2002 learning from latino families afta research conference

Health Care Access: Learning From Latinos and Their Families American Family Therapy Academy Clinical Research Conference Niagara by the Lake, Ontario. October 18 2002 Gonzalo Bacigalupe, ED.D. Associate Professor University of Massachusetts Boston [email_address]

Learning from Latino Families
What does research tells us about Latino men? Lessons from research from health care access disparities
What does the counseling field tells us?
Insights from three research projects:
In-Depth Interviews with Therapists
The Mas Salud Project (Bacigalupe, Upshur, Cortes, Torres, Gorlier, & Chernoff) DHHS-CMMS Funding
Medication Use ad English Proficiency: Latino Elderly (Mutchler, Bacigalupe, & Gottlieb) NIH-NIA Funding
Research and Clinical implications

The View From the Top

Health Access Disparities
Persistent gap between majority and minority populations; the research evidence is overwhelming (but policy is not always directed by powerful research…)
Health insurance is a family issue:
Among families with children, Latino families are most likely to have at least one uninsured member (41%), followed by non-Hispanic African-American families (23%), and non-Hispanic white families (13%) (Institute of Medicine, 2002)
Socioeconomic conditions play an important role but even not socio-economically disadvantaged people of color have different health care experiences (with similar medical conditions and health coverage).

Health Access Disparities
Problematic Research Trends:
Clinical evidence research (EBT) may be studying minority clinical populations but not as collaborating partners fostering resentment and suspicion rather than partnerships
Prevalent focus to one bullet approaches misses opportunities for culturally competent interventions
Few research leadership positions by those who resemble the population studied or researchers are “added on” as the “population studied is diversified”
Prevalence of large and costly studies with tremendous overheads and little impact on communities studied. But studies that require high level of community involvement are rarely funded adequately.
Continuous attention to disintegrated approaches to research that mirror and reinforces non-holistic health interventions as well as in child protective services, education, housing, and working conditions
Including in the sample a 5% of …
Policy Trends:
Relevance of fatherlessness and fatherhood as an economic opportunity to delimit role of the government in supporting families while keeping ideological intervention intact (i.e., Wade Horn at ACF)
9/11: war, anthrax, immigrants as potential terrorists
PRA and the recession

Some Specific Research Implications
We have to be careful with single views of global masculinities: Different cultures construe masculinity differently (Hearn, 2001)
We need more complex models of acculturation since culture and gender intersect in complex ways along time or acculturation is not necessarily something to achieve
Acculturation levels have divergent impact on men and women smoking (Perez, 2001)
Men had less level of social acceptance while more proficient in English than women (Arcia et. al., 2001)
Acculturation does not mediate the impact of health status on health related quality of life (Van et. al., 2002)
High levels of acculturation were associated with unprotected sexual behavior (Marks et.al., 1998)
Strength oriented research has potential:
Men who have been tested for HIV are better at assisting and educating others (Fernandez et. al., 2002)
Sexual behavior is still dominated by strong ideas about gender roles with with grave consequences in the prevention of STDs and HIV/AIDS among Latino adolescents and adults
In a study of condom use: women associated safe sex with good communication while men associated safe sex with trust (McQuiston & Gordon, 2000)
Menstrual bleeding influences sexual behavior: Decrease intercourse and potential contraception (Davis, 2002)
Scores on a Masculinity Scale Ideology were significantly associated with HIV-risk-related sexual behavior (Pleck, et.al, 1993)
Men with more traditional gender role beliefs reported less condom self-efficacy and less condom social norms reported less condom use (Marin et.al., 1997)

Health Disparities & Reaffirming Masculinity
Lack of preventive care and self care
Illness are construed as intrusive and as enemy that threatens social status
Reluctance to acknowledge medical problems regardless of age: if I don’t see it or sense it, it must not be there
Fear and distrust of being used to try new medicines and of being part of an experiment. Or, as a client told me: Like a “car” that goes for repair once and then needs further repair “because the repair guys are damaging the other parts”
Medical interventions are often seen as a sign of weakness and some are associated with an homophobic stance (i.e.., prostate examination)
Acculturation messages for men tend to infantilize them or target them for the marketing of changes but not to care necessarily: cars ( SUV ), clothing ( adventurous ), creams and colognes ( sexy ), sports ( goods and muscles )
Traditional beliefs about masculinity correlate with substance abuse and violence in Latino teens (Pleck, 2001)

Framing the Questions: Latinos’ Health
Identity, Identities, & Invisibility
Masculinity is intersected first by the prevailing Latino familistic ideology.
Identities and categories are in flux (i.e., census) but not the opportunities
Media portrayal (i.e., the body as an individual health project)
Discrimination and Institutionalized Racism
Obstacles to Relationship with PCP (Navigating, Choosing, Addressing)
Immigration Status (Self and Family)
Border families: Taking care here and there
Acculturation as a health risk
Income Inequality (Salaries, Stability, Capital, Retirement) and Working Conditions
The role of ethnicity and race can be contextualized by social status but the reverse is also possible as health disparity research suggests
Social Networks
Effective but often overstated or do not work for prevention
Role of Extended family is not understood by policy makers
Mental Health
Transgressing the Macho Myth and Reality
Holistic: Dignity, Expert Advice, and Collaborative Choices
Deficit Orientation gets funding as it proves need while strength orientation is marginalized
Health Insurance Access
A public health calamity despite Latinos positive response to public campaigns

Meta-Model

Latino Men Speak
A personal relationship with physicians is highly valued, is expected and is experienced as the basis for a trustworthy relationship. Although Latinos have various degrees of English fluency, generally language constitutes a barrier for adequate health care. Various participants reported having experienced personal problems with receptionists and nurses; in some instances, they referred to "racist attitudes" among African-American staff towards Latinos.
Many participants report having migrated in search of better health care and that their family and community networks have supported this migration.
The quantitative findings suggest that Latino men underutilize preventive care and use emergency care only when they are acutely ill . The focus group suggests that men who are more knowledgeable about health services are able to communicate with less knowledgeable ones, giving them important advice regarding access and prevention. Thus, similar groups may be recommended to improve access and utilization among Latino males.

Latino Men Speak
Some of the men in the interviews suggested that psychosocial and cultural Latino dimensions inhibit preventive use of care when health problems and treatment may affect sexual functioning. These factors include shyness ( timidez ), arrogance ( soberbia ), pride ( orgullo ), and machismo . Physicians with "good manners" (buenos modales) who do not raise these issues, were identified by participants as not necessarily providing quality health services. These psychosocial and cultural dimensions may also contribute to the underutilization of preventive care.
For men diagnosed with HIV, Confianza is a central in the definition of good medical care. Trusting the health-care professional is related to physicians and nurses understanding the condition . Participants demand an integrated approach, with professionals addressing not only health issues but also questions about their everyday life at home and in the community.

Identifying & Negotiating Access Barriers

Providers Barriers Model

Overcoming Barriers

Elderly Latinos Research Project: Initial Findings
Search for better health care mirrors the intergenerational immigration process--not a self-care lonely endeavor. This “ extended family project” presents opportunities for preventive care and better health outcomes if it is supported by a network of community services
Elderly patients are willing to travel and spend time if they are able to connect with others at the community center. Thus, outreaching to these places can be an effective way of reaching systematically this group.
Patients obtain medicines through a combination of strategies that include the formal medical recommendation as well as the network of relatives and friends
Our interviewees follow through with physician’s recommendations unless medical personnel is perceived as not respectful
Therapists who help negotiate the puzzles of accessing health care providers and/or social services find that these patients will use them effectively later on in therapeutic work
Competent therapists may not necessarily have to connect continuously with other health care providers but have to be well-informed of major procedures and preventive measures (diabetes, prostate examination, cardiovascular care, etc.)

Implications and Opportunities for Systemic Research and Interventions
Difficulties understanding enrollment systems and maintaining consistent coverage, and incurring costs outside the insurance plan
CBOs are key intermediaries but fund them
Trust/ Confianza impact on provider-patient relationship
Administrative and support staff are constitutive of the care equation
Cultural competence is key in preventive care (Diabetes)
Language barriers are not just about translating
Use of the ER is coping mechanism to negotiate preventive health care which are reinforced by gender ideologies

Implications and Opportunities for Systemic Research and Interventions
Patient care: Need for integration and one stop services:
Latino patients expect that health-care providers will inform them and facilitate their access to different services and material resources. Clinical settings serving this population should have the resources available to make referrals and facilitate access to social services including housing, welfare, and child-care. Given the importance of confianza (trust) among Latinos, it’s crucial to create conditions that enhance stable and personalized provider-patient relationships..
Public-health campaigns need to target the extended family
Target family members that are most respected by children’s parents (i.e., grandmothers, aunts, and compadres). In the case of older adults, sons and daughters participate actively in the care of their parents. The group findings suggest that adult children influence their parents’ search for better care, insurance access, preventive and emergency care. Efforts directed to the older adult and the elderly should also target their adult children.

Working with Latinos: Therapists’ Perspectives
Developing trust is a sometimes complex task: simply adopting a collaborative stance without sharing something useful with the family will make them doubt the usefulness of the situation
Latinos may construe group situations (even the family group situation) as potential classroom context and as such the therapist is perceived as a potential teacher that deserves a great deal of respect.
The immigration process is central, even in those cases where the patients are second or third generation since family members may still be in the process of immigrating or are in continuous contact with the family members located here. This process includes dealing with the psychological impact of being assaulted or discriminated while immigrating to the U.S.

Socializing boys and girls into what being a man is central, not necessarily about reaffirming a macho socialization but often as a way of transmitting a set of responsibilities for the boys.
While homophobic display are common, Latino men are much more comfortable being physically close to their fellow peers and towards their children.
Latinos may construe non-medical personnel as dangerous and family members may disguise the truth to protect family’s sense of identity ( i.e., not to condone child abuse)

The therapist as a Cultural Broker ; a Bridge between Institutions; Collaborator that Keeps Hope Alive; Learner of a Story and Stories; Advocate and Educator; Witness; Keeps Larger System View; Maintains a Dual Vision (Continuity and Change) like Immigrant Families Do; Involves and Accepts Extended Family’s Participation (as defined by the person who seeks help) ; Envisions Clients as Future Members of their Agency or Institution
The therapist understands Clients’ Fear of Institutions as Part of Reality rather than as Resistance to Obtain Services

Researchers and Funding Information
The Listening to Latino Therapists Project research was conducted by Gonzalo Bacigalupe with funding from grants from the Mauricio Gaston Institute and the University of Massachusetts Healey Grant
The Mas Salud Project included Co-Principal Investigators Drs. Gonzalo Bacigalupe, Carole Upshur, Dharma Cortes, and Andres Torres. Research associates included Drs. Mariam Chernoff and Juan Carlos Gorlier. This project was funded by a Hispanic Health Grant from the Centers for Medicare and Medicaid Services.
The ongoing Elderly Medication and Literacy Project includes Co-Principal Investigators Drs. Jan Mutchler, Gonzalo Bacigalupe, and Alison Gottlieb. This project is funded by the National Institute of Aging

2002 learning from latino families afta research conference

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