Health Disparities and Disabilities among Hispanic Populations Lucy Wong-Hernandez, M.S. School of Allied Health Sciences East Carolina University & Monica Carrion-Jones, MD Physical Medicine and Rehabilitation Brody Medical School

Objectives Identify the target population Identify health disparities among this population Causes of Health Disparities and Disabilities How can we decrease the gap

Hispanic Population This ethnic group includes any person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. According to the population estimates of the U.S. Census Bureau review of 2006, there are approximately 42.6 million Hispanics in the U.S. (14% of total population).

Health Disparities As define by the National Institute of Health (NIH) “…health disparities indicates differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States."

Where are the Hispanics?

Areas of Health Disparities Cancer Diabetes Heart Disease HIV/AIDS Immunization Infant Mortality Stroke Asthma Work-Related Injuries

Cancer In 2003, Hispanic men were 19% less likely to have prostate cancer as non-Hispanic white men. In 2003, Hispanic women were 39% less likely to have breast cancer as non-Hispanic white women. Hispanic men and women have higher incidence and mortality rates for stomach and liver cancer. In 2003, Hispanic women were 2.2 times as likely as non-Hispanic white women to be diagnosed with cervical cancer.

Diabetes In 2003 Mexican American adults were 2 times more likely than non-Hispanic white adults to have been diagnosed with diabetes by a physician. In 2002, Hispanics were 1.5 times as likely to start treatment for end-stage renal disease related to diabetes, as compared to non-Hispanic white men. In 2003 Hispanics were 1.5 times as likely as non-Hispanic Whites to die from diabetes.

Heart Disease In 2004, Hispanics were 10% less likely to have heart disease, as compared to non-Hispanic whites. In 2003 Mexican American men were 30% less likely to die from heart disease, as compared to non-Hispanic white men. Mexican American women were 1.2 times more likely than non-Hispanic white women to be obese.

HIV / AIDS Hispanics accounted for 18% of HIV/AIDS cases in 2004. Hispanic males had over 3 times the AIDS rate as non-Hispanic white males. Hispanic females had over 5 times the AIDS rate as non-Hispanic white females. Hispanic men were 2.7 times as likely to die from HIV/AIDS as non-Hispanic white men. Hispanic women were 4.5 times as likely to die from HIV/AIDS as non-Hispanic white women.

Immunization In 2004 Hispanic adults aged 65 and older were 20% less likely to have received the influenza (flu) shot in the past 12 months -- as compared to non-Hispanic whites of the same age group. In 2004, Hispanic adults aged 65 and older were 40% less likely to have ever received the pneumonia shot, -- as compared to non-Hispanic white adults of the same age group. Although Hispanic children 19 to 35 months old had comparable rates of immunization for hepatitis, influenza, MMR, and polio -- they were slightly less likely to be fully immunized, when compared to non-Hispanic white children.

Infant Mortality In 2003, infant mortality rates for Hispanic subpopulations ranged from 4.6 per 1,000 live births to 8.2 per 1,000 live births, compared to the non-Hispanic white infant mortality rate of 5.7 per 1,000 live births. In 2003, Puerto Ricans had 1.4 times the infant mortality rate of non-Hispanic whites. Puerto Rican infants were 2.1 times as likely to die from causes related to low birth weight, as compared to non-Hispanic white infants. Mexican American mothers were twice as likely as non-Hispanic white mothers to begin prenatal care in the 3rd trimester, or not receive prenatal care at all.

Asthma During 1993-1995 in the northeast U.S., Hispanics/Latinos had an asthma death rate of 34 per million -- more than twice the rate for white Americans (15.1 per million).

Work-Related Injuries Mexican foreign born workers accounted for more than two thirds (69 percent) of the 2,440 fatally injured, foreign born workers between 1995 and 2000. Lower percentages of fatally injured workers came from Cuba (146 or 6 percent), El Salvador (131 or 5 percent), Guatemala (90 or 4 percent), and Dominican Republic (87 or 4 percent).

Stroke In 2003, Hispanic men were 20% less likely to die from a stroke than non-Hispanic white men. In 2003 Hispanic women were 30% less likely to die from a stroke than non-Hispanic white women.

Causes of Health Disparities Socioeconomic factors Lifestyle behaviors Social and built environment Access to preventive health-care services Access to affordable health insurance

Socioeconomic factors Education attainment Employment Poverty Insurance coverage

NO Usual Place of Care (Preventive care in a clinic or health center VS. doctor’s office) Race/Ethnicity Percentage Hispanic/Latino Women 56.4% Non-Hispanic White Women 41.4% Non-Hispanic Black Women 40.9%

NO Health Insurance Coverage Hispanic/Latino Percentage U.S. Born 18.3% Foreign-born U.S. Citizen 22.0% Not U.S. Citizen 51.9%

Lifestyle behavior Lack of physical activity Alcohol intake Smoking Food intake (diet)

Social Environment Educational and economic opportunities Racial/ethnic discrimination Neighborhood and work conditions Lack fluency in English Lack of familiarity with the U.S. health-care system

Access to preventive health-care services Cancer screening HIV screening Vaccination Pre-natal care

What is happening in NC?

Social and economical well-being

Maternal care

Adult Health

Communicable diseases

Adult Health

Violence and Injuries

Health Promotion

How do we eliminate the GAP? Increment National Standards on Culturally and Linguistically Appropriate Services. Community education that involves all members of the community Knowing the problem and the causes (Research). Promoting preventive health care that is also culturally sensitive.

DISABILITY AMONG HISPANICS ****

Disability Overview: Disability Definition Access & Challenges Health & Disability Disparities Issues Cultural Sensitivity & Competency Recommendations for Research

DISABILITY Disability definition: The condition of having a disability or limitation. The period or length of such a condition A disadvantage or deficiency, especially a physical or mental impairment that interferes with or prevents normal achievement in a particular area or major life activities of the individual. Law: A legal incapacity or disqualification.

In 2005, an estimated 20.6% civilians not living in an institution (or 53.9 million people) met the criteria for disability. Women and girls with disabilities are estimated to number 28.6 million, which is 21.3% of the female population. An estimated 25.3 million men and boys with disabilities make up 19.8% of the male population. One in five Americans has a diagnosed disability; more than half of those with disabilities are female.

Americans with and without disability by gender

Females report more limitations in old age, while males report more limitations in youth.

Disabilities in NC Approximately: 1,139,375 adults 18 and over experience a disability. Representing 18.3% of the population Women: 19.4% or 648,215 Men: 17.0% or 491,160

Disabilities in NC Rate by Age: Age 5 to 20 = 7.4 % Age 65 and over = 43% Causes: Genetic Work related injuries Automobile and industrial accidents Environmental contamination Rate by Race & Ethnicity: Hispanics 13.8% Whites non-Hispanics 18.5% Blacks 19.1% Native Americans 23.5%

Demographic Trends 8.2% --- of Hispanic Americans It is projected that by the year 2020, --- 30% of the new workers entering into the labor force will be people from diverse cultural and ethnic backgrounds --- also classified as people from minority backgrounds. According to data from the Department of Labor: There is a higher incidence of work disabilities among minorities: 13.7% --- of African Americans 8.2% --- of Hispanic Americans AS COMPARED TO: ONLY 7.9% --- of White Americans who acquired a work related disability.

What is Culture? Culture is a collective reality of a group of people --- and it is from this collective reality --- that attitudes, behaviors, and values are formed and become reinforced among a group of people. Culture is commonly held characteristics such as beliefs, values, customs and patterns of behaviors held by a group, which has been learned and reinforced through a socialization process.

Hispanic / Latino The Hispanic American population: is the fastest growing and most diverse ethnic group in the U.S. According to the latest US Census report of 2000 --- and its latest revision (2005) – the U.S Hispanic or Latino population is projected to grow from 31.7 million (12% of the population) in 1999 -- to 98.2 million (24% of the U.S. population) by 2050. This indicates the Hispanic American population has grown over 7 times ---- and as fast as the rest of the nation --- between 1980 to 1990 and 1990 to 2005.

Hispanic Hispanic is not a racial group – it is an ethnic group (including White Europeans, Blacks, Asians of various ethnic groups including indigenous and “mestizos”). Hispanics are united by a common language – but not all Hispanics are fluent in the Spanish language. 15.3 % --- have some type of disability (US). They are mostly affected by what is labeled as “preventable causes of disability.”

Access to Health Care among Hispanic Women: U.S., 2000-2002* Among the nation’s 33.4 million Hispanic women: 31% do not have health insurance coverage; 20% do not have a usual clinic to go for medical care; and 22% experienced unmet health care needs during the past year due to cost. *Centers for Disease Control and Prevention (CDC, 2005)

Lack of access to health care creates health disparities.

What is “Health Disparity?” A health disparity is a difference in health status that is persistent across subgroups of a population. Source: http://www.health.state.mn.us/

Consequences of Health Disparities Absence of and poor health care contributes to chronic illnesses. Chronic illnesses become permanent disabilities. Disabilities may become complicated by secondary disabling conditions. There is close correlation between disability and poverty. 25% of the population diagnosed as disabled is living at poverty level or lower.

Barriers Affecting Hispanics with Disabilities

Health Disparities among Persons with Disabilities Less health insurance coverage and use of the health care systems. Higher rates of chronic illnesses and secondary conditions. Lower rates of social participation. Lower rates of recommended health behaviors (e.g. smoking cessation, diet, etc). Less participation in health screening (women with disabilities).

Health & Disability Disparities Over 53 million Americans have either a severe or a non severe disability Disparities in rates of disability are pronounced for culturally diverse groups Hispanic Americans with disabilities are second to African Americans with disabilities with a 20.0% Self-reported health status is one of the lowest at: 30.4% for Good and 47.7% for Poor health.

Health & Disability Disparities: Social and Economic Burden Persons with disabilities are less likely to be meaningfully employed. Severity of disability impacts employment status -- as well as quality of employment. Women with disabilities are at higher risk for unemployment and low socioeconomic status.

Cultural Sensitivity A good starting point to implement good practices of health care services and improve health equity -- begins with Cultural Sensitivity: Being aware of your own cultural feelings and that of others. Respect to cultural implications. Reasonable accommodations and flexibility. Culturally based services and outreach.

Cultural & Disability Sensitivity Persons with disabilities are people first -- equally deserving respect and quality health care. Having a disability is only one aspect of a person's life

Cultural Competence Individual -The ability to communicate effectively with individuals representing diverse racial and ethnic heritages. Organization -The ability to be responsive to diverse cultural, ethnic, or linguistic clientele. Research - evaluate changing demographics, culturally-based consumer-centered services, and validation of best practices as key for increasing cultural competence.

Why is Cultural Competence important to avoid health disparities? Patient diversity Concepts of illness and healthcare Changing expectations in the medical and other health care fields.

Unequal Treatment: Confronting Racial and Ethnic Barriers in Health Care, (CDC. 03.2002)

Endurance is a cultural value. Important cultural factors for providing services to Hispanic Americans Perception of health and disabilities varies. Cultural perception of mental illness may cause difficulties in identifying and gaining support from the family. Long-term rehabilitation and lack of coping skills may be treated as being “weak” or “irresponsible”. If disability may be perceived as something that cannot change (fate) and efforts are placed on adjusting vs. treatment and rehabilitation. Endurance is a cultural value.

Hispanic Family Traditionally, members of the nuclear family are the most important source of support and guidance in many different situations. The extended family and friends safety-net is an additional support system. Outside help is avoided if possible with the exception of Clergy or Doctors.

The idea of needing "professional counseling, therapy or social services" has certain negative connotations --- not very appealing to a traditional Hispanic family. The perception of service systems is directly affected by their cultural values and beliefs.

Common Emotional Reactions of Family Members Take into consideration the impact of disability on the family and the family role of the person with the disability.

Common Emotional Reactions of Family Members Depression: Depression is a common and long-term consequence of disability. Depression may be expressed as anger.

Anxiety: Anxiety is a common reaction to the chaotic change and uncertainties that follows the onset of a disability. Challenges with emotional liability and coping with the situation can create an atmosphere of sustained anxiety.

Anger: Anger has been reported as a common consequence of injury related disability and to frustration.

Prolonged Emotional Distress: The effects of adjusting to a disability may persist for a long time. Physical and mental exhaustion can reduce coping ability, diminish hope, and exacerbate emotional distress.

Working with Culturally, Ethnically and Linguistically Diverse Groups Identify the cultural and linguistic background of the individual with the disability and his/her immediate family members. Learn about their culture, beliefs, and values and how these affect their attitudes toward disabilities. Understand the cultural implications and how individuals manage mental and physical illnesses.

Language Barriers Use qualified interpreters and translators with appropriate training. Preferably a person that is not related to the individual. Adopt the Standards on Culturally and Linguistically Appropriate Services (CLASS)

Research Needs to Eliminate Health & Disability Disparities Cultural Competence Culturally based health care practices Community Participation Capacity to respond to the increasing needs of the Hispanic population in reference to prevention, health care and eliminating health and disabilities disparities.

Recommendations for Future Research -- Cultural Competence Evaluate the needs for Cultural Competence training. Evaluate the outcomes of Cultural Competence in service delivery. Examine the awareness and application of cultural factors.

Recommendations for Future Research -- Community Participation Evaluate the effects of lack of education and training on service provision. Research the impact of collaboration of community participation. Evaluate accessibility in private and public health care sectors. Evaluate Health and Wellness educational services for youth and adults with disabilities.

Recommendations for Future Research -- Resources Research the effectiveness of skills development models for research related to health and disabilities. Examine how community-based research methods provide insight to eliminate health and disability disparities. Identify partnership models that can be developed to facilitate knowledge transfer.

Final Thoughts A “one size fits all” health care system cannot meet the needs of an increasingly diverse American population. Rather than making assumptions, take the time to uncover the information you need while fostering a working rapport with culturally diverse clients/patients. It is within our power to make a change and narrow the gap of health and disabilities disparities. ****

References E-mail: jonesmo@ecu.edu E-mail: wongl@ecu.edu https://cccm.thinkculturalhealth.org A Physician’s Practical Guide To Culturally Competent Care www.ncminorityhealth.org N. C Office of Minority Health and Disparities www.omhrc.gov National Office of Minority Health www.cdc.gov CDC, 2006 www.census.gov US Census Bureau review 2005 (a)

MULTUMESC Mahalo!