Improving access to services during labor and delivery for Latina immigrants: Using qualitative and quantitative metho

1. Improving access to services during labor and delivery for Latina immigrants: Using qualitative and quantitative methods to create evidence-based clinical professional development strategies Tilly A. Gurman, MPH, DrPH Candidate Allisyn C. Moran, PhD, MHS American Public Health Association Annual Meeting November 7, 2006

2. Background: • Latinas less likely to initiate prenatal care until after 1st trimester1 • Misunderstanding by staff and lack of patient-provider communication2 • Use of interpreters3 • Improve satisfaction • Reduce medical errors Sources: 1. Lillie-Blanton M et al. (2003) 2. Kagawa-Singer (2003); Andrulis D, Goodman N, & Pryor C (2002); and Documét & Sharma (2004) 3. Flores et al. (2003); Andrulis D et al. (2002); and Morales LS et al. (1999)

3. Objectives • Explain barriers to accessing services during labor and delivery (L&D) as experienced by Latina immigrants • Identify factors that predict inappropriate use of interpreters by clinical staff in L&D • Describe how qualitative and quantitative methods can identify cultural competency training needs for clinical staff in L&D

4. Methods Qualitative: • Latina immigrants who delivered in area hospitals during last 12 months • Twelve in-depth semi-structured interviews (n=6) • Two focus groups (n=7) Quantitative: • Labor and delivery clinical staff in 5 hospitals in mid-Atlantic city (n=200) • Self-administered anonymous survey

5. Analysis Qualitative: • Review transcripts and identify recurrent themes Quantitative: • Factor analysis to develop indices • Inappropriate use of interpreter • Linear regression

6. Qualitative Results: Patients experienced suboptimal quality of care due to poor communication with clinical staff, resulting in failure to understand analgesia, laboratory tests, and discharge instructions … yet they were pleased with the quality of care they received

7. Qualitative Results: Respeto and confianza: “… I think that I wouldn’t be nice, because they have everything very well prepare. They are well educated. But me, one who doesn’t know anything can’t give their opinion on something like this”

8. Qualitative Results: Familia: Family members and friends were crucial links to the health care system.

9. Qualitative Results: “…they had more women on the floor… all the women there crying, the pain. There was no room inside to lay them down or to take care of them.” “…Not like there, because there, one is raised like a little animal. It’s not like here, here they take care of the babies, and they take care of the sick.” Comparison with country of origin:

10. Provider Characteristics • Occupation: 46% clinicians; 54% nurses • Gender: 82% female; 18% male • Race/ethnicity: 57% White; 2.5% Latino 23% African American; 11% Asian American • Language: 6.5% fluent Spanish • Confident in ability to meet needs of Latinas (47.5%) • Belief that receiving training is very important/important (88.5%)

11. Quantitative Results: Inappropriate use of interpreter • Latino ethnicity (β=8.9; p=0.01) • Importance of credibility of individual introducing new practice guideline (β=2.88; p=0.006) • Belief that family members can serve as appropriate interpreters (β=1.77; p=0.001) • Use of general mass media channels as source of information regarding medicine (β=1.70; p=0.006) • Belief that a patient’s country of origin can predict health behaviors (β=1.58; p=0.001)

12. Implications: Value of obtaining patient voices • Provides narratives to use as examples and case studies during trainings • Discordance between experiencing substandard care and patient satisfaction • Identified potential interventions for patients • Feedback to hospital sites about assessing patient satisfaction

13. Implications:Professional development strategies • Importance of cultural and religious beliefs in health-related behaviors • Discourage stereotyping patients based on country of origin • Encourage using professional media for information

14. Final products • Individualized reports summarizing survey findings • Tailored professional development strategies • Used reports to guide the curriculum for each site • Used qualitative findings to give voice to patients • Video created for patients used to guide discussions with providers about appropriate use of interpreters

15. Conclusion Obtaining the voices of patients through qualitative methods, in combination with the quantitative surveys of providers, allowed for the creation of more comprehensive strategies for ensuring cultural competency for clinical staff in L&D

16. Sources Cited Andrulis D, Goodman N, & Pryor C (2002). What a difference an interpreter can make: Health care experiences of uninsured with limited English proficiency Boston, MA: The Access Project. Documét, P. I. & Sharma, R. K. (2004). Latinos' health care access: Financial and cultural barriers. Journal of Immigrant Health, 6, 5-13. Flores, G., Laws, M. B., Mayo, S. J., Zuckerman, B., Abreu, M., Medina, L., & Hardt, E. J. (2003). Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. Pediatrics, 111, 6-14. Kagawa-Singer, M., & Kassim-Lakha, S. (2003). A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Academic Medicine, 78(6), 577-587. Lillie-Blanton M, Rushing OE, & Ruiz S (2003). Key Facts: Race, Ethnicity, and Medical Care Kaiser Family Foundation. Morales LS, Cunningham WE, Brown JA, Liu H, & Hays RD (1999). Are Latinos less satisfied with communication by health care providers. J Gen Intern Med, 14, 409-417.