A successful guide in understanding Latino immigrant patients: An aid for health care professionals

Abstract

Objective

It has been shown that cultural and linguistic barriers may have a great impact on the quality of health care received by immigrants. The recent growth of Latino immigrants in new areas of the country (particularly in the South) has presented great challenges to the health care system and health care professionals in these states. Through a NCI funded community-based educational program (Sowing the Seeds of Health), we created an informative DVD to aid health care providers in better understanding Latino immigrant health beliefs and health care seeking behaviors. The educational DVD presented information on how to provide culturally competent care as it relates to Latino immigrants, their expectations when seeking care, and common cultural beliefs and practices. Health care professionals and Latino immigrants participated in the development and content of the DVD.

Methods

The intervention was delivered though various mediums; on-site, on-line, two national webcasts and mailed copies of the DVD. Pre- post self-administered questionnaires assessing knowledge and attitudes regarding culture competency and relevant topics addressed in the DVD.

Results

Four-hundred and sixty-three (N=463) health care professionals participated from across the United States. Intervention produced significant overall knowledge increase (p-value <0.001) in cultural competency, Latino cultural beliefs and barriers to healthcare access for Latino immigrants.

Conclusion

The findings indicate that a short DVD offered via multiple mediums may be a promising avenue for educating health care professionals about the needs and expectations of Latino immigrants in the U.S.

Introduction

One-third of the population in the United States consists of racial/ethnic minorities, with Latinos encompassing the largest minority group.¹ Between 2000 and 2006, Latinos represented one-half of the nation’s overall population growth, which has been attributed primarily to immigration and birth rates.^{1, 2} The largest influx of Latino immigrants has occurred over the last few decades with Latinos arriving to new areas of the country, bringing an array of challenges to both the health care system and health care providers in those areas. Historically, Latinos resided in a few select states, with nearly two-thirds living in California, Texas, Florida and New York.¹ However, with increased employment opportunities in the Southern region of the country, thirty-five percent of Latinos nationwide currently live in the Southeastern United States.³ The migration of populations to areas of the country not prepared to accommodate the health care needs of the new inhabitants presents various challenges, ranging from not knowing where to get care to language barriers and cultural competence among providers. In fact, studies have shown that recent Latino immigrants are less likely to have access to health care and health care resources than those who have been living in the U.S. for a longer period of time.^3–5 Evidence suggests quality patient-provider communication is associated with increased adherence to treatment, patient satisfaction and overall enhanced health outcomes.^5–8 Patients’ inability to communicate with providers and health care professionals can greatly affect overall health and health care seeking behaviors, particularly when the provider and the patient do not speak the same language.⁷ In addition to language barriers, it has been shown that financial difficulty, lack of health insurance options, lack of transportation, inability to take time from work, difficulty scheduling appointments, embarrassment and procrastination may prevent Latino immigrants’ from seeking health care.^{3, 5, 9, 10} As such, comprehensive efforts in addressing the above mentioned obstacles are needed among Latino immigrants as well as health care providers. Although it is imperative for recent immigrants to comprehend the health care system in the U.S., it is equally important for providers to understand the cultural beliefs, expectations and barriers to care among Latino immigrants to narrow the gap between the two groups, generating an overall positive experience for both the provider and the patient.

Understanding common cultural beliefs and health care seeking behaviors among the Latino immigrant population is an important aspect in facilitating competent care. Reduced amounts of time and amplified clinical demands have emphasized the importance of proficient and efficient training that can accommodate the provider’s multiple demands.¹¹ According to Casebeer et al, on-line training that is available for health care professionals has increased significantly, but the majority of studies have not been thoroughly assessed.¹² The purpose of this paper is to describe the development, implementation, and evaluation of a short DVD entitled, “A Guide to Working with Latino Patients in Alabama” used to reach health care professionals in a state that has recently received a large and fast influx of Latino immigrants.

Methods

“A Guide to Working with Latino Patients in Alabama” was developed as part of a larger program entitled, “Sowing the Seeds of Health” (SSH). SSH is a community-based educational program with the goal of reducing the incidence of breast and cervical cancer among the Latina immigrants via community health advisors or “promotoras de salud.” The SSH program draws on women’s interest in family planning to promote early detection of breast and cervical cancer. The development of the curriculum was based on an extensive qualitative and quantitative needs assessment among Latino immigrants in two Southern states (Memphis, Tennessee and Birmingham, Alabama). SSH incorporated an educational intervention component targeting Latina immigrants in the community ranging from how to navigate the health care system to the importance of breast and cervical cancer screening. Another aspect of the program consisted of education of health care providers with whom these immigrants were likely to interact. The focus of this paper is on the second component.

The conceptualization of the training component was initially based on views and input from health care providers as well as individuals involved in providing services to Latino immigrants through community-based organizations. Suggested methods of delivery varied, but it was determined that it was essential to offer the training in a short, condensed manner to accommodate professionals’ busy schedules and provide continuing medical education.

Specific cultural values that were considered to be central in the Latino culture played a major role in the development of the content of the DVD. It is important to note that the Latino culture is extremely diverse and culture traditions, values and practices can range throughout and within various countries.^{5, 13} Therefore, input was received from the local Latino population and served as a critical component in developing the training content.

Aspects of the Latino culture that may interfere with patient-provider communication and care were at the forefront of the curriculum. Content of the training was based on the following themes: (1) Barriers in accessing care among Latino immigrants in the U.S.; (2) Health care system in the U.S. vs. Latin America, including Latino immigrants’ expectation when seeking care; (3) social construction of health and illness in the Latino culture; and (4) use of complementary medicine; and (5) a brief overview as to why the topic of breast and cervical cancer was being addressed among Latina immigrants.

Local professionals with expertise in the topics above were recruited to address each of the cited themes. Scripts were developed by the professionals in conjunction with program investigators, managers and coordinators. Facets of the training content were reviewed by a community advisory committee consisting of Latino community health advisors, community-based organizations serving Latino immigrants, and a Hispanic Healthcare Outreach program at a local hospital in Birmingham, Alabama. Once scripts were reviewed and finalized, each session was digitally videotaped and edited for dissemination purposes. Following the complete digital production of the training, a website was developed in conjunction with the University of Alabama at Birmingham (UAB) Division of Preventive Medicine Information Technology team, which included the training as well as the pre- and post-test assessments.

In an effort to develop and implement medical education, the program partnered with the accredited UAB School of Medicine Division of Continuing Medical Education (CME) to offer certification and continuing medical education credit. The educational activity was allocated 1 (one) continuing medical education credit for physicians and nurses. Only participants that completed the training and the assessment measures (pre/post tests), were awarded a CME certification.

A comprehensive approach was taken to reach health care professionals at all levels of the health care system as well as varied levels of technical ability. Training was offered via on-line, on-site, through a national webcast and hard copies of a DVD mailed upon request. In order to reach nurses, social workers and clinical staff, the program partnered with local hospitals, health departments and continuing educational training networks to also offer continuing education units as needed.

To platform and deliver the educational guide, a link was strategically placed on the UAB School of Medicine Division of Continuing Medical Education website as well as the UAB Minority Health & Health Disparities Research Center website. The website was also promoted during SSH presentations, community meetings and seminars. Participants that completed the tutorial on-line were given the capability to print their CME certificate immediately following the training.

On-site education was integrated through statewide conferences, community meetings, as well as clinic specific trainings. The majority of the on-site tutorials were offered using a combination of live presentations and recorded portions of the developed DVD.

A live webcast and satellite conference was planned and implemented in collaboration with the Alabama Department of Public Health Training Network. The webcast was offered nationwide and free of charge as part of the Public Health Training Network. Continuing Medical Education credit was available for physicians and Continuing Education Units were available for nurses and social workers. Certification was provided following successful completion of the on-line registration and assessment measures. In combination with pre-recorded segments of the DVD, a panel of experts was recruited to present specific thematic categories and address participant’s questions and comments. The conference was recorded and available on the Alabama Department of Public Health Training Network website following the live webcast.

In addition to the above mentioned mediums of delivery, hard copies of the DVD and pre-post assessments were mailed, as requested, to participants with pre-addressed, stamped envelopes. These participants were informed of the DVDs existence through conferences, presentations and word of mouth. The on-line portion of the training also gave the participants the option to request a hard copy of the DVD. All copies of the DVD were distributed free of charge.

Pre and post-test assessments were conducted to evaluate changes in knowledge of cultural competence in healthcare for Latino immigrants, expectations of Latino patients seeking care, and common health beliefs and practices of the Latino immigrants’ culture. The measurements consisted of demographic information and a set of twelve multiple choice questions at baseline and following the training session. Answers to the knowledge questions were coded as correct or incorrect and Mc Nemar tests were conducted to assess the statistical significant differences between the baseline and post-training answers.

Self perceived increase in knowledge about cultural competency, Latino cultural beliefs and barriers to healthcare access for Latinos were also evaluated. Participants were asked to rate their knowledge on these three areas before and after the training through a scale from 1 to 5, 1 being the lowest and 5 the highest. Paired t-tests for each of the three questions were conducted to compare the scores before and after the training. The significance level was set at 0.05, and all statistical analyses were conducted using SPSS version 16.(8).

Results

Data collection took place between fall of 2007 and summer of 2009, four-hundred and sixty-three (N=463) individuals participated in the training: 106 participated in the webcast, 110 attended on-site training sessions, and 192 accessed the training through the website. Additionally, 85 DVDs were hand delivered or mailed as requested. However, out of the 85 DVDs that were distributed, only one person returned the pre and post test evaluation; therefore it is unclear if the others watched the DVD. Consequently, they were not included in the analysis. Four hundred and fifty-nine (459) participants completed the baseline assessment and four hundred and seven (407) completed the post-training assessment.

Almost half of the sample (44%) was 30 years of age or younger (Table 1). All on-site sessions were held in the state of Alabama, and 26 states were represented in the webcast. Nearly 30% of the sample was either nurses or nurse practitioners, 16.2% were students in the health care related fields, 9.9% were social workers, 6.5% were physicians, 3.9% were health educators, and the remaining were professionals in health care related fields.

Table 1.

Demographic Information of Participants (n = 515)

	%
Age (y)
≤30	41.2
31–40	14.9
41–50	19.0
51–60	21.4
≥61	3.5
State of residence
Alabama	46.6
Tennessee	1.9
Others (24 states)	12.5
Unknown	39.0
Occupation
Physician	5.2
Nurse practitioner	2.6
Nurse	31.3
Students health-related fields	16.4
Social workers	10.8
Other professionals in healthcare-related fields	33.7

Forty-two percent (42%) of participants reported seeing less than 5% of Latino patients in an average month, 23.5% reported seeing between 5% and 10%, 11% reported seeing between 11% and 20%, 10.4% reported seeing between 21% and 30%, and the remainder (13%) reported seeing 31% or more.

Overall, knowledge was higher following the training. Ten of the 12 questions reflected a statistically significant increase in knowledge (Table 2). Even though most of the questions had a high percentage (more than 80%) of correct answers at baseline, there was an increase in the percentage of correct answers following the training.

Table 2.

Health Care Providers’ Knowledge on Cultural Beliefs Regarding Health, Health Care Seeking, and Barriers to Health Care Access Among Latino Immigrants(n = 45)^a

	% Right Answers		P (McNemar Test
	Pretest	Posttest
Cervical cancer incidence among Latinas in the United States compared with non-Hispanics (2 times higher)	69.2	68.1	.721
Latinas in the United States have a ____ higher mortality rate due to cervical cancer than white women (40%)	25.6	48.9	<.001
Any bilingual person has the ability to interpret for medical visits if the provider speaks slowlyb	81.9	92.0	<.001
Recent Latino immigrants are most likely to seek medical care when ___ (Only when he/she is very sick or has been sick for a long period of time)	98.5	99.8	.070
When faced with medical decisions, Latino immigrants are likely to: (Make health decisions only after consulting family and close friends)	90.3	98.0	<.001
Many Latino immigrants do which of the following to avoid illness. (Pray and/or make offerings to God, drink herbal teas, avoid exposure to aburpt changes in temperature)	81.0	94.0	<.001
Translation and interpretation are synonyms/mean the same thingb	86.3	92.0	<.001
Most Latin American countries share to common set of cultural beliefs in addition to a common languageb	25.2	39.5	<.001
Self-medication using shared or imported prescription drugs is common in the Latino immigrants community in Alabamab	81.0	98.0	<.001
Perceived discrimination and fear of deportation are common reasons Latino immigrants in Alabama do not seek health careb	89.4	96.5	<.001
If an interpreter is needed during a medical visit ___ (The provider should talk directly to the patient not the interpreter)	87.8	97.8	<.001
When seeking medical care, recent Latino immigrants are often accustomed to _____ (Paying for services when they are received)	44.5	88.8	<.001

Differences were also found when examining increase in knowledge based on the mode of delivery. The webcast and the on-site modes of delivery were not as effective (no statistically significant differences) as the internet website when it came to explaining the differences between translation and interpretation. These differences may be due to the fact that this portion of the DVD was done live as part of the webcast and on-site training and the speaker may not have emphasized such distinction. On the other hand, when asking if any bilingual person has the ability to interpret for medical visits, the knowledge increased for the on-site and internet modes of delivery but not for the webcast. At the end of the training, participants perceived themselves more knowledgeable about cultural competence, Latino cultural beliefs and barriers to healthcare for Latinos than before the training. Results of the scores are presented in Table 3.

Table 3.

Health Care Providers’ Self-perceived Knowledge About Cultural Competence, Latino Cultural Beliefs Regarding Health, and Barriers to Health Care Access for Latinos

	Your Knowledge Before Training Mean (SD)	Your Knowledge After the Training Mean (SD)	P (Paired t Test)
Cultural competency	3.0 (1.15)	4.0 (1.11)	<.001
Latino cultural beliefs regarding health	3.1 (1.22)	3.7 (1.24)	<.001
Barriers to health care access for Latinos	3.3 (1.26)	3.9 (1.15)	<.001

The overall qualitative feedback about the usefulness of the training to their practice was very encouraging. One participant answered: “A lot of the things mentioned [were] a complete shock to me, now I can change my ideas and ways of practicing care of the Latino population.” Another participant mentioned: “The comparisons between the expectations Latinos have about health care and the way health care is in the U.S. is very informative. It is helpful to me to know how to communicate with my patients.”

On the other hand, some participants experience technical problems with the webcast or problems with the volume of some of the recorded portions of the DVD. Some people participating in the webcast suggested the need for more time for questions. One webcast participant mentioned: “I would allow more time for the questions, this is a topic that generates a lot of discussion and there are many situations that people would like to share. If there could be more interaction or a panel like conference, I think it will help a lot.”

Discussion

The findings of this study indicate that offering training through multiple media methods may be successful in educating health care professionals on the Latino immigrant population. The curriculum was designed to positively influence health care professionals’ ability to better understand their Latino immigrant patients. Outcome measures provide support that the training was effective in increasing overall knowledge in regards to cultural competence, Latino culture beliefs and common barriers to health care.

In order to eradicate health care inequalities and barriers, comprehensive methods must be developed and tested.¹⁴ This study confirms that addressing cultural competence for the continuously growing Latino population entails creative approaches in the curriculum content and means of delivery. The results indicate that executing training from multiple mediums serves as an effective method for increasing cross-cultural knowledge and awareness in health care professionals. The need for competence training is reflected in the literature, proving that language barriers reduce patient satisfaction and quality of care and enhances the probability of medical error.¹⁵. According to Reschovsky et al, educating health care providers on cultural competence and common culture beliefs can aid in developing provider-patient understanding.⁷

Literature is available on incorporating culture competence in medical and nursing school curriculum. Mandates from organizations such as the Liaison Committee on Medical Education are in place that require programs to address health care disparities,¹⁶ but limited studies have documented the implementation of training health care professionals in the clinical setting.² Evidence suggests the need for more studies to establish a customary approach to cultural competence in health care.¹⁷

A commentary produced by Taylor et al suggests valuable steps to improve “culturally competent communication,” which are subsequently mentioned. Incorporating continuous competency training as part of an organizations core values and infrastructure could increase overall awareness in both staff members and professionals.⁶ Gathering and assessing data on demographics and language preferences can serve as a resource for clinic requirements and overall quality assurance.⁶ At the national level, policies and standards are in place to develop culture competence in the health care setting.⁶ The U.S. Department of Health and Human Services Office of Minority Health has issued national standards in providing culturally appropriate services to patients;¹⁸ however, implementation of such standards is scarcely documented. Cultural competence training as mentioned in this study could serve to abide by these national standards.

Overall, the program was successful in its attempts to educate health care professionals at various levels of the health care system; however, some limitations deserve comment. Participation and completion of the educational portion of the program was strictly voluntary, suggesting participation was based on the individual’s interest in the topic of cultural competence as it relates to Latino immigrants. Suggestions to resolve this issue include mandatory participation required by clinics or improved incentives for completion of the training. An additional limitation of this study is that data were collected via self-administered questionnaires, relying on self-reported data and individuals perceived increase in knowledge. Further studies on how training directly impacts provider-patients interactions should be conducted to determine overall influence on practice behaviors and implications. This study does not evaluate outcomes such as provider’s attitudes, awareness or behaviors change following the training. A more intense intervention could be conducted to assess the influence cent of overall behavior change. Not all participants enrolled in the webcast and on-line versions of the training completed the post-test, leaving gaps in the number of completed pre and post assessments. This breach limited data collection to only those that completed both pre and post assessments. Incentives to complete the training were limited and could be improved. Also, it was difficult to maintain data on mailed assessments, as most participants did not return either the completed pre or post tests.

Despite dramatic increases in the Latino population in the United States, cultural competence training is not always offered in the healthcare setting. Health care students and practicing professionals spend enormous amounts of time learning about symptoms and treatments for conditions, yet capacity can be greatly increased when adequate training is in place to create a better understanding of diverse backgrounds.¹⁹

This guide offers a viable and effective way to provide culture competence training. Factors that contributed to the success of this study include the incorporation of multiple mediums to acquire the training and the ability for providers to complete the training in less than an hour. The findings indicate that a short DVD may be a promising avenue for educating health care professionals about the needs of Latino immigrants in the U.S.