Individuals with limited English proficiency (LEP) face substantial health-related challenges. Compared to English-proficient speakers, they have been found to more likely self-report poorer health status,1 to less likely receive preventative care,2 and to less likely have regular access to health care.3 Additionally, individuals with LEP who primarily speak Spanish were less likely to have had their blood pressure or cholesterol checked within the last year3; had higher rates of diabetes, obesity, and disabilities4; and reported higher scores on psychological distress4 when compared to English-proficient and English-only groups.
In a study of Latinos with diabetes, individuals with LEP treated by language-discordant physicians (physicians who did not speak Spanish) were significantly more likely to have poor glycemic control. In contrast, individuals with LEP treated by language-concordant physicians (physicians who spoke Spanish) were no more likely to have poor glycemic control than Latino English-speaking patients.5 Therefore, training health professionals to speak Spanish may help address some health disparities at both the interpersonal and the societal levels in a population with LEP that is primarily Spanish-speaking.
The Hispanic population in the United States rose from approximately 50.7 million in 2010 to about 56.5 million in 2015.6 In 2015, an estimated 41.0% of Spanish speakers spoke English “less than ‘very well.’”7 In 2016, Spanish speakers accounted for 64% of the total population with LEP.8 Thus, a clear need exists to have Spanish-proficient health care providers, including physical therapists.
No estimates were found for the number of physical therapists who possess fluency in Spanish. However, the data do reveal a lack of diversity in the physical therapy profession. According to the American Physical Therapy Association, 91.7% of physical therapist members reported their race as White, and only 2.4% identified their ethnicity as Hispanic/Latino in 2013.9 In contrast, the 2016–2017 Physical Therapist Centralized Application Service Applicant Data Report revealed greater diversity, with 70.27% of accepted applicants being White and 8.21% identifying as Hispanic/Latino.10
Demographic changes in the health care workforce, like those being seen in physical therapy, may or may not translate to providers with the language skills to serve Spanish-speaking individuals with LEP. For the present time, in an effort to respond to the growing population with LEP, many health professions education programs are addressing Spanish proficiency in their curriculum.11–13
REVIEW OF LITERATURE
Examples of Spanish language training in health professions education programs are documented in the literature, including their effects on student attitudes and beliefs about learning Spanish.11–13,15 For instance, the Doctor of Pharmacy Program at Butler University started a Spanish language and culture initiative, which incorporates 5 elective courses, a medical Spanish service-learning course, a 2-week Spanish language and cultural immersion trip, and an advanced practice pharmacy experience.11 Faculty evaluated this initiative 7 years after beginning it. In a written reflection completed at the end of the experience, all students reported an increase in confidence in their ability to provide care for and communicate with Spanish-speaking patients. Since the introduction of the language and culture initiative, the percentage of pharmacy students at Butler University graduating with a major or minor in Spanish increased from 1% (2 students) in 2004 to 11% (11 students) in 2010. This indicates that curricular changes helped to foster an interest in developing Spanish proficiency among its student population.
In the medical school at The University of North Carolina at Chapel Hill, students complete a medical Spanish course, sociocultural seminars, clinical placements, service-learning activities, immersion opportunities, and simulated patient scenarios throughout their curriculum.12 Faculty evaluated the program 4 years after its initiation. When reflecting on the Spanish language curriculum as part of program evaluation, the medical students generally wanted more opportunities to communicate in Spanish. Learners recommended that the program (1) increase contact time with native Spanish speakers; (2) increase the availability of community-based practices with large Spanish-speaking populations; (3) use a more concise, clinically focused medical Spanish textbook; and (4) group students together to provide opportunities to practice with one another.
The Doctor of Physical Therapy (DPT) Program at the University of Texas at El Paso also integrates Spanish language across its curriculum. This curriculum pillar consists of the following: one required Spanish medical terminology course, service-learning with Spanish-speaking community members with LEP, Spanish language learning opportunities threaded throughout the clinical courses, and the opportunity for clinical education experiences with Spanish-speaking clients with LEP.13
The 15-contact hour Spanish course is taught by bilingual physical therapists in outpatient clinical settings over 8 weeks. On a weekly basis, the students receive didactic instruction and practice clinically relevant Spanish with volunteer Spanish-speaking patients. If a student self-assesses as possessing average proficiency of 4–7 with speaking, understanding, reading, and writing Spanish (using the scale from the Language Experience and Proficiency Questionnaire [LEAP-Q])14 upon entering the DPT Program, the Spanish course faculty complete a short in-person interview to determine section placement. For learners who entered the program prior to 2018, students with low proficiency were placed in the beginner section, and students with intermediate Spanish proficiency were placed in the advanced section. Students with average self-ratings of 8–10 were also placed in the advanced section. (Starting in 2018, an intermediate section was added.) At the end of the Spanish course, students receive either a pass or fail grade primarily based on performance on weekly written quizzes and a final practical examination.
In 2017, Villarreal and Pechak15 studied the effect of this curriculum on students' Spanish vocabulary, self-rated Spanish proficiency, and perceived benefits of learning Spanish. From the first semester to the fifth semester, students reported overall improved self-ratings of Spanish proficiency (speaking, understanding, reading, and writing) and demonstrated improved vocabulary test scores. Questionnaire results also indicated that students recognized personal and professional benefits from learning Spanish.
The previous studies offer information relevant to implementing Spanish language training that is specific to health professions programs. Additionally, the literature exploring language learning in general provides insight on effective pedagogy. For example, in order to develop self-efficacy when learning a foreign language, Graham16 suggested teachers provide “mastery experiences” that challenge students but ultimately allow them to succeed. In this study, French students in the low self-efficacy group tended to attribute their lack of success with learning English to “low ability,” where the possibility for improvement is limited by a fixed and inherent quality to oneself. Meanwhile, no student in the high-efficacy group suggested “low ability” as a factor that undermined their success. Instead, students in the high-efficacy group suggested that using learning strategies ineffectively hindered their success. The investigator argued that because students in the high-efficacy group could be trained to more effectively use learning strategies, the barriers preventing success in this group could be more easily addressed than those in the low self-efficacy group. She also highlighted how “social persuasion” can act as a barrier (when forming negative self-comparisons to other students) and a facilitator (when defining success in self-improvement) to foreign language proficiency.16
When considering pedagogy explicitly, Horwitz17 recommended that students go beyond simple translation, vocabulary memorization, or grammar application and instead adopt holistic strategies for language learning. When using holistic approaches and incorporating experiential learning strategies (telecollaborative exchanges, service-learning experiences, and a study abroad program), Moreno-Lopez et al18 noted reduced student anxiety about communicating in Spanish compared to teaching with a traditional classroom methodology. However, transitioning students away from traditional approaches comes with challenges. Brown19 found that students tended to value grammar teaching and overt error correction, which he argued, may lead to frustration when students must use the language spontaneously (as in interpersonal communication).
In an effort to better understand what constitutes effective pedagogy for teaching Spanish in health professions curricula, this study aimed to explore students' attitudes and beliefs about learning Spanish in a physical therapist education program. Understanding the students' attitudes and beliefs will help faculty determine the need for curricular changes. These findings may guide other health professions educators when designing new or improved language training approaches.
The inclusion criteria for participants were as follows: (1) the student was currently enrolled in the University of Texas at El Paso (UTEP) DPT Class of 2018 and (2) the student self-reported that they possessed a beginner or intermediate level of Spanish proficiency upon entering the UTEP DPT Program. Students who reported that they were fluent in Spanish when entering the UTEP DPT Program were excluded.
The primary investigator of this study (who is a member of the UTEP DPT Class of 2018) was excluded from the study. Additionally, a second student who did meet the inclusion criteria was excluded as she assisted the primary investigator with data collection. Sixteen participants volunteered for the study, and all read and signed an informed consent form.
The University of Texas at El Paso Institutional Review Board determined this study to be exempt. The study had 2 parts: an online survey and focus groups.
For part 1 of the study, all 16 participants completed an online survey (Appendix A, Supplemental Digital Content 1, http://links.lww.com/JOPTE/A60). Each was assigned a unique identification number by the co-investigator. Only she had access to the key in order to protect student confidentiality for part 1 of the study. Participants answered questions regarding their age, gender, race/ethnicity, geographical region of upbringing, and overall self-assessment of Spanish proficiency when he/she first entered into the DPT Program. Using the scale from the LEAP-Q,14 students also self-assessed their level of proficiency on a scale from 0 to 10 (0 being “none” and 10 being “perfect”) regarding speaking, understanding, reading, and writing Spanish. They ranked their Spanish proficiency for these items for 2 points in time: when they matriculated and at the time of the study (semester 5 of 8 in the DPT Program).
The remainder of the online survey was adapted from the Spanish Language Learning and Beliefs and Attitudes Questionnaire used in a study conducted by Villarreal and Pechak.15 The participants identified which Spanish medical terminology course section they were placed in (beginner or advanced) as well as whether they agreed with their placement. They specifically indicated the percentage they thought they had improved in overall Spanish proficiency since the start of the DPT Program and how much they thought they would improve by the end of the final semester of the DPT Program. Finally, they rated their level of agreement with each of the 13 statements concerning attitudes and beliefs about learning Spanish using a Likert scale. Participants provided answers to this online survey using Qualtrics,20 an online survey administration tool.
Using demographic data collected from part 1, the researchers used purposive sampling to create 2 focus groups: beginner and intermediate. The first focus group included all 5 of the participants who were beginner Spanish speakers. The second group consisted of 6 of the 11 participants who were intermediate Spanish speakers, with participants purposively selected to represent varied responses regarding whether they self-identified as Hispanic, Latino, or of Spanish-origin and whether they indicated their geographical region of upbringing as being on the US/Mexico border. The primary investigator scheduled the focus groups within 2 weeks of completion of the online survey.
Across medical21,22 and nursing23 education programs, focus groups have been conducted to evaluate student perceptions about the effectiveness of new initiatives regarding curriculum/program development. This methodology has been used to get detailed responses from students in an environment conducive to discussion. They are semi-structured in nature; facilitators follow a prewritten script but also prompt discussion with nonscripted questions to allow participants to elaborate on their responses.21,24,25 Focus groups typically comprised of 3–10 participants21,25; responses are often audio taped in order to produce a transcript for later content analysis.21,23,26
Prior to the initiation of the focus groups, each participant was randomly assigned an identifier (eg, A1, B2, or C3) to maintain their anonymity. Additionally, each of the questions from the focus group script (Appendix B, Supplemental Digital Content 2, http://links.lww.com/JOPTE/A61) was randomly assigned in advance to one of the participants to answer. During each focus group, the co-investigator (C.P.) facilitated reading from the focus group script while asking probing questions when appropriate. The facilitator structured the focus groups based on training she received in a prior study. In the aforementioned study, a consultant with expertise in focus group methodology guided the study design and conducted the focus group.27 Each of the 13 statements concerning attitudes and beliefs about learning Spanish from the online survey was projected one-by-one on a screen. At the same time, the predetermined participant was asked whether he or she agreed/disagreed with the statement and why. After the participant provided his/her answer and reasoning, the facilitator then asked the other participants if they had anything to add or elaborate on. After others provided input, the focus group continued with the next statement.
The beginner Spanish focus group lasted 57 minutes and the intermediate Spanish focus group lasted 49 minutes. The primary investigator took notes using a laptop computer and audio recorded each focus group. After both focus groups were completed, the primary investigator transcribed the audio recordings to generate verbatim transcripts. The recordings were then compared to the transcripts a second time to ensure transcription accuracy.
Part 1: Online Survey
Descriptive statistics were used to examine responses to the online survey, including participant characteristics.
Part 2: Focus Group
QSR International's NVivo 11 Software was utilized for qualitative data management.28 The co-investigator had been using qualitative methodology and NVivo software for over a decade; she trained and supervised the primary investigator who had no prior experience. After initial training with the software and practice with the data, each investigator independently performed content analysis of the transcripts and identified themes. They then reconvened to compare their individual analyses, identify discrepancies, and resolve them by adding, combining, or deleting themes. After the investigators reached agreement on the major themes for each focus group, the primary investigator then coded the qualitative data for each focus group using the agreed-upon themes. Some data were coded under multiple themes depending on relevance. However, the primary investigator attempted to minimize these instances unless the data considerably reinforced more than one theme. The co-investigator subsequently reviewed the coding to verify agreement between the researchers.
Three forms of triangulation were used in this study.29 Implementing analyst triangulation, 2 investigators were involved in data collection and analysis. The researchers also utilized methods triangulation by comparing qualitative data from the focus groups to aggregated quantitative findings from the survey. Finally, they completed triangulation of sources by collecting data from multiple participants with varying Spanish proficiency at different points in time. The fourth method of triangulation, theory/perspective triangulation, was not used in this study.29
Table 1 summarizes participant demographics for the online survey, and Table 2 displays participant demographics for the focus groups. Of note, a greater percentage of the intermediate focus group identified as Hispanic, Latino, or of Spanish origin (54.5% vs 20.0%) compared to the beginner focus group, and more identified their region of upbringing from a US/Mexico border region (63.6% vs 20.0%). On average, participants in both groups reported improvement in Spanish-speaking proficiency from the start of the DPT Program to the fifth semester (1.3 points in the beginner group; 1.4 points in the intermediate group). Participants in both groups also reported an improvement in proficiency of understanding Spanish from the start of the DPT Program to the fifth semester (an average of 0.7 points in the beginner group; 1.0 points in the intermediate group). From baseline to the fifth semester, the beginner group reported a greater perceived overall improvement in Spanish proficiency when compared to the intermediate group (51.0% vs 26.0%). However, when asked about perceived projected improvement by graduation, participants in the beginner group reported an anticipated improvement of just 11.0% while participants in the intermediate group reported an expected 21.7% improvement.
In this study, the investigators defined statements that had at least 70% of participants report “agree”/“strongly agree” or “disagree”/“strongly disagree” as those that received a “strong majority” of shared responses. As seen in Table 3, a strong majority of each group reported that they “agreed” or “strongly agreed” with positive statements in the online survey: statements 2, 3, 7, 8, and 10. However, responses revealed that not all positive statements were supported by both groups. Only the beginner group participants generally agreed with statements 4 and 9. Meanwhile, only the intermediate group agreed with statement 11.
In contrast, a strong majority of each group reported they “disagreed” or “strongly disagreed” with negative statements in the online survey: statements 1, 6, and 13. Only the beginner group had a strong majority disagree with statement 5.
Overall, however, the survey revealed that participants had positive attitudes about learning Spanish in a DPT program. Most participants from both groups had personal and professional goals to improve their Spanish proficiency. Additionally, the majority believed that they personally and professionally benefited from working on improving their Spanish language proficiency during their DPT education.
The results from both focus groups support the survey findings. Specifically, all focus group participants expressed positive attitudes and beliefs about learning Spanish in a DPT program.
Six major themes emerged from the beginner focus group. These were constructive learning environment, need for more integrated Spanish learning opportunities, demographic relevance, gap between wanting and doing, grades as a facilitator and barrier, and therapeutic relationships. Table 4 provides examples of representative quotes.
Theme 1: Constructive Learning Environment
The most prominent theme was that participants valued having a constructive learning environment, where each student could make errors and receive constructive feedback. They practiced Spanish with their classmates and mock patients during low-risk case scenarios without fear of causing harm to real patients.
Theme 2: Need More Integrated Spanish Learning Opportunities
When considering the Spanish curriculum, the students recommended additional formal integrated Spanish learning opportunities. They identified a “gap” between the Spanish terminology course offered during their first semester and the infrequent times when they were obligated to practice Spanish in later clinical courses. All agreed that there were limitless informal chances to practice Spanish with Spanish-speaking individuals on and off campus. However, they admitted to not pursuing these opportunities independently. Thus, they recommended increasing the number of structured and required Spanish learning experiences across the curriculum.
Theme 3: Demographic Relevance
Students not from the El Paso region reported that before living in a predominantly Spanish-speaking community, they failed to recognize the need for developing their Spanish proficiency. After living in El Paso for over a year, they recognized Spanish proficiency as an important factor in community integration. The student from El Paso mentioned a desire to stay after graduating. She stated that improving her Spanish proficiency was an important professional goal of hers because of the region's demographics.
Theme 4: Gap Between “Wanting” and “Doing”
An emergent theme in the students' responses was a gap between “wanting” and “doing.” The students demonstrated a strong, new found desire to improve their Spanish but did not actively put that desire into action. They reported rigorous courses and lack of time as major barriers to developing Spanish proficiency. However, several of the students also attributed this discrepancy to an internal barrier; they admitted that even when they had free time, they did not take the initiative to practice.
Theme 5: Grades as a Facilitator and Barrier
When reflecting on grades as another external influence, students identified them as both a facilitator and a barrier. In general, students reported that grades helped keep them accountable for practicing Spanish. However, because grades were not assigned for Spanish-related activities after the first semester, one student reported that learning Spanish was not a priority as she progressed through the curriculum. Another student mentioned she initially had a fear of failing out of the program because of her lack of Spanish proficiency. While students demonstrated a desire for more integrated formal Spanish learning opportunities, they preferred to be graded with a participation grade instead of a letter grade.
Theme 6: Therapeutic Relationship
Overall, students agreed that improving their Spanish proficiency helped them develop therapeutic relationships with predominantly Spanish-speaking patients. However, because their Spanish proficiency was limited to health care-related vocabulary and phrases, some reported not being able to hold general conversations in Spanish. This lack of proficiency undermined their ability to develop genuine relationships with patients.
Seven major themes were identified from the intermediate Spanish focus group. These were constructive learning environment, cultural heritage, significant personal relationships, therapeutic relationships, demographic relevance, need more integrated Spanish learning opportunities, and professional asset. Table 5 displays representative quotes.
Theme 1: Constructive Learning Environment
The most prominent theme was that students benefited from having a constructive learning environment where they could make mistakes while attempting to practice Spanish. They contributed to this positive environment by helping each other practice and giving constructive feedback. However, they also identified moments when having more fluent Spanish speakers in their section of the course served as a barrier for learning because of the disparity in proficiency levels.
Theme 2: Cultural Heritage
Several reported that being proficient in Spanish was an important aspect of their identities as Hispanic/Latino individuals since language connected them with their heritage and family in Mexico. Some, however, also identified anxiety associated with having only intermediate proficiency as a Hispanic/Latino. They reported internalized guilt for not having gained fluency in the language, often stemming from expectations of society and their own family or even personal expectations that they should be able to speak Spanish fluently.
Theme 3: Significant Personal Relationships
Students had mixed experiences with having a family member, friend, significant other, or someone close to them who speak Spanish predominantly. For those who did, all stated that these relationships served as a motivator to improve their Spanish. However, others indicated this as a source of anxiety when actually speaking it with them. Those who did not have a significant personal relationship with someone who spoke Spanish predominately reported a lack of opportunity to practice outside of class, which hindered improving their Spanish proficiency.
Theme 4: Therapeutic Relationships
Students reported that their Spanish proficiency had advantages and disadvantages for developing patient rapport in the workplace. Some noted that speaking Spanish helped them communicate with Spanish-speaking patients and helped them gain their respect. However, other students mentioned that communicating ineffectively because of their lack of proficiency actually could undermine a patient's trust in their competency as a physical therapist.
Theme 5: Demographic Relevance
There were differing views when considering the utility of Spanish proficiency beyond the US/Mexico border region. Some students mentioned that learning Spanish was necessary in order to address the growing Hispanic population in the United States and in the region. Other students argued that while the population was indeed growing, being proficient in Spanish would only be useful regionally.
Theme 6: Need More Integrated Spanish Learning Opportunities
In general, students demonstrated a desire to have more frequent formal chances to speak Spanish in class. They noted that the current curriculum does include some Spanish learning activities in some clinical courses. However, they were interested in having more experiences that were structured so they would be forced to use their Spanish.
Theme 7: Professional Asset
Students often reported a level of professional benefit from speaking Spanish proficiently. They asserted that employers would view them as more marketable when compared to their non–Spanish-speaking colleagues. They reported that Spanish proficiency would not only help them develop relationships with patients but would also help them perform evaluations more efficiently and effectively with patients with LEP.
DISCUSSION AND CONCLUSION
The purpose of this study was to explore students' attitudes and beliefs about learning Spanish in a physical therapist education program. The quantitative survey revealed that participants had positive attitudes and beliefs about learning Spanish in a DPT program. The qualitative data from the focus groups supported the survey findings. Additionally, the results from the focus groups provided the investigators with a deeper insight into what the participants perceived as supporting or impeding their learning. By understanding the students' attitudes and beliefs, faculty will be able to assess the need for curricular changes. The findings may also help guide other health professions educators when designing new or improved language training approaches.
Participants in both the beginner and intermediate focus groups noted that a constructive learning environment supported their desire to learn Spanish. Educators should intentionally design learning experiences to address failures as part of the overall learning process and to provide students with “mastery experiences” that challenges students at a level they could succeed at; Graham16 identified this approach as a way to foster self-efficacy when learning a foreign language.
The participants in both groups also reported they wanted to improve their Spanish proficiency so that they could enhance their therapeutic relationships with patients with LEP. Gonzalez et al noted that patient–provider language concordance was “significantly associated with a lower likelihood of confusion, frustration, and language-related poor quality ratings, and was positively associated with patient-reported overall quality of care.”30(p745) In designing Spanish language training in their curricula, health professions educator should consider incorporating experiences that reflect students' values for enhancing therapeutic relationships.
Both groups also indicated a need for more formal and integrated Spanish learning opportunities where students were forced to practice. However, the literature shows that improving Spanish proficiency requires more than just having “more opportunities” to practice one's Spanish.18 In a study published by the American Council on the Teaching of Foreign Languages, Moreno-Lopez et al18 highlighted the importance of giving learners additional experiences outside of the traditional language classroom and spending greater time face-to-face with Spanish-speaking individuals.
To address these shared themes, educators might consider incorporating cooperative learning techniques in their curriculum. Unlike competitive and individual-centered structures often found in the traditional classroom setting, cooperative learning techniques depend on small group participation grounded in positive interdependence for language learning.31 This structure shifts the classroom dynamic from passive learning to active, engaged participation. One example of this technique is jigsaw strategy, where “each member of a group has a piece of information needed to complete a group task.”32(p114) In 2010, Mengduo and Xiaoling32 found that after a 10-week college English class utilizing jigsaw strategy, students reported several benefits: more active engagement during class; more recognition that each member's effort was integral for group success; and more positive views toward face-to-face interaction. Moreover, Suwantarathip and Wichadee33 found in their 2010 study that after 14 weeks of English language instruction incorporating in cooperative learning activities, students reported reduced anxiety when speaking English across all proficiency levels and improved language proficiency determined by performance on an English proficiency test. Incorporating cooperative learning activities in Spanish across a DPT curriculum may help educators create the positive learning environments that students value.
When considering themes from each group explicitly, the beginner group's motivations for learning Spanish were more extrinsic than the intermediate group. Their responses concerning grades demonstrate the need for external accountability. With this in mind, educators might consider incorporating Spanish into a minimum of one course each semester and assigning a grade for participation. This is distinct from the current UTEP DPT curriculum because participation in the integrated Spanish learning opportunities were not graded. This strategy could, in turn, help to bridge the gap between wanting and doing. It would provide beginner students in particular with an external incentive to continue improving without adding the stress of grade based on mastery.
While the intermediate group's motivations were more intrinsic than the beginner group, it is important to consider which type of motivation can lead to faster and/or greater rates of improvement in Spanish proficiency. In a study of students enrolled in introductory-level Spanish courses from 2 suburban high schools in San Diego, Lee34 compared the effect of motivation type on grade achievement in the previous 2 semesters/quarters of the year. The investigator found that students who were driven by integrative motivation had better grades than those driven by instrumental motivation. Specifically, students who had an “interest in participating in sociocultural activities and willingness to identify with the second language group”34(p92) performed better than students who were motivated by “employment opportunities, career advancement, reading technical/specialized materials, and translation.”34(p92) With this finding in consideration, health professions educators should not overlook the importance of cultural competency and community immersion experiences when designing Spanish learning experiences.
This study did not address whether the participants truly improved their Spanish proficiency. The participants in the beginner group self-reported an average improvement of 1.3 points (on a scale from 0 to 10) from the first to the fifth semester, and participants in the intermediate group self-reported an average increase of 1.4 points. The developers of the LEAP-Q determined that their tool was valid for determining language proficiency14; however, only the scale from the LEAP-Q was used by the participants to self-assess, not the entire tool. Additionally, the participants' self-assessment of baseline proficiency was collected retrospectively. Thus, the investigators are unable to conclude anything about actual gains except that the participants believe that their Spanish proficiency had improved. Researchers at the UTEP DPT Program are in the process of revising and validating a measure that English–Spanish bilingual physical therapist faculty and clinicians may use to rate students' clinically relevant Spanish proficiency.35 If validated, this tool may be useful for assessing improvements in physical therapist students' Spanish proficiency.
While attempts were made to limit threats to research validity, the investigators recognize the potential for bias. One limitation introduced in this study was using one of the DPT Program's faculty member as the focus group facilitator; participants' responses may have been influenced by having their professor in the room. Having a focus group facilitator that participants did not know would have eliminated this potential influence.
Another limitation is that some participant statements were coded under more than a single theme. For example, some students reported that they wanted to improve their Spanish proficiency to communicate with their family in Mexico. Depending on the wording of their response, their statement may have been coded under “Cultural Heritage,” “Significant Personal Relationship,” or both. However, the investigators minimized instances of coding under multiple themes, unless a statement considerably reinforced more than one theme.
Additionally, member checking was not performed as a verification method after the focus groups. Specifically, the proposed themes were not sent to the participants to determine if they agreed with them. Attempts were made, however, during each focus group to ensure that what was documented in the transcript was what the participant intended to communicate, using probing questions such as “did I understand you to mean…?”
This study also excluded individuals who self-identified as fluent, but the students did not take a standardized assessment to quantify their Spanish proficiency. As such, this study may have omitted students who may not test at a “fluent” level as determined by a standardized language proficiency examination. Irrespective of how these students might have performed, the investigators chose to exclude these self-reported fluent students because their viewpoint toward learning Spanish might be different from a speaker of intermediate proficiency. Future research is recommended to understand that specific student population's experience with advancing their Spanish proficiency, particularly related to formal medical terminology.
Finally, in contrast to the previously described demographic profile of physical therapists and accepted applicants,9,10 the participants in this study represented greater diversity. Of the 16 participants who completed the online survey for this study, 7 participants (43.8%) identified as Hispanic/Latino. Additionally, 8 participants (50%) identified their region of upbringing on the US/Mexico border, and all were in a DPT program located on the US/Mexico border. Therefore, the attitudes and beliefs about learning Spanish of the participants in this study may differ markedly from those of students in most other DPT programs. Health professions educators at other institutions may face the unique challenge of first convincing their students to recognize the value of improving their Spanish proficiency.6–8 Nonetheless, our study findings still have relevance to other DPT programs. Purposive sampling ensured that the focus groups included participants from outside the region who are not Hispanic/Latino and who do more closely represent demographics seen in other DPT programs.
In conclusion, students in the beginner and intermediate focus groups provided unique perspectives related to their attitudes and beliefs about learning Spanish in a DPT curriculum. While some themes emerged that were consistent between groups, others were specific to the participant's level of proficiency. This study provides several recommendations on how to incorporate Spanish language learning experiences in the curriculum of health professions education programs, including but not limited to promoting a constructive learning environment, focusing on developing therapeutic relationships, and integrating more learning opportunities outside of the classroom. These practical recommendations may serve as a guide for the design or enhancement of Spanish language training models in health professions curriculum.
The primary author was supported by the UTEP Graduate School 2017 Summer Research Assistantship to complete this research. We would also like to thank students from the UTEP DPT Class of 2018 for their participation in this study.
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