Healthbeat

Rural governments often fail to communicate with residents who aren’t proficient in English

2024-12-10T16:34:45+00:00

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Eloisa Mendoza has spent 18 years helping people who aren’t fluent in English navigate complex legal documents. She guides them through stressful events and accompanying dense paperwork, such as citizenship applications, divorces, and birth certificate translations.

Mendoza works in Elko, Nevada, situated in a remote region in the state’s northeastern corner. Her work has become increasingly important as the town’s Hispanic or Latino population has grown to about 26%. The share of people age 5 or older who speak a language other than English at home increased to 18% as of 2022, while Spanish is the language spoken in nearly 15% of households.

Despite rising demand for local rural governments to communicate with residents in languages other than English, state lawmakers in Nevada left out smaller counties from a recently enacted statewide language-access law. More state and local governments have enacted similar measures during the past few years, but they’re mostly concentrated in urban or suburban jurisdictions.

Rural America is largely white and predominantly English-speaking but has rapidly grown more diverse. Implementing state and local language-access laws, however, is a challenge, researchers say, given standards can vary across state agencies and localities, making it difficult to ensure high-quality assistance is provided to speakers of various non-English languages.

Not providing language access to people who need it is not only a violation of civil rights protected by Title VI of the Civil Rights Act, but it also can create public health and safety concerns, said Jake Hofstetter, a policy analyst for the Migration Policy Institute, a think tank focused on immigration policy and research.

While language access is a federal protection, 11 states and Washington, D.C., have created broad policies targeted to their populations. And some states have laws targeting specific sectors, such as education or health care. Other language-access laws have taken root in such municipalities as Austin, Texas; Philadelphia; and Portland, Maine.

Pandemic public health info lacking in Spanish

At the height of the Covid-19 pandemic, state and local governments lacking strong language-access systems struggled to communicate vital public health information to diverse communities. An analysis of Covid information posted on health department websites of the 10 most populous U.S. cities found it was not fully provided in Spanish.

Hispanic people in Elko County, a remote region in the northeastern corner of Nevada, make up more than a quarter of the population.

The number of white residents in rural parts of the nation decreased by about 2 million from 2010 to 2020, according to an analysis by the Carsey School of Public Policy at the University of New Hampshire. And the percentage of people who are members of a racial or ethnic minority living in rural areas increased from 20% in 2010 to 24% in 2020, with the largest share being Hispanic.

As of 2021, 25 million people age 5 or older in the United States had limited English proficiency, of whom nearly two-thirds were Hispanic, according to KFF, a health information nonprofit that includes KFF Health News. Nevada is one of nine states where at least 10% of people have limited English proficiency.

According to a 2023 KFF-Los Angeles Times survey of immigrants, about 31% with limited English proficiency said they faced language barriers when trying to access health care. A quarter said they struggled to apply for government financial help with food, housing, or health coverage. And immigrants limited in their ability to speak English were twice as likely to be uninsured as immigrants who were proficient in English, and they had worse health outcomes.

Since the pandemic emergency ended, Hofstetter has seen a significant number of state policies addressing language access, he said, but he doesn’t see many local policies that focus on the issue in rural areas.

Hofstetter said Nevada’s most recent law on language access, approved in 2023, is unique in that it specifically identifies and requires the state’s most populous counties — Clark and Washoe — to create and implement language-access plans. A separate bill, also approved last year, appropriated $25 million to agencies for implementing language access plans.

Eloisa Mendoza works at Family Resource Centers of Northeastern Nevada, where she helps people who aren't fluent in English navigate legal processes and paperwork.

Democratic state Sen. Edgar Flores, who represents part of Clark County and was a co-sponsor on the most recent language-access law, said lawmakers have faced pushback from state agencies for various attempts at strengthening requirements to provide information and documents in languages other than English. He said officials cite limited staffing and funding.

“I think, unfortunately, our rural jurisdictions are already incredibly limited with resources and, at the time of this request, there was a concern that they were not in a position to meet the requirements,” Flores said. “That’s the bottom line.”

He said that while some agencies and jurisdictions had created language-access plans in past years, legislators found they were not always implemented and enforced. For this reason, Flores said, lawmakers decided it would be better to focus on the state’s two largest counties first while they work toward expanding policies to “every ZIP code, every agency.”

“We have folks from all walks of life who have now made Nevada their home,” Flores said. “We have an obligation to them.”

Gaps in language access are nationwide

People living in rural areas may still benefit from a patchwork of resources through state agencies that provide services in their counties or local programs that are required to address language access because of federal funding.

But gaps in the framework of federal, state, and local protections exist nationwide, Hofstetter said.

The degree to which local governments offer communications in languages other than English varies for several reasons, including enforcement of civil rights protections. That enforcement relies on civil rights complaints, which often must be filed by residents who may not know their rights related to language access, Hofstetter said.

Community members may also face resistance from local leaders on expanding access to services and information in other languages. In 2018, Mendoza supported offering ballots in Elko County in Spanish as well as English. County commissioners, three of whom are still on the board, unanimously voted to recommend the county clerk delay offering bilingual ballots as long as possible after questioning census demographic data and stating they didn’t have funding to translate the ballots.

Having access to ballots in their preferred language helps voters better understand initiatives affecting them, many of which are health-related, such as a Nov. 5 ballot question that asked voters to weigh in on whether to enshrine a right to abortion within the state’s constitution. The measure passed with 64% of voters in favor and needs to be approved once more in 2026 to be implemented.

The Nevada Legislature convenes again in February, and Flores said he’s certain there will be at least one language-access bill. Hofstetter said he anticipates more state and local policies addressing the issue within the next few years.

“I would imagine that that’s going to include some rural areas,” he said.

Jazmin Orozco Rodriguez is a reporter for KFF Health News, Healthbeat’s national reporting partner.

Blood test for prostate cancer aims to improve odds for Black men

2024-09-16T12:55:55+00:00

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Leanne Woods-Burnham is a top prostate cancer researcher.

But being a top researcher doesn’t guarantee your relatives get the best care.

Burnham’s husband struggled to persuade a doctor to run a common prostate cancer screening test, even though he was over 40, Black, and had several relatives who had been diagnosed with advanced cancer.

“It was like pulling teeth,” Burnham said. It was especially concerning because Black men have a much higher rate of death from prostate cancer than white men. When caught early, prostate cancer is curable.

Burnham, an assistant professor at the Morehouse School of Medicine, has long thought that standard clinical guidelines don’t match the needs of Black men, as her father was diagnosed with prostate cancer at age 50.

Now she’s accumulating the evidence to prove it. And she has persuaded Grady Health System, the largest public hospital–based system in the Southeast, to revise its prostate cancer screening guidelines in an effort to boost health equity by identifying the disease early among Black men.

One study Burnham conducted found that among 500 Black men, over half had never discussed prostate cancer testing with their primary care physician.

It may come as a surprise to many that there’s a simple blood screening test, the prostate-specific antigen. Detecting high levels of the antigen doesn’t necessarily mean a person has prostate cancer, but it does indicate that further screening is needed. The test is an appealing initial screening option for men who want to avoid a rectal exam.

Dr. Leanne Woods-Burnham, an assistant professor at the Morehouse School of Medicine, researches prostate cancer. She believes the clinical guidelines for screening do not meet the needs of Black men, who die of prostate cancer at a higher rate.

Less aggressive testing is the norm

There are three major authorities on prostate cancer screening guidelines, said Dr. Yolanda Wimberly, Grady’s chief health equity officer. The American Urological Association, the National Comprehensive Cancer Network, and the European Association of Urology recommend screening for Black men between ages 40 and 45.

But the U.S. Preventive Services Task Force, an influential federal body that evaluates evidence and writes clinical guidelines, has not adopted that guideline, instead recommending that men between 55 and 69 years old consider getting the test.

That less aggressive testing recommendation is driven by concerns about overdiagnosis and treatment, according to the task force’s website.

The task force guidelines are adopted by health systems, typically becoming part of electronic workflows that shape how primary care providers interact with patients.

The task force acknowledged the need for more aggressive screening for some Black men with its Grade C recommendation for earlier testing for some patients (“recommendation depends on a patient’s situation”) in 2018.

But, Burnham pointed out, that recommendation is not necessarily integrated into busy providers’ electronic systems.

To meet the needs of Black men in Atlanta, and to try to reduce the prostate cancer mortality rate in the state, Burnham asked Grady Health System to revamp its screening guidelines.

That strategy worked. Grady now screens for prostate cancer in men over 40, Wimberly said, meaning an additional 2,000 men have been added to the list of people who will be tested.

“It’s really a bold move to step outside of what the U.S. Preventive Service Task Force is saying for the general population and realizing that Grady’s population is that high-risk population,” Burnham said. “They’re setting the example.”

Dr. Anuj Desai, a urologist at Georgia Urology who is not affiliated with Grady or Morehouse School of Medicine, said there are stories in everyone’s practice in prostate cancer of a disproportionate risk to the Black population.

“What Grady’s doing is very important. I think it will be impactful, and I think that it will save lives,” he said.

Desai emphasized that men who have higher levels of PSA detected in the screening test don’t necessarily have aggressive cancer.

“It really just gives us information so that we can follow them to prevent complications that otherwise we would have not even had on our radar,” Desai said.

System neglects Black men, at high risk

“African American men die at a higher rate than men from any other race or ethnic group, which was of great concern at Grady,” Wimberly said of prostate cancer. “Through provider and community outreach, Grady can close the disparity gap and achieve health equity.”

In 2021, the latest year for which data is available, over 3,500 new cases of prostate cancer were diagnosed in Black men. In 2022, 411 Black men died from prostate cancer, according to the U.S. Centers for Disease and Prevention.

Black men are twice as likely to die from prostate cancer as white men, Desai said.

Burnham believes Grady is the first major health system to adopt the more aggressive guidelines, and she hopes other hospitals will follow, even if the U.S. Preventive Services Task Force does not.

Grady has also developed a cheeky media campaign to go along with the effort to get more men screened, playing on reluctance to have a physical exam.

“No gowns, no gloves,” is the slogan. “Prostate screening, it’s just a blood test.”

The digital and social media ads are specifically targeted to men over 40 in Fulton and DeKalb County Zip codes with higher rates of prostate cancer, as well as to women who can influence men to get tested, Grady spokesperson Danielle Hackett said. The health system’s campaign also includes a video encouraging screening from Black prostate cancer survivors.

Burnham and her Morehouse School of Medicine team also run a robust community screening program, providing free tests for men at local events. The Prostate Cancer Precision Prevention Program is on track to screen 2,000 men over the next two years.

Earlier this year, the team screened around 100 men at an event at The King Center. Dexter Scott King, son of the Rev. Martin Luther King Jr., died earlier this year of prostate cancer at age 62.

Burnham shares her father’s experience to help encourage screening, and she sees her role as a changemaker in a public health system that has been shaped by systemic racism. Many experiments do not include specimens from diverse patients.

“Then from the science, we go to clinical trials,” which may not be designed to recruit diverse patients, Burnham said. Recommendations like those for prostate cancer screening are not tailored to diverse populations.

“There has been a systemic neglect of diverse populations in medicine and science,” Burnham said.

She is an advocate for a federal law that would require require insurers to provide free PSA tests for high-risk patients at no cost, as many women have no co-pays for mammograms. Several states, including New York and Illinois, have adopted a similar measure.

“We’re part of the population that has been marginalized, but now we get to sit at the decision-making tables,” Burnham said. “We’ve lived it with our families, but now we have our degrees, we have our MDs, we have our PhDs and we’re saying, we don’t like what we’ve seen, and we want to change it.”

Rebecca Grapevine is a reporter covering public health in Atlanta for Healthbeat. Contact Rebecca at rgrapevine@healthbeat.org.