Clinical Cornerstone
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HYPERTENSIONIN HISPANICS • Vol. 6, No. 3
Barriers to Health Promotion and
Disease Prevention in the Latino
Population
Joseph R. Betancourt, MD, MPH
Alexander R. Green, MD
Senior Scientist,Institute for Health Policy
Director for Multicultural Education,Multicultural Affairs Office
Massachusetts General Hospital
Assistant Professor of Medicine, Harvard Medical School
Boston, Massachusetts
Research Fellow
Beth IsraeI-DeaconnessMedical CenterHarvard Medical School
Boston, Massachusetts
J. Emilio Carrillo, MD, MPH
Angela Maina, BS
Associate Professor of Clinical Medicine and Public Health
Weill Medical College of Cornell University
New York, New York
Research Assistant
Institute for Health Policy
Boston, Massachusetts
The Latino population of the United States is expected to increase substantially in the next 25 years.
Although recent health promotion and disease prevention interventions have improved the health of the
majority of Americans, the Latino community has derived less benefit from these advances. This is due
to a number of interrelated factors, including a disproportionate representation of Latino Americans in
the low socioeconomic strata and in the uninsured population. Even when insured, Latino Americans face
significant barriers to health promotion and disease prevention. This policy analysis identifies barriers
at the organizational and structural level of health care delivery, as well as at the level of the medical
encounter. It provides a practical framework for intervention that is founded on the recruitment of
Latino Americans into the health care workforce and leadership, the restructuring of health systems to
be more responsive to the needs of diverse populations, and health care provider education on how to
improve cross-cultural understanding and communication. By investing in a multifaceted approach that
addresses barriers to health promotion and disease prevention in the Latino population, we can improve
the quality of care delivered to this population and help eliminate racial and ethnic disparities in health
care. (Clinical Cornerstone. 2004;613]:16-29) Copyright © 2004 Excerpta Medica.
INTRODUCTION
advances. A review of the President's Initiative
to Eliminate Racial/Ethnic Disparities in Health
by the US Department of Health and Human Services shows that, compared with the general population, Latino Americans have poorer outcomes in
diabetes and HIV/AIDS, have lower rates of blood
pressure control, and receive fewer childhood
and adult immunizations. 2 It is likely that if a
greater Latino subgroup analysis of the data were
undertaken, more disparities in health would be
observed. 3
The Latino population of the United States is
expected to increase from 31 million (11% of the
population) to 59 million (18% of the population)
by 2025.1 In addition to being one of the youngest
populations (36% under the age of 18 years), the
Latino population is one of the most rapidly growing
groups in the United States. I Although health promotion and disease prevention interventions have
improved the health of the majority of Americans,
the Latino population has benefited less from these
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Vol. 6, No. 3
BACKGROUND
POLICY ANALYSIS
The term Latino refers to a very broad and heterogeneous group with distinct nationalities, religions,
degrees of acculturation, and socioeconomic status.
Recent studies suggest that differences between
Latino subgroups (eg, Puerto Ricans, Cubans, and
Mexicans) in sociodemographic characteristics,
health status, and use of health services are sometimes of equal or greater magnitude than differences
between ethnic groups. 4,5 The health disparities faced
by many Latino subgroups are the result of a number
of complex interrelated factors. First, the poverty rate
for Latino adults is at least twice that of the rest of
the population, and more than one third of Latino
children live in poverty.6 This puts them at risk for
many negative social determinants of health, including low levels of education, living in dangerous
neighborhoods and poor housing, and working in
hazardous occupations, among others. Second, nearly 40% of the Latino population <65 years do not
have health insurance. Latino children make up 29%
of the uninsured under 18 years of age compared to
11% of white children. One quarter of the nation's
44 million uninsured are Latino--of these 11 million, 9 million have at least one family member who
is employed. In fact, Latino Americans are more than
twice as likely to lack health insurance as the population overall, v Insurance alone, however, does not
yield high-quality health care or appropriate access
to health services. Beyond insurance, there exist
other barriers to care, both at the organizational and
structural level of health care delivery, as well as at
the level of the medical encounter. Thus, even when
insured, Latino Americans face significant barriers
to health promotion and disease prevention interventions. For example, less acculturated Latino
Americans whose health beliefs may diverge from
the mainstream, or who may have limited health literacy and English proficiency, face great difficulty
maneuvering through a complex and intricate health
care system.
Given the health challenges facing Latino
Americans today, it becomes imperative to better
understand the state of access to health promotion and
disease prevention for this population. This is particularly important given that the majority of the conditions that disproportionately affect Latino Americans
are both preventable and treatable.
Many Latino Americans who attempt to gain access
to the US health care system face organizational, structural, and/or provider-based barriers that preclude them
from fully capitalizing on health promotion and disease
prevention interventions. These barriers include institutional policies and procedures, the inability to get timely appointments, lack of after-hours medical advice, and
long waiting times for referrals to necessary medical
specialists and diagnostic and therapeutic interventions,
among others. 8 This results in decreased standard medical screening, 6 a later stage at presentation of various
medical conditions, 9,1° and inappropriate and inadequate treatment. 11,12Together, these conditions have led
to the significant racial and ethnic disparities in health
outcomes prevailing today. For example, the diabetes
morbidity and mortality rates for Latino Americans are
almost 30% higher than for white Americans. 13
ORGANIZATIONAL
BARRIERS:
LEADERSHIP AND WORKFORCE
ISSUES
Our health care systems, structural processes of care,
and health policies are, in large part, shaped by the
leaders who design them. Furthermore, our health care
system's success hinges on the workforce that carries
out these policies and procedures. From this organizational standpoint, one factor that can affect both the
availability and acceptability of health care for Latino
Americans is the degree to which the nation's health
care professionals and leadership reflect the racial and
ethnic composition of the general population.
Institutional Leadership
Latino Americans are woefully underrepresented
in health care leadership and decision-making positions (eg, state or county health officials, faculty in
17
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•
HYPERTENSION IN HISPANICS
medical and public health schools). 6 In the absence
of strong quantitative data, a plethora of anecdotal
evidence suggests that lack of diversity in the leadership and workforce of health care organizations
results in structural policies, procedures, and delivery
systems that are inappropriately designed or poorly
suited to serve diverse patient populations. 8,14 Given
their social and cultural understanding of the communities they serve, health care professionals from
minority groups may be more likely to organize health
care delivery systems to meet the needs of
minority populationsJ 5 Examples of barriers to care
include limited clinic hours of service that do not
account for community work patterns, bureaucratic
intake processes that create fear of deportation
among the undocumented, and long wait times to make
appointments and at the actual time of the visit. 5 Data
regarding diversity in leadership are quite revealing.
For example, <2% of senior leadership in health care
management is nonwhite. 14 In academic health centers,
underrepresented minorities (ie, Latino Americans,
African Americans, and Native Americans) make up
only 3% of the medical school faculty. In addition,
53% of the Latino medical school faculty teach in medical schools in Puerto Rico, highlighting the underrepresentation of Latino faculty in the continental
United States. 16 Similarly, despite the fact that minorities comprise 30% of the US population, 17 <16% of
public health school faculty positions are held by
minority scholars, and only 17% of all city and county
health officers are from minority groups (Figure 1). 6
•
Vol. 6, No. 3
Health Care Workforce
The importance of racial and ethnic diversity in the
health care workforce is well correlated with the ability of health care organizations to deliver high-quality
care to socioculturally diverse patient populations.
For example, for minority patients, it has been shown
that in cases where there was racial concordance
between the patient and the physician, patient satisfaction and self-rated quality of care were higher. 18
Other work has established the preference of minority
patients for minority physicians. 19,2° The reason for
this preference may be language-based. For example,
it has been shown that Spanish-speaking Hispanic
patients are more satisfied when their provider speaks
Spanish. 21
A review of the data on racial and ethnic diversity
of the health care workforce reveals that only 6% of
all physicians in 1995 were Latino Americans. 22
Approximately 24% of Latino physicians in officebased practices in California care for patients whose
primary insurer is Medicaid (compared with 18% of
white physicians), and 9% care for patients who are
uninsured (compared with 6% of white physicians). 2°
The prognosis for the future is not much brighter.
Data from 1997 show that enrollment of Mexican
Americans and mainland Puerto Ricans into medical
school dropped by 8.7% and 31%, respectively, and
that in that same year, only 11% of all graduates were
from underrepresented minorities. 22
Similar racial disparities are found in other health
professions as well (Figure 2). For example, Latino
18-
•
3%
[ ] 16%
[] 17%
16
14
v
12
r0J
Q_
aJ
10
8
6
O
4
2
0
/
-
-
Medical School
Faculty
1
-
-
Public Health
Faculty
F
- - I
City/County
Health Officials
Figure I. Percentage of minority professional representation. Adapted with permission. 636
18
Clinical Cornerstone
Americans represent only 5% of all practicing dentists. 6 Unlike medical schools, which experienced an
initial increase in minority enrollment in the early
1990s that subsequently tapered off later that decade,
dental schools experienced a steady decrease in
minority matriculation (as a proportion of total
matriculation) throughout the 1990s. 23 Despite gains
in minority enrollment in baccalaureate nursing programs, minorities comprise only 3.2% of the current
nursing workforce. 6,23 Similarly, despite increases in
minority enrollment in pharmacy schools in the
1990s, individuals from underrepresented minorities
make up only 2.9% of the nation's pharmacists and
3.8% of optometrists. 23
•
HYPERTENSION IN HISPANI¢$
•
Vol. 6, No. 3
their role as providers of care to vulnerable populations.
These "at-risk" systems are not conducive to health promotion and disease prevention for Latino Americans.
The recent emergence of Medicaid managed care
is likely to pose challenges to the Latino patient as
well. Bureaucratic intake and appointment-making
processes, limited choice of providers, and lack of
information about these new systems are some of
the possible challenges. Despite efforts to facilitate
transition and enrollment into Medicaid managed
care, people with limited English proficiency and/or
those with limited experience dealing with complex
health care systems will have difficulty selecting a
primary care provider or maneuvering through a
health plan. The barriers in commercial managed
care organizations (MCOs) are not likely to be
STRUCTURAL BARRIERS TO CARE
Latino Americans are significantly more likely than
their majority counterparts to receive care in hospital
outpatient departments (particularly academic health
centers and public hospitals), community-based clinics,
emergency rooms, and other safety-net providers. 24,25
As a result, Latino Americans receive care in systems
that often provide poor continuity, have dated medical
record systems, maintain limited after-hours services
(including telephone access to health care professionals), and depend on graduate housestaff (residents and
fellows) as primary providers. To complicate matters,
public hospitals and academic health centers are facing unprecedented fiscal challenges, which jeopardize
[]
6.0%
[] 5.0%
[] 2.9%
o~
v
[]
~i!~~i !i~!~!i!~~i !~~i !i~!~!i~~i !i~!;!~i !~~i !i~i
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r-
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t~
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Figure 2. Latino health care workforce: Percentage of health care professionals who are Latino. Adapted with
permission.6,16
19
Clinical Cornerstone
•
HYPERTENSION IN HISPANICS
different. It is difficult to follow these trends, however, because Medicaid managed care and commercial MCOs are not required by legislation or court
mandate to collect racial and ethnic identifiers
for people enrolled in their plans. For example,
although the National Committee for Quality
Assurance's Health Plan E m p l o y e r Data and
Information Set 26 includes a focus on disease areas
•
Vol. 6, No. 3
and others of low socioeconomic status equally, several barriers are especially pertinent to the Latino
population (Table).
S t r u c t u r a l B a r r i e r s to C a r e in t h e Latino
Population
Extramural Barriers
Latino Americans disproportionately reside in
either urban or rural locations designated as medically underserved or health professional shortage
areas, aa As a result, they often have to depend on
public transportation and travel significant distances
to see a health care provider. 29 Moreover, certain
health care facilities have limited operating hours and
minimal telephone and after-hour access to providers.
These factors have clear and direct effects on access
to care:
• 30% of Latino Americans, compared with 27%
of blacks and 16% of whites, reported that they
have "very little" or "no" choice in where to go
for medical care. 6
• 53% of Latino Americans, compared with 47%
of blacks and 30% of whites, use an emergency
room, outpatient department, or clinic as a source
of medical care. 6
• A 1998 National Association of Public
Hospitals & Health Systems survey of 25 urban
safety-net hospitals reported that African
Americans and Latino Americans had the highest number of visits, accounting for 40.9% and
31.7% of hospital visits, respectively. 3°
• 47% of Latino Americans in 1993 had a dental
visit, compared with 64% of whites. 6
(eg, hypertension) or dimensions of performance
(eg, quality of communication), it does not focus
on quality of health care for minority patients,
given that it does not report performance and outcomes separately by race or ethnicity. Similarly,
at the level of hospital accreditation, the Joint
Commission on Accreditation of Health Care Organizations performance measures are devoid of racial
or ethnic identifiers (although hospitals must
demonstrate their multilingual capacities, however
rudimentary, using data that are neither aggregated
nor benchmarked). 27
Types of S t r u c t u r a l B a r r i e r s
Structural barriers arise when patients are faced
with the challenge of obtaining health care from systems that are inherently complex, underfunded,
bureaucratic, archaic in design, or simply inaccessible
by common means of transportation. Structural barriers can be divided into extramural--barriers
patients experience from their home to the health care
center--and intramural--barriers patients experience
from the health care center to the provider's office.
Although many of the aforementioned structural barriers to care may affect whites, African Americans,
TABLE. STRUCTURAL BARRIERS TO HEALTH P R O H O T I O N A N D DISEASE PREVENTION
INTERVENTIONS A H O N G LATINO AMERICANS.
Extramural
Intramural
Availability of providers
Bureaucratic intake processes
Proximity of HCF
Long waiting times for appointments
Operating hours of HCF
Lack of interpreter services
Transportation to HCF
Difficult referral to tests and specialists
Telephone access to providers
Language-appropriate signage
Knowledge of available resources
Language-appropriate health education
Child care
Poor continuity of care
HCF = health-care facility.
20
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Vol. 6, No. 3
"major" problem gaining access to specialty care
(Figure 3A). 6 Another study revealed that 46% of
Latino Americans (vs 39% of blacks and 26% of
whites) do not have a regular doctor (Figure 3B). 6
Intramural Barriers
Even when Latino patients complete the journey
to a health care facility, they face several additional
barriers to care. For example, bureaucratic intake
processes and long waiting times for appointments
limit access to health care providers. 29 In addition,
facilities that provide care to Spanish-speaking
patients but lack interpreter services or do not provide
culturally or linguistically appropriate health education materials severely compromise the quality of
care delivered. 31,32 Doctor-patient communication
without an interpreter, in the setting of even a minimal
language barrier, is recognized as a major challenge
to effective health care delivery.33-37 Research in this
area has shown that:
• Spanish-speaking patients discharged from the
emergency room are less likely than their
English-speaking counterparts to understand
their diagnosis, prescribed medications, special
instructions, and plans for follow-up care38; less
likely to be satisfied with their care or willing to
return if they had a problem; more likely to
report problems with their care39; and less satisfied with the patient-provider relationship. 4°
• Physicians who have access to trained interpreters report a significantly higher quality of
patient-physician communication than physicians who used other methods. 41
• Hispanic patients whose physicians do not
speak the same language are more likely to
omit medication, miss office appointments,
and visit the emergency room for care. 42
Referral to specialists and continuity of care
are other critical barriers that Latino Americans
face. A large survey by the Commonwealth Fund
reported that 22% of Latino Americans, compared
with 16% of blacks and 8% of whites, reported a
PROVIDER-BASED
BARRIERS
Provider-Patient Communication
Provider-based barriers to care emerge during the
medical encounter, when sociocultural differences
between patient and provider are not fully appreciated,
accepted, explored, and/or understood.43 During the
medical encounter, a provider's ability and willingness
to communicate across language barriers and to understand sociocultural variations in health beliefs, values,
and behaviors are critical to the delivery of high-quality
health care. Given the small proportion of Latino physicians, Latino patients often receive care from physicians
who may not speak their language, understand their
social situation, or value their cultural beliefs. As a result,
cultural and linguistic barriers in the medical encounter
may lead to the following:
• Poor communication between patient and
provider 4446
• Patient dissatisfaction with care ~s,21
• Poor compliance with both medications and
health promotion and disease prevention
interventions47-5
Furthermore, differential treatment of Latino
Americans (based on race/ethnicity or social class)
may also affect health care delivery and outcomes.
For example, studies have shown that Latino
Americans are less likely than whites to receive certain procedures and surgeries such as coronary artery
bypass graft, angioplasty, and kidney transplant] 1
The root causes of these disparities in care have not
21
Clinical Cornerstone
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HYPERTENSION IN HISPANICS
•
just one of many factors leading to the vast heterogeneity of the Latino population, it has a particularly strong impact on health care. Latino Americans
who have spent more time (years or generations)
been fully elucidated. It is hypothesized that poor
communication and patient preferences may play an
important role. The effect of provider bias based on
race, ethnicity, or social class, whether overt or subconscious, has been shown to affect medical decision
making as well. 52,53
interfacing with the mainstream culture of the
United States will often have different cultural
beliefs and values than those who have just arrived
in the country. The following research results illustrate this:
• High levels of acculturation have been correlated with high levels of adherence to medical
therapy. 51
Acculturation
The role of acculturation (integration with the
predominant culture) and its effect on health beliefs
and behaviors such as compliance in the Latino
population cannot be overemphasized. While this is
A
Vol. 6, No. 3
25
• 22%
[] 16%
[] 8%
eO
O
o_
20
15
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l,a
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10
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i!i!iiii
i
u
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i
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Blacks
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1
Whites
B
• 46%
50-
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45-
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40-
8
2
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o_
353025-
o
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o_
201510S0
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Latinos
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Figure 3. Percentage of minorities reporting (A) difficulty in gaining access to health care specialists and (B) n o t
having a regular doctor.
22
Clinical Cornerstone
•
HYPERTENSION IN HISPANICS
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Vol. 6, No. 3
• Low levels of acculturation among Latino
Americans have been linked to low utilization
of preventive measures and tests such as breast
self-examination, Pap smear, and mammography and to poor health outcomes, including
invasive cervical cancer. 54-56
• High acculturation levels have been shown to
contribute to increasing the probability of highrisk behaviors such as alcohol abuse and smoking, particularly for Latina women. 57,58
practical framework that focuses on 3 umbrella categories of interventions--organizational, structural, and
provider-based--it becomes clearer how initiatives in
this area could assist in the elimination of racial/ethnic
disparities in medical care. Three main targets arise:
• Provider-based barriers to care are accentuated
when issues of acculturation are not recognized
and handled appropriately by providers.
There should be a significant national focus on research, policy, and programs that aims to both fortify
the educational pipeline and strengthen the capacity
of Latino health professionals to assume positions of
leadership.
Target 1: Increasing the Representation of Latino
Americans in the Health Professions and
Health Care Leadership
Target 2: Innovations in Health Care System and
Structure Design
There are ample opportunities to address the many
simple (yet pervasive) structural barriers to care defined
herein. Efforts should include those that streamline health
systems and make them more responsive to the needs
of diverse populations, including Latino Americans;
initiatives that aim to provide Latino Americans with
culturally and linguistically appropriate information to
make health care decisions; and mechanisms to ensure
that, at a minimum, health care systems that care for
large populations of patients with limited English
proficiency have effective interpreter services available.
Perceptions and Expectations of Health Care
Dissatisfaction with health care may lead to a
reluctance to seek health promotion and disease prevention or to follow up with diagnostic or treatment
plans. Further work is needed to understand Latino
patients' opinions regarding the qualities of a good
health care system. In recent studies, it was shown
that Latinos are:
• Less satisfied with the quality of their health
care than are whites 21,59
• Inclined to feel they are more likely to be treated unfairly by health care practitioners and the
health care system because of their ethnicity
and limited language proficiency59,6°
Although these findings may not be generalizable,
they do shed some light on the Latino experience with
health care.
Target 3: Cross-Cultural Education
Given the underrepresentation of Latino Americans
among health care providers, targeting providers' attitudes and practices is a crucial part of overcoming the
barriers to care that Latino patients face. The movement toward cross-cultural education of health professionals should be widely supported.
In addition, to effectively monitor any improvement in health promotion and disease prevention for
the Latino and other underserved populations, health
systems (including hospitals and MCOs) should be
encouraged to collect race, ethnicity, and languageproficiency data. Without this provision, we severely
limit the ability to measure the quality of care delivered to Latino Americans, and thus preclude systems
innovations and quality improvement.
DISCUSSION
This policy analysis gives us a starting point from
which we can critically analyze the barriers that limit
the ability of Latino Americans to benefit from health
promotion and disease prevention initiatives. Given a
23
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Vol. 6, No. 3
8. National Hispanic/Latino Health Initiative. Public
Health Rep. 1993;108:534-558.
9. Samet JM, Hunt W, Lerchen M, Goodwin J. Delay in
seeking care for cancer symptoms: A population-based
study of elderly New Mexicans. J NatI Cancer Inst.
1988;80:432-438.
10. Vernon S, Tilley B, Neale A, Steinfeldt L. Ethnicity,
survival, and delay in seeking treatment for symptoms
of breast cancer. Cancer. 1985;55:1563-1571.
11. Giacomini MK. Gender and ethnic differences in
hospital-based procedure utilization in California.
Arch Intern Med. 1996;156:1217-1224.
12. Carlisle DM, Leake BD, Shapiro ME Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County,
1986 through 1988. Am J Public Health. 1995;85:
352-356.
13. US Bureau of the Census. Resident population of
the US: Estimates by sex, race, and Hispanic origins,
with median age. Available at: www.census.gov/
population/www/cen2000/briefs.html. Internet release:
February 27, 1998.
14. Evans RM. Increasing minority representation in
health care management. Health Forum J. 1999;
42:22.
15. Nickens HW. The rationale for minority-targeted programs in medicine in the 1990s. JAMA. 1992:267:
2390, 2395.
16. Bureau of Health Professions. Detailed Occupation and
Other Characteristics from the EEO File for the United
States, 1990 (Census of Population Supplementary
Reports). Rockville, Md: US Government Printing
Office; 1990.
17. US Bureau of the Census, 2000. Census Bureau (US).
Population Division National population estimatescharacteristics. Available at: www.census.gov/popesff
estimates.php. Accessed September 9, 2004.
18. Saha S, Komaromy M, Koepsell TD, Bindman AB.
Patient-physician racial concordance and the perceived
quality and use of health care. Arch Intern Med. 1999;
159:997-1004.
19. Moy E, Bartman BA. Physicians' race and care of
minority and medically indigent patients. JAMA.
1995;173:1515-1520.
20. Komaromy M, Grumbach K, Drake M, et al. The role
of black and Hispanic physicians in providing health
care for underserved populations. N Engl J Med.
1996;334:1305-1310.
21. Morales LS, Cunningham WE, Brown JA, et al. Are
Latinos less satisfied with communication by health
care providers? J Gen Intern Med. 1999;14:409-417.
22. Association of American Medical Colleges. Minority
Students in Medical Education (Facts and Figures XI).
Washington, DC: AAMC; 1998.
23. Institute of Medicine. The Right Thing to Do, The
Smart Thing to Do. Enhancing Diversity in the Health
Professions. Washington, DC: Academy Press; 2001.
24. Lillie-Blanton M, Martinez RM, Salganicoff A. Site
of medical care. Do racial and ethnic differences persist? Yale J Health Policy, Law, Ethics. 2001;1:1-17.
CONCLUSIONS
Latino Americans with health insurance face myriad
barriers to health promotion and disease prevention.
These include barriers related to their underrepresentation in the nation's health care leadership and workforce; their difficulty navigating the complicated structural processes of the health care system; and their
being cared for by providers who lack an understanding
of their language or health beliefs. While there are no
easy remedies, a targeted approach that focuses on programming, research, policy, advocacy, and outreach initiatives toward eliminating the organizational, structural, and provider-based barriers that Latino Americans
face should help improve the health status of this
growing population. Only by investing in a multifaceted
approach that addresses barriers to health promotion
and disease prevention specific to the Latino population
can we ensure that this population obtains high-quality
health care. The payoff, if the initiatives are successful,
will be the eventual elimination of racial and ethnic disparities in health care and the improvement of health
care not only for the Latino population but for all individuals in the United States.
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31. Betancourt JR, Carrillo JE, Green AR. Hypertension
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33. Kirkman-Liff B, Mondragon D. Language of interview: Relevance for research of southwest Hispanics.
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59. Leigh WA, Lillie-Blanton M, Martinez RM, Collins
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60. [Henry J.] Kaiser Family Foundation. Race, Ethnicity
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Address c o r r e s p o n d e n c e to: Joseph R. Betancourt, MD, MPH, Massachusetts General Hospital, 50 Staniford
Street, Suite 942, Boston, MA 02114. E-mail: [email protected]
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Clinical Cornerstone
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Vol. 6, No. 3
Dialogue Box
EDITORIAL BOARD
preter services and/or cultural competence training
benefits all ethnic groups.
Can't much of the disparity in health care for
Hispanics be explained solely by socioeconomic
factors and lack of access?
EDITORIAL BOARD
What are your thoughts about "acculturation"?
BETANCOURT
Although lower levels of education, lower socioeconomic status, and inadequate access are all
major contributors to disparities in health care and
cardiovascular outcomes, these factors are clearly
not acting alone. During my tenure working on
the Institute of Medicine Report on Equal
Treatment, it was readily apparent that after controlling for socioeconomic status and access
issues, significant differences in the quality of
care received varied by the patient's race and ethnicity. Thus, even if they weren't the most underinsured population in the United States, I believe
that the language barrier as well as cultural issues
would still place Hispanic families at higher risk
for suboptimal health care.
BETANCOURT
Acculturation has had a "mixed" impact on the
health of Hispanic patients. On one hand, as people
become more fluent in the language, more fluent in
the customs, and gain a better understanding of how
the health care system works, they tend to become
more adherent with taking medication and will
achieve better outcomes. On the other hand, acculturation also can have a detrimental effect on health.
For example, it has entailed adoption of unhealthy
eating habits and a diet loaded with fat and "fast
foods," which, in turn, has fostered obesity and the
development of type 2 diabetes mellitus. Thus,
acculturation has been a doubled-edged sword--by
improving the navigation of our health care system
and adherence to treatment, it has improved health;
through adoption of our dietary practices, it has
proved detrimental to health.
EDITORIAL BOARD
If financial constraints allowed you to focus
your efforts on only one of the factors responsible, which would give you the most "bang for
your buck"?
EDITORIAL
BOARD
How prominent a position should ethnicity
assume in the medical record?
BETANCOURT
Of the 44 million uninsured Americans, 11 million
are Hispanic. Because Hispanics comprise 25% of
the uninsured despite representing only 13% of the
population, as a starting point I would probably
invest in improving access to care. I can't emphasize enough, however, that research has identified
a number of challenges. Although it is important
to make investments in access and improving economic opportunities, other improvements must be
accomplished within the health care setting to
reduce the disparities. Such interventions would
not necessarily have to be tailored toward any particular population. For example, support of inter~ , ~ : ~ , ~ , ~ , ~ . : T ~ ; ~ , ~ + : ~
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BETANCOURT
Its inclusion is important because the collection
of race and ethnicity data within health care allows
us to better monitor disparities and outcomes.
However, it has been largely debated as to where to
put such information. Should ethnicity be included
at the beginning of the medical record, "This is a
72-year-old Hispanic man, with a medical history
of diabetes and hypertension..." or should it be
added to the social history, "This gentlemen is
Hispanic and has come from this country and immigrated during this time..."? It's played both ways.
Some believe that putting this information in the
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Clinical Cornerstone
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HYPERTENSION IN HISPANICS
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Vol. 6, No 3
pronged effort using both of these strategies was
required. Minority recruitment as the sole strategy would be inadequate, because we cannot recruit
history of present illness might be an unnecessary
tangent and thus would put it there only if it were
relevant to the illness, for example, an African
American with sickle cell. Although this issue still
creates tension for many people, I think there is universal agreement that etbnicity belongs in the medical record.
BETANCOURT
the numbers that would be required to meet the
needs of our increasingly diverse population.
Health care providers in training as well as those
in practice need to be made more culturally aware
and gain a better understanding of the impact that
race, ethnicity, and culture have on clinical decision making. In this regard, I would argue that
there is much we are not taught in our training that
would make us more effective providers. These 2
strategies are by no means mutually exclusive-we should strive to both improve the cultural competency of our health care workforce as well as
I think it's because the problem does not rest solely
at the level affected by groups like the AAMC.
Looking at the educational pipeline, you'll find
increase the percentage of ethnic minorities in this
workforce. Minorities should be recruited not just
so they can care for their own, but so they can also
that only -50% of Hispanics graduate from high
school, and as you move up the pipeline, the num-
be involved in curriculum development, leadership
policy development, and so forth.
EDITORIAL BOARD
Why do you think that groups like the American
Association of Medical Colleges (AAMC) have
been so unsuccessful in attracting Hispanics into
the health care professions?
ber of Hispanics decreases further. This problem
is compounded by the fact that a few years ago,
10% of Hispanics who were accepted to medical
EDITORIAL
school chose not to go. I think, as suggested in
our last IOM (Institute of Medicine) Report, that
greater attention and efforts have to be focused
earlier in the educational pipeline. To have a
greater impact, medical educators need to be more
involved in the various programs nationwide that
groom students at a young age and cultivate their
interest in the sciences and future careers in health
care professions, whether it is medicine, dentistry,
nursing, psychology, or public health.
EDITORIAL
BOARD
There is a subset of the population that might
regard any effort to recruit minorities as a form
of "affirmative action" and react negatively to
it. How would you address such a response?
BETANCOURT
Some terms are "hot buttons"; once you say them,
no matter how you explain it, it's difficult for people to get past that initial hot-button reaction.
People bristle at the term affirmative action. To
many, it means taking people who aren't qualified
and, solely based on their race or ethnicity, moving them up, above others who are more qualified,
or giving them an opportunity they don't deserve.
That is not what we are talking about, which is
why I think we try to choose our terms very carefully. We are aiming to develop and recruit a
highly qualified pool of minority students to
become physicians. Similarly with cultural sensitivity, I think the field has evolved significantly to
BOARD
Are there any data comparing the effectiveness
of changing the cultural makeup of the health
care professions with improving the cultural
competency of the professions?
BETANCOURT
Our position in both IOM Reports was that a 2-
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Clinical Cornerstone
be about more than just political correctness,
making people nicer, or teaching them the best
ways to care for the Hispanic patient. Instead, it
is now about giving providers a set of tools and
skills to add to their tool bag, add to their review
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HYPERTENSION IN HISPANICS
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Vol. 6, No. 3
systems, and improve the social history, in a much
more evidence-based fashion. We are positioning
the issues of cultural competence and diversity in
the health care system in these ways to make them
more palatable.
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