¿Habla español? Cultural Care for Our Hispanic Population

The US Census estimates that more than 43 million people in our nation speak Spanish as their primary language. Hispanics have become America’s largest minority group, and there’s no doubt that their influence is transforming the entire country. Because of an increase in Hispanic patients, many pharmacists have a myriad of questions concerning Latinos and their attitude towards medication and health care practices. So let’s start with the basics. What do the terms “Hispanic” and “Latino” mean? Which term is correct?

In the late 1970s, the US government began using the word Hispanic to describe Spanish-speaking individuals who live in the US. The term derives from the Latin word for Spain, “Hispania”, and it’s defined as “people who speak Spanish and trace their family origin to Spain.” This term was not truly accurate thirty years ago, and there are several problems with it and its definition today.

First, most people in the United States who speak Spanish do not trace their heritage to Spain. Their ancestry is firmly and deeply rooted in Latin America. Their connection is truly “New World” American rather than “Old World” European. Furthermore, as soon as Spanish conquistadors set foot on the American continent, they began to replace the thriving Native American culture and languages with their own. Many people feel that use of the term Hispanic diminishes the importance of Native American contributions within the Americas.

Throughout the US, the term Latino is gaining in popularity. This word is defined as a person who speaks Spanish and comes from any of twenty different Latin American countries. In addition to countries in Central and South America, Caribbean countries such as the Dominican Republic, Puerto Rico, and Cuba are also included. Each Latin American country has its own unique character, history and flavor. As a result of these regional differences, the term Latino is very important because it preserves an individual’s unique national origin. Most Latinos are intensely proud of their distinct American heritage.

Furthermore, Latino is a racially neutral term. Realizing that Latinos and Latinas form part of an ethnic group that is made up of many different races is very important for healthcare professionals. It’s also essential for pharmacists and other healthcare providers to be aware that most Latinos have some degree of indigenous ancestry. Their genetic makeup has a bearing on the prevalence of certain diseases such as diabetes and asthma within the Latino ethnic group.
Currently, the terms Hispanic and Latino are used interchangeably: both are correct. Therefore, it’s perfectly appropriate for you to use either term. Choose the term you are most comfortable using.

Latin American countries are vitally unique. Hispanic culture is extremely diverse and represents a rich tapestry textured with traditional values. Although Latin America is steeped in rich tradition, the majority of countries are severely impoverished. Unemployment is common, and the average wage in many countries is much less than two dollars per hour. As a result of poor economic conditions, each country vastly differs in its ability to provide basic health and human services. Most Latin Americans have extremely limited access to health care. In many remote areas, people may walk an entire day just to visit a clinic. Sadly, a nurse, doctor or even basic medication may not be available once they arrive.

Most individuals live in poverty and suffer from extremely poor nutrition. Few basic necessities are available. It is not unheard of for entire villages to survive without electricity or clean water. Under these circumstances, having a family doctor or obtaining an annual physical is next to impossible. Family ties are often very strong between Hispanics living in Latin America and their American relatives. Consequently, the difficult living conditions in Central and South America can have a tremendous impact on Latinos living in the US.

Adding to the complex problems of poverty and inadequate nutrition is the fact that poor educational systems exist throughout Latin America. Education is in a state of crisis in many countries south of the border. For many Latin Americans, education is a luxury – not a necessity. Individuals who lack a basic educational foundation have much greater difficulty learning a second language such as English. According to Census statistics, approximately one-third of Hispanics over the age of 25 have no more than a ninth grade education. Sadly, many Hispanics who immigrated to the United States as children are unable to read or write in Spanish. For adults with limited educational opportunities, the learning curve for English can require seven years or more. This places the burden of communication squarely on the shoulders of America’s pharmacists and healthcare providers.

Pharmacists need to recognize the differences between Latin Americans. They must understand that Hispanic health care is not a “one-size-fits-all” affair. Several common threads must be considered on the journey to becoming more culturally competent.

Hispanic views on health care and medical treatment are as complex as Hispanics are themselves. As you work with bilingual staff members and Hispanic patients, you may witness cultural conflicts between Latinos from different countries. Challenges can involve concepts as basic as the use of the Spanish language or differences in education and acculturation. Americans from different parts of our country have different accents and use a variety of slang. Similarly, Hispanics from different parts of Latin American often have different speech patterns. Even though both groups speak Spanish, an individual from Guatemala may have difficulty understanding an interpreter from Argentina. Occasionally misinterpretations such as these can lead to serious cultural breakdowns that border on discrimination.

Protection from discrimination is an important feature of our society. As a result of the Civil Rights Act of 1964, Americans are protected from discrimination based on race, religious preference, color, sexual orientation, disability or national origin. Recently through Executive Order 13166, individuals with limited English proficiency have also been granted Civil Rights protection. The purpose of this legislation is “to provide equal access to services for persons, who as a result of their national origin do not speak English as their primary language.” This legislation also protects persons who may have a limited ability to write or understand English. As a result of this federal mandate, agencies or programs that receive Federal financial assistance are required to provide meaningful access to people with limited English proficiency.

But, what does providing meaningful access to services really mean? In an effort to comply with this new federal legislation, many pharmacies, hospitals and doctors offices now provide telephone translating services to their Hispanic patients or distribute informational materials in Spanish. There may be downsides to both of these practices. Telephone translation services can be painfully impersonal. The interpreter, although they are fulfilling their job requirements, have no real knowledge of the patients or insight into their conditions. Furthermore, Hispanic patients usually find it extremely difficult to build a trusting relationship with a pharmacist through the use of a telephone translator. Since health care issues are by nature very personal, they are often extremely difficult to discuss with a complete stranger. This communication barrier is often very challenging for older, female Latina patients who may be embarrassed to discuss their most intimate problems by telephone. Even distributing translated documents may cause problems. Patients may be unable to read them because they are functionally illiterate or the material is poorly translated. In these cases, an individual can become completely alienated by our attempts at inclusion. So what should you do?

The answer is to develop, implement and plan a cultural and linguistically appropriate strategy (CLAS) that will guarantee equal access to the valuable services you provide. Ensuring translators are at your disposal is one part of the plan. Providing well-translated brochures and documents is another important component of any CLAS. However, the most critical component of your plan must include a commitment to learning Spanish. Knowing even very basic Spanish will go a long way towards building trust with your Hispanic patients. You don’t have to be fluent in Spanish to be able to communicate effectively. Possessing a few survival Spanish skills is very helpful. This step forms part of an effective linguistic strategy for providing better service to Hispanics with limited English proficiency.

Hopefully you now realize the importance of providing equal service to all individuals regardless of their English proficiency. Learning “poquito español” will help you build trusting relationships with your Latino patients. However, you should also become familiar with several important cultural aspects involving Hispanics and their attitudes towards health care.

For example, a lack of preventative care is very common in the Hispanic community. Many Hispanics do not have a family doctor who performs routine check-ups. Others may not want to take time off from work to undergo an annual physical or receive minor treatment. In fact, going to the doctor may not be considered “macho.” Hispanics often seek healthcare services only when they or members of their family are in a crisis. When this occurs, they tend to visit hospital emergency rooms for care.

In addition to a lack of preventative health care, serious misconceptions about nutrition and weight are common among Hispanics. Carrying “a few extra pounds” in Hispanic culture is considered healthy. Most new mothers want to have a “fat” baby because they equate the concept of fat with being healthy. This also indicates to others that you have sufficient income to afford plenty to eat. Obesity in the Hispanic population is a serious health issue that is leading to numerous problems including an increase in type 2 diabetes, heart disease and hypertension. Long work hours and pressure to make decisions based on the welfare of your entire family are very common. As a result, following a healthy exercise program and making lifestyle changes are difficult for many Hispanics.

Also in addition to lack of preventative care and misconceptions about weight, many Hispanics display a fatalistic view of life. This tendency is called fatalismo and it’s even more prevalent where chronic diseases such as asthma, obesity and diabetes are concerned. Many Hispanics feel that the state of a person’s health is directly related to God’s approval or disapproval of that person’s behavior. For example, if you are afflicted by diabetes, it may be considered your burden to bear. Hispanics often dismiss the idea of a cure, and resign themselves to the fact that nothing can be done about the situation. They may adopt the following attitude: “If I want to go off of my diabetic diet or fail to take my medication to enjoy a family outing, I can always return to it tomorrow. After all, it won’t make that much of a difference. My disease is here today, and it will still be here tomorrow.”

Self treatment of symptoms instead of seeking professional medical advice is also common in Hispanic culture. Homeopathic remedies are important aspects of Latino health care that often represent the first step in treatment. Curative recipes may be passed down from one generation to the next. These usually involve teas infused with a variety of herbs. Individuals who are familiar with herbs and know how to use them are highly regarded and respected. This can present a serious complicating factor when providing pharmaceutical care to Hispanics. Without asking individuals specifically, it’s impossible to know what other chemical compounds they may be taking. Certain combinations of herbs can cause very dangerous drug interactions.

Believe it or not, Latino convenience stores called “tiendas” provide an important, and sometimes dangerous, health care connection for Hispanics living in the US. In most Latin American countries, individuals can legally purchase antibiotics and other medications at a tienda without a prescription. The practice of buying prescription medications at the corner market is becoming much more common in the United States. An estimated two-thirds of American tiendas sell “under the counter” prescription medications to their customers. Sometimes, the FDA has banned drugs that are currently being sold for safety reasons.

Dipyrone or Metamizol, which goes by the street name “Mexican aspirin”, is one of the most common and dangerous drugs readily available at many tiendas. “Aspirina Mexicana” is still marketed in Mexico, Central America and some European countries. Because such drugs are readily available back “home,” many Latinos don’t understand why they can’t purchase them in the US without a prescription. Many Hispanics believe Dipyrone is simply a stronger form of aspirin. Latinos often use this drug for alleviating pain or fever. Unfortunately, Dipyrone carries serious health risks. The drug is incredibly potent and is found in the pyrazolone class of analgesics. It can critically deplete white blood cells and induce a medical condition called agranulocytosis which may lead to fatal infections. (South Med J. 1996 June; 89(6):612-4. Dorr, VJ, Cook, J. “Agranulocytosis and Near Fatal Sepsis due to “Mexican Aspirin”) Throughout the US, Mexican aspirin is commonly available in a syrup form that is given to infants, along with tablets and injectable liquids.

By far, the largest obstacle to providing better health care services to Latinos is overcoming the language barrier. Here are some simple tips that anyone can use to help bridge the communication gap:

Be extremely polite: Courtesy titles in Hispanic culture are very important. Use words such as señor, señora and señorita instead of first names. Latinos tend to be more formal in their demeanor. Calling someone by their first name without building a relationship first can be considered impolite.

Pronounce names correctly: Ask if you are pronouncing the name properly and verify that you have the correct surname. Many Latinos have both a paternal and maternal surname. In fact, a Hispanic name often consists of four parts: First name, second name, paternal surname and maternal surname. The correct “last” name is the paternal surname or apellido paterno. (ah-pay-YE-do pa-TER-no)

Speak slowly: Non-native speakers need time to process what you have said. By speaking slowly, you will increase your patient’s ability to understand you.

Dates of birth: Latinos speak and write dates using the following format: day/month/year. Having the day and month juxtaposed can cause serious patient identification errors.

Language classes: Invest in industry-specific Spanish classes. The knowledge you gain will help you build valuable relationships with your Spanish-speaking patients. This will also encourage your patients to speak English with you. They will feel like very important customers which, of course, they are!

Slipping in Slang

The use of slang terminology is a hallmark of the construction industry. There are as many different jargons as there are specific trades and specialties. Each trade’s vocabulary is different and it’s often very colorful. These factors alone can cause communication problems. Add the facts that slang usage can change practically overnight and new phrases are added daily; now you’ve got a potential accident in the making caused by simple miscommunication.

The meaning of a slang word or phrase isn’t always obvious to someone outside the building industry. It can be hidden in a description like saying “he’s circling the drain” to describe an employee who’s likely to be terminated. Slang can also come from current expressions taken from movies or television shows. In addition, shortened forms of words like “specs” for specifications and “prep” for preparation also are part of common slang vocabulary. When it comes to trade jargon, actual work experience is the best teacher, but it can still be hard for novices to understand — even for a beginner whose native language is English.

If slang causes problems for native speakers, what impact does it have on non-native speakers in the work force?

The answer is simple: the use of slang can have an enormous effect on a non-native speaker’s ability to perform the tasks you require. In construction any sort of miscommunication can cause serious misunderstandings that can result in delays and costly mistakes. It can put employees’ safety in jeopardy. For this reason alone, it’s important to be aware of what you say and how you say it. Both can influence how well and how quickly you are understood, especially in an emergency situation.

When adults learn English as a second language, slang can be misinterpreted and misused. When I was in high school, I had a teacher from Holland. Since I had her class before lunch, she often read the lunch menu aloud. She never failed to describe the corn we were having for lunch as a “nose of corn” instead of an “ear of corn.” Our class always howled with laughter. Most of the time she communicated well in her second language, but she never quite figured out which body part to use when talking about corn. Have you ever wondered why we say an “ear” of corn rather than an eye, an arm or a nose of corn? This is a simple example of a common phrase that a native-speaker uses without question, but a non-native speaker may never acquire without years of practice.

This communication disconnection occurs in non-native speakers because they tend take words or phrases literally rather than in context. This type of mistake happens frequently to anyone learning a second language. The slang a native-speaker uses is always hard to grasp. One of our construction clients learned this example the hard way. He asked several Hispanic employees to “police the area” at the end of the day. That’s exactly what they did. Because they didn’t understand the request, they looked for police in the area and didn’t pick up any trash! The employees performed the task literally instead of figuratively.

To correct this common communication challenge, set a great example by eliminating as much slang as possible from your speech. Using slang is a habit you can break. It’s just like controlling any other behavior you want to change; it won’t be easy but it will be rewarding. Start by examining how you give instructions to your employees. Eliminate slang there to give more efficient, streamlined directions. Taking this important step will make your instructions easier to follow. Next, make every effort to teach your non-native speakers the correct form of a word before they learn the shortened or slang form. In Spanish, words are rarely abbreviated. (See sidebar for construction slang to avoid.) For more effective communication on your job site, it’s best to avoid slipping on slang as much as possible.

Construction Slang to Avoid: Teach non-native speakers the correct form of a word before using the shortened or slang form. In Spanish, words are not usually abbreviated. Here is a list of slang terms to avoid at your job site:

1. ID: Identification
2. Specs: Specifications
3. Prep: Preparation
4. Fudge: Not using precise design specifications
5. On the bubble: Level
6. Op: Equipment operator
7. Pipe fighter: Pipe fitter
8. Pump up the volume: Work faster
9. Super: Supervisor
10. Roach Coach: Lunch van

The New Language of Construction Safety

From rigging and scaffolding to a wide variety of lethal chemicals, hazards are common on construction job sites. Are workers with limited English proficiency another danger on today’s multicultural construction projects? Possibly. Many safety experts believe that accidents resulting from language and cultural barriers will soon become among the most dangerous and costly in the industry.

Predictions are that Hispanics will comprise more than 50% of the construction workforce within the next five years. The accident and fatality rate for Hispanics in construction is already much higher than it is for either African-Americans or Caucasians.

What’s the reason for this disparity?

The answers are both cultural and linguistic. Cultural attitudes play a very important role in workplace safety. The workplace in Latin America is a hierarchy with a well-defined chain of command. Workers go up the ladder with ideas or suggestions to their immediate supervisor. To many Latinos, a “good” employee trusts and respects his supervisor implicitly — without questions. Asking questions can be seen as a threat to the supervisor’s authority instead of a desire for clarification. This cultural barrier to communications is just as serious as a language barrier where safety practices are concerned. Even though most Hispanic workers are learning English, for many it is a Herculean task. According to US census figures, almost two-thirds of Hispanics over the age of 27 are functionally illiterate. For average Hispanic adults the learning curve to speaking English fluently can take up to seven years. Consequently, implementing training policies that are spoken and/or printed in English only will be ineffective and potentially dangerous.

There are many questions concerning how to deal with the potential dangers associated with non-English speaking workers in the construction industry. There’s no doubt that job sites will always pose some risks, however employers bear the ultimate responsibility for making the workplace as safe as possible.

Cultural diversity and Spanish language training for supervisory personnel will continue to provide some of the answers to this complex 21^st century construction issue. A change in awareness may provide others. Think about the ways you can create a new language of safety on your job site. When translators are not available, speak slowly, be direct using short simple sentences, and when possible use demonstrations—show specific safety techniques and have all employees practice them. This critical training and facilitated communication is an important aspect of the new language of safety that will reduce accidents and promote increased efficiency.

Five Great Tips for Communicating Safely

• Speak slowly. Non-native English speakers need extra time to process what you are saying. Translating from one language into another isn’t automatic

• Be direct. Use short, simple sentences, especially when giving instructions. People learning English get lost in long sentences with complicated grammar.

• Use a normal speaking voice. Don’t speak in a loud voice. Your employee doesn’t have trouble hearing you. They have trouble understanding you.

• Use bilingual employees wisely. They are one of your company’s biggest assets. Group non-English speaking employees with bilingual ones. If possible, group people from the same countries together. Their language and accents will be the same.

• Color. Identify bilingual employees with a brightly colored hard hat. When seconds count in an emergency they can be found quickly.

20 Tips for Effective Training

Myelita’s Twenty Tips for Effective Training

1. Know Your Customer: Learn everything you can about your client before designing your program
1. For associations: What are the characteristics of members who attend training programs?
2. When possible, get email addresses from program participants in advance.

i. Send attendees a welcome message. Start building the relationship before beginning your training

ii. Develop a survey of no more than 5 questions for participants to answer in your email. If you keep your request for information “short and sweet” you are more likely to get responses.

iii. If you don’t get responses, take your survey as a
“pre-training” questionnaire. Distribute it at the start of your program and take up the responses during the first break. Review them quickly at your next break and alter your program’s content if necessary.

iv. Make sure to include some of your attendee’s learning objectives in your program. Nothing angers people more than being asked for input and then being ignored!

v. Keep the email addresses in your database for e-zines and newsletters

vi. After the program, send another email to thank the attendees for making it a great day and offer further assistance

2. Walk in the audience’s shoes: Take an on-site tour of their facility or meet your client in their corporate environment.
1. If the client is in a distant state, find a company with similar needs in your area and ask for a meeting. Who knows? You might convert this meeting into another training session.
3. Set a good atmosphere: Specify the type of room set up and equipment you prefer. Put this list in your contract or service agreement.
4. Arrive early: Make sure you got the room set-up and equipment you need. Make sure everything works.
5. Solve problems: Never create problems with a bad attitude. You won’t be asked back for another program nor will you get an important referral to other clients
1. If you didn’t get the room set-up or equipment you requested or if the gear doesn’t work, go to your “Plan B”
2. You should be able to do your program with nothing if you had to!
6. Begin working as soon as your participants arrive
1. Welcome them as they enter the room to begin putting names and faces together
2. Always ask your client to prepare name tags or have blanks in your travel kit to take with you to the site
3. Ask questions to your attendees and use the answers to make your program personal and relevant. Something simple like “why are you attending my program today” makes for a great ice-breaker.
7. Use good training structure
1. State your program’s learning objectives in a conversational way
2. Make your program follow a logical progression
3. Before a break, summarize what you have covered and state what you will be doing when the group returns from the break. Your audience will appreciate the fact that you have a plan and that you are sharing it with them.
4. If your training program is suited for role-play or other interactive activities, give ample time for these. Intersperse them through the program. This sort of activity is good just before a break. It provides the group an opportunity to move around, change their focus and put your plan into action.
5. What activities will you use to illustrate your training objectives?
8. Design effective handouts: Don’t cram too much on a page. The learner needs “white space” for a more powerful visual effect. Having adequate “white space” on a page makes it easier to read and allows space for taking notes.
9. Create effective PowerPoint presentations that you can easily and quickly modify for other programs
1. Take care when selecting the background you use for your presentation.
2. All LCD projectors do not maintain consistent background or font colors. The age of the projector’s bulb can make your snazzy presentation look horrible!
3. Personally, I prefer a neutral background and font color. It works well in either light or dark rooms and with almost any kind of projection system.
10. Use Your Voice Effectively: Pitch, Power, Pause, and Pace
11. Warm up your voice and body before beginning your presentation: Correct breathing and stretching prior to a program will prevent damage to your vocal cords
1. Pace yourself so you are at your best from start to finish
12. Practice telling your stories — and write them down!
1. Never tell the same story or joke to the same group twice. Boring!
2. Keep your story list in your client file for easy reference
3. Know the length or timing of your stories so you can eliminate them if you must to keep within your time constraints
13. Keep It Moving! Plan your movement to help make points. Movement is critical to the “flow” of your presentation. No one likes a speaker that is afraid to leave the podium!
1. Move when it’s appropriate, be in character when necessary
2. Good training can be good theatre
3. When making an important point, stand still so the attention is on you and what you are saying
4. Practice your gestures in front of a full-length mirror
14. Use sustaining feedback: Sustaining feedback builds rapport and trust between audience and trainer.
1. When you ask a question and the participant gives you an incorrect answer, don’t say, “no that’s wrong.”
2. Ask them to think a little more and present options to them
3. Giving negative feedback will inhibit your audience. They will be afraid to answer your next question. No one wants to get the answer wrong. Set your group up for success!
4. Make sure to give positive feedback when the learner asks a question. It is OK to “table” the question and return to it later in your program. Just make sure that you do!
15. Use an “off the beaten path” approach:
1. Yes, even adults like to win prizes – I take prizes to give away after breaks and at the end of the day. I’ll ask content questions and the winner gets a prize. You will be surprised how hard people will work for the smallest prize or recognition!
2. Sight gags are great fun and can be extremely useful
16. Know your equipment thoroughly: Take extra batteries for microphones and any other wireless gear.
1. Put your program on a CD or portable USB drive in case you have computer problems
17. Know your body, your voice and YOUR limitations:
1. It’s better to cancel a date and reschedule it than it is to try to train when you are sick!
2. If the show must go on, make a contingency plan
3. Seek an NSA colleague that can pinch hit for you if absolutely necessary
18. Buy a small, satellite travel clock: Put it on top of your computer where you can see it but your audience can’t. Use the clock to keep your program on track. Most large retailers carry these clocks for $10 or less.
1. Never go over your allotted time! A pro always adjourns on time
2. Clients get annoyed with speakers who start late and/or run over their allotted times
19. Schedule breaks regularly
1. Watch your audience, if they appear droopy and are squirming in their seats, it’s time to take a break, no matter where you are in your program — the audience always comes first!
20. Treat every program like it’s the first one you’ve ever done!
1. Be a good cheerleader. Show your enthusiasm for your subject and your audience
2. Make your content sound fresh. You might have done your program thousands of times — but your audience is hearing it for the first time. Make it memorable.