1. Toward Effective Patient- Provider Communication with Elderly Latinos Raquel Diaz-Sprague, PharmD MS MLHR Adjunct Instructor, School of Allied Medical Professions College of Medicine & Public Health October 6, 2004

2. Hispanic? Latino? In the 2000 census the term “Hispanic” was changed to “Spanish, Hispanic or Latino” and defined as follows: “A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race.”

3. Hispanic? Latino? Region Matters Regional use of the terms varies –in the Eastern region the term “Hispanic” is used more frequently. The term “Latino” is more common in the Western region. Hayes-Bautista, D.E., Chapa, J., (1987). Latino Terminology: Conceptual bases for Standardized terminology. American Journal of Public Health 77 (1),61-68. http//www.whitehouse.gov/OMB/fedreg/

4. Hispanic/Latino by National Origin Mexicans 66% Central and South Americans 15% Puerto Rican 9% Cuban 4% Other 6% http//www.whitehouse.gov/OMB/fedreg/

5. Hispanic/Latino Geographic Distribution Hispanic/Latino Geographic Distribution Mexican Americans reside mostly in the Southwest. Cubans are concentrated in Florida. Puerto Ricans live mostly in the Northeast, New York, New Jersey, and in Chicago. New immigrants are coming directly to job markets in many Midwestern cities.

6. Ethnic and Racial Minority Health Care Disparities Health care disparities are a fact of life for ethnic and racial minorities in the US. In 2002 the Institute of Medicine (IOM) released a report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” http://www.iom.edu/Object.File/Master/13/172/13

7. Unequal treatment (IOM) The IOM report states that racial and ethnic minorities receive a lower quality of health care than whites. Even when insurance and income are the same as those of whites, minorities often receive fewer tests and less sophisticated treatment for heart disease, cancer, diabetes, and HIV/AIDS. They also receive more diabetes-related limb amputations.

8. Unequal Treatment (IOM) Disparities were consistently found across a wide range of disease areas and clinical services Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account

9. Unequal Treatment (IOM) Disparities are found across a range of clinical settings, including public and private hospitals, teaching and non- teaching hospitals, etc. Disparities in care are associated with higher mortality rates among minorities (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995) http://www.iom.edu/Object.File/Master/13/172/13

10. Unequal Treatment (IOM) The sources of these treatment disparities are rooted in historic and persistent current inequities. Biases, prejudices and negative racial stereotypes, the panel concluded, may be misleading doctors and other health professionals “Subtle Racism in Medicine” New York Times, March 22, 2002

11. Bias in Clinical Encounters In clinical encounters, the IOM study found evidence that stereotyping, biases, and uncertainty in the part of health care providers contribute to unequal treatment Providers and future providers must strive to increase their awareness of the health care gaps between racial and ethnic groups in the United States

12. Factors in Unequal Treatment (IOM) Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors – including patient preferences, refusal of treatment, poor adherence, financial limitations, biological differences Disparities arising from the clinical encounter

13. Strategies to End Care Disparities Strategies to end disparities include: Use of "evidence-based" guidelines Improving provider-patient communication Providing Interpreter services for Limited English Proficiency (LEP) patients Recruiting and retaining racial and ethnic minorities in health professions

14. Education is Key Minority patients need help learning how to access and navigate through the US healthcare system Cross cultural curricula should be integrated early in the health care providers training and be a part of required practitioner’s continuing education

15. Aging and Hispanic/Latino Except for Cubans, the US Hispanic/Latino population is relatively young The median age for Mexican Americans is 23.6; Puerto Ricans’ median age is 26.8; for Central/South Americans is 28.4; and for Cubans is 41.1. These demographics have implications for care-giving and dependency

16. Hispanic/Latinos 65 and over Hispanic/Latinos age 65 and over comprise 5.6% of all older Americans This group is expected to grow more quickly than other ethnic minority groups By 2020 they will be 9% of all people 65 and older in the U.S By 2050 they will increase to 16.4% www.agingstats.gov/chartbook2000/tables-population.html

17. One in 5 Centenarians will be a Hispanic/Latino by 2050 In 1990 the population of Hispanic/Latino centenarians -- elders over the age of 100 -- comprised less than 1% of the total centenarians in the US. By 2050 the number of Hispanic/Latino centenarians is expected to be over 19%. www.agingstats.gov/chartbook2000/tables-population.html

18. Elderly Hispanics Live With Family Census population survey shows elderly Hispanic/Latinos to live with relatives, to an extent second only to Asian populations (U.S. Census Bureau, 2000). Preferences for living with relatives has been well documented in the literature for all Hispanic/Latino ethnic groups.

19. Hispanic Families: Lifelong Mutual Assistance Hispanic/Latino elders live with family both as a result of health or economic necessity and because of cultural expectations and traditions. Traditionally they provide childcare, cooking and other services. Expectations are lifelong mutual assistance and reciprocity among family members

20. Mexican Americans Elders Wish to Live With Family In several surveys, often the primary reason given by the Mexican American elders for living with their children is: “Because my child wants me to live with him/her” and/or “it is best for everyone if parents live with their children.”

21. Latino’s Double Burden: Lack of Insurance & Limited English Proficiency Lack of health insurance and LEP are barriers to access to medical care and social services by Latino/Hispanics. Doty & Ives call it “Latino double burden.” 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.

22. “Linguistically Isolated” Many elderly Hispanic/Latinos have limited English proficiency (LEP) and belong to a category that the U.S. census terms “linguistically isolated.” On the other hand, preferential use of Spanish language by Hispanic/Latino elders can serve as a benefit to their quality of life and sense of ethnic identity.

23. “What is Culture?” Culture can be identified as one’s worldview which includes “experiences, expressions, symbols, materials, customs, behaviors, morals, values, attitudes, and beliefs created and communicated among individuals,” and past down from generation as cultural traditions

24. Cultural Proficiency Health care providers need to work toward cultural proficiency with the population they care for. Cultural traits define the use of language, the role of family, religion & spirituality, the definitions of illness, and the use of healing methods and treatment practices

25. Caveat: Cultural Heterogeneity The danger of “cultural competence training” is oversimplification of culture and the creation of stereotypes. Regardless of culture, each person is a unique individual The heterogeneity of the various Hispanic/Latino groups cannot be overemphasized.

26. Latino/Hispanic Cultural Notes In contrast to “mainstream” American values, Latinos tend to have a higher degree of: Familism. Family or group needs take precedence over the needs of the individual.

27. Present-orientation Present orientation. Present time realities have more value than future possibilities. A popular saying is: “Mañana es otro día y Dios dirá.” "Tomorrow is another day and God will tell.”

28. Respect and Formality The communication style of Hispanics is more formal than that of a “mainstream” Americans both in content and form. Many Latinos report that they find Americans frequent and casual use of slang and vulgar expletives (“palabrotas”) offensive, even shocking.

29. Respect for Hispanic/Latino Elders Respect for elders is expected and valued. Greetings are formal. Sr., Sra., Srta, (Mr., Mrs., Miss) precedes last names. Formal professional titles, doctor, ingeniero, profesora, licenciada, etc. are often used. Don & Do ña are used in front of male and female first names, respectively, as a sign of respect.

30. Respect for elders In Spanish, it is inappropriate to address elders by their first name and/or in the “tu” (familiar) form. They should be addressed by their last name, in the “usted” (formal) form

31. Religion/Religiosity Religion is a serious matter in the Hispanic/Latino community. Devotions and church attendance is more common than among native-born Americans and higher than among other immigrant groups. They use of the word “God” reverently, not casually

32. Catholicism Catholicism is a strong bond among Hispanics that crosses all lines of national origins and levels of assimilation. Births, baptisms, marriages, rites of puberty, holidays, even names involve religion. Some 70 percent of Hispanic/Latinos are Roman Catholic. Devotion to the Virgin Mary and patron saints is strong.

33. Personalism Older Hispanic/Latinos expect health care personnel to be warm and personal and to show deference and caring. They have a strong need to be treated in a polite and pleasant manner - con dignidad - “with dignity”

34. Building Rapport with Latino/Hispanic Elders Efforts to build rapport can go a long way to facilitate 2-way communication A prior polite and cheerful exchange of pleasantries can facilitate medical history- taking and physical examination