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Ohlinger, Nadine I.
They say this clinic is for migrants
h [electronic resource] :
b cultural sensitivity in a rural health center /
by Nadine I. Ohlinger.
[Tampa, Fla.] :
University of South Florida,
Thesis (M.A.)--University of South Florida, 2005.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
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Mode of access: World Wide Web.
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ABSTRACT: The growing number of minority populations living in the United States makes it mandatory that all health care organizations seek to be culturally sensitive. There is no consensus on the definition of the term cultural sensitivity. The goal of this thesis is to define what cultural sensitivity means in a rural health center, from the perspective of the staff as well as the Hispanic patient. Anthropological methods, such as participant observation, semi-structured interviews, and archival data analysis, show that the qualities that Hispanic patients value in a clinic are 1) attention, 2) availability of Spanish language, 3) financial assistance, 4) solution to their health problems, 5) presence of Hispanics around the clinic, and 6) clinic services. Furthermore, 90% of staff responses indicate acceptance and respect of patients health beliefs and practices.
Adviser: Dr. Roberta Baer.
Rural health services.
t USF Electronic Theses and Dissertations.
They Say that this Clinic is for Migrants: Cultural Sensitivity in a Rural Health Center Nadine I. Ohlinger A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Anthropology College of Liberal Arts and Sciences and Master of Public Health Department of Community and Family Health College of Public Health University of South Florida Major Professor: Roberta Baer, Ph.D. Jeanine Coreil, Ph.D. Nancy Romero-Daza, Ph.D. Date of Approval: April 8, 2005 Keywords: cultural competence, culturally appr opriate, culturally congruent, culturally relevant, cultural diversity, Hispanics, Mexi can-American, rural health services, migrant farmworkers Copyright 2005, Nadine I. Ohlinger
ii I dedicate this thesis to my husband Landon, for his love, support, and patience throughout this project, my daughter Isbel, for teaching me to slow down, and my mother, whose constant encouragement helped me finish this project. In loving memory of my aunt, Gloria Royce, who inspires me to improve the quality of health care that we receive, and my father-in-law Fred Ohlinger, whose wisdom guides me daily.
iii Acknowledgements I would like to thank the patie nts and staff members of the rural health center for their participation in this project and for trusti ng me to follow through with the project. I would also like to thank Diana Lopez for givi ng me the opportunity to work at the clinic, which proved to be an invaluable experience in my life. I am indebted to the members of my committee, Dr. Roberta Baer, Dr. Nancy Romero-Daza, and Dr. Jeanine Coreil, for their encouragement, expertise, a nd mentorship in this project.
iv Table of Contents List of Figures vii Abstract viii Chapter 1: Introduction 1 Chapter 2: Literature Review 6 Introduction 6 Background of the Problem 6 Anthropological Contributions 8 Who is Hispanic? 12 Cultural Values 12 Acculturation 15 Health Beliefs 17 Folk Illness 18 Migrant Farmworkers 19 Biomedical Culture 20 Cultural Sensitivity 21 Definition 22 What It Means to be Culturally Competent 23 Factors Affecting (or related to) Cultural Sensitivity 24 Models of Cultural Competence 26 Summary 31 Chapter 3: Methodology 32 Introduction 32 Internship Setting 32 Research Questions 33 Informed Consent 34 Interviews 34 Sampling 35 Observations 36 Archival Records 37 Analysis 38 Limitations 38 Bias 40 Summary 40 Chapter 4: Results 41 Introduction 41
v Patient Interviews 41 Demographics 41 What Patients Like About the Clinic 44 Attention 44 Language 45 Financial Assistance 47 Solution 48 Presence of Hispanics 49 Clinic Services 49 What Patients Do Not Like About the Clinic 50 Long Wait 50 Patients Suggestions for Improvement 52 Patients Perceptions on Educational Information Handouts 53 Staff Interviews 54 Demographics 54 Cultural Sensitivity Training 56 Medical Interpre tation Training 58 Staffs Perceptions of Cultural Sensitivity 58 Definition of Cultural Sensitivity 58 Why Be Culturally Sensitive? 59 Cultural Sensitivity in Action 61 Staffs Awareness of Hispanic Values and Health Beliefs 64 Staffs Perceptions of How the Clinic Practices Cultural 64 Sensitivity How Staff Members Would Measure the Impact 66 of cultural sensitivity Is There Room for Improvement? 67 Staff as Advocates for Migrant Workers 69 Comparison of Patient and Staff Responses 70 Observations 71 Front Desk-Patient Interactions 72 Fast Track Observations 73 Provider Observations 74 Archival Data 76 Administration Records 76 Health Education Materials 78 Summary 82 Chapter 5: Recommendations and Conclusions 83 Introduction 83 Conclusions 83 Anthropological Difference 88 Contributions to Anthropology 89 Contributions to Applied Anthropology 90 Contributions to Public Health 91 Recommendations 93
vi Summary 95 References 96 Appendices 102 Appendix A: Patient Oral Consent Guide English 102 Appendix B: Patient Oral Consent Guide Spanish 103 Appendix C: Patient Interview Questions English 104 Appendix D: Patient Interview Questions Spanish 106 Appendix E: Staff/Provider Interview Questions 108 Appendix F: Recommended Standards for Culturally and 109 Linguistically Appropriate Health Care Services Appendix G: Cultural Competence Resources 111
vii List of Figures Figure 1: Ethnicity 42 Figure 2: Gender 42 Figure 3: Age Distribution 43 Figure 4: Length of Time Coming to Clinic 43 Figure 5: Positive Clinic Attributes 43 Figure 6: Distribution of Occupations 54 Figure 7: # of Years Worki ng at the Clinic 54 Figure 8: Staff Ethnicity 55 Figure 9: Kind of Cultural Se nsitivity Training 57 Figure 10: Extent of Cultural Sensitivity Training 57 Figure 11: % Readability of H ealth Education Materials 81 Figure 12: Model of Cultural Sensiti vity for Rural Health Centers 81
viii They Say This Clinic is for Migrants: Cultural Sensitivity in a Rural Health Center Nadine I. Ohlinger ABSTRACT The growing number of minority populati ons living in the United States makes it mandatory that all health care organizations s eek to be culturally sensitive. There is no consensus on the definition of the term cultural sensitivity. The goal of this thesis is to define what cultural sensitivity means in a rura l health center, from the perspective of the staff as well as the Hispanic patient. An thropological methods, such as participant observation, semi-structured interviews, and archival data analysis, show that the qualities that Hispanic patients value in a clinic are 1) attention, 2) availability of Spanish language, 3) financial assistance, 4) solution to their health problems, 5) presence of Hispanics around the clinic, and 6) clinic serv ices. Furthermore, 90% of staff responses indicate acceptance and respect of patients health beliefs and practices. Results demonstrate that while the clinic is culturally sensitive, there are a few recommendations that would improve the quality of care that Hi spanics receive. Based on the results of the data collection, a practical model for other ru ral health centers to build upon a culturally sensitive health care system is developed.
1 Chapter One Introduction Cultural competence and cultural sensitivity are concepts that are well known in the health care industry. However, there is no consensus in the liter ature on the definition of cultural sensitivity. Anth ropological concepts and me thodology provide an excellent approach to tackle the issues of cultura l competence/cultural sensitivity from both an emic and etic perspective. This study combines public health and anthropology to evaluate what cultural sensitivity means to Hispanic patients and rural health center staff. The following is a true story about a migran t farm worker. It is also a typical story. A pseudonym has been used to protect the patients identity. Margarita is seven months pregnant. She is supposed to be work ing in the fields toda y, but instead she is taking the day off to go to the local clinic so that she can see the midwife about the stomach pains she has been having. Her brother in law drops her off at the clinic early in the morning before it even opens, and she does no t have a ride home from the clinic. At the clinic, she does not unders tand the forms she is given to fill out, and is unable to communicate this to the front desk personnel because they do not speak Spanish. She sees no indication in the lobby that the midwif e will understand her either, so she starts to walk home. On her way home, she goes in to premature labor, and her unborn child suffers from fetal distress and dies. Margaritas situation could have been ameliorated if the clinic had provided her with transportation, Spanish-speaking pers onnel, forms in Spanish, and an inviting
2 environment for Spanish speaking patients. Th ere is a movement within the health care industry that has received much attention r ecently: cultural sensitivity and/or cultural competence. Cultural sensitivity is defined as the extent to which ethnic or cultural characteristics, experiences, norms, values, be havior patterns, and beliefs of a target population, and relevant historical environmental, and social forces are incorporated in the design, delivery, and evaluation of targeted health interventions, including behavioral change materials and programs (Reniscow, et al 2002:493). Because of the well known expansion of minority populations, now more than ever health care providers will need to take into account non-medical factors of patients situations, such as their cu ltural background. If the goal of health care is to improve overall health, cultural competence is imperative. There is a direct relationship between culturally competent health care and an impr ovement in access to and quality of care, and ultimately health outcomes. In any health care situation, there is an amalgamation of three cultures: the patients, the doctors, and the health care organiza tions. In order to establish congruence and cultural sensitivity, the three cultures have to come together and understand the interrelationship of the health care situation. Although the need for culturally sensitive he alth care is heavily cited in the empirical literature, there is no consensus as to the definition of cultural sensitivity. This project will attempt to define what cultural sensitivity means in a rural health center, from the perspective of the staff as well as the Hispanic patient. The goal of the project is to characterize the role of cultural sensitivity in a clinic whose mission is to provide all services in a culturally sensitive manner in order to promote healthy outcomes in the population [it] serves (Suncoast Community Health Centers 2002). While there are
3 many models that attempt to operationalize cu ltural sensitivity or cultural competence, the ultimate goal of this project is to devel op a model that other rural health centers can use to build upon a culturally se nsitive health care system. This project came about from an app lied anthropology a nd public health internship that I had at a clinic in west centr al Florida (HC). As a health educator I was able to conduct participan t observation, understand the administrative processes of a health care organization, and de velop trusting relationships w ith patients and staff. My position as health educator was enriched b ecause in addition to my graduate school training in the field of health education, I al so had the insight from my anthropological background and training in applied anthropology This provided an excellent opportunity to contribute to public health and anthropol ogical research by developing a qualitative study of cultural sensitiv ity, a topic that is very evident in the clinic. This qualitative study uses grounded theory to examine the extent to which a clinic that caters to many migrants and Hisp anics is culturally sensitive. Unlike most studies conducted on the topic of cultural comp etence or cultural se nsitivity, this study utilizes anthropological research methods to attain a holistic pe rspective of what providing culturally sensitive services really means in a rural health center. Chapter Two provides an overview of the lit erature that is rele vant to cultural competence and establishes the need for cultural competence/cultural sensitivity. In addition, a review of the anthropological lite rature on Hispanic cultural values, such as familismo fatalismo respeto simpata and personalismo as well as Hispanic health beliefs is also examined. Other anthropologi cal contributions, such as the concept of worldviews, Kleinmans explan atory model, and successful culturally competent health
4 care programs are dissected. A brief synopsis of biomedical culture is also provided in Chapter Two. The terms cultural competence and cultural sensitivity are defined and the factors relevant to cultural sensitivity ar e discussed. Finally, chapter two also reviews some of the models of cultural competence. Chapter Three describes the methodology employed to complete this study. Within this chapter, the intern ship that preceded and inspired this study is also discussed. The goal of the study is to define what cultur al sensitivity means in a rural health center, from the perspective of the staff as well as the Hispanic patient. The qualitative methodology included thirty-one open-ended inte rviews with patients, twenty-one openended interviews with staff members, partic ipant observation, structured observations, and analysis of archival data. The research questions that guided this study are: 1) What does cultural sensitivity mean to patients? 2) What does cultural sensitivity mean to HC staff? 3) Does cultural sensitivity mean di fferent things to pa tients and staff? 4) What makes a clinic culturally sensitive? The informed consent process, sampling, and analysis of the data are discussed in this chapter. The limitations and bias asso ciated with this study are also reviewed. Chapter Four presents and discusses the main findings from the data collection methods and analysis. Results of the patient interviews show that the most important factors that keep patients coming to the clinic are: 1) the staff gi ves them attention; 2) services are available in Spanis h; 3) financial assistance is av ailable; 4) they are given a solution to their health problem; and 5) th ere are Hispanics everywhere throughout the clinic. The majority of the patients believe d that the clinic does understand and have
5 knowledge of the cultural values that Hispanic s share. Results from the staff interviews illustrated that medical assistants should be required to complete medical interpretation training. In addition, slightly more than half of the staff interviewees reported that they had not received cultural competence training. In this chapter, the staff members various definitions of cultural sensitivity are presente d, as well as their perceptions of how the clinic practices cultural se nsitivity. In addition, Chapte r Four presents the staff respondents examples of how they believe they are culturally sensitive. Findings show that although staff members can not give an exact definition for the term cultural sensitivity, they intuitively know what it means. The majority of respondents exemplified how they are aware of the cultura l values that Hispanics share as well as their health beliefs. The final chapter, Chapter Five, offers conclusions and recommendations for the HC, based on the findings presented in Chapte r Four. In this chapter, the literature reviewed in Chapter Two is connected with the findings discussed in Chapter Four. In addition, this chapter also presents the proj ects contributions fo r anthropology, applied anthropology, and public health. Based on the findings from the data collection, the recommendations are intended to improve the ex cellent services that the HC provides.
6 Chapter Two Literature Review Introduction This chapter examines and reviews the litera ture that is related to this study. The first section orients the reader by pr oviding a background on the importance of eliminating health disparities, and outlines various barriers to healthcare. Relevant information on the health beliefs and cultural valu es of Hispanics is also presented in this chapter. In addition to an understanding of Hispanic patients culture, a background on biomedical culture is also provided. This chapter also defines the term cultural sensitivity, and discusses the si gnificance of cultural sensi tivity in health care. The various models of cultural competence are disc ussed in this chapter as well. Lastly, within this chapter, the reader will be introdu ced to the contributions that anthropologists have made towards understanding the dynamics th at impact the health care of Hispanics. Background of the Problem The US Department of Health and Huma n Services issued a document, Healthy People 2010, which highlights the health prio rities that are necessary to ensure that good health, as well as a long life, are enjoye d by all (US Department of Health and Human Services 2003a). One of the goals of Healthy People 2010 is to eliminate health disparities among populations. Race and ethnicit y are considered fact ors that contribute to health disparities, for example the highe r rates of Hispanics who die from diabetes,
7 African Americans who die from heart diseas e, or Vietnamese who die from cervical cancer. However, the higher prevalence of disease among certain populations cannot be attributed to one single factor, such as biologic or genetic ch aracteristics. Rather, health disparities are the result of a complex re lationship of genetic, environmental, and sociocultural factors. In the publication titled, U nequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002), The Institu te of Medicine (IOM) conducted a review of literature and determined that the pr eponderance of studies find that even after adjustment for many potentially confounding f actors including racial differences in access to care, disease severity, site of care (e.g., geographic va riation or type of hospital or clinic), disease prevalence, co-morbidity or clinical charac teristics, refusal rates, and overuse of services by whites racial and ethnic disparities remain (p. 8). The IOM authors (2002) also found th at in many studies there is a direct relationship between health care disparities and worse health out comes, and that the cause of disparities appears to be closely related to factors related to the health system, health care providers, and patients. Within Healthy People 2010, access to care has been labeled as one of the ten leading health indicators that will be used to measure the health of the nation over the next ten years. There are many dimensions i nvolved with access to care. For instance, income level, health insurance, and ongoing so urces of primary care are all factors that directly relate to access to care. There are several barrier s to accessing care, including financial, structural and soci ocultural barriers. Financia l barriers include not having adequate health insurance or financial capab ility of paying for health services. Many
8 studies have been conducted, which establish that there is a relationship between lower socioeconomic status (SES) and poorer hea lth (Feinstein 1993, House et al. 1996, and Marmot & Wilkinson 1999). Structural barriers refer to the lack of available providers to meet health care needs, as well as the lack of transportation and h ealth care facilities available. Finally, sociocultural barriers ar e those factors such as cultural or language differences which prevent an in dividual from seeking or obtai ning adequate care (Cooper, Hill, and Powe 2002, and US Department of Health 2003b). Ethnic minority populations who face individual and institutional discrimina tion are more likely to confront stressors, such as financial, structural, and sociocultural limitations. This thesis project focuses on the sociocultural barriers to health care that ethnic minority populati ons confront daily. Anthropological Contributions Anthropology basically transl ates as the study of human beings. At the heart of being human is the concept of culture. The pow er of culture and its influence on health is a well known subject among many in the health pr ofessions. In an attempt to define the nebulous term culture, many have offered defi nitions. The result is a wide array of definitions, which one can pick and choose depending on the study at hand. For this study, the term culture is defined as tha t complex whole which includes knowledge, belief, art, morals, law, custom, and any othe r capabilities and habits acquired by man as a member of society (Tylor 1871:1). Speci fically, culture encompasses values, beliefs, and perceptions of the world, which are shared by a group of individu als. It is these values, beliefs, and perceptions that manifest in peoples behavior. Medical anthropology is a field of anth ropology that encompasses the study of medical phenomena as they are influenced by social and cultural features and social and
9 cultural phenomena as they are illuminated by their medical aspects (Lieban 1977:15). According to Lieban (1977), health and diseas e are not only related to biological factors, but also to a persons socioec onomic resources and how he/she utilizes those resources. A persons culture will determine the type of health care that he/she will seek and the way that he/she will percei ve illness and its symptoms (Kleinman et al. 1978). Furthermore, culture will also influence the level of importance that a person will place upon changing his/her health-related behavior. Success of a culturally sensitive health care program will take place only if the progr am is developed and implemented within the framework of the communitys culture. Anthropological methodology, such as participant-observation, unstructured interviews, ethnographies, cross-cultural comparis ons, as well as being culturally relative guarantees that health care providers w ill have a better understanding of a target populations culture. One of the outstanding features of anthr opology is its holistic perspective. It encompasses the social, pol itical, economical, and environmental aspects of a persons life. Many anthropologist s have been involved in the successful development and implementation of culturally competent health care programs. In a diabetic educational program for Puerto Ricans in New York City, Brosnan (1976) examined Puerto Rican kinship system household organization, economic system, customs and values, and beliefs about health and illness. Brosnans investigation into the Puerto Rican culture found that Puerto Ricans ha ve a fatalistic view towards life and rely heavily on family and close friends for support. The author suggested effective ways to address diabetes education programs such as involving the entire family in the education process, which should be conducted in the patients homes during evening hours.
10 Another anthropologically-based study on adolescents with asthma showed how an anthropological approach to health care is ideal. Rich et al. (2000) sought to learn more about adolescents beliefs about asthma and the role of asthma in their daily life experience. Study participants were given a video camera to document their lives as it relates to their asthma. Upon analyzing the video foot age, the authors found that participants were improperly us ing their inhalers, despite many health education attempts. Because the adolescents were empowered with the video camera, they were able to show many different aspects of their lives that a questionnaire would not illuminate. For instance, the video demonstrated how asth ma affected the family and other unknown environmental factors eviden t only through the camera lens The visual anthropology approach of using a video camera not only em powered the participants, but also proved to be an effective health edu cation strategy as it portrayed real-life experiences of people living with asthma. In aiming to understand the factors that relate to the prev ention of chemical exposure among farmworkers, Quandt et al. (1998) conducted formative research using methodology such as ethnography, participant ob servation, unstructured and structured interviews, and focus groups. The authors f ound that the farmworkers do not believe that they are susceptible to chemical exposure, a nd if they do get exposed, it is out of their control. While they did not discuss the deve lopment of a prevention program, the authors showed how anthropological methods can be used to successfully determine a populations beliefs and values of a health-related issue, as well as other social and physical environment-related issues.
11 Many times, patients are labeled as nonc ompliant when in actuality their worldview is not compatible with Western or biomedical worldview. In order to understand a patients behavi or, one needs to understa nd his/her worldview, which consists of [his or her] basic assumptions a bout the nature of reality (Galanti 1991:5). Worldview is defined by peopl es religion, and their relati onship to nature (Galanti 1991). For instance, voodoo death is a phenomen on that occurs in countries, such as Haiti, which Western practitioners with a diffe rent worldview are constantly seeking to explain. To a Haitian, a voodoo death occurs wh en someone is cursed by another person. However, Western doctors and scientists have numerous scientific ex planations, such as stress or loss of will to live (Galanti 1991). Both worldviews have a different understanding of voodoo death. Kleinman et al. (1978) begin to address the concept of worldview when they distinguish disease as the bi ologic (or Western) maladap tation of the body, and illness as the culturally constructed experience whic h explains discomfort An individuals explanatory model explains how that individual perceives the causes and symptoms of his/her illness. Kleinman et al.s (1978) work on explanatory models has served as a useful guide for health care professionals. They suggest a patient-centered focus of determining the health problem by asking questions such as: What do you think has caused your pr oblem? Why do you think it started when it did? What do you think your sickness does to you? How does is work? How severe is your sickness? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness? (Kleinman et al. 1978:256)
12 The patients explanatory model will reveal the hidden cultural meanings that are related to his/her illness, such as beliefs, values and attitudes. Several studies have shown that a populations worldview will greatly affect the manner in which it interprets health interventions (Britton 1996, Ca ssidy 1987, Ito 1999, Olson 1999, Opala 1996). For example, Brooke Olson (1999) found that many Native Americans view diabetes as a white mans disease (p. 191) a nd are therefore reluctant to seek and are suspicious of biomedical treatment. Accordi ng to Olson (1999), Indians view a large body as a sign of health and wealth, and educational interventi ons that focus on weight loss are futile. Consequently, Olson suggested culturally appr opriate educational strategies such as native games, stories, and talking circles. Olsons research shows that health care interventions must be tackled from a populations worldview. In the health care industry, the culture of the patient, the patients family, the provider, and the health care organization merge together to form relationships, which will ultimately affect the quality of care that minority groups r eceive. It is impossible to know about every single culture that exists. However, it is mandatory that health care providers become knowledgeable about the cultu res of the patients who visit their health care agency. For this study, the most promin ent cultural groups that attend the HC are Hispanics who share similar cultural values. The following section discusses the healthrelated cultural values that many Hispanics share. Who is Hispanic? Throughout this paper, the term Hispanic will refer to a group of people who share similar cultural values, and in many cases language. It is impor tant to note that not all Hispanics share the same health beliefs a nd cultural practices (Kit tler & Sucher 1995).
13 Many factors, including politic s, health beliefs, level of acculturation, and socioeconomic status will affect the approach that many Hispan ic patients will take on th eir health care. I will distinguish the specific cultural groups when describing differences or similarities of patients in order to av oid overgeneralization. Cultural Values The cultural concepts of familismo fatalismo respeto simpata and personalismo make up a unique belief system that has an impact on the health behavior of some Hispanics, such as Mexican Amer icans, Puerto Ricans, and other Central American groups. Familismo describes the strong concept of family among Hispanics where the mutual needs of the family unit are more important than th e needs of individual family members (National Council of La R aza, 1998). In addition, among Hispanics, family and extended family are very involved in the health and well being of the entire family. The extended family includes compadres who are individuals that became a part of the family because they were asked to be godparents or were long time friends of the family. Padrinos (godparents) are also very involved in an individuals health care and decision making process (Zoucha 2000). Respeto refers to the importance of proper a nd moral behavior in front of another person. Hispanics regard doctors with high respect. Although they might not understand a treatment regimen, they will follow doctors orders to show respect. Moreover, Hispanic patients expect resp ect from their health care provi ders, and will not return to them if they feel they have not received it (National Council of La Raza 1998). To show respect, health care providers should address their Hispanic patients using formal Spanish terms, such as usted (formal you), and/or Seor or Seora (Mr. or Mrs.). Health care
14 providers should also recognize the eldest male member or father as head of household, and should establish a personal relationship with him as an entre to the rest of the family. The head of household should always be included in the conve rsation, or at least be asked permission to speak to the family me mber privately. By r ecognizing the head of household, the health care provider shows that he/she has respect, which will lead to less friction during the patients course of health care (Zoucha 2000). Fatalismo is a cultural concept that describe s how natural illness is caused by Gods will, therefore, there is very little that an individual can do to prevent or survive the disease (National Council of La Raza 1998). For this reason, little interest in preventive health behaviors is displayed (G ans et al. 1999, and Quatromoni et al. 1994). Quatromoni et al. (1994) found that Mexican-Americans and Puer to Ricans believed that preventive measures were ineffective (p. 873), and therefore not necessary for good health. In fact, feeling hea lthy was more important to diab etic Hispanics than measuring glucose levels (Quatromoni et al. 1994). Simpata describes the value of being polite and pleasant. In fact, health care providers who have a neutral attitude are regarded as negative in the Hispanic culture (Flores 2000). Personalismo is the Hispanic value based on friendliness, trust, and intimate relationships, especially with hea lth care providers. For instance, Hispanics regard physical touch as a means of communi cation. It is quite common to see family members and friends openly embracing and show ing affection to one another. Although Hispanics are more conservative with strange rs, health care professi onals could begin to establish personalismo with his/her Hispanic client by offering a handshake, and/or asking about the clients family before dealing with the actual business of health care. If
15 a provider is distant th e client might not return for hi s/her next appointment (National Council of La Raza, 1998). Along the lines of personalismo Mexican Americans associate attention spent on someone as a sign showing that the person ca res for the individual who is receiving the attention (Zoucha 2000). For inst ance, if a health care provider spends time listening to a persons concerns regarding his/her health, th en the person is regarded as caring because he/she is giving the patient atte ntion. Health care providers sh ould take time to engage in small talk by asking about the family, and avoi d feeling rushed. This allows the patient to feel like the health care provider cares for him/her. All of the Hispanic cultural values, familismo fatalismo respeto simpata and personalismo can occur to different degrees, depending on such factors as the individuals level of acculturation, educa tion, gender, socioeconomic background, and age. Over time, if a health care provider s hows respect with a pers ons culture, he/she will establish confianza or trust, with the patient (N ational Council of La Raza 1998). The lack of attention to these Hispanic values can lead to patients not having a connection with their health care provider, not being compliant, and not being satisfied with the quality of care. Acculturation A patients level of acculturation has a dire ct effect on his/her approach to health care, affecting perception and health seeki ng behavior. Acculturation is defined as a multidimensional process in which individuals whose primary learning has been in one culture takes over characteristic ways of living from another culture (Hazuda, Haffner, Stern, and Eifler 1988). Acculturation occurs in different degrees for different cultural
16 factors, such as language use, family struct ure, and health behavi ors (Borrayo & Jenkins 2003). In terms of access to car e, a person with a lower acculturation level is more likely to encounter language barriers, which will directly affect access to health care. Perception of quality of care may also vary according to acculturation level. For instance, a person who has recently moved to the United States and has a different worldview and is accustomed to a different appr oach to health care might have a different perception of the quality of his/her health care than a person who has been actively participating in US health care for many year s. The relationship between acculturation and health is complex and dependent on ot her variables. Generally speaking, lower acculturation levels have been associated with better health, wh ile higher acculturation levels are associated with poorer health (Clark & Hofsess 1998). For instance, acculturation leads to many unhealthy eating habits existent in the United States, such as increased consumption of high-fat salad dres sings, and high sugar drinks, such as soda and Kool Aid, which have replaced traditiona l fruit-based beverages (Aldrich & Variyam 2000, and Prez-Escamilla et al. 2001). There exist tools that have been validate d to measure the acculturation levels of Mexican-Americans specifically. However, m easuring levels of acculturation of each patient interviewed is beyond the scope of this study. There are many complex factors related to acculturation level, which will not be determined in the patient interview. Therefore, for this study, I will not be measur ing acculturation level. However, it is an important factor that health care providers should be awar e of, as it may affect the way that they communicate with their patie nts, how patients understand them, and consequently how patients will prac tice their own health care.
17 Health Beliefs The Western biomedical model explains that disease is caused by some agent, such as a bacteria or virus. Many Hispanics attribute the onset of disease to witchcraft (unnatural) or an imbalance of hot and cold qua lities (natural). It is important to note, however, that some Hispanics, depending on factors such as socio-economic class or education level may not believe in witchcraft. Hispanics tend to have both a biomedical and folk belief system, as evident in the example of diabetes (Castro, Furth, & Karlow 1984). For example, as a result of this belief system, Hispanics do not view diabetes as a disease occurring as a result of witchcraft, but recognize it as natura lly occurring (Weller, et al. 1999). Mexicans also attribute strong emotions, such as fright and anger, to diabetes onset (Poss & Jezewski 2002, and Weller et al. 1999). Weller et al. (1999) also found that overall among Hispanics, diabetes is thought to be hereditary, or occurring as a result of eating sweets. Similarly, severa l studies conducted speci fically with MexicanAmericans found that Mexican-Americans have a dual belief system, seeking treatment from a folk healer for certain health condi tions, and from a doctor for other health conditions (Chvez 1984). Furthermore, wh en Mexican-Americans do seek treatment from biomedical professionals, they perceive the doctors to be l acking in understanding (Chvez 1984). For this reason, it is imperative that health care prac titioners have a clear understanding of the health beliefs and cultural values of their patients. Mexican-Americans may sometimes use home remedies first, and then seek treatment from a doctor (Chvez 1984). Severa l studies indicate that Hispanics use folk remedies to treat diabetes although the remedi es are supplemental to and not in lieu of their prescribed medicine (Hunt, Arar & Akana 2000, Quatromoni et al. 1994, and
18 Weller et al. 1999). It is impor tant for health care profe ssionals to be aware of and understand the health beliefs of Hispanics in order to provide culturally sensitive health care. Folk Illness A folk illness is defined as syndromes from which members of a particular group claim to suffer and for which their culture provides an etiology, a diagnosis, preventive measure, and regimens of healing (Helman 2000:86) A folk illness attributes more than just symptoms as the cause for illness. For instance, a sick patient can suffer from changes in the environment, be a victim of supernatural forces, or be having trouble in the family. Individuals, belonging to a certain cultural group, learn about folk illnesses by learning how to express them and respond to them. One of the more prominent folk illnesses in Mexican culture is empacho Empacho occurs when the intestines are blocked by a foreign matter, such as food (T rotter 1985). According to Trotter (1985), eating improperly cooked foods, eating empacho -causing foods at the wrong time (such as bananas late at night), and swallowi ng chewing gum are some of the causes of empacho Some of the remedies for empacho include stomach massage and the use of greta which is a powder that has high lead co ntent and results in lead poisoning. In essence, health care provider s should be aware of the folk illness of the population with which they work so that they can accurat ely diagnose and treat a patients health condition.
19 Migrant Farmworkers According to the National Center for Farm worker Health, approximately 85% of all migrant workers are minorities, of whom most are Hispanic (including MexicanAmericans as well as Mexicans, Puerto Rican s, Cubans, and workers from Central and South America) (National Center for Farmwo rker Health 2005). At the HC, migrant workers encompass 30% of all patients w ho utilize clinic services. A migrant farmworker is an individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months and who establishes for the purpose of such employment a temporary abod e (US Department of Health and Human Services 1980). As agricultural workers, migrants endure hard phys ical labor, fatigue, poverty, prejudice and hostil ity (Coughlin & Wilson 2002). In addition, migrant farmworkers are also exposed to health hazards and unhealthy living and work conditions. Consequently, their health care tends to be more focused on acute care, rather than preventive care (Coughlin & Wilson 2002, Meister 1991). Migrant farmworkers are unique with respect to health care issues because of their migratory nature, which affects income, edu cational level, health status, and health behavior. Factors that impede access to hea lth care include affordability, language, and transportation (Coughlin & Wilson 2002, Gwy ther, & Jenkins 1998, and Napolitano & Goldberg 1998). Legal status is also a barrier to obtaining health care, since approximately one-third of all migrant farmworkers are either undocumented or unauthorized to work in the United States (Couglin & Wilson 2002). Even though some migrants may be eligible fo r Medicaid, most do not have health insurance and do not participate in Medicaid because of lack of awareness of be nefits, and inconvenient hours
20 and locations of enrollment offices (Gwyther & Jenkins 1998). Farmworkers work long, nontraditional hours and are not likely to take tim e off from work to tend to health care matters (Coughlin & Wilson 2002, and Napolitano & Goldberg 1998). Furthermore, they typically do not appear at the clinic seeking preventive or ch ronic illness ca re. Rather, they focus on getting treatment for their acute illnesses. A further challenge to health care providers is that migrant farmworkers ar e hard to reach because of their migratory nature, and because their residence tends to be isolated in rural agricultural communities (Coughlin & Wilson 2002). For these reasons, it is imperative that migrant health centers are culturally sensitive. Biomedical Culture Like the patients, health care providers also have their own culture, which is a mixture of their own cultural roots and Wester n biomedical culture. In general, members of the biomedical culture have high social status and high earning power, and have their own set of medical lingo, which laypeople can not understand. Their view of health and medicine is that in order for something to exist, it must be measured and observed. Medical school students are taught to emphasize the individual patient, rather than his/her family or community (Helman 2000). The health care providers beliefs and values combine to form a worldview that is often ve ry different than the patients worldview. A patient is likely to feel misunde rstood and dissatisfied if a pr ovider fails to consider the patients worldview, and recognizes his own as the right one. Anthropologists have found that an individuals education, belie fs, social and cultural background will help determine what is said, how it is said, a nd how it is heard and interpreted in a consultation (Helman 1985:8). A health care consultation is successful when both
21 provider and patient respect one anothers be liefs and values, and a treatment regimen which blends both cultures is established. Pa tients are more likely to trust the provider and adhere to the treatment regimen. Cultural Sensitivity Almost one third of the nations populati on consists of ethnic ally diverse groups, and by 2050 that number will increase to almo st one half of the US population (Wells 2000). Health care professionals will encount er more and more patients who have different languages, customs, beliefs, values and behaviors than their own. Because of this demographic shift, the need for culturall y sensitive interventions is strong, especially in community health centers that are most likely to serve diverse populations. The shift toward cultural competence is a st rategy that is recognized by the entire medical community as a way to decrease the he alth disparities gap. Recently on January 4, 2005, congress introduced a bill entitled H ealthy People, Healthy Choices Act of 2005. The Act documents that a lack of acce ss to culturally sensitive medical care and guidelines for healthy eating a nd exercise habits contributes to poor health outcomes for minority citizens (Library of Congress 2005). The Act also authorizes grants and use of money towards conducting minority health programs. The Department of Health and Human Se rvices, Office of Minority Health (2001) has developed National Standards for Culturally and Linguistically A ppropriate Services in Health Care. The Standards can be seen in Appendix F of this thesis. In the document titled A Practical Guide for Implementi ng the Recommended National Standards for Culturally and Linguistically Appropriate Servic es in Health Care (2001), health care organizations are given a step -by-step guide on how to become culturally competent,
22 with checklists within each section. The entire guide is thorough, covering every single aspect of cultural competence, and is availa ble for free on the Office of Minority Healths website, www.omhrc.gov/clas and is an excellent resource for health care organizations that aim at becoming and continuing to be cult urally competent. A list of other excellent cultural competence resources is availa ble in Appendix G of this thesis. Definition of Cultural Sensitivity There is no accepted definition for the term cultural sensitivity in the empirical literature. Cultural sensitivity is used in terchangeably and can be synonymous with many other terms such as cultural competence, cult urally relevant, cultu rally appropriate, and cultural diversity. All of th ese terms are synonymous and convey the idea of improving and promoting cross-cultural understanding. Cu ltural competence has been defined as: a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effec tively in cross-cultural situations (Cross, Bazron, Dennis, & Isaacs 1989). For the purposes of this study, the de finitions for these terms are used interchangeably. However, Glanz, Rimer, and Lewis (2002) offer a holistic definition for cultural sensitivity, which is the operational definition that will be used throughout this project. They define cultural sensitivity as: The extent to which ethnic or cultu ral characteristics, experiences, norms, values, behavior patterns, and beliefs of a target population, and relevant historical, environmental, and social forces are incorporated in the design, delivery, and evaluation of targeted health interventions, including behavioral change materials and prog rams (Reniscow, et al 2002: 493). This definition of cultural sens itivity is distinguished from the term cultural competence because it emphasizes health interventions, ma terials, and messages as the focus. The difference between cultural competence and cultural sensitivity is that cultural
23 competence emphasizes the capacity to be cult urally sensitive at the interpersonal, individual level. Whichever definition for cultural sensitivity/cultural competence is being used, it nevertheless emphasizes the integration of cultural knowledge and awareness into policies, practices, and attitude s of an organization in order to increase the quality of health care, which will inevitabl y result in better health outcomes for patients. Without the integration of cultural sensitivity into organizational culture, culturally sensitive efforts on the individual level are less likely to be effective. What it Means to be Culturally Competent Health care professionals should firs t have the knowledge and awareness of cultural information, such as health beliefs of a particular ethnic group, and incorporate that information into the pl an of intervention. They s hould recognize and respect not only the patients ethnic group, but also the en vironment in which the patient lives, as well as effective interventions that work with that partic ular ethnic group. While it may be impossible to know everything there is to know about a particular culture, an ethnographic approach to cultural competen ce will help practitione rs arrive at an understanding of an individuals culture (Bonde r, Martin, & Miracle 2001). Influenced by anthropological methods, the process of learning how to ask includes inquiry, reflection and analysis, and ev aluation and assessment thr oughout the interaction between patient and provider (Bonder, Martin, & Miracl e 2001). For instance, further inquiry into a patients background can include questions abou t social networks, and health beliefs of his/her particular health condition. A culturally compet ent healthcare system whose Hispanic population is twenty percent shoul d include Hispanic staff members who speak
24 Spanish and are trained in medical interpre tation, cultural sensitivity workshops for all staff, and patient education ma terials available in Spanish (R orie, Paine, & Barger 1996). Factors Affecting (or Related to) Cultural Sensitivity Some of the factors that hinder Hispanics access to health care are high cost of health care, undocumented immigration status fo r a large percentage of individuals, lack of health insurance, language barriers, a nd the unsuitable operating hours and locations of some health care organizations that cater to the Hispanic population (Chvez 1984). An understanding of the cultural issues surrounding a health care practice is essential in the provision of effective care and de livery of services. Language is a barrier to health care that affects many people, and can result in a patient never returning for health care. Several studies that conducted patient sa tisfaction surveys with Spanish speaking patients, as well as patients who spoke English found that Spanish speaking Latino respondents were more dissatisfied with th e provider communication than the white English speaking respondents (Carrasquillo et al. 1999 and Mora les et al. 1999). Difficulties in understanding a health situation can result in patients improperly following treatment regimens, not returning for fo llow up visits, requiring more unnecessary diagnostic tests, or being labeled as noncompliant (Singleton 2002). In addition to patients cultural barriers, organizational barriers also affect the degree to which a health care system exhibits cultural sensitivity. In order to be culturally sensitive, health care centers should ha ve interpreters onsite, or at least should have the ability to make them available as necessary (Betanco urt et al. 2003). Interpreters should be cautiously distingui shed from bilingual workers because they are specifically trained to interpret in medical settings and use medical terminologies.
25 Bilingual workers used as interp reters are often called ad hoc interpreters. Using ad hoc interpreters can result in many communicati on errors, including omissions, additions, substitutions, and abbreviations of what th e patient and provider were saying (Baker, Hayes & Fortier 2003). In addition, many ad hoc interpreters may permit his or her own cultural values and beliefs to distort the practitioners message and therefore inaccurately convey the message to the patient (Bonder, Martin & Miracle 2001). Many health care centers use untrained sta ff, such as front office personnel, or patients family members as interpreters. In addition, some clin ics use the patients family member to translate medical informa tion when an interpreter cannot be found. This poses a problem for the patient as well as the provider, who is expected to convey private health information about the patient (S ingleton 2002). Use of an interpreter raises issues of privacy concerns for the patient. Whether a patient knows the interpreter well, or not at all, he/she may be uncomfortable sharing his/her personal problems, and may be less likely to open up to the provider. In a ddition to not having ad equate interpretation training offered to staff, many health care organizations also do not offer training to providers on how to use an interpreter (Baker, Hayes & Fo rtier 2003). Often times, these approaches to interpretati on result in misunderstanding a nd miscommunication between patient and provider. Baker, Hayes & Fortier (2003) conduct ed a study with approximately four hundred Spanish speaking patients at a hospital to determine patients satisfaction with their provider and interprete r. They found that the pa tients who communicated in Spanish with their provider had higher sati sfaction ratings with their providers than patients who communicated with their provider th rough an interpreter. Their results also
26 showed that patients who used an interpreter perceived their provider as less respectful and less friendly. Furthermore, patients who did not have an interp reter, but believed they should have had one, had the lowest leve l of satisfaction with their provider (Baker, Hayes & Fortier 2003). While having an interpre ter is better than not having one at all, providers should be encouraged to make every possible effort to ensure a connection with their patient. In addition to having adequately trained me dical interpreters, health care centers should also have written information, incl uding administrative forms and educational materials that are culturally appropriate, written in low literacy levels, and properly translated in the common non-English language, such as Spanish. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to ma ke appropriate health decisions (National Library of Medicine 2000). In 1993, approximately one quarter of th e US population had marginal literacy skills. Most health education materials are written above a tenth grade level, even though many adults read below this level. Efforts to address low health literacy include assessing patients literacy le vels, revising education materials into plain language, and providing patients wi th oral and video instruction in addition to written materials (Singleton 2002). Models of Cultural Competence Like the many definitions of cultural competence that exist in the health care industry, so are there are a number of models of cultural competence that aim at helping an organization achieve or improve cultura l competence. There appears to be a consensus in the empirical l iterature which suggests that organizations progress through
27 developmental stages until ultimately accomplishing cultural competence. The specific stages that organizations must undergo are ye t to be in harmony, but there is an essence that progression is necessary. For this study, only a selected few models will be discussed to give the reader a sense of the kind of work that is published on the topic of cultural competence. The most widely cited model is th e Cultural Competence Continuum (CCC) (Cross et al. 1989). The CCC includes six hier archical levels of cultural proficiency. For instance, individuals or organizations that are at the cultural destructiveness level have attitudes of superiority and practices th at suppress other cultures. An organization that acknowledges cultural differences and is not destructive towards other cultures but still does not have the capacity to help other cu ltures is in the cultura l incapacity level. In this level, the organization still believe s that the Western health care approach is superior. Once the organization recognizes that Western medicine is not superior, it will begin to move from the cultural blindness level. Cultural blindness describes an organization that believes that there are no cu ltural differences. In the cultural precompetence level, the organization identif ies its weaknesses and seeks to improve efforts to become culturally competent. The cultural competence level includes attitudes of acceptance and resp ect of culturally different he alth beliefs and practices, active training of staff to be culturally comp etent, and institutionalized dimensions of cultural competence in the health care organiza tions policies. The final stage, cultural proficiency categorizes organizations that embrace diverse cultures, serve as role models, actively participate in cultural competence research and disseminate information.
28 This model extends the definition of cultural competence into serving the greater research and academic community. Similar to the CCC, the Cultural Devel opment Model (CDM) also includes six stages along a continuum that lead to cultural competence (Wells 2000). However, unlike the CCC, the CDM divides the stages into a cognitive phase and an affective phase. The first three stages of the cognitiv e phase are cultural incompetence, cultural knowledge, and cultural awareness. Once the organization recognizes and understands the cultural implications of health behavior, it moves into the affective phase. The affective phase consists of cultural sensitivity, which is the integration of cultural knowledge and awareness into individual and in stitutional behavior. The fifth stage of the affective phase is cultural competence, which considers organizations that habitually undertake cultura lly appropriate health care interventions. Finally, like the CCC, the cultural proficiency stage incl udes the institutiona lization of cultural competence, as well as teaching and researc h. Both the CCC and CDM consider barriers to progression through the levels or stages that lead to cultura l competence. Barriers such as lack of interpreters, lack of diversity am ong personnel, and lack of an understanding of the health beliefs of other cultures can prevent awarene ss and action (Wells 2000). Unlike the CCC and the CDM, The Process of Cultural Competence in the Delivery of Healthcare Services model assu mes that cultural comp etence is an ongoing, lifelong process, rather than a process that ultimately ends in cultural proficiency like the CCC and the CDM profess. The author of the model, Campinha-Bacote (2002), asserts that the development of the model wa s influenced by her nursing background as well as her interests in medi cal anthropology. Her influenc e from medical anthropology
29 is evident in one of the five assumptions of the model which states that there is more variation within ethnic groups than across ethnic groups (Campinha -Bacote 2002:181). The model consists of five constructs which are cultural awareness, cultural knowledge, cultural skill, cultura l encounters, and cu ltural desire. Spec ifically, cultural awareness is the aw areness of ones own background and the recognition of personal biases and prejudices of other cultures. Cultural knowledge involves understanding patients worldviews, as well as patients disease incidence and prevalence, and treatment efficacy. Cultural skill is the healthcare providers ability to obtain accurate cultural information related to the pa tients health problem. Cultu ral encounters is a construct that reinforces and supports pr oviders to interact with patien ts and refine and modify their existing beliefs about their patients cultural back ground. It is within this construct that providers are encouraged to evaluate patie nts linguistic needs to determine if an interpreter is in need. Lastly, cultural desire describes the providers motivation to fulfill the previous four constructs as wanting to become more culturally competent, rather doing it just to fulfill a requirement, for example. This construct emphasizes the providers genuine passion to be open and flex ible with others, to accept differences and build on similarities, and to be willing to learn from others as cultural informants (Campinha-Bacote 2002). Finally, Purnells Model for Cultural Co mpetence draws specifically from the field of anthropology, among other disciplines and emphasizes the dynamics of culture (Purnell 2000). The Purnell Model was develope d with the intention of being used by all health care disciplines across all health care settings. The model is based on nineteen major assumptions, which will not be enumerated in this paper. However, the
30 assumptions cover broad perspectives on cu lture, such as assumption number 3 one culture is not better than anot her culture; they are just diffe rent. The model also covers more specific assumptions, such as number eight if clients are coparticipants in care and have a choice in health-related goals, plans, and interventions, health outcomes will be improved. This comprehensive model stands out from the other cultural competence models because it takes the ex tra step to operationalize the often blurry term culture. Like most models, however, this model is not specifically aime d at one particular culture, but rather attempts to generalize the idea of cultural competence across cultures as well. Visually, the circular model is composed of rims which re present the global society level, community level, family level, and personal level. The interior of the model is composed of 12 pi e-shaped cultural do mains, such as communication, family roles and organization, nutrition, and death r ituals (Purnell 2000 a nd Purnell 2002). The models described in this section sta nd as evidence that cultural competence is not only a necessity, but also that it is r eceiving the attention required to impact the enormous health disparities gap. An examina tion of the various models reveals that there are many similar concepts that lead to cult ural competence. Both Camphinha-Bacotes model and Purnells model of cultural co mpetence involve detailed information and emphasis on the term culture, whereas the CCC and CDM emphasize the stages that lead to cultural competence. The CCC and the CDM serve as more practical tools that health care organizations can use to assess and trac k their own progress of attaining cultural competence (or cultural proficiency). Ideal ly, a model that combines the detailed attention to the concept of culture and all th e factors related to cu lture with a stagesoriented approach that can guide health care agencies to visually determine a starting and
31 ending point should be developed. In Chapter Four, a cultural sensitivity model for rural health centers with a large Hi spanic population is discussed. The model, which is based on the HC in this study, is intended to serve as a practical tool of cultural sensitivity for rural health centers (Figure 13). Summary With the growing number of non-English speakers, it is imperative that health care centers provide adequate tr aining to health care providers to improve and enhance communication skills, as well as to increase levels of knowledge and awareness of other cultures. This chapter discussed the issues rela ted to cultural sensitivity, such as patients culture, and biomedical culture. In addition, this chapter al so summarized the literature that documents the importance and necessi ty for cultural competence and cultural sensitivity in health care. Chapter Three outlines the methodology used to carry out this project, as well as the research quest ions that guided the data collection.
32 Chapter Three Methodology Introduction The process of investigation for this st udy is discussed in th is chapter. The research design was developed to understand the extent to which a rural health clinic is culturally sensitive. The data collection met hods used in this design were chosen with the intention of triangulating th e data. Triangulation is a rese arch technique that employs several different methods of data collection to cross-check the data and ensures that the data are valid and representative of the rese arch topic (Schensul, Schensul, & LeCompte 1999). A discussion of the internship setting, as well as the informed consent process is also discussed in this chapter. In add ition, ethnographic data co llection methods used, including open-ended interviews, observations, and archival records, and the path taken to analyze this study is also clarified in this chapter. Internship Setting The data for this project were collected at a rural health cen ter (HC) in West Central Florida. The HC is a not-for-prof it primary health care provider that offers comprehensive services in a rural town in Flor ida. The mission at HC is to provide all services in a culturally sensitive manner in order to promote healthy outcomes in the population [it] serves (Suncoast Community H ealth Centers 2002). Th e services that the HC provides are medical, dental, mental he alth, transportation, health education, pharmacy, and referrals. In 2003, the HC serv ed 12,000 patients. Approximately 59% of
33 the patients were Hispanic. Fu rthermore, 49% of all patients consider Spanish to be their primary language. Thirty percent of all HC patients are farmworkers and their families, while the remaining 70% are area residents. My role in the internship was part-time public health educator for approximately one year. My primary responsibility at th e HC was to implement a health literacy program. As a health educator, my daily tasks included assessing patients health behaviors, developing patient action plans, teaching diabetes and hypertension classes, and maintaining accurate records of daily activities. In addition, I also acted as a resource person for diabetes and hypertensi on information for patients and staff, and collaborated with health care staff to implem ent the health literacy study. Having worked at the clinic, I gained entre with staff me mbers and conducted participant observation. As a fellow employee, patients and staff were ab le to trust me and perceive me as not a stranger. The goal of this project is to define what cultural sensitivity means in a rural health center, from the perspective of the st aff as well as the Hispanic patient. Openended semi-structured interviews were c onducted with thirty-one Spanish speaking patients and twenty-one staff members. Research Questions The following research questions guid ed the focus of the research study: What does cultural sensitivity mean to patients? What does cultural sensitivity mean to HC staff? Does cultural sensitivity mean differ ent things to patients and staff? What makes a clinic culturally sensitive?
34 Informed Consent The USF Institutional Review Board (IRB) reviewed and approved this project. Staff members who participated in the inte rviews were asked to sign consent forms, which explained the project and informed them of their rights as part icipants of a study. Because most of the patients at the clinic are illiterate and undocumented, it would be inappropriate and unethical to ask them to sign a formal document. Consequently, the IRB granted a waiver of written consent from patients, and allowed patients to give oral consent. In order to obtain oral consent, I read the patient interviewees a shorter version of the consent form, which I wrote at a low li teracy level and translated into Spanish. The waiver of written consent did not affect the rights and welfare of the participants. I provided them with information about the study and assured them that their participation would not affect their healthcare and that their name would not be used to identify their answers. Interviews I conducted approximately fifty-two semi-s tructured, open-ended interviews with patients, front office personnel, medical as sistants, providers, a nd stakeholders in administration. Twenty-one staff members we re interviewed. The goal of the staff interview questions was to determine the exte nt to which staff members were aware of the term cultural sensitivity, what the term m eans, and their percepti on of how the clinic enforces cultural sensitivity. Unfortunately, the staff interview ques tions were not pilot tested because of the lack of time that the staff had to participate in the interviews. Thirty-one Spanish-speaking patients were interviewed. The goal of the patient interviews was to give the patients a voice and determine patients perceptions of what
35 qualities they seek in a clinic. While the main goal was to assess what cultural sensitivity means to patients, the interview did not dir ectly ask the patients that question. It is difficult to ask patients their opinion of cu lturally competent services when more than likely they have never heard that term used before. The questions focused more on the likes and dislikes of a clinic to determine patterns and themes that relate to cultural competence. I composed and translated into Spanish the patient interview questions. Two different Mexican American staff member s reviewed and corrected the translation for clarity, content, appropriateness, and literacy level. The patient interview questions were pilot tested with four Spanish-speaking patients. The patient interview consisted of sixteen open-ended questions and lasted approximately twenty minutes. Sampling For this project, a convenience sample of Hispanic patients at the HC was used. Participants were determined by criterion-based selection because the study aimed at understanding patterns and variab ility among Hispanics. The only inclusion criteria were that the patients must be Spanish speaking-onl y, and they must be patients of the clinic. In addition, patients must have been older th an eighteen years of age. Gender was not a factor in determining participation for this study. The only patients who were not eligible were those who did not speak Spanish and were not patients at the HC. They were not eligible because they were not the focus of the study. Unfortunately, the HC data system does not distinguish nationalities. As prev iously stated, there are many differences among Hispanics, such as Mexicans and Colomb ians. Ideally, patients would have been sampled according to their nationality. Howe ver, because average estimates of the
36 patients nationalities were not available from the clinic, sampling was not intentionally performed by different nationalities. In order to obtain an unbiased sample, I interviewed Spanish-speaking patients, as labeled by the front desk, as they entered the clinic at any given time. For example, I approached the front desk at 10 a.m. and attempted to interview the next Spanishspeaking patient who approached the front desk. While the patient waited for her name to be called, the interview was conducted. In terviews took place in a private room, where the patient could still hear if she wa s being paged by her physician or nurse. Staff members were determined for the interview process by way of a convenience sample. I approached the sta ff member and asked if they wanted to participate in the interview and whether or not they had time at that moment. If the staff member was interested but did not have time at the present moment, I scheduled a time that was convenient for the staff member. In terviews were conducted in private rooms. Observations For the observation component of the proj ect, previously recorded notes were used. I had previously observed patien t/provider interaction, patient/front desk interaction, and overall c linic atmosphere for a different project. Observation was chosen as a method because the interact ions between patient and provid er during a clinic visit are an important component in determining cultu ral sensitivity. During the observations, I closely observed how the doctors communicated with non-English speaking patients, and what efforts they made, if any, to address cu ltural issues. In addition, I also observed the interpretation process between the provider, the patient, and the interpreter.
37 Archival Records Administrative documents related to polic y, such as strategic plans, and records showing the accreditation process were reviewed. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) is an organization that establishes standards and renders accreditat ion to health care organizations. While it does not have a specific compliance standard that relates to cultural competency, it does have a section titled Patient Rights and Orga nizational Ethics. Under th is section, the question Are the patients treated as individuals with unique personal and health needs? is addressed. Ways in which the HC has attempted to address this standard to JCAHO compliance were explored. Small samples of the various health edu cation materials that are given to patients were also reviewed. The quality improveme nt manager acquired the health education materials from the clinic provi ders and passed them on to me for use in this study. Items related to cultural sensitivity, including av ailability of information in Spanish, and readability in Spanish guided the review pro cess. There are many different tools used to assess the readability level of reading materials. Because it is most used, I applied McLaughlins (1969) SMOG Readability Formula. Contreras et al (1999) conducted a study to that determined that the SMOG form ula is also valid with Spanish health education materials. Materials were also evaluated for their print quality and for the presence of graphics, which also aids low literacy patients to understand the information on the handout.
38 Analysis The interviews were not tape recorded, a nd therefore were not transcribed. The PI took notes on all interviews and typed the notes on the word processor. Notes were taken on what the participant said, using shorthand and abbreviations, and facial expressions and reactions in or der to accurately portray the context of the interview and the interviewee. A top to bottom analysis a pproach was used to code observations and interviews by categories and themes in order to determine patterns and recurring themes. The study data was inputted in to qualitative data analysis software, Ethnograph, which was later used to code, sort, and analyze the data. The archival data was reviewed for releva nce to cultural sensitivity policies. Each administrative record was reviewed and disc ussed in the results section. The health education materials were analyzed using the SMOG Readability Formula. The quality of the handout was evaluated using the categories legible or i llegible. The results were then displayed in a frequency distri bution to determine overall patterns. Limitations For this project, there were many limitations which one is likely to encounter at any time when conducting research at a very bus y rural health center. One limitation is that most patients were migrants, and proba bly had illegal residence status. Migrant workers who are typically marginalized do not have much trust for strangers and are apprehensive when asked to participate in a study. Some of the patients required a lot of probing and even then, they still did not want to talk very much. I tried as much as possible to get them to feel comfortable w ith me by explaining who I was and where I was from, and by helping them if they asked me for help (ie translating a document for
39 them). Unfortunately some of them did not voice their opinion fully. Another limitation is that I was at the whim of patients avai lability. If patients were called during the interview, they had to stop the interview proce ss. Some of them did not return to me to finish the interview. This happened with six patients. Those interviews were not considered for this project. Another major limitation was the staffs lack of time to participate in the interviews. Because there is a heavy patient load, they always seemed in a hurry. Furthermore, none of the staff members wanted to sacrifice their lunch hour or come in early or stay late for the interview. Theref ore, the interviews we re conducted while they were working, taking their fifteen or twenty minute break. This type of setting is not relaxed and not ideal for interviews. Neverthe less, I was able to get complete responses from all the interviewees. A further weakness of this study is that it focused on only one ethnicity, Hispanics. There are many other cu ltures that attend the clinic, and they all have their own individual health beliefs. Finally, one more weakness of this study was that I was not able to assess the cultural competence levels of the staff memb ers due to the time constraints with staff members. There are many instruments that he alth care organizations can use to evaluate the levels of cultural competence of the staff. In order to get a definite idea of whether or not the staff members are culturally compet ent, they should be evaluated using a validated instrument that precisely tests fo r cultural competence levels. This way the clinic can target where specific improvements are needed when providing cultural sensitivity training to the staff.
40 In a follow up study, it would be interest ing to measure the acculturation of the patients. Acculturation levels would be in teresting to know in the patient interviews because there might be a correlation between ti me living in the country and perception of whether or not the clinic is a good clinic. Bias Because of the time issue, the way I sampled the patient interviews might not be that representative because I only sampled t hose who were in fast track, where there is always at least a thirty minute wait. I was not able to interview patients with appointments because they were seen by the doctor right away. Another bias is my own, as a clinic em ployee. Although I did my best to be as objective as possible, it is unde niable that I brought in my own experience and my own biases to the project. Selection of the st aff members could have been biased because there is a possibility that those who interviewed with me may have felt more amiable towards me than others who chose not to engage in the interview. Summary This chapter outlined the research ques tions used to guide the data collection process. In addition, this chapter also disse cted the different forms of data collection methods used to address the re search questions. Finally, the analysis protocol was also discussed for each method of data collec tion, as well as the process of ensuring participants informed consent. The resu lts of these data collection methods are discussed in the next chapter.
41 Chapter 4 Results and Discussion Introduction In this chapter, the findings from this study are reported and discussed. Results are first grouped by type of data collection, th en by themes or topic. Where applicable, figures are provided to illustra te the frequency distribution of the data. The research questions are also addresse d throughout this chapter. Patient Interviews Demographics In May of 2003, 59% of the to tal population of patients at the HC was Hispanic. In addition, almost half of the patients spoke Sp anish. For this projec t, a total of thirtyone patients were interviewed. As seen in Figure 1, roughly 75% of the respondents were from Mexico, the remaining 25% were from El Salvador (n=2), Guatemala (n=2), Puerto Rico (n=1), Peru (n=1), and Brazil (n=1). Note: The patient from Brazil was interviewed in Spanish. Figure 2 shows how twenty-three (74%) of the interviewees were female. Approximately 39% of the interviewees were between eighteen to thirty years old, 32% were between thirty-one to forty years old, 26% were forty-one to fi fty years old, and one patient was over the age of sixt y-five. None of the patients were between fifty-one and sixty-four years old. A distribution of the respo ndents ages is illust rated in Figure 3. In terms of insurance, the majority of the pati ents sampled (71%) did not have any type of insurance. This is representative of the genera l clinic statistics, in which two-thirds of the
42 clinics population is migrant workers, most of whom do not have medical insurance. The remaining 30% of the interviewees we re evenly distributed as either having Medicaid (n=3), county insuranc e (n=4), or private insuran ce (n=2). Fortunately, there was a fairly even distribution of the length of time that th e patients had been attending the clinic (Figure 4). Furthermore, there was no difference in the responses between those patients who had been attending the clinic for many years, and those who had just started coming to the clinic. One-fourth of the re spondents reported that they had only been coming to the clinic for less than one year. Sl ightly more patients (29%) said that they had been attending the clinic anywhere from one to five years. Another 25% said they had been visiting the HC between five to ten years, and 19% said they had been going to the clinic longer than ten years. One inte rviewee reported that she had been coming to the clinic for eighteen years, while another patient, who had been attending the HC for five years, said that since she arrived [to th e clinic], they made [her] get to know this place. 0 20 40 60 80 100 Mexi ca n Sal v adorian Guatemalan Pu ert o R ican Peruvian B ra zil ia nFigure 1: Ethnicity 0 20 40 60 80 100 FemaleMaleFigure 2: Gender
43 0 20 40 60 80 100 < 1 y e a r 1 5 y r s 5 1 0 y r s > 1 0 y r sFi g ure 4: Len g th of Time Coming to the Clinic 0 20 40 60 80 100 18-30 yrs31-40 yrs41-50 yrs51-64 yrs>65 yrsFigure 3: Age Distribution 0 10 20 30 40 50 60 70 80 90 100 A t t e n t i o n L a n g u a g e F i n a n c i a l A s s i s t a n c e S o l u t i o n H i s p a n i c sFi g ure 5: Positive Clinic Attributes
44 Within this subsection, the results of the patient interviews ar e presented. This section reviews the answer to Research Questi on #1: What does cult ural sensitivity mean to patients? Because the term cultural sensitivity is a foreign word to most patients, the interview question aimed at finding out what qual ities patients look for in the clinic. The qualities, according to the in terviewees, are 1) attention; 2) language; 3) financial assistance; 4) solution; 5) Hisp anics; and 6) clinic services In addition, the results of what patients do not like about the clinic, wh ich is the long wait, and their perceptions on health education materials are presented a nd discussed. Patients also offered their suggestions for ways to improve the clinic. Th e results of their comments are also listed in this section. What Patients Like About the Clinic The distribution of the following factors is illustrated in Figure 5. Attention Overwhelmingly, 65% of the patients repor ted that they are pleased with the attention that the staff gives them. These fi ndings confirm other stud ies which show that patients value the attention that staff gives them and associate that attention as a sign that the health care provider cares for him/her (Zoucha 2000). Responses within this theme ranged from feeling like they are taken car e of, treated right, served well, and looked after. For instance, one patie nt who had been coming to the clinic for five years said, They treat me well. In all my appointment s when Ive come here, they have always welcomed me. Another patient describes how attentive the staff members are when she said, What I like about this clinic is that they care about their pa tients because they look for them, they call them. A different patien t gladly offered her praises of the clinic
45 when she stated that another thing [she] like[s] is that theyre always trying to take care of [patients], even if [they] miss an appoint ment. Theyll always call, theyre always concerned. A critical factor that keeps patients coming back to the clinic is that they feel like they are not neglected, but rather nurtured and respected. Language Slightly less than half (48%) of the patie nts interviewed responded that one of the characteristics that they like about HC is that the staff members speak Spanish. Spanish is the primary language of over 50% of the clin ics patients. Many patients felt that [the staff] know[s] [their] culture because they speak Spanish. According to patients, speaking Spanish is directly re lated to understanding Spanish culture, which in turn made them feel comfortable receiving health care fr om the staff. Speaking Spanish fluently typically grants a person access and sensitivit y to the dynamics of the culture which many Hispanics share. Cultural nuances such as respeto familismo and personalismo are intertwined with the Spanish language. For instance, when asked to talk about the reasons that they feel th e clinic does or does not unde rstand the culture of most Hispanics, 39% of the patients answered that the clinic is knowledgeable of their culture because there is a lot of people that speak Spanish. One patients response for why she feels comfortable coming to the clinic is an example of the strong connection between language and culture: Before I was very scared, because th e doctors were very direct, they didnt know how to tell you things, a nd one would feel bad. But when one knows how to talk to you, they espe cially say it more gently. If you returned, they would scold you. Now the majority speak more. Also, before you always had to bring an interpreter.
46 Many patients simply felt that they li ke the clinic because the staff speaks Spanish. The existence of a Spanish speaki ng staff is something that most patients mentioned in their interview. As one patient stated, the majority of people speak Spanish. I dont leave with any doubts. I ask them and they an swer me. In fact, all of the medical assistants at the HC speak Spanish fluently. The reality of the quality of health care that Hispanics receive, especially those who do not speak English, is daunting. Many health care workers do not speak Spanish, and either do not have an interpreter at all, or do not have one that is properly trained to interpret medical information. When the pa tients were asked how their communication was with clinic personnel, all patients, with the exception of one person, said that the communication between them and their provider and medical assistant was fine. Many patients commented that if their provider di dnt speak Spanish, they always had an interpreter who did speak Spanish. One patient felt that the interpreter was not paying attention to her, and therefore she did not ask the docto r the questions that she had. One of the patients who had been coming to the HC for nine years touched upon this reality when asked in what ways the clin ic makes her feel comfortable. She shared a story about why she lik ed the clinic. [The HC staff] is nice. I like the mi dwife. The other midwife from Joyce Ely doesnt speak Spanish and I felt bad because she told me that I had to be operated so I wouldnt get pregnant and I felt that was wrong for her to tell me that. So I came here, and I told the midwife the symptoms I was feeling, como Mexicanos , like Mexicans, the shakes, and she told me everything was okay. I later found out that I could take a different type of birth control and not have to be operated. This patients story is repr esentative of the experience of many other migrants and nonEnglish speakers. In the case of this patient, there was obviously a lack of
47 communication between the patient and provide r because of the language barrier. Many patients also feel more open to discuss th eir symptoms and medical concerns if they know that someone will understand them. One pa tient stated that she ask[s] everything because [her doctor] speaks Spanish. Anot her patient demonstrated her commitment to the HC when she stated, We understand the do ctor, thats why I come all the way over here from Lakeland. One patient described an in cident that happened to he r over four years ago. She explained: [the doctor] was checking my heart, right as I started coming to the clinic. They gave me medicine that I didn't need. It wasn't for my condition. It could have been because they might not have understood the symptoms that I told them. Later, they just told me to throw that medicine away. Her response depicts the reasons why the existence of properly trained medical interpreters is imperative in order for health care centers to become culturally sensitive. Financial Assistance Approximately 45% of the respondents e xpressed that the c linics policies of financial assistance is one of the reasons why they feel comfortable coming to the clinic. In terms of financial assistance for patients, the clinic has a strict policy of not turning anyone down because they can not afford medi cal care. The clinic operates on a sliding fee scale. There are financial counselors who counsel patients to determine whether they are eligible for Medicaid or county insurance. Patients who are not eligible for government subsidized insurance are classifi ed into different pay categories, based on
48 their income. For instance, when asked if she has ever had trouble receiving medical care at the clinic, one patient said: No, because I didnt know that my Me dicaid expired. They sent me to the financial counselor and she gave me a chance, and they took care of me even though I only had eight dollars. Here theres more availability, because other places tell you Im sorry, come another time. Medical and dental care is available to all patients, even if they can not afford to pay for the services at the time they are rende red. Other services such as prescriptions are offered at low prices, while others su ch as transportation, outreach, and health education are completely free of cost. One of the patients confirmed the clinics policy when she stated that there are good doctors. Sometimes if one cant pay everything at the moment, one can say Ill give you this much money on this date. Another patient articulated her appreciati on for the clinic when she said here there is a [financial] plan that they can he lp you out according to your salary. That is a big help. Theyve always treate d me well and given me a hand. An essential component of culturally sensitive health care is making services accessible to all patients. One patient repr esented the voice of the migrant community when she stated that they say that this clinic is for migrants. When it rains, we dont get paid, and this clinic helps in that manner. The HC accommodates migrant workers, who are not only uninsured, but also whose incomes are not always consistent or reliable, with their flexible financial policy. Solution Curiously, a significant number of patie nts (42%) conveyed that one of the reasons why they continue to come to this clin ic is because they are offered a solution, or a prescription, to their medica l problem. Precisely phrased, one patient said what she
49 liked was the effectiveness, every time that [she has] come with a problem, they have given [her] a solution. A few of the patie nts (n=3) expressed satisfaction that their children received a prescription and felt better One patient declared that [she] [has] never wanted to change to another clinic be cause they give [her] medicine. When [she] brings her baby sick, they take care of him. Another patient asserted her views when she said, What I like they give me medicine and cure me. I come with all kinds of problems and they help me. Theres nothing I dont like. Finally, one patient iterated her feelings about why she doesnt go to ot her clinics when she stated I dont know the pediatrician well. The pediat rician before was very good. She tended to us very well, she gave me prescriptions, and she was very good. When I go to othe r clinics, they dont give me prescriptions. Presence of Hispanics Twenty-nine percent of the patients in terviewed reported that the presence of Hispanics all over the clinic is what they like. Some patients commented about how the HC tends to so many other Hispanic patients. For instance, one patient said they know us well because Hispanic people have been coming for so long., and that is why they continue coming. Other patients remarked on th e large percentage of Hispanics that work at the clinic. Clinic Services Unexpectedly, only 3 patients, 10%, name d the availability of transportation as one of the reasons why they lik e coming to the clinic. One of the leading factors that obstructs migrant workers from attaining heal th care is lack of tr ansportation. The HC
50 offers this service free of charge to all pa tients who need it. Several of the patients expressed their gratitude for transporta tion. For instance, one patient said: What I like. That's hard. The services that they offer. When they go to your house, when you don't have a car, when I don't have money, they still offer you their services. Don't like. Well, nothing, I like everything. Another patient said I feel great here because I have a special child I bring here with me and when he has to go to Tampa, the van takes us, so I have no complaints. Patients did not recognize any other clinic services as reasons for why th ey come to the clinic. In essence, although there were onl y three patients that discusse d, if briefly, transportation, it demonstrates the importance of having that service available. What Patients Do Not Like About the Clinic This section discusses the re sults of what patients do not like about the clinic. Half of the respondents felt that there is nothi ng that they do not lik e about the clinic and that everything is fine. Only a couple pati ents had specific complaints or needs, such as the bathrooms needed to be fixed, and the need for another clinic closer to Tampa. However, more than half of the patients co mplained about the long wait time when they come in for services. Long Wait The HC sees patients with and withou t appointments. Patients who have appointments generally do not have to wait more than twenty minutes to be seen. Those patients who do not have appointme nts are directed to fast trac k. There is always a long wait time in fast track. Patients can expect to wait at least three hours, if not all day, to be seen by a doctor or nurse pr actitioner. Slightly over half of the pa tients (55%) interviewed responded that they do not like the long wait that is constant at the clinic. It
51 is important to note that all of the patients who were interviewed for this study did not have appointments. They had to wait a long tim e to be seen by the doctor, which is what made it possible to conduct the interviews for this study. Many of the patients were passionate when they conveyed their dissatisfaction with the long wait time. For instance, one pati ent said, I get so a ngry. I get here at 9 a.m. and I dont leave until 5 p.m. They should send me home and tell me when to come back. They know better when its my turn. Similarly, other patien ts complained about not being able to eat or make other plans fo r the day because they had to spend the entire day waiting for their turn in the clinic. One patient voiced her opinion when she said that the staff should communicate with patients, say you know what, we have a lot of patients, but come back in one to two hours. So I can get stuff done. They should tell patients how long theyll wait. Many patients dont talk because theyre afra id, so they wait all day. Another patient, who was also annoyed w ith the long wait time, said that they should respect peoples times. You have an appointment for two to three months, and then when you come, they cant even attend you in time. Along the lines of respect, another patient also felt that they make [p atients] wait every single time. They dont respect [the patients]. Ot her respondents (23%) reported that they have heard other patients complain about the long wait. Some patients criticized the long wait time and asserted that since they make [patients] wait so long, it makes [patients] not want to come. [Patients] have to wait too long. Although many of the patients complained about the long wait time, a few of the patients expressed their tolerance because th e benefits outweigh the drawbacks. For example, one patient who felt there are no ba d things at the clinic expressed that It could be the long wait, but one has to unde rstand that that is normal.
52 When asked whether they had ever expe rienced problems receiving medical care at the clinic, 93% of the patients expre ssed that they had never had any problems receiving medical care. Only two patients had specific complaints about the providers who treated them. Accordi ng to one of the patients, she has heard other patients complain about a provider bei ng too harsh and antagonistic. Patients Suggestions for Improvement One of the questions in the interview asked patients what they felt should be improved at the clinic. The majority of the pa tients, 14%, either did not know or felt that everything was fine at the clin ic. Thirty-two percent of the patients confirmed that the long wait needs to be improved. Other s uggestions for positive changes included increasing the number of doctors, fixing the bathrooms, and having a seminar on customer service to improve employees att itudes. One patient had a suggestion for improving the clinic when she stated: What I like. We work in the "campo", if we get out late, we have a day that it is open late. Sometimes if th e day care says my daughter is sick, then we can run over here. But we woul d like it if they c ould be open late another day. Up north they have tw o days they open late you know, since we work late. It would be great if they could be open on Saturdays. Patients Perceptions of Wheth er the Clinic Understands the Cultural Values of Hispanics The majority, 90%, of the patients interviewed believed that the clinic does understand and have knowledge of th e cultural values that Hispan ics share. Nearly all of the reasons were because most of the staff speaks Spanish and is Hispanic. For instance, one patient explained:
53 The customs are in the language. Yes, they understand our customs, because the doctors, knowing the lan guage, can answer your questions, because the customs are in the langu age. When you come from Mexico, you come with a ton of pills and they know that thats the custom that we Mexican have. But I think they do know our culture. Another patient responded that they have al ways treated [her] with respect. When [patients] come from the campo [the field], [they] are dirt y. The people from [the HC] know that [patients] work in the fields. The small percentage of patients who did not feel that the clinic understood their culture stated that they dont understand. They are different. They are accustomed to one th ing. For example, I dont know if my doctor will like me or not because Im Hispanic because theres a lot of racism. Patients Perceptions on Educat ional Information Handouts The availability of Spanish materials is one of the key components of a clinic that is culturally sensitive. Administrative forms, educational information passed on to patients, as well as prescripti on information should be availa ble in Spanish. One patient said I like them. They give me the medicine in Spanish. They explain things to me in Spanish. Everything is in Spanish. When patients were asked how they feel about the educational information that the doctors or nurses occasionally give to them, 70% said that they felt fine with the educational information. Very few patients elaborated on this question, even after probing. A few patient s acknowledged that they understood [the information] because they give it to [patie nts] in [their] language. The remaining 30% of patients said that they had never been given any handouts. Staff Interviews This section addresses the results of the interviews conducted with HC employees. The interview questions addressed Research Qu estion #2: What does cultural sensitivity
54 mean to HC staff? Related to this question, the inte rviewees were surveyed about the extent of their training and what type of tr aining on cultural sensit ivity they have had. These results are also discusse d in this section. Staff also proposed their ideas for improvement and proclaimed their opinions on the health care needs of migrant workers in general. Demographics A total of twenty-one HC employees were interviewed. Five of the respondents were administrators, five were doctors or nurse practitioners, and eleven were staff members, such as front office personnel and medical assistants (Figure 7). When asked to describe their job at the c linic, some of the interviewees simply stated their position, while others described their job. Those that described their job provi ded insight into the general attitude of the workforce. For inst ance, one provider said he go[es] above and beyond to help get medicines, acquire medici nes, [and] get the best deals. Another respondent, whose job involves constant contact with patients, commented, I love my job, I deal with patients, they talk to me, I love being around people. 0 20 40 60 80 100 Adminstration Prov id er StaffFigure 6: Distribution of Occupations 0 20 40 60 80 100 1-5 yr6-10 yr11-20 yr >21 yrFigure 7: # Years Working at the Clinic
55 Forty-eight percent of th e interviewees had been working there between one to five years. Another 24% had six to ten years experience at the clinic. In addition, 24% of the respondents had been working there betw een eleven to twenty years, and one staff member had been working at the clinic for twenty-six years (Figure 7). In terms of the employees backgrounds, 33% were Anglo-American, 29% were Mexican, 29% were Hispanic non-Mexican such as Puerto Rican and South American, and 10% were Philipino and Indian. This sa mple is representative of the general staff demographics. Based on my participant obs ervation, which spanned over one year at the clinic, 100% of the medical assistants were bi lingual. Many of them were raised in the same community where the clinic is located. Two providers out of seven providers were bilingual and of Hispanic descent. The remaining providers utilized their medical assistants as interpreters. 0 20 40 60 80 100 A ng l o A m eri ca n Mexican Non-M exican OtherFigure 8: Staff Ethnicity
56 Cultural Sensitivity Training Approximately 29% of the staff member s had never had any kind of training on cultural sensitivity. Another 33% of the interviewees had not had formal training on cultural sensitivity (Figure 9). Rather, they reported that the only kind of training they have had on the topic is through experience. One staff member who identified herself as Mexican emphasized the lack of training that she had in nursing school and the importance of hiring staff members that shar e the same culture of the patients. She responded that the only cultural sensitivity training that she has had was being brought up in church, morals from [her] parents a nd community. Teach you what you believe in but you dont disbelieve in what people thi nk. In nursing they give you a book with a couple of paragraphs. Twenty-nine percent of the staff interviewed said that they had either been trained in school or they read their own literature on the subject (Figure 9). The HC human resource department offered training according to only 24% of the respondents. Nineteen percent of the interviewees stated that they learned how to be culturally sensitive from their coworkers. Th ree respondents felt that they followed their instincts when it came to cultural sensitivity. As one staff member said, its more or less common sense how you would want to be treated. When asked how often they receive trai ning, more than 50% of the staff members reported that they receive no training, or not often. Twenty-f our percent of the interviewees said they receive training year ly, and 14% said they receive training every day. Those who said they receive traini ng every day felt that being in the work environment trained them on how to be sensi tive to other cultures. One staff member said
57 everyday you work, thats training. You learn from patients, patients bring medicine from Mexico, they trust their doctor, and we have to accept their feelings about what is good in th eir country is good here. I think to myself at least they are using something. One member of administration explained the clinics policy on cultural sensitivity training: Everyday. Every employee gets it upon orientation. We talk about it periodically every 6 months. Our polic y is built around cult ural sensitivity because it is so important to all cu ltures. How they approach getting health care starts at the front. Immediately we don t turn away. We show were understanding of the situation th eyre in. Policies, ethics, start there. Health care practices, health education, try to build that around their beliefs their views of authority, health diet, etc. Try to do all to make it available and open. As for disease management and medicines they take, we gear everything and ensure that our staff is sensitive to that. Inconsistent with the administrators re sponse, only 24% of the staff mentioned that they had received cultural sensitiv ity training with human resources. 0 20 40 60 80 100 Y early Ev eryd a y No n e or not o ftenFi g ure 10: Extent of Cultural Sensitivity Training 0 20 40 60 80 100 E xpe rience S ch o o l HR In s tinc t Seminars Coworker N o n eFi g ure 9: Kind of Cultural Sensitivity Training
58 Medical Interpretation Training Only two out of eleven medical assistants reported that they had received training on medical interpretation. In support of th e idea that medical interpretation training should be required at the clinic, one of th e providers commented, We have assistants that translate, and most of the time it helps, but sometimes they have limited experience in medical terminology so I ask patients mo re questions and get the answer Im looking for. Although all medical assistants are bili ngual, if they are not properly trained in medical interpretation, they are not aw are of medical terminology, communication techniques, and the role of an interpreter. Staffs Perceptions of Cultural Sensitivity Definition of Cultural Sensitivity There were two purposes of asking staff members to define the term cultural sensitivity : to determine whether employees ha d heard of the term, and explore the different definitions of the term. All of the staff members were able to define cultural sensitivity in some way. Although there was no c onsensus on the definition of the term, most definitions involved one or more of the following descriptions: action, understanding, knowledge, respect, and sensitiv ity. Seven respondents included an action word in their definition, such as using appropriate language and mannerisms and trying to find somebody to help them w ho speak their language. Six people also included having an understanding of another persons culture in their description of cultural sensitivity. For instance, one definition given was People, they feel they belong to a certain culture, feel o ffended by other cultures or by ru les or hospital policies from this country, we try to unde rstand their culture, have to be very sympathetic. Three
59 interviewees included knowledge as a component of cultural sensitivity. For instance, one person said cultural sensitivity is knowing where people are coming from, whether poor, middle class, or wealthy, and trying to understand their ethnic background. Other descriptions of cultural sensitivity included b eing sensitive to different cultures in the area and respecting beliefs of the person. One provider expressed how important cultural sensitivity is when she said: you have to see and know ideas of patient culture know which country they came from, what are the norms for them, their food, their dress, traditional culture for delivery, beliefs, what mother in law wants patients to do, what medicine they are used to taking, sometimes you have to respect their idea or educate them because the home environment sometimes will not allow them to take treatment. Although it is beyond the scope of this study to perform a linguistic analysis of the term cultural sensitivity and all of the forms of the definition given in the interviews, it is possible to determine that staff members ar e aware of the term, and sufficiently know what it means. As was expected, members of the administration team had a much more clear idea of what cultural sensitivity meant. Their definitions were more holistic and went beyond the basic definitions that other staff members provided. For example, one administrator gave the definition as Ones insight and understanding of a nothers responses and actions based on the values that they have learne d or developed from their family, towns, or country. Accepting of it. Not necessarily accept it but be aware that it exists and use it in dealing with people aware of their customs. Why Be Culturally Sensitive? Staff members were asked wh ether or not they felt that cultural sensitivity was relevant to the clinic. Of all the respons es, 48% believed that the clinic should be culturally sensitive because of the diverse popula tion that attends the clinic. For instance,
60 one staff member said that because the HC [has] many different pe ople from different economic backgrounds, and education levels, thei r intellectual attitude about health care can vary, according to how their culture define s them. Slightly less than one-fourth of all the interviewees believed that cultural sens itivity is essential, otherwise patients will not return to the clinic. One staff member reinforced the importance of cultural sensitivity when she said this is the place where most of the community comes. They come sick and we have to treat them how we woul d want to be treated. We have to be sensitive. Every person is different but we have to be that way for the community so they can come see us. Another 14% of the respondents believed that the only way th at the clinic can achieve compliance is by being culturally se nsitive. As one administrator pointed out if an individual comes from a culture where they believe certain disease comes from A and youre not doing A, th en the treatment course might not respond or they might not engage in tr eatment at all. If you dont realize whats playing in the background, th en you might ruin the chance at getting well. Staff members were asked to describe the ways in which cultural sensitivity affects health. Approximately 33% of th e responses believed that there was a relationship between cultural sensitivity and pa tient compliance. For instance, one staff member responded: compliance if you try to explain the reason you are doing it, in spite of whats on their mind, theyll comply b ecause they know the reason. If its adjusted to their culture they comply. Just like diet. The policy of this clinic is cultural sensi tivity take anybody whatever income or culture. Open to any culture. Another 38% of the responses recognized that cultural sensitivity affects health outcomes. A nurse commented that people te nd to get healthier sooner if you let people believe in whatever it is that they believe. It helps them heal faster. One provider
61 expressed her conviction on the value of cultura l sensitivity when it co mes to health when she declared tremendously because they can bring disease under control and reduce their chances of heart attack. Emotionally they are tuned in with you. They trust you more. Similarly, 19% of the responses fe lt that cultural sensitivity affects health because patients will have more trust on the health care team, which will ultimately increase health outcomes. Fourteen percent of the staff members di d not feel that there was a relationship between cultural sensitivity and health outcome s. This could be because there is not a strong emphasis on cultural competence or cultura l sensitivity training at the clinic, as supported by the statistics from this study. Fifty-seven percent of the interviewees responded that they had received either no tr aining or not often on cultural sensitivity. Those who did not acknowledge a relationshi p between health and cultural sensitivity exemplify the lack of clarity of the term, and the need fo r greater understanding of the purpose and reason for achievi ng cultural sensitivity. Cultural Sensitivity in Action Staff members, providers, a nd administrators were asked to discuss in what ways they practice cultural sensitivity. This was the key question in the interview because it allowed respondents to contextualize their unde rstanding of the term cultural sensitivity. All of the respondents, except two, showed ways in which they were culturally sensitive. Only two respondents replied th at they practice cultural sens itivity training by treating everybody equally and not being different with anybody. When one understands and is aware of the dynamics of different culture s and how they influe nce patients health beliefs, then one can customize the approach that each person receives on an individual
62 basis and attain justice. Ninety percent of the interviewees demonstrated that they understand and are aware of the cultural values that Hispan ics share and explained how their behavior embodied the meaning of bei ng culturally sensitive. Unfortunately, it is not possible to present all of the responses in this paper. However, a chosen few can portray the magnitude to which the HC is cu lturally sensitive. A Mexican staff member responded: when I see patients, I see where they come from, I am sensitive to their feelings and beliefs, etc. People don t believe in receiving prenatal care cuz they dont see the midwife until la bor in their country, so I have to educate them. I do a lot of education, get to their level of understanding. Thats the challenge. I use simple wo rds and make them to repeat what I said, at least a sentence because some times they speak little Spanish (if they speak a native dialect). One staff member shows how she is culturally sensitive when she says that When you have Mexican children, you are supposed to touch them because if you dont, you have envy. I speak Spanish so that helps. I dont want to offend people, so I use words theyre comfortable with. I gear vocabulary to their level of understanding. One member of administration provided this explanation: As Im thinking of a special treatmen t or regimen, I ask myself is this something the patient w ill intellectually agree with? Will they buy into it? Ask my medical assistant if th ey think theyll agree. I use my experiences and employ them in my thought process to help me decide. Another staff member illustrates awareness of her own culture and how that can affect cultural sensitivity when she stated, We all have different cultures, with different expressions, so we have to be careful the wa y we express ourselves to not offend them. In the time Ive been here, Ive adapted to the way I behave around them to make them comfortable.
63 All of these responses, in addition to thos e not reported in this paper, show that the staff members at the HC are aware of the term cultural sensitivity, whether it be intuitively or intellectually. The fact that they adjust their behavior based on a persons culture confirms that they know the culture. Staffs Awareness of Hispanic Values and Health Beliefs Although the question was not specifically asked, many staff members expressed their awareness of Hispanic values and hea lth beliefs. For instan ce, one nurse showed her awareness of Mexican health beliefs when she said thi ngs like umbilical cord, they put bands around them, as long is it stay clean and doesnt hurt the baby, I respect their beliefs. Anothe r provider said: With the female population, most Latin as appreciate touch, eye contact, humor. I try to deal with them in wa ys that they are comfortable with. With males, they are more reserved with language and mannerisms, until I gain trust. So I tend to be more rese rved and try to be more professional. Talk about my personal life. Keep ing it medical, collegiate, dont just keep it on that level. Also talk a bout their personal and home life. Not just about health. Another nurse commented on Mexican health beliefs: most of our patients come in with their beliefs. Weve been known to have patients who believe they had evil eye and we honor that. One time I had a patient that died, two year old when he came to the clinic, and the mom insisted it was evil eye. We as Mexican dont believe in having pelvic exam if lady is a virgin, we ha ve to honor that, we have all kinds of religions coming in. Respeto is a value that many Hispanics share, and one that has a great impact on health care. A provider w ho has a clear understanding of respeto would know that doctors are regarded with utmost respect, and that the eldest male member of the family and/or father is the head of household. One provider showed hi s awareness of the concept of respeto when he said its imperative to understand if they dont look you in
64 the eye, its not disrespect but being respectab le. Another medical assistant describes her awareness of the Hispanic value of respeto when she said: If a patient comes, sometimes the husband wants to speak for the wife. If you are gonna give them care then you have to get used to it. Sometimes I know where theyre coming from. The stuff they use. I learn from them, ask questions when it comes to medicines. They bring their own stuff. I try to understand why they use what they use. You might think its dumb but thats just them. I try to unders tand where they come from (beliefs, background, etc.). Staff Perceptions of How the Clinic Practices Cultural Sensitivity Staff members were asked to describe the ways in which the clinic did or did not practice cultural sensitivity. The largest pe rcentage of responses, 43%, named language as the key reason for why the clinic was cultura lly sensitive. This is consistent with patients responses of what they like about the clinic and what keeps them coming. However, there are other dimensions of cultura l sensitivity that the clinic does exhibit, though not to the same extent as language. For instance, other staff members responded that the clinics flexible financial policy make s the clinic culturally sensitive. Only one staff member suggested the availability of tr ansportation as a reason for why the clinic is culturally sensitive. Thirty-eight percent of the respondents stated that the clinic is culturally sensitive because of the way it treats patients, either respecting their beliefs, treating them equally, or doing things the patients way. Fo r example, one staff member asserted: I see [cultural sensitivity] every day that Im here. They dont get in the patients business. They dont dictate to patients how to live their lives. Having bilingual employees, handouts in English and Spanish, having medical assistants that speak Spanish in every single doctors office, we celebrate 5 de Mayo which Im sure other clinics dont do.
65 One provider who doesnt speak Spanish commented: Overall, everybody is trying to respect patients feelings. We even go to the extent if they bring medicine back from another country, we go to this book in the pharmacy and see if we can find the equivalent. Educational materials in Spanish, handouts we give and if we dont, we try to make sure they have a son/daughter who reads English. Sometimes patients bring us Spanish foods and we accept that happily in order for them to trust us, that we can mingle with you They bring me presents, I display them to make them happy that yes, we appreciate them. In a separate question, staff members we re asked to specify how they think the clinic tries to overcome patients barriers to he alth care. This question was asked to elicit responses from staff members w ho might not have had a clear understanding of the term cultural sensitivity. Interestingly, the results from this question were different than the results from the question on how the clinic prac tices cultural sensitiv ity. Essentially, both questions were the same because the goal of cu ltural sensitivity is to alleviate patients barriers to health care. Where almost half of the responses believed that language is what makes the clinic culturally sensitive, only 24% of the respondents named language as a factor for how the clinic tries to overcome patie nts barriers to health care. For instance, employees mentioned the existence of bilingual workers and bilingual pamphlets. The difference in responses can be attributed to an unclear idea of what cu ltural sensitivity is. In addition, some staff member s may not view language as a barrier to health care. When asked how the clinic minimizes pa tients barriers, just over 80% reported various services that the clin ic offers. The most frequent clinic service named that overcomes patients barriers was transportation. For instance, one pers on articulated that
66 Because sometimes its hard to reac h [patients], I think teaching them, through leaflets. Transportation, we re a free clinic, based on their income. We let them know this. Bu t transportation is the big problem. We have people who go out of their way to pick them up, like employees, we will go find them if something is wr ong with the test results. One way or the other, well do our best. Staff members mentioned that having all the services available in one location helped patients receive better health care. Other se rvices mentioned include referrals, health education, and outreach. More than half the staff, 62%, also pointed out that the clinic helps patients overcome barriers by providing financial assistance, whereas only 14% named financial assistance when asked how th e clinic is culturally sensitive. These results may also suggest a cloudy comprehensio n of what cultural sensitivity means. How Staff Members Would Measure the Impact of Cultural Sensitivity Slightly less than half, 48% of the staff in terviewed believed that the way to determine whether or not cultural sensit ivity is having an impact on health outcomes is to monitor patients compliance and health results. Fo r instance, one person responded, If theyre keeping up with their medications and losing weight like theyre told to, its by them coming back to us and you only see the differe nce as they come back. Another staff member replied, They heal faster and recover at a faster pace, measured by the time that it takes to heal. Four interviewees, 19%, be lieved that patients testimonies are the way to determine if the clinic is culturally se nsitive. One informant stated, every day we receive new people that say my people sent me here, stuff like that. Another person answered, Patients testimony theyll come back and tell us. We made an impact in their life and in their situation, and the fact that they come back.
67 Is There Room for Improvement? HC employees were asked if they felt ther e were any barriers that kept the clinic from being culturally sensitive. Eight employees, 38%, responded that there were no barriers. The remainder of the staff members re vealed a number of barriers to health care at the clinic. Two employees recognized that a major barrier to pr oviding optimal health care to patients is a tight budget, or lack of funding. One pers on criticized the health care system when she said that it has turned into a thing of money. Another employee expressed that Sometimes [the clinic] can really be so focused on the finances that we lose sight of individuals falling t hough the cracks. Unless we start probing, there are people that dont come to the window because they dont have money. Were not open on weekends. We should take a mobile van to Wimauma. But thats not cost effective. Two employees mentioned that the clinic hour s, such as not being open on weekends, are barriers to patients. One nurse contextualized the patients perspective when she stated More financial help, longer clinic h ours. I wouldnt mind so as long as our people would be seen. There is such a need for night hours and weekends for our patients that wo rk. Coming from that background, we did without because my dad was the one that drove and he worked late so we never went to the doctor. Another medical assistant expressed the plight of migrant workers when she said a lot of people dont want to miss work, thats why theres non-compliant patients, but theres no way to help them, a lot dont want to mi ss work because theyre on a budget. Other barriers cited include not havi ng enough time with patients an d a lack of diversity among administrators. Employees offered a variety of ideas that can grant patients more access to health care. Five respondents felt that there was nothing el se that the clinic needs to do to be
68 culturally sensitive, because the only thing that they have left to do is take [patients] by their hand and pick them up and bring them to the appointment. The most prominent suggestion, 33%, for becoming more culturally se nsitive was to educate the staff. For instance, one employee offered her opinion when she stated There are times that patients leave the clinic and there is miscommunication and they leave embarrassed. They dont ask their opinion. More educating the staff, and transportation is too limited. They need more drivers or vans. Or more buses for those that are far. Another respondent supported th e idea of continuing educati on, research more different cultures customs, find out any subtleties we mi ght not be aware of. When a member of administration was asked whether the clin ic places enough importance on cultural sensitivity, the response was yeah, we dont, but when do we do it? Train support staff and let them role play, let provi ders learn through osmosis, l earn from staff. As stated by the administrator, providers and staff may be willing to become culturally competent, but the reality of the health care industry is different. This persons comment hints at the institutional level barriers to cultural competence, such as lack of time and funding. Several staff members believed that hiri ng more employees from the community would make the clinic more culturally sensitiv e. In their review of literature related to cultural competence, Betancourt et al ( 2003) found that minority populations make up less than 20% of all city and county health officers. Furthe rmore, the authors assert that a lack of diversity in the leadership and work force of an organization is more likely to result in poorly designed delivery systems, and a disconnection between health care systems and the communities they serve. Fourteen percent of the in terviewees recommended that the clinic should make more of an effort to seek out patients, such as advertising with ne wspapers and instituting
69 a mobile van. A couple suggestions focused on logistics, such as hi ring more doctors and broadening the parking lot. Staff as Advocates for Migrant Workers With the exception of four staff members, all interviewees demonstrated that working at the clinic is more than just a j ob, its a mission. The majority of employees at the clinic work there because they believe in helping those who need help the most. For instance, when asked what changes should be made in the health care system to better meet the needs of migrant workers, one participant asserted, recognition, to begin with, people dont even recognize th at there is a migrant popula tion to begin with the produce they buy, who they came from. They dont just cross borders. Another member of administration reported how the clin ic itself is making small changes to meet the needs of migrant workers when she said: There should be a linking of health education information, so you could see their records online. Migratory activity makes it difficult to take records with them. There should be a national linking of health information. Were already starti ng it with immunizations. Were piloting it in [a pediatric clinic aff iliated with the HC]. Its a Florida program, linking Florida. Anywhere in the state of Florida well be able to see them. Eventually, th ey will link nationally. A few employees expressed their opinion on insurance: Insurance a lot dont have social secu rity so they dont have insurance. A lot of them cant even afford $15 on scale A that would help them out with medicines. Give people that work in the fields insurance. Obligate employers to give private insurance, because they pay their taxes, with proper health care, it prevents diseases. The organizational culture at the HC is one that advocates for the community in which it stands. From the top level of the organization, administrators and policy makers
70 at the HC advocate for the rights of migrant workers and exercise their power to offer migrant workers the best quality of health care. The staff member s also feel strongly about advocating the rights of migrant worker s, expressing their st rong beliefs about the population. The clinic allows pa tients to feel freedom: when the patients come to the clinic, they know their rights and beliefs ar e respected and no one will try to change them. Comparison of Patient and Staff Responses This section answers Research question #3: Does cultural sensitivity mean the same thing to patients and staff? While there is no standard definition for cultural sensitivity, it is possible to determine where the similarities and differences are between patients and staff and providers. These re sults can be used to customize cultural sensitivity training by reinforcing the simila rities and emphasizing the differences as points for greater understanding. The resu lts are compared in this section. Both staff members (43%) and patients (48%) agreed that language is an important factor in being culturally sensitiv e. More patients (62%) than staff (38%) considered personal attention to be an issue that affects whether or not patients keep coming to the clinic. Patients named several other factors that keep them coming to the clinic, which staff members did not recognize as factors for what makes the c linic culturally sensitive. Patients said they want a solution to their pr oblem. Not one staff member mentioned that as a value of being culturally sensitive. However, staff members (80%) did mention that the services that the clinic offers are what make the clinic culturally sensitive. The clinic services are in essence a solution to patient s problems. The presence of Hispanic
71 patients and staff was another reason that patients named as what they like about the clinic. Staff members did not recognize th is as a component of cultural sensitivity. Observations While it is imperative that individual staff members behave in a culturally competent manner, it is only a small component of achieving cultural competence. As cultural sensitivity was previously defined, it is the extent to which a populations cultural beliefs are inco rporated in the design, delivery, a nd evaluation of targeted health interventions, including beha vioral change materials and programs [Reniscow, et al 2002: 493]. As a participant observer, I worked as a health educator teaching diabetes and hypertension classes. I was able to experi ence the reality of the clinic day in and day out, observe problems with patients and how st aff reacted to those problems, and observe how patients interacted with the staff. Pa rticipant observation c onducted in the doctors offices, front desk area, and general clinic area sheds some light on the degree to which the clinic practices cultural sensitivity. One obvious characteristic of the HC is th at all medical assistants are fluent in Spanish. The presence of Spanish-speaking is ubiquitous in the clin ic. One can turn a corner and hear employees speaking Spanish to each other and to patients. In the employee break room, the predominant langua ge is Spanish. Beyond speaking Spanish, many of the medical assistants live in the HC community, and identify with many of the migrant patients. Some were raised as migr ants themselves, and their parents worked in the fields until nighttime. Front office pers onnel have fostered personal relationships with the patients. They refer to patients as mija , which is a term of endearment in Spanish. According to one key informant who has close ties with th e patients, patients
72 call this place the Mexican clinic. Before even entering the clinic, one sees members from the community standing outside selling traditional Mexican foods, such as tacos, burritos, and homemade ice cream. Outside, the parking lot is alwa ys full of cars. Patients sit outside waiting for their rides to pick them up. Inside, there are posters and signs written in Spanish so that all Spanis h speaking patients can understand. Doctors offices and waiting rooms have Spanish magazine s and other Spanish reading materials. There is a constant feeling of frenzy because there are so many patie nts and so little time to see them all. At any given time, the lobby is full of patients waiting to be seen by the doctor. Mothers are there with all their children, who are growi ng eager and anxious while they endure the long, so metimes all-day wait to be seen by the doctor. Front desk-patient interactions Front desk personnel were formally observed on one busy Monday morning. There was a constant flow of patients. Th ere were three staff members there, all who spoke Spanish fluently and were of Mexican descent. One worker had been there for only two months, the other for one year, and th e other had been working at the clinic for five years. One of them confirmed that pati ents are never sent awa y. If they owe money, their record is highlighted a nd sent to the financial counsel or, who then tries to qualify them for insurance, or classifies them on a pay scale and/or sets them up on a flexible payment plan. An American employee, who speaks Spanish, shouted from the back of the office, and asked what bodega meant. The front desk personnel offered two different meanings of the word, but the righ t meaning of the word was chosen based on the patients ethnicity. A patie nt came in because her doctor had sent her a letter, written in Spanish, but she needed someone to explain th e letter to her. She was registered to see
73 a doctor in fast track to have the letter explained to her. It may have been that the woman was illiterate, or that she spoke little Span ish and spoke mostly an indigenous language from Mexico. A similar incident occurred durin g an interview with a patient. After the interview, the woman frantically asked me to interpret a letter, which was from her finance company. She also asked me for some advice, based on what th e letter said. She told me about how hard it is to be poor and that no one understands. Fast-track observations Structured observations took place over one week span, usually in the mornings. It was not possible to select patients who went through fast track according to language spoken. Rather, observations were conducted du ring a specific time, with all patients entering the office during that time. Howeve r, results will be reported on observations with Spanish speaking patients only. All medical assistants in the fast track area spoke Spanish fluently. The triage nurse, Graci ela (a pseudonym), identified herself as Mexican. Her office is warm and friendl y with depictions of her own cultural background. On the wall, there is a mini ature Mexican house, an indigenous Mexican tapestry, a Mexican hat, and pict ures of herself and her friends. She appeared to be very in tune with Mexican patients cultural beli efs. While embracing the biomedical beliefs that she learned in nursing school, Graciela ad mittedly also encourages patients to take home remedies. Her job as triage nurse was to identify the problem, find out what treatment patients are undergoing, and send them to the right place. After observing her office, it was obvious that this position re quires someone like Graci ela to effectively diagnose patients. One patient entered the o ffice with extremely hi gh blood pressure and insisted that it was because of the air condi tioning. Although I did not hear Maria or the
74 doctor explain to the patient that it was not because of the air conditioning that she had high blood pressure, the patient was imme diately sent to the hospital. Provider observations All patients were asked permission to be observed. A total of four, out of seven, providers were observed either in their offices or in the fa st track area. One provider spoke Spanish fluently and did not have an interpreter, while the remaining three providers did utilize interprete rs. It was during their office visits that I was able to examine how the interpreters communicate information between the doctor and the provider. Two out of four medical assistants who were all bilingual, reported that they had medical interpretation trai ning. Structured observations with one medical assistant who had no medical interpretation training provided much evidence for why medical interpretation training should be mandatory for all medical assistants. During a visit with a patient, the patient talked mostly to the assi stant, rather than the doctor. The assistant seemed to be the focus of the interaction, because the provider looked at the assistant during the visit. When the provider aske d the patient a questio n, she looked at the assistant, rather than the patient. There wa s even a time that the assistant answered the patients question herself, without translating the question to the docto r. The provider did not ask the assistant to translate the question either. Ba ker, Hayes & Fortier (2003) assert that when providers do not look at their patient but rather at the interpreter, they are effectively decreasing the patients sense of c onnection to the provider. For this reason, the HC should train providers on how to use th eir interpreters to effectively communicate and develop a relationship with their patients.
75 Another provider, who spoke little Spanis h, showed her frustration with a patient who was labeled as noncompliant. The patie nt had returned from Mexico four months prior to the office visit and had run out of her diabetes medication three weeks ago. She also had not followed through with obtaining he r insurance. She had problems with her feet, and needed to be referred to a podiat rist and cardiologist. The provider showed disapproval by throwing her hands up and shakin g her head in disapproval. There was no apparent reaction from the patient; however th at could have been be cause the patient was trying to be respectful of the provider. During another providers office visits, he s poke to patients in very basic, simple elementary Spanish. Although there was a transl ator in the office, he spoke directly to the patient in Spanish, and understood the pati ents responses. The doctor and patient, who were laughing together, had a personable relationship. Another provider, who says its more than just being Hispanic or knowing the language, expressed his views on cultural competence when he stated that Not all cultures are the same. I learn a new Mexican word every day. He mentioned a sobadora , which is a person that massages, and said he has to know his competitors and know what other traditional treatments his patients are getting. This provider asked patien ts whether they prefer to speak Spanish or English. One patient complained of a mermada , a Mexican term for stuffy nose, and the doctor explained to her that she was having allergies. He used very simple terms, polvito verde , or green powder, to e xplain that pollen was causi ng her stuffy nose. He also let the patient know that medicines are ch eaper at the clinic th an anywhere else. This patients visit with the doctor lasted onl y five minutes. However, the visit seemed to have lasted longer because the doctor was constantly communicating with the patient,
76 even while examining her. During another pa tients visit, the same provider used the word animales to explain to the patient that her results fr om the stool examination did not have parasites. He broke the explanat ion down into terms th at the patient would understand. Archival Data Administration Records The HC provides patients with a Patient Satisfaction Survey. The survey is in English as well as Spanish. The survey asks pa tients to give a grade, from A = excellent, to F = poor, on four categories related to provi ders, cleanliness, registration, and access. Each survey asks four questions on one of the categories, and every month, a different category is surveyed with a minimum of one hundred patients. Some of the questions on the survey evaluate the willingness of the provider to answer patients questions, how easy it was to make an appointment, and the condition of the waiting room. The patients also have a comments section where they can express their opinions. This survey is the clinics way of assessing patient s needs and improving quality of care. According to the 2002 Patient Satisfaction Report Card, patie nts showed more than 90% satisfaction with all the categories in the survey. The biggest concern from the survey was patient waiting time, in which there is an 84% satisfac tion rate. Unfortunately, the clinic did not analyze the results from this survey by language. There is no way of knowing what percentage of Spanish-speaking patients actually participated in the survey, and how they felt about each category. In 2003, the HC conducted the Patient Satisfaction Survey with Spanish speaking patients. Employees asked a total of one hundr ed and eighty-five patients questions in a
77 face-to-face interview. The re sults from the HC survey were similar to the results obtained from the present study. A high perc entage of patients (67%) showed overall satisfaction with various asp ects of the clinic. Moreover, 97% of the Spanish-speaking patients surveyed felt that they understood wh at their physician explained regarding their health problem. Seventy-four percent said that they would return to the clinic and almost 100% said they would recommend the clinic to friends and family. In this report, the clinic recognizes the need to train the st aff regarding low literacy Spanish speaking patients and proper interpretati on. The report recommends the use of ad hoc interpreters, and emphasizes that all health care organiza tions should assure that Spanish speaking patients have access to trained medical interpre ters. However, there is no evidence that the HC is making efforts to properly train their bilingua l staff members on medical interpretation. The HC publishes a newsletter that is ci rculated to all staff members at staff meetings every other month. I had access to two of the newsletters. Both of the newsletters consisted of information about staff birthdays, anni versaries, and other pertinent information helpful to employees. Regrettably, neither of the newsletters shared information on how to become more culturally sensitive, nor clues on raising awareness on patients cultures. Another document, entitled Health Care Plan Progress Report, summarized the goals of the clinic, and the extent to whic h the goals were achieved in 2001-2002. The report highlighted areas that needed improvement, such as 1st trimester enrollment of pregnant women, and suggested ways to achie ve the set goal. Some goals focused on segments of the clinic populat ion, such as pediatrics and ge riatrics. However, there was
78 no emphasis on setting goals for improving th e health care of migrant workers or Hispanic patients specifically. Administrative documents related to polic y were reviewed in order to determine what policy-related steps the clinic is ta king to be culturally sensitive. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) is the accrediting organization for all health care centers. The JCAHO manual disc usses the issue of cultural sensitivity in one chapter. The chapter Patient Rights and Organization Ethics, standard RI.1.2.1. enforces that patients cu ltural, psychosocial, spiritual, and personal values are respected. The manual suggests an example that shows compliance with the standard is to prepare printed materials th at demonstrate sensitivity to the culture of these patient groups. At the time of data collection, the HC was undergoing the reaccredidation process. It was not possible to obtain specific evidence of how the clinic intended to comply with this standard. Ho wever, in the section below, I discuss the results of the evaluation of the health education materials offered at the clinic. Health Education Materials A total of twenty-two handouts or bookl ets written in Spanish were evaluated based on readability, quality, and presence of graphics. The SMOG readability formula was used to determine the reading level in which each health education material was written. The SMOG Readability Formula is a method used to determine the reading level of written materials. The formula includes counting sentences in the beginning of the material, ten sentences in the middle, and ten sentences near the end of the written material. In each group of sentences, one is to count every word that has three or more syllables. The total number of words with more than three syllables is counted and a
79 SMOG Conversion Table provides the reading level for the written material. As previously mentioned, this formula is used onl y as an estimate so that one can have an idea of the reading level at which the materials are written. The SMOG formula was developed for the English language. However, because there is no readability formula available for the Spanish language, the SMOG fo rmula was used. Contreras et al (1999) found that SMOG can be used to assess readability in Spanish. Therefore, the SMOG formula was used as an estimate to get an idea of the readability of the handouts. Most materials should have been written at most a 6th grade reading level, given that a large percentage of Spanish-speaki ng patients have low educational levels. However, with the exception of one handout written on a 10th grade level, all of the handouts surveyed were written in at least a 12th grade reading level. Some were actually written as high as a 16th grade reading level, which woul d require most people to have a dictionary to help them understand what they were reading. For example, one handout on Hyperthyroidism was written on a 13th grade reading level. Th e first two sentences read in Spanish: Exceso de actividad de la glndula tiroi des, glndula endocrina que regula todas las funciones del cuerpo. El resu ltado es la superproducin de la hormona tiroidea. Translated in English, the text reads: Excessive activity of the thyroid gland, an endocrine gland that regulat es all of the bodily func tions. The result is the overproduction of the thyroid hormone. The handout included a picture of the throat area that was not labeled at all. A patient who has very limited reading ability and low educational level would more than likely not understand the concep t that was explained in the first two sentences.
80 The quality of all the materials samp led was good, with the exception of one handout which was illegible. The quality of the handouts was determined by whether or not the text could be read. Fifteen out twenty-two (68 %) of the handouts did not have any graphics on them. This is significant because pictures assist persons with low literacy to understand the material th ey are reading. Although it wa s hard to determine when each handout was published, the majority of them had been published more than five years ago. The clinic should make an e ffort to update the materials. Some pharmaceutical companies have made the e ffort to publish their health education materials in low literacy levels. Furthermor e, there is a heightened awareness of the importance of literacy in the health field. Efforts should be taken to acquire new materials that are writ ten in at least a 6th grade reading level, if not lower. Although health literacy is also a major concern with the Hispanic population, it was beyond the scope of this study to determine the health literacy levels of the patients interviewed. It was evident, however, that pa tients with low health literacy would not be able to understand the materials that were sampled. For instance, according to Doak & Doak (2004), one of the words to watch wh en creating health e ducation materials is oral, they suggest using by mout h instead. Just as an example, there were several of the handouts that used the term oral Of all the patients that were surveyed, 77% felt that they understood the health education informati on that was given to them. Some of them added that it is because they are in Spanish that they understood them. However, these results are not consistent with the results from the evaluation of the handouts. See the table below for a summary of the results of ev aluation of the health education materials.
81 Based on the results of the interviews, participant observatio n, and analysis of archival data, a model of cultural sensitivity sp ecifically for rural h ealth centers with a large Hispanic patient populat ion was developed (Figure 12). Figure 12: Model of Cultural Sens itivity for Rural Health Centers 1. Mandatory Medical In terpretation Training 2. Properly translated health educati on materials at low literacy levels 3. Holistic health care, with all services offe red in one location (medical, dental, acute care, OBGYN, laboratory, X-ray, referrals health education, and outreach) 4. Transportation 5. Flexible clinic hours open late and on Saturdays 6. Financial Assistance for patients 7. Regular cultural competence training 8. Culturally diverse staff and administra tion representative of the community 9. Culturally appropriate messages av ailable throughout the clinic 10. Participation in cultural comp etence research and dissemination 11. Constant assessment of patient satisfaction using qualitative met hods such as face-toface interviews and focus groups Fi g ure 11: % Readabilit y of Health Education Materials23 14 27 18 14 50 10 20 30 40 50 60 70 80 90 1001 0 t h 12th 1 3 t h 14th 1 5 t h 16 t h
82 Summary This chapter presented the results of the patient interviews, staff interviews, observations, and archival record s. The results were discu ssed by answering the research questions that guided this inqui ry. The conclusions for this project and recommendations for the clinic are offered in chapter five.
83 Chapter Five Conclusions and Recommendations Introduction The following chapter presents the conclu sions from this study, as well as the recommendations offered to the HC studied. The eleven recommendations are based on the patients interviews, staff suggestions, and results from the study. In addition to conclusions and recommendations, this chap ter also discusses the difference that anthropology made to this st udy, as well as the contributions that this study made to the fields of public health, anthropol ogy, and applied anthropology. Conclusions There is not much anthropol ogical literature availabl e on the topic of cultural competence. Indeed, there is much that the area of anthropol ogy can contribute to cultural competence. As an anthropological and public heal th contribution, this project aimed at advocating the patients voice, and offers meaningful descriptions of what cultural sensitivity means to patients, providers, and health care agencies. The purpose of this study was to explore th e definition of cultural sensitivity from both the staff and the patients perspective. The methodology used to complete this inquiry included open-ended semi-structured interviews, observations and analysis of archival data. The review of literature disc ussed the cultural values among Hispanics and biomedical professionals. This study is dis tinct in that it takes into account the emic
84 perspective, which provides an insiders, or part icipants, view of what is important in the health care situation. The first research question that guided this study was What does cultural sensitivity mean to patients? Unlike the staff interviews, patients were not specifically asked whether or not they feel the clinic is culturally sensitive because of a lack of understanding and awareness of the term. The patient interv iews aimed at determining a starting point for what Hispanic patients perc eive to be qualities th at a favorable rural health clinic should have. Essent ially, the patient interviews ga ve the HC patients a voice. The attributes that Hispanic patients look for in a clinic are that they receive attention from staff, services in Spanish, financial a ssistance, a solution to their health problem, and Hispanics should be everywhere in the clin ic. The majority of patients felt that the clinic does understand the Hispanic culture, mostly because the staff speaks Spanish and are Hispanic. The second research question was What does cultural sensitivity mean to HC staff? Although half of the respondents had not been trained in cult ural competence, all of them defined cultural sensitivity as e ither using appropriate language, and knowing and understanding a persons culture. The third research question was Does cultur al sensitivity mean different things to patients and staff? As previ ously stated, patients were not directly aske d what cultural sensitivity means. However, based on the resu lts of this study, it can be determined that at the HC, the patients and staff have a concor dant view of favorable qualities that a rural health center that caters to a large percentage of Hispan ics should have. Both groups
85 view language, attention, presence of Hispan ics, and solution to health problems as factors of culturally sensitive health care. Finally, the fourth research question aimed at determining what makes a clinic culturally sensitive. The evaluation of this project was determined using a combination of the two most widely cited cultural competence models, the Cultural Competence Continuum Model and the Cultural Developmen t Model. The HC is in between the cultural pre-competence and cultural competence levels of the Cultural Competence Continuum, and the cultural competence leve l of the Cultural Development Model. Based on the staff interviews, it can be determ ined that a signifi cantly high percentage (90%) of staff show acceptance and respect of patients health beliefs and practices. However, because, according to staff member s, employees are not actively trained in cultural competence, the HC has not yet progres sed into the cultural competence level. The final level, cultural proficiency, invol ves serving as role models and actively participating in cultural competence research and disseminating that information. It is at this level that the clinic should s oon be in with a few improvements. The literature suggests that some Hispan ic cultural values that may be of importance in the medical encounter are fatalismo respeto simpata and personalismo (Flores 2000, National Council of La Raza 1998, and Zoucha 2000,). This study confirmed that these cultural concepts are indeed important to Hispanic patients, as evident in some of the staffs responses to how they themselves are sensitive to Hispanic patients. Patients also named attention from staff as one of the reasons that made them feel comfortable when they came to the clinic which is a value that research shows many Hispanics share (personalism).
86 A review of the literature also showed that some of the ba rriers to health care that affect migrant workers are language, affordability, and transportation (Betancourt et al. 2003, Carrasquillo et al. 1999, Chvez 1984, Mora les et al. 1999, Napolitano & Goldberg 1998, National Center for Farmworker Health 2005, and Singleton 2002). Findings from this study serve as evidence that the patients at the rural health center, many of whom were migrants, believed that language, affordability, and transportation were some of the reasons that kept them coming to the clinic. Only three patients named transportation as a reason for why they like this clinic. Tran sportation is one of the main factors that makes HC a culturally sensitive clinic. The f act that patients have a reliable source of transportation, even though they may not have a vehicle, is outstanding. It is not possible to determine why such few patients discu ssed transportation during the interview. However, based on prior observa tions and staff responses to interviews, there could be a lack of communication to patients about the av ailability of transportation. Other reasons for why patients like the clinic include the existence of Hispanics in the clinic, and getting a solution to their problem. If the mission of the HC is to provide cu lturally sensitive health care, they have accomplished their mission because a large perc entage of the staff, mainly medical assistants, is Hispanic. Many of them live in the community and were raised in the culture that is similar to th e patients culture. Language is a key component of any culturally sensitive program. The HC has succeeded in making Spanish available throughout the clinic. However, it is not th e only component of a cultural sensitivity model. There should be an equally str ong emphasis on other components, such as
87 transportation availability, flexible clinic hou rs, and financial assistance, all of which the clinic succeeds in accomplishing. Based on the evaluation of the admini strative documents that were made available for this study, the HC does an ex cellent job assessing Hispanic patient satisfaction levels. The clinic should be commended for their diligence in maintaining the satisfaction of their patients. However, as the clinic itself rec ognizes, there is always room for improvement. The survey should c ontinue to be utili zed using face-to-face methods on a regular basis. Patients should be given a voice to e xpress their feelings about the clinic, and their voices should be presented to employees during staff meetings as a way to reinforce and promote the idea of cultural sensitivity. While the clinic does recognize the need to train nursing staff to in terpret properly, they should also be required to complete a formal medical interpreta tion class, in which they can receive a certification. Thereafter, the clinic should offer continuing education classes in medical interpretation and cultural sensitivity training eith er at the clinic or in other facilities. The services that the HC offers are wit hout a doubt an excellent example of how a rural health center should operate. The HC accomplishes many exemplary activities, and definitely serves as a model for other rural health centers to follow. While there are many models of cultural competency availabl e, many of them are more abstract than practical, and are not specific to rural health centers that cater to a large Hispanic population. Based on this study, a model for cu ltural sensitivity in rural health centers with large Hispanic populations was devel oped. The model is shown in Figure 13. A condensed version of this study will be provided to the HC. The written report will summarized the methods, results, and conclusions of this study. In addition,
88 recommendations will be provided in the conde nsed report, as well as an appendix that lists further resources in cultural competence. The HC studied in this project offers th e rest of the health care community much evidence on how to provide excellent health care in a culturally competent manner. The clinic is indeed a model for cultural compet ence, despite the few improvements that need to be made. The clinic should engage in sharing their experience with other clinics and health care agencies, as well as researchers, and be advocates for cultural competence and cultural sensitivity. The HC should be actively participating in the community, outside of the free health fairs that they offer. Ind eed, the clinic needs to reinforce the idea of cultural competence and culturally sensitive health care as necessary and prove to the rest of the world that it does make a difference. Anthropological Difference The discipline of anthropology enriched this study with qualitative methodology. Anthropological methodology, which included participant observat ion and open-ended interviews, introduced another dimension to evaluation of programs by presenting the emic perspective. Readers were able to unde rstand the patients perspective of what they do and do not like about the clinic, as well as the staff members own perspective of what their views are on cultural sensitivity. Thr ough participant observat ion, I was better able to understand the intricacies of the clinic, such as patient-provi der interactions and employee relations, and consequently situate th e reader to give him/her the most accurate portrayal of what goes on in a rural health cen ter. Working at the clinic allowed me to understand the perspective of being a staff member at the HC, as well as gain an entre to the world of patients.
89 Because they are culturally relative, anth ropologists who work in the health care industry play an important role in advo cating for cultural co mpetence and cultural sensitivity. They can encourage health car e providers, who have a tendency to stay focused on the medical issues surrounding h ealth problems, to also focus on other sociocultural issues surrounding the problem, such as a patients cultural values. Anthropologists can assist health care provide rs to assess patients worldviews, engage in a more ethnographic approach during the patien t/provider interaction, and evaluate their own biases. This will prevent health care provi ders from using stereotypes to guide their knowledge of culture. Contributions to Anthropology This study contributes to ge neral anthropological research in several ways. The field of anthropology, which is the study of cultures, suggests that there are certain cultural values that some Hispanics share, such as personalismo, familismo, and respeto. Results from this study confirmed that some Hispanics still share those values. A confirmation that anthropological methods are an excellent way to explore human problems from the holistic perspective is an other contribution made to anthropology. This study also advanced general anthropolog ical research on the topic of cultural sensitivity because there is little informati on available in the anth ropological literature about cultural competence and cultural sensitiv ity. The idea that cultu re has a very strong impact on health is also reinfo rced from the project findings. Another anthropological core va lue, cultural relativity, wa s reinforced and utilized throughout the internship and thesis. Unless he alth care providers are underlying cultural sensitivity, they will not be able to provide the best health care that patients deserve. At
90 the same time, this study confirmed that cult ure is important in any human relationship, including the relationship between patient provider, and health care agency. Contributions to Applied Anthropology Applied anthropology, which has often been called the fifth subdiscipline, bridges theory and practice (Ervin 2000). If the goal of applied anthropology is to focus on policy and practice, this study has indeed made several contributions to applied anthropology. For instance, this study put into practice many of the anthropological methods, such as participant observation, uns tructured interviews, and analysis of archival data to reinforce th at qualitative methods are indeed ideal for research on social issues. Furthermore, this study focused on ma king improvements in the clinics policy as it relates to cultural competen ce/cultural sensitivity. In addition, this study also emphasizes the emic perspective of both providers and patients. The common anthropological terms and methods, such as ethnocentrism, holis m, culture, cultural relativity, and participant observation were applied in the fi eld and put into practice. This study shows that applied anthropology is a subdisc ipline that is necessary in order to truly represent and advocate for the human conditi on. Furthermore, the goal of the project went beyond merely interpreting what cultural competence/cultural sensitivity should be, to defining what it actually means to those who function in the heal th care industry: the patients, the providers, and the health care ag ency. From the results of this study, the contribution to applied anthropology also in cludes a model of cultural sensitivity that other clinics can utilize. Fi nally, this project has contribut ed many valuable lessons to other applied anthropolo gists working in the field of pub lic health, who are engaged in the evaluation of a health care organization, especi ally in the area of cultural competence.
91 Contributions to Public Health This study made several contributions to public health by underscoring the value and necessity of cultural competence, which is a well known concept in public health. This study confirmed the relevance of cultura l competence and reinforced the need for culturally competent health care in order to decrease the health care disparities gap, which is the goal of Healthy Pe ople 2010. The problem of low h ealth literacy is also well known. Archival analysis examined the readab ility level of a small sample of health education materials and showed that a significantly high pe rcentage of the educational handouts given to patients is written above the twelfth grade reading level. The findings confirm that this is still a problem and at the same time highlights the need for public health practitioners to continue scrutinizi ng health education materials and questioning the quality of educational handouts. Another major contribution to public health is the emphasis th at this study placed on cultural values. Public health, in partic ular, health education, has previously been criticized for blaming the victim (McLeroy et al. 1993). Many of the theories that guide public health education pr esuppose that individuals are re sponsible for their illness. For instance, the Health Belief Model, which is a widely used theory in health education, is based on the assumptions that the individual must believe that his/her health is in jeopardy, perceive the symptoms of that illnes s, and believe that the benefits of changing his/her behavior outweigh the ba rriers of the illness (Rosenst ock 1974). This theory fails to consider other factors that may influence the individuals behavior, such as cultural environment, as well as the policy and politic al environment. Directly related to the blaming the victim issue is the issue of ch anging an individuals behavior rather than
92 changing the environment that supports and maintains unhealthy lifestyles (McLeroy et al. 1993). This study challenges the tendenc y towards blaming the victim by focusing on patients and staffs perspective and the cultural dynamics associated with their situation, as well as policy analysis and provides a d eeper understanding of the interrelationships in improving health outcomes. Finally, this study contributed to the fiel d of public health education by showing how an evaluation of a rural health center s hould take place. One of the responsibilities of a public health educator is to evaluate the effectiven ess of the health education program. Publishing the evaluation results serve as a way of improving the health education field by disseminating the su ccesses and failures, and making future recommendations to other health care profe ssionals (Cotrell et al. 1999). This study emphasizes the use of qualitative methods to gi ve the health care recipients a voice in the health care organization. In addition, cultu ral competence is an issue that exists throughout all public health se ttings, and should be emphasized in all public health programs. Finally, public health professionals can use the research de sign of this project to conduct their own organizations evaluation of cultural competence, and either apply the Model of Cultural Sensitivity for Rural Centers (Figure 13) or develop their own model of cultural sensitivity.
93 Recommendations The following recommendations for the clin ic are based on results from the data collection, as well as recommendations from the patients and staff. 1. The first and foremost important recommendation for this clinic is to form a cultural sensitivity/competence committee. The committee should be composed of members from the patien t population, the community itself, the staff, providers, and administration. Once the comm ittee is established, the following recommendations can take place. There ar e many resources available, as seen in Appendix G, which can assist the committ ee in undertaking the major efforts of enforcing and reinforcing cultural sensitiv ity and cultural competence at the HC. 2. Assess the cultural competence level of all staff members, providers, and administrators as a starting point for cultural competence training. Based on the study results, cultural competence training should emphasize that equal treatment does not mean cultural sensitivity. 3. Conduct ongoing cultural competence training on a regular basis, such as during staff meetings and in the newsletter. Cultural sensitivity should be reinforced constantly. Training can include ro le modeling, problem solving, and case studies, and basically any t ype of educational strategy that actively engages the person, rather than lis tening to a lecture. 4. Make transportation services more available to patients by placing signs throughout the building, or aski ng providers to let their pa tients know about it. If the clinic has logistical problems of not having enough drivers, then the clinic
94 should consider finding a way to hire more drivers to make the services more available to patients. 5. Offer mandatory medical interpretation trai ning to all medical assistants and front desk personnel. There are agencies, such as AHEC (Area Health Education Center) that offer medical interpreta tion training at affordable rates for community health centers. 6. Decrease the long wait time. While the pr oblem of a long wait is well known at the clinic, it is a major barrier to patient s who do not have the time to spend away from work at the clinic. Efforts shoul d be made to address the barrier, by increasing funding, hiring more doctors, or developing an alternative system of intake for fast-track patients. For instan ce, some patients suggested that it would be helpful to them if they were given an approximate wait time so that they could leave the clinic and either eat or run erra nds, and return at the suggested time. 7. The clinics hours of operation should in clude Saturdays to accommodate the schedules of migrant workers, who tend to work long days. 8. Members from the community should be hi red to work in administration, as well as the board of trustees to give the patie nts a voice in the decision-making process of the HC. 9. Efforts should be made to obtain up-to-da te health education materials that are written at low literacy levels, and properly translated into Spanish, as well as representative of the Hispan ic culture. There are many agencies and websites that offer health education materials at inexpe nsive, if not free, rates to community health centers. There are many webs ites listed on Appendix G that offer
95 appropriate health education materials. If there are certain materials that can not be found in Spanish, the clinic should make an effort to translate the health education information into Spanish, a nd consider making the handouts available to other clinics. 10. The clinic should continue to conduct Patient Satisfaction Surveys and use the results in an action plan for cultural competency. 11. The clinic should seek a grant to estab lish itself as a model center for cultural competency. Not only will others be able to learn first hand how cultural competence works in a clinic, but it provide s the clinic with more ways to obtain funding resources. 12. The committee should publish the results from cultural competence evaluations so that other health care organizations can learn from their experience in cultural sensitivity and cultural competence. Summary In summary, this chapter presented th e conclusions of a study that aimed at defining cultural sensitivity in a rural health center from the perspective of the patient, staff, and provider. The conc lusions were based on the lite rature review described in Chapter Two and the findings presented in Chapter Four. In a ddition, recommendations for improving the HC were given, based on the results of the evaluation.
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102 Appendix A: Patient Oral Consent Guide English Hi, my name is Nadine and I m doing a research project for my school, the University of South Florida. I would like to ask you some questions while you wait for the doctor about what you think of the HC. Im not going to use yo ur name. Nothing you say will affect the care that you get here at [the] Your decision to particip ate in this research study is completely voluntary. You are free to participate in this research study or to withdraw at any time. You can stop answering the questions when you want. If you have any questions about this proj ect, I can give you the phone number of my teacher at the University. Do you want her phone number? Will you help me by answering some questions?
103 Appendix B: Patient Oral Consent Guide Spanish Hola mi nombre es Nadine y estoy lleva ndo a cabo un proyecto para mi escuela, la Universidad del Sur de la Florida. Me gus taria hacerle preguntas mientras espera al doctor. Yo quiero entender como los paci entes de HC se sienten con la a de HC. Yo no voy a usar su nombre ni le voy a decir a nadie lo que usted me dice. Nada de lo que usted me diga afectar el cuidado de sal ud que usted recibe. Su decisin en participar en este estudio es voluntaria. Usted esta libre de participar en este estudio o de retirarse del estudio en cualquier momento. Usted se puede negar a contestar cualquier a pregunta que no quiera contestar. Si usted tiene preguntas sobre este proyecto, le puedo dar el numero de telefono de mi profesora en la Universidad. Quiere ese numero de telefono? Me puede ayudar a contestar unas preguntas?
104 Appendix C: Patient Int erview Questions English Hello. My name is Nadine and Im a health educator here at the HC. Right now Im working on a project for the HC and the uni versity. We want to find out how our patients feel about the HC. Do you have some time to answer a few of my questions? Your opinions are very important to us to assure that we ar e giving you the best quality of services that you dese rve and that you should be receiving. 1. What languages do you speak? 2. How old are you? 3. What is your nationality? 4. What health insurance do you have? 5. How long have you been coming to the HC? 6. What services do you use here at the clinic ? (ie mental heal th, dental, medical, lab, x-ray, referrals, health education, obgyn, pediatrics, transportation, pharmacy) 7. In what ways does the clinic make you feel good when you are here? (probes environment & surroundings, staff, doctors, assistants) 8. How do you feel about the written inform ation that the doctors and nurses give you sometimes? (probes understand the materials, helpful) 9. Have you or your family ever experienced difficulty getting health care here at the ? (probe b/c of $, transportation, language) 10. How do you think that other pa tients feel about the HC? 11. How is your communication between yourself and the doctor? (probe language, etc) 12. How is your communication between yourself and the medical assistants? (probe language) 13. How is your communication between yourse lf and the front desk personnel? (probe language) 14. What are some things that you like and dont like about HC? 15. What are some things that you think we need to improve?
105 Appendix C: (Continued) 16. What are some of the reasons that make you think that the HC understands or doesnt understand your custom s as a hispanic person?
106 Appendix D: Patient Int erview Questions Spanish Hola. Mi nombre es Nadine y yo soy una e ducadora de salud aqui en la a y tambien una estudiante de la Universidad del Sur de la Florida. Ahora estoy trabajando en un proyecto para la a, y la Univ ersidad. Nosotros queremos saber como la a lo trata a usted. Tiene usted tiempo para contesta r unas preguntas? Sus opinions son muy importante para nosotros, para segurar que estamos dando la major calidad de servicios que merece y que debe de estar recibiendo. 1. Que idioma habla usted? 2. Cuantos aos tiene usted? 3. De que pais es usted? 4. Que clase de seguro medico tiene usted? 5. Cuanto tiempo hace que usted viene a la a? 6. Cuales son los servicios que usted usa aqui en la a. Por ejemplo el dentista, medico, laboratorio, referidos, educaci on de salud, la partera, pediatra, transportacion, farmacia, o psicologo) 7. En que manera la a de HC le hace sen tir bien cuando usted esta aqui? (el ambiente, los doctores, assistente s, o la gente en general) 8. Como se siente con la informacion sobr e salud que le dan los doctores y las enfermeras de vez en cuando? Por ejem plo, pamphletos, papelitos) (probes understand the materials, helpful) 9. Usted o su familia ha tenido problemas recibiendo atencion medica aqui en la a? (probe porque no tienen dinero, transportacion, o idioma) 10. Como piensa usted que los otros paci entes se siente con la a de HC? 11. Como esta la comunicacion entre uste d y su doctor? (probe lenguaje) 12. Como esta la comunicacion entre usted y las asistentas medicas? (probe lenguaje) 13. Como esta la comunicacion entre usted y las trabajadoras de la ventanilla? 14. Cuales son las cosas que a usted le gu stan y no le gustan de la a en HC?
107 Appendix D: (Continued) 15. Cuales son las cosas que usted cree que se deben mejorar en la a en HC? 16. Cuales son las razones que le hacen pe nsar que la a de HC conoce o no conoce sus costumbres como persona hispana?
108 Appendix E: Staff/Provider Interview Questions 1. Please tell me about what your job here at the HC. 2. How long have you been working at this clinic? 3. Please tell me about your cultural or ethnic background. 4. How would you define cultural sensitivity? 5. How is it relevant to the clinic (or why do you think HC should or should not be culturally sensitive)? 6. What kind of training have you had in being culturally sensitive? 7. How often do you receive training? 8. In what ways do you practice cultural sensitivity? 9. In what ways do you think that HC does or does not practice cultural sensitivity? 10. In what ways do you think that culturall y sensitive health care affects health? 11. How would you measure the impact of cultu ral sensitivity on health outcomes? 12. In what ways do you think HC tries to ove rcome patients barriers to health care? 13. Are there barriers that keep HC from being culturally se nsitive? If so, what are they? 14. What ideas do you have for how the HC can become more culturally competent? 15. What kind of changes should be made in th e health care system to better meet the needs of migrant workers?
109 Appendix F: Recommended Standards fo r Culturally and Linguistically Appropriate Health Care Services Based on an analytical review of key laws, re gulations, contracts, a nd standards currently in use by federal and state agencies and other national organizations, these proposed standards were developed with input from a national advisory committee of policymakers, providers, and researchers. In the [full report], each standard is accompanied by commentary that addresses its relationship to existing laws and standards, and offers recommendations for implementation and oversight to providers, policymakers, and advocates. Preamble: Culture and language have considerable im pact on how patients access and respond to health care services. To ensure equal access to quality health care by diverse populations, health care organizations and providers should: 1. Promote and support the attitudes, behavi ors, knowledge, and skills necessary for staff to work respectfully and effectiv ely with patients and each other in a culturally diverse work environment. 2. Have a comprehensive management st rategy to address culturally and linguistically appropriate services, incl uding strategic goals, plans, policies, procedures, and designated staff responsible for implementation. 3. Utilize formal mechanisms for community and consumer involvement in the design and execution of service delive ry, including planning, policy making, operations, evaluation, and training and, as appropriate, treatment planning. 4. Develop and implement a strategy to recru it, retain and promote qualified, diverse and culturally competent administrative, al and support staff that are trained and qualified to address the needs of the raci al and ethnic communities being served. 5. Require and arrange for ongoing education a nd training for administrative, al, and support staff in culturally and linguis tically competent service delivery. 6. Provide all clients with limited English pr oficiency (LEP) access to bilingual staff or interpretation services. 7. Provide oral and written notices, includi ng translated signage at key points of contact, to clients in their primary la nguage informing them of their right to receive no-cost interpreter services. 8. Translate and make available signage and commonly-used written patient educational material and other materi als for members of the predominant language groups in service areas. 9. Ensure that interpreters and bilingual staff can demonstrate bilingual proficiency and receive training that includes the skills and ethics of interpreting, and knowledge in both languages of the terms a nd concepts relevant to al or non-al encounters. Family or friends are not considered adequate substitutes because they usually lack these abilities.
110 Appendix F: (Continued) 10. Ensure that the clients' primary spoken la nguage and self-identif ied race/ethnicity are included in the health care organizati on's management information system as well as any patient records used by provider staff. 11. Use a variety of methods to collect and utilize accurat e demographic, cultural, epidemiological and al outcome data for racial and ethnic groups in the service area, and become informed about the ethni c/cultural needs, res ources, and assets of the surrounding community. 12. Undertake ongoing organizat ional self-assessments of cultural and linguistic competence, and integrate measures of access, satisfaction, quality, and outcomes for CLAS into other organi zational internal audits a nd performance improvement programs. 13. Develop structures and procedures to address cross cultural ethical and legal conflicts in health care delivery and compla ints or grievances by patients and staff about unfair, culturally insens itive or discriminatory treatment, or difficulty in accessing services, or denial of services. 14. Prepare an annual progress report documenting the orga nizations' progress with implementing CLAS standards, including information on programs, staffing, and resources. 1999, HHS Office of Minority Health and Resources for Cross Cultural Health Care
111 Appendix G: Cultural Competence Resources The Center for Cross Cultural Health www.crosshealth.com The Cross Cultural Health Care Program www.xculture.org www.diversityrx.org A website sponsored by Th e National Conference of State Legislatures, Resources for Cross Cultural Heal th Care, and the Henry J. Kaiser Family Foundation of Menlo Park, CA. A Guide to Choosing and Adapting Culturally and Linguistically Competent Health Promotion Materials http://gucchd.georgetown.edu/nccc /documents/Materials_Guide.pdf The Henry J. Kaiser Family Foundation Compendium of Cultural Competence Initiatives in Health Care http://www.kff.org/uninsured/6067-index.cfm Migrant Clinician Network www.migrantian.org National Alliance for Hispanic Health www.hispanichealth.org National Association of Co mmunity Health Centers www.nachc.com National Center for Cultural Competence http://gucchd.georgetown.edu/nccc/ National Center for Farmworker Health Has bilingual teaching materials www.ncfh.org Pfizer Principles for Clear Health Co mmunication: A Handbook for Creating Patient Education Materials That Enhance Unders tanding and Promote Health Outcomes http://www.pfizerhealthliter acy.com/pdfs/Pfizers_Principl es_for_Clear_Health_Commun ication.pdf US Department of Health and Human Services Office of Minority Health http://www.omhHC.gov/clas/index.htm
112 Appendix G: (Continued) University of Washington Harborview Medical Center www.ethnomed.org