Connecting to the Hispanic/Latino Community: Essential Elements for Quality Care

1. Connecting to the Hispanic/Latino Community:Essential Elements for Quality Care Eduardo R. Ochoa, Jr., M.D. Assistant Professor General Pediatrics, Maternal Child Health UAMS Colleges of Medicine and Public Health

2. Overview • Introduction • Culture and its Role • Environmental Landscape • Impact on Health and Health Care • The Culturally Competent Encounter • Connection to Disparities

3. What Is Culture? • Material culture • Paintings, tools, sculpture, etc. • Non-material culture • Common behaviors, thoughts, customs, beliefs that bind a group within society • Other aspects of culture • Food, language, dress, dance, body adornment, dating practices, religion

4. Culture in the Health Arena • Every patient-provider interaction is a cross-cultural experience • The provider must have comfort with his or her own cultural background • The patient brings a set of cultural values that will uniquely impact his or her health • Bridging the cultural divide is the essence of a quality encounter

5. Cultural Competence • Describes the system meeting the client • “The set of behaviors, attitudes and policies that come together in an institution, agency, or among a group of individuals, that allows them to work effectively in cross-cultural situations.” • Cross, TL, BJ Bazron, KW Dennis, and MR Isaacs. “The Cultural Competence Continuum”

6. Cultural Competence • “…the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.” • JR Betancourt, AR Green and JE Carrillo, “Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches”, The Commonwealth Fund, October 2002.

7. Value of Cultural Competence • Vehicle to achieve better access to care • Strategy to attract new patients • Vehicle to reduce racial and ethnic disparities in outcomes and quality • Better understanding of the consumer • Part of an organizational strategy to address barriers to quality care

8. Environmental LandscapeUS Population

9. US Demographic Projection • Children’s Defense Fund 2030 Predictions • 5.5 million more Hispanic children • 2.6 million more African-American children • 1.5 million more children of other races • 6.2 million fewer white, non-Hispanic children Hanson MJ: “Ethnic, Cultural, and Language Diversity in Intervention Settings,” in Developing Cross-Cultural Competence: A Guide for Working with Young Children and Their Families, eds, EW Lynch, MJ Hanson, Baltimore MD: Paul H. Brookes Publishing Company, 1992, p.7.

10. Environmental LandscapeArkansas Population • Race/Ethnicity 19902000 • White 82.7 80 • African-American 15.9 15.7 • Hispanic 0.8 3.2 • Other 1.3 3.1 • Includes Asian, American Indian, Pacific Islander

11. Environmental LandscapeLatinos in Arkansas • Top three Latino growth states • North Carolina, Arkansas, Georgia • 1990 Arkansas Latinos: 20,000 • 2000 Arkansas Latinos: 87,000+ • 3.2% total state population, probably 5%+ • 2004: 121,000+, 4.4%, probably 7%+ • Hispanics now dominant US minority • 5% of all Pulaski County births in 2001

13. AR Latinos

14. Environmental LandscapeWhy Latinos Come to Arkansas • Economic opportunity • Relative wage boom, available low-skill jobs • Poultry, agriculture, construction, service, factory/manufacturing • Social factors • Arkansas contacts, perception of safety • “American dream” factor • Home ownership, family growth, education

15. Environmental LandscapePublic Schools • Microcosm of state situation • All issues intersect: poverty, health, immigration, hunger, housing • Explosion of language minority students • ’93-’94: 4,071; ’03-’04: 23,626 480% • 5.2% K-12 studs,80% Spanish-speaking • 3/4 of Limited English Proficiency

16. Impact on Health • Barriers to health and health care access • Language, language, language • Lack of knowledge about care systems • Immigration factors • Poverty, educational attainment • Provider workforce insufficiency • Alternative vs. Traditional US system • Lack of health insurance

17. Impact on Health CarePublic Health • Of all patients served by ADH, 8.2% Latino in 2001 • 50% of ADH clientele in Sevier county (DeQueen) and >30% in Benton and Washington counties Latino in 2001 • WIC, prenatal, immunization services highly utilized • Partnerships formed to deliver services

18. Impact on Healthcare • US public and private health workforce • US 15% Latino, 3.5% US MDs Latino • CA 31% Latino, 4% CA MDs Latino • 6.1% 2001 Med School Graduates Latino • 7% African American (13% US population) • 3.2% 2000 medical school faculty Latino • 1.9% UAMS COM Latino faculty • Largely without culture or language training

19. Impact on Healthcare • Language • 39% of Spanish-speaking adults speak English “not well” or “not at all” • Inability to cross language barrier affects all health and social service delivery • Agencies have few, if any, bilingual staff • Federal mandate to improve service to LEP persons-Executive Order 13166

20. Impact on Health

21. Impact on HealthNew Immigrants • Unfamiliar US care systems • Not accustomed to making appointments • Difficult to navigate large medical centers • Little help available in Spanish • Unsure how to apply for, use and renew health insurance • Not accustomed to preventive care, screenings, disease surveillance

22. Impact on Health and Healthcare • Immigration Issues • Many mixed status and separated families • 1996 welfare reform laws bar even documented from benefits for 5 years • No documents=Invisible=Vulnerable • Fear of being asked for documents • Mobility across border • Possible comprehensive reform

23. Immigration

24. Impact on Health • Traditional methods of care • Herbal remedies • Alternative caregivers • curanderas, parteras, sobadoras, hierbistas • Availability of prescription drugs • Family-centered decisions about health • Cultural beliefs about health and disease • “sugar” vs. diabetes, etc.

25. Culturally Competent Encounter • Country of origin-not all from Mexico • Reasons for leaving native country • First or native language • Education attained, literacy issues • Informed consent issues • Religion-not all Catholic • End of life considerations

26. Latino Cultural Concepts • La Familia-The Family, Gender roles • Respeto-Respect • Social modesty; sensitivity in HC encounter • Confianza-Confidence • Personalismo-Personal Familiarity • Spiritual Impact-role of faith and religion • Fatalismo, espiritismo

27. Latino Cultural Concepts • Other beliefs about disease • Empacho, Bilis • Mal Ojo • Envidia • Mal Aire • Traditional Healers • Non-licensed providers

28. The Culturally Competent Encounter • National Standards for Culturally and Linguistically Appropriate Services in Health Care • HHS Office of Minority Health, March 2001 • 14 standards organized by themes • Culturally Competent Care, Language Access Services, Organizational Supports for Cultural Competence

29. The Culturally Competent Encounter • Realms for cultural competence • Organizational • Minority leadership recruitment, development, promotion; community involvement • Systemic • Community assessment, data collection, quality • Clinical • Awareness of sociocultural influences, training of staff, patient empowerment

30. The Culturally Competent Encounter • Understand community or client being served and what social and cultural influences impact health and behavior • Understand how these factors interact with the system in ways that prevent quality care access • Identify barriers and intervene • Monitor outcomes

31. The Culturally Competent Encounter • Avoid stereotyping • Vast heterogeneity among racial and ethnic subgroups • Differences by national origin, educational attainment, socioeconomics, religion • Engage in dialogue • Linguistically appropriate communication and negotiation is the key

32. Connection to Disparities • Access to health information, services • Language access • Quality measurements, data collection • Workforce education • Community education • Systems change

33. Connection to DisparitiesCurrent Efforts • Community • La Casa Health Network • Community Health Center expansion • Multi-partner effort: ADHHS, JCCSI, ACH, Baptist Health, La Casa, LULAC, Pulaski County, City of LR • UAMS • Chancellor’s Racial and Ethnic Health Disparities Taskforce