“Hispanic Cultural Competence for Medical Education Curriculum”

1. “Hispanic Cultural Competence for Medical Education Curriculum”

2. Hispanic Cultural Competence Medical Education Curriculum Introduction • Hispanics are the largest ethnic group in the United States (40 million or 14.5 of the total U.S. population) • In order to promote the health of Hispanics, the largest group of the workforce of the near future, it has been recognized that it is important to develop “cultural competence” staff training in various sectors of the health system.

3. Hispanic Cultural Competence Medical Education Curriculum Introduction • Through this project, the NHMA will complete the following: • Collect “Cultural Competence” definitions • Collect “Cultural Competence” books and journal articles • Develop a virtual library of information focused on cultural competence and Hispanic health • Conduct a literature search of medical articles regarding Hispanic health • Collect examples of medical education curriculum • Plan and coordinate a Hispanic Health for the Office of Minority Health, U.S. Department of Health and Human Services • Convene a one day meeting of cultural competence experts to produce recommendations for guidelines for cultural competence medical education curriculum

4. Hispanic Cultural Competence Medical Education CurriculumMethodology • NHMA Conference Plenary Session Guidance • The relationship between mind and body (biology of belief) • The physiology of the healing • The relationship between nutrition and health, with a focus on the typical Hispanic diet • The current health seeking behavior of Hispanics with focus on traditional healing and conventional medicine • The importance of family dynamics and health promotion and treatment information among Hispanics • Traditional healing practices • Hispanic history in the Southwest with a focus on developing and understanding of the unique transfer of information from the health provider to different generations in the Mexican American family.

5. Hispanic Cultural Competence Medical Education CurriculumMethodology • Cultural Competence Definition • Cultural Competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross cultural situations. • It reflects the ability to acquire and use knowledge of the health related beliefs, attitudes, practices, and communication patterns of patients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups. • Cultural competency also focuses attention on population-specific issues, including health-related beliefs and cultural values (the socioeconomic perspective), disease prevalence (the epidemiological perspective), and treatment efficacy (the outcome perspective). [HRSA Cultural Competency: A Journey.www.bphc.hrsa.gov.2000]

6. Hispanic Cultural Competence Medical Education CurriculumMethodology • Dr. Like’s Framework • The society of Teachers of Family Medicine Core Curriculum Guidelines, “Recommended Core Curriculum Guidelines on Cultural Sensitive and Competent Health Care” [Robert C. Like, M.D., M.S.] • A focus on Attitude Change [Information on perceptions (views, customs, traditions, values and behavior) that can generate awareness and self-awareness on the part of practitioner and patient] • A focus on Knowledge [Knowledge on the attitudes, values, beliefs, and behaviors of certain cultural groups] • A focus on Skills [Tools and skills]

7. Hispanic Cultural Competence Medical Education CurriculumMethodology • Literature Review • A broad but cursory search of the literature on “Latino Health” was conducted to identify the type of information that is relevant to developing Hispanic cultural competence for medical education curriculum.

8. Hispanic Cultural Competence Medical Education CurriculumMethodology • Limitations of Data • Many of the search terms used tended to produce the same content results. • None of the searches appeared to produce sufficient information on subgroup knowledge (Dominicans, Puerto Ricans, Mexicans, South Americans, regional, and local) • Few curriculum models were found, and few of these focused on Hispanic culture. • Little information was found on self-awareness of physicians, experiences with self-awareness activities or attitude change per se, in medical students or physicians

9. Hispanic Cultural Competence Medical Education CurriculumMethodology • Limitations of Data (Continued) • The eventual goal and future goal is to review a “critical mass” of these studies and codify the findings. • Future searches should explore the databases – California, New York, Puerto Rico • Future searches should explore the databases belonging to the 10 Regions of the USDHHS for Hispanic Health information • Focus groups in New York will be used to gather additional knowledge to cultural health patterns amongst Puerto Ricans, Mexicans, and Dominicans.

10. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Demographics of Hispanics in the U.S. • Hispanic are 40 million, 14.5 % of the population. • Heterogeneous Sub-groups • Mexican-American, Puerto-Rican, Dominican, Cuban-American, Central and South Americans • Social Economic Status (SES) • Poor, young, less educated • Occupations • Few managers

11. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Health Policy Issues • Access to Health Care • Cultural Competence • Hispanic Health Professions Development • Managed Care Issues • Data Collection • Research • Racial and Ethnic Disparities in Health • Hispanic Children’s Health • Hispanic Women’s Health • Hispanic Elderly Health • Immigrants Health

12. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Health Policy Issues (Continued) • Priority Issues Summary • LEP and Title VI of the Civil Rights Act • Quality of Health Care • CLAS Standards

13. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Crossing the Quality Chasm • The report, “Crossing the Quality Chasm” from the Institute of Medicine, in 2001, proposes six areas for improvement to address key dimensions in which today’s health care system functions at far lower levels than it can and should. • Health care should be: • Safe, • Effective, • Patient–Centered, • Timely, • Efficient, and • Equitable

14. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Crossing the Quality Chasm (Continued) • Care based on continuous healing relationships • Customization based on patient needs and values • The patient is the source of control • Shared knowledge and free flow of information • The need for transparency

15. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Crossing the Quality Chasm (Continued) • Hispanics are less involved in their health care than they would like • Hispanics find it harder to understand instructions from their doctors • Hispanics find it less easy to understand instructions on prescription bottles • Hispanics had more communication problems with their doctors • Hispanics have the highest rate of self-rating of health as fair or poor • Hispanics have less satisfaction with their quality of health care

16. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Culture and Health • Aztec History • The Aztecs believed that: • Just as the balance of the opposing forces in the cosmos must be maintained. • Imbalances in the human body led to disease • Disease could also be caused by uncleanliness • Herbs used to treat several illness • Body and Spirit was one inseparable entity. • Santeria • Curanderismo

17. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Understanding Health Status • The Hispanic Paradox • For the past twenty years, there has been widespread evidence of a Hispanic paradox regarding health in the United States, in which most Hispanic groups are characterized by low socioeconomic status, but better than expected health and mortality outcomes. • A closer look reveals variation by age, gender, Hispanic subgroup, acculturation, country of birth and cause of death. • Possible under-reporting of Hispanic deaths, “salmon bias and healthy migrant effects, and risk profile may contribute to, but do not explain, the paradox the Reasons for this paradox are likely to be multi factorial and social in origin.

18. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Understanding Health Status • Acculturation and Assimilation • The detrimental and beneficial effects • The family as a positive social support • Connections to health outcomes not satisfactorily documented

19. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Cultural Competence and Hispanics - Categorized • Stress • Attitudes • Knowledge – Psychoneuroimmunology • Skills

20. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Cultural Competence and Hispanics - Categorized • Nutrition • Attitudes • Knowledge – Advances in Nutritional Science • Skills

21. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Cultural Competence and Hispanics - Categorized • Diabetes • 2-3 times more common in Hispanics than in whites • 700,000 Hispanics and Mexican-Americans have diabetes and don’t know it • Diet • High use of saturated fat • Stats higher in Mexican-Americans • Obesity • Especially in children • Higher rates of complications • Amputations, eye and kidney disease

22. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Cultural Competence and Hispanics - Categorized • Diabetes • Attitudes • Fear of insulin • Fear of becoming blind • Fatalism • Skills • To discuss diabetes with family • To understand • Referrals to resources

23. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication • A fundamental skill that must be learned by medical students, residents, and physicians is how to communicate with patients effectively. • Communication Issues with Hispanics • Lack of Trust • Familiarity with subject • Personal Bias

24. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication • Providers must be aware and be able to communicate with persons speaking other languages. • Providers must be aware of basic communication precepts such as how to recognize patterns in non-verbal and verbal communication: • Non-verbal communication • Verbal Communication

25. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Non-verbal communication • Silence, • Distance – Hispanic Prefer close proximity • Eye contact • Emotional expressiveness • Body language • Touch • Invisible person syndrome • Treating adults like children • The feeling of linguistic isolation • Technical Talk

26. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Verbal Communication • Tone of voice • Addressing a person • Formality • Importance of verbal communication • Direct questions and appropriateness of requesting certain types of information

27. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Spanish Language • There are some 32 million Americans who speak a language other than English at home. • Spanish is the main “other language” in the U.S. • A majority of Hispanics in the U.S. are bilingual and likely to retain their Spanish language skills as their communities are replenished with new Spanish speaking immigrants and the increasing growth of Spanish media. • Only 24% of Hispanics were born outside the U.S. and Puerto Rico, 77% report Spanish as their primary language and the language they speak at home.

28. Physician – Patient Interaction and Communication (Continued) • Spanish Language • Approaches to language used in the U.S. in various business services include: • Bilingual Staff • Interpreters • Language Skills Training • Internal Language Banks • Phone-based Interpreter Services • Written Translators • The Robert Wood Johnson Foundation has recently established a national effort, “Hablamos Juntos”, to develop and evaluate language technology for use in the health care system in emerging Spanish markets across the country. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence

29. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Use of Medical Interpreters • Due to the prevalence of Spanish language by Hispanics, it is critical to provide training for physicians and medical students about the proper use of interpreters. • We know that language can be a major barrier in the physician-patient interaction when there is no understanding between the two.

30. Physician – Patient Interaction and Communication (Continued) • Use of Medical Interpreters • These barriers can lead to: • Misdiagnoses, • medical errors, • lack of informed consent, • under use as well as over use of testing and referrals, • poor compliance, • patient dissatisfaction, • patient mistrust, • patient increased stress, • malpractice claims and • poor health outcomes. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence

31. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Use of Medical Interpreters • The use of medical interpreters is a major challenge that needs to be promoted in order to deliver quality of health care to an increasing number of LEP patients in the U.S. Certification of medical interpreters as a unique occupation and the subsequent reimbursement policy development by the public and private sector is seen as a promising mechanism to move forward.

32. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Communication Skills for Cultural Competence Curriculum • A curriculum about cultural competence should address communication issues for Physician-Patient Communication focused on the ethnic patients and their communication patterns.

33. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Building a Cultural Base • A practical way to understand some from another culture is to be aware and learn to recognize the ways in which their culture and yours differ. • Americans have a tendency to be more informal but reserved in their initial contacts and relationships in general. • Traditional Hispanics, on the other hand, tend to bemore formal on first encounters and to address people by their last names. • In relationships, Hispanics tend to share more about their personal lives, and more of the talk about their family, children, and husbands, whereas Anglo Saxons tend to be reserved regarding their personal lives.

34. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Physician – Patient Interaction and Communication (Continued) • Building a Cultural Base • To effectively communicate with Hispanics, you need to get to know who they are, how they live, their likes and dislikes and what they enjoy in life.

35. Hispanic Cultural Competence Medical Education CurriculumCore Competencies for Hispanic Cultural Competence • Conclusion • Given the increasing growth of the Hispanic population in the United States, it is imperative that the health professions continue to develop curricula that address attitudes, knowledge and skills about cross-cultural education. • Cultural Competence Curriculum should include a component that is ethnic specific, in this case, on Hispanics. • Hispanics are regional and sub-group dominant with their own cultural peculiarities. • Hispanics have demographic trends, historical traditions, traditional medicine knowledge, fundamental values and beliefs, policy issues, language and communication needs, • And a growing body of medical literature.