Recognizing and Overcoming the Barriers to Health Care in the Hispanic/Latino Community

1. Recognizing and Overcoming the Barriers to Health Care in the Hispanic/Latino Community Rebeccah L Brown, MD Associate Professor of Clinical Surgery and Pediatrics Associate Director of Trauma Services Cincinnati Children’s Hospital Medical Center

2. Texas Total Population 21,325,018 Hispanic Population 6,824,006 (32%) 2nd Largest Hispanic Population

3. New Mexico – “The Land of Enchantment” Total Population 1,829,146 Hispanic Population 770,070 (42%)

4. The Latino Explosion

5. The Latino Explosion

6. Population Growth in USA • Over 40 million Hispanics in USA today • Unprecedented growth • Fastest growing racial/ethnic minority group • Increasing 7x faster than rest of US population • Almost 60%  since 1990 • Have surpassed African-Americans as largest minority (16.5%) • Hispanic children are the largest minority group of children (11.6 million; 16% of population < 18 yrs) • By 2050, an estimated 102 million Hispanics will reside in the US - 1 of every 4 Americans will be of Hispanic/Latino heritage

7. Population Growth in Greater Cincinnati/Northern Kentucky • Hispanic population is escalating in the Greater Cincinnati/Northern Kentucky area • 435%  Boone County (KY) • 140%  Campbell County (KY) • 137%  Kenton County (KY) • 83%  Hamilton County (OH) • 113%  Dearborn County (IN) • Largest Hispanic populations in Cincinnati -Springdale, Hamilton, Sharonville, Norwood, and Fairfield • Largest Hispanic populations in Northern KY-Covington, Florence

8. Barriers to Hispanic Health Care Cultural differences Language Lack of health insurance Education Poor understanding of US health care system Poverty Transportation Immigration status Cultural insensitivity/racism

9. Health Foundation of Greater Cincinnati 2005 Hispanic/Latino Health Survey • Based on interviews with 535 men and women at the Su Casa Hispanic Festival in Sept 2005 • 75.6% had come to live in Greater Cincinnati since 2000 • 49.1% reported personal (not household) incomes < $20,000 • 78.8% were not acculturated, meaning they had a strong preference for the Spanish language and social environment • 32.9% reported Spanish as their preferred or only language • 60% have no health insurance coverage, including Medicaid (compared to 13.1% percent for overall region) • 55.6% felt Hispanics receive lower-quality health-care than others

10. Health Foundation of Greater Cincinnati 2005 Hispanic/Latino Health Survey • Top barriers to accessing health care services • High cost of care (40.4%) • No insurance (39.1%) • Wait for an appointment (36.4%) • Not speaking English (35.9%) • Provider not speaking Spanish (31.4%) • No interpreter available (21.5%) • Finding a doctor (21.3%) • Transportation (20%)

11. Cultural Differences • Rely more on home remedies and over-the-counter meds • Rely on advice from family members • Seek professional advice only if problems persist • Less compliant with routine check-ups and preventive/screening measures • More apt to trust health care providers who speak their language or share similar cultural background

12. The Language Barrier • Hispanics who speak primarily Spanish • 61% are uninsured • Most do not have a regular doctor • 1/3 rely on public or community clinics (compared to 12% English-speaking Hispanics, 10% Blacks, and 7% Whites) • Of 600 uninsured Spanish-speaking Hispanics surveyed, almost 60% responded that interpretive language assistance was not available from their health care provider

13. Immigration Status

14. The Health Insurance Crisis • About 44 million Americans are uninsured (1 out of every 7) • # of uninsured increased by 2.4 million from 2001-2002 • 12% of all children are uninsured • Hispanics are the least insured of all – nearly 40% of adults and 31% of children are uninsured

15. Disparity in Health Insurance Coverage White Non- Hispanic 10% 10% 22% Hispanic FB - Naturalized 25% 55%

16. Uninsured Hispanics Benefit US Economy But Do Not Reap Health Benefits

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18. Barriers to Health Insurance • Work for small, low wage businesses that do not offer insurance • Individual insurance is prohibitively expensive • Not poor enough to qualify for Medicaid, but too poor to buy private health insurance • Uninformed about existing assistance programs (ie. CHIP) • Cultural, educational, and language barriers limit interactions with physicians and ability to complete paperwork required for assistance • Concerned about being labeled a “public charge” • Immigrant, non-citizens

19. Access to Primary Care The Importance of Having a “Regular Doctor” • About 30% of Hispanics lack a usual source of health care compared with < 16% of whites • Hispanic children are nearly 3x as likely as non-Hispanic white children to have no usual source of health care • Hispanics are twice as likely to rely on hospitals or clinics for health care than whites • Decreased chance of receiving adequate preventive care and other important health services

20. The Double Burden • Lack of insurance  poor access to health care • Limited English  poor communication with health care providers  disparity in quality of health care  decreased quality of life, loss of economic opportunities, and perceptions of injustice/social inequity

21. Disproportionate Health Care Problems Among Hispanics • Asthma • Chronic obstructive pulmonary disease • Diabetes • HIV/AIDS • Obesity • Suicide • Teenage pregnancy • Alcoholism • Tuberculosis

23. Breaking Down The Barriers • Master the language • Train bilingual staff (receptionists, nurses, technicians, physicians) • Provide skilled medical interpreters • “Medical interpreters should be recognized as allied health professionals, who bill for their services, which should be just as reimbursable as lab services.” • Elena Rio, President, National Hispanic Medical Association • Schedule Spanish-speaking clinic hours • Provide signage and written instructions in Spanish • Teach patients English • Aim for perfect communication/understanding

24. Breaking Down The Barriers • Develop child care programs in Latino communities so parents can take time to go to physician • Provide child care at health care facility • Provide information on importance of preventive care, especially for children • Provide info on CHIPs • Develop local/regional/national telephone hotlines in Spanish to respond to medical questions • Be familiar with community resources

25. Breaking Down The Barriers • Utilize focus groups to “zero in” on issues important to the Hispanic/Latino community • Establish bilingual liaisons with the Latino community to build relationships and earn trust • Establish health care facilities in Latino communities or send mobile units • Approach transportation authority to have buses routed to Latino communities • Print bus schedules in Spanish

26. Breaking Down The Barriers • Expand outreach for public assistance programs • Government incentives to encourage small businesses to offer coverage • Oppose federal health mandates that increase costs of providing health care • Change tax law to allow individuals to deduct entire cost of purchasing health insurance (Fair Care Act) • Lobby for health insurance for all

27. Motor Vehicle Safety - The Stats • Motor vehicle crashes are #1 cause of death in Hispanics 1-24 years • Hispanic children < 4 years have 2nd highest death rate from motor vehicle crashes (2nd only to African-American children) • Hispanic children 5-12 years have 72% higher death rate from motor vehicle crashes than Caucasians • Minority children are at about 3x greater risk of air-bag related injuries due to riding more frequently in the front seat of vehicles with passenger-side airbags

28. Motor Vehicle Safety - The Stats • Per vehicle mile traveled, Hispanic children are 3x more likely to die • 3x less likely to use child safety restraints and 3x less likely to ride in the backseat • Much less likely to wear seatbelts • Despite fewer miles traveled, teenage Hispanics are twice as likely to die

29. Motor Vehicle Safety Hispanics vs Whites •  seat belt use (22% vs 38%) •  EtOH use (31% vs 24%) •  EtOH levels •  fatality •  insurance (24% vs 50%) •  hospital costs • Motor Vehicle Safety in Illinois Hispanic Communities - Findings from Focus Groups

30. Barriers to Hispanic Injury Prevention • Poverty • Unable to afford child safety restraints, helmets • Older cars without seatbelts, airbags • Overcrowding of cars • Riding in back of pickup trucks • Language barriers • Cultural barriers • Lack of insurance •  access to medical care • Not familiar with US child restraint and safety belt laws

31. The Problem Skyrocketing Hispanic Population + Barriers to Injury Prevention  Marked Increase in Injuries and Deaths  Emerging Public Health Crisis

32. Hispanic Youth Injury Prevention Initiative • Modeled after the faith-based African-American Youth Injury Prevention Initiative • Similar to African-Americans, Hispanics also have strong ties to family and the church • We hypothesized that a faith-based initiative similar to that developed for African-American youth would be successful in the rising Hispanic population as well • The model is in place, but must be culturally adapted for the Hispanic population and their specific injury prevention needs and concerns

33. Hispanic Youth Injury Prevention Initiative • Supported by Toyota Manufacturing of North America A Committed Partner to Safety

34. Development of the Initiative • Establish relationships with key Hispanic faith and community leaders • Conduct surveys and focus groups to identify population characteristics and unique areas of concern among Hispanics about injury and injury prevention • Conduct pre-intervention observations of vehicle restraint use among Hispanics • Develop culturally relevant injury prevention curriculum based on outcomes of surveys and focus groups • Implement curriculum into faith-based Hispanic community

35. Occupant Protection Survey Results (n = 250) • 84% reported wearing their seat belt “always”; 11% reported wearing their seat belt “most of the time” • Parents reported that 68% of children under 5 years of age were always restrained and rode in the back seat 96% of the time • Only 37% of parents were aware that Ohio law requires children to ride in a car seat until they are both 4 years old and 40 lbs • Barriers to use of proper restraints included distance travel >50 miles or an ill or fussy child

36. Occupant Protection Observations • Observation of restraint use was significantly lower than self-reported use • Only 34% of children were properly restrained and 42% of children rode in the back seat (reported 68% and 96%) • Only 34% of drivers and 55% of adult passengers were observed wearing seat belts (reported 95% always to most of time)

37. Hispanic Parent Focus Groups • 42 eligible Hispanic parents (19 males and 23 females) • Median age of both male and female participants was 25-34 years • Median income $10,000 – $24,000 • 68% were high school graduates or less • Majority were from Mexico (66.7%), Central America, South America, Puerto Rico, and Dominican Republic • Mean length of time in USA was 7.4 years (range 1 month - 22 years) • Total number of children among participants was 88 (mean 2.1; range 1-4) with a mean age of 6 years (range 1-20 years) • Majority of children (71.6%) were ≤ 8 years of age and 94% were ≤ 12 years of age

38. Key Factors Leading to Misuse/Non-Use of Child Restraints • Inability to afford them • No tradition of using them in their native country • Lack of knowledge about how to properly install and use the seats • Lack of understanding of child safety laws • Very short or very long trips • In a hurry • Overcrowding in vehicles • Riding in someone else’s car • Ill, fussy, or misbehaving children

39. Barriers to Seat Belt Usage • Females were more likely to wear seatbelts than males (96% vs 79%) • Discomfort, especially during pregnancy • Lack of awareness of the consequences of not using seat belts • Didn’t feel that there was a need to buckle up while riding in the back seat • More people in car than seatbelts

40. Focus Group Findings • Parenting styles, unfamiliarity with laws, child behavior, and situational factors (trip length, vehicle overcrowding, alcohol use) emerged as important issues • Language is a significant barrier • Many felt that literature is often erroneously translated into Spanish without regards to the diversity of Hispanic cultural origins • Most participants reported either driving under the influence of alcohol or allowing their children to ride with someone under the influence of alcohol on at least one occasion • Only 50% of participants had driver’s licenses (39% of females; 63% of males), while 86% stated that they drive either their own car or borrow one from a relative or friend • Many were unfamiliar with the rules of the road and safety precautions

41. Focus Group Findings • Most sought safety advice from family and trusted friends. • Most reported that faith was an important component of injury prevention, but that we must take actions to protect ourselves. • All participants attended church, and nearly all (98%) were receptive to obtaining occupant protection information from a faith-based source. • Other suggested avenues of delivering safety information included child care centers, clinics, community centers, grocery stores, and restaurants.

42. Motor Vehicle Restraint Use in the Hispanic Community 250 pre-intervention observations at churches

43. Where we are now…… • We have identified 6 faith-based centers committed to participate in the Hispanic YIP program • We have developed and translated into Spanish safety curricula to address the following: • Recognizing what happens in a crash: why are safety restraints important? • Car seat safety • Use of the booster seat • Importance of buckling up for children, teens, parents, and grandparents • Importance of children < 12 yrs sitting in the back seat • Correct travel behavior • Teen driving • Laws of the road • Dangers of drinking and driving • Bicycle safety • We have conducted of 6 preliminary occupant protection observations at 6 different sites (3 in KY; 3 in OH). Will conduct unannounced observations at conclusion of program and 6 months later to determine effectiveness of program. • Delivery of safety message • Sunday school lessons • Sermons focused on safety • Safety messages in church newsletter • Teen safety groups/role models • Parent/grandparent groups • Theatrical performances

44. Where we are going… • Partner with the Hispanic business community to identify best ways to spread safety message to community • Spanish safety newsletters • Community safety events • TV/radio/billboard safety messages • Spread the good news…propagate to other faith-based and business organizations • Package the program for distribution and implementation regionally, nationally, and globally

45. Growth, Opportunity, and Change

46. MissionTo advocate for and empower members of the Hispanic community and to bridge the gap between communities by inspiring and supporting healthy attitudes and behavior through substance abuse prevention and intervention

47. Abriendo Puertas Abriendo Brazos Abriendo Corazones