“Fui a la Bristol”

Anecdotal Healthcare for the Latino Patient in Santa Ana

Laura Chaverri M.D.February 13, 2019

Population

Latinos comprise 18 % of US population with projections to 30% by 2050

As of 2012 the largest percentage of Latinos are in New Mexico at 47%.

California has the highest number overall with 14 million or 38%.

7.4% of all the physicians in the US are Latino with 4% in CA and numbers are dropping overall

1/3 are expected to retire within the next 10 years

Demographics of Santa Ana 2010

78.2% Hispanic/Latino

80% Mexican

Remainder are mostly Central American from

El Salvador, Guatemala, Honduras

South American: Ecuador, Peru, Columbia

Cubans and Puerto Ricans ( less than 1%)

Young population: median age in Santa Ana is 29 years

Density is 4.6 per housing unit making Santa Ana the most densely populated city in America with a population over 50,000

Top causes of deaths in Latinos

1. Heart disease

2. Malignant neoplasms ( cancer)

3. Accidents

4. Human immunodeficiency virus infection (HIV) , rate is 7 X higher in Latinas

5. Homicide

6. Strokes

7. Diabetes mellitus

8. Chronic liver disease and cirrhosis

Disproportionately higher rates of obesity and diabetes mellitus

69 percent of Mexican Americans older than 20 years are obese, compared with 33 percent of the non-Latino white population

11.8 percent of Latinos older than 20 years have type 2 diabetes (13.3 percent of Mexican Americans)

A higher-calorie diet, a more sedentary lifestyle, and genetic factors contribute to this problem

Because of less access to health care, Latinos with diabetes are often diagnosed later and have a greater risk of complications.

We are not all the sameEducational level

English language proficiency

Financial resources

Adherence to folk customs and beliefs

Country of origin

Health status

Preferred language; dialect variances

Among the first concepts that health care providers must take into consideration when treating Latinos is that there is huge sub-cultural variation in the Latino population. The Latino population in the United States is incredibly diverse having origins in Mexico, Central and South America and the Caribbean. Each of these sub-areas has its own linguistic and dialectic variations as well as differences in beliefs, lifestyles, and customs.

U.S born vs. Immigrant vs. time in the U.S.

Recognize that social and cultural differences exist between Latinos from different rural and urban environments, socioeconomic classes, levels of education and acculturation, and attitudes toward health care delivery modalities.

DiabetesI have found that my thin patients who appear to have more Indian background are more difficult to control

Studies show Spanish-speaking patients who are treated by Spanish-speaking clinicians tend to have better control of their diabetes

Latino men may have major concerns about sexual function.

Nonprofessional suggestions from trusted friends or family members often displace the health care provider's medical advice

Cancer

incidence of cancer is generally lower, however incidence of stomach, liver, and cervical cancer is significantly higher

Mexican Americans have the highest global incidence of gallbladder cancer. Genetic predisposition toward chronic gallstones, which stems from hereditary factors affecting cholesterol secretion in bile, may play an important role. High-calorie diets and obesity, may also explain the increased risk

Unintentional deaths highest unintentional fatal occupational injury rate.

demand high physical labor and tend to be dangerous and unpleasant.

language barriers during training and on the job

the assignment of more hazardous tasks

employer's unwillingness to invest in safety training,

better equipment, and protective gear for recruits who may be seasonal, transient, or undocumented laborers.

Chronic liver disease Chronic infection with hepatitis B or hepatitis C. Citizens of Brazil,

Ecuador, and Venezuela experience a high prevalence of hepatitis B

Higher prevalence rates of hepatitis B infection and antibodies to HCV have been found among Mexican Americans with more treatment resistant genotypes

Although alcohol consumption among Hispanics is lower than that of United States whites, Hispanics have a higher mortality rate from hepatic cirrhosis

Latino men are more likely to binge-drink heavily

Higher rate of fatty liver leading to cirrhosis

Primary Barrier

shortage of bilingual AND bicultural providers so patients can feel open about

their concerns and complaints

Barriers• may view the unfamiliar U.S. health care system as intimidating

and unfriendly

• believe they receive lower quality medical care and lesser treatment because of discrimination and racism and perceived health provider bias

• language

• limited education

• limited financial resources

• fear of deportation ( Prop 187)

• lack of transportation

• don’t get sick time to go to doctor

More barriers to good health

• two jobs

• live in unsafe neighborhoods and cannot walk outside once it is dark

• no parks or recreation close by

• Working poor

• Healthy foods are expensive

• Embarrassment and procrastination may prevent from seeking health care

Literacy

Determine level of literacy to help determine how to proceed; can he/she read or write ? In English?

Take the time to give simple explanations

Make sure the patient understands

Encourage questions

Be prepared to explain things several times

Write out critical instructions

Is there someone who can translate at home?

“Personalismo”Early attention to building rapport will go a long way to facilitate communication

Rapport begins through exchange of pleasantries or chit-chat before beginning the business of medical history-taking and physical examination

It is expected health care personnel to be warm and personal and express a strong need to be treated with dignity

Personalismo, part 2

disrespectful to greet by first name

may be viewed as dismissive through brusque or blunt manner, especially now with EHR

easily discouraged if not polite

may feel it is an inconvenience to bother the doctor with their worries and may not advocate for themselves

hold doctors in high regard but doesn’t always carry over to PA’s or NP’s and feel they are getting substandard care

holistic views, spiritual health very important

Fatalismo• Strong belief that uncertainty is inherent in life and each day is taken as it

comes. The term is often used by Latinos to express their belief that the individual can do little to alter fate

• This mindset manifests in health beliefs and behaviors in significant ways

• Latino patients are more likely than whites to believe that having a chronic disease like cancer is a death sentence

• defeatist attitude, chronic disease is little short of a death sentence “ I suffer from”, “I am sick”

• They may prefer not to know if they have cancer, and may believe that cancer is God’s punishment

• As a result may be less likely to seek preventive screenings and may delay visiting a western doctor until symptoms become severe. They may avoid effective therapies for cancer and other chronic diseases, especially radical new treatments and invasive procedures

“Respecto”

Means that each person is expected to defer to those who are in a position of authority because of age, gender, social position, title, economic status, etc.

Healthcare providers, and doctors especially, are viewed as authority figures

They may be hesitant to ask questions or raise concerns about a doctor’s recommendations, being fearful that doing so might be perceived as disrespectful

They may nod to demonstrate careful listening and respect when a doctor is talking, rather than agreement about treatment

Verify which language they prefer

Don’t be offended by the weak female handshake

Don’t use the “tu” forms, use “Usted”

Much of our population have jobs that require repetitive motion and/or heavy physical labor

Usually not born in the US

Many of our patients are raising their grandchildren due to the child’s parents incarceration, mental illness or substance abuse

Some Latinos find their health care in non-clinical places, relying on folk medicine and traditional healers. This reliance does not necessarily replace modern biomedicine; rather, herbal remedies and other non-allopathic treatments often are utilized in conjunction with Western medical care. One way of describing the distinction is that modern Western doctors are primarily trained to diagnose and treat diseases (in a purely biomedical sense), while traditional healers approach the patient as one suffering from an illness-that is, a culturally located experience of sickness.Among some Latino subcultures, folk illnesses such as empacho (a digestive ailment), mal de ojo (the "evil eye"), mollera caida (fallen fontanelle), susto (fright illness), and nervios (vulnerability to stressful experiences) are commonly described; and traditional healers range from curanderos (Mexican healers) and sobadores (traditional masseuses and bone setters) to yerberos (herbalists) and espiritistas (spiritual healers).Reliance on folk medicine certainly is not to be found in every, or even most, Latino communities; but it does exist as part of the health care landscape and is found among many patients from Mexico, as well as from various other regions within Latin America. Significantly, some patients appear to experience greater improvement after meeting with folk practitioners than with Western doctors.

Our patients tend to -

our patients tend to not refill the meds when they run out thinking treatment is over

Will stop treatment once symptoms disappear

Will stop chronic disease meds “because I feel fine, doc!” or “ I am taking too many medications”

More likely to take the medical advice of a family member or friend

Buy medications in Mexico

Narrow the Gap

• Non Latino physicians need to be prepared to be culturally effective with the medical care of a large and growing population of Latino patients

• Proper Use of a Translator

• Use of promotoras – these are people that are specially trained from the community to render patient education

Use health education in Spanish

“Fuí a la Bristol”

Many of our patients think because we are closed on the weekends that they have to go to outside doctors and they go to the cash medical clinics that are numerous on Bristol .

These providers charge at least $100 for the visit with extra charges for shots such as Vitamin B12 and antibiotics. They also package acetaminophen and ibuprofen and sell them at inflated prices

Meds Dispensed by a local physician

“Dr. Pacheco”One of the realities that we face today is that alternative therapies are usually not documented in writing

Word of mouth is the favored method of transmission of culturally-based information

Stories about alternative therapies also frequently appear in the media, and this is especially true of the ethnic media

BOTANICAS

Herbal remedies (Remedios caseros)

Folk medicine

Commonly Used Herbs

Spanish name English name Medicinal use

Siete azares Seven blossoms (Passion Flower, Linden Flower, Rose Petals, Chamomile, Anise Seeds, and TiloStar

Insomnia and anxiety

Barbas de elote Corn silk Diuretic

Arnica Arnica Swelling

Nopales Cactus palms Diabetes

Linaza Flaxseed Cholesterol lowering

Savila Aloe vera, sage Wound healing

Manzanilla Chamomile GI

hierbabuena Spearmint GI

Spanish name Common name Medicinal use

Semilla de apio Celery seed Arthritis

Uña de diablo Devil’s claw arthritis

Eucalipto Eucalyptus URI

Ruda Rue Antispasmodic, used for dysmenorrhea, eye strain

Cola de caballo Shave grass Diuretic

Uña de gato Cat’s claw Immune booster

Valeriana valerian Insomnia

Betamethasone-clotrimazole-bacitracin

Injectable Vitamin B complex

http://www.arizonacert.org/medical-pros/herbs/hispanic-herbs.pdf

Nopales

Used widely to help decrease blood sugar

Common Myths

high cholesterol makes you dizzy

Insulin causes blindness

“un coraje” (an episode of anger) or “un susto”

can cause diabetes, high blood pressure , stroke

Eye twitching is the sign of a stroke

Therapeutic Xrays

Good doctors order lots of labs

Stepping on cold floors cause colds

Lower quality of care if meds not prescribed at visit “ the doctor didn’t do anything for me”

A common pediatric folk illness that concerns parents is caida de la mollera (sunken fontanel). Thought to occur when the nipple is pulled suddenly from the infant's mouth, this is believed to cause the soft palate to be pulled down, which in turn causes the anterior fontanel to be drawn down. Treatment is often initiated by the mother or grandmother and involves sucking vigorously on the anterior fontanel. This treatment may result in bruising on the head and may be mistakenly interpreted as a sign of child abuse. If a curandero is summoned, they may push up on the soft palate during a healing ceremony, effectively curing the illness. An alternate folk treatment for caida de la mollera is to turn the baby upside down for approximately one minute and then tap the baby's feet three times. This will reportedly elevate the fontanel to its normal position.

The sunken anterior fontanel seen with caida de la mollera may actually be a symptom of dehydration. look for other symptoms of dehydration, including tachycardia, dry mucous membranes and decreased urine production.

Mollera caida

Sobadora actually translates to “masseuse”.

they are providers, usually women in the community that are sought after to help with fertility and aches and pains after an injury. Many times they can assess the position of the uterus (anteverted vs. retroverted) and if it is retrovertedthe “uterus has fallen” and is thought to lead to infertility

“La sobadora me dijo que tengo la matríz caida”

Mi epsoso me cuida Coitus interruptus or condoms

Me duele el pulmón Upper back pain

Me duele el rinón Low back/flank pain

Me duele la cintura Low back pain

Para botar el agua Diuretic

Me duele los ovarios Usually lower abdominal pain, not always pelvic pain

Un doctor “particular” Doctor in private practice

Decaiminientos; ánimo decaído fatigue and listlessness

Miedo de quedar chueca Hemiplegia from a stroke

limpia Colon cleansing ; spiritual cleansing

Fiebre por dentro Not a fever

When they say…..…they mean

Things to keep in mind

Diabetes: screen EVERYONE once a year!

HTN

Hyperlipidemia

TB

Cystercercosis

Osteoporosis at a younger age

Illiteracy

Use of other’s medications or meds they bought in TJ

some home remedies and candies can be tainted with lead

“Vaporu”

To get patient instructions in Spanish:Google “the diagnosis in english” Spanish

Google the meds they bought in their country

Concluding Remarks Hispanics/Latinos comprise a large proportion of the population in Orange

County, as well as a large part of the population growth of the county. As such, the health status of this community greatly impacts the pulse of the entire community.

Barriers include poor access, poverty, miscommunication

Build trust

empathize

appreciate unique cultural values, struggles and perceptions of disease

As with any patient you may encounter respect, kindness and a smile is paramount

More http://www.newsweek.com/hispanic-doctor-shortage-

community-need-73465

http://www.newsweek.com/unlicensed-doctors-fill-need-

hispanic-mds-73235

http://www.newsweek.com/health-care-hispanics-are-

diverse-population-73233

https://www.aafp.org/afp/2013/0101/p48.html

http://latinophysiciansofca.org/diverse-state-californias-

latino-doctors-push/

http://hogarhispano.homestead.com/hispanichealth.html