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Clinical Cornerstone • HYPERTENSION IN HISPANICS • Vol. 6, No. 3

Barriers to Health Promotion and Disease Prevention in the Latino Population Joseph R. Betancourt, MD, MPH Senior Scientist, Institute for Health Policy Director for Multicultural Education, Multicultural Affairs Office Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School Boston, Massachusetts

J. Emilio Carrillo, MD, MPH Associate Professor of Clinical Medicine and Public Health Weill Medical College of Cornell University New York, New York

Alexander R. Green, MD Research Fellow Beth IsraeI-Deaconness Medical Center-

Harvard Medical School Boston, Massachusetts

Angela Maina, BS Research Assistant Institute for Health Policy Boston, Massachusetts

The Latino population of the United States is expected to increase substantially in the next 25 years.

Although recent health promotion and disease prevention interventions have improved the health of the

majority of Americans, the Latino community has derived less benefit from these advances. This is due

to a number of interrelated factors, including a disproportionate representation of Latino Americans in

the low socioeconomic strata and in the uninsured population. Even when insured, Latino Americans face

significant barriers to health promotion and disease prevention. This policy analysis identifies barriers

at the organizational and structural level of health care delivery, as well as at the level of the medical

encounter. It provides a practical framework for intervention that is founded on the recruitment of

Latino Americans into the health care workforce and leadership, the restructuring of health systems to

be more responsive to the needs of diverse populations, and health care provider education on how to

improve cross-cultural understanding and communication. By investing in a multifaceted approach that

addresses barriers to health promotion and disease prevention in the Latino population, we can improve

the quality of care delivered to this population and help eliminate racial and ethnic disparities in health

care. (Clinical Cornerstone. 2004;613]:16-29) Copyright © 2004 Excerpta Medica.

INTRODUCTION The Latino population of the United States is expected to increase from 31 million (11% of the

population) to 59 million (18% of the population) by 2025.1 In addition to being one of the youngest

populations (36% under the age of 18 years), the

Latino population is one of the most rapidly growing groups in the United States. I Although health pro-

motion and disease prevention interventions have improved the health of the majority of Americans, the Latino population has benefited less from these

advances. A review of the President's Initiative

to Eliminate Racial/Ethnic Disparities in Health by the US Department of Health and Human Ser- vices shows that, compared with the general population, Latino Americans have poorer outcomes in

diabetes and HIV/AIDS, have lower rates of blood

pressure control, and receive fewer childhood and adult immunizations. 2 It is likely that if a

greater Latino subgroup analysis of the data were undertaken, more disparities in health would be observed. 3

16


B A C K G R O U N D

The term Latino refers to a very broad and hetero-

geneous group with distinct nationalities, religions,

degrees of acculturation, and socioeconomic status.

Recent studies suggest that differences between

Latino subgroups (eg, Puerto Ricans, Cubans, and

Mexicans) in sociodemographic characteristics,

health status, and use of health services are some-

times of equal or greater magnitude than differences

between ethnic groups. 4,5 The health disparities faced

by many Latino subgroups are the result of a number

of complex interrelated factors. First, the poverty rate

for Latino adults is at least twice that of the rest of

the population, and more than one third of Latino

children live in poverty. 6 This puts them at risk for

many negative social determinants of health, includ-

ing low levels of education, living in dangerous

neighborhoods and poor housing, and working in

hazardous occupations, among others. Second, near-

ly 40% of the Latino population <65 years do not

have health insurance. Latino children make up 29%

of the uninsured under 18 years of age compared to

11% of white children. One quarter of the nation's

44 million uninsured are Latino--of these 11 mil-

lion, 9 million have at least one family member who

is employed. In fact, Latino Americans are more than

twice as likely to lack health insurance as the popu-

lation overall, v Insurance alone, however, does not

yield high-quality health care or appropriate access

to health services. Beyond insurance, there exist

other barriers to care, both at the organizational and

structural level of health care delivery, as well as at

the level of the medical encounter. Thus, even when

insured, Latino Americans face significant barriers

to health promotion and disease prevention inter-

ventions. For example, less acculturated Latino

Americans whose health beliefs may diverge from

the mainstream, or who may have limited health lit-

eracy and English proficiency, face great difficulty

maneuvering through a complex and intricate health

care system.

Given the health challenges facing Latino

Americans today, it becomes imperative to better

understand the state of access to health promotion and

disease prevention for this population. This is partic-

ularly important given that the majority of the condi-

tions that disproportionately affect Latino Americans

are both preventable and treatable.

P O L I C Y A N A L Y S I S

Many Latino Americans who attempt to gain access

to the US health care system face organizational, struc-

tural, and/or provider-based barriers that preclude them

from fully capitalizing on health promotion and disease

prevention interventions. These barriers include institu-

tional policies and procedures, the inability to get time-

ly appointments, lack of after-hours medical advice, and

long waiting times for referrals to necessary medical

specialists and diagnostic and therapeutic interventions,

among others. 8 This results in decreased standard med-

ical screening, 6 a later stage at presentation of various

medical conditions, 9,1° and inappropriate and inade-

quate treatment. 11,12 Together, these conditions have led

to the significant racial and ethnic disparities in health

outcomes prevailing today. For example, the diabetes

morbidity and mortality rates for Latino Americans are

almost 30% higher than for white Americans. 13

O R G A N I Z A T I O N A L BARRIERS:

L E A D E R S H I P A N D W O R K F O R C E ISSUES

Our health care systems, structural processes of care,

and health policies are, in large part, shaped by the

leaders who design them. Furthermore, our health care

system's success hinges on the workforce that carries

out these policies and procedures. From this organiza-

tional standpoint, one factor that can affect both the

availability and acceptability of health care for Latino

Americans is the degree to which the nation's health

care professionals and leadership reflect the racial and

ethnic composition of the general population.

Institutional Leadership Latino Americans are woefully underrepresented

in health care leadership and decision-making posi-

tions (eg, state or county health officials, faculty in

17


medical and public health schools). 6 In the absence

of strong quantitative data, a plethora of anecdotal

evidence suggests that lack of diversity in the leader-

ship and workforce of health care organizations

results in structural policies, procedures, and delivery

systems that are inappropriately designed or poorly suited to serve diverse patient populations. 8,14 Given

their social and cultural understanding of the commu-

nities they serve, health care professionals from

minority groups may be more likely to organize health

care delivery systems to meet the needs of

minority populationsJ 5 Examples of barriers to care

include limited clinic hours of service that do not

account for community work patterns, bureaucratic

intake processes that create fear of deportation

among the undocumented, and long wait times to make

appointments and at the actual time of the visit. 5 Data

regarding diversity in leadership are quite revealing.

For example, <2% of senior leadership in health care management is nonwhite. 14 In academic health centers,

underrepresented minorities (ie, Latino Americans,

African Americans, and Native Americans) make up

only 3% of the medical school faculty. In addition,

53% of the Latino medical school faculty teach in med-

ical schools in Puerto Rico, highlighting the under-

representation of Latino faculty in the continental

United States. 16 Similarly, despite the fact that minor-

ities comprise 30% of the US population, 17 <16% of

public health school faculty positions are held by

minority scholars, and only 17% of all city and county

health officers are from minority groups (Figure 1). 6

H e a l t h C a r e W o r k f o r c e

The importance of racial and ethnic diversity in the

health care workforce is well correlated with the abil-

ity of health care organizations to deliver high-quality

care to socioculturally diverse patient populations.

For example, for minority patients, it has been shown

that in cases where there was racial concordance

between the patient and the physician, patient satis-

faction and self-rated quality of care were higher. 18

Other work has established the preference of minority

patients for minority physicians. 19,2° The reason for

this preference may be language-based. For example,

it has been shown that Spanish-speaking Hispanic

patients are more satisfied when their provider speaks Spanish. 21

A review of the data on racial and ethnic diversity

of the health care workforce reveals that only 6% of

all physicians in 1995 were Latino Americans. 22

Approximately 24% of Latino physicians in office-

based practices in California care for patients whose

primary insurer is Medicaid (compared with 18% of

white physicians), and 9% care for patients who are

uninsured (compared with 6% of white physicians). 2°

The prognosis for the future is not much brighter.

Data from 1997 show that enrollment of Mexican

Americans and mainland Puerto Ricans into medical

school dropped by 8.7% and 31%, respectively, and

that in that same year, only 11% of all graduates were from underrepresented minorities. 22

Similar racial disparities are found in other health

professions as well (Figure 2). For example, Latino

v

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O

18-

16

14

12

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8

6

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Medical School Public Health City/County Faculty Faculty Health Officials

• 3% [ ] 16% [] 17%

Figure I. Percentage of minority professional representation. Adapted with permission. 636

18

Clinical Cornerstone • HYPERTENSION IN HISPANI¢$ • Vol. 6, No. 3

Americans represent only 5% of all practicing den-

tists. 6 Unlike medical schools, which experienced an

initial increase in minority enrollment in the early

1990s that subsequently tapered off later that decade,

dental schools experienced a steady decrease in

minority matriculation (as a proportion of total

matriculation) throughout the 1990s. 23 Despite gains

in minority enrollment in baccalaureate nursing pro-

grams, minorities comprise only 3.2% of the current nursing workforce. 6,23 Similarly, despite increases in

minority enrollment in pharmacy schools in the

1990s, individuals from underrepresented minorities

make up only 2.9% of the nation's pharmacists and

3.8% of optometrists. 23

S T R U C T U R A L BARRIERS T O C A R E

Latino Americans are significantly more likely than

their majority counterparts to receive care in hospital

outpatient departments (particularly academic health

centers and public hospitals), community-based clinics, emergency rooms, and other safety-net providers. 24,25

As a result, Latino Americans receive care in systems

that often provide poor continuity, have dated medical

record systems, maintain limited after-hours services

(including telephone access to health care profession-

als), and depend on graduate housestaff (residents and

fellows) as primary providers. To complicate matters,

public hospitals and academic health centers are fac-

ing unprecedented fiscal challenges, which jeopardize

their role as providers of care to vulnerable populations.

These "at-risk" systems are not conducive to health pro-

motion and disease prevention for Latino Americans.

The recent emergence of Medicaid managed care

is likely to pose challenges to the Latino patient as

well. Bureaucratic intake and appointment-making

processes, limited choice of providers, and lack of

information about these new systems are some of

the possible challenges. Despite efforts to facilitate

transition and enrollment into Medicaid managed

care, people with limited English proficiency and/or

those with limited experience dealing with complex

health care systems will have difficulty selecting a

primary care provider or maneuvering through a

health plan. The barriers in commercial managed

care organizations (MCOs) are not likely to be

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o I X .

t ~

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1- O r -

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~i!~i~i!ii~!!~i!!!!~ii~!!~i~i!~!~!!iii!~ii~i!ii!i~!!!;!!i~!~i~i!ii~i ~ii~ii~!~!i~iii~i~!~ii~ii~!~ii~i~i~!iiiiii~i~i~!~ii!!!!~!i~!~i~!~i~ii~!i~i~ii~i~

[ ] 6 .0% [ ] 5.0% [ ] 2.9% [ ] 3 .8% [ ] 3.2%

I I I I Physicians Dentists Pharmacists Optometrists Nurses

Figure 2. Latino health care workforce: Percentage of health care professionals who are Latino. Adapted with permission.6,16

19


different. It is difficult to follow these trends, how-

ever, because Medicaid managed care and commer-

cial MCOs are not required by legislation or court

mandate to collect racial and ethnic identifiers

for people enrolled in their plans. For example,

al though the National Commit tee for Quality

Assurance 's Health Plan Employer Data and

Information Set 26 includes a focus on disease areas

(eg, hypertension) or dimensions of performance

(eg, quality of communication), it does not focus

on quality of health care for minority patients,

given that it does not report performance and out-

comes separately by race or ethnicity. Similarly,

at the level of hospital accreditation, the Joint

Commission on Accreditation of Health Care Orga-

nizations performance measures are devoid of racial

or ethnic identifiers (although hospitals must

demonstrate their multilingual capacities, however

rudimentary, using data that are neither aggregated

nor benchmarked). 27

Types of St ructura l Barr iers

Structural barriers arise when patients are faced

with the challenge of obtaining health care from sys-

tems that are inherently complex, underfunded,

bureaucratic, archaic in design, or simply inaccessible

by common means of transportation. Structural bar-

riers can be divided into extramural--barriers

patients experience from their home to the health care

center--and intramural--barriers patients experience

from the health care center to the provider's office.

Although many of the aforementioned structural bar-

riers to care may affect whites, African Americans,

and others of low socioeconomic status equally, sev-

eral barriers are especially pertinent to the Latino

population (Table).

Structura l Barr iers to Care in the Lat ino

Populat ion

Extramural Barriers Latino Americans disproportionately reside in

either urban or rural locations designated as medi-

cally underserved or health professional shortage

areas, aa As a result, they often have to depend on

public transportation and travel significant distances

to see a health care provider. 29 Moreover, certain

health care facilities have limited operating hours and

minimal telephone and after-hour access to providers.

These factors have clear and direct effects on access

to care:

• 30% of Latino Americans, compared with 27%

of blacks and 16% of whites, reported that they

have "very little" or "no" choice in where to go

for medical care. 6

• 53% of Latino Americans, compared with 47%

of blacks and 30% of whites, use an emergency

room, outpatient department, or clinic as a source

of medical care. 6

• A 1998 National Association of Public

Hospitals & Health Systems survey of 25 urban

safety-net hospitals reported that African

Americans and Latino Americans had the high-

est number of visits, accounting for 40.9% and

31.7% of hospital visits, respectively. 3°

• 47% of Latino Americans in 1993 had a dental

visit, compared with 64% of whites. 6

TABLE. STRUCTURAL BARRIERS TO HEALTH PROHOTION AND DISEASE PREVENTION INTERVENTIONS A H O N G LATINO AMERICANS.

Extramural Intramural

Availability of providers

Proximity of HCF

Operating hours of HCF

Transportation to HCF

Telephone access to providers

Knowledge of available resources

Child care

Bureaucratic intake processes

Long waiting times for appointments

Lack of interpreter services

Difficult referral to tests and specialists

Language-appropriate signage

Language-appropriate health education

Poor continuity of care

HCF = health-care facility.

20


"major" problem gaining access to specialty care

(Figure 3A). 6 Another study revealed that 46% of

Latino Americans (vs 39% of blacks and 26% of

whites) do not have a regular doctor (Figure 3B). 6

Intramural Barriers

Even when Latino patients complete the journey

to a health care facility, they face several additional

barriers to care. For example, bureaucratic intake

processes and long waiting times for appointments

limit access to health care providers. 29 In addition,

facilities that provide care to Spanish-speaking

patients but lack interpreter services or do not provide

culturally or linguistically appropriate health educa-

tion materials severely compromise the quality of

care delivered. 31,32 Doctor-patient communication

without an interpreter, in the setting of even a minimal

language barrier, is recognized as a major challenge

to effective health care delivery. 33-37 Research in this

area has shown that:

• Spanish-speaking patients discharged from the

emergency room are less likely than their

English-speaking counterparts to understand

their diagnosis, prescribed medications, special

instructions, and plans for follow-up care38; less

likely to be satisfied with their care or willing to

return if they had a problem; more likely to

report problems with their care39; and less satis-

fied with the patient-provider relationship. 4°

• Physicians who have access to trained inter-

preters report a significantly higher quality of

patient-physician communication than physi-

cians who used other methods. 41

• Hispanic patients whose physicians do not

speak the same language are more likely to

omit medication, miss office appointments, and visit the emergency room for care. 42

Referral to specialists and continuity of care

are other critical barriers that Latino Americans

face. A large survey by the Commonwealth Fund

reported that 22% of Latino Americans, compared

with 16% of blacks and 8% of whites, reported a

P R O V I D E R - B A S E D B A R R I E R S

Prov ide r -Pa t i en t C o m m u n i c a t i o n

Provider-based barriers to care emerge during the

medical encounter, when sociocultural differences

between patient and provider are not fully appreciated,

accepted, explored, and/or understood. 43 During the

medical encounter, a provider's ability and willingness

to communicate across language barriers and to under-

stand sociocultural variations in health beliefs, values,

and behaviors are critical to the delivery of high-quality

health care. Given the small proportion of Latino physi-

cians, Latino patients often receive care from physicians

who may not speak their language, understand their

social situation, or value their cultural beliefs. As a result,

cultural and linguistic barriers in the medical encounter

may lead to the following:

• Poor communication between patient and provider 4446

• Patient dissatisfaction with care ~s,21

• Poor compliance with both medications and

health promotion and disease prevention interventions47-5

Furthermore, differential treatment of Latino

Americans (based on race/ethnicity or social class)

may also affect health care delivery and outcomes.

For example, studies have shown that Latino

Americans are less likely than whites to receive cer-

tain procedures and surgeries such as coronary artery

bypass graft, angioplasty, and kidney transplant] 1

The root causes of these disparities in care have not

21


been fully elucidated. It is hypothesized that poor

communication and patient preferences may play an

important role. The effect of provider bias based on

race, ethnicity, or social class, whether overt or sub-

conscious, has been shown to affect medical decision

making as well. 52,53

Acculturation

The role of acculturation (integration with the

predominant culture) and its effect on health beliefs

and behaviors such as compliance in the Latino

population cannot be overemphasized. While this is

A 25

e -

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O o _

"d

l ,a e -

u (1)

20

15

10

just one of many factors leading to the vast hetero-

geneity of the Latino population, it has a particu-

larly strong impact on health care. Latino Americans

who have spent more time (years or generations)

interfacing with the mainstream culture of the

United States will often have different cultural

beliefs and values than those who have just arrived

in the country. The following research results illus-

trate this:

• High levels of acculturation have been correlat-

ed with high levels of adherence to medical therapy. 51

• 22% [] 16% [] 8%

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i I I 1

Latinos Blacks Whites

B

8 2 m o_

o

r- (u

o o_

50-

45-

40-

35-

30-

25-

20-

15-

10-

S-

0

• 46% [] 39% [] 26%

I L l Latinos Blacks Whites

Figure 3. Percentage of minorities reporting (A) difficulty in gaining access to health care specialists and (B) n o t

having a regular doctor.

22


• Low levels of acculturation among Latino

Americans have been linked to low utilization

of preventive measures and tests such as breast

self-examination, Pap smear, and mammogra-

phy and to poor health outcomes, including invasive cervical cancer. 54-56

• High acculturation levels have been shown to

contribute to increasing the probability of high-

risk behaviors such as alcohol abuse and smok- ing, particularly for Latina women. 57,58

• Provider-based barriers to care are accentuated

when issues of acculturation are not recognized

and handled appropriately by providers.

Perceptions and Expectations of Health Care Dissatisfaction with health care may lead to a

reluctance to seek health promotion and disease pre-

vention or to follow up with diagnostic or treatment

plans. Further work is needed to understand Latino

patients' opinions regarding the qualities of a good

health care system. In recent studies, it was shown

that Latinos are:

• Less satisfied with the quality of their health care than are whites 21,59

• Inclined to feel they are more likely to be treat-

ed unfairly by health care practitioners and the

health care system because of their ethnicity

and limited language proficiency 59,6°

Although these findings may not be generalizable,

they do shed some light on the Latino experience with

health care.

D I S C U S S I O N

This policy analysis gives us a starting point from

which we can critically analyze the barriers that limit

the ability of Latino Americans to benefit from health

promotion and disease prevention initiatives. Given a

practical framework that focuses on 3 umbrella cate-

gories of interventions--organizational, structural, and

provider-based--it becomes clearer how initiatives in

this area could assist in the elimination of racial/ethnic

disparities in medical care. Three main targets arise:

Target 1: Increasing the Representation of Latino

Americans in the Health Professions and

Health Care Leadership

There should be a significant national focus on re-

search, policy, and programs that aims to both fortify

the educational pipeline and strengthen the capacity

of Latino health professionals to assume positions of

leadership.

Target 2: Innovations in Health Care System and

Structure Design

There are ample opportunities to address the many

simple (yet pervasive) structural barriers to care defined

herein. Efforts should include those that streamline health

systems and make them more responsive to the needs

of diverse populations, including Latino Americans;

initiatives that aim to provide Latino Americans with

culturally and linguistically appropriate information to

make health care decisions; and mechanisms to ensure

that, at a minimum, health care systems that care for

large populations of patients with limited English

proficiency have effective interpreter services available.

Target 3: Cross-Cultural Education

Given the underrepresentation of Latino Americans

among health care providers, targeting providers' atti-

tudes and practices is a crucial part of overcoming the

barriers to care that Latino patients face. The move-

ment toward cross-cultural education of health profes-

sionals should be widely supported.

In addition, to effectively monitor any improve-

ment in health promotion and disease prevention for

the Latino and other underserved populations, health

systems (including hospitals and MCOs) should be

encouraged to collect race, ethnicity, and language-

proficiency data. Without this provision, we severely

limit the ability to measure the quality of care deliv-

ered to Latino Americans, and thus preclude systems

innovations and quality improvement.

23


C O N C L U S I O N S

Latino Americans with health insurance face myriad

barriers to health promotion and disease prevention.

These include barriers related to their underrepresenta-

tion in the nation's health care leadership and work-

force; their difficulty navigating the complicated struc-

tural processes of the health care system; and their

being cared for by providers who lack an understanding

of their language or health beliefs. While there are no

easy remedies, a targeted approach that focuses on pro-

gramming, research, policy, advocacy, and outreach ini-

tiatives toward eliminating the organizational, structur-

al, and provider-based barriers that Latino Americans

face should help improve the health status of this

growing population. Only by investing in a multifaceted

approach that addresses barriers to health promotion

and disease prevention specific to the Latino population

can we ensure that this population obtains high-quality

health care. The payoff, if the initiatives are successful,

will be the eventual elimination of racial and ethnic dis-

parities in health care and the improvement of health

care not only for the Latino population but for all indi-

viduals in the United States.

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33. Kirkman-Liff B, Mondragon D. Language of inter- view: Relevance for research of southwest Hispanics. Am J Public Health. 1991;81:1399-1404.

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37. Erzinger S. Communication between Spanish-speaking patients and their doctors in medical encounters. Culture Med Psychiatry. 1991 ; 15:91.

38. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med. 1997;15:1-7.

39. Carrasquillo O, Orav EJ0 Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999; 14:82-87.

40. Baker DW, Hayes R, Fortier JR Interpreter use and satisfaction with interpersonal aspects of care for

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41. Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275:783-788.

42. Hornberger J, Itakura H, Wilson SR. Bridging language and cultural barriers between physicians and patients. Public Health Rep. 1997;112:410-417.

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44. Stiles WB, Putnam SM, Wolf MH, James SA. Interaction exchange structure and patient satisfaction with medical interviews. Med Care. 1979; 17:667-681.

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59. Leigh WA, Lillie-Blanton M, Martinez RM, Collins 60. KS. Managed care in three states: Experiences of low- income African-Americans and Hispanics. Inquiry. 1999;36:318-331.

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Address correspondence to: Joseph R. Betancourt, MD, MPH, Massachusetts General Hospital, 50 Staniford

Street, Suite 942, Boston, MA 02114. E-mail: [email protected]

26


Dialogue Box

EDITORIAL BOARD

Can't much of the disparity in health care for

Hispanics be explained solely by socioeconomic factors and lack of access?

B E T A N C O U R T

Although lower levels of education, lower socio-

economic status, and inadequate access are all major contributors to disparities in health care and

cardiovascular outcomes, these factors are clearly

not acting alone. During my tenure working on

the Institute of Medicine Report on Equal

Treatment, it was readily apparent that after con-

trolling for socioeconomic status and access

issues, significant differences in the quality of

care received varied by the patient's race and eth-

nicity. Thus, even if they weren't the most under-

insured population in the United States, I believe

that the language barrier as well as cultural issues

would still place Hispanic families at higher risk

for suboptimal health care.

EDITORIAL BOARD

If financial constraints allowed you to focus

your efforts on only one of the factors respon- sible, which would give you the most "bang for your buck"?

B E T A N C O U R T

Of the 44 million uninsured Americans, 11 million

are Hispanic. Because Hispanics comprise 25% of

the uninsured despite representing only 13% of the

population, as a starting point I would probably

invest in improving access to care. I can't empha-

size enough, however, that research has identified

a number of challenges. Although it is important

to make investments in access and improving eco-

nomic opportunities, other improvements must be

accomplished within the health care setting to

reduce the disparities. Such interventions would

not necessarily have to be tailored toward any par-

ticular population. For example, support of inter-

preter services and/or cultural competence training

benefits all ethnic groups.

EDITORIAL BOARD

What are your thoughts about "acculturation"?

B E T A N C O U R T

Acculturation has had a "mixed" impact on the

health of Hispanic patients. On one hand, as people

become more fluent in the language, more fluent in

the customs, and gain a better understanding of how

the health care system works, they tend to become

more adherent with taking medication and will

achieve better outcomes. On the other hand, accul-

turation also can have a detrimental effect on health.

For example, it has entailed adoption of unhealthy

eating habits and a diet loaded with fat and "fast

foods," which, in turn, has fostered obesity and the

development of type 2 diabetes mellitus. Thus,

acculturation has been a doubled-edged sword--by

improving the navigation of our health care system

and adherence to treatment, it has improved health;

through adoption of our dietary practices, it has

proved detrimental to health.

E D I T O R I A L B O A R D

How prominent a position should ethnicity assume in the medical record?

BETANCOURT

Its inclusion is important because the collection

of race and ethnicity data within health care allows

us to better monitor disparities and outcomes.

However, it has been largely debated as to where to

put such information. Should ethnicity be included

at the beginning of the medical record, "This is a

72-year-old Hispanic man, with a medical history

of diabetes and hypertension..." or should it be

added to the social history, "This gentlemen is

Hispanic and has come from this country and immi-

grated during this time..."? It's played both ways.

Some believe that putting this information in the

~ , ~ : ~ , ~ , ~ , ~ . : T ~ ; ~ , ~ + : ~ ~ . ~ ~ ' ~ L ~ ; ~ , ~ + ~ k - - ~ ' ¸ ~ " ~ ' + ~ ~ . . . . . . . ~ , ~ ' ~ - ~ , . , ~ , ~ ~ . . . . . . . . . . . . . , , ~ . , ~ , ~ . . . . . . . . k . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

Clinical Cornerstone • HYPERTENSION IN HISPANICS • Vol. 6, No 3

history of present illness might be an unnecessary

tangent and thus would put it there only if it were

relevant to the illness, for example, an African

American with sickle cell. Although this issue still

creates tension for many people, I think there is uni-

versal agreement that etbnicity belongs in the med-

ical record.

EDITORIAL BOARD Why do you think that groups like the American

Association of Medical Colleges (AAMC) have been so unsuccessful in attracting Hispanics into

the health care professions?

B E T A N C O U R T

I think it's because the problem does not rest solely

at the level affected by groups like the AAMC.

Looking at the educational pipeline, you'll find

that only -50% of Hispanics graduate from high

school, and as you move up the pipeline, the num-

ber of Hispanics decreases further. This problem

is compounded by the fact that a few years ago,

10% of Hispanics who were accepted to medical

school chose not to go. I think, as suggested in

our last IOM (Institute of Medicine) Report, that

greater attention and efforts have to be focused

earlier in the educational pipeline. To have a

greater impact, medical educators need to be more

involved in the various programs nationwide that

groom students at a young age and cultivate their

interest in the sciences and future careers in health

care professions, whether it is medicine, dentistry,

nursing, psychology, or public health.


Are there any data comparing the effectiveness of changing the cultural makeup of the health care professions with improving the cultural

competency of the professions?

B E T A N C O U R T

Our position in both IOM Reports was that a 2-

pronged effort using both of these strategies was

required. Minority recruitment as the sole strate-

gy would be inadequate, because we cannot recruit

the numbers that would be required to meet the

needs of our increasingly diverse population.

Health care providers in training as well as those

in practice need to be made more culturally aware

and gain a better understanding of the impact that

race, ethnicity, and culture have on clinical deci-

sion making. In this regard, I would argue that

there is much we are not taught in our training that

would make us more effective providers. These 2

strategies are by no means mutually exclusive--

we should strive to both improve the cultural com-

petency of our health care workforce as well as

increase the percentage of ethnic minorities in this

workforce. Minorities should be recruited not just

so they can care for their own, but so they can also

be involved in curriculum development, leadership

policy development, and so forth.


There is a subset of the population that might

regard any effort to recruit minorities as a form of "affirmative action" and react negatively to

it. How would you address such a response?

B E T A N C O U R T

Some terms are "hot buttons"; once you say them,

no matter how you explain it, it's difficult for peo-

ple to get past that initial hot-button reaction.

People bristle at the term affirmative action. To

many, it means taking people who aren't qualified

and, solely based on their race or ethnicity, mov-

ing them up, above others who are more qualified,

or giving them an opportunity they don't deserve.

That is not what we are talking about, which is

why I think we try to choose our terms very care-

fully. We are aiming to develop and recruit a

highly qualified pool of minority students to

become physicians. Similarly with cultural sensi-

tivity, I think the field has evolved significantly to

28


be about more than just political correctness,

making people nicer, or teaching them the best

ways to care for the Hispanic patient. Instead, it

is now about giving providers a set of tools and

skills to add to their tool bag, add to their review

systems, and improve the social history, in a much

more evidence-based fashion. We are positioning

the issues of cultural competence and diversity in

the health care system in these ways to make them

more palatable.

29

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