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 NursingClemson University

Clemson, South Carolina

OUTLINE Current Issue (Introduction/Background)

Communication barriers causing health disparities for Latinos

Study Purpose Develop a tool to measure student provider

readiness to treat Latinos Learn about student provider perceptions and

cultural competence in treating Latino patients Instrument Development (Methods) Focus Groups (Results) Pilot Surveys (Results) Conclusions/Further Research

Final survey currently in progress (n=1500 medical and nursing students)

SIGNIFICANT CHANGE NATIONALLY IN THE SOUTHEAST

NATIONAL GROWTH IN THE LATINO POPULATIONLatino Non-Latino

WhiteTotal Nation

2010 2000 2010 2000 2010 2000Percent 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 1Georgia 96 11North Carolina 111 6Tennessee 134 3

LARGEST CHANGE IN LATINO POPULATION, BY STATE

(U.S. Census Bureau, 2010)

RESULTING HEALTHCARE ISSUES AND DISPARITIES FOR LATINOS

More than 1 in 4 Hispanics lack a usual healthcare provider. (Pew Hispanic Center/Robert Wood Johnson Foundation, 2008)

Hispanics are 3 times as likely as non-Hispanic whites to lack a usual healthcare provider. (Centers for Disease Control and Prevention, 2006)

17.8% of Hispanics of all ages report being in fair or poor health. Compared with 11% of non-Hispanic whites. (The Commonwealth Fund, 2008)

RESULTING HEALTHCARE ISSUES AND DISPARITIES FOR LATINOS (CONT.)

23% of Latinos report having received poor quality of medical treatment or care in the last year (Pew Hispanic Center, 2008)

The healthcare provider community does not reflect the ethnic diversity of the patient community in the Southeast. Under-represented as providers

CHALLENGE—COMMUNICATION BETWEEN LATINO PATIENTS AND PROVIDERS “[H]ispanics and Asians report more difficulty

communicating with their doctors than both whites and blacks.” (Mead, et al., 2008)

“[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)

“[E]fforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.” (Morales, et al., 1999)

“[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)

DEFINING CULTURAL COMPETENCE “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.” The Commonwealth Fund (Betancourt, et al., 2002)

Skill sets and cultural knowledge that we can emphasize to prepare our future providers.

HOW TO ADDRESS THE COMMUNICATION CHALLENGE

Improved readiness to treat Latino

patients

THIS STUDY: GOALS AND OBJECTIVES Student Provider Perceptions of Latino Patients in

Cancer Care Settings, NIH/NCI Grant 1R15CA135349-01A2 (PIs: Mayo, RM; Sherrill, WW)

To develop and evaluate an instrument (MaNSRT) to assess medical and nursing students’ readiness to treat Latino patients.

To inform the design of focused, effective interventions in medical and nursing education for the region.

In the process, to learn about medical and nursing student perceptions, existing cultural competence training, and current readiness to treat Latino patients.

Student Provider Knowledge Indicesa.Latino Knowledge Indexb.Latino Cancer Knowledge Index(e.g., knowledge of communities, culture, personal involvement, cancer rates, risk, screening)

Student Provider Psychological Indicesa.Comfort with Latinos Indexb.Cultural Competence with Latinos Indexc.Attitudes Toward/Beliefs About Latinos Index(e.g., provider beliefs about patient compliance and cultural factors impacting care, social and behavioral factors impacting care of Latinos)

Student Provider Language and Experience Indices

a.Spanish Language Proficiencyb.Previous Experience with Latinos

Student Provider Social DemographicsSexRaceAge

Education (nurse/physician)

Medical and Nursing

Students’ Readiness to

Treat Latinos in Cancer Care(MaNSRT)

Theoretical Framework

Model based on Van Ryn (2002)

INSTRUMENT DEVELOPMENT: THE HEALTH PROFESSIONALS SURVEY Systematic literature review (Mayo, Sherrill, et al.,

2007). Preliminary study conducted

Convenience sample of n=65 junior and senior nursing students at Clemson University using draft instrument

Participating students provided feedback (e.g., face validity, question clarity and readability)

Consistent responses across sample; i.e., students did not appear to have a high level of readiness to work with Latino patients

Cronbach’s alphas calculated for subscales to determine reliability

Preliminary correlations among subscales determined Draft survey instrument assessed by expert reviewers Focus groups

6 focus groups n=27 participants

INSTRUMENT DEVELOPMENT (CONT.) Survey Revision First Pilot Test (n=38 nursing students) Second Plot Test (n=99 medical and nursing students Further Survey Revision and Recruitment Final Survey Completed Implementation of Final Survey (n=1500 medical

and nursing students) [[Currently in progress]]

Partnering Institutions:

SURVEY REVISION: PILOT TO FINALLikert scale vs. Item-specific questions

Recent opinion: Uncertainty with Likert ScaleRespondent acquiescenceTendency to agree with attitude statements

Revision with our Survey ExpertQuestions with more discriminatory powerChanged from 1-4 response scale to 1-5 scaleMajority of Final Survey: Item-specific question

SURVEY REVISION: PILOT TO FINALLikert scale vs. Item-specific questions

Importance of Revision Removes potential bias and leading questionsGathers a more direct opinionResponses more representative of participant’s intuitive opinions and knowledge

Other Revisions:Better readability and visual aestheticsFluidity in question order

LIKERT SCALE: PILOT SURVEY

ITEM-SPECIFIC: FINAL SURVEY

ITEM-SPECIFIC: FINAL SURVEY

ITEM-SPECIFIC: FINAL SURVEY

FOCUS GROUPS

FOCUS GROUPS

FOCUS GROUPS: THEMES The medical and nursing students showed some

general cultural knowledge about the Latino population Mostly acquired from media and social influences Also, from basic stereotypical observations made during

everyday encounters with the ethnic group

Clinical and educational settings accounted for a small percentage of the acquired knowledge of Latino cultures, behaviors and practices.

Students express that they are trained more “disease-oriented,” rather than “patient-oriented” Cultural competence training requires assessment and

communication with the patient as a whole, including their family members (especially with Latinos)

FOCUS GROUPS: THEMES (CONT.) Students did not show overt prejudice, but some

admitted some discomfort in treating Latinos. Students revealed issues caused by poorly addressed

communication barriers, especially concerning the use of interpreters.

According to student providers, cultural competency education concerning Latinos is currently very limited. Some institutions recognize the need for personal

non-verbal communication, some language skills and experience with interpreters.

Students perceive that institutions do not always focus on these objectives.

PILOT SURVEY RESULTS:N=99 MEDICAL AND NURSING STUDENTSSurvey Question N Minimum Maximum Mean Standard

DeviationPlease 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

Key: Responses: 1-4 scale

H/L=Hispanic/Latino

PILOT SURVEY RESULTS:N=99 MEDICAL AND NURSING STUDENTS

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

Key: Responses: 1-5 scale

H/L=Hispanic/Latino

PILOT SURVEY RESULTS: THEMES Student provider skills

Variable ability to explain treatment options and clinical trials

Variable ability to build satisfactory rapport with Latino patients

Variable ability to determine communication preferences

Variable difficulty with clinical assessments due to cultural background of patient

Variable skill level communicating with interpreters Student provider perceptions

Do not avoid speaking to Latino families because of language barriers

CONCLUSIONS In general, medical and nursing students report

insufficient readiness to effectively treat Hispanic/Latino patients Stereotypical attitudes and beliefs Limited cultural competence skills Barriers in the healthcare delivery system Healthcare is still challenged with Latino-

patient-provider communication skills and readiness to treat Latino patients

Presents a challenge for medical and nursing schoolsNot a traditional education model

“Patient-oriented” vs. “Disease-oriented”

CONCLUSIONS The MaNSRT survey may be an effective

instrument to assess nursing and medical student readiness to treat Latino patients. Also indicate the need for improved cultural

competence education, especially in the Southeast Applied to any student provider program or health

profession to employ interventions

The MaNSRT survey is currently being implementing with medical and nursing students of four institutions in the Southeast. Preparation to be used universally Currently recruiting more medical and nursing

programs to participate in the MaNSRT survey

SURVEY PARTICIPATION If your institution or educational program

would be interested in participating in our next survey, please contact our team. Jessica Meehan

jnmeeha@g.clemson.edu (856) 305-0110

Dr. Windsor Sherrill wsherri@clemson.edu

Dr. Rachel Mayo rmayo@clemson.edu

QUESTIONS?