Respectful Communication

1
Respectful Communication

• Certain topics are taboo in some cultures. E.g.,
  asking an older Latina/Hispanic unmarried woman
  about sex behavior can be considered offensive.
• You may want to tell the patient that you realize
  that some things are not normally discussed, but
  that it is necessary so that the best care can be
  planned

2
Alternative Complementary Healing
Systems/Techniques

• Latino/Hispanic alternative and complementary
  healing systems or techniques include
  Curanderismo, Espiritismo, and Santeria.
• Healers include
• Curanderos (general practitioners of Mexican folk
  healing)

3
Alternative Complementary Healing
Systems/Techniques

• Espiritistas (Puerto Rican faith healers)
• Santeros (Cuban faith healers)
• Yerbistas (herbalists)
• Sobadores (massage therapists)
• Folk healers often treat children for conditions
  such as

4
Alternative Complementary Healing
Systems/Techniques

• Colico (colic)
• Empacho (locked bowels)
• Susto (fright)
• Mal de ojo (evil eye)
• Caida de la mollera (fallen fontanel)

5
Alternative Complementary Healing
Systems/Techniques

• Healers also perform spiritual cleansing
  (barridas or limpias).
• Insufficient data exists regarding the extent to
  which alternative and complementary healers and
  systems are used by Hispanics
• Villa, M.L., Cuellar, J., Gamel, N., Yeo, G.
  (1993). Aging and Health Hispanic American
  Elders (2nd edition), SGEC Working Paper Series,
  Number 5, Ethnogeriatric Reviews, Stanford
  Geriatric Education Center.

6
Latino Health Care Gaps

• Compared with non Latino whites, Latinos are
  three times as likely to be uninsured.
• Many have no regular source of primary care,
  receive fewer check-ups, cancer screenings and
  other preventive services. They rely heavily on
  sporadic and emergency room care.
• As a result of late diagnosis, breast cancer is
  the leading cause of cancer death among Latinas.
• National Cancer Institute, Cancer Net, Breast
  Cancer Facts, 1999

7
Hispanic/Latinos Double burden

• Doty and Ives have extensively documented Latinos
  Double burden
• 1) Limited English proficiency (LEP)
• 2) Lack of health insurance
• Together, the double burden can be a death
  sentence
• 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.

8
English-only Healthcare Providers

• In the US, providers tend to be monolingual --
  English only.
• And/or have insufficient knowledge of Spanish and
  lack awareness of medically relevant aspects of
  culture
• Latino patient and Anglo provider have
  communication gap, and different worldviews

9
Evaluating Effective Communication

• Providers should evaluate whether questions or
  instructions given to LEP patients have been
  understood
• To be polite, some Hispanic/Latino patients will
  nod yes but not really comprehend.

10
Nonverbal Communication

• Much of communication between people is
  nonverbal. One must learn it to be able to truly
  communicate
• However, Nonverbal Communication is rarely a part
  of Foreign Language training in the higher
  education system

11
Nonverbal communication

• Nonverbal communication is the sum of
  non-linguistic messages that are encoded and
  decoded through
• Gestures
• Facial expressions
• Eye contact
• Tone of voice
• Pauses, silences

12
Communication gaps

• Cultural, linguistic, and nonlinguistic gaps can
  lead to miscommunication and mistrust.
• Health care personnel must be trained in cross
  cultural assessment and in both the verbal and
  nonverbal aspects of communication

13
Two-way communication ethical imperative

• To prevent poor health outcomes for
  Hispanic/Latinos and to lighten their double
  burden
• Efforts to improve the quality of Anglo-Latino
  communication in health care settings are ethical
  imperatives.

14
Translation vs. Cultural Adaptation

• Health messages and patient education documents
  should be not only linguistically translated but
  also culturally adapted.
• Straight translation into Spanish has many
  limitations.
• Cultural adaptation is a more effective method to
  achieve health promotion.

15
Conceptual equivalence

• In translation, conceptual equivalence is more
  important than linguistic equivalence
• Health behavior modification approaches must be
  culturally appropriate to be effective

16
Latinos in Columbus Health gaps

• Uninsured Latinos in Columbus report job-related
  injuries, trauma, diabetes, hypertension,
  allergies, need for birth control, skin rash and
  other conditions
• Often they can not afford to take time away from
  work to go to a doctor during the day
• Source State of La Clinica Latina A First Year
  Report Raquel Diaz-Sprague, PharmD MS MLHR,
  January 29, 2002

17
Latinos in Columbus Health Care Gaps

• As Latinos are the least paid workers, and the
  least insured, they can not afford the cost of a
  primary care medical consultation or to buy the
  prescriptions they need to control chronic
  diseases or conditions such as allergies, asthma,
  diabetes, and hypertension

18
Latinos in Columbus Health gaps

• Traumatic injuries sometimes are left unattended
  resulting in irreparable losses.
• E.g., Marcos, a 48 year old Mexican construction
  worker was opening a door by hammering on a
  concrete wall on a Tuesday afternoon

19
Latinos in Columbus Health gaps

• A piece of concrete flew into his right eye. He
  felt like he was bleeding but no blood was coming
  from the eye. The pain was acute. His foreman
  examined him, told him its nothing gave him
  Tylenol and told him to keep working or hell be
  fired

20
Latinos in Columbus Health gaps

• Marcos kept taking Tylenol and kept working with
  eye pain for 5 days.
• The foreman finally took him to an emergency room
  on Sunday evening
• He had an emergency operation to remove a metal
  piece from the eye.

21
Latinos in Columbus Health gaps

• The operation cost 2000. He gave the hospital
  all he had, 400.
• The foreman refused to help pay. The hospital
  refused to do follow up care. He needs an
  operation to correct the eye muscles. He cant be
  scheduled for lack of resources for payment.
• He has lost 95 vision in that eye.

22
Mistaken Identities Fear Factor

• Some Latinos are putting off going to a doctor
  because of fear they will be asked to show
  papers. They may or may not have legal papers.
• They may be using someone elses papers with a
  different name and a different date of birth.

23
Bridging the Gaps

• In 2000 HHS published guidelines Cultural and
  Linguistically Appropriate Services (CLAS) urging
  providers to
• Provide qualified interpreters.
• Provide written materials in the patients
  language

24
Nearly 45 Million Uninsured

• Nearly 45 million Americans 15.6 of the U.S.
  population did not have health insurance during
  a typical month in 2003.
• This represents an increase of 5 million people
  and more than 1 percent of the population since
  1990
• Source "Protecting the Protecting the Uninsured
  Kenneth E. Thorpe, Ph.D.
• New England Journal of Medicine October 6, 2004
• Volume 351 October 7, 2004 Number 15
• http//content.nejm.org/

25
Health care -- a human right

• Lack of access to care for the working poor and
  the 45 million uninsured in the US - the richest
  nation on earth - is an ethical issue requiring
  action response.
• Lack of access to health care puts people at risk
  for severe conditions that could have been
  effectively managed when diagnosed and treated at
  an early stage.

26
Helping Latinos in Columbus

• Many new Hispanic/Latino immigrants have unmet
  primary health care needs. Most are uninsured,
  have little financial resources and rely on
  episodic or emergency care.
• From 1999-2002, I led a group of volunteers as
  Chair of Latino Health Alliance and Founding
  Director of La Clinica Latina. The clinic
  currently operates for about 3 hours 2 or 3
  nights a month. It is funded by the OSU Medical
  Center. The staff is all volunteer.

27
La Clinica Latina

• Mission of La Clinica Latina
• To educate Latinos in Columbus on health care
  issues and provide free primary care in a
  bilingual and bicultural atmosphere.

28
La Clinica Latina (cont.)

• The clinic opened on December 19, 2000. An
  8-month old boy presenting a leg burn was the
  first patient. The burn was caused by a chemical
  gel leaking from a cheap diaper. He was treated
  and recovered quickly. We fell in love with him.
  His parents were so very grateful.
• La Clinica provided 727 patient visits to 320
  patients in 2001.
• Source State of La Clinica Latina A First Year
  Report
• Raquel Diaz-Sprague, PharmD MS MLHR, January 29,
  2002

29
La Clinica Latina Reception Area(snapshot taken
in 2002)
30
Educating Health Providers Medical Communication
with Latinos (AMP 641)

• AMP 641 evolved from a minimodule in the Medical
  Humanities Program for MEDI and MEDII.
• Course offered Spring Quarter open to students
  in any college.
• AMP 641 is included in the Latino/a Studies
  curriculum of the College of Humanities, Division
  of Comparative Ethnic Studies.

31
Medical Communication with Latinos (AMP 641)

• The course provides instruction on medical
  terminology, cultural adaptation in translation,
  medically relevant aspects of Hispanic/Latino
  culture, service learning
• Permission of Instructor is required. Instructor
  Raquel Diaz-Sprague, PharmD
• Contact diaz-sprague.1_at_osu.edu

32
Thoughts and Reflection

• Almost one in 6 people in the US lacks health
  insurance. The number of uninsured is growing as
  costs escalate.
• The nation must end this health injustice.
  Creative solutions to provide access to health
  care for all are needed. It is an ethical
  imperative.

33
Thoughts and Reflection

• Charitable free clinics while providing a
  wonderful and noble service can do little to
  alleviate the US health care access crisis.
• Expanding a network of free or low-cost clinics,
  is at best a bandage over a deep, festering
  wound.
• Universal coverage is needed

34
Final Thought and Reflection

• The inhumanity of slavery in the US could not
  have been ended by expanding emancipation, but by
  abolishing the institution of slavery!
• So must this nation abolish, for all time to
  come, the inhumanity of lack of health care
  coverage built in the US healthcare system.
• Will we join the civilized world?
• Source Intercultural Understanding and
  Communication Can Help Bridge Health Gaps for
  Latinos Presentation by Raquel Diaz-Sprague,
  American Association for Practical and
  Professional Ethics, 13th Annual Meeting.,
  February 27, 2004