Consider cultural issues to help improve outcomes
Hispanic population expected to rise by 22%
By Mary Beth Beutter, RN, BSN
Quality Improvement Coordinator
Home Health of Ancilla Health Care
Mishawaka, IN
Ruth Davidhizar, RN, DNS, CS, FAAN
Dean of Nursing
Bethel College, Mishawaka, IN
Gregory Bechtel, RN, MPH, PhD
Associate Professor
Medical College of Georgia, Augusta
University of Alabama, Birmingham
If you don’t already serve Hispanic clients, rest assured that soon will change. The U.S. Depart ment of Commerce, U.S. Census Bureau in Washington, DC, expects the Hispanic-American population to increase by 22% by the year 2050 — making one in every four Americans Hispanic by the mid-point of the coming century. As early as 2010, Hispanics are expected to outnumber all other minority groups in the United States. This situation presents a unique case management challenge for the simple reason that many Hispanics separate themselves from other cultural groups by retaining their language and cultural identity.
The care plan you develop for your Hispanic clients must be based on your assessment of cultural differences and utilization of culturally appropriate interventions. The provision of culturally competent primary care must involve assessment and understanding of the clients’ health beliefs and behaviors in the context of culture.
As you develop an appropriate care plan, it helps to look at six cultural characteristics that influence health care outcomes and compliance with care plans. These characteristics are outlined in the Giger and Davidhizar Cultural Assessment Model. (For a detailed discussion of the assessment model, see Case Management Advisor, June 1998, pp. 97-100.) They are:
• communication;
• space;
• social organization;
• time;
• environmental control;
• biological differences.
In addition to the specific cultural characteristics that affect compliance listed in this article, it’s important to note that many Hispanics rely on traditional healers. That is not only due to cultural beliefs, but also due to lack of adequate financial resources and health insurance.
o Communicating with Hispanic clients. Hispanic-Americans may be bilingual. However, most Hispanic-Americans from Mexico prefer to speak Spanish. To complicate matters, even a bilingual case manager may have difficulty communicating with a Hispanic client because there are more than 50 Spanish dialects spoken by Hispanic-Americans. Even though certain words tend to have the same meaning regardless of dialect, that doesn’t guarantee clear communication with Hispanic clients.
If clear communication is not possible, case managers should use a translator. The translator should have an understanding of health care because this will reduce the client’s anxiety. If you can’t find a qualified translator, you may use a family member for many case manager/client interactions. However, it’s essential to use a fluent, medically knowledgeable translator for initial visits requiring paperwork, lengthy medical and family histories, and care instructions.
Show proper respect
Spanish language materials are useful but not enough in themselves. Even when Spanish materials are used, a translator should be present to help the client better understand any documents that must be signed and to help explain any services that are being provided. In addition, when you give care instructions, you must continuously evaluate learning by questioning and listening to the responses. When you are explaining a procedure, it’s often helpful to have family members present to lend support to the client. (See story, p. 191, for more suggestions for reaching diverse cultural groups.)
Respect and personal relationships are important to the case manager/client relationship. Respect dictates appropriate deferential behavior toward others on the basis of age, sex, social position, economic status, and position of authority. Hispanic-Americans generally view health care professionals as authority figures who deserve respect. However, communicating your respect for the client is also important to a successful case manager/client relationship. You can use verbal and nonverbal techniques to communicate that respect. Until a relationship is established, use a more formal approach. For example, calling a client who is not well known to you by a first name is not considered appropriate by most Hispanic clients. In addition, the tone of your voice can help convey your respect for the client.
Respect also means avoiding confrontation and using generous amounts of tact and diplomacy. Rather than object to information, many Hispanic-Americans will remain silent. Hispanic clients may appear to be agreeable out of courtesy and respect only to later fail to comply with care instruc tions, which often results in a poor outcome.
To help promote the personal relationship so highly valued by Hispanic clients, always greet the client by name and inquire about the client’s health and well-being and the health and well-being of the client’s family before getting down to business. This approach builds trust between case managers and their Hispanic clients.
In addition, Hispanic-Americans value physical touch as part of their nonverbal communication. If you work with clients face-to-face, offering a handshake as a greeting will help build a personal relationship.
One last aspect of communication worth mentioning is eye contact. Hispanic clients generally avoid direct eye contact until a relationship is established. Not only is eye contact avoided out of respect but also because some Hispanics relate eye contact to evil spirits. Some illnesses are attributed to an "evil eye" given by another.
o Understanding Hispanic clients’ personal space. In social or home care environments, group togetherness and physical presence of family and friends is important to Hispanic clients. Hispanic women value closeness and physical contact, but they are more modest during health care examinations. It’s important for case managers to remember that Hispanic women prefer female care providers. In addition, case managers should remind home care providers to provide privacy when giving physical care to Hispanic women.
o Hispanic clients’ social needs are family-oriented. The Hispanic population centers its society on the family. This may be a nuclear family or an extended family that includes grandparents, aunts, uncles, cousins, and friends. The case manager must assess the client’s family to learn the values, the flow of authority, and how decisions are made. Educating the entire family and including the entire family in the plan of care often improve compliance and clinical outcomes.
Traditionally, the Hispanic male is recognized as the authority figure. The father is the primary decision maker for the family. The Hispanic female is usually submissive and often puts the needs and wants of others above her own. A Hispanic family may wish to give personal care to a critically ill family member in the home rather than have that care provided by a home care professional. How ever, if a male client requests that care be given by a home care professional rather than burden the family, then the family will respect these wishes.
Another very important social organization for most Hispanic-Americans is the Roman Catholic Church. Roughly 90% of Hispanic-Americans are Roman Catholic. Many Hispanic-Americans direct their prayers and religious promises to the Virgin of Guadalupe. Your client may wish to keep a religious symbol such as a rosary, statue, shrine, or amulet close by at all times. If your Hispanic client requires an inpatient admission, he or she may wish to bring religious articles along. The religious articles may reinforce the belief that God is in control and thus may provide support for your client during a stressful time.
o Many Hispanic clients focus on the present. Hispanic-Americans usually are characterized by a present time orientation. This is especially true for those of lower socioeconomic status. Case managers must assess Hispanic clients for time orientation issues that may affect compliance and outcomes. For example, if clients are oriented to the present, they will have trouble taking medications as prescribed, adhering to long-term care plans, and understanding acute vs. chronic illness.
Case managers should make sure the client understands the importance of taking medication, keeping medical appointments, and following procedures as ordered. For example, careful education may help the Hispanic client understand why insulin must be taken exactly when it is ordered and why following the diabetic dietary regimen is so important in preventing complications.
o Many Hispanic clients have a fatalistic view of health. Many Hispanic-Americans have a fatalistic view of life and health that leads to an external locus of control. Hispanic clients frequently believe that life and health are controlled by divine will, fate, and the environment. In matters of health and illness, the Hispanic client often takes little personal responsibility.
In addition, many Hispanic clients rely on various forms of folk medicine. Folk medicine may be used as an alternative to Western medicine, or, as clients become more assimilated into American culture, as an addition to Western medicine.
Some Hispanic-Americans believe illness is the result of hot and cold imbalances. Temperature itself, hot or cold, is an aspect of substances found in medicines, elements, air, food, and bodily organs that can be used to restore balance. Methods for restoring hot/cold balance include prayer and herbal remedies.
Curanderos (healers) are the most respected healers because they are believed to be chosen and empowered by God. Curanderos live in Hispanic communities and practice out of their homes, using herbal remedies, prayers, teas, and rituals to correct hot/cold imbalances. Case managers must assess what treatments clients believe will work and what fears they may have about medical treatments included in the care plan.
Even when you are skeptical, you must show respect for your Hispanic clients’ personal beliefs to gain cooperation and improve compliance with your care plans. For example, a diabetic woman who has had a cesarean and developed a post-operative wound infection may follow the direction of a local folk healer to take herbs and teas. However, you must educate the client on the need for insulin and the disease process that makes the insulin necessary. If you incorporate the treatment recommended by the folk healer in your treatment plan, it communicates your respect for the client and helps you gain cooperation.
o Understanding the importance of genetics.
There is a direct relationship between race and such biological variations as body structure, skin color, enzymatic variations, susceptibility to disease, nutritional preferences and deficiencies, and psychological characteristics. There also is an the increasing incidence of communicable disease in Hispanic-Americans. Consider these facts from the literature (for references, see box, below):
• Hispanic-Americans have an incidence of tuberculosis that is 4.3 times greater than the rate in the white population in the United States.
• Hispanics account for 14% of reported AIDS cases, 21% of AIDS cases among women, and 22% of pediatric AIDS cases in the United States.
• The rate of AIDS in the Hispanic population is triple the rate of non-Hispanics.
• Roughly 85% of health problems in Hispanics involve communicable diseases, including skin disorders, respiratory tract infections, diarrhea, nutritional problems, macroscopic parasitosis, and amebiasis. Hepatitis C also is found to occur a higher rate among Hispanic-Americans.
Case managers should note that reuse of needles and syringes after home injection of medications and vitamins may be a contributing factor to the rise of AIDS and hepatitis in the Hispanic-American population.
Your careful assessment of Hispanic clients for cultural issues that impact health outcomes and compliance will help you provide culturally appropriate care. Making an effort to develop appropriate care plans increases the likelihood of achieving successful outcomes and providing optimal health for your Hispanic clients.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content