Transcript U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

“Hispanic Cultural Competence for Medical
Education Curriculum”
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.
Hispanic Cultural Competence Medical Education Curriculum
Introduction
 Through this project, the NHMA will complete the
following:
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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
Hispanic Cultural Competence Medical Education Curriculum
Methodology
NHMA Conference Plenary Session Guidance
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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.
Hispanic Cultural Competence Medical Education Curriculum
Methodology
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Cultural Competence Definition
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Cultural Competence is a set of attitudes, skills,
behaviors, and policies that enable organizations and
staff to work effectively in cross cultural situations.
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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.
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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 Medical Education Curriculum
Methodology
Dr. Like’s Framework
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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.]
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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 Medical Education Curriculum
Methodology
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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.
Hispanic Cultural Competence Medical Education Curriculum
Methodology
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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
Hispanic Cultural Competence Medical Education Curriculum
Methodology
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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.
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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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
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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Health Policy Issues
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Access to Health Care
Cultural Competence
Hispanic Health Professions Development
Managed Care Issues
Data Collection
Research
Racial and Ethnic Disparities in Health
Hispanic Children’s Health
Hispanic Women’s Health
Hispanic Elderly Health
Immigrants Health
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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Health Policy Issues (Continued)
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Priority Issues Summary
LEP and Title VI of the Civil Rights Act
Quality of Health Care
CLAS Standards
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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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:
 Safe,
 Effective,
 Patient–Centered,
 Timely,
 Efficient, and
 Equitable
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Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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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
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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Crossing the Quality Chasm (Continued)
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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 Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
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Culture and Health
 Aztec History
 The Aztecs believed that:
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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
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.
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
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
 Cultural Competence and Hispanics -
Categorized
• Stress
 Attitudes
 Knowledge – Psychoneuroimmunology
 Skills
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
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 don’t 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
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
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
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
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
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
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.
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.
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.
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
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referrals,
poor compliance,
patient dissatisfaction,
patient mistrust,
patient increased stress,
malpractice claims and
poor health outcomes.
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.
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.
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.
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.
Hispanic Cultural Competence Medical Education Curriculum
Core Competencies for Hispanic Cultural Competence
 Conclusion
 Given the increasing growth of the Hispanic population in
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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.