cultural and ethnic issues in the management of asthma in Canada. Appropriately designed studies should better define the barriers in the optimal delivery of asthma care influenced by these parameters.

Introduction

Asthma is one of the most common inflammatory lung diseases in the world.[1–3] In North America, asthma is one of the most common chronic diseases,[4,5] and in the United States, asthma is the most common chronic illness among children under 12 years of age.[6–11] It is responsible for about 5000 deaths annually and about 2.5 million hospitalizations or emergency department (ED) visits per year.[1,8,12,13] In Canada, asthma is highly prevalent in the general population,[14] and there has been a sharp increase in incidence in the past 20 years.[14–16] For instance, in 1996–97, around 2.2 million persons were diagnosed with asthma (12.2% of children and 6.3% of adults).[15] However, the 2000–2001 surveys show that approximately 3 million people are currently affected by asthma[14] and 8.4% of the population over the age of 12 years and 12% of children have been diagnosed.[15] The impact in the age groups of 15–24 and 65 and over is great.[16] Asthma mortality rates also increased sharply in Canada in the 1970s and early 1980s but have more recently declined.[15]

Asthma places a heavy burden on healthcare expenditures,[16] reduces productivity, increases absenteeism and job loss, and significantly affects the quality of life of the individuals involved as well as their families.[17] In Canada, approximately 146,000 emergency room visits are reported annually due to asthma exacerbations.[15] Its etiology and dramatic epidemiology have recently been comprehensively reviewed.[18] Within Canada, we have recently demonstrated important, if not major, shortcomings in the control of asthma.[19]

In 2000, the annual healthcare costs related to asthma – ED visits, inpatient and outpatient care, and hospitalizations[20] – were estimated to be over $2 billion CAD (Canadian dollars) per year[17] whereas the costs in 1990 were $650 million CAD.[16,17] The economic impact associated with asthma exceeds that for tuberculosis and HIV/AIDS combined.[14]

Methods

In order to find links between asthma and health literacy in a cultural/ethnicity perspective, we performed a systematic review of all publications on the topic of asthma, health, and literacy among cultural groups from 1980 to 2006 using the Internet and manually searching through journals: Medline (Ovid), ERIC, EMBASE, PsycINFO, Google, Google Scholar, Sociological Abstracts and Anthropology Plus. Key words included: “asthma,” “culture,” “ethnicity,” “literacy,” “health,” “health literacy,” “health beliefs,” “adults,” “disease management,” “chronic condition,” “ethnocultural groups,” “minority groups,” and “newcomers/immigrants.” In order to be included, the publications had to comply with all of the following criteria: had to have factors related to asthma and literacy/health literacy as well as an established relationship between these factors; had to have a sample composed entirely of adult patients and their families, of which the patients with asthma and/or other chronic conditions could be extrapolated; had to have samples comprising immigrants/newcomers/minorities; had to have been published in 1980 and onward; had to have been published in English; had to have reported quantitative or qualitative data; and had to have standardized self-reporting measures. We chose what we considered to be the most relevant and important articles/documents in the research literature to date. Because many of the studies were qualitative, a formal meta-analytic review was not undertaken.

Results

More than 650 articles were initially identified in our review, of which 65 met our inclusion criteria and examined the factors related to asthma and literacy/health literacy with a cultural angle; these are categorized and summarized below.

Literacy/Health Literacy and Asthma

An essential factor in patient education has been shown to be literacy[13,21] and, more specifically, health literacy.[22] In Canada, approximately half of the adult population appears to have some difficulties with reading in one of the official languages of Canada.[23] The recent report on the 2003 International Adult Literacy and Skills Survey from Statistics Canada[24] suggested that over 3 million Canadians aged 16–65 years have problems with reading and understanding printed materials. This suggests that literacy is still a very significant problem in Canada.[24] There is growing concern in the fields of health and healthcare about the possible contribution of low literacy to poor health.[23,25,26] Evidence indicates that literacy is directly related to overall health status and chronic health status.[26] People with low literacy levels are more likely to earn less, be hospitalized more,[25] and are less likely to seek care.[23,25] Moreover, people with low literacy skills have less knowledge about medical conditions and associated treatment and have an overall inadequate understanding of health issues.[26] This suggests that “low literacy skills” likely contribute to “low health literacy,”[27] defined as a person's ability to obtain, understand, appraise, and communicate basic health information.[23,28]

Health literacy has been a growing focus of health research around the world and is a key issue in health promotion.[21,22, 29–33] It is a key outcome measure of health promotion,[34] in which 3 levels have been identified: functional, interactive, and critical health literacy.[29,30,35] According to the WHO,[29,33] unless health literacy is achieved, efforts to reduce disparities in health,[36] decrease cost, and enhance healthcare in a given society will not succeed.[22,34,37] Health literacy has been shown to be a crucial contributor to better health outcomes and an essential factor in managing chronic diseases.[11,13, 38–40] Being health-literate is having the knowledge, skills, confidence, and ability to access accurate information and high-quality services,[6,22,30] become aware of symptoms,[13,21] understand disease-related information and guidelines,[41,42] follow written medical instructions, communicate with service providers[21,43,44] negotiate the complexity of healthcare, and obtain proper and timely care,[29,33] all of which are key issues that enable an individual to prevent, manage, and/or control the disease.[13,21] On the other hand, limited health literacy has been found to have an adverse affect on the interaction between the patient, provider, and the health system in general, and thus negatively affects the patients' ability to manage their personal health.[22,30] As with other chronic conditions, inadequate health literacy could be considered a key barrier to asthma knowledge, prevention, and self-care (self-management).[13,20,21]

According to the US literature, among asthma patients who presented themselves to emergency departments, health literacy has been found to compound the threat to health, and this issue is more common among people from different ethnic and cultural backgrounds.[13,15] These studies have also found that patients' health literacy appears to have a direct relationship with their health status,[21] and those with low health literacy are more likely to be hospitalized and have significantly higher morbidity and mortality rates than those with adequate literacy.[1,11,13,41] Many studies in the United Kingdom, United States, and Australia have shown that patients with low health literacy skills have less knowledge about their health and treatment, lower self-management skills, higher rates of chronic illnesses, and they tend not to effectively participate in preventive care.[13,22,45] They also have a poor understanding of disease processes, poor recall, poor comprehension of advice and directions (such as administration, medications, and appointments), poor problem-solving skills,[46] and they hold health beliefs that interfere with care. These patients are also less able to navigate within the healthcare system to access and obtain the necessary information and services.[29,33]

Ethnocultural/Minority Groups

Groups within a society are regarded as a minority when they share a common cultural background that is different from the majority population.[14] Each ethnic group can be defined as a social group with its own distinctive language, values, religion, customs, beliefs, and attitudes.[11] These groups have usually had lower socioeconomic status (SES) and a weak position in a given society for several generations.[47,48] They are often considered hard-to-reach populations,[49] likely due to healthcare providers' failure to employ proper and effective communication strategies, which may contribute to the minority populations' lower use of preventive measures and health promotion interventions. In multicultural countries like Canada,[28] 3 major minority groups can be defined: (1) immigrants (those who come to Canada for a better life) including labor immigrants; (2) refugees/asylum seekers; and (3) Aboriginal minority groups.[35] According to Statistics Canada,[24] Canada is home to almost 4 million individuals who identified themselves as visible minorities in 2001, accounting for 13.4% of the total population. It should be noted that a person categorized as belonging to a visible minority may well have lived in Canada for all of his or her life.

In addition, about 1.8 million people living in Canada (6.2% of the total population) are immigrants who arrived during the 10 years between 1991 and 2001.[14,24] In spite of this, no study could be found in Canada to investigate how culture, ethnicity, and languages, as major determinants of health and healthcare, could influence asthma management as well as attitudes and beliefs about asthma. However, studies in Australia and the United States[8,17, 49–51] have concluded that vulnerable populations, such as immigrants and ethnic minorities and those in lower SES groups,[11] are disadvantaged due to lower literacy rates,[16] cultural barriers,[4,52] language limitations,[17] and differing educational opportunities.[32,48,49] Similar conditions are also more common among the poor, physically and mentally disabled individuals, and older adults with different ethnic backgrounds.[35] These studies have clearly demonstrated that people's cultural beliefs and attitudes are associated with their health behaviors and outcomes.[5] Given the high number of ethnocultural communities in Canada,[53] there is a gap in the literature about how culture and ethnicity may affect the populations' beliefs and practices about asthma prevention, control, or management. Two main questions are discussed in this review: (1) How suitable and relevant is current patient medication information for ethnocultural communities about asthma?; and (2) What are effective approaches and strategies to build partnerships/relationships between care providers and patients from different cultural groups? Answers to these questions would improve our knowledge and guide future researchers in their efforts towards developing better measures of the impact of culture and ethnicity on asthma prevalence, incidence, prevention, and management. It would also lead to designing future intervention studies aimed towards helping patients and their families control and manage asthma. In addition, awareness of ethnic and cultural variations in how asthma is viewed by different patients, healthcare professionals, and policy makers can better meet the needs of individuals from the diverse ethnic/cultural groups that they serve.[28] This review article aims to answer these questions and increase our knowledge about ethnocultural communities' views and understanding of asthma prevention, control, and management. We are also interested in finding out about the possible interactions between cultural beliefs, literacy, health literacy, and health outcomes among patients with asthma.

Cultural and Demographic Perspectives on Asthma Management

Studies examining the demographic trends and cultural variables in the prevalence and severity of asthma and other chronic disease[45] have repeatedly shown a higher incidence for those with low SES, particularly in the urban, inner-city environment.[1,6,16,41,43] Race and ethnicity have also been shown in the US literature to be high risk factors, largely due to a strong association with low SES[43,54] because lower SES tends to create conditions that are conducive to a higher prevalence, morbidity, and mortality related to many health issues and illnesses.[38,44,53] According to US studies, minority groups are found to bear a disproportionate share of the burden of asthma. For instance, asthma prevalence, incidence, and death rates are higher among nonwhites than whites across several age groups.[43] Black and Hispanic Americans tend to suffer more from asthma than do whites,[12,13,43,44,47,55] and there are substantially higher rates of asthma morbidity, hospitalization, and mortality among these groups.[12,13,17,43,56] Socioeconomic status, cultural barriers, and language barriers also affect ethnocultural and immigrant communities in Canada[57] through substandard housing[39] and fewer educational and employment opportunities. As a result, they are more likely to be exposed to environmental and occupational hazards,[44] making it much more difficult to avoid or minimize allergens and other irritants, which are key factors in the management of asthma.[43,58] The urban-rural gradient – exposure to a poor, urban, Westernized environment, and cultural beliefs – can further increase the prevalence, incidence, and mortality of asthma.[43] Therefore, it is necessary to examine these disparities with respect to a minority/immigrant group's overexposure to environmental/occupational hazards in an aim to examine viable approaches to improve their health outcomes.

Health Beliefs, Culture Beliefs, and Asthma

Understanding the evolution of individuals' worldviews[58] and belief systems[38] includes the meaning that people attribute to their health and illness, which in turn influences the decisions they make about prevention or treatment and to what degree they adhere to treatment.[13,49,51] It also includes the factors that play key roles in their health practices – literacy and language skills and effective healthcare provider communication.[28] The factors that require greater attention include cultural beliefs and practices, subculture, religion, health beliefs, education, personality, life experiences, events occurring at the same time as the onset of the disease, and interactions with the healthcare system.[47,55] These factors inform a person's worldview and hence the “health beliefs” that need to be examined and given proper weight in how a person, or even a cultural or ethnic group, responds to and interacts with the healthcare system and treatments prescribed by care providers.[11,51,56,58]

The approach of viewing the healthcare system (eg, the biomedical system) as a culture in itself – the “medical culture” – with its own belief systems, paradigms, customs, and language is useful in understanding the issue of patient compliance.[56] It is evident that there is currently a largely unexplored disparity between the beliefs and expectations of healthcare providers and patients, particularly if there is also a disparity between the cultures/ethnicity of the two.[36,47,51] Approaching biomedicine as a culture in itself, such that interactions between patients and healthcare providers become a communication between cultures, or transactions between worldviews, appears to be a necessary process in establishing a trusting and effective partnership and thus improving the health outcomes of patients with asthma.[38,52,55,59,60] Recent studies have documented the prominent belief held by many people with asthma, which holds that if they do not have any active symptoms of asthma, then they do not have asthma; for example, asthma is not perceived as a chronic disease, and thus, daily management through medication is not respected.[21,56,61] This is in sharp contradiction with the biomedical belief that asthma is chronic and needs to be managed daily, regardless of symptoms.[56] This example shows the necessity of examining the patients' views and beliefs about their illness, in order to avoid miscommunication and misunderstanding between the healthcare provider and patient.

Furthermore, both the provider and patient perspectives and beliefs need to be openly discussed in order to facilitate communication between providers and patients, and both perspectives need to be understood and negotiated.[17,52] This approach can then explain how patients and their support systems experience and understand asthma, including their ideas about etiology, medications, alternative health practices, and their health behaviors.[55] However, there has been very little research in Canada on understanding patients' perspectives; rather, most literature presents only the healthcare provider's perspective, which is only half of the picture.[57] It is necessary to add to this the view that the present healthcare system in Canada and elsewhere in the Western countries, herein called the biomedical system,[56] is a sociocultural construction that needs to be examined as such.

Cultural Competency and Asthma

To address many of the aforementioned sociocultural issues, some educational programs have recently been developed for physicians and other healthcare providers with the aim of improving their “cultural competency.”[50] This is defined as the provider's ability to work effectively with people who come from different sociocultural backgrounds, including varied linguistics, customs, beliefs, and values.[20,60] The premise is that with increased knowledge and understanding of different cultures, communication between the care provider and the patient is facilitated. However, there have been practical challenges in implementing this in clinical practice.[20] The healthcare system needs to provide services that are respectful, empowering, and culturally sensitive.[48,56] In this regard, healthcare providers also need to gain knowledge and skills to be culturally competent[5,26] in order to provide services to people from different linguistic, cultural, and ethnic backgrounds.[47] Specific training and a standard curriculum needs to be developed to fill this gap, which would allow the healthcare provider to understand the perspective of the patient, and to tailor specific patient education material and approaches according to their needs, thereby building a stronger patient-provider relationship to improve asthma care outcomes.[13]

For training in “cultural competency” to be effective, all of the factors discussed above need to be taken into account and integrated, including learning new and adaptable communications skills, new methods of teaching and interacting with patients, and having a good grasp on various cultures and health beliefs. This combination would then contribute to strengthening the alliance between the care provider and patient as well as increasing the patient's health knowledge and literacy.[4] Understanding the need to take the time to communicate with patients openly about their health beliefs[62] – how they view their illness and treatment – is hypothesized to improve their health literacy as well as empower them to take charge of their illness and its treatment.[52,58] Therefore, increasing health literacy among minorities and other disadvantaged groups empowers them with the skills required to make better educated health decisions and therefore achieve better health outcomes.

Asthma Management and Patient Education

Despite the development of new medications for the treatment of asthma and the creation of national guidelines to improve its diagnosis and management,[59] noncompliance with asthma medications remains a concern.[39,58] The prevalence and incidence of the disease continues to increase in Canada, which in turn simultaneously increases the challenge involved in properly managing asthma.[6,19,38] Patients with asthma need to be made aware that asthma is a serious disease that can be well controlled with appropriate self-management.[41] Most of the efforts aimed at improving a patient's self-management[22] of asthma have been focused on patient education[41,49] and behavioral modification made directly by healthcare providers.[38,63]

Healthcare systems are generally designed in such a way that they are most accessible for the mainstream culture and do not acknowledge the diverse cultural and ethnic groups' beliefs and practices about health and illness. This issue might prevent healthcare providers from reaching people with different cultural backgrounds and also minorities with low SES to build a mutually trusting relationship in terms of providing understandable and relevant patient education for asthma management. Indeed, the emphasis of most patient education in Canada is on providing written materials that patients take home with them.[11,13,49] Extensive written instructions are often referred to as “written action plans” or “written asthma management plans” (WAMP)[6] and usually include goals of the therapy, doses and frequencies of medication, and actions to take in the event of asthma exacerbations.[6,20,54] However, and as previously mentioned, the fact of mostly relying on written material as the baseline for a patient's education may impede proper communication between the healthcare provider and the patient,[6,11,49,64] particularly among individuals with limited knowledge of the prevailing language.[48] This has a negative impact on patient education as well as on the quality of care and health outcomes.[60] Furthermore, most of the written didactic information is not well suited to people with low literacy or language skills.[3,6,11,48,64] Barriers to asthma information are further exacerbated by the use of medical terminology by healthcare professionals (verbal language of healthcare professionals), which is not understandable to most of the lay population[49] and especially not to people from different ethnocultural communities or those with language/reading difficulties.[44] The format and structure of forms, directions, explanations, and educational materials are also difficult to follow by these groups.[44] Finally, the educational materials and services presented by the healthcare system itself are mainly provided in the context and language of the prevalent culture,[13] which also tends to not be accessible to the aforementioned groups. Therefore, in order to improve asthma outcomes via improving patient knowledge, attitudes, and self-management behaviors, appropriate interventions that take cultural and language differences into consideration should be adopted.[17,39,49]

Another challenge with asthma education is the possible differences between the cultural beliefs and practices of patients with those of healthcare providers.[5,8,49] While educational interventions have been found to be effective in improving knowledge about the disease and use of services in some studies,[3,20,52] providing information by healthcare providers is not always effective in changing patients' behaviors or promoting healthy practices.[3,20,49,63] This is particularly the case among people with different cultural and ethnic backgrounds,[62] a low literacy level,[11,39,41] and those in low socioeconomic brackets.[54] In addition, existing asthma-related management strategies – such as patient-provider partnerships – do not properly address many of the major challenges faced by vulnerable and marginalized populations.[13,49] A study of blacks, Hispanics, and Asians with asthma in the United States found that these groups are less likely to: communicate effectively with care providers; be involved in self-management; understand the severity of their asthma; and practice preventive measures.[9] Consequently, they do not receive optimal asthma care and education.[3,43] As with another example in Australia and the United Kingdom, asthma morbidity and mortality rates are higher in ethnic minority groups and among new immigrants.[11,17,26,45,63] Some of the main contributing factors for this disparity are the patients' failure to comply and follow through on medical regimens that they do not understand, or because they do not culturally agree with the education provided by physicians or the stated rationale for their actions.[49,52]

All of the aforementioned factors present great barriers in educating patients about their illness and treatment, as well as with providing useful and relevant information to those with low knowledge levels of the prevalent language.[11,16,39,41] Given that people with limited literacy and knowledge of the prevalent language may be at risk for multiple adverse health consequences,[11,21,26,56,61] researchers in many developed nations in Europe,[11,45,63] Australia,[17,49,51] and the United States have highlighted the importance of patient-centered care, communication skills, and cross-cultural training of healthcare professionals as a means of improving quality of care and eliminating persistent racial and ethnic disparities.[7,17,36,43,47,56,60] Researchers in these countries have proposed different approaches for this purpose. For instance, as a response to the low literacy rates, language and cultural barriers, and issues in patient education,[13] some researchers have studied visually based printed materials[5] to aid in providing proper asthma education.[11,13] The emphasis in these materials is on pictures, symbols, and stickers rather than on written or verbal supports, which can be provided in various modalities, including pamphlets, flip charts, and videos.[38] The advantage of this approach is that it simplifies the often complex medical information, generating a support that is better suited to those with low literacy[41] or language skills, without necessarily requiring access to new technologies and that can be easily adapted to better respond and be more acceptable to culturally sensitive target communities.[8,31] However, due to mixed findings regarding the use and effectiveness of visual materials reported by some recent studies,[6,27,65] it is both logical and practical to use a combination of written, oral, and visual materials to deliver health-related information to minorities and people from different ethnic backgrounds.

Addressing problems in asthma-related education requires strategies that focus not only on improving the accessibility and level of comprehension of asthma information to all patients, but also on understanding the root of the asthma related problem (ie, sociocultural and environmental factors), evaluating the source of the health information, and communicating the gathered information with others, including the caregivers. In the American and Australian healthcare systems, the strategies that have been applied for improving limited-English-speaking patients' understanding of issues related to asthma and other chronic conditions and also in building proper patient-provider relationships[8,50] include healthcare provided by bilingual/bicultural professionals, the use of bilingual health and culture brokers who can interpret the health materials, and the use of translation via written, oral, or other technologies.[11,48,56] The aim is to ensure that the best available information is supplied to patients in a manner that is accessible and comprehendible to them so that they are willing and capable of following the treatment and recommendations at home.[11,27] However, few studies could be identified in the Canadian literature that have examined the health outcomes of services provided by bilingual physicians, medical interpreters, or culture brokers in chronic diseases.[40] It is possible that the same strategies that have been applied by the American and Australian healthcare systems could also be considered as practical approaches in asthma management among different minority and cultural groups in Canada.

Focus has also been placed recently on improving the communication skills of physicians and other healthcare providers as a part of providing better patient education and in attempts to improve patient adherence to treatment.[13] This involves learning new communication techniques with patients and their families,[44] learning to recognize and assess for low literacy skills, learning to use more visual[28] and kinesthetic teaching/instruction methods,[27] and encouraging the use of surrogate readers and alternative support systems.[27,50] Due to low comprehension among patients about their disease, which in the general population has been shown to be as low as 50%,[38,39,58,59,62] interactive methods such as the teach-back method, in which the patient restates what was said in his or her own words, have been found to be particularly useful.[57] With this method, both the patient and care provider are aware of any miscommunications or misunderstandings and can then control them.[63] The key to successful communication with patients who have lower levels of education or in English proficiency is the establishment of a trusting patient-provider relationship,[55] as well as a partnership in which the patient is considered an active participant in his or her treatment.[1] This partnership in every step of managing asthma is the key for success.[43,54,59] The incorporation of cultural sensitivity and competency is essential if care providers are to understand,[2,4] respond to, and help newcomer or minority patients deal with the concerns they bring to the care providers.[52,56]

Discussion

The pressures of today's healthcare environments generally make it difficult for physicians to spend an extended period of time with their patients, which affects the establishment of a trusting patient-provider relationship, patient education, and the quality of patient care.[41,50] Less time spent with patients translates into an increased reliance on home-based care and written guidance/materials, which may lead to difficulties in comprehension for those with a low level of literacy and language proficiency.[5,13,38] One factor of note in patient-provider communication is the issue of treatment compliance or adherence,[38,45] which is a cause of frustration for many healthcare staff and also affects management of chronic illnesses such as asthma. Many patients do not adhere to the prescribed treatment, partly due to miscommunication between themselves and care providers. This has been noted particularly in specific demographic groups, namely among males, poorer populations, and ethnic minorities.[7] Noncompliance with treatment recommendations may be due to lack of, or inadequate, health literacy, which prevents a person from accessing, understanding, evaluating, and communicating asthma-related information.[5,7,65] The issues of compliance vs patient resistance stem primarily from misunderstandings that occur between healthcare providers and the patient in terms of their beliefs about health and illness.[17,28,42] To improve the patient-provider relationship and communication within it, healthcare providers need to be familiar with various cultural groups and their traditional beliefs and practices, and to also have an understanding of the links between cultural beliefs and health outcomes.[50,56]

The main obstacle in patient-provider communication is considered to be linguistic differences, particularly when the patient's first language, or the language spoken at home, is not the prevalent language of the healthcare system.[38] This presents a barrier in accessing healthcare, prevention services, consultation with healthcare providers, and the long-term management of asthma which may lead to medical errors with serious consequences.[61] Therefore, proficiency in the language used between the care provider and patient plays an important role in the patient's ability to understand and follow the prescribed asthma therapy and recommendations.[15] For many chronic medical problems, patients' reported improvement might be greater after encounters with same-language practitioners than with physicians who do not share their patients' languages.[52] It is then imperative that language be taken into consideration and proper support provided, either by the patient's family or friends or through the use of interpreter services,[56] although it is important to note that translation may not always be literal or completely correct. Translation services have been shown to increase patient satisfaction and therefore facilitate a positive experience of the healthcare system.[54]

Conclusions

Minority groups and immigrants form an increasing proportion of the total population in many Western societies.[24] There is a knowledge gap in the Canadian literature regarding the relationship between culture/ethnicity, health literacy and asthma, and how they intersect. According to the Canadian Asthma Control Task Force,[15] there is no organized approach to systematically collect asthma-related data from diverse population groups in Canada. Despite considerable investments by provincial and federal governments in Canada to prevent and manage asthma by increasing individuals' access to proper information and services,[17] little is known about whether ethnocultural communities use them, when and for what purposes the services and information are likely used, and the perceptions of users towards the services and information. The differences between the patients' and healthcare providers' attitudes and beliefs about illness[39] and how the differences may affect patients' access to proper care and health outcomes is another knowledge gap in the literature. The observed gaps indicate a need for further investigation to address the cultural differences[4] in asthma prevalence, incidence, prevention, and management to provide policy and research recommendations and interventions. There is a need for a more systematic approach to the impact of ethnocultural and health literacy issues on healthcare in general, but in the context of this review, for asthma in particular.

Funding Information

This project was funded by an unrestricted educational grant from AstraZeneca Canada and partly from Social Sciences and Humanities Research Council of Canada.