Habla Español? Cultural Care for Our Hispanic Population

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The U.S. Census estimates that more than 43 million people in our nation speak Spanish as their primary language. Hispanics have become America’s largest minority group, and there’s no doubt that their influence is transforming the entire country. Because of an increase in Hispanic patients, many pharmacists have a myriad of questions concerning Latinos and their attitudes towards medication and healthcare practices. So let’s start with the basics. What do the terms ''Hispanic'' and ''Latino'' mean? Which term is correct?

In the late 1970s, the U.S. government began using the word Hispanic to describe Spanish-speaking individuals who live in the U.S. The term derives from the Latin word for Spain, "Hispania", and is defined as "people who speak Spanish and trace their family origin to Spain." This term was not truly accurate thirty years ago, and there are several problems with it and its definition today.

First, most people in the United States who speak Spanish do not trace their heritage to Spain. Their ancestry is firmly and deeply rooted in Latin America. Their connection is truly "New World" American rather than "Old World" European. Furthermore, as soon as Spanish conquistadors set foot on the American continent, they began to replace the thriving Native American culture and languages with their own. As such, many people feel that the use of the term Hispanic diminishes the importance of Native American contributions within the Americas.

Throughout the U.S., the term Latino is gaining in popularity. This word is defined as a person who speaks Spanish and comes from any of twenty different Latin American countries. In addition to countries in Central and South America, Caribbean countries such as the Dominican Republic, Puerto Rico, and Cuba are also included. Each Latin American country has its own unique character, history, and flavor. As a result of these regional differences, the term Latino is very important because it preserves an individual's unique national origin. Most Latinos are intensely proud of their distinct American heritages.

Furthermore, Latino is a racially neutral term. Realizing that Latinos and Latinas form part of an ethnic group that is made up of many different races is very important for healthcare professionals. It's also essential for pharmacists and other healthcare providers to be aware that most Latinos have some degree of indigenous ancestry. Their genetic makeup has a bearing on the prevalence of certain diseases such as diabetes and asthma within the Latino ethnic group.

Currently, the terms Hispanic and Latino are used interchangeably: both are correct. Therefore, it's perfectly appropriate for you to use either term. Choose the term you are most comfortable using.

Latin American countries are vitally unique. Hispanic culture is extremely diverse and represents a rich tapestry textured with traditional values. Although Latin America is steeped in rich tradition, the majority of countries are severely impoverished. Unemployment is common, and the average wage in many countries is much less than two dollars per hour. As a result of poor economic conditions, each country vastly differs in its ability to provide basic health and human services. Most Latin Americans have extremely limited access to healthcare. In many remote areas, people may walk an entire day just to visit a clinic. Sadly, a nurse, doctor, or even basic medication may not be available once they arrive.

Most Latin American individuals live in poverty and suffer from extremely poor nutrition. Few basic necessities are available. It is not unheard of for entire villages to survive without electricity or clean water. Under these circumstances, having a family doctor or obtaining an annual physical is next to impossible. Family ties are often very strong between Hispanics living in Latin America and their American relatives. Consequently, the difficult living conditions in Central and South America can have a tremendous impact on Latinos living in the U.S.

Adding to the complex problems of poverty and inadequate nutrition is the fact that poor educational systems exist throughout Latin America. Education is in a state of crisis in many countries south of the border. For many Latin Americans, education is a luxury-not a necessity. Individuals who lack a basic educational foundation have much greater difficulty learning a second language such as English. According to census statistics, approximately one-third of Hispanics over the age of 25 have no more than a ninth-grade education. Sadly, many Hispanics who immigrated to the United States as children are unable to read or write in Spanish. For adults with limited educational opportunities, the learning curve for English can require seven years or more. This places the burden of communication squarely on the shoulders of America's pharmacists and healthcare providers.

Pharmacists need to recognize the differences between Latin Americans. They must understand that Hispanic healthcare is not a "one-size-fits-all" affair. Several common threads must be considered on the journey to becoming more culturally competent.

Hispanic views on healthcare and medical treatment are as complex as Hispanics are themselves. As you work with bilingual staff members and Hispanic patients, you may witness cultural conflicts between Latinos from different countries. Challenges can involve concepts as basic as the use of the Spanish language or differences in education and acculturation. Americans from different parts of our country have different accents and use a variety of slang. Similarly, Hispanics from different parts of Latin American often have different speech patterns. Even though both groups speak Spanish, an individual from Guatemala may have difficulty understanding an interpreter from Argentina. Occasionally misinterpretations such as these can lead to serious cultural breakdowns that border on discrimination.

Protection from discrimination is an important feature of our society. As a result of the Civil Rights Act of 1964, Americans are protected from discrimination based on race, religious preference, color, sexual orientation, disability, or national origin. Recently, through Executive Order 13166, individuals with limited English proficiency have also been granted civil rights protection. The purpose of this legislation is "to provide equal access to services for persons, who as a result of their national origin do not speak English as their primary language." This legislation also protects persons who may have a limited ability to write or understand English. As a result of this federal mandate, agencies or programs that receive federal financial assistance are required to provide meaningful access to people with limited English proficiency.

But, what does providing meaningful access to services really mean? In an effort to comply with this new federal legislation, many pharmacies, hospitals, and doctors offices now provide telephone translating services to their Hispanic patients or distribute informational materials in Spanish. There may be downsides to both of these practices. Telephone translation services can be painfully impersonal. The interpreters, although they are fulfilling their job requirements, have no real knowledge of the patients or insight into their conditions. Furthermore, Hispanic patients usually find it extremely difficult to build a trusting relationship with a pharmacist through the use of a telephone translator. Since healthcare issues are by nature very personal, they are often extremely difficult to discuss with a complete stranger. This communication barrier is often very challenging for older, female Latina patients who may be embarrassed to discuss their most intimate problems by telephone. Even distributing translated documents may cause problems. Patients may be unable to read them because they are functionally illiterate or the material is poorly translated. In these cases, an individual can become completely alienated by our attempts at inclusion. So, what should you do?

The answer is to develop, implement, and plan a cultural and linguistically appropriate strategy (CLAS) that will guarantee equal access to the valuable services you provide. Ensuring translators are at your disposal is one part of the plan. Providing well-translated brochures and documents is another important component of any CLAS. However, the most critical component of your plan must include a commitment to learning Spanish. Knowing even very basic Spanish will go a long way towards building trust with your Hispanic patients. You don't have to be fluent in Spanish to be able to communicate effectively. Possessing a few survival Spanish skills is very helpful. This step forms part of an effective linguistic strategy for providing better service to Hispanics with limited English proficiency.

Hopefully you now realize the importance of providing equal service to all individuals regardless of their English proficiency. Learning "poquito español" will help you build trusting relationships with your Latino patients. However, you should also become familiar with several important cultural aspects involving Hispanics and their attitudes towards healthcare.

For example, a lack of preventative care is very common in the Hispanic community. Many Hispanics do not have a family doctor who performs routine check-ups. Others may not want to take time off from work to undergo an annual physical or receive minor treatment. In fact, going to the doctor may not be considered "macho." Hispanics often seek healthcare services only when they or members of their family are in a crisis. When this occurs, they tend to visit hospital emergency rooms for care.

In addition to a lack of preventative healthcare, serious misconceptions about nutrition and weight are common among Hispanics. Carrying "a few extra pounds" in Hispanic culture is considered healthy. Most new mothers want to have a "fat" baby because they equate the concept of fat with being healthy. This also indicates to others that you have sufficient income to afford plenty to eat. Obesity in the Hispanic population is a serious health issue that is leading to numerous problems including an increase in type 2 diabetes, heart disease, and hypertension. Long work hours and pressure to make decisions based on the welfare of your entire family are very common. As a result, following a healthy exercise program and making lifestyle changes are difficult for many Hispanics.

In addition to lack of preventative care and misconceptions about weight, many Hispanics display a fatalistic view of life. This tendency is called fatalismo, and it's even more prevalent where chronic diseases such as asthma, obesity, and diabetes are concerned. Many Hispanics feel that the state of a person's health is directly related to God's approval or disapproval of that person's behavior. For example, if you are afflicted by diabetes, it may be considered your burden to bear. Hispanics often dismiss the idea of a cure, and resign themselves to the fact that nothing can be done about the situation. They may adopt the following attitude: "If I want to go off of my diabetic diet or fail to take my medication to enjoy a family outing, I can always return to it tomorrow. After all, it won't make that much of a difference. My disease is here today, and it will still be here tomorrow."

Self-treatment of symptoms instead of seeking professional medical advice is also common in Hispanic culture. Homeopathic remedies are important aspects of Latino healthcare that often represent the first step in treatment. Curative recipes may be passed down from one generation to the next. These usually involve teas infused with a variety of herbs. Individuals who are familiar with herbs and know how to use them are highly regarded and respected. This can present a serious complicating factor when providing pharmaceutical care to Hispanics. Without asking individuals specifically, it's impossible to know what other chemical compounds they may be taking. Certain combinations of herbs can cause very dangerous drug interactions.

Believe it or not, Latino convenience stores called tiendas provide an important, and sometimes dangerous, healthcare connection for Hispanics living in the U.S. In most Latin American countries, individuals can legally purchase antibiotics and other medications at a tienda without a prescription. The practice of buying prescription medications at the corner market is becoming much more common in the United States. An estimated two-thirds of American tiendas sell "under-the-counter" prescription medications to their customers. Sometimes, the FDA has banned drugs that are currently being sold for safety reasons.

Dipyrone, or Metamizol, which goes by the street name "Mexican aspirin", is one of the most common and dangerous drugs readily available at many tiendas. "Aspirina Mexicana" is still marketed in Mexico, Central America, and some European countries. Because such drugs are readily available back "home," many Latinos don't understand why they can't purchase them in the U.S. without a prescription. Many Hispanics believe Dipyrone is simply a stronger form of aspirin. Latinos often use this drug for alleviating pain or fever. Unfortunately, Dipyrone carries serious health risks. The drug is incredibly potent and is found in the pyrazolone class of analgesics. It can critically deplete white blood cells and induce a medical condition called agranulocytosis which may lead to fatal infections (South Med J. 1996 June; 89(6):612-4. Dorr, VJ, Cook, J. "Agranulocytosis and Near Fatal Sepsis due to 'Mexican Aspirin'"). Throughout the U.S., Mexican aspirin is commonly available in a syrup form that is given to infants, along with tablets and injectable liquids.

By far, the largest obstacle to providing better healthcare services to Latinos is overcoming the language barrier. Here are some simple tips that anyone can use to help bridge the communication gap:

Be extremely polite: Courtesy titles in Hispanic culture are very important. Use words such as señor, señora, and señorita instead of first names. Latinos tend to be more formal in their demeanor. Calling someone by their first name without building a relationship first can be considered impolite.

Pronounce names correctly: Ask if you are pronouncing the name properly and verify that you have the correct surname. Many Latinos have both a paternal and maternal surname. In fact, a Hispanic name often consists of four parts: First name, second name, paternal surname, and maternal surname. The correct "last" name is the paternal surname or apellido paterno (ah-pay-YE-do pa-TER-no).

Speak slowly: Non-native speakers need time to process what you have said. By speaking slowly, you will increase your patient's ability to understand you.

Dates of birth: Latinos speak and write dates using the following format: day/month/year. Having the day and month juxtaposed can cause serious patient identification errors.

Language classes: Invest in industry-specific Spanish classes. The knowledge you gain will help you build valuable relationships with your Spanish-speaking patients. This will also encourage your patients to speak English with you. They will feel like very important customers which, of course, they are!

About the Author

Myelita Melton is the author of more than 18 books and CDs in SpeakEasy Communications' popular SpeakEasy Spanish™ series. She has trained thousands of pharmacists in "Survival Spanish for Pharmacists" programs across the country. SpeakEasy Communications urges you to celebrate the use of Spanish in the workplace on "Hola Day" this October 1st. Just say "hola" (OH-la) or use any other Spanish phrase you know on October 1st. For more information, please contact Myelita Melton at Myelita@speakeasyspanish.com.

Breaking the Language Barrier

To connect with Spanish-speaking patients, Myelita Melton, president of SpeakEasy Communications, offers the following tips:
  • Be polite. Courtesy titles are important. Use señor and señora rather than first names. Confirm surnames. Ask if you are pronouncing the name correctly.

  • Speak slowly. Non-native English speakers need extra time to process what you are saying. Translating from one language into another is not automatic.

  • Be direct. Use short, simple sentences. People learning English are often confused by long sentences with complicated grammar.

  • Use a normal speaking voice. Don't speak in a loud voice. The person you are talking to doesn't have trouble hearing you. They have trouble understanding you.

  • Errors in dates. Be aware that Latinos tend to write dates using the day/month/year format. This may cause problems with documents such as insurance forms.

  • Language classes. Knowing "poquito español" makes a big difference. This knowledge will help you build relationships with your Spanish-speaking patients. It will also encourage them to speak English with you.

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