Consumers and providers of healthcare are increasingly culturally and linguistically diverse.1 This diversity brings opportunity as well as challenges. One challenge is the need for providers to overcome communication barriers, which is essential for the provision of quality healthcare services and delivery of community-based health-related educational campaigns. Healthcare providers who are versed in the language and culture of the persons being treated have a greater chance of communicating effectively, which allows for the development of communication campaigns that specifically appeal to special groups.2
Habesha, also referred to as Abesha, are collectively the Semitic-speaking inhabitants and descendants of the Ethiopian and Eritrean regions. Amharic is the predominant language spoken by a significant section of the Habesha people and is widely used in government agencies and the Ethiopian mass media.3 There is currently no universal Amharic term to describe stroke as a cerebrovascular event.4,5 The purpose of this pilot study is to explore the efficacy of introducing the phrase “Ye-Angol Tikat” as standardized terminology to describe stroke as “brain attack” in the Amharic language.
Recent statistics support that stroke is the fifth leading cause of death in the United States and the second leading cause of death worldwide.6,7 Ischemic stroke occurs when blood flow is interrupted to parts of the brain because of pathological changes in the vessels or when thrombi in the circulatory system result in obstruction of blood flow cutting off oxygen and nutrients to the brain tissue. Hemorrhagic stroke occurs when an artery in the brain ruptures and bleeds directly into the brain tissue. Stroke affects people of all ethnic backgrounds, age, and creed. The absence of nomenclature to describe stroke in the native language of the Habesha community likely limits the ability to effectively educate the community about the disease and the importance of seeking immediate medical care.
Communicating the warning signs, symptoms, and preventative care about stroke in a person’s native language is crucial. It is very important that accurate transfer of information with understanding takes place between patients and the healthcare providers.8 This study, and many others like it, has led to the support of the use of trained interpreters in person or digitalized audiovisual means to improve communication during hospital and clinic visits.9 Although this improves communication within the hospital settings, language barriers still pose a limitation on preventive education about diseases such as heart attack, stroke, hypertension, and diabetes because there are many languages that lack a proper native (non-English) terminology to describe these diseases.
Amharic does not have a widely accepted descriptive word or phrase to describe stroke as a cerebrovascular event, which adds the challenge to effectively educate the Habesha community about the disease and the importance of seeking immediate medical care. Coining a descriptive term using lay language, so that the general population could have the correct understanding of what the medical professionals are trying to communicate is not a unique idea. For example, the medically used term “myocardial infarction” is widely understood by English speakers as “heart attack” indicating the sudden, devastating nature of the condition affecting the heart. This logic once more is observed as the medically used abstract term “stroke” is explained to the lay person as “brain attack.”
According to the US Census Bureau brief release, African-born US migrants and citizens have doubled each year since 1970. Nigerians, Ethiopians, Egyptians, and Ghanaians make up 41% of this population.10 Census Bureau data further indicate that Texas is the state with the third largest African-born population. The Ethiopian population in Dallas Fort Worth (DFW) metro area estimate varies greatly. The 2011–2015 Census Bureau American Community Survey 5-year data estimated the population at 11 061. This number is significantly lower than the population estimate by DFW International Alliance and Ethiopian community, that is, 36 000 and 40 000, respectively. Inevitably, however, this estimate does not include Eritrean population in DFW metro area. Eritreans are included in the study because they are descendants of the same origin who still share close cultural similarities, many Eritreans have lived in Ethiopia, and many of them speak the Amharic language especially the ones who were reared in Ethiopia. The Census Bureau also indicates that DFW metro area is the sixth fastest growing of African-born population in the United States, with large Nigerian and Ethiopian populations. This makes the DFW area a desirable location for this pilot study.
This pilot study used snowballing to recruit Amharic-speaking individuals currently living in the DFW metroplex (United States). The study received ethical approval from the University of Texas Southwestern Institutional Review Board. Members of this community who self-identified as Habesha completed a 47-item paper or online survey (both forms were made available and contained identical language). Each participant completed the survey only once. To maintain privacy and confidentiality, the survey collected demographic data without any protected health information (eg, We did not collect names and dates of birth) that could identify individual participants. Participants were initially recruited from churches and social or religious events such as “Mahaber,” “Ekub,” and “Edir.” Snowballing was then used to identify additional locations where large groups of Habesha were likely to congregate (eg, mosques, grocery stores, restaurants, and barbershops). All survey data were entered into a RedCap database. Data analyses were performed using SAS v9.4 (SAS Institute, Cary, North Carolina). Data were first examined for measures of central tendency (mean, median, and interquartile range). Regression analysis and log linear models were used to examine responses comparing persons who self-identified as having medical training (eg, physicians and nurses) and those who denied medical education.
A total of 294 survey responses were collected during a 2-week period in August 2017. Of these, 256 (87%) answered at least 90% of questions. As noted in Table 1, the participants were primarily male (67%) and younger than 65 years. The age range was divided into 3 categories: 18 to 39 years (50%), 40 to 64 years (46%), and 65 years or older (4%). Most, 288 (98%), were born in Ethiopia or Eritrea. Of these, 93% agreed or strongly agreed that a native term for stroke was important (Table 2). There were 17 respondents born in the United States, 14 of which agreed or strongly agreed that a native term for stroke is important.
To assess respondents’ knowledge of stroke signs and symptoms as well as risk factors, the survey included 6 questions with correct and incorrect answers. Only 6% of the participants answered all of the questions correctly that were related to risk factors of stroke, 14% of the people did not correctly identify any of the risk factors for stroke, and 65% of the people correctly identified half of the risk factors for stroke. Six percent of the participants accurately identified all of the signs and symptoms of stroke, 31% got a score of at least 4 of 5 when asked about signs and symptoms of stroke, 18% did not correctly identify any of the signs of stroke, and 60% correctly identified half of the signs of stroke. Our data showed participants who identify the risk factors and the signs and symptoms of stroke correctly were more likely to call 911.
There is support from the Habesha community to disseminate terminology in Amharic that describes stroke. Several different questions were asked to determine whether most of this community wants a native term to describe stroke. Regardless of birthplace, participants overwhelmingly agreed it is important to have a native term. Those born in Ethiopia and those born outside Ethiopia mutually agreed in the importance of having a native term to describe stroke.
The phrase “Ye-Angol Tikat” may provide a means to raise stroke awareness by using a descriptive term of the disease in a culturally unique and familiar setting to the Habesha community. The use of personally descriptive terms is supported by literature. Evidenced in part by the American Heart Association’s successful marketing of “heart attack” as a lay phrase to replace “myocardial infarction,” the neurology and neurosurgery professions have steadily advocated replacing the outdated term “cerebrovascular accident” with more descriptive terms such as “stroke” and “brain attack.”11 Across the globe, the term “brain attack” is increasingly being used to drive awareness.12 Reaching out to certain groups of people in the community in places they frequent is a proven way of health intervention as shown by the Dallas Heart Study, where they successfully used barbershops as venues to monitor blood pressures of African American men and their compliance with antihypertensive treatment.13
To further explore how urgently the respondents will seek emergency medical attention when stroke occurs, the term “Ye-Angol Tikat” in Amharic and the term “stroke” were used in the survey questions. The respondents were slightly more likely (2% greater) to call 911 (activate the emergency medical response system) when the term “Ye-Angol Tikat” was used as compared with the English word “stroke.” The findings show that using a native term to describe stroke does not hinder the population from getting medical help. On the contrary, the study strengthens the idea that, as the term “Ye-Angol Tikat” becomes familiar and widely used, Amharic-speaking Habesha will have more stroke awareness and therefore will seek medical treatment urgently. Although our survey was not random, we were able to obtain a sample that is representative of the Habesha population in the DFW area that closely matches US Census Bureau data. The sample is representative of participants from different demographics with different education backgrounds, ages, sexes, and birthplaces (Table 1).
Most of the participants did not know the risk factors or the signs and symptoms of stroke, but they responded they will call 911 in case of a stroke. It might be that people chose the answer “call 911” by default. For those who use a translator to communicate with their medical provider, it brings up the question of how they are currently translating medical diagnoses such as stroke. Lack of knowledge on stroke signs and symptoms further leads to late arrival to medical treatment and missing out on reperfusion therapy. Estimates support that 65% of patients arrive to the hospital too late to receive reperfusion therapy.14 The reasons for late arrival include lack of access and limited knowledge or awareness of stroke signs and symptoms.15
There are limitations to this study. First, the survey was only produced in English, which presented a potential language barrier because some participants only spoke Amharic. There were 4 people on the research team who spoke Amharic and were able to provide translation when needed. At times, even these team members found it challenging to describe some of the English terminologies in Amharic while translating the questions. The term “Ye-Angol Tikat” could be an unfamiliar term for those who do not know its use in this context. When taken literally, “brain attack” could be interpreted as an injury caused by an attack secondary to some sort of a blunt trauma to the brain. However, this is a problem that will be encountered when the term is presented alone, literally without the context considered here. However, it would likely become less of a problem because it is publicized and used in the appropriate context for a period of time in print and mass media and other venues. The term “brain attack” for stroke is likely to become widely adopted just like “heart attack” has become the layperson’s term for myocardial infarction throughout many cultures. Using descriptive terms such as brain attack or heart attack adequately alerts the victim and is self-explanatory to what actually happens.
The results of this study support that the introduction of the phrase “Ye-Angol Tikat” to inform the Habesha community about stroke could lead to improved receptiveness to seek treatment in case of a stroke emergency. Future community outreach is needed to close the gap created by language barriers and lack of understanding of risk factors and signs and symptoms of stroke. It is hoped that further research and introducing the term “Ye-Angol Tikat” in Amharic will help educate a substantial number of Amharic-speaking people nationwide regarding the devastating effect of stroke in loss of life and permanent disability. The introduction of a native term for stroke, and dissemination of education, in culturally unique venues supports increasing awareness of stroke in the Habesha community and could be a model used for replication in other ethnic minority populations.
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Keywords:© 2019 American Association of Neuroscience Nurses
cerebrovascular accident; cultural sensitivity; health promotion; public health education; stroke prevention