Transcript Toward Effective PatientProvider Communication with Elderly Latinos Raquel Diaz-Sprague, PharmD MS MLHR Adjunct Instructor, School of Allied Medical Professions College of Medicine & Public Health October 6,

Toward Effective PatientProvider Communication
with Elderly Latinos
Raquel Diaz-Sprague, PharmD MS
MLHR
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
race.”
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//www.whitehouse.gov/OMB/fedreg/
Hispanic/Latino by National Origin
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Mexicans 66%
Central and South Americans 15%
Puerto Rican 9%
Cuban 4%
Other 6%
• http//www.whitehouse.gov/OMB/fedreg/
Hispanic/Latino Geographic
Distribution
• Mexican Americans reside mostly in the
Southwest.
• 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.”
• http://www.iom.edu/Object.File/Master/13/172/13
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 nonteaching 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)
• http://www.iom.edu/Object.File/Master/13/172/13
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,
2002
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
(IOM)
• Health systems-level factors – financing,
structure of care; cultural and linguistic
barriers
• Patient-level factors – including patient
preferences, refusal of treatment, poor
adherence, financial limitations, biological
differences
• Disparities arising from the clinical
encounter
Strategies to End Care Disparities
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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%
• www.agingstats.gov/chartbook2000/tables-population.html
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%.
• www.agingstats.gov/chartbook2000/tables-population.html
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
Assistance
• Hispanic/Latino elders live with family both
as a result of health or economic necessity
and because of cultural expectations and
traditions.
• 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
overemphasized.
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 orientation. Present time
realities have more value than future
possibilities.
• 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.
•
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/Religiosity
• 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
• 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.
Personalism
• 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 historytaking and physical examination