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Linguistic and Cultural Barriers to Diabetes Treatment
and Management for the Latino Population
Maria J. Nape, J.D.
June 3, 2016
Medical Interpreting Spanish/English On-‐site
Document and Website Translation Spanish/English
Cultural Competence Training for Healthcare
[email protected] 505.289.9259
Overview
My Story
Hispanic/Latino Defined
Language Barriers
Interpreting Issues
Laws
Cultural Competence
Recommendations
My Story
Farmworker Council
Person or lineage from Mexico, Central America, South America,
Caribbean
Latino/ HispanicDefined Race vs. Ethnicity
Countries of Origin for Hispanic/
Latinos living in the U.S.
Americas Caribbean
Puerto Rico, Cuba, Dominican Republic
Mexico Central America South America
Language Barriers
Can you guess?
Cognates
Spanish English
Hospital
Televisión
Mental
Caso
Balance
False Cognates
Spanish English
Ėxito
Embarasada
Papa
Crudo
Constipado
Real and False Cognates
Cognates
Spanish English
Hospital Hospital
Televisión Television
Mental Mental
Caso Case
Balance Balance
False Cognates
Spanish English
Exito Exit?
Embarasada Embarassed?
Papá Papa?
Crudo Crude?
Constipated Constipado ?
Medical Interpreting/ Translation Errors
Spanish English Se pegó
She hurt herself
Once
(English)
Intoxicated Intoxicado?
Use and placement directions
Birth control
Antibiotics
Monolingual/ Bilingual Continuum
Spanish Preferred/ Moderate English
English/ Spanish
Full Fluency
Spanish Only
Spanish Preferred
with Some English
No interpreter needed?
Provider Comments
We got by
Patient understands English
Accompanied by spouse
Accompanied by child
Always the PATIENT’S CHOICE
Only patient knows level of understanding
LEP
LANGUAGE ACCESS LAWS
NEW MEXICO ADMIN. CODE
FEDERAL LAWS
NMAC 13.10.22.11 Requires Managed Health Care Plan to develop, implement, and maintain plan that addresses pa9ent cultural and linguis9c diversity. Plan must address:
Title VI of the Civil Rights Act of 1964 requires language access for all providers receiving federal funds, including Medicare and Medicaid.
(1) How MHCP identifies language needs; (2) Measures chosen to ensure access for LEP persons in administrative and health care encounters with the plan and its providers; (3) Steps to ensure availability of adequate interpretation services within its network, which shall include a description of specific contracts or other arrangements for interpretation …
Executive Order 13166 (Year 2000) Requires federal agencies to identify any need for services for those with limited English proficiency and to implement a system so LEP persons can have meaningful access. Affordable Care Act §1557 Non-‐Discrimination Requirement §1331 Plain Language Requirement
Medicaid coverage options
Points of contact
Spoken
Wri7en
Call center Informa;on forms
Front office staff
Insurance info
Answering Service
Financial Policies
Side conversations – everything audible
No-‐show policies
Voice mail greetings
Office rules
Pre-‐ and Post surgery and medica;on instruc;ons
POC ORAL -‐ OUTSIDE APPT
US LEP POPULATION BY NATIVITY
Source: Migration Policy Institute (MPI) tabulations from the U.S. Census Bureau’s 1990 and 2000 Decennial Censuses and 2010 and 2013 American Community Surveys (ACS).
LATINO PROGRAMS
IN ENGLISH AND SPANISH
Diabetes is an urgent health problem in the Latino community. Their rates of diabetes are almost double those of non-Latino whites.
Getting information to the community about the seriousness of diabetes, its risk factors and those who may be at risk,
and ways to help manage the disease is essential.
For practitioners: http://www.diabetes.org/in-my-community/awareness-programs/latino-programs/
For Patients: Leídos en español
• Type 1 & Type 2 • Prevention • Recipes • Glucose in your blood • Symptoms • Nutrition Plans
Nueva campaña para adultos con prediabetes
La campaña de Anuncios de Servicio Público tiene un mensaje simple pero fuerte: Nadie está exento de tener prediabetes.
Spanish Information Sheets for Patients
• Working Together to Manage Diabetes • Do it for them! But for you too
• Am I at risk for Type 2? • What is depression?
• Physical activity and Diabetes http://www.niddk.nih.gov/health-‐information/informacion-‐de-‐la-‐salud/diabetes/
Pages/default.aspx
Cultural Competence
Linking communication to health outcomes
Communication ↓
Patient Satisfaction ↓
Adherence ↓
Health Outcomes
Cultural Barriers Real dialogue at a regular diabetes check-‐up by family practitioner in Albuquerque
DOCTOR QUESTIONS/ COMMENTS
PATIENT RESPONSES
Morning blood sugar? 275
What did you have for dinner last night?
Tortillas, frijoles, arroz
No more of those foods *Silence
Eat only lean meats, vegetables, low-‐carb side dishes
*Silence
You are head of kitchen – family will eat what you serve
*Silence
What are cultural issues presented?
Spanish-‐speaking patients with diabetes
Need for Community Health Workers
• Liaison between provider and patient • Linguistic and Cultural bridge • Needed follow-‐up to ensure adherence
• Can provide supplemental health education
Excerpts from “Cultural
Considerations in Diabetes Education”
AADE Practice Synopsis July 28,
2015
� Careful attention to cultural influences are critical for behavior changes, which optimize diabetes clinical outcomes.
Current assessments -‐ 12.8% of Hispanic and Native Latin Americans (compared to 7.6% of Non-‐Hispanic white Americans) affected by diabetes.
New CDC data -‐ Hispanics have 51% higher diabetes death rates than Caucasians
Highlights necessity for cultural .preparedness of the diabetes educators of today and tomorrow
Trust Issues
Eligibility for NM public benefits by immigration status
Immigration Status Program
Undocumented Can safely apply for: • WIC (Women, Infants, and Children) • EMSA (Emergency Medical Services for
Aliens) • School breakfast, school lunch, and summer
meals programs • Some hospital charity care programs,
community clinics, and county health programs
Legal Permanent Resident (Green card)
• Children under 18 applying for Medicaid or SNAP/food stamps
• Pregnant women applying for Medicaid • Receiving disability-‐related assistance (such
as SSI) and applying for SNAP
Immigration Status Medicaid Exchange
LPR (green card holder)
Possible 5-‐yr waiting period
P
Refugee/Asylee ↓
P
Battered spouse, child or parent Victim of trafficking (or spouse, child, sibling, or parent)
↓
P
Cuban/Haitian entrant ↓
P
Iraqi and Afghan Immigrant granted Special Immigrant Visa ↓
P
Lawful temporary residents and individuals with “non-‐immigrant status”, including: U visas, Worker visas, Student visas, Citizens of Micronesia, the Marshall Islands
P If pregnant, under 21, or receiving SSI
P Excluding visitors
Temporary Protected Status (TPS) ↓
P
Deferred Action Status (but note that Deferred Action for Childhood Arrivals is not an eligible status for health coverage UNLESS the youth entered the US before 1996)
↓
P With exclusions
HISPANIC CULTURAL VALUES THAT CAN AFFECT THE PATIENT-‐PROVIDER RELATIONSHIP
Simpatia
Personalismo
Respeto
Familismo
Managing Type II Diabetes within the Hispanic Community
Kathy Nobles
Term
Definition How cultural values can serve as
barriers to treatment
Ways to demonstrate respect for cultural
values
Simpatia
Kindness, politeness, pleasantness, avoidance of hostile confrontation
Neutral attitude of many American physicians may be perceived as negative, resulting in inaccurate history, decreased satisfaction with care, treatment nonadherence and poor follow-‐up
Emphasize courtesy, a positive attitude, and social amenities
Term Definition How cultural values can serve as barriers to treatment
Ways to demonstrate respect for cultural values
Familismo
Collective loyalty to extended family that supersedes the needs of the individual
Patients may delay or defer important treatment decisions to permit consultation with their family
Failure to recognize this cultural value may result in unnecessary conflict, dissatisfaction with care, nonadherence to treatment, delays in initiating insulin therapy and poor continuity of care
Encourage patients to bring family members to visits
Provide sufficient time and opportunity for the extended family to discuss important medical decisions
Educate the patient's family about diabetes
Encourage the family to support the patient's treatment efforts
Term Definition How cultural values can serve as barriers to treatment
Ways to demonstrate respect for cultural values
Personalismo
Formal friendliness, warm, personal relationship, characterized by interactions that occur at close distances (e.g., handshakes, placing a hand on the shoulder
When lacking, patients may believe that the physician does not care about them and may be reluctant to share crucial details about their diabetic status, may become nonadherence to medications, may be reluctant to consider starting insulin, and may be dissatisfied with their care
When interacting with patients, decrease physical distance and increase appropriate physical contact
Show interest in the patient's life at each visit (e.g., starting the visit with a brief conversation about the patient's family, work, or school)
Provide a business card or beeper number
Term Definition How cultural values can serve as barriers to treatment
Ways to demonstrate respect for cultural values
Respeto
Respect, including targeted communication based on age, gender, social position, and economic status
Patients may be hesitant to ask questions because questioning an authority figure (e.g., a physician) is viewed as disrespectful
Patients may nod in response to physician's instructions as a sign of respect even when they do not understand
When respeto is perceived as lacking, patients may become resentful and distant
Use Spanish terms of respect (e.g., usted, the polite form of "you," instead of the informal tu)
Use appropriate titles and greetings
Whenever possible, involve patients in medical decisions, such as decisions to start insulin
Ask about the patient's concerns, particularly regarding insulin
Attendance
Adherence &
Participation
� On-‐site Interpreters
� Community Health workers
� Incorporate cultural understanding � Educational Sessions and Events -‐ tips
RECOMMENDATIONS