CULTURAL CONSIDERATIONS IN THE DELIVERY OF DENTAL SERVICES TO THE HISPANIC COMMUNITY E. Angeles Martínez-Mier, DDS, MSD, PhD Ana G. Gossweiler, DDS, MSD

CULTURAL CONSIDERATIONS IN THE DELIVERY OF DENTAL SERVICES TO THE HISPANIC

COMMUNITY

E. Angeles Martínez-Mier, DDS, MSD, PhD

Ana G. Gossweiler, DDS, MSD

U.S. Demographics

Rapidly becoming more diverse Minority populations growing at a fast

pace Hispanic group becoming the largest

minority group in the U.S.

Indiana Demographics

Population has tripled between 1990 and 2002 Mexicans 60% Median age 25

13% of the population in Indiana Indianapolis 65 000 to 85 0000 according

to local studies

Hispanics or Latinos in Indiana

Hispanics or Latinos of any race 214,536Mexican 153,042Puerto Rican 19,678Cuban 2,754Others 39,062

U.S. Census Bureau, Census 2000

Culture

What is it? Where is it found? Who has it? When is it used? Why is it important?

Culture

The skills, art, etc., of a given people in a given period, civilization

Webster’s New World Dictionary

Culture

Slide by Valery Yontz, PhD, University of Hawaii

Culture is: Guides how people live What they believe and value How they communicate What are their habits, customs and tastes Guides the ways they meet various needs

of society How goods and services are produced and

distributed

Definitions

Cross-cultural Intercultural Subculture Values Beliefs Stereotyping Ethnocentrism

Cross-cultural

Refers to any comparison of cultural differences or the situations in which such differences exist

Intercultural

Refers to the actual interaction between people of different cultures

Subculture

Formed by a group of persons who have developed interests or goals different from the primary culture, based on such things as occupation, sex, age, social class, or religion.

Values

Ideas about what is right and wrong, desirable and undesirable, normal and abnormal, proper and improper

A set of organized rules for making choices, reducing uncertainty and reducing conflicts within a given society

Beliefs

Belief is a psychological state in which an individual holds a premise or an argument to be true without necessarily being able to adequately prove their point to other people who may or may not agree.

Stereotyping

Refers to the common behavior of assuming that individuals possess certain characteristics or traits because they are members of a particular group.

Fails to recognize the individual

Ethnocentrism

Natural belief that one’s culture is superior to that of others

Care is needed not to demean clients whose oral health practices may be rooted in culture rather than scientific fact

Iceberg Concept

Primarily out of Awareness

Primarily in Awareness

Is the culture always visible to the observer?

Primarily in Awareness

Fine arts Literature Drama Music Dancing Games Cooking Dress

May be obvious to the observer

Primarily Out of Awareness

Notions of modesty Conceptions of beauty Patterns for handling emotions Conception of self Conception of justice Decision making patterns Attitudes toward the dependent Patterns of superior/subordinate

relationship

Not necessarily obvious to the observer

Health Care Issues Related to Culture

Culture influences: - communication (language, tone,

nonverbal communication) - trust - behavior - understanding wellness and illness - seeking health care - receiving and complying with care

Cultural Competency’s Definition


The ongoing process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different people. Includes the capacity to respond appropriately to the needs of populations whose cultures are different from what might be “the dominant or mainstream culture.”

Goals of Cultural Competency


Self- exploration Personal development Attitude and values clarification Ethnic and cultural literacy Empowerment—equality and excellence Basic skills proficiency Social competency

Skills and Characteristics of Cultural Competency


Respectful Willingness to share, risk change,&

explore Understand the power of action and words Ability to recognize learning opportunities Possessing knowledge of one’s self Being aware of ignorance Having attitude that “Different is okay: not

good or bad

Right or Wrong

“We must be able to recognize and deal with beliefs of others if we wish to obtain communication.”

Samovar & Porter

Intercultural Communication

Good Bad

http://www.yourpointofview.com/

Bad Good

http://www.yourpointofview.com/

Cultural Competency Components


Develop an awareness of one’s own existence

Demonstrate knowledge and understanding of other cultures

Accepting/respecting cultural differences Stop assuming that others’ beliefs and

values are the same as yours Stop judging attitudes as good or bad Be open to range of cultural encounters Adapt to be congruent with other cultured

persons

Cross’s Cultural Competency Continuum


Cultural destructiveness Cultural incapacity Cultural blindness Cultural pre-competence Cultural competence Cultural proficiency

Cross, T; 2001

Why is cultural competenceimportant to dental professionals? It assist in recognizing the elements of culture that are relevant during a patient care (communication issues, religion, family networks, gender norms, sense of humor, etc…)

Benefits of gaining intercultural competence

Provide compatible messages with patient’s cultural values and beliefs

Increase the relevancy of health education

Increase effectiveness of dental care with a diverse client

Increase a practitioner’s multicultural knowledge

Cultural Assessment Domains


Ethnic identity/history Communication Activities of daily living Orientation to time Food practices Family relationships Birth and death rituals Spiritual/religious orientation Bio-cultural ecology Illness beliefs High-risk behaviors Health practices and practitioners

Hispanics/Latinos: Key Cultural Points

Ethnic Identity and History Latin America designates all those countries and

territories in the Americas where languages derived from Latin are spoken: Spanish, Portuguese, French, and their creoles.

The region was home to many indigenous peoples and advanced civilizations (Aztecs, Mayan, and Incas). With the arrival of the Europeans the indigenous peoples lost power to the Europeans. European powers, most notably Spain and Portugal, colonized the region. After independence movements, the countries of the region became independent by the late 19th century.

Diversity within the Hispanic Community

People in Latin America are a mixture of many racial groups.

Their origins include over 22 countries

While Spanish is usually the common language, there is a wide variety of idiomatic speech patterns and dialects

Diversity = Mix of Cultures

Hispanics/Latinos: Key Cultural Points Communication

Casual conversation prior to “the point” Resistance to lose language Maintain outward expressions of dignity

and calm Touching, kissing, hugging between family

in public Make eye contact, hold hands, hug

Hispanics/Latinos: Key Cultural Points Activities of Daily Living (ADLs)

Respect for tradition Hard working Follow cultural/family practices, cleaning,

cooking, etc. (practice of traditional things in the U.S.)

Collectivism

Latinos prefer the company of others versus being alone.

Sharing is an activity that is an outgrowth of collectivism.

Drinking alcohol and smoking are experiences that are shared with other friends. How long a man drinks with his friends is often

determined by when his wife arrives to tell him it is time to come home.

Chong, The Latino Patient


Orientation to Time Flexible sense of time

Food Practices Very traditional Special events Family traditions


Family Relationships Connectedness to extended family Children taught to repress aggressive and

assertive behavior Machismo/Marianismo

Cultural values and gender Machismo

refers to the man’s masculinity and puts the man at the center of the social life. It is exhibited through courage and authoritarian attitude

Marianismo Refers to the woman’s position at

home and in the family. A woman earns respect through her dedication to her children and husband

Cultural values and gender As the need for income increases,

there is greater financial pressure on the wife to enter the workforce.

As she contributes to the family income, she will attain more independence and greater parity in the family decision making process.

Her exposure to the workplace and her social contacts outside the home will tend to accelerate the process of acculturation.


Birth and Death Rituals Male/Female roles well defined during

funeral and births Women pampered more during pregnancy Cultural traditions practiced at funerals


Spiritual and Religious Orientation Catholics Some develop special relationships with

saints Some superstitions Sacrifice in the world is helpful to salvation


Bio-Cultural Ecology Higher caries, periodontal disease prevalence.

Lower prevalence of oral pharyngeal cancer Physical appearance: From American Indian to

European characteristics


Illness Beliefs Illness result of bad luck or God’s punishment.

The causes of some illness are found outside the body. Powers of good and evil.

Illness prevented by proper diet, wearing amulets, use of candles, avoiding harmful people

May use combination of folk and Western Medicine

Folk Healers

Use of Natural Healers / Curanderos / SpiritistsHarmful Magic: Evil-eye/Mal de ojo: Excessive admirationFright/Susto: Associated with a traumatic experienceEvil-hex/Mal Puesto: Motivated by jealousy or vengeance

Gomez 1977

Folk Medicine

Perception of Health and Education

Educated Latinos: Healthy refers to “a state of complete

physical, mental, and social well-being and not merely the absence of disease.”

World Health Organization Less Educated Latinos:

Health has a religious perspective. Disease is seeing as a warning or punishmentGod is the giver of all, including my health


High Risk Behaviors Diet Infants should “eat well”

“No come bien” Bottle feeding at night

Nutritional habits and acculturation The Latino/Hispanic diet is very diverse. But, in

general the diet is low in vegetable fats and high in fiber content when compared with non-Latino whites diets

The less acculturated the Hispanic patient is, the more likely they are to eat fruits, rice, beans, meat, fried food and whole milk

More acculturated Latinos have diets that are a risk factor for obesity, diabetes and hypertension

Alcalay et al. 1999, Otero-Sabogal et al. 1995, Alcalay et al. 1992


Health Practices and Practitioners Family care for young and old Discuss health of family members Respond well to individualized attention


Health Practices and Practitioners Use of herbs to cure dental diseases Clove – anesthetic properties Honey – healing properties –soft tissue Eruption of primary teeth linked to many

diseases Tooth “mouse”, not tooth fairy

What is a culturally-competent dental professional? A health care provider that understands:

The beliefs, values, traditions and practices of a cultural group that influence oral health.

Their patients culturally-related needs, illness and health beliefs, health practices and approaches to seeking care.

Suggestions for the Dental Team Determine your client’s language skills, health beliefs

and behaviors, dietary preferences, and cultural remedies for illness

Attempt to make connections between cultural remedies and current standards of care

Translate context instead of just words Examine current office hours Provide patient material in appropriate language and

educational level Work with community health partners to increase the

health of the community Create community partnerships

Things to Avoid

Judgmental phrases Imposing White Culture Explaining minority issues via “lower on

the evolutionary scale” Stereotyping

Health Disparities

Health disparities refer to gaps in the quality of health and health care across racial and ethnic groups.

The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care."

Healthy People 2010

“To promote oral health and prevent oral diseases, oral health literacy among all groups is necessary. In addition, oral health services – preventive and restorative – should be available, accessible, and acceptable to all persons in the United States. In areas where different languages, culture, and health care beliefs would otherwise be barriers to care, a cadre of clinically and culturally competent providers must be available to provide care.”

CDC

Barriers to Health Care Access that are Related to Health Disparities Lack of insurance coverage, language barriers,

lack of cultural awareness, limited or no bilingual resources or staff, and little or no Spanish language literature

Oral Health In America: A report of the Surgeon General THE INDIANA COMMISSION ON HISPANIC/LATINO AFFAIRS

What barriers to health care access can be decreased by culturally competent health professionals?

Lack of insurance coverage, language barriers, lack of cultural awareness, limited or no bilingual resources or staff, and little or no Spanish language literature

Oral Health In America: A report of the Surgeon General THE INDIANA COMMISSION ON HISPANIC/LATINO AFFAIRS

Health Disparities

Dental Epidemiological Data

Home Page - NIDCR/CDC Dental, Oral and Craniofacial Data Resource Center (DRC)

Samuel Betances

“We cannot tell people to forget what they know. We cannot argue that it is better to know less rather than more.”

Documents

CULTURAL CONSIDERATIONS IN THE DELIVERY OF DENTAL SERVICES TO THE HISPANIC COMMUNITY E. Angeles Martínez-Mier, DDS, MSD, PhD Ana G. Gossweiler, DDS, MSD