Elena Rios

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

 NHMA partners, National Hispanic Health Coalition,
  California Endowment, and DHHS OMH
Hispanic Cultural Competence

       NHMA Annual Conference Plenary Session Guidance

         The relationship between mind and body (biology of
         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.
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]
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]
Hispanic Cultural Competence

    Demographics of Hispanics in the U.S.
     Hispanics are 40 million, 14.5 % of the
     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
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
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
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
        Hispanics have the highest rate of self-rating of health
         as fair or poor
        Hispanics have less satisfaction with their quality of
         health care
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
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
Hispanic Cultural Competence

 Physician – Patient Interaction and
   • 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
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
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
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.
Hispanic Cultural Competence

 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

 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.
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
       Traditional Hispanics, on the other hand, tend to be
        more 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.
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
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
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
   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.