Hispanic Cultural Competence for Medical Education

1
Hispanic Cultural Competence for Medical
Education Curriculum
2
Hispanic Cultural Competence Medical Education
Curriculum Introduction

• Hispanics are the largest ethnic group in the
  United States (40 million or 14.5 of the total
  U.S. population)
• 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 staff
  training in various sectors of the health system.

3
Hispanic Cultural Competence Medical Education
Curriculum Introduction

• Through this project, the NHMA will complete the
  following
• Collect Cultural Competence definitions
• Collect Cultural Competence books and journal
  articles
• Develop a virtual library of information focused
  on cultural competence and Hispanic health
• Conduct a literature search of medical articles
  regarding Hispanic health
• Collect examples of medical education curriculum
• Plan and coordinate a Hispanic Health for the
  Office of Minority Health, U.S. Department of
  Health and Human Services
• Convene a one day meeting of cultural competence
  experts to produce recommendations for guidelines
  for cultural competence medical education
  curriculum

4
Hispanic Cultural Competence Medical Education
Curriculum Methodology

• NHMA Conference Plenary Session Guidance
• The relationship between mind and body (biology
  of belief)
• The physiology of the 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.

5
Hispanic Cultural Competence Medical Education
Curriculum Methodology

• 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.2
  000

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Hispanic Cultural Competence Medical Education
Curriculum Methodology

• Dr. Likes 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

7
Hispanic Cultural Competence Medical Education
Curriculum Methodology

• Literature Review
• A broad but cursory search of the literature on
  Latino Health was conducted to identify the
  type of information that is relevant to
  developing Hispanic cultural competence for
  medical education curriculum.

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Hispanic Cultural Competence Medical Education
Curriculum Methodology

• Limitations of Data
• Many of the search terms used tended to produce
  the same content results.
• None of the searches appeared to produce
  sufficient information on subgroup knowledge
  (Dominicans, Puerto Ricans, Mexicans, South
  Americans, regional, and local)
• Few curriculum models were found, and few of
  these focused on Hispanic culture.
• Little information was found on self-awareness of
  physicians, experiences with self-awareness
  activities or attitude change per se, in medical
  students or physicians

9
Hispanic Cultural Competence Medical Education
Curriculum Methodology

• Limitations of Data (Continued)
• The eventual goal and future goal is to review a
  critical mass of these studies and codify the
  findings.
• Future searches should explore the databases
  California, New York, Puerto Rico
• Future searches should explore the databases
  belonging to the 10 Regions of the USDHHS for
  Hispanic Health information
• Focus groups in New York will be used to gather
  additional knowledge to cultural health patterns
  amongst Puerto Ricans, Mexicans, and Dominicans.

10
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Demographics of Hispanics in the U.S.
• Hispanic 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

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Health Policy Issues
• Access to Health Care
• Cultural Competence
• Hispanic Health Professions Development
• Managed Care Issues
• Data Collection
• Research
• Racial and Ethnic Disparities in Health
• Hispanic Childrens Health
• Hispanic Womens Health
• Hispanic Elderly Health
• Immigrants Health

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Health Policy Issues (Continued)
• Priority Issues Summary
• LEP and Title VI of the Civil Rights Act
• Quality of Health Care
• CLAS Standards

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• 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 todays health care system functions at
  far lower levels than it can and should.
• Health care should be
• Safe,
• Effective,
• PatientCentered,
• Timely,
• Efficient, and
• Equitable

14
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Crossing the Quality Chasm (Continued)
• Care based on continuous healing relationships
• Customization based on patient needs and values
• The patient is the source of control
• Shared knowledge and free flow of information
• The need for transparency

15
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Crossing the Quality Chasm (Continued)
• 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

16
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Culture and Health
• Aztec History
• The Aztecs believed that
• Just as the balance of the opposing forces in
  the cosmos must be maintained.
• Imbalances in the human body led to disease
• Disease could also be caused by uncleanliness
• Herbs used to treat several illness
• Body and Spirit was one inseparable entity.
• Santeria
• Curanderismo

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Understanding Health Status
• The Hispanic Paradox
• For the past twenty years, there has been
  widespread evidence of a Hispanic paradox
  regarding health in the United States, in which
  most Hispanic groups are characterized by low
  socioeconomic status, but better than expected
  health and mortality outcomes.
• A closer look reveals variation by age, gender,
  Hispanic subgroup, acculturation, country of
  birth and cause of death.
• Possible under-reporting of Hispanic deaths,
  salmon bias and healthy migrant effects, and
  risk profile may contribute to, but do not
  explain, the paradox the Reasons for this paradox
  are likely to be multi factorial and social in
  origin.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Understanding Health Status
• Acculturation and Assimilation
• The detrimental and beneficial effects
• The family as a positive social support
• Connections to health outcomes not satisfactorily
  documented

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Cultural Competence and Hispanics - Categorized
• Stress
• Attitudes
• Knowledge Psychoneuroimmunology
• Skills

20
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Cultural Competence and Hispanics - Categorized
• Nutrition
• Attitudes
• Knowledge Advances in Nutritional Science
• Skills

21
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Cultural Competence and Hispanics - Categorized
• Diabetes
• 2-3 times more common in Hispanics than in whites
• 700,000 Hispanics and Mexican-Americans have
  diabetes and dont know it
• Diet
• High use of saturated fat
• Stats higher in Mexican-Americans
• Obesity
• Especially in children
• Higher rates of complications
• Amputations, eye and kidney disease

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Cultural Competence and Hispanics - Categorized
• Diabetes
• Attitudes
• Fear of insulin
• Fear of becoming blind
• Fatalism
• Skills
• To discuss diabetes with family
• To understand
• Referrals to resources

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Physician Patient Interaction and Communication
• A fundamental skill that must be learned by
  medical students, residents, and physicians is
  how to communicate with patients effectively.
• Communication Issues with Hispanics
• Lack of Trust
• Familiarity with subject
• Personal Bias

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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

25
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Physician Patient Interaction and Communication
  (Continued)
• Use of Medical Interpreters
• Due to the prevalence of Spanish language by
  Hispanics, it is critical to provide training for
  physicians and medical students about the proper
  use of interpreters.
• We know that language can be a major barrier in
  the physician-patient interaction when there is
  no understanding between the two.

30
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Physician Patient Interaction and Communication
  (Continued)
• Use of Medical Interpreters
• These barriers can lead to
• Misdiagnoses,
• medical errors,
• lack of informed consent,
• under use as well as over use of testing and
  referrals,
• poor compliance,
• patient dissatisfaction,
• patient mistrust,
• patient increased stress,
• malpractice claims and
• poor health outcomes.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Physician Patient Interaction and Communication
  (Continued)
• Communication Skills for Cultural Competence
  Curriculum
• A curriculum about cultural competence should
  address communication issues for
  Physician-Patient Communication focused on the
  ethnic patients and their communication patterns.

33
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for 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.

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Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Physician Patient Interaction and Communication
  (Continued)
• Building a Cultural Base
• To effectively communicate with Hispanics, you
  need to get to know who they are, how they live,
  their likes and dislikes and what they enjoy in
  life.

35
Hispanic Cultural Competence Medical Education
Curriculum Core Competencies for Hispanic
Cultural Competence

• Conclusion
• Given the increasing growth of the Hispanic
  population in the United States, it is imperative
  that the health professions continue to develop
  curricula that address attitudes, knowledge and
  skills about cross-cultural education.
• Cultural Competence Curriculum should include a
  component that is ethnic specific, in this case,
  on Hispanics.
• Hispanics are regional and sub-group dominant
  with their own cultural peculiarities.
• Hispanics have demographic trends, historical
  traditions, traditional medicine knowledge,
  fundamental values and beliefs, policy issues,
  language and communication needs,
• And a growing body of medical literature.