1. Culturally Appropriate Approaches to Addressing Latino Behavioral Health Disparities
Vincent Guilamo–Ramos, Ph.D., MPH, LCSW, RN
Center for Latino Adolescent and Family Health (CLAFH)
New York University, Silver School of Social Work
May 25, 2016

2. Agenda Latino Behavioral Health Disparities
Latino Behavioral Health Service Utilization
Enhancing Culturally Appropriate Approaches to Behavioral Health: Conceptual Frameworks

3. Latino Behavioral Health Disparities

4. Latinos in the United States
There are roughly 55 million* Latinos living in the United States, comprising approximately 17 percent of the nation’s total population.
Latinos accounted for nearly 50 percent of the population change in the United States during 2013–14.
Proportion of Latinos in the United States
Increase of approximately 1.15 million Latinos
-168,906 Deaths
+305,601 Migration
+1 Million Births
Source: U.S. Census Bureau July 1, 2014 estimates.
Latinos represent 17.4% of the total U.S. population.
Median age for Latinos is 27 years while overall U.S. population is 37 years.
During 2013–14 the Latino population grew 2.1 percent, while the overall population grew by 0.7 percent.
Sources: 1) U.S. Census Bureau, July 2013 Population Estimates; 2012 National Population Projections. 2) U.S. Census Bureau, National Characteristics: Population by Sex, Race, and Hispanic Origin

5. Age Distributions for Latinos Versus Whites, 2011
Sources: 1) Pew Research Hispanic Center 2011 American Community Survey. 2) U.S. Census Bureau, 2013 American Community Survey.

6. Latinos: A Young Population
Latinos are younger than the general U.S. population. 27 37
Median age of Latinos:
Median age of overall population:
years
years 25 27 28 40
years
years
years
years
Mexicans
Population pyramid before this
Guatemalans
Puerto Ricans
Cubans
Mexicans are the youngest Latino subgroup, with a median age of 25 years.
Source: U.S. Census Bureau. Annual Estimates o Resident Population by Sex, Age, Race and Hispanic Origin for the United States and States.

7. Burden of Mental and Behavioral Health Disorders
Top 10 mental and behavioral disorders in the United States:
Major depressive disorder
Bipolar disorder
Drug use disorders
Dysthymia
Anxiety disorders
Autism and Asperger’s Syndrome
Alcohol use disorders
Eating disorders
Schizophrenia
ADHD and conduct disorder
Source: U.S. Burden of Disease Collaborators (2013). The state of U.S. health, 1990–2010: burden of diseases, injuries, and risk factors. JAMA, 310(6), 591–608.

8. Mental Health Among Adults
Past-Year Major Depressive Episode* (MDE) Among Persons Age 18 and Older, by Race/Ethnicity, 2013.
In the United States, 6.7 percent of persons age 18 and older (approximately 15.6 million) in 2013 had at least one MDE within the past year.
5.8%
*Major Depressive Disorder is the most common mental health disorder.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.

9. Mental Health Among Adolescents
Past-Year Major Depressive Episode* (MDE) Among Adolescents Age 12–17, by Race/Ethnicity, 2013.
11.4%
In the United States, 10.7 percent of adolescents age 12–17 (approx. 2.6 million) in 2013 had at least one MDE within the past year.
*Major Depressive Disorder is the most common mental health disorder.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.

10. Latino Behavioral Health Service Utilization

11. Mental Health Service Utilization
Any mental health service use:
Adults are asked whether
they received treatment or counseling for any problem with emotions, "nerves," or mental health in
the past year in any inpatient or outpatient setting or used prescription medication in the past
year for a mental or emotional condition, not including treatment for use of alcohol or illicit
drugs.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008–12 (2008–10 Data, Revised March 2012).

12. %
However, estimates of any mental illness show comparable rates among White, Black, and Latinos.
Estimates of any mental illness in past year were comparable among racial/ethnic groups, with Latinos 15 percent, blacks 17 percent, and whites 19 percent.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008–12 (2008–10 Data, Revised March 2012).

13. %
Among adults WITH any mental illness, Latinos report lower rates of mental health service utilization.
Yet, estimates of mental health service use among adults with a mental illness is significantly lower among blacks and Latinos.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008–12 (2008–10 Data, Revised March 2012).

14. Treatment Utilization Among Latinos With
Major Depressive Episode (MDE)
Past-Year Major Depression Treatment Among Latinos Age 18 and Older With MDE, 2013
Past-Year Major Depression Treatment Among Latino Adolescents Age 12–17 With MDE, 2013
*Major Depressive Disorder is the most common mental health disorder.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.

15. Barriers to Engagement Among Latinos
Reasons for Not Using Mental Health Services Among Latino Adults With Serious Mental Illness Who Had an Unmet Need for Services in the Past Year, 2008–12
Culturally appropriate approaches to engage Latinos may present an opportunity to address these barriers.
Prejudice and discrimination: felt that mental health service use might cause neighbors/community to have a negative opinion, might have a negative effect on employment, concerns over confidentiality, did not want others to find out, or concerns over being committed or having to take medication
structural barriers: no transportation, inconvenient, did not know where to go
for services, or did not have time
cost or insurance coverage: could not afford cost, health insurance does not cover mental health services, or insurance does not pay enough for mental health services
low perceived need: did not feel the need for services or felt that they could handle the problem without treatment
Did not think services would help: concerns over efficacy
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008–12 (2008–10 Data, Revised March 2012).

16. U.S. Health Occupations by Hispanic or Latino Ethnicity, 2010–12
Hispanic/Latino
Non-Hispanic/Latino
Physicians
6.0%
94.0%
Advanced Practice Registered Nurses
4.4%
95.6%
Registered Nurses
5.4%
94.6%
Physician Assistants
10.8%
89.2%
Psychologists
6.2%
93.8%
Counselors
10.4%
89.6%
Social Workers
11.6%
88.4%
The limited number of Latino behavioral health providers presents an additional challenge to health service engagement among Latinos.
Source: HRSA. Sex, Race, and Ethnic Diversity of U.S. Health Occupations (2010–12), January 2015.

17. Enhancing Culturally Appropriate Approaches to Behavioral Health: Conceptual Frameworks

18. Key Concepts: Cultural Appropriateness/Competency
Image: Flags of many nations.
Key Concepts: Cultural Appropriateness/Competency
The concept of cultural competency has a positive effect on patient care delivery by enabling providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients.
Cultural competency is critical to reducing health disparities and improving access to high-quality health.
—National Institutes of Health
Greater cultural appropriateness associated with
Increased treatment adherence
Higher patient satisfaction
Overall improvement in health
behaviors and outcomes
Culture involves a number of elements, including personal identification, language, customs…and institutions that are often specific to ethnic… or social groups. For health care providers, these elements influence beliefs surrounding health… and delivery of health services.
Sources: 1) National Institutes of Health. Cultural Competency. U.S. Department of Health & Human Services; ) U.S. Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care; 2013.

19. Innovative Provider-Level Strategies for Addressing Barriers to Service Utilization
Cultural Formulation
Enhanced Latino Behavioral Health Outcomes
Behavioral Health Access,
Engagement,
and Treatment
Shared Decision-Making
Transnationalism

20. The Cultural Formulation Framework
The cultural formulation framework analyzes cultural factors that affect clinical encounters.
Particularly useful when the service provider is unfamiliar with the patient’s cultural background.
Framework examines the cultural boundaries between the patient and the provider.
The framework also assesses the impact of cultural factors on health- seeking behaviors of the patients.
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

21. The Cultural Formulation Framework
The Cultural Formulation Framework consists of five steps:
Step 1. Cultural identity of the individual Step 2. Cultural explanations of the individual’s illness Step 3. Cultural factors related to psychosocial environment and levels of functioning Step 4. Cultural elements of the relationship between the patient and provider Step 5. Overall cultural assessment for diagnosis and care
Note: This section will introduce the concept of cultural appropriateness. Becoming a culturally appropriate provider is a developmental process that requires constant awareness of a patient’s contextual factors (see factors above) in order to provide effective care. There are many individual/ cultural factors that influence patient’s health. Health care providers should be aware of all of these factors so that they can tailor their care to the individual. Brainstorm how factors such as race, religion, language, etc. might influence health care.
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

22. Step 1. Cultural Identity
Consider:
Example Questions to Ask:
Individual’s ethnic or cultural reference
Involvement with both the culture of origin and the host culture
Language abilities, use, and preference (including multilingualism)
Born in United States?
Acculturation?
Religion/religiosity?
Educational background?
Employment?
Migratory experience?
What else?
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

23. Step 2. Cultural Explanations of Illness
Consider:
Example Questions to Ask:
Meaning and perceived severity of the individual’s symptoms in relation to norms of the reference group(s)
Local illness categories used to identify the condition
Perceived causes and explanations that the individual and reference group(s) use to explain the illness
Experiences with healthcare utilization
Individual’s understanding of illness?
Idioms of distress? (e.g.. ataques de nervios- “attack of nerves”)
What else?
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

24. Step 3. Cultural Factors Related to Psychosocial Environment and Levels of Functioning
Consider:
Example Questions to Ask:
Culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability
Stresses in the local social environment
Role of religion and kin networks in providing emotional, instrumental, and informational support
Main sources of support?
Primary concerns regarding illness?
What else?
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

25. Step 4. Cultural Elements of the Patient–Provider Relationship
Consider:
Example Questions to Ask:
Individual differences in culture and “status” between the individual and the clinician.
Provider–patient differences may cause challenges in accurate diagnosis and treatment (e.g., difficulties in discerning symptoms and understanding their cultural significance, in determining whether a behavior is normal or pathological).
Barriers and facilitators to patient–provider communication?
Ways to improve patient– provider relationship quality?
What else?
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

26. Step 5. Overall Cultural Assessment
Consideration of how cultural considerations specifically influence diagnosis and care.
Source: Lewis–Fernandez, R, & Diaz, N. (2002). The Cultural Formulation: A Method for Assessing Cultural Factors Affecting the Clinical Encounter.

27. Digging Deeper: Transnationalism

28. Digging Deeper: Transnationalism
Processes by which immigrants forge and sustain multistranded relations that link their societies of origin and settlement. 5
Things to Consider:
Cultural Identity
Sources of Emotional and Practical Support
Beliefs About Health
Access to Health Care
Healthcare Practice
Image: Blue globe with two arrows (one pointing southeast, the other northwest) curling around it..
Source: Basch, L, Glick Schiller ,N, & Blanc–Szanton, C, eds. (1994). Nations Unbound: Transnational Projects, Postcolonial Predicaments, and Deterritorialized Nation–States. London: Gordon and Breach.

29. Digging Deeper: Transnationalism
Cultural Identity
Where was the patient born? Where was he or she raised? How does the patient identify his or her identity?
Sources of Emotional and Practical Support
Who are the patient’s main sources of support? Where does the patient seek help and guidance? What forms of support does your patient need (emotional, mental, financial, etc.)?
Source: Basch, L, Glick Schiller ,N, & Blanc–Szanton, C, eds. (1994). Nations Unbound: Transnational Projects, Postcolonial Predicaments, and Deterritorialized Nation–States. London: Gordon and Breach.

30. Digging Deeper: Transnationalism
Beliefs About Health
What is the patient’s attitude toward his or her own health? What factors does the patient think affect his or her health? How amendable is the patient to healthcare treatment?
Access to Health Care
Where is the patient’s primary source of health care? Does the patient have a regular provider outside of the mainland United States?
Healthcare Practices
How often does the patient seek healthcare services? How does the patient’s transnational travel affect his or her healthcare visits?
Source: Basch, L, Glick Schiller ,N, & Blanc–Szanton, C, eds. (1994). Nations Unbound: Transnational Projects, Postcolonial Predicaments, and Deterritorialized Nation–States. London: Gordon and Breach.

31. Further Enhancing Patient Engagement

32. Shared Decision-Making
“A collaborative process that allows patients and their providers to make healthcare treatment decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”
Graphic: Drawing of one hand reaching to hold the hand of another.

33. 1. Invite the Patient to Participate
Patients may not realize that there is more than one viable option for treatment.
By offering an invitation to collaborate on treatment decision, you are letting them know they have choices.
This reassures the patients that their goals and concerns are an important part of the decision-making process.
Sample language:
“Sometimes things in medicine aren’t as clear as most people think. Let’s work together so we can come up with the decision that’s right for you.”
Change smart art
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

34. 2. Present the Options Sample language:
“Here are some choices we can consider.”
“Let’s take a few minutes to review the options you have.”
Before making an informed decision, patients need to know all the options available to them.
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

35. 3. Provide Information on Benefits and Risks
Sample language:
“Let’s go over the benefits and the harms of the options you’re considering.”
“I want to be sure that I’ve explained things well. Please tell me what you heard (or wrote down) about _____ [most important benefits and harms].”
Give balanced information.
It is also important to check in with patients to make sure they correctly understand the potential benefits and harms.
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

36. 4. Help the Patient Evaluate the Options Based on His or Her Goals and Concerns
Sample language:
“People have different goals and concerns. As you think about your options, what’s important to you? For example, some people... while other people....”
Patients may not be comfortable raising their personal goals and concerns for treatment. By actively inquiring, you are giving them permission to speak about what is important to them.
Once you’ve elicited this information, you can help them look at their options based on their preferences
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

37. 5. Facilitate Deliberation and Decision-Making
Sample language:
“Considering what we’ve discussed, do you have a preference about the direction we take?”
“Is there any more information you need?”
“What’s the hardest part about deciding?”
“From what I hear you saying, here’s what I’d suggest.... How does that sound?”
Patients may not be ready to make a decision immediately. Probing for what else they need to know or do before they make the decision can be helpful.
If they are ready to decide, you can help facilitate a final decision.
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

38. 6. Assist With Implementation
Sample language:
“Let’s take a moment to talk about the next steps.”
Close conversation by laying out the next steps for the patient.
Source: Wexler, R. (2012). Six Steps of Shared Decision-Making (SDM). Informed Medical Decisions Foundation.

39. Vincent Guilamo–Ramos, Ph.D., MPH, LCSW, RN, ACRN
CONTACT
Vincent Guilamo–Ramos, Ph.D., MPH, LCSW, RN, ACRN