“Cultural Competence” NHMA/California Endowment Congressional Briefing Elena Rios, MD, MSPH July 22,2003

1. “Cultural Competence”NHMA/California Endowment Congressional BriefingElena Rios, MD, MSPHJuly 22,2003

2. Hispanic Cultural Competence • Hispanics are the largest ethnic group in the United States (40 million or 14.5 of the total U.S. population) • Hispanics are the largest ethnic group without health insurance (33% < 65 years of age) • 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” in various sectors of the health system • NHMA partners, National Hispanic Health Coalition, California Endowment, and DHHS OMH

3. Hispanic Cultural Competence • NHMA Annual Conference Plenary Session Guidance • The relationship between mind and body (biology of belief) • The physiology of 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.

4. Hispanic Cultural Competence • 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]

5. Hispanic Cultural Competence • 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]

6. Hispanic Cultural Competence • Demographics of Hispanics in the U.S. • Hispanics 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 of decision-makers

7. Hispanic Cultural Competence • IOM’s “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 focused on the consumer: • Safe, • Effective, • Patient–Centered – including culture, values • Timely, • Efficient, and • Equitable

8. Hispanic Cultural Competence • Unequal Treatment Report, 2002 • Disparities in Health Exist in the U.S. for racial and ethnic groups • Cultural Competence Recommendation: • Institutionalize training for health professional students and providers • Incentivise provider reimbursements to increase quality health care

9. Hispanic Cultural Competence • The Commonwealth Fund 2002 Report: • 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

10. Hispanic Cultural Competence • Understanding Hispanic Health Status • Acculturation and Assimilation • The detrimental and beneficial effects • The family as a positive social support • Multi-generation approach to health care • Combination citizen status, immigrants • Connections to health outcomes not satisfactorily documented – data needs

11. Hispanic Cultural Competence • Cultural Competence and Hispanics • Stress (SES, Mental Health, Domestic violence, Environment, etc.) • Attitudes • Knowledge – Psychoneuroimmunology • Skills • Nutrition (Hispanic diet, grocery store products) • Attitudes • Knowledge – Advances in Nutritional Science • Skills

12. 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

13. 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

14. 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 • NHMA a partner in the Kaiser/RWJF Physician Bias and Health Disparities Campaign

15. 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.

16. 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

17. 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.

18. 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.

19. Hispanic Cultural Competence • Cultural Competence & Health Policy Issues • Access to Health Care can be increased • Health Care Costs can be cut drastically • Cultural Competence Guidelines, Priorities, Committees • Hispanic Health Professions Development • Managed Care Issues • Data Collection on Minorities • Research on Trends, Interventions • Racial and Ethnic Disparities in Health • Hispanic Children’s, Women’s, Elderly Health • Immigrant’s Health • Public Health Research

20. Hispanic Cultural Competence • Cultural Competence & Health Policy Issues • LEP and Title VI of the Civil Rights Act • Quality of Health Care & Patient Safety • Medical errors, poor compliance, malpractice, poor health outcomes • DHHS OMH CLAS Standards • Medicare: • Quality Demonstration Projects • Incentives for Providers in Hispanic areas – -Puerto Rico, US-Mexico border, rural/urban • Language Services • Legal Immigrant Services

21. Hispanic Cultural Competence • Conclusion • Given the increasing growth of the Hispanic population in the United States, it is imperative that the health system continue to develop cultural competence policies that address attitudes, knowledge and skills about cross-cultural education. • Hispanics are regional and sub-group dominant with their own cultural peculiarities that health policies should include. • Hispanics have demographic trends, historical traditions, traditional medicine knowledge, fundamental values and beliefs, legal status, language/communication needs, and a growing body of medical literature. • Cultural Competence Policy should be ethnic specific, in this case, Hispanics – designed with Hispanic experts and organizations and community leaders.