Reflections on Obstacles to Stroke Awareness in Spanish-Speaking Hispanic Populations: Lost in Translation

Stroke prevalence for Hispanic groups in the United States is projected to increase by 29% by 2030, with the highest increase estimated to occur in Hispanic men.1 Given that stroke is a leading cause of mortality and disability in Hispanic populations, and the time sensitivity of acute medical treatment of stroke, there is an urgent need for stroke awareness campaigns culturally and linguistically tailored to Spanish-speaking Hispanic populations. Studies have shown poor awareness of the signs and symptoms of stroke in US-based minority communities, including immigrant and US-born Hispanic adults.2,3 Studies on stroke literacy disparities have shown that language and communication are significant barriers to stroke awareness among the estimated 16 million Hispanic adults in the United States with limited English-speaking proficiency.4 These barriers are reinforced by the diversity of Spanish medical terminology and existing structural inequities.4,5 Hispanic adults' recall of health information and satisfaction with healthcare provider interaction are related to practitioners' cultural competency, including their regard for patients' language preference.6 Spanish is identified as a native language by many Hispanic populations; however, there are inherent differences in terminology among the various dialects.4 For example, the word stroke translates to “ictus” in Spanish; however, this term is often unrecognized by some Spanish-speaking populations.4 The term more commonly recognized is “embolia”; however, other translations exist including “infarto cerebral,” “trombosis,” or “accidente cerebrovascular.”4 The healthcare and lay community may describe medical terms differently, which may further decrease Spanish-speaking Hispanic adults' access to patient-centered and empathetic stroke awareness education.4 Despite the large and increasing Hispanic population in the United States and the need to increase stroke literacy in this group, no culturally tailored and linguistically appropriate version of the commonly used FAST7 (Face, Arm, Speech, and Time) or BE-FAST7 (Balance, Eyes, Face, Arm, Speech, and Time) acronym has been validated in Hispanic groups with limited English-speaking proficiency and widely adopted in Spanish stroke awareness campaigns. Although comprehensive courses and educational programs for Spanish stroke awareness exist,4,8 an acronym may help learners recall procedural tasks (eg, activating emergency medical services) quickly when faced with distractions (eg, stroke symptoms). Mass public education using FAST7 has been associated with a greater likelihood of activating emergency medical services at a population level.7 However, the FAST7 and BE-FAST7 acronyms may not be sufficient for Spanish-speaking Hispanic populations with limited English-speaking proficiency. A research team in Costa Rica created CAMALEON, which stands for CAra (face), MAno (hand), LEnguaje (language), and telefONo (telephone).9 CAMALEON includes 3 common stroke signs and symptoms including slurred speech, weakness in 1 arm or leg, and facial drooping.9 However, the acronym does not address the vision changes and lack of coordination or balance that are signs of stroke and often present in English-language stroke awareness campaigns. In addition, the word CAMALEON translates to chameleon and does not stress the urgency in activating emergency medical services in the same way the word FAST7 does in English. Furthermore, CAMALEON is a tailored approach to stroke literacy for Hispanic individuals in Costa Rica, but it may not meet the needs of speakers of diverse Spanish dialects across the United States. Current stroke education campaigns for Spanish-speaking Hispanic adults in the United States often include content with verbatim translations of the English educational tool. In the Spanish translation of FAST, the F represents “rostro caído,” which is facial drooping. Each letter follows a similar pattern, and when the Spanish stroke signs are listed, their initial letters do not form the word FAST7 as they do in English (ie, R = rostro caído, B = brazo débil, D = difficultad para hablar, T = tiempo de llamar al 911 [RBDT]), which may lead to difficulty in recalling the acronym and its messaging. Language discordance creates a gap in the translational accuracy of FAST7 for Spanish-speaking Hispanic adults, limiting the call to activate emergency medical services quickly. Researchers in the United States have created the acronym AHORA,10 encompassing the elements of BE-FAST7 in Spanish. Although the acronym translates to “now” in English, “ahora” alone does not emphasize urgency unless it is paired with the Spanish word “mismo,” because “ahora mismo” implies immediately or urgently. The word “ahora” on its own is more commonly used to mean “the present moment” or “in a minute.”10 Furthermore, additional text is necessary to indicate the need to activate emergency medical services quickly. The text associated with the acronym itself does not include the call to action. Our nurse-led group has created the acronym RÁPIDO, which means fast in Spanish and also encompasses the elements of BE-FAST7 in Spanish; the R is for “rostro caído” (facial drooping), A is for “alteración del equilibrio” (alteration in equilibrium), P is for “pérdida de fuerza en un brazo o pierna” (unilateral weakness), I is for “impedimento visual” (visual impairment), D is for “dificultad para hablar” (difficulty speaking or understanding speech), and O is for “obtenga ayuda rápido, llame a emergencia!” (obtain help fast, call emergency services!).11 Although these Spanish stroke awareness acronyms have been created, there remains an urgent need to validate these acronyms in a representative population of Spanish-speaking Hispanic individuals living in the United States, with careful methodological considerations for acculturation and limited English-speaking proficiency. Furthermore, the benefits of Spanish-speaking individuals saying the word “stroke” in English when speaking to emergency services personnel in the United States also need to be considered in Spanish stroke awareness campaigns. Satisfaction with healthcare and trust in healthcare systems are significantly associated with perceived racial bias in the healthcare system.12 Discrimination is a concern for Hispanic populations, and limited English-speaking proficiency may serve as a barrier to equitable healthcare for Spanish-speaking Hispanic individuals.12 Culturally and linguistically competent healthcare and education result in better patient outcomes, as language concordance promotes trust and reduces perceived discrimination.12 Neuroscience nurses assume pivotal roles in the achievement of evidence-based and patient-centered healthcare and education. Therefore, the need to increase stroke literacy in Spanish-speaking Hispanic individuals and those with limited English-speaking proficiency must be met with careful cultural and linguistic considerations in developing an appropriate educational tool to increase stroke sign and symptom awareness. English-proficient Hispanic groups may also benefit from a Spanish stroke awareness acronym because this may be more culturally appropriate and relatable than current stroke awareness acronyms in English that lack a culturally tailored approach to their messaging. Once a culturally tailored, linguistically appropriate stroke awareness acronym is validated and adopted, a nationwide Spanish stroke awareness campaign can be launched, with the aim to increase recognition of the common stroke signs and activation of prompt lifesaving emergency medical services for Hispanic groups in the United States. The effort required by neuroscience nurses and others to accomplish these goals would be offset by subsequent improvements in clinical outcomes and quality of life after stroke, and healthcare costs, potentially saving millions in stroke-related healthcare expenditures in the United States. These efforts can also be considered responsive to existing neuroscience nursing and American Heart Association research priorities that address persistent health disparities in minority populations.5,13