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
Slide by Valery Yontz, PhD, University of Hawaii
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
Slide by Valery Yontz, PhD, University of Hawaii
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
Slide by Valery Yontz, PhD, University of Hawaii
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
Slide by Valery Yontz, PhD, University of Hawaii
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
Slide by Valery Yontz, PhD, University of Hawaii
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
Slide by Valery Yontz, PhD, University of Hawaii
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
Hispanics/Latinos: Key Cultural Points
Orientation to Time Flexible sense of time
Food Practices Very traditional Special events Family traditions
Hispanics/Latinos: Key Cultural Points
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.
Hispanics/Latinos: Key Cultural Points
Birth and Death Rituals Male/Female roles well defined during
funeral and births Women pampered more during pregnancy Cultural traditions practiced at funerals
Hispanics/Latinos: Key Cultural Points
Spiritual and Religious Orientation Catholics Some develop special relationships with
saints Some superstitions Sacrifice in the world is helpful to salvation
Hispanics/Latinos: Key Cultural Points
Bio-Cultural Ecology Higher caries, periodontal disease prevalence.
Lower prevalence of oral pharyngeal cancer Physical appearance: From American Indian to
European characteristics
Hispanics/Latinos: Key Cultural Points
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
Hispanics/Latinos: Key Cultural Points
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
Hispanics/Latinos: Key Cultural Points
Health Practices and Practitioners Family care for young and old Discuss health of family members Respond well to individualized attention
Hispanics/Latinos: Key Cultural Points
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.”