National Latino AIDS Awareness Day Cultural Competency Workshop Conceptual Overview

1. National Latino AIDS Awareness DayCultural Competency WorkshopConceptual Overview

2. Objectives • Define and understand key terminology • Discuss the implications of demographic trends for health disparities • Explain how cultural beliefs shape clinical encounters • Describe effective techniques for working with minority patients

3. Latino or Hispanic? • Latino Population • Many cultures that include people from: • North America ∙ Central America • South America ∙ Caribbean • Languages: English, Spanish, Portuguese, Mayan, Guarani • Diverse background of individuals indigenous of: • African, European, Anglo, Asian, Middle Eastern descent • “Hispanic” inclusive of only Iberian Peninsula in Spain • Guyana, French Suriname, & some non-Spanish speaking indigenous groups not consider themselves “Latino”

4. Culture Is…? • Things: Tools, clothing, buildings, art • Ideas: Thoughts, beliefs, values, expectations • Behaviors: Traditions, rituals, manners, roles, language • Taught/Learned • Passed from generation to generation • All of the above

5. Culture • A concept (an idea; something formed by mentally combining all of the characteristics or particulars related to that subject) • An integrated pattern of knowledge, beliefs, behaviors, whose soul purpose is to transmit this knowledge to succeeding generations • A unification process, which combines customary beliefs, shared attitudes, and values

6. Health as a Cultural Construct • Culture Defines: • How health care information is received • How rights and protections are exercised • What is considered to be a health problem • How symptoms and concerns are expressed • Who should provide treatment for the problem • What type of treatment should be given • In Latin America health is • “the perfect harmony between your internal and external world” • In the U.S. health is • “the absence of illness”

7. Cultural Competency is…? • The ability to work effectively in cross-cultural situations • A course offered at UNO • Knowledge of every cultural norm and more • Both A and C • All of the above

8. How would a Culturally Competent Health Care Facility Operate? • The facility is capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency • The facility is engaged in an intentional and continuous process of learning about and integrating cultural knowledge into every facet of what they do to better serve culturally diverse communities • Staff hold a deep respect for cultural differences and are eager to learn, and are willing to accept, that there are many ways of viewing the world

9. BE SAFE Model • Barriers to Care – real or perceived gaps • Ethics – principles determining “right” or “wrong” • Sensitivity – cultural awareness by provider • Assessment – collecting data in context of pt culture • Facts – understanding of pts beliefs and values • Encounters – awareness of communication cultural norms

10. Barriers to Care • Linguistic Issues • Access to Care and HIV Testing • Constructs of Culture and Gender • Stigma • Bias of Health Care Provider

11. Ethics • Principles that should guide health care facilities • Autonomy- information necessary for an informed decision • Beneficence –putting the patient’s best interest first • Non-malfeasance – “above all, do no harm” • Justice – all individuals treated equally regardless of culture, race, ethnicity, or language barriers

12. Sensitivity of the Provider • Stages of Cultural Competency

13. Unique Issues • Low tolerance for anything that involves time • Facilitation of translation through use of family or friends as translators • + more multilingual signs are now used in health care settings • Heavy accents are associated with poverty, lower socio-economic levels, etc

14. Unique Issues • No 15 minute “one size fits all” model • Physicians usually meet patients in their office before exam • Often treat the whole family and ask about them • Eyesight problems or illiteracy? • Folk Medicine • Using herbs & oils allows a sense of control • Consider an active coping process

15. Assessment • Culturally Based Assessments and Treatment Plans • ETHNIC Model • Explanation – “Why do you think you have these symptoms?” • Treatment – “What kinds of medicines have you tried?” • Healers – “Have you sought advice from folk healers?” • Negotiation of treatments plan • Determine the Intervention • Collaborate to make possible the optimal and holistic treatment

16. Assessment • Explanatory Model • “What do you think caused your problem?” • “Why do you think it started when it did?” • “What do you think your sickness does to you?” • “How severe is it?” • “What kind of treatment do you think you should receive?” • “What are the most important results you hope to achieve?” • What are the chief problems your sickness has caused?” • What do you fear most about your sickness?”

17. Facts Fatalism Family Friendly, Humble, & Vulnerable Trust Respect • Cultural Beliefs and Values • Fatalismo • Familismo • Simpatia • Confianza • Respeto • How can these affect the clinic visit? • Gender Roles • Marianismo & Machismo • Use of Folk Medicine

18. Encounters • Eye contact – demonstrates respect • Facial Expression – an unexaggerated, friendly smile • Gestures – stand up, walk to, & greet patient • Touch – greet with handshake and offer handshake upon completion of the encounter • Voice Intonation – speaking loudly will not understanding • Addressing Latino Patients – the use of titles • The Use of Interpreters

19. Demographic Changes and Health Disparities

20. Demographic Changes by Race/Ethnicity

21. Persons Living with HIV/AIDS by Parish Louisiana, 2007

22. Latino Population Map Key >9% 7-9% 4-7% <4%

23. Nationwide • Latinos comprise 15% of the US population, but accounted for 17% of all new HIV infections in 2006 • Incidence of HIV/AIDS 3X the rate for Whites • Latino males accounted for 18% of all males living with HIV/AIDS • Latina females accounted for 15% of all females living with HIV/AIDS • In 2005, HIV/AIDS was the fourth leading cause of death among Latino men and women aged 35–44 • Most common methods of HIV transmission were: • For males: 1) MSM sexual contact 2) Injection drug use 3) High-risk heterosexual contact • For females: 1) High-risk heterosexual contact 2) Injection drug use

24. Race/Ethnicity of PLWAs in Louisiana 3% 30% 66%

25. Southern Region of Louisiana Rates Among Latino/Hispanics • There are a reported 579 Cases of HIV/AIDS in Louisiana Among Latinos/Hispanics

26. Latino Population • Many languages, many cultures • The Effects of Hurricanes • Pre-K: substantially Honduran and other Central American professionals • Clustered, well educated, well paying jobs in health care, business, and government • Post K: • Influx of less educated largely male laborers • Mexico, Nicaragua, Brazil • Some undocumented, limited knowledge of foreign culture • Dispersed

27. Health Disparities Defined • Population-specific differences in the presence of • Disease • Health outcomes • Access to health care

28. Latino Population • Implications for healthcare • Language & Health Care Expectations • “Latino physicians show a friendliness to patients, and ask about the family” • Pre-natal care for undocumented/Spanish speaking women • Documentation • Domestic & Occupational Barriers to Care • Acculturation conflicts • Educational difficulties

29. Barriers to Care • Linguistic Issues – English, Spanish, Portuguese, Guarani, etc. • Access to Care and HIV Testing • Under/uninsured – lack of citizenship, job characteristics, poverty • Education – 50% Latinos not completing high school • Transportation, no childcare, excessive waiting times, can’t miss work • Constructs of Culture and Gender • Religious beliefs • Gender roles • Fatalistic views of life – “que sera, que sera” • Stigma – greater than in U.S. culture • Bias of Health Care Provider

30. Tragic Consequences: Cases of Inadequate Communication Misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia

31. Tragic Consequences: Cases of Inadequate Communication After 36 hours of work up for a drug overdose, comatose patient reevaluated Diagnosis: Intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery Hospital paid $71 Million settlement

32. Tragic Consequences Case #2 Misinterpretation Spanish speaking woman told a resident that her two-year old had “hit herself” when she fell off her tricycle Resident misinterpreted twowords W/O interpreter present, mother signed over custody of her two children

33. Conclusions • All patients have the right to fair and competent care • Race, ethnicity, language, and culture must be included when planning care for the patient • Cultural competency in health care is the ability to work cross-culturally in order to address the needs of the patient.

34. Resources • Delta AETC archives (1999-2009) PowerPoint Presentations • National Minority AIDS Education and Training Center (2002) BE SAFE: A Cultural Competency Model for Latinos. Washington D.C., Howard University • Louisiana Department of Health and Hospitals Office of Public Health (2009).Louisiana HIV/AIDS Surveillence Quarterly Report (6/30/09) • Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008;300:520–529. • CDC. WISQARS [Web-based Injury Statistics Query and Reporting System] Leading causes of death reports, 2005 [2005 reports re Hispanic/Latinos]. Accessed March 18, 2008.