Rachel Mayo, Windsor Westbrook Sherrill, Sarah Griffin, Veronica Parker, Department of Public Health Sciences

1
Assessing Medical Student Readiness to Treat
Latinos in Cancer Care Settings

• Rachel Mayo, Windsor Westbrook Sherrill, Sarah
  Griffin, Veronica Parker, Department of Public
  Health Sciences
• Clemson University

Acknowledgements NCI Grant 1R15CA135349-01A2 (
coPIs Mayo, RM Sherrill, WW)
2
Outline

• Challenge of cultural competence among healthcare
  providers
• Standards related to cultural competence
• NIH Study Provider Perceptions of Latino
  Patients
• MaNSRT survey development
• Challenge of inter-institutional projects

3
Collaboration and Tenacity

• Third time is the charm
• Pilot work
• Reviewer comments
• Expert advice
• Expert team

4
ChallengeA New Population in the Southeast

• Influx marks the first time this region has
  experienced large-scale immigration by a
  non-traditional population since early- to
  mid-1800s (Maas 2004)
• Predominantly 1st and 2nd generation Hispanics

5
Challenge A New Population in the Southeast
State Change in Hispanic Population (2000-2008)
South Carolina 88.1
Arkansas 82.1
North Carolina 79.8
Georgia 79.7
Tennessee 64.6
State Change in Hispanic Population (2000-2008)
Arizona 53.0
Florida 43.9
Texas 32.5
California 22.9
New Mexico 17.9

• More than ¼ of Hispanic adults do not have a
  usual health care provider (Livingston et al.
  2008).
• Health care provider community does not reflect
  the ethnic diversity of patient community in the
  Southeast.

6
Resulting Healthcare Issues and Disparities for
Latinos

• More than 1 in 4 Hispanics lack a usual
  healthcare provider. (Pew Hispanic Center/Robert
  Wood Johnson Foundation, 2008)
• Hispanics are 3 times as likely as non-Hispanic
  whites to lack a usual healthcare provider.
  (Centers for Disease Control and Prevention,
  2006) Hispanics and Asians report more
  difficulty communicating with their doctors than
  both whites and blacks. (Mead, et al., 2008
• 23 of Latinos report having received poor
  quality of medical treatment or care in the last
  year (Pew Hispanic Center, 2008)
• 17.8 of Hispanics of all ages report being in
  fair or poor health.
• Compared with 11 of non-Hispanic whites. (The
  Commonwealth Fund, 2008)

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Cultural Competence - LCME

• IS 16 MUST have Policies and Practices to
  achieve appropriate diversity among students,
  faculty, staff, and other academic members
• Aspiring physicians will be best prepared for
  medical practice in a diverse society if they
  learn in an environment characterized by, and
  supportive of, diversity and inclusion training
  is facilitated in
• - Basic Principles of culturally competent
  health care
• - Recognition of health care disparities and
  creating solutions to them
• - Importance of care of medically underserved
  populations
• - Development of professional attributes needed
  to provide care in a multidimensional diverse
  society.

8
This Study Goals and Objectives

• Student Provider Perceptions of Latino Patients
  in Cancer Care Settings, NIH/NCI Grant
  1R15CA135349-01A2
• (PIs Mayo, RM Sherrill, WW)
• To develop and evaluate an instrument (MaNSRT) to
  assess medical and nursing students readiness to
  treat Latino patients.
• To inform the design of focused, effective
  interventions in medical and nursing education
  for the region.
• In the process, to learn about medical and
  nursing student perceptions, existing cultural
  competence training, and current readiness to
  treat Latino patients.

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• Student Provider Knowledge Indices
• Latino Knowledge Index
• Latino Cancer Knowledge Index
• (e.g., knowledge of communities, culture,
  personal involvement, cancer rates, risk,
  screening)

Theoretical Framework Model based on Van Ryn
(2002)

• Student Provider Psychological Indices
• Comfort with Latinos Index
• Cultural Competence with Latinos Index
• Attitudes Toward/Beliefs About Latinos Index
• (e.g., provider beliefs about patient compliance
  and cultural factors impacting care, social and
  behavioral factors impacting care of Latinos)

Medical and Nursing Students Readiness to
Treat Latinos in Cancer Care (MaNSRT)

• Student Provider Language and Experience Indices
• Spanish Language Proficiency
• Previous Experience with Latinos

Student Provider Social Demographics Sex Race
Age Education (nurse/physician)
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Instrument Development MaNSRT Health
Professionals Survey

• Systematic literature review (Mayo, Sherrill, et
  al., 2007).
• Preliminary study conducted (n65 nursing
  students)
• Participating students provided feedback (e.g.,
  face validity, question clarity and readability)
• Cronbachs alphas calculated for subscales to
  determine reliability
• Draft survey instrument assessed by expert
  reviewers
• Focus groups
• 6 focus groups
• n27 participants

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Instrument Development (cont.)

• Survey Revision
• First Pilot Test (n38 nursing students)
• Second Plot Test (n99 medical and nursing
  students
• Further Survey Revision and Recruitment
• Final Survey Completed
• Implementation of Final Survey (n1200 medical
  and nursing students)

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Partnering Institutions

• 4 Nursing Programs
• 3 Medical Programs
• Similar institutional structures, curricula, and
  student populations

13
SURVEY REVISION PILOT TO FINAL

• Likert scale vs. Item-specific questions
• Importance of Revision
• Removes potential bias and leading questions
• Gathers a more direct opinion
• Responses more representative of participants
  intuitive opinions and knowledge
• Other Revisions
• Better readability and visual aesthetics
• Fluidity in question order

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LIKERT SCALE PILOT SURVEY
15
ITEM-SPECIFIC FINAL SURVEY
16
ITEM-SPECIFIC FINAL SURVEY
17
ITEM-SPECIFIC FINAL SURVEY
18

• Student Provider Psychological Indices
• Comfort with Latinos Index
• Cultural Competence with Latinos Index
• Attitudes Toward/Beliefs About Latinos Index

19
Emerging Themes

• Experience

• Training/Curriculum

• Participants had different perceptions re amount
  and quality of curriculum content focused on
  Hispanic/Latino health and culture.
• Participants voiced a desire to have more about
  Hispanic/Latino health and culture in their
  curriculum. However, they are clearly emphasized
  that their clinical experiences have the most
  impact on their perceptions and practices (more
  than anything taught in a classroom setting)

• Participants had a difficult time thinking about
  skills/preparation for Cancer prevention/care in
  isolation from other similar chronic health
  conditions.
• Nursing students reported having more
  training/experience in cancer prevention than
  medical students

20
Focus Groups
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Focus Groups Themes

• The medical and nursing students showed some
  general cultural knowledge about the Latino
  population
• Mostly acquired from media and social influences
• Also, from basic stereotypical observations made
  during everyday encounters with the ethnic group
• Clinical and educational settings accounted for a
  small percentage of the acquired knowledge of
  Latino cultures, behaviors and practices.
• Students express that they are trained more
  disease-oriented, rather than
  patient-oriented
• Cultural competence training requires assessment
  and communication with the patient as a whole,
  including their family members (especially with
  Latinos)

22
Pilot Survey Results Themes

• Student provider skills
• Variable ability to explain treatment options and
  clinical trials
• Variable ability to build satisfactory rapport
  with Latino patients
• Variable ability to determine communication
  preferences
• Variable difficulty with clinical assessments due
  to cultural background of patient
• Variable skill level communicating with
  interpreters
• Student provider perceptions
• Do not avoid speaking to Latino families because
  of language barriers

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Conclusions

• In general, medical and nursing students report
  insufficient readiness to effectively treat
  Hispanic/Latino patients
• Stereotypical attitudes and beliefs
• Limited cultural competence skills

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Conclusions

• The MaNSRT survey may be an effective instrument
  to assess nursing and medical student readiness
  to treat Latino patients.
• Also indicate the need for improved cultural
  competence education, especially in the Southeast
• Applied to any student provider program or health
  profession to employ interventions
• The MaNSRT survey is currently being implementing
  with medical and nursing students of four
  institutions in the Southeast.
• Preparation to be used universally
• Currently recruiting more medical and nursing
  programs to participate in the MaNSRT survey

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How much clinical experience have you had with
Hispanics or Latinos?

1. None
2. Very Little
3. Moderate
4. Considerable
5. Extensive

26
In your opinion, how often do you feel adequately
trained to deal with the needs of Hispanic/Latino
patients?

1. Almost never
2. Less than half the time
3. About half the time
4. More than half the time
5. Almost always

27
Based on your training and experience, please
rate your skill level in the following aspects of
care for Hispanic/Latino patients Communicating
effectively through a healthcare interpreter?

1. Not at all skillful
2. Not very skillful
3. Somewhat skillful
4. Very skillful
5. Extremely skillful

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• Survey Research Challenges
• Student Recruitment
• Managing Incentives
• Solicitation Waves
• Program incentives vs. Student incentives

29

• The Challenge of Inter-Institutional Research
• Program Logistics
• IRB
• Educational Program Risks and Benefits
• Nursing and Medical School Curricula

30
References

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