Communication with Latino Patients--Improving Medical and Nursing Education

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  • Workforce not diverse, patient populations diverse* 1-low disagreement, 4-high Separate likert and i-s
  • As you all know, the ethnic group that we refer to as Hispanic or Latino has had major population growth in the last 10-20 years. Before we go too far, I’d like to discuss that terminology for a moment. The phrase Hispanic is a Census term. This particular group doesn’t really prefer that descriptor and they don’t self-reference that way. For that reason, we choose to use Latino. However, our participants are not the patients but are student providers. Because most literature uses “Hispanic”, we found that Hispanic/Latino was the best, most understandable phrase to use in our project. The individual terms will be used interchangeably in the presentation, but that is what we prefaced and defined in the survey. Another note—we recognize the diversity that this ethnic group presents, and that it can mean different things to different communities. However, in the Southeast, the Latino community is quite uniform. Our target population is predominantly Mexican and generally underserved in healthcare. That is the group that we referred to and our participants understood that. Pay attention to what is happening nationally. Shades of blue=20-100+% change. National trend. Southeast region=denser percent change, more dark blue.
  • The Latino population in the US has been rapidly expanding. Latinos account for 56% of total national growth, 2000-2010, US Census Bureau Under-reported: more Latinos claiming “white” or “some other race” on 2010 U.S. Census, The Beacon-News States with the largest percent change: SC=#1
  • Major policy makers and institutions, including IOM and CDC, are recognizing disparities in healthcare concerning Latinos.
  • Read.
  • Improved cultural competency skills will improve communication skills with Latino patients. How to improve cultural competency? Exposure/experience and education at the undergraduate and graduate level. Our study is interested in interventions at the educational level.
  • We want to assess current readiness to treat Latino patients in student providers (medical and nursing). Once evaluated, educational interventions can be designed to improve cultural competence and communication skills and thus enhance the student provider readiness to treat Latino patients, which will hopefully reduce disparities.
  • Theoretical framework used to measure current student provider readiness to treat Latino patients—indices employed in MaNSRT survey.
  • We are trying to identify gaps in the care of Latino patients, especially in medical and nursing education. Communication is a huge gap. If identified, we can develop interventions to close those gaps, including with communication. The gap is not just linguistic. Cultural competence is the gap (language is just one of those skills).
  • LESS TIME< GET TO QUESTIONS One particular area of revision: Much recent opinion among survey researchers has focused on the potential problems associated with Likert scales, particularly respondent acquiescence, or the tendency for respondents to agree with attitude statements. Working with our survey expert, we attempted to devise questions and scales with greater discriminatory power than the standard Likert scale.
  • Revisions, pilot process Changes between pilot and final, changes in likert to is Examples, why important Much recent opinion among survey researchers has focused on the potential problems associated with Likert scales, particularly respondent acquiescence, or the tendency for respondents to agree with attitude statements. Working with our survey expert, we attempted to devise questions and scales with greater discriminatory power than the standard Likert scale.
  • Pilot survey: Likert scale, 1-4 response scale
  • Final survey: Item-specific question, 1-5 response scale Measuring skill sets (Student provider language and experience index) *Read questions
  • Item-specific Measuring cultural familiarity (Student Provider Knowledge Index)
  • Item-specific Measuring student provider opinions on Latinos (Student Provider Psychological Index)
  • Now we will give some feedback on what students are saying about their experiences with Latinos, their perceptions on the communication challenge, and their opinions on their cultural competence training.
  • About communication Themes Nurses and medical students Any provider
  • If the student providers feel comfortable, they won’t see them as something separate (which they do now).
  • Survey comparisons, pull out communication Questions from current survey on communication LIKERT SCALE vs. IS **1-4 scale
  • Survey comparisons, pull out communication Questions from current survey on communication LIKERT SCALE vs. IS
  • IMPORTANT, EXPLAIN WELL Variable ability– between agree-disagree Lacking confidence in communication skills and interpreter use when caring for Latino patients
  • Speak afterwards, exchange cards
  • Communication with Latino Patients--Improving Medical and Nursing Education

    1. 1. COMMUNICATION WITH LATINO PATIENTS— IMPROVING MEDICAL AND NURSING EDUCATION Rachel Mayo, Windsor Sherrill, Sarah Griffin, Caroline Swiger, Jessica Meehan, Taylor Hughes, Janet Evatt, Veronica Parker* Department of Public Health Sciences *Department of Nursing Clemson University Clemson, South Carolina
    2. 2. OUTLINE <ul><li>Current Issue (Introduction/Background) </li></ul><ul><ul><li>Communication barriers causing health disparities for Latinos </li></ul></ul><ul><li>Study Purpose </li></ul><ul><ul><li>Develop a tool to measure student provider readiness to treat Latinos </li></ul></ul><ul><ul><li>Learn about student provider perceptions and cultural competence in treating Latino patients </li></ul></ul><ul><li>Instrument Development (Methods) </li></ul><ul><li>Focus Groups (Results) </li></ul><ul><li>Pilot Surveys (Results) </li></ul><ul><li>Conclusions/Further Research </li></ul><ul><ul><li>Final survey currently in progress (n=1500 medical and nursing students) </li></ul></ul>
    3. 3. SIGNIFICANT CHANGE NATIONALLY IN THE SOUTHEAST
    4. 4. NATIONAL GROWTH IN THE LATINO POPULATION LARGEST CHANGE IN LATINO POPULATION, BY STATE (U.S. Census Bureau, 2010) Latino Non-Latino White Total Nation 2010 2000 2010 2000 2010 2000 Percent of total population (%) 16.3 12.5 63.7 69.1 -- -- Percent Growth (%) 43.0 1.2 9.7 State Percent Change (%), 2000-2010 Rank in Nation South Carolina 148 1 Georgia 96 11 North Carolina 111 6 Tennessee 134 3
    5. 5. RESULTING HEALTHCARE ISSUES AND DISPARITIES FOR LATINOS <ul><li>More than 1 in 4 Hispanics lack a usual healthcare provider. (Pew Hispanic Center/Robert Wood Johnson Foundation, 2008) </li></ul><ul><ul><li>Hispanics are 3 times as likely as non-Hispanic whites to lack a usual healthcare provider. (Centers for Disease Control and Prevention, 2006) </li></ul></ul><ul><li>17.8% of Hispanics of all ages report being in fair or poor health. </li></ul><ul><ul><li>Compared with 11% of non-Hispanic whites. </li></ul></ul><ul><ul><li>(The Commonwealth Fund, 2008) </li></ul></ul>
    6. 6. RESULTING HEALTHCARE ISSUES AND DISPARITIES FOR LATINOS (CONT.) <ul><li>23% of Latinos report having received poor quality of medical treatment or care in the last year (Pew Hispanic Center, 2008) </li></ul><ul><li>The healthcare provider community does not reflect the ethnic diversity of the patient community in the Southeast. </li></ul><ul><ul><li>Under-represented as providers </li></ul></ul>
    7. 7. CHALLENGE—COMMUNICATION BETWEEN LATINO PATIENTS AND PROVIDERS <ul><li>“ [H]ispanics and Asians report more difficulty communicating with their doctors than both whites and blacks.” (Mead, et al., 2008) </li></ul><ul><li>“ [W]hen health care providers fail to understand sociocultural differences between themselves and their patients, the communication and trust between them may suffer.” (Betancourt, et al., 2002) </li></ul><ul><li>“ [E]fforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.” (Morales, et al., 1999) </li></ul><ul><li>“ [T]he field of ‘cultural competence’ in health care has emerged in part to address the factors that may contribute to racial/ethnic disparities in health care.” (Betancourt, et al., 2002) </li></ul>
    8. 8. DEFINING CULTURAL COMPETENCE <ul><li>“ Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.” </li></ul><ul><ul><li>The Commonwealth Fund </li></ul></ul><ul><ul><li>(Betancourt, et al., 2002) </li></ul></ul><ul><li>Skill sets and cultural knowledge that we can emphasize to prepare our future providers. </li></ul>
    9. 9. HOW TO ADDRESS THE COMMUNICATION CHALLENGE Improved readiness to treat Latino patients
    10. 10. THIS STUDY: GOALS AND OBJECTIVES <ul><li>Student Provider Perceptions of Latino Patients in Cancer Care Settings,  NIH/NCI Grant 1R15CA135349-01A2 </li></ul><ul><ul><li>(PIs: Mayo, RM; Sherrill, WW) </li></ul></ul><ul><li>To develop and evaluate an instrument ( MaNSRT ) to assess medical and nursing students’ readiness to treat Latino patients. </li></ul><ul><li>To inform the design of focused, effective interventions in medical and nursing education for the region. </li></ul><ul><li>In the process, to learn about medical and nursing student perceptions, existing cultural competence training, and current readiness to treat Latino patients. </li></ul>
    11. 11. <ul><li>Student Provider Knowledge Indices </li></ul><ul><li>Latino Knowledge Index </li></ul><ul><li>Latino Cancer Knowledge Index </li></ul><ul><li>(e.g., knowledge of communities, culture, personal involvement, cancer rates, risk, screening) </li></ul><ul><li>Student Provider Psychological Indices </li></ul><ul><li>Comfort with Latinos Index </li></ul><ul><li>Cultural Competence with Latinos Index </li></ul><ul><li>Attitudes Toward/Beliefs About Latinos Index </li></ul><ul><li>(e.g., provider beliefs about patient compliance and cultural factors impacting care, social and behavioral factors impacting care of Lati nos) </li></ul><ul><li>Student Provider Language and Experience Indices </li></ul><ul><li>Spanish Language Proficiency </li></ul><ul><li>Previous Experience with Latinos </li></ul>Student Provider Social Demographics Sex Race Age Education (nurse/physician) Medical and Nursing Students’ Readiness to Treat Latinos in Cancer Care (MaNSRT) Theoretical Framework Model based on Van Ryn (2002)
    12. 12. INSTRUMENT DEVELOPMENT: THE HEALTH PROFESSIONALS SURVEY <ul><li>Systematic literature review (Mayo, Sherrill, et al., 2007). </li></ul><ul><li>Preliminary study conducted </li></ul><ul><ul><li>Convenience sample of n=65 junior and senior nursing students at Clemson University using draft instrument </li></ul></ul><ul><ul><li>Participating students provided feedback (e.g., face validity, question clarity and readability) </li></ul></ul><ul><ul><li>Consistent responses across sample; i.e., students did not appear to have a high level of readiness to work with Latino patients </li></ul></ul><ul><li>Cronbach’s alphas calculated for subscales to determine reliability </li></ul><ul><li>Preliminary correlations among subscales determined </li></ul><ul><li>Draft survey instrument assessed by expert reviewers </li></ul><ul><li>Focus groups </li></ul><ul><ul><li>6 focus groups </li></ul></ul><ul><ul><li>n=27 participants </li></ul></ul>
    13. 13. INSTRUMENT DEVELOPMENT (CONT.) <ul><li>Survey Revision </li></ul><ul><li>First Pilot Test (n=38 nursing students) </li></ul><ul><li>Second Plot Test (n=99 medical and nursing students </li></ul><ul><li>Further Survey Revision and Recruitment </li></ul><ul><li>Final Survey Completed </li></ul><ul><li>Implementation of Final Survey (n=1500 medical and nursing students) [[Currently in progress]] </li></ul><ul><li>Partnering Institutions: </li></ul>
    14. 14. SURVEY REVISION: PILOT TO FINAL <ul><li>Likert scale vs. Item-specific questions </li></ul><ul><ul><li>Recent opinion: Uncertainty with Likert Scale </li></ul></ul><ul><ul><ul><li>Respondent acquiescence </li></ul></ul></ul><ul><ul><ul><li>Tendency to agree with attitude statements </li></ul></ul></ul><ul><ul><li>Revision with our Survey Expert </li></ul></ul><ul><ul><ul><li>Questions with more discriminatory power </li></ul></ul></ul><ul><ul><ul><li>Changed from 1-4 response scale to 1-5 scale </li></ul></ul></ul><ul><ul><ul><li>Majority of Final Survey: Item-specific question </li></ul></ul></ul>
    15. 15. SURVEY REVISION: PILOT TO FINAL <ul><li>Likert scale vs. Item-specific questions </li></ul><ul><ul><li>Importance of Revision </li></ul></ul><ul><ul><ul><li>Removes potential bias and leading questions </li></ul></ul></ul><ul><ul><ul><li>Gathers a more direct opinion </li></ul></ul></ul><ul><ul><ul><li>Responses more representative of participant’s intuitive opinions and knowledge </li></ul></ul></ul><ul><li>Other Revisions: </li></ul><ul><ul><li>Better readability and visual aesthetics </li></ul></ul><ul><ul><li>Fluidity in question order </li></ul></ul>
    16. 16. LIKERT SCALE: PILOT SURVEY
    17. 17. ITEM-SPECIFIC: FINAL SURVEY
    18. 18. ITEM-SPECIFIC: FINAL SURVEY
    19. 19. ITEM-SPECIFIC: FINAL SURVEY
    20. 20. FOCUS GROUPS
    21. 21. FOCUS GROUPS
    22. 22. FOCUS GROUPS: THEMES <ul><li>The medical and nursing students showed some general cultural knowledge about the Latino population </li></ul><ul><ul><li>Mostly acquired from media and social influences </li></ul></ul><ul><ul><li>Also, from basic stereotypical observations made during everyday encounters with the ethnic group </li></ul></ul><ul><li>Clinical and educational settings accounted for a small percentage of the acquired knowledge of Latino cultures, behaviors and practices. </li></ul><ul><li>Students express that they are trained more “disease-oriented,” rather than “patient-oriented” </li></ul><ul><ul><li>Cultural competence training requires assessment and communication with the patient as a whole, including their family members (especially with Latinos) </li></ul></ul>
    23. 23. FOCUS GROUPS: THEMES (CONT.) <ul><li>Students did not show overt prejudice, but some admitted some discomfort in treating Latinos. </li></ul><ul><ul><li>Students revealed issues caused by poorly addressed communication barriers, especially concerning the use of interpreters. </li></ul></ul><ul><li>According to student providers, cultural competency education concerning Latinos is currently very limited. </li></ul><ul><ul><li>Some institutions recognize the need for personal non-verbal communication, some language skills and experience with interpreters. </li></ul></ul><ul><ul><li>Students perceive that institutions do not always focus on these objectives. </li></ul></ul>
    24. 24. PILOT SURVEY RESULTS: N=99 MEDICAL AND NURSING STUDENTS Key: Responses: 1-4 scale H/L=Hispanic/Latino Survey Question N Minimum Maximum Mean Standard Deviation Please indicate to what extent you agree or disagree: I am able to explain treatment options and clinical trials to H/L patients. 97 1 4 2.67 0.673 As a provider, I feel able to provide satisfactory rapport with H/L patients. 96 1 4 2.84 0.670 In providing clinical care, I will avoid speaking to H/L families because of language barriers. 98 1 4 1.54 0.691 A patient’s cultural background can make it difficult to conduct an adequate clinical assessment. 96 1 4 2.84 0.670
    25. 25. PILOT SURVEY RESULTS: N=99 MEDICAL AND NURSING STUDENTS Key: Responses: 1-5 scale H/L=Hispanic/Latino Survey Question N Minimum Maximum Mean Standard Deviation Based on your training and experience, please rate your skill level in the following aspects of care for H/L patients: Communicating effectively through a healthcare interpreter. 98 1 4 2.93 0.763 Based on your training and experience, please rate your skill level in the following aspects of care for H/L patients: Determining patients’ communication preferences. 99 1 4 2.93 0.659
    26. 26. PILOT SURVEY RESULTS: THEMES <ul><li>Student provider skills </li></ul><ul><ul><li>Variable ability to explain treatment options and clinical trials </li></ul></ul><ul><ul><li>Variable ability to build satisfactory rapport with Latino patients </li></ul></ul><ul><ul><li>Variable ability to determine communication preferences </li></ul></ul><ul><ul><li>Variable difficulty with clinical assessments due to cultural background of patient </li></ul></ul><ul><ul><li>Variable skill level communicating with interpreters </li></ul></ul><ul><li>Student provider perceptions </li></ul><ul><ul><li>Do not avoid speaking to Latino families because of language barriers </li></ul></ul>
    27. 27. CONCLUSIONS <ul><li>In general, medical and nursing students report insufficient readiness to effectively treat Hispanic/Latino patients </li></ul><ul><ul><li>Stereotypical attitudes and beliefs </li></ul></ul><ul><ul><li>Limited cultural competence skills </li></ul></ul><ul><ul><li>Barriers in the healthcare delivery system </li></ul></ul><ul><ul><li>Healthcare is still challenged with Latino-patient-provider communication skills and readiness to treat Latino patients </li></ul></ul><ul><ul><ul><li>Presents a challenge for medical and nursing schools </li></ul></ul></ul><ul><ul><ul><li>Not a traditional education model </li></ul></ul></ul><ul><ul><ul><ul><li>“ Patient-oriented” vs. “Disease-oriented” </li></ul></ul></ul></ul>
    28. 28. CONCLUSIONS <ul><li>The MaNSRT survey may be an effective instrument to assess nursing and medical student readiness to treat Latino patients. </li></ul><ul><ul><li>Also indicate the need for improved cultural competence education, especially in the Southeast </li></ul></ul><ul><ul><li>Applied to any student provider program or health profession to employ interventions </li></ul></ul><ul><li>The MaNSRT survey is currently being implementing with medical and nursing students of four institutions in the Southeast. </li></ul><ul><ul><li>Preparation to be used universally </li></ul></ul><ul><ul><li>Currently recruiting more medical and nursing programs to participate in the MaNSRT survey </li></ul></ul>
    29. 29. SURVEY PARTICIPATION <ul><li>If your institution or educational program would be interested in participating in our next survey, please contact our team. </li></ul><ul><ul><li>Jessica Meehan </li></ul></ul><ul><ul><ul><li>[email_address] </li></ul></ul></ul><ul><ul><ul><li>(856) 305-0110 </li></ul></ul></ul><ul><ul><li>Dr. Windsor Sherrill </li></ul></ul><ul><ul><ul><li>[email_address] </li></ul></ul></ul><ul><ul><li>Dr. Rachel Mayo </li></ul></ul><ul><ul><ul><li>[email_address] </li></ul></ul></ul>
    30. 30. QUESTIONS?

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