Respectful Communication

1. Respectful Communication • Certain topics are taboo in some cultures. E.g., asking an older Latina/Hispanic unmarried woman about sex behavior can be considered offensive. • You may want to tell the patient that you realize that some things are not normally discussed, but that it is necessary so that the best care can be planned

2. Alternative & Complementary Healing Systems/Techniques • Latino/Hispanic alternative and complementary healing systems or techniques include: Curanderismo, Espiritismo, and Santeria. • Healers include: • Curanderos (general practitioners of Mexican folk healing)

3. Alternative & Complementary Healing Systems/Techniques • Espiritistas (Puerto Rican faith healers) • Santeros (Cuban faith healers) • Yerbistas (herbalists) • Sobadores (massage therapists) • Folk healers often treat children for conditions such as:

4. Alternative & Complementary Healing Systems/Techniques • Colico (colic) • Empacho (locked bowels) • Susto (fright) • Mal de ojo (evil eye) • Caida de la mollera (fallen fontanel)

5. Alternative & Complementary Healing Systems/Techniques • Healers also perform spiritual cleansing (barridas or limpias). • Insufficient data exists regarding the extent to which alternative and complementary healers and systems are used by Hispanics • Villa, M.L., Cuellar, J., Gamel, N., & Yeo, G. (1993). Aging and Health: Hispanic American Elders (2nd edition), SGEC Working Paper Series, Number 5, Ethnogeriatric Reviews, Stanford Geriatric Education Center.

6. Latino Health Care Gaps • Compared with non Latino whites, Latinos are three times as likely to be uninsured. • Many have no regular source of primary care, receive fewer check-ups, cancer screenings and other preventive services. They rely heavily on sporadic and emergency room care. • As a result of late diagnosis, breast cancer is the leading cause of cancer death among Latinas. • National Cancer Institute, Cancer Net, Breast Cancer Facts, 1999

7. Hispanic/Latinos “Double burden” • Doty and Ives have extensively documented Latinos “Double burden” • 1) Limited English proficiency (LEP) • 2) Lack of health insurance • Together, the “double burden” can be a death sentence • Doty, M. and Ives, B. “Quality of Health Care for Hispanic Populations: Findings from the Commonwealth Fund 2001 Health Care Quality Survey.”Commonwealth Fund (March 2002), Pub # 526.

8. English-only Healthcare Providers • In the US, providers tend to be monolingual -- English only. • And/or have insufficient knowledge of Spanish and lack awareness of medically relevant aspects of culture • Latino patient and Anglo provider havecommunication gap, and different worldviews

9. Evaluating Effective Communication • Providers should evaluate whether questions or instructions given to LEP patients have been understood • To be polite, some Hispanic/Latino patients will nod “yes” but not really comprehend.

10. Nonverbal Communication • Much of communication between people is nonverbal. One must learn it to be able to truly communicate • However, Nonverbal Communication is rarely a part of Foreign Language training in the higher education system

11. Nonverbal communication • Nonverbal communication is the sum of non-linguistic messages that are encoded and decoded through • Gestures • Facial expressions • Eye contact • Tone of voice • Pauses, silences

12. Communication gaps • Cultural, linguistic, and nonlinguistic gaps can lead to miscommunication and mistrust. • Health care personnel must be trained in cross cultural assessment and in both the verbal and nonverbal aspects of communication

13. Two-way communication: ethical imperative • To prevent poor health outcomes for Hispanic/Latinos and to lighten their “double burden” • Efforts to improve the quality of Anglo-Latino communication in health care settings are ethical imperatives.

14. Translation vs. Cultural Adaptation • Health messages and patient education documents should be not only linguistically translated but also culturally adapted. • Straight translation into Spanish has many limitations. • Cultural adaptation is a more effective method to achieve health promotion.

15. Conceptual equivalence • In translation, conceptual equivalence is more important than linguistic equivalence • Health behavior modification approaches must be culturally appropriate to be effective

16. Latinos in Columbus: Health gaps • Uninsured Latinos in Columbus report job-related injuries, trauma, diabetes, hypertension, allergies, need for birth control, skin rash and other conditions • Often they can not afford to take time away from work to go to a doctor during the day • Source: State of La Clinica Latina: A First Year Report” Raquel Diaz-Sprague, PharmD MS MLHR, January 29, 2002

17. Latinos in Columbus: Health Care Gaps • As Latinos are the least paid workers, and the least insured, they can not afford the cost of a primary care medical consultation or to buy the prescriptions they need to control chronic diseases or conditions such as allergies, asthma, diabetes, and hypertension

18. Latinos in Columbus: Health gaps • Traumatic injuries sometimes are left unattended resulting in irreparable losses. • E.g., Marcos, a 48 year old Mexican construction worker was opening a door by hammering on a concrete wall on a Tuesday afternoon

19. Latinos in Columbus: Health gaps • A piece of concrete flew into his right eye. He felt like he was bleeding but no blood was coming from the eye. The pain was acute. His foreman “examined” him, told him “it’s nothing” gave him Tylenol and told him to keep working or he’ll be fired

20. Latinos in Columbus: Health gaps • Marcos kept taking Tylenol and kept working with eye pain for 5 days. • The foreman finally took him to an emergency room on Sunday evening • He had an emergency operation to remove a metal piece from the eye.

21. Latinos in Columbus: Health gaps • The operation cost $2000. He gave the hospital all he had, $400. • The foreman refused to help pay. The hospital refused to do follow up care. He needs an operation to correct the eye muscles. He can’t be scheduled for lack of resources for payment. • He has lost 95% vision in that eye.

22. Mistaken Identities & Fear Factor • Some Latinos are putting off going to a doctor because of fear they will be asked to show “papers.” They may or may not have legal papers. • They may be using someone else’s papers with a different name and a different date of birth.

23. Bridging the Gaps • In 2000 HHS published guidelines Cultural and Linguistically Appropriate Services (CLAS) urging providers to: • Provide qualified interpreters. • Provide written materials in the patient’s language

24. Nearly 45 Million Uninsured • Nearly 45 million Americans — 15.6% of the U.S. population — did not have health insurance during a typical month in 2003. • This represents an increase of 5 million people and more than 1 percent of the population since 1990 • Source: "Protecting the Protecting the Uninsured” Kenneth E. Thorpe, Ph.D. • New England Journal of Medicine October 6, 2004 • Volume 351 October 7, 2004 Number 15 • http://content.nejm.org/

25. Health care -- a human right • Lack of access to care for the working poor and the 45 million uninsured in the US - the richest nation on earth - is an ethical issue requiring action response. • Lack of access to health care puts people at risk for severe conditions that could have been effectively managed when diagnosed and treated at an early stage.

26. Helping Latinos in Columbus • Many new Hispanic/Latino immigrants have unmet primary health care needs. Most are uninsured, have little financial resources and rely on episodic or emergency care. • From 1999-2002, I led a group of volunteers as Chair of Latino Health Alliance and Founding Director of La Clinica Latina. The clinic currently operates for about 3 hours 2 or 3 nights a month. It is funded by the OSU Medical Center. The staff is all volunteer.

27. La Clinica Latina • Mission of La Clinica Latina • To educate Latinos in Columbus on health care issues and provide free primary care in a bilingual and bicultural atmosphere.

28. La Clinica Latina (cont.) • The clinic opened on December 19, 2000. An 8-month old boy presenting a leg burn was the first patient. The burn was caused by a chemical gel leaking from a cheap diaper. He was treated and recovered quickly. We fell in love with him. His parents were so very grateful. • La Clinica provided 727 patient visits to 320 patients in 2001. • Source: State of La Clinica Latina: A First Year Report” • Raquel Diaz-Sprague, PharmD MS MLHR, January 29, 2002

29. La Clinica Latina: Reception Area(snapshot taken in 2002)

30. Educating Health Providers: Medical Communication with Latinos (AMP 641) • AMP 641 evolved from a minimodule in the Medical Humanities Program for MEDI and MEDII. • Course offered Spring Quarter open to students in any college. • AMP 641 is included in the Latino/a Studies curriculum of the College of Humanities, Division of Comparative Ethnic Studies.

31. Medical Communication with Latinos (AMP 641) • The course provides instruction on medical terminology, cultural adaptation in translation, medically relevant aspects of Hispanic/Latino culture, service learning • Permission of Instructor is required. Instructor: Raquel Diaz-Sprague, PharmD • Contact diaz-sprague.1@osu.edu

32. Thoughts and Reflection • Almost one in 6 people in the US lacks health insurance. The number of uninsured is growing as costs escalate. • The nation must end this health injustice. Creative solutions to provide access to health care for all are needed. It is an ethical imperative.

33. Thoughts and Reflection • Charitable “free clinics” while providing a wonderful and noble service can do little to alleviate the US health care access crisis. • Expanding a network of free or low-cost clinics, is at best a “bandage” over a deep, festering wound. • Universal coverage is needed

34. Final Thought and Reflection • The inhumanity of slavery in the US could not have been ended by expanding emancipation, but by abolishing the institution of slavery! • So must this nation abolish, for all time to come, the inhumanity of “lack of health care coverage” built in the US healthcare system. • Will we join the civilized world? • Source: “Intercultural Understanding and Communication Can Help Bridge Health Gaps for Latinos” Presentation by Raquel Diaz-Sprague, American Association for Practical and Professional Ethics, 13th Annual Meeting., February 27, 2004