“Cultural Competence”NHMA/California Endowment Congressional Briefing

Elena Rios, MD, MSPHJuly 22,2003

Hispanic Cultural Competence

Hispanics are the largest ethnic group in the United States (40 million or 14.5 of the total U.S. population)

Hispanics are the largest ethnic group without health insurance (33% < 65 years of age)

In order to promote the health of Hispanics, the largest group of the workforce of the near future, it has been recognized that it is important to develop “cultural competence” in various sectors of the health system

NHMA partners, National Hispanic Health Coalition, California Endowment, and DHHS OMH

Hispanic Cultural Competence

NHMA Annual Conference Plenary Session Guidance

The relationship between mind and body (biology of belief)

The physiology of healing The relationship between nutrition and health, with a

focus on the typical Hispanic diet The current health seeking behavior of Hispanics with

focus on traditional healing and conventional medicine The importance of family dynamics and health

promotion and treatment information among Hispanics Traditional healing practices Hispanic history in the Southwest with a focus on

developing and understanding of the unique transfer of information from the health provider to different generations in the Mexican American family.

Hispanic Cultural Competence

Cultural Competence Definition Cultural Competence is a set of attitudes, skills,

behaviors, and policies that enable organizations and staff to work effectively in cross cultural situations.

It reflects the ability to acquire and use knowledge of the health related beliefs, attitudes, practices, and communication patterns of patients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.

Cultural competency also focuses attention on population-specific issues, including health-related beliefs and cultural values (the socioeconomic perspective), disease prevalence (the epidemiological perspective), and treatment efficacy (the outcome perspective). [HRSA Cultural Competency: A Journey.www.bphc.hrsa.gov.2000]

Hispanic Cultural Competence

Dr. Like’s Framework

The society of Teachers of Family Medicine Core Curriculum Guidelines, “Recommended Core Curriculum Guidelines on Cultural Sensitive and Competent Health Care” [Robert C. Like, M.D., M.S.] A focus on Attitude Change [Information on

perceptions (views, customs, traditions, values and behavior) that can generate awareness and self-awareness on the part of practitioner and patient]

A focus on Knowledge [Knowledge on the attitudes, values, beliefs, and behaviors of certain cultural groups]

A focus on Skills [Tools and skills]

Hispanic Cultural Competence

Demographics of Hispanics in the U.S. Hispanics are 40 million, 14.5 % of the

population Heterogeneous Sub-groups

Mexican-American, Puerto-Rican, Dominican, Cuban-American, Central and South Americans

Social Economic Status (SES) Poor, young, less educated

Occupations Few managers of decision-makers

Hispanic Cultural Competence

IOM’s “Crossing the Quality Chasm” The report, “Crossing the Quality Chasm” from

the Institute of Medicine, in 2001, proposes six areas for improvement to address key dimensions in which today’s health care system functions at far lower levels than it can and should.

Health care should be focused on the consumer: Safe, Effective, Patient–Centered – including culture, values Timely, Efficient, and Equitable

Hispanic Cultural Competence

Unequal Treatment Report, 2002

Disparities in Health Exist in the U.S. for racial and ethnic groups

Cultural Competence Recommendation: Institutionalize training for health

professional students and providers Incentivise provider reimbursements

to increase quality health care

Hispanic Cultural Competence

The Commonwealth Fund 2002 Report: Hispanics are less involved in their health care

than they would like Hispanics find it harder to understand

instructions from their doctors Hispanics find it less easy to understand

instructions on prescription bottles Hispanics had more communication problems

with their doctors Hispanics have the highest rate of self-rating of

health as fair or poor Hispanics have less satisfaction with their quality

of health care

Hispanic Cultural Competence

Understanding Hispanic Health Status

Acculturation and Assimilation The detrimental and beneficial effects The family as a positive social support Multi-generation approach to health

care Combination citizen status, immigrants Connections to health outcomes not

satisfactorily documented – data needs

Hispanic Cultural Competence

Cultural Competence and Hispanics • Stress (SES, Mental Health, Domestic violence,

Environment, etc.)AttitudesKnowledge – PsychoneuroimmunologySkills

• Nutrition (Hispanic diet, grocery store products)AttitudesKnowledge – Advances in Nutritional ScienceSkills

Hispanic Cultural Competence

Physician – Patient Interaction and Communication• Providers must be aware and be able to

communicate with persons speaking other languages.

• Providers must be aware of basic communication precepts such as how to recognize patterns in non-verbal and verbal communication:

Non-verbal communication Verbal Communication

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued)

Non-verbal communication Silence, Distance – Hispanic Prefer close proximity Eye contact Emotional expressiveness Body language Touch Invisible person syndrome Treating adults like children The feeling of linguistic isolation Technical Talk

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued)

Verbal Communication Tone of voice Addressing a person Formality Importance of verbal communication Direct questions and appropriateness

of requesting certain types of information

NHMA a partner in the Kaiser/RWJF Physician Bias and Health Disparities Campaign

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued) Spanish Language

There are some 32 million Americans who speak a language other than English at home.

Spanish is the main “other language” in the U.S. A majority of Hispanics in the U.S. are bilingual

and likely to retain their Spanish language skills as their communities are replenished with new Spanish speaking immigrants and the increasing growth of Spanish media.

Only 24% of Hispanics were born outside the U.S. and Puerto Rico, 77% report Spanish as their primary language and the language they speak at home.

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued) Spanish Language

Approaches to language used in the U.S. in various business services include:• Bilingual Staff• Interpreters• Language Skills Training• Internal Language Banks• Phone-based Interpreter Services• Written Translators

The Robert Wood Johnson Foundation has recently established a national effort, “Hablamos Juntos”, to develop and evaluate language technology for use in the health care system in emerging Spanish markets across the country.

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued) Use of Medical Interpreters

The use of medical interpreters is a major challenge that needs to be promoted in order to deliver quality of health care to an increasing number of LEP patients in the U.S. Certification of medical interpreters as a unique occupation and the subsequent reimbursement policy development by the public and private sector is seen as a promising mechanism to move forward.

Hispanic Cultural Competence

Physician – Patient Interaction and Communication (Continued)Building a Cultural Base

A practical way to understand some from another culture is to be aware and learn to recognize the ways in which their culture and yours differ.

Americans have a tendency to be more informal but reserved in their initial contacts and relationships in general.

Traditional Hispanics, on the other hand, tend to be more formal on first encounters and to address people by their last names.

In relationships, Hispanics tend to share more about their personal lives, and more of the talk about their family, children, and husbands, whereas Anglo Saxons tend to be reserved regarding their personal lives.

Hispanic Cultural Competence

Cultural Competence & Health Policy Issues

Access to Health Care can be increased Health Care Costs can be cut drastically Cultural Competence Guidelines, Priorities,

Committees Hispanic Health Professions Development Managed Care Issues Data Collection on Minorities Research on Trends, Interventions Racial and Ethnic Disparities in Health Hispanic Children’s, Women’s, Elderly Health Immigrant’s Health Public Health Research

Hispanic Cultural Competence

Cultural Competence & Health Policy Issues

LEP and Title VI of the Civil Rights Act Quality of Health Care & Patient Safety Medical errors, poor compliance, malpractice,

poor health outcomes DHHS OMH CLAS Standards Medicare:

Quality Demonstration Projects Incentives for Providers in Hispanic areas –

-Puerto Rico, US-Mexico border, rural/urban Language Services Legal Immigrant Services

Hispanic Cultural Competence

Conclusion Given the increasing growth of the Hispanic

population in the United States, it is imperative that the health system continue to develop cultural competence policies that address attitudes, knowledge and skills about cross-cultural education.

Hispanics are regional and sub-group dominant with their own cultural peculiarities that health policies should include.

Hispanics have demographic trends, historical traditions, traditional medicine knowledge, fundamental values and beliefs, legal status, language/communication needs, and a growing body of medical literature.

Cultural Competence Policy should be ethnic specific, in this case, Hispanics – designed with Hispanic experts and organizations and community leaders.