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					Toward Effective Patient-
Provider Communication
  with Elderly Latinos
Raquel Diaz-Sprague, PharmD MS
 Adjunct Instructor, School of Allied
       Medical Professions
College of Medicine & Public Health
          October 6, 2004
         Hispanic? Latino?
• In the 2000 census the term “Hispanic”
  was changed to “Spanish, Hispanic or
  Latino” and defined as follows:
• “A person of Cuban, Mexican, Puerto
  Rican, South or Central American, or other
  Spanish Culture or origin, regardless of
 Hispanic? Latino? Region Matters
• Regional use of the terms varies –in the
  Eastern region the term “Hispanic” is used
  more frequently.
• The term “Latino” is more common in the
  Western region.
• Hayes-Bautista, D.E., Chapa, J., (1987). Latino
  Terminology: Conceptual bases for
  Standardized terminology. American Journal of Public
  Health 77 (1),61-68.
• http//
    Hispanic/Latino by National Origin

•   Mexicans 66%
•   Central and South Americans 15%
•   Puerto Rican 9%
•   Cuban 4%
•   Other 6%
• http//
     Hispanic/Latino Geographic

• Mexican Americans reside mostly in the
• Cubans are concentrated in Florida.
• Puerto Ricans live mostly in the Northeast,
  New York, New Jersey, and in Chicago.
• New immigrants are coming directly to job
  markets in many Midwestern cities.
 Ethnic and Racial Minority Health
         Care Disparities
• Health care disparities are a fact of life for
  ethnic and racial minorities in the US.

• In 2002 the Institute of Medicine (IOM)
  released a report entitled “Unequal
  Treatment: Confronting Racial and Ethnic
  Disparities in Health Care.”
     Unequal treatment (IOM)
• The IOM report states that racial and
  ethnic minorities receive a lower quality of
  health care than whites.
• Even when insurance and income are the
  same as those of whites, minorities often
  receive fewer tests and less sophisticated
  treatment for heart disease, cancer,
  diabetes, and HIV/AIDS. They also receive
  more diabetes-related limb amputations.
    Unequal Treatment (IOM)
• Disparities were consistently found
  across a wide range of disease areas
  and clinical services
• Disparities are found even when
  clinical factors, such as stage of
  disease presentation, co-morbidities,
  age, and severity of disease are taken
  into account
     Unequal Treatment (IOM)
• Disparities are found across a range of
  clinical settings, including public and
  private hospitals, teaching and non-
  teaching hospitals, etc.
• Disparities in care are associated with
  higher mortality rates among minorities
  (e.g., Bach et al., 1999; Peterson et al.,
  1997; Bennett et al., 1995)
    Unequal Treatment (IOM)
• The sources of these treatment disparities
  are rooted in historic and persistent
  current inequities. Biases, prejudices and
  negative racial stereotypes, the panel
  concluded, may be misleading doctors and
  other health professionals
 “Subtle Racism in Medicine” New York Times, March 22,
    Bias in Clinical Encounters
• In clinical encounters, the IOM study found
  evidence that stereotyping, biases, and
  uncertainty in the part of health care
  providers contribute to unequal treatment
• Providers and future providers must strive
  to increase their awareness of the health
  care gaps between racial and ethnic
  groups in the United States
   Factors in Unequal Treatment
• Health systems-level factors – financing,
  structure of care; cultural and linguistic
• Patient-level factors – including patient
  preferences, refusal of treatment, poor
  adherence, financial limitations, biological
• Disparities arising from the clinical
    Strategies to End Care Disparities

• Strategies to end disparities include:
• Use of "evidence-based" guidelines
• Improving provider-patient communication
• Providing Interpreter services for Limited
  English Proficiency (LEP) patients
• Recruiting and retaining racial and ethnic
  minorities in health professions
           Education is Key
• Minority patients need help learning how
  to access and navigate through the US
  healthcare system
• Cross cultural curricula should be
  integrated early in the health care
  providers training and be a part of required
  practitioner’s continuing education
     Aging and Hispanic/Latino

• Except for Cubans, the US Hispanic/Latino
  population is relatively young
• The median age for Mexican Americans is
  23.6; Puerto Ricans’ median age is 26.8;
  for Central/South Americans is 28.4; and
  for Cubans is 41.1.
• These demographics have implications for
  care-giving and dependency
    Hispanic/Latinos 65 and over
• Hispanic/Latinos age 65 and over comprise
  5.6% of all older Americans
• This group is expected to grow more quickly
  than other ethnic minority groups
• By 2020 they will be 9% of all people 65 and
  older in the U.S
• By 2050 they will increase to 16.4%
    One in 5 Centenarians will be a
       Hispanic/Latino by 2050
• In 1990 the population of Hispanic/Latino
  centenarians -- elders over the age of 100 --
  comprised less than 1% of the total
  centenarians in the US.

• By 2050 the number of Hispanic/Latino
  centenarians is expected to be over 19%.

Elderly Hispanics Live With Family

• Census population survey shows elderly
  Hispanic/Latinos to live with relatives, to
  an extent second only to Asian
  populations (U.S. Census Bureau, 2000).
• Preferences for living with relatives has
  been well documented in the literature for
  all Hispanic/Latino ethnic groups.
Hispanic Families: Lifelong Mutual
• Hispanic/Latino elders live with family both
  as a result of health or economic necessity
  and because of cultural expectations and
• Traditionally they provide childcare,
  cooking and other services. Expectations
  are lifelong mutual assistance and
  reciprocity among family members
Mexican Americans Elders Wish to
        Live With Family
• In several surveys, often the primary
  reason given by the Mexican American
  elders for living with their children is:
  “Because my child wants me to live with
  him/her” and/or “it is best for everyone if
  parents live with their children.”
    Latino’s Double Burden: Lack of
Insurance & Limited English Proficiency

• Lack of health insurance and LEP are
  barriers to access to medical care and
  social services by Latino/Hispanics.
• Doty & Ives call it “Latino double burden.”
• 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.
       “Linguistically Isolated”
• Many elderly Hispanic/Latinos have limited
  English proficiency (LEP) and belong to a
  category that the U.S. census terms
  “linguistically isolated.”
• On the other hand, preferential use of
  Spanish language by Hispanic/Latino
  elders can serve as a benefit to their
  quality of life and sense of ethnic identity.
       “What is Culture?”

• Culture can be identified as one’s
  worldview which includes “experiences,
  expressions, symbols, materials, customs,
  behaviors, morals, values, attitudes, and
  beliefs created and communicated among
  individuals,” and past down from
  generation as cultural traditions
          Cultural Proficiency
• Health care providers need to work toward
  cultural proficiency with the population
  they care for.
• Cultural traits define the use of language,
  the role of family, religion & spirituality, the
  definitions of illness, and the use of
  healing methods and treatment practices
 Caveat: Cultural Heterogeneity
• The danger of “cultural competence
  training” is oversimplification of culture and
  the creation of stereotypes. Regardless of
  culture, each person is a unique individual
• The heterogeneity of the various
  Hispanic/Latino groups cannot be
 Latino/Hispanic Cultural Notes

• In contrast to “mainstream” American
  values, Latinos tend to have a higher
  degree of:
• Familism.
• Family or group needs take precedence
  over the needs of the individual.
• Present orientation. Present time
  realities have more value than future
• A popular saying is:
• “Mañana es otro día y Dios dirá.”
• "Tomorrow is another day and God
  will tell.”
       Respect and Formality

• The communication style of Hispanics is
  more formal than that of a “mainstream”
  Americans both in content and form.

• Many Latinos report that they find
  Americans frequent and casual use of
  slang and vulgar expletives (“palabrotas”)
  offensive, even shocking.
Respect for Hispanic/Latino Elders
• Respect for elders is expected and valued.
• Greetings are formal. Sr., Sra., Srta, (Mr.,
  Mrs., Miss) precedes last names. Formal
  professional titles, doctor, ingeniero,
  profesora, licenciada, etc. are often used.
• Don & Doña are used in front of male and
    female first names, respectively, as a sign of
         Respect for elders
• In Spanish, it is inappropriate to
  address elders by their first name
  and/or in the “tu” (familiar) form.

• They should be addressed by their
  last name, in the “usted” (formal) form
• Religion is a serious matter in the
  Hispanic/Latino community.
• Devotions and church attendance is
  more common than among native-born
  Americans and higher than among
  other immigrant groups.
• They use of the word “God” reverently,
  not casually
• Catholicism is a strong bond among
  Hispanics that crosses all lines of
  national origins and levels of
  assimilation. Births, baptisms,
  marriages, rites of puberty, holidays,
  even names involve religion. Some 70
  percent of Hispanic/Latinos are Roman
  Catholic. Devotion to the Virgin Mary
  and patron saints is strong.
• Older Hispanic/Latinos expect health care
  personnel to be warm and personal and
  to show deference and caring.
• They have a strong need to be treated in a
  polite and pleasant manner - con dignidad
  - “with dignity”
       Building Rapport with
       Latino/Hispanic Elders

Efforts to build rapport can go a long way
to facilitate 2-way communication

A prior polite and cheerful exchange of
pleasantries can facilitate medical history-
taking and physical examination

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