Toward Effective PatientProvider Communication with Elderly Latinos

1
Toward Effective Patient-Provider 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

2
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.

3
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 forStandardized
  terminology. American Journal of Public Health 77
  (1),61-68.
• http//www.whitehouse.gov/OMB/fedreg/

4
Hispanic/Latino by National Origin

• Mexicans 66
• Central and South Americans 15
• Puerto Rican 9
• Cuban 4
• Other 6
• http//www.whitehouse.gov/OMB/fedreg/

5
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.

6
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

7
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.

8
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

9
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)
• http//www.iom.edu/Object.File/Master/13/172/13

10
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

11
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

12
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

13
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

14
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 practitioners continuing
  education

15
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

16
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

17
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

18
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.

19
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

20
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.

21
Latinos 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.

22
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.

23
What is Culture?

• Culture can be identified as ones 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

24
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

25
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.

26
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.

27
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.

28
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.

29
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.

30
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

31
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

32
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.

33
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

34
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