Visual Resources for Postoperative Care to Overcome Language and Cultural Barriers

Plastic & Reconstructive Surgery · 2021 · 6 citations

• Medicine
• Family medicine
• Nursing

Visual patient health information, such as illustrations and videos, improves patient comprehension, recall, and compliance compared to written materials, especially in populations with low health literacy and language barriers.1–4 Surgical mission work in Guatemala exemplifies one such population. Many patients are Indigenous Mayan, unfamiliar with allopathic surgical care, and do not speak or read Spanish, the primary language for the majority-Ladino health care system.5 We surveyed caregivers of such pediatric patients and found only 42.2 percent (27 of 64 patients) preferred speaking in Spanish with their providers, while the rest preferred Mayan languages such as Q’eqchi’, Poqomchi, or K’iche’. Understanding written Spanish provides an even bigger challenge: only 34.9 percent of caregivers (22 of 63) could read Spanish fluently and 23.8 percent (15 of 63) were unable to read at all. Despite working closely with health promoters fluent in Mayan languages, we still witnessed instances of miscommunication, such as worried parents expending precious resources to bring their child to a city health center for evaluation of normal ear fluid drainage after tympanostomy. To improve communication, we enlisted medical illustrators to work with local partners and patient families to iteratively develop culturally appropriate, illustrated postoperative instructions intended to supplement face-to-face provider-patient communication. Over three missions between 2019 and 2020, we refined the instructions to include cleft lip and palate repair, tympanostomy, microtia repair, and hand surgery (Fig. 1) (see Figures, Supplemental Digital Content 1, which shows cleft lip and palate repair postoperative care instructions in Spanish, https://links.lww.com/PRS/E714; Supplemental Digital Content 2, which shows postoperative care instructions after ear tube placement in Spanish, https://links.lww.com/PRS/E715; Supplemental Digital Content 3, which shows drain stripping instructions for after microtia repair in Spanish and English, https://links.lww.com/PRS/E716; Supplemental Digital Content 4, which shows drain removal instructions for after microtia repair in Spanish and English, https://links.lww.com/PRS/E717; Supplemental Digital Content 5, which shows split-thickness skin graft donor-site care in Spanish and English, https://links.lww.com/PRS/E718; and Supplemental Digital Content 6, which shows steps for proper handwashing without running water in Spanish, https://links.lww.com/PRS/E719). The illustrations contain universal symbols, such as emoticons and the prohibition sign, as well as culturally familiar objects, such as tortillas (Figs. 1 and 2). They were designed to address anticipated postoperative concerns, including an illustration depicting normal drainage from the ear after placement of ear tubes (Fig. 3). Families were given paper instructions to take home and sent digital versions via a messaging application. In surveying the effectiveness of the cleft lip and palate illustrated instructions, 90.3 percent (28 of 31 caregivers) reported the illustrations were critical to understanding postoperative care.Fig. 1.: Illustrated Spanish instructions for upper extremity cast care after surgery. Models in the illustrations were based on Guatemalan children. Copyright © artist Elizabeth B. Card.Fig. 2.: Guatemalan foods as liquid, soft, and regular diet following cleft lip and palate repair surgery. Foods depicted are offered in the local hospital (e.g., flavored gelatin) or are common Guatemalan foods. This illustration is adapted from illustrated Spanish postoperative care instructions for cleft lip and palate repair surgery (see Figure, Supplemental Digital Content 1, https://links.lww.com/PRS/E714). Copyright © artist Elizabeth B. Card.Fig. 3.: Middle ear fluid drainage after ear tube placement. These illustrations are adapted from illustrated Spanish postoperative care instructions for ear tube placement surgery (see Figure, Supplemental Digital Content 2, https://links.lww.com/PRS/E715). Copyright © The Children’s Hospital of Philadelphia.During feedback sessions, we learned that some parents wished the illustrated instructions contained their native Mayan language. Given the majority of our Mayan-speaking families cannot read Mayan language, and nearly all have access to a smartphone, we recruited videographers to create a video explaining the instructions in Mayan languages. These videos were then compressed to allow for easy transfer via standard text messaging or social media applications. [See Video 1 (online), which shows cleft lip and palate repair postoperative care instructions spoken in Spanish. See Video 2 (online), which shows cleft lip and palate repair postoperative care instructions spoken in Q’eqchi’. See Video 3 (online), which shows cleft lip and palate repair postoperative care instructions spoken in Poqomchi. See Video 4 (online), which shows ear tube placement postoperative care instructions spoken in Spanish.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video shows cleft lip and palate repair postoperative care instructions spoken in Spanish.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_3skimh6k"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"This video shows cleft lip and palate repair postoperative care instructions spoken in Q’eqchi’.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_orxiivti"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3.","caption":"This video shows cleft lip and palate repair postoperative care instructions spoken in Poqomchi.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_0jrzqzhy"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4.","caption":"This video shows ear tube placement postoperative care instructions spoken in Spanish.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_nujw6qub"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} We encourage other teams with language and cultural barriers to invest in the development of similar locally appropriate visual resources; however, we realize many do not have access to illustrators, videographers, or local artists. Therefore, we established an open-access repository of visual communication resources at smilesforguatemala.org/visual-resources, and have plans to expand to allow for free sharing of culturally specific materials for patient instruction. Our goal is to foster collaborations among global practitioners by allowing other teams to download our resources and upload their own. We hope this repository will be useful within cross-cultural contexts across the United States and abroad, where concise and explicit communication is vital for vulnerable populations. ACKNOWLEDGMENTS The authors would like to thank the all the members of Asociación Compañero Para Cirugía and their health promoters, especially Marta de la Cruz, for their integral contributions throughout this project. They would also like to thank all the members of Smiles for Guatemala, especially Dr. Luv R. Javia and Dr. Ines C. Lin, for writing the text for the instructions, Max Lovitz-Wolfson and Tatiana Prado, who translated the instructions into Spanish, and Don Heebner, who built the website. Finally, they would like to thank the doctors, nurses, and housekeeping staff of the Laboratorio Clínico San Lazaro for their commitment to excellence in patient care. DISCLOSURE The authors declare no competing interests. No funding was received for this article.