Hispanics make up the largest and fastest-growing minority group in the U.S. For decades, health services researchers have puzzled over a paradox among them: Hispanics live longer and have lower death rates from heart disease, cancer, and many of the other leading causes of death than non-Hispanic white residents despite having social disadvantages, including lower incomes and worse access to health coverage. There are many theories why, including the stronger social networks, healthier eating habits, and lower smoking rates among some Hispanic groups, particularly newer arrivals.
But focusing on national data can mask important differences linked to whether Hispanics have health insurance, speak primarily Spanish or English, or grew up in the U.S. or another country. The very heterogeneity of the Hispanic population — they come from more than 20 countries, with widely differing experiences and social circumstances, including immigration status — makes it hard to pinpoint problems, including high rates of diabetes, liver disease, and certain cancers and poor birth outcomes among some Hispanic groups.1 A 2015 study from the Centers for Disease Control and Prevention (CDC) was the first to examine health indicators by Hispanics’ country of origin and whether they were born in the U.S. — shining light on important differences. (See Q&A with Ana Penman-Aguilar, Ph.D., M.P.H., chief science officer and associate director for science at the CDC’s Office of Minority Health and Health Equity.)
In this issue of Transforming Care, we delve into efforts led by health care researchers, clinicians, and health plans to identify and address health disparities among the particular Hispanics they serve. It is a complement to our September issue, which examined efforts to address health disparities among African Americans.
Culturally Targeted Approaches
Because nearly a third of Hispanics in the U.S. are not fluent in English, many efforts to engage them begin with translation. But focusing on language alone can fall short, especially if the translation doesn’t take into account cultural differences.
CalViva Health, a health plan serving Medicaid beneficiaries in California’s Fresno, Kings, and Madera counties, with support from Health Net, a larger Medicaid plan, uses quality and claims data to identify disparities among its members and then conducts interviews with patients and clinicians to uncover what may be fueling them. This approach revealed that in one rural clinic serving mostly Hispanic patients, many from El Salvador, only half of women attended postpartum visits between 21 and 56 days after delivery (as tracked by the HEDIS performance measure). By comparison, in a nearby urban clinic also serving predominantly Hispanic patients though fewer Salvadorians, 73 percent of women had timely postpartum visits.
The interviews revealed that many Salvadorian women follow the traditional practice of quarantining themselves after delivery: remaining in their homes for 40 days and covering their ears, nose, and other body parts to prevent evil spirits from entering the body. “Providers didn’t understand why they were coming in very heavily dressed, with ear plugs and long pants or sweats and socks in the summer and the members told us they felt their cultural practices weren’t being acknowledged,” said Eulalia Witrago, M.P.H, a senior cultural and linguistic specialist at Health Net.
To encourage more Salvadorian women to attend postpartum visits, staff worked with clinics to educate clinicians about the quarantine practice and included a question (created in conjunction with Salvadorian women) to the obstetric history form about women’s cultural beliefs. CalViva staff have also helped clinics set up electronic reminders to schedule postpartum visits during women’s 35th week of pregnancy.
Navigation for Patients and Clinicians
Seattle-based Harborview Medical Center has long experience navigating patients’ cultural traditions. For 24 years, cultural mediators have offered interpretation, health education, case management, and advocacy to patients with African, Asian, and other backgrounds; about 40 percent are Spanish speakers, and many are undocumented and/or uninsured. “It’s a really unique program,” says Lea Ann Miyagawa, M.N., R.N., assistant nurse manager of Community House Calls. “There’s nothing else in the state like it and very few like it in the country.”
Harborview pays for the program, including the salaries of eight staff cultural mediators. Some help patients by attending their medical appointments, visiting them in their homes, and connecting them with primary care and other supports. (See Q&A with Rosemary Cano, one of Harborview’s cultural mediators.) Others work with hospitalized patients to make sure they understand their treatment options. “I try to get to patients and their families as soon as possible,” says José Mayorga, a cultural mediator who works with Hispanics who are hospitalized because they’ve had traumatic accidents, are undergoing surgery, or are seriously ill. Clinicians can refer patients to Mayorga, and he also reaches out to patients who’ve indicated they prefer Spanish-language communication and/or have Hispanic-sounding surnames.
Mayorga takes into account patients’ age, country of origin, and level of education and often relies on metaphors that are relevant to their life experiences to help them understand procedures. “If a patient needs debriding of the toe, I ask ‘What do you do when you’re landscaping and find a tree with dead branches?’ They will say ‘Cut to the healthy part.’”
He also encourages clinicians to carefully consider their words, particularly related to end-of-life decision making. Hispanics are less likely than white patients to have documented their end-of-life wishes, and in some cases their religious beliefs and distrust about physicians’ motives may complicate conversations about palliative care and end of life. “If a doctor is not careful and says, ‘There is nothing else I can do,’ patients may think the doctor’s knowledge is at its limits and say, “Let’s find a second opinion,’” he says. “But if a doctor explains that all efforts to save the patient were done, it will ease the process.”
Mayorga has also helped honor Hispanic families’ traditions, once arranging for a priest to serve first communion to a child suffering from severe burns who was not expected to recover, and another time holding a quinceañera, or girl’s 15th birthday party, in the hospital so a sick grandfather could attend. “No mariachis,” he said, “but we had a party.”
Using Community Health Workers
Many efforts to address health disparities among Hispanics rely on promotores de salud, or community health workers. In Arizona’s Pima County, home to Tucson with a population that is over a third Hispanic, an effort funded through a CDC REACH (Racial and Ethnic Approaches to Community Health) grant launched in 2008 deployed promotores to educate Hispanics about the risks of cervical cancer. At that time, cervical cancer rates among Hispanic women were twice those among whites, and they were 50 percent more likely to die from the disease.
The initiative was led by Francisco Garcia, M.D., distinguished outreach professor of public health, obstetrics, and gynecology at the University of Arizona and the son of a local promotora. Garcia worked with a group of promotores from Tucson’s Mexican-American community to adapt a cervical cancer curriculum that had been designed for medical professionals for lay audiences. The promotores then used this curriculum to train other women to spread the word about the risks of HPV infection, including developing cervical and other cancers, and the importance of having regular Pap smears and getting the HPV vaccine, which since its 2006 introduction in the U.S. had begun to reduce cervical cancer mortality, but had not been well publicized among Hispanic communities.
This approach spread over six years and trained 700 women to serve as cervical cancer promotores throughout Arizona and beyond, reaching an estimated 12,500 people by partnering with county health departments, family planning clinics, and community health centers. They also gave presentations in churches and schools and held barbecues and mother/daughter teas, once even setting up a presentation in the produce section of a grocery store.
“Eventually the program become so popular, anywhere the promotores would go women would pull them aside to ask for information or help navigating the health care system,” says Martha Moore-Monroy, M.A., lecturer in public health and program manager at the University of Arizona. Surveys among people who saw the presentations found that nearly all understood the common modes of HPV transmission and its risks. In addition to providing information and health system navigation, the program led some clinics to change their cervical cancer prevention and treatment practices.
Identifying Behavioral Health Problems
Hispanics are less likely to receive treatment for depression, anxiety, and other behavioral problems than white patients because of barriers to accessing care and stigma surrounding behavioral health problems. Salud Family Health Centers, a federally qualified health center with 14 clinics and one mobile unit that treats many Hispanics in Northeast Colorado, has for 20 years integrated behavioral health into primary care to encourage more people to get treatment. All patients are regularly screened for depression and other problems then offered immediate consults with a behavioral health provider. “We just go in and say, ‘I am part of your care team,’” says Jonathan Muther, Ph.D., a psychologist and Salud’s vice president of medical services. “We say, ‘Your primary care provider is going to work with physical needs. I would like to work on other aspects of your health including your mood and stress. Can I ask questions we ask all of our patients?’ This approach can be powerful in that it normalizes behavioral health care.”
Many Hispanic patients’ behavioral problems are rooted in stress related to their immigration status and/or traumatic experiences in their home countries. “Family splitting is really, really tough, with some parents in Mexico, some parents here,” says Muther. “And we hear on a daily basis stories about the violence in Mexico: a mom whose son was kidnapped in Mexico and she hasn’t heard from him in a month. Or a patient who experiences suicidal ideation and trauma linked to having been recruited by a gang in Mexico.”
Salud’s social workers and counselors, most of whom are bilingual, offer short-term therapy focused on remediating symptoms and coping strategies, since most patients only come once or twice. “We only get one or two cracks at it with our patients,” Muther says.
Effects of Immigration Enforcement on Health
Evidence indicates that immigration policy and enforcement have an effect on the health of Hispanic immigrants by increasing stress and discouraging people from seeking care. And newer research suggests that stressors related to immigration can have a spillover effect on the health and wellbeing of U.S.-born Hispanics (i.e., those not subject to deportation) as well as foreign-born Hispanics. One study found that Hispanic babies born in Iowa in 2008 — the year following the largest Immigration and Customs Enforcement Agency raid to date, at an Iowa meatpacking plant — were 24 percent more likely to be born with low birth weight than the year before the raid. Rates increased among babies of both U.S.-born and foreign-born Hispanic women, but not among babies born to white women.
Collaborative Care for “Diapression”
Behavioral health problems, particularly depression, can complicate efforts to engage Hispanics in their health. In particular, many Hispanics living with diabetes also have depression, and each of the conditions can worsen and make it harder to manage the other — a syndrome so pervasive that some refer to it as “diapression.”
University of Southern California researchers have been experimenting with ways to adapt proven approaches to managing comorbid diabetes and depression to the needs of low-income, Hispanic patients. They’ve borrowed the IMPACT model of depression care — in which nurses or psychologists offer education, care management, and antidepressant medication and/or therapy — but added social workers to the care teams to help patients manage their financial, social, and emotional problems. In a randomized control trial at two Los Angeles County primary care clinics, the approach worked better than the usual care in reducing patients’ depression symptoms.
Since then, the researchers have leveraged technology in an effort to make this approach financially feasible across Los Angeles County, the nation’s second-largest safety-net system in which about 30 percent of Hispanic diabetic patients also have depression. They created an algorithm to review an electronic disease registry and identify diabetic patients, and then use automated calls with interactive voice response to screen them each quarter for depression. Patients use keypads or natural speech to answer questions about their depressive symptoms, pain, management of their condition, and physical and social activities.
Those who screen positive for depression then receive monthly calls, during which an artificial intelligence persona known as “Amy” asks about their symptoms, whether they are adhering to prescribed antidepressant medication, and whether they’ve been using problem-solving approaches. Patients select the call times and language and the questions are tailored to their particular circumstances and responses. After each call, patients’ care teams receive updates about their progress and reminders to follow up about identified issues.
In a six-month trial comparing this approach with the usual depression care and the social worker–led IMPACT model, the technology-facilitated approach proved as effective as the social worker/IMPACT model in reducing depression symptoms and prevalence (and more effective than usual care). Only the technology-facilitated model was associated with improvement in diabetes control measures (i.e., reduced cholesterol levels and greater likelihood of getting an HbA1c test) and depression remission. And patients using the technology were more satisfied with their care, perhaps because it reduced the stigma of talking about depression. “Patients told us they felt comfortable reporting their symptoms to an automated system and felt there was no judgment,” says Shinyi Wu, Ph.D., a systems engineer at the University of Southern California. Wu also noted the approach may have been effective because the interactive voice response system didn’t require low-income patients, who often have low literacy, to read written materials.”
Targeting Maternal Health
Overall, Hispanic women tend to have similar, or in some cases better, birth outcomes as non-Hispanic whites, but Puerto Rican women fare worse than whites. Babies born to Puerto Rican women are more likely to be low birth weight and to die during their first year of life than white and other Hispanic babies. Puerto Ricans also have a high prevalence of type 2 diabetes, a risk factor for adverse pregnancy outcomes.
Researchers from the University of Massachusetts in Amherst, Mass., have been engaging Puerto Rican women during their pregnancies to disrupt what can often become a continuum of obesity, gestational diabetes, and subsequent type 2 diabetes. “Pregnancy is a teachable moment for women,” says Lisa Chasan-Taber, Sc.D., a University of Massachusetts professor of epidemiology. “They have a number of contacts with the health care system during their prenatal appointments, and are often motivated to make changes for themselves and their babies.”
Chasan-Taber and her team have targeted two groups of Puerto Rican women: those who are overweight or obese at the beginning of their pregnancies, and women who develop gestational diabetes. They invite these women to work with health educators, many hired from the Puerto Rican community, to take modest, practical steps to increase their physical activity and healthy eating habits. “We’re not suggesting they come into the lab or get a gym membership,” says Chasan-Taber. “Even 10-minute bouts of moderate exercise or increasing their walking pace can be effective.” The health educators also help women modify their traditional diets to make them healthier.
The experiences of health plans and clinicians working to identify and reduce health disparities among different groups of Hispanics offer lessons for others. Some may be applicable to other low-income groups who face obstacles to accessing care because of their work hours, lack of transportation, or lack of income to devote to health.
To help, some health systems are leveraging their buying power to create job opportunities for Hispanics. Baystate Brightwood Health Center, which serves predominantly Hispanics in Springfield, Mass., created a training program for personal care assistants to improve the economic prospects of its patients, who clinic leaders say have an average annual income of around $7,500.
But some issues affect Hispanics in particular, including the lack of trust in the health care system bred both by immigration challenges and the underrepresentation of Hispanics in health care professions. “I have been in practice for 30 years and the percentage of Hispanic physicians has dropped during that time,” says Judith Flores, M.D., chair of the National Hispanic Medical Association’s board of directors. The association offers mentoring programs for Hispanic physicians and has been studying ways to encourage Hispanics to enroll in medical school. Salud Family Health Centers, meanwhile, has had success training its own Hispanic clinicians, in part through an exchange program that brings psychologists from Chile and Puerto Rico to the Colorado clinics.
Leaders of many of the programs profiled here say it is important to acknowledge that immigration status affects health, even more so after the Trump administration proposed changes to the “public charge” rule that experts say could discourage legal immigrants from accessing Medicaid and other publicly funded health care services.
“Where you were born shouldn’t matter,” says Michelle Doty, M.P.H., Ph.D., vice president of Survey Research and Evaluation for the Commonwealth Fund, who has studied Hispanic health disparities. “Ensuring people can get help to prevent or treat problems is a public health concern. There are no boundaries where there is illness in community, and so it behooves us to take care of everyone.”