Assessing M edical S tudent R eadiness to T reat L atinos in C ancer C are S ettings

1. Assessing Medical Student Readiness to Treat Latinos in Cancer Care Settings Rachel Mayo, Windsor Westbrook Sherrill, Sarah Griffin, Veronica Parker, Department of Public Health Sciences Clemson University Acknowledgements: NCI Grant: 1R15CA135349-01A2 (coPIs: Mayo, RM; Sherrill, WW)

2. Outline • Challenge of cultural competence among healthcare providers • Standards related to cultural competence • NIH Study – “Provider Perceptions of Latino Patients” • MaNSRT survey development • Challenge of inter-institutional projects

3. Collaboration and Tenacity • Third time is the charm • Pilot work • Reviewer comments • Expert advice • Expert team

4. Challenge—A New Population in the Southeast • Influx marks the first time this region has experienced large-scale immigration by a non-traditional population since early- to mid-1800s (Maas 2004) • Predominantly 1st and 2nd generation Hispanics

5. Challenge– A New Population in the Southeast • More than ¼ of Hispanic adults do not have a usual health care provider (Livingston et al. 2008). • Health care provider community does not reflect the ethnic diversity of patient community in the Southeast.

6. Resulting Healthcare Issues and Disparities for Latinos • More than 1 in 4 Hispanics lack a usual healthcare provider. (Pew Hispanic Center/Robert Wood Johnson Foundation, 2008) • Hispanics are 3 timesas likely as non-Hispanic whites to lack a usual healthcare provider. (Centers for Disease Control and Prevention, 2006) “[H]ispanics and Asians report more difficulty communicating with their doctors than both whites and blacks.” (Mead, et al., 2008 • 23% of Latinos report having received poor quality of medical treatment or care in the last year (Pew Hispanic Center, 2008) • 17.8% of Hispanics of all ages report being in fair or poor health. • Compared with 11% of non-Hispanic whites. (The Commonwealth Fund, 2008)

7. Cultural Competence - LCME • IS – 16 MUST have Policies and Practices to achieve appropriate diversity among students, faculty, staff, and other academic members Aspiring physicians will be best prepared for medical practice in a diverse society if they learn in an environment characterized by, and supportive of, diversity and inclusion – training is facilitated in: - Basic Principles of culturally competent health care - Recognition of health care disparities and creating solutions to them - Importance of care of medically underserved populations - Development of professional attributes needed to provide care in a multidimensional diverse society.

8. This Study: Goals and Objectives • Student Provider Perceptions of Latino Patients in Cancer Care Settings, NIH/NCI Grant 1R15CA135349-01A2 • (PIs: Mayo, RM; Sherrill, WW) • To develop and evaluate an instrument (MaNSRT) to assess medical and nursing students’ readiness to treat Latino patients. • To inform the design of focused, effective interventions in medical and nursing education for the region. • In the process, to learn about medical and nursing student perceptions, existing cultural competence training, and current readiness to treat Latino patients.

9. Patient Race/Ethnicity Class Culture • Student Provider Knowledge Indices • Latino Knowledge Index • Latino Cancer Knowledge Index • (e.g., knowledge of communities, culture, personal involvement, cancer rates, risk, screening) Theoretical Framework Model based on Van Ryn (2002) • Student Provider Psychological Indices • Comfort with Latinos Index • Cultural Competence with Latinos Index • Attitudes Toward/Beliefs About Latinos Index • (e.g., provider beliefs about patient compliance and cultural factors impacting care, social and behavioral factors impacting care of Latinos) Medical and Nursing Students’ Readiness to Treat Latinos in Cancer Care (MaNSRT) • Student Provider Language and Experience Indices • Spanish Language Proficiency • Previous Experience with Latinos Student Provider Social Demographics Sex Race Age Education (nurse/physician)

10. Instrument Development: MaNSRT Health Professionals Survey • Systematic literature review (Mayo, Sherrill, et al., 2007). • Preliminary study conducted (n=65 nursing students) • Participating students provided feedback (e.g., face validity, question clarity and readability) • Cronbach’s alphas calculated for subscales to determine reliability • Draft survey instrument assessed by expert reviewers • Focus groups • 6 focus groups • n=27 participants

11. Instrument Development (cont.) • Survey Revision • First Pilot Test (n=38 nursing students) • Second Plot Test (n=99 medical and nursing students • Further Survey Revision and Recruitment • Final Survey Completed • Implementation of Final Survey (n=1200 medical and nursing students)

12. Partnering Institutions • 4 Nursing Programs • 3 Medical Programs • Similar institutional structures, curricula, and student populations

13. SURVEY REVISION: PILOT TO FINAL • Likert scale vs. Item-specific questions • Importance of Revision • Removes potential bias and leading questions • Gathers a more direct opinion • Responses more representative of participant’s intuitive opinions and knowledge • Other Revisions: • Better readability and visual aesthetics • Fluidity in question order

14. LIKERT SCALE: PILOT SURVEY

15. ITEM-SPECIFIC: FINAL SURVEY

16. ITEM-SPECIFIC: FINAL SURVEY

17. ITEM-SPECIFIC: FINAL SURVEY

18. Student Provider Psychological Indices • Comfort with Latinos Index • Cultural Competence with Latinos Index • Attitudes Toward/Beliefs About Latinos Index

19. Emerging Themes Experience Training/Curriculum • Participants had different perceptions re: amount and quality of curriculum content focused on Hispanic/Latino health and culture. • Participants voiced a desire to have more about Hispanic/Latino health and culture in their curriculum. However, they are clearly emphasized that their clinical experiences have the most impact on their perceptions and practices (more than anything taught in a classroom setting) • Participants had a difficult time thinking about skills/preparation for Cancer prevention/care in isolation from other similar chronic health conditions. • Nursing students reported having more training/experience in cancer prevention than medical students

20. Focus Groups

21. Focus Groups: Themes • The medical and nursing students showed some general cultural knowledge about the Latino population • Mostly acquired from media and social influences • Also, from basic stereotypical observations made during everyday encounters with the ethnic group • Clinical and educational settings accounted for a small percentage of the acquired knowledge of Latino cultures, behaviors and practices. • Students express that they are trained more “disease-oriented,” rather than “patient-oriented” • Cultural competence training requires assessment and communication with the patient as a whole, including their family members (especially with Latinos)

22. Pilot Survey Results: Themes • Student provider skills • Variable ability to explain treatment options and clinical trials • Variable ability to build satisfactory rapport with Latino patients • Variable ability to determine communication preferences • Variable difficulty with clinical assessments due to cultural background of patient • Variable skill level communicating with interpreters • Student provider perceptions • Do not avoid speaking to Latino families because of language barriers

23. Conclusions • In general, medical and nursing students report insufficient readiness to effectively treat Hispanic/Latino patients • Stereotypical attitudes and beliefs • Limited cultural competence skills

24. Conclusions • The MaNSRT survey may be an effective instrument to assess nursing and medical student readiness to treat Latino patients. • Also indicate the need for improved cultural competence education, especially in the Southeast • Applied to any student provider program or health profession to employ interventions • The MaNSRT survey is currently being implementing with medical and nursing students of four institutions in the Southeast. • Preparation to be used universally • Currently recruiting more medical and nursing programs to participate in the MaNSRT survey

25. How much clinical experience have you had with Hispanics or Latinos? None Very Little Moderate Considerable Extensive

26. In your opinion, how often do you feel adequately trained to deal with the needs of Hispanic/Latino patients? Almost never Less than half the time About half the time More than half the time Almost always

27. Based on your training and experience, please rate your skill level in the following aspects of care for Hispanic/Latino patients – Communicating effectively through a healthcare interpreter? Not at all skillful Not very skillful Somewhat skillful Very skillful Extremely skillful

28. Survey Research Challenges • Student Recruitment • Managing Incentives • Solicitation Waves • Program incentives vs. Student incentives

29. The Challenge of Inter-Institutional Research • Program Logistics • IRB • Educational Program Risks and Benefits • Nursing and Medical School Curricula

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