National Latino AIDS Awareness Day

Cultural Competency WorkshopConceptual Overview

Objectives

• Define and understand key terminology

• Discuss the implications of demographic trends for health disparities

• Explain how cultural beliefs shape clinical encounters

• Describe effective techniques for working with minority patients

Latino or Hispanic?• Latino Population

• Many cultures that include people from:• North America ∙ Central America • South America ∙ Caribbean

• Languages: English, Spanish, Portuguese, Mayan, Guarani

• Diverse background of individuals indigenous of:• African, European, Anglo, Asian, Middle Eastern descent

• “Hispanic” inclusive of only Iberian Peninsula in Spain

• Guyana, French Suriname, & some non-Spanish speaking indigenous groups not consider themselves “Latino”

Culture Is…?

A. Things: Tools, clothing, buildings, art

B. Ideas: Thoughts, beliefs, values, expectations

C. Behaviors: Traditions, rituals, manners, roles, language

D. Taught/Learned

E. Passed from generation to generation

F. All of the above

Culture• A concept (an idea; something formed by

mentally combining all of the characteristics or particulars related to that subject)

• An integrated pattern of knowledge, beliefs, behaviors, whose soul purpose is to transmit this knowledge to succeeding generations

• A unification process, which combines customary beliefs, shared attitudes, and values

Health as a Cultural Construct

• Culture Defines:• How health care information is received

• How rights and protections are exercised

• What is considered to be a health problem • How symptoms and concerns are expressed

• Who should provide treatment for the problem

• What type of treatment should be given

• In Latin America health is• “the perfect harmony between your internal and external

world”

• In the U.S. health is• “the absence of illness”

Cultural Competency is…?

A. The ability to work effectively in cross-cultural

situations

B. A course offered at UNO

C. Knowledge of every cultural norm and more

D. Both A and C

E. All of the above

How would a Culturally Competent Health Care Facility Operate?

• The facility is capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency

• The facility is engaged in an intentional and continuous process of learning about and integrating cultural knowledge into every facet of what they do to better serve culturally diverse communities

• Staff hold a deep respect for cultural differences and are eager to learn, and are willing to accept, that there are many ways of viewing the world

BE SAFE Model

•Barriers to Care – real or perceived gaps

•Ethics – principles determining “right” or “wrong”

•Sensitivity – cultural awareness by provider

•Assessment – collecting data in context of pt culture

•Facts – understanding of pts beliefs and values

•Encounters – awareness of communication cultural norms

Barriers to Care

• Linguistic Issues

• Access to Care and HIV Testing

• Constructs of Culture and Gender

• Stigma

• Bias of Health Care Provider

Ethics• Principles that should guide health care facilities

1.Autonomy- information necessary for an informed decision

2.Beneficence – putting the patient’s best interest first

3.Non-malfeasance – “above all, do no harm”

4.Justice – all individuals treated equally regardless of culture, race, ethnicity, or language barriers

Sensitivity of the Provider• Stages of Cultural Competency

Unique Issues

• Low tolerance for anything that involves time

• Facilitation of translation through use of family or friends as translators

• + more multilingual signs are now used in health care settings

• Heavy accents are associated with poverty, lower socio-economic levels, etc

Unique Issues

• No 15 minute “one size fits all” model• Physicians usually meet patients in their office

before exam

• Often treat the whole family and ask about them

• Eyesight problems or illiteracy?

• Folk Medicine• Using herbs & oils allows a sense of control

• Consider an active coping process

Assessment• Culturally Based Assessments and Treatment Plans

• ETHNIC Model

• Explanation – “Why do you think you have these symptoms?”

• Treatment – “What kinds of medicines have you tried?”

• Healers – “Have you sought advice from folk healers?”

• Negotiation of treatments plan

• Determine the Intervention

• Collaborate to make possible the optimal and holistic

treatment

Assessment• Explanatory Model

• “What do you think caused your problem?”

• “Why do you think it started when it did?”

• “What do you think your sickness does to you?”

• “How severe is it?”

• “What kind of treatment do you think you should receive?”

• “What are the most important results you hope to

achieve?”

• What are the chief problems your sickness has caused?”

• What do you fear most about your sickness?”

Facts• Cultural Beliefs and Values

• Fatalismo• Familismo• Simpatia• Confianza• Respeto• How can these affect the clinic

visit?

• Gender Roles• Marianismo & Machismo

• Use of Folk Medicine

• Fatalism• Family• Friendly, Humble, &

Vulnerable • Trust• Respect

Encounters

• Eye contact – demonstrates respect

• Facial Expression – an unexaggerated, friendly smile

• Gestures – stand up, walk to, & greet patient

• Touch – greet with handshake and offer handshake upon completion of the encounter

• Voice Intonation – speaking loudly will not

understanding

• Addressing Latino Patients – the use of titles

• The Use of Interpreters

Demographic Changes and Health Disparities

Demographic Changes by Race/Ethnicity

31.00%

33.00%

African American

2000

2008

61.00%

63.00%

Caucasian

2000

2008

2.00%2.50%3.00%3.50%4.00%

Hispanic/Latino

2000

2008

1.00%

1.50%

2.00%

Asian

2000

2008

0.00%

1.00%

American Indian

2000

2007

Persons Living with HIV/AIDS by ParishLouisiana, 2007

Latino Population Map Key

>9%

7-9%

4-7%

<4%

Nationwide

• Latinos comprise 15% of the US population, but accounted for 17% of all new HIV infections in 2006

• Incidence of HIV/AIDS 3X the rate for Whites

• Latino males accounted for 18% of all males living with HIV/AIDS

• Latina females accounted for 15% of all females living with HIV/AIDS

• In 2005, HIV/AIDS was the fourth leading cause of death among Latino men and women aged 35–44

• Most common methods of HIV transmission were: • For males: 1) MSM sexual contact 2) Injection drug use

3) High-risk heterosexual contact

• For females: 1) High-risk heterosexual contact 2) Injection drug use

Race/Ethnicity of PLWAs in Louisiana

66%

3%

30%

Southern Region of Louisiana Rates Among Latino/Hispanics• There are a reported 579 Cases of HIV/AIDS in

Louisiana Among Latinos/Hispanics

Region: Region 1New Orleans Area

Region 2Baton Rouge Area

Region 3Houma Area

Region 4Lafayette Area

Region 5

# of HIV/ AIDS:

305 43 17 45 80

Percent: 5% 1% 3% 4% 9%

Latino Population• Many languages, many cultures

• The Effects of Hurricanes• Pre-K: substantially Honduran and other Central

American professionals• Clustered, well educated, well paying jobs in health

care, business, and government

• Post K:• Influx of less educated largely male laborers• Mexico, Nicaragua, Brazil• Some undocumented, limited knowledge of foreign

culture • Dispersed

Health Disparities Defined

• Population-specific differences in the presence of

• Disease

• Health outcomes

• Access to health care

Latino Population• Implications for healthcare

• Language & Health Care Expectations• “Latino physicians show a friendliness to

patients, and ask about the family”

• Pre-natal care for undocumented/Spanish speaking women

• Documentation• Domestic & Occupational Barriers to Care• Acculturation conflicts• Educational difficulties

Barriers to Care• Linguistic Issues – English, Spanish, Portuguese, Guarani, etc.

• Access to Care and HIV Testing• Under/uninsured – lack of citizenship, job characteristics, poverty• Education – 50% Latinos not completing high school• Transportation, no childcare, excessive waiting times, can’t miss work

• Constructs of Culture and Gender• Religious beliefs• Gender roles• Fatalistic views of life – “que sera, que sera”

• Stigma – greater than in U.S. culture

• Bias of Health Care Provider

Tragic Consequences:

Cases of Inadequate Communication

• Misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia

Tragic Consequences:

Cases of Inadequate Communication

• After 36 hours of work up for a drug overdose, comatose patient reevaluated

• Diagnosis: Intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery

• Hospital paid $71 Million settlement

Tragic Consequences Case #2

Misinterpretation• Spanish speaking

woman told a resident that her two-year old had “hit herself” when she fell off her tricycle

• Resident misinterpreted two words

• W/O interpreter present, mother signed over custody of her two children

Conclusions

• All patients have the right to fair and competent care

• Race, ethnicity, language, and culture must be included when planning care for the patient

• Cultural competency in health care is the ability to work cross-culturally in order to address the needs of the patient.

Resources• Delta AETC archives (1999-2009) PowerPoint

Presentations

• National Minority AIDS Education and Training Center (2002) BE SAFE: A Cultural Competency Model for Latinos. Washington D.C., Howard University

• Louisiana Department of Health and Hospitals Office of Public Health (2009).Louisiana HIV/AIDS Surveillence Quarterly Report (6/30/09)

• Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008;300:520–529.

• CDC. WISQARS [Web-based Injury Statistics Query and Reporting System] Leading causes of death reports, 2005 [2005 reports re Hispanic/Latinos]. Accessed March 18, 2008.