Cultural Considerations in the Delivery of Health Services to the

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E. Angeles Martínez-Mier, DDS, MSD, PhD
Ana G. Gossweiler, DDS, MSD
U.S. Demographics
   Rapidly becoming more diverse
   Minority populations growing at a fast pace
   Hispanic group becoming the largest minority
    group in the U.S.
Indiana Demographics
   Population has tripled between 1990 and 2002
     Mexicans60%
     Median age 25

   13% of the population in Indiana
     Indianapolis   65 000 to 85 0000 according to local
Hispanics or Latinos in Indiana

   Hispanics or Latinos of any race
    Mexican               153,042
    Puerto Rican          19,678
    Cuban                 2,754
    Others                39,062

                   U.S. Census Bureau, Census 2000
   What is it?
   Where is it found?
   Who has it?
   When is it used?
   Why is it important?

   The skills, art, etc., of a given people in
    a given period, civilization

                       Webster’s New World Dictionary
   Culture is:
     Guides how people live
     What they believe and value
     How they communicate
     What are their habits, customs and tastes
     Guides the ways they meet various needs of society
     How goods and services are produced and distributed

               Slide by Valery Yontz, PhD, University of Hawaii

   Cross-cultural
   Intercultural
   Subculture
   Values
   Beliefs
   Stereotyping
   Ethnocentrism

   Refers to any comparison of cultural
    differences or the situations in which such
    differences exist

   Refers to the actual interaction between
    people of different cultures

   Formed by a group of persons who have
    developed interests or goals different
    from the primary culture, based on such
    things as occupation, sex, age, social
    class, or religion.

 Ideas about what is right and wrong,
  desirable and undesirable, normal and
  abnormal, proper and improper
 A set of organized rules for making choices,
  reducing uncertainty and reducing conflicts
  within a given society

   Belief is a psychological state in which an
    individual holds a premise or an argument
    to be true without necessarily being able
    to adequately prove their point to other
    people who may or may not agree.

   Refers to the common behavior of assuming that
    individuals possess certain characteristics or traits
    because they are members of a particular group.

                  Fails to recognize the individual

 Natural belief that one’s culture is superior to
  that of others
 Care is needed not to demean clients whose

  oral health practices may be rooted in culture
  rather than scientific fact
  Iceberg Concept
Is the culture always visible to the observer?

                  Primarily in Awareness

                Primarily out of Awareness
Primarily in Awareness

May be obvious to the observer

   Fine arts
    Literature
    Drama
    Music
    Dancing
    Games
    Cooking
    Dress
    Primarily Out of Awareness
Not necessarily obvious to the observer

   Notions of modesty
   Conceptions of beauty
   Patterns for handling emotions
   Conception of self
   Conception of justice
   Decision making patterns
   Attitudes toward the dependent
   Patterns of superior/subordinate relationship
Health Care Issues Related to Culture
    Culture influences:
      - communication (language, tone, nonverbal
      - trust
      - behavior
      - understanding wellness and illness
      - seeking health care
      - receiving and complying with care
Cultural Competency’s Definition

   The ongoing process of actively developing and
    practicing appropriate, relevant, and sensitive
    strategies and skills in interacting with culturally
    different people. Includes the capacity to respond
    appropriately to the needs of populations whose
    cultures are different from what might be ―the
    dominant or mainstream culture.‖

                                  Slide by Valery Yontz, PhD, University of Hawaii
Goals of Cultural Competency
   Self- exploration
   Personal development
   Attitude and values clarification
   Ethnic and cultural literacy
   Empowerment—equality and excellence
   Basic skills proficiency
   Social competency

            Slide by Valery Yontz, PhD, University of Hawaii
Skills and Characteristics of Cultural
   Respectful
   Willingness to share, risk change,& explore
   Understand the power of action and words
   Ability to recognize learning opportunities
   Possessing knowledge of one’s self
   Being aware of ignorance
   Having attitude that ―Different is okay: not good or

             Slide by Valery Yontz, PhD, University of Hawaii
    Right or Wrong

   ―We must be able to recognize and deal with
    beliefs of others if we wish to obtain

                    Samovar & Porter
                    Intercultural Communication
Good                Bad

Bad               Good
Cultural Competency Components

   Develop an awareness of one’s own existence
   Demonstrate knowledge and understanding of other
   Accepting/respecting cultural differences
   Stop assuming that others’ beliefs and values are the
    same as yours
   Stop judging attitudes as good or bad
   Be open to range of cultural encounters
   Adapt to be congruent with other cultured persons

             Slide by Valery Yontz, PhD, University of Hawaii
Cross’s Cultural Competency Continuum

  Cultural destructiveness
  Cultural incapacity

  Cultural blindness

  Cultural pre-competence

  Cultural competence

  Cultural proficiency
                                                                    Cross, T; 2001

              Slide by Valery Yontz, PhD, University of Hawaii
Why is cultural competence
important to dental professionals?
   It assist in recognizing the elements
    of culture that are relevant during a
    patient care (communication issues,
    religion, family networks, gender
    norms, sense of humor, etc…)
Benefits of gaining intercultural
    Provide compatible messages with patient’s cultural
     values and beliefs
     Increase the relevancy of health education
     Increase effectiveness of dental care with a diverse
     Increase a practitioner’s multicultural knowledge
Cultural Assessment Domains
   Ethnic identity/history
   Communication
   Activities of daily living
   Orientation to time
   Food practices
   Family relationships
   Birth and death rituals
   Spiritual/religious orientation
   Bio-cultural ecology
   Illness beliefs
   High-risk behaviors
   Health practices and practitioners

               Slide by Valery Yontz, PhD, University of Hawaii
Hispanics/Latinos: Key Cultural Points
    Ethnic Identity and History
        Latin America designates all those countries and territories in the
         Americas where languages derived from Latin are spoken: Spanish,
         Portuguese, French, and their creoles.
        The region was home to many indigenous peoples and advanced
         civilizations (Aztecs, Mayan, and Incas). With the arrival of the
         Europeans the indigenous peoples lost power to the Europeans. European
         powers, most notably Spain and Portugal, colonized the region. After
         independence movements, the countries of the region became
         independent by the late 19th century.
Diversity within the Hispanic Community

                       People in Latin America are
                        a mixture of many racial
                       Their origins include over 22
                       While Spanish is usually the
                        common language, there is a
                        wide variety of idiomatic
                        speech patterns and dialects
Diversity = Mix of Cultures
Hispanics/Latinos: Key Cultural Points
   Communication
       Casual conversation prior to ―the point‖
       Resistance to lose language
       Maintain outward expressions of dignity and calm
       Touching, kissing, hugging between family in public
       Make eye contact, hold hands, hug
Hispanics/Latinos: Key Cultural Points
   Activities of Daily Living (ADLs)
       Respect for tradition
       Hard working
       Follow cultural/family practices, cleaning, cooking, etc.
        (practice of traditional things in the U.S.)
   Latinos prefer the company of others versus being
   Sharing is an activity that is an outgrowth of
   Drinking alcohol and smoking are experiences that
    are shared with other friends.
       How long a man drinks with his friends is often determined
        by when his wife arrives to tell him it is time to come home.
                   Chong, The Latino Patient
Hispanics/Latinos: Key Cultural Points

    Orientation to Time
        Flexible sense of time
    Food Practices
        Very traditional
        Special events
        Family traditions
Hispanics/Latinos: Key Cultural Points

     Family Relationships
         Connectedness to extended family
         Children taught to repress aggressive and assertive
         Machismo/Marianismo
Cultural values and gender
   Machismo
     refersto the man’s masculinity and puts the man
     at the center of the social life. It is exhibited
     through courage and authoritarian attitude
   Marianismo
     Refersto the woman’s position at home and in the
     family. A woman earns respect through her
     dedication to her children and husband
Cultural values and gender
 As the need for income increases, there is
  greater financial pressure on the wife to enter
  the workforce.
 As she contributes to the family income, she will
  attain more independence and greater parity
  in the family decision making process.
 Her exposure to the workplace and her social
  contacts outside the home will tend to
  accelerate the process of acculturation.
Hispanics/Latinos: Key Cultural Points
     Birth and Death Rituals
       Male/Female   roles well defined during funeral and
       Women pampered more during pregnancy

       Cultural traditions practiced at funerals
Hispanics/Latinos: Key Cultural Points
     Spiritual and Religious Orientation
         Catholics
         Some develop special relationships with saints
         Some superstitions
         Sacrifice in the world is helpful to salvation
Hispanics/Latinos: Key Cultural Points

    Bio-Cultural Ecology
      Higher caries, periodontal disease prevalence. Lower
       prevalence of oral pharyngeal cancer
      Physical appearance: From American Indian to European
Hispanics/Latinos: Key Cultural Points

    Illness Beliefs
        Illness result of bad luck or God’s punishment. The causes of
         some illness are found outside the body. Powers of good
         and evil.

      Illness prevented by proper diet, wearing amulets, use of
       candles, avoiding harmful people
      May use combination of folk and Western Medicine
Folk Healers
   Use of Natural Healers / Curanderos /
    Harmful Magic:
    Evil-eye/Mal de ojo: Excessive admiration
    Fright/Susto: Associated with a traumatic
    Evil-hex/Mal Puesto: Motivated by jealousy or
                        Gomez 1977
Folk Medicine
Perception of Health and Education

   Educated Latinos:
     Healthyrefers to ―a state of complete physical,
     mental, and social well-being and not merely
     the absence of disease.‖
                 World Health Organization
   Less Educated Latinos:
     Healthhas a religious perspective. Disease is
     seeing as a warning or punishment
       God    is the giver of all, including my health
Hispanics/Latinos: Key Cultural Points
     High Risk Behaviors
       Diet

       Infants    should ―eat well‖
               ―No come bien‖
         Bottle   feeding at night
Nutritional habits and acculturation

   The Latino/Hispanic diet is very diverse. But, in general the
    diet is low in vegetable fats and high in fiber content when
    compared with non-Latino whites diets
   The less acculturated the Hispanic patient is, the more likely
    they are to eat fruits, rice, beans, meat, fried food and whole
   More acculturated Latinos have diets that are a risk factor for
    obesity, diabetes and hypertension
                 Alcalay et al. 1999, Otero-Sabogal et al. 1995, Alcalay et al. 1992
Hispanics/Latinos: Key Cultural Points
    Health Practices and Practitioners
      Family care for young and old
      Discuss health of family members

      Respond well to individualized attention
Hispanics/Latinos: Key Cultural Points
    Health Practices and Practitioners
      Use of herbs to cure dental diseases
      Clove – anesthetic properties

      Honey – healing properties –soft tissue

      Eruption of primary teeth linked to many diseases

      Tooth ―mouse‖, not tooth fairy
What is a culturally-competent dental
   A health care provider that understands: The
    beliefs, values, traditions and practices of a cultural
    group that influence oral health.
   Their patients culturally-related needs, illness and
    health beliefs, health practices and approaches to
    seeking care.
Suggestions for the Dental Team
   Determine your client’s language skills, health beliefs and behaviors,
    dietary preferences, and cultural remedies for illness
   Attempt to make connections between cultural remedies and current
    standards of care
   Translate context instead of just words
   Examine current office hours
   Provide patient material in appropriate language and educational
   Work with community health partners to increase the health of the
   Create community partnerships
Things to Avoid
   Judgmental phrases
    Imposing White Culture
    Explaining minority issues via ―lower on the
    evolutionary scale‖
    Stereotyping
Health Disparities
   Health disparities refer to gaps in the quality of
    health and health care across racial and ethnic
   The Health Resources and Services Administration
    defines health disparities as "population-specific
    differences in the presence of disease, health
    outcomes, or access to health care."
Healthy People 2010

   “To promote oral health and prevent oral diseases, oral health
    literacy among all groups is necessary. In addition, oral health
    services – preventive and restorative – should be available,
    accessible, and acceptable to all persons in the United States.
    In areas where different languages, culture, and health care
    beliefs would otherwise be barriers to care, a cadre of
    clinically and culturally competent providers must be available
    to provide care.”
                                                             CDC
Barriers to Health Care Access that are
Related to Health Disparities
   Lack of insurance coverage, language barriers, lack of cultural
    awareness, limited or no bilingual resources or staff, and little
    or no Spanish language literature

                  Oral Health In America: A report of the Surgeon General
What barriers to health care access can be decreased by
culturally competent health professionals?

       Lack of insurance coverage, language barriers, lack of cultural
        awareness, limited or no bilingual resources or staff, and little
        or no Spanish language literature

                      Oral Health In America: A report of the Surgeon General
Health Disparities

Dental Epidemiological Data

Home Page - NIDCR/CDC Dental, Oral
 and Craniofacial Data Resource
 Center (DRC)
    Samuel Betances

   ―We cannot tell people to forget what they know.
    We cannot argue that it is better to know less rather
    than more.‖

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