Even beyond the barriers of language and culture, attempts at effective outreach to the Hispanic community may profoundly challenge health providers in varied and unexpected ways. Strategies for developing and bringing new health models, education and access to individuals within their own community settings are an essential but largely overlooked component of the health care system in the United States. Community-based organizations within Hispanics neighborhoods, barrios, colonias, and other ethnic enclaves provide a significant point of entry and opportunity to expand on any outreach effort you may be involved in.

While the health care system has established some links to historically black universities, colleges, and medical schools, and through health-education programs and African-American churches; limited relationships exist with the Hispanic community. In fact, the Hispanic community has a completely different institutional structure when it comes to issues of health and health services, a structure with little organic or historical connection to mainstream providers. In America's barrios and colonias there are no "Historically Hispanic" colleges and universities or medical schools and the Catholic Church, with over three-quarters of all Hispanics, sees its focus on the spiritual aspects of life.

As a result, a network of hundreds of local community-based organizations have emerged in almost every Hispanic community in America. For the past 30 years, these organizations have acted as frontline advocates for and providers of Hispanic health care and social services, yet continue to struggle for existence because of limited funding.

Strategies for bringing new health models, education and access to individuals within their own community settings are an essential but largely overlooked component of the health care system in the United States.

...a network of hundreds of local community-based organizations have emerged in almost every Hispanic community in America.

In 1996, in New Mexico, Youth Development, Inc. (YDI) was able to move a youth outreach program from a gym-based after-school setting to its own community training center, a converted 2,000 square foot residential house in the south valley section of Albuquerque. Since many of the twenty-five 9 to12 year-old students YDI worked with each year were "latchkey" kids (children who returned home from school while their parents were still at work), the organization was able to utilize this house as a training facility for home safety and nutrition. Along with basic instruction on safety hazards such as exposed electrical plugs, they also instructed the children, many of whom already cooked for themselves and their younger brothers and sisters, on how to safely prepare healthy and nutritious Hispanic meals. Along with showing them videos on nutrition and health, and providing recipes, YDI staff and a volunteer chef also gave them hands-on cooking instructions in the center's kitchen. The effectiveness of the program was confirmed when a number of the kids' parents began asking for and receiving instructions on how to prepare these healthy Hispanic recipes.⁸⁶

...in Chicago . . . Pilsen-Little Village Community Mental Health Center provided an after school and summer school program for children whose families are in treatment for substance abuse.

In Los Angeles, youths were taken on a field trip to Kaiser Permanente's Sunset Hospital in Hollywood. There they learned about health care issues, saw how a hospital works, and met with physicians, nurses, a physical therapist, and other health care professionals. After the tour they all expressed their desire to work in health care. After a similar tour of the UCLA campus, all the youngsters announced they wanted to be college students and health care providers. They were told they could do both.

As a result of Kaiser Permanente's participation in this project, the East Los Angeles Multicultural Area Health Education Center (MAHEC) was granted funds to provide childhood immunization services, and began to consider other ways in which it, as a health care institution, could participate in preventative and outreach role-modeling opportunities for Hispanic and other youths from underserved communities.⁸⁷

Key Concept

To earn confianza in a targeted community find out who is respected in the community.

Don't assert your agenda, instead listen for the community's agenda — what people are asking for — and assign your priorities based on their needs.

...outreach programs must demonstrate a capacity and willingness to allow community priorities to guide them.

Spanish-language signs, educational materials, and videotapes do not work as well when they're simply translated directly from English.

If a patient feels that the provider has violated the rules of respeto, the patient may terminate treatment.

1. To earn confianza (trust) in a targeted community find out who is respected in the community. Ask your patients, your staff, business owners, clergy, members of the media, and teachers who are the respected leaders and agencies that serve the community's needs.
   
2. Remember the value of personalismo (familiarity). Go to local leaders and ask for their opinions about what people in the community most need. Ask them who is already helping with that, and what outreach resources are available. Ask for advice about who you should work with. Don't assert your agenda, instead listen for the community's agenda — what people are asking for — and assign your priorities based on their needs.
   
3. To work effectively with community-based organizations, outreach programs must demonstrate a capacity and willingness to allow community priorities to guide them. They must earn the community's trust or confianza; reach into the community through existing, respected groups; select culturally relevant media and/or materials to convey their messages; and, target whole families with understanding and respect.
   
4. To effectively meet the needs of Hispanic communities, health outreach and promotion programs should also target the specific community or Hispanic subgroup they seek to serve. Spanish-language signs, educational materials, and videotapes do not work as well when they're simply translated directly from English. They have to be developed specifically for the target population. The person(s) developing the materials should be familiar with the language, literacy level, and culture of a specific target group and should have the materials reviewed by members of the target audience. Providers must be open receivers and listeners of "culture" and its dynamics in the delivery of health care.
   
5. Respeto (respect) dictates appropriate deferential behavior toward others on the basis of age, sex, social position, economic status, and authority. The provider enters into a reciprocal interaction when treating an Hispanic patient. If a patient feels that the provider has violated the rules of respeto, the patient may terminate treatment. Younger providers, even though they will be awarded respeto as authority figures, are expected to be especially formal in their interactions with older patients. Formality is a sign of respect, but should not be confused with emotional distance.

Understanding the rules of the culture, how it functions, and how it is influenced foreshadows effective prevention strategies. The prevention strategies employed must be tailored to the targeted individual and his/her environment, including culture and social norms. Individual change may be difficult without communal support or guides. Some of the components which are more resistive to change may be assisted with public and organizational policy changes.

The prevention strategies employed must be tailored to the targeted individual and his/her environment, including culture and social norms.

The purpose of promoting healthy behaviors is to foster decisions that will maintain good health and have early detection of health problems.

1. Lifestyle Choices

Key Concept

Diet, exercise, and weight control appear to be factors that contribute to good health. The current standards for appropriate diet, weight, and exercise levels are based on mainstream whites. Based on these standards, Hispanics report as overweight, lacking exercise, and falling short of the recommended daily allowances of fruits and vegetables. Standards must be determined specifically for Hispanics with programs established that promote good lifestyle choices and have support systems instituted to sustain change.

The current standards for appropriate diet, weight, and exercise levels are based on mainstream whites...standards must be determined specifically for Hispanics...

2. Mental Health

To promote good mental health, social stress and cultural conflict must be addressed as many Hispanics are first, second, and third generation immigrants. Research has shown it takes approximately three generations to acculturate. For many others for which the border moved, social stress and cultural conflict must also be dealt with, as the invasion of the dominant culture forced unwanted changes in their behaviors. Validation of cultural strengths and ethnic heritage are needed in conjunction with the coping skills to manage social stress and conflict.

Research has shown it takes approximately three generation to acculturate.

Screening and prevention should be accompanied by additional resources and services...it is not enough to screen for alcohol without services for the problem drinker.

Key Concept

The motivation foreshadowing risk behaviors may be individually driven; however, there appears to be strong social influences, especially for sociocentric groups, such as Hispanics.

Accurately assessing the array of mental processes that influence behavior is inherently difficult, primarily because it relies on that person's subjective report of how he or she feels, justification for a particular behavior, and the often lack of awareness of cues. Consequently, it is difficult to determine what prevention or intervention strategy will actually reduce risk behaviors. Initial model development supports the notion of reducing risk factors and increasing protective factors across many areas of a person's life. The motivation foreshadowing risk behaviors may be individually driven; however, there appears to be strong social influences, especially for sociocentric groups, such as Hispanics. Consequently, the models developed and validated for Hispanics must include the many domains or social influences surrounding the person.

In order to consistently prevent or reduce risk behaviors, refusal skill training and life-skill training programs that are specifically targeted to Hispanics should be used. As a sociocentric group with additional life stressors, such as discrimination and poverty, the expected models are more complex than just saying "no."

Although few models have been validated specifically for Hispanics, the current mainstream models being tested include a comprehensive approach which reduces risk factors, increases protective factors, and addresses use/abuse in all domains or environments.

Risk Factors vary considerably according to an individual's age, psychosocial development, ethnic/cultural identity, and environment. However, the impact of any single risk factor may change over time with the development of changes in his or her environment. Some of the risk factors to consider include social acceptance, parents or peer usage, stressors, availability, accessibility, etc.

Protective Factors can increase a child's resilience to substance abuse, since they act as buffers to initiating or continuing substance use. The literature on protective factors and resilience is more diffuse than that for risk factors, and there is less clarity about which factors are most important in the prevention of substance abuse, especially for Hispanics. Some protective factors include group support, knowledge, laws, etc.

Domains interact, with the individual at the core of the framework, primarily through an individual's risk and protective factors. The precise nature of the links between substance use and each of the risk factors identified under the six domains (individual, family, peer, school, community, and society) are not yet fully understood. Research must be directed to understanding the decision and influence paths to use/abuse for members of sociocentric groups, such as Hispanics.⁹³

Each year, smoking kills more people than AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires — combined!

...there is an increase in Hispanic smokers, which may be an indicator of potential problems.

Studies have documented that tobacco products are advertised and promoted disproportionately to ethnic communities. Examples of target promotions include the introduction of a cigarette product with the brand name "Rio" and an earlier cigarette product "Dorado," which was advertised and marketed to the Hispanic community. Thus, targeted comprehensive Hispanic community approach is needed to prevent smoking, including economic interventions, counter advertising, retailer-directed interventions, environmental policies, etc.

In the past, helping people quit smoking was the primary focus of efforts to reduce tobacco use at all ages in order to reduce the risk of premature death. In recent years, the focus of tobacco control has expanded to include strategies to prevent individuals from ever starting to smoke — particularly young people, since the decision to use tobacco is nearly always made in the teenage years, and about one-half of young people who take up smoking continue to use tobacco products as adults. Yet, there are no validated models specifically for Hispanic youths.⁹⁵

Studies have documented that tobacco products are advertised and promoted disproportionately to ethnic communities.

...the decision to use tobacco is nearly always made in the teenage years...

Issues such as domestic violence, violence in the workplace, emergency room visits, homicide, suicide, and assaults are all public health issues. Crime tends to occur in neighborhoods with high poverty. People who are victims of crime often experience both physical and mental health problems. There is no data available to specifically depict Hispanic health issues and crime; however, crime prevention and the injuries and loss due to crime should be considered in health models.

PRFI’s response was to try and develop an effective referral system to help reconnect families with the health care system and educate them on the importance of long-term preventative health care action.

The clinic also provided crucial lifesaving interventions for the children of undocumented workers and others who might have fallen through the cracks in the health care system had the clinic not been there. One example involved a 12 year-old girl who had recently arrived from Mexico who was diagnosed with acute lupus, and referred to treatment. Another instance was a 10 year-old boy, suffering possible brain damage from a traffic accident that took place while he was being illegally transported from Mexico to New York. He was also provided long-term medical treatment as a result of a clinic diagnosis.

By providing a people-friendly environment with offerings from coffee and snacks for parents, to lollipops and stickers for their young patients, to children's books, art supplies and health educational videos in the waiting room, PRFI created a model of an informal community based bilingual/bicultural health care facility.

With the end of its foundation funding in 1998, PRFI was able to negotiate with Wycoff Hospital for the establishment of a five-day a week pediatric satellite clinic to be based within PRFI. This reflected a recognition by this mainstream health care provider that working on prevention programs with a culturally competent community-based organization could provide benefits for the patient population, while at the same time providing economic benefit to the hospital in the form of reduced costs.⁹⁸

...prevention programs are most successful when they emphasize the connection between the individual, their family and the community.

...it is critical to understand that even though there may be relevant factors in mainstream/ egocentric-based models, they cannot be generally applied to Hispanics as a sociocentric group and expect successful outcomes.

Access to health services is a major barrier for Hispanics. Despite the benefits many Hispanics have gained from risk-reduction, outreach, and prevention efforts; reinforcement of positive cultural traits, and clinical treatment; Hispanics remain the United States population least likely to have access to a regular source of health care services and most likely to underutilized available health care services. Currently, health care benefits are primarily linked to type of employment. Although Hispanics are the group most likely to be employed, they are not working in jobs which offer health care benefits. Approximately, one-third of full-time employed Hispanics do not have health care benefits. Access to treatment must be addressed and corrected, along with the availability of culturally competent care.

Access to health services, particularly those relating to chronic and disabling conditions is of prime importance to Hispanic adults. However, Hispanic adults are the group least likely to see a physician. According to the National Ambulatory Medical Care Survey, the number of physician visits per year for persons 45 to 64 years old was 4.8 for Mexican Americans, Cuban Americans, and Puerto Ricans, compared to 5.6 for non-Hispanic blacks and 6.5 for non-Hispanic whites.⁹⁹

For many Hispanics, health insurance is another major barrier to service, if not the major barrier to health care utilization. As noted earlier Hispanics are the racial/ethnic group least likely to be insured.

Over one-third of working adult Hispanics are uninsured....

...a study of UCLA Emergency Medicine Center went on to find that ethnicity — not language, gender, or insurance status, was the main predicator for inadequate pain relief.

...Hispanics today comprise 12% of the U.S. population, only 4.3% of physicians, and less than 3% of registered nurses are Hispanic.

On a cultural level you may encounter a definitional problem about who is a health care provider and what that person does. In traditional Hispanic culture physicians, nurses, and other health care professionals are seen as authority figures to be visited when one is sick. The idea of going to a doctor when one is feeling well may strike some Hispanics as odd (or if uninsured, an unaffordable luxury). Consequently, for many Hispanics, care such as physical exams or screenings for diabetes, cholesterol, heart disease, cancer, etc. may be unfathomable. One result is that Hispanics with high cholesterol levels have been found to be less aware of their situation than their non-Hispanic white counterparts. That is also why one- third of Hispanic, adolescent women who make their first gynecological visit do so for a pregnancy test compared with one-tenth of non-Hispanic women.

Since Hispanic women tend to look forward to pregnancy as a natural part of life, they do not see it as an illness or a medical condition. Therefore, they are less likely to visit a health care provider once they have confirmed they are pregnant. Consequently, Hispanic mothers are more than three times as likely as non-Hispanic white mothers to have late or no prenatal care, (approximately 30% receive no prenatal care). Although the infant mortality rate for Hispanic mothers (6.8 per 1,000 live births) is similar to that of non-Hispanic white mothers (6.9 per 1,000 live births), there is no question that the benefits Hispanic mothers derive from traditional Hispanic diets, family-support, etc. could be greatly supplemented and improved upon by regular prenatal check-ups with a health care professional.¹⁰³

Through outreach and prevention programs many Hispanics are now being exposed to healthy living models that no longer see hospitals as a place where you go to die. At the same time, new service models are being developed that respond to the need for culturally competent treatment for Hispanic patients and clients.

Case Study

One example is taking place at the Women's and Children's Hospital of the University of Southern California School of Medicine. In their paper, "Evaluation of a Culturally Competent Outpatient Management Program of Insulin-requiring Diabetes in Pregnancy in a Latina population," doctors Carolina Reyes,

A similar project has been initiated in Oklahoma City, Oklahoma by the Latino Community Development Agency. A project summary report states that, "To decrease service access barriers, enhance service efficiency and reduce costs, our agency decided to develop a multi-service community center." Located in a 27,000 square foot converted school house in a low-income Hispanic community, it has been dubbed "Clinica Amistad" or Friendship Clinic. Among the culturally competent services it offers is pediatric care for children up to the age of 16, an immunization center, a well-baby clinic, a daycare program, drop-in child care, community college classes, after-school programs (including health education) for school-age children, and a recreational youth facility for teens.¹⁰⁶

Of course, only when mainstream institutions including major managed care programs, public and private hospitals, clinics, and nursing facilities fully integrate into their systems culturally competent approaches to patient care, will Hispanic and other populations in the United States feel confident they can receive the best care possible. A proxy indicator to access culturally competent care is client satisfaction and patient perceptions of quality. To determine the effectiveness of developing models for Hispanics, client satisfaction must be assessed for both critical care and long term care. These assessments are necessary as more institutions are transitioning to the new service models.

A number of major institutions have already transitioned to this new service model, including Harbor View Medical Center in Seattle, Washington and Thomason Hospital in El Paso, Texas. Often providing these kinds of culturally competent services proves to be both low-cost and high-benefit from a care-delivery, as well as, from a financial point of view.

...provides transportation for family care givers of patients, particularly migrant workers from the eastern part of the state, where the injury or illness of one family member can be highly disruptive to the lives of others.

To promote its holistic approach to service, the hospital has developed a motivational CARE program. The “C” stands for community and recognizes the hospital's role in helping to make the surrounding community a better place for families to live in and prosper, the “A” stands for accountability not only for the health care dollars they administer but also to the shared values of the community they are a part of, the “R” stands for respect and dignity, "the most important research and development program we have in terms of healing," according to Duarte, and the “E” is for excellence of service and care-delivery, a standard expected of every staff member regardless of their position.¹⁰⁹

The desire of health care professionals to...develop more effective ways of serving Hispanic and other patients’ needs, will create the kind of American health care system we can be proud of.