Differing interpretations of health care encounters: A qualitative study of non-Latinx health care providers' perceptions of Latinx patient behaviors

A Cyclical Model of Barriers to Healthcare for the Hispanic/Latinx Population

As the Hispanic/Latinx population in the United States continues to grow, disparities in health outcomes for this population continue to widen. Worse health outcomes can be attributed to a variety of barriers to healthcare specific to this population, but scant literature exists that presents the connections among them. Many of these barriers to healthcare stem from institutional racism, disparities in socioeconomic status, and xenophobia. To synthesize barriers that hinder the Hispanic/Latinx population from receiving quality healthcare, we propose a cyclical model. The model begins with obstacles present before even visiting a healthcare provider, including structural inequalities, cultural beliefs, documentation status, scheduling, and transportation. Next, the model poses barriers during the visit with a healthcare provider, including problems with provider bias, cultural barriers, and interpretation services. Finally, the model presents barriers that occur after the medical encounter, including payment, medication adherence, indigent care, and follow-up appointments or referrals. Once the patient needs to schedule a follow-up appointment or referral, the cycle restarts with the barriers present before accessing care. All of these barriers to healthcare are areas for potential mitigation of the healthcare disparities that currently disadvantage the Hispanic/Latinx population. The proposed Hispanic Cyclical Healthcare Barrier (HCHB) model helps organize solutions to the barriers, illustrating the need for multiple interventions due to the interconnectedness of the barriers.

Examining the Qualitative Experiences of Latinx Nurses During the First Wave of COVID-19

Introduction: The world has been impacted by the coronavirus disease 2019 (COVID-19) pandemic since March of 2020. Latinx nurses have been some of the most underrepresented in being studied during this time and have been greatly affected by it. To the best of our knowledge, there are no published studies that focus on the qualitative experiences of Latinx nurses during the first wave of the pandemic. Methods: Data analysis included thematic analysis to identify main themes experienced by Latinx nurses. A qualitative descriptive study design was employed to conduct a parent study with 100 nurses across the United States reflecting on their experiences during the first wave of the COVID-19 pandemic, data collected from May to September 2020. Formal coding of the interview data was conducted utilizing Dedoose cloud-based software. Results: Five main themes emerged, including (1) connection to patients' personal touch and empathy, (2) connection to Latinx nurses, (3) connection to family and friends, (4) connection to food as care, and (5) coping. Within the theme of coping, subthemes of (5.1) faith, (5.2) maladaptive behaviors, and (5.3) self-care activities emerged. Conclusion: These experiences can help shape the pathway to be better prepared for any emergency or future pandemic.

PROGRESO-II: Developing Culturally Tailored Materials for a Social Network-Based Intervention to Promote HIV Pre-Exposure Prophylaxis Initiation Among Latina Seasonal Farmworkers

Latina Seasonal Farmworkers (LSFW) in South Florida are a community affected by human immunodeficiency virus (HIV) due to cultural barriers, stigma, and lack of awareness of pre-exposure prophylaxis (PrEP). Building on the PROGRESO study, this study sought to: (1) develop and pre-test scientifically supported and culturally tailored PrEP materials for PROGRESO and (2) assess the acceptability of these PrEP materials by LSFW who use alcohol and/or drugs. PrEP messages were selected based on a literature review, feedback from experts working on PrEP programs, and recommendations from a four-member scientific expert panel through a two-level Delphi method. A culturally tailored PrEP presentation was developed and presented to sixteen LSFW, who engaged in four focus groups. Materials were modified based on participants' suggestions. Thematic analysis was used to assess the acceptability and usability of these materials in the LSFW community. Participants responded positively to the PrEP messages and understood their importance for Latinx communities. Participants felt empowered and comfortable enough with the information to distribute the messages to partners, children, and friends with the aid of a physical pamphlet or flyer. A strong cultural context of familialismo and confianza was present in comments made by our participants. This study has the potential to increase LSFW's PrEP awareness and initiation. Future studies may implement a hybrid-interview approach, allowing individuals to self-select into a virtual or in-person focus group. Such flexibility may increase participation and discussion by allowing participants to attend in a format they are most comfortable with, as noted by participants in this study.

Human Connection: Oncologist Characteristics and Behaviors Associated With Therapeutic Bonding With Latino Patients With Advanced Cancer

PURPOSE

Therapeutic alliances (TAs) between oncologists and patients are bonds characterized by mutual caring, trust, and respect. We here relate oncologist characteristics and behaviors to TA among Latino and non-Latino patients with advanced cancer.

METHODS

Participants included non-Latino oncologists (n = 41) and their Latino (n = 67) and non-Latino White (n = 90) patients with advanced cancer who participated in Coping with Cancer III, a multisite, US-based prospective cohort study of Latino/non-Latino disparities in end-of-life cancer care, conducted 2015-2019. Oncologist characteristics included age, sex, race, institution type, Spanish language proficiency, familismo practice style (emphasis on family) and clinical etiquette behaviors. Patient-reported TA was assessed using the average score of six items from The Human Connection scale. Hierarchical linear modeling (HLM) estimated effects of oncologist characteristics on TA.

RESULTS

Of 157 patients, a majority were female (n = 92, 58.6%) and age younger than 65 years (n = 95, 60.5%). Most oncologists were male (n = 24, 58.5%), non-Latino White (n = 25, 61%), and age 40 years and older (n = 25, 61%). An adjusted HLM in the full sample showed that Latino patient ethnicity was associated with significantly lower TA (β = -.25; P < .001). In an adjusted stratified HLM for TA, among Latino patients, oncologist familismo practice style (β = .19; P = .012), preference using first names (β = .25; P = .023), and greater Spanish fluency (β = .11; P < .001) were positively associated with TA. In contrast, familismo practice style had no impact on TA for non-Latino White patients.

CONCLUSION

Latino patients with advanced cancer had worse TAs with their oncologists versus non-Latino patients. Modifiable oncologist behaviors may be targeted in an intervention designed to improve the patient-physician relationship between oncologists and their Latino patients with advanced cancer.

Enrollment of Spanish-speaking Latinx adults in clinical trials: Five lessons learned from a randomized study in substance use treatment

Latinx individuals are the largest ethnic minoritized group in the United States (US) at 19% of the population. However, they remain underrepresented in clinical research, accounting for less than 8% of clinical trial participants. Consideration of cultural values could help overcome barriers to inclusion in clinical trials and result in better recruitment and retention of Latinx individuals. In this commentary, we describe general guidance on culturally responsive modifications to facilitate the successful recruitment and retention of Spanish-speaking Latinx participants in Randomized Clinical Trials (RCTs) for substance use. We identify five culturally responsive strategies to help enroll participants in RCTs: 1. Create an ethnically diverse research team, 2. Assess available community partners, 3. Familiarize oneself with the target community, 4. Establish confianza (trust) with participants, and 5. Remain visible to participants and staff from recruitment sites. Representation of Latinx individuals in clinical trials is essential to ensure treatments are responsive to their needs and equitydriven. Some of these strategies can further research in helping to promote the participation of Latinx individuals experiencing substance use concerns, including outreach to those not seeking treatment.

Comparison of Narrative Video and Flipchart Presentation to Promote Cervical Cancer Screening Among Latinas Along the Border

INTRODUCTION

Cervical cancer incidence and mortality is higher among Latinas compared with non-Hispanic White women and barriers to screening include lack of knowledge, lack of access to health care, and cultural factors. Both video and printed material have been found effective as health education tools in underserved populations. The purpose of this study was to show no difference between a flipchart presentation facilitated by a community health worker and a narrative video with limited in-person interaction in increasing cervical cancer screening rates among Latinas along the U.S.-Mexico border.

METHODS

Study design: Randomized controlled study. Participants: women in a community-based cervical cancer screening program.

OUTCOMES

Primary outcome was screening completion and secondary outcomes were changes in psychosocial variables.

RESULTS

Total sample size was 500. Most participants were born in Mexico, had a low annual income, preferred Spanish, and did not have a regular doctor. Overall, 371 (74.2%) participants completed screening. There was no significant difference in screening completion between educational delivery modes. The only variable significantly associated with screening completion was age, with 51- to 65-year-olds being 44% more likely than 21- to 40-year-olds to have a Pap test. The only psychosocial variable that was significantly different by delivery mode was perceived susceptibility. The majority of all participants found both the video and flipchart presentation to be acceptable.

CONCLUSION

A health promotion program delivered via self-administered video or PowerPoint slides showed no difference in increasing cervical cancer screening rates.

Implementing a mailed stool sample screening program in clinics providing care for an underserved Hispanic population

Colorectal cancer (CRC) is a leading cause of cancer-related deaths in Hispanics in the US. Despite this, Hispanics are being screened for CRC at a much lower rate than their non-Hispanic white counterparts. Implementing mailed fecal immunochemical tests (FITs) is a cost-effective intervention for increasing CRC screening rates in vulnerable populations, such as Hispanic populations in border metroplexes. We aimed to describe the effect of introductory calls coupled with mailed in-home FIT kits on CRC screening completion in two federally qualified health centers (FQHCs) in a US-Mexico border county. This was a prospective, pragmatic, two-arm intervention study with participants allocated to receive a FIT kit with a reminder call (usual care) or usual care preceded by an introductory call. The primary outcome was the percentage of patients who returned the FIT kits. Participants who returned to the FIT were primarily unemployed (54.4%), had less than a high school education (60.2%), lived in the US for at least 20 years (74.4%), and had poor self-reported health (54.4%). In addition, we observed a statistically significant increase in the absolute rate (4.5%, P = 0.003) of FITs returned when a mailed FIT kit was preceded by an introductory call compared with no initial call. This study demonstrated that adding an introductory phone call significantly improved the screening completion rate in a mailed-out CRC screening intervention in the US-Mexico border population.

Non-Latinx Healthcare Provider's Knowledge and Awareness of Latinx Geriatric Clinical Health Needs

OBJECTIVES

Due to the exponential growth in the Latinx older adult population, culturally responsive services are needed, especially since most healthcare providers are non-Latinx with limited Spanish or bilingual skills. One place to start is by drawing a formative assessment of the healthcare providers' knowledge and awareness of the healthcare needs of Latinx older adults.

METHODS

Focus groups were conducted to explore the healthcare providers' knowledge and awareness of cultural and structural barriers and facilitators to accessing health care services for Latinx older adults.

RESULTS

Results note that healthcare providers perceived the healthcare needs for Latinx older adults to be underutilized for healthcare services, preventive interventions for healthy diet/lifestyle, and healthcare knowledge. Providers reported Latinx family over-involvement, religiosity, immigration, and language/lack of interpreters as barriers to seeking timely healthcare. Finally, healthcare providers said that family support, the location of healthcare services, and community-based partnerships were all facilitators for seeking healthcare.

CONCLUSIONS

Findings suggest providers' conflicting perspectives toward the Latinx communities.

CLINICAL IMPLICATIONS

Healthcare services can consider implementing trainings for non-Latinx providers to recognize conflicting perspectives and reduce implicit bias toward the Latinx communities.

Caregiver perspectives on barriers and facilitators to primary care for autistic adults: A qualitative study

Background

Primary care is associated with greater access to healthcare services and improved health outcomes. However, autistic adults report challenges accessing and utilizing primary care, in addition to unmet healthcare needs. The need to minimize existing barriers and identify strategies to facilitate successful healthcare encounters is increasingly important as autistic adults represent a growing segment of society. Minimal research has examined primary healthcare encounters for this population.

Methods

As part of a larger convergent parallel design mixed-methods study that recruited autistic adults, caregivers of autistic adults, and primary care providers treating autistic adults, interviews were conducted with 31 caregivers of autistic adults. Caregivers were predominantly female (94%), and the autistic adult they cared for were primarily male (87%), with a mean age of 24 years. Thematic analysis was employed to elucidate the barriers to care, suggestions to mitigate challenges, and/or successful strategies implemented during care encounters for autistic adults, as reported by their caregivers.

Results

Reported here are the results only from the caregiver interviews, in which seven themes emerged: (1) finding a primary care provider; (2) patient-provider communication; (3) anxiety due to unpredictability, an overstimulating sensory environment, and waiting time; (4) participation of consumers in the healthcare process; (5) stigma and assumptions about autism; (6) caregiver experiences; and (7) the impact of culture and ethnicity on care.

Conclusion

Findings from this study have the potential to inform the development of, or improve existing, client-centered interventions to improve primary healthcare services for autistic adults.

Effect of Text Message Reminders on Attendance at Cervical Cancer Screening Appointments in a Predominantly Hispanic Population

Hispanic women have the highest rates of incident cervical cancer in the United States (U.S.) and are 1.9 times more likely to die from cervical cancer than non-Hispanic Whites. Objective: Assess the impact of text message reminders on cervical cancer screening attendance and completion. Design: Pragmatic non-randomized study design using propensity matched analysis. Setting: Community-dwelling low-income females in the U.S./Mexico border community. A total of 2,255 mainly Hispanic females aged 21-65. Methods: Text message reminders in addition to usual care (telephone call reminders). Results: After adjusting for significant factors and propensity score matching, individuals in the text reminder group had 11% lower screening incidence than individuals without text reminders (risk difference [RD] = -0.11, 95% CI: -0.16, -0.05; p < .001). Conclusion: Participants with text reminders were less likely to complete cervical screening than usual practice in a predominantly Hispanic population. Our study demonstrates that reminders' content rather than method may be vital to improving our population's cancer screening rates.

Identifying Gaps in Oral Care Knowledge, Attitudes, and Practices of Latinx Parents/Caregivers of Children With and Without Autism Spectrum Disorders

Purpose: This pilot study used data from a survey to examine the knowledge, attitudes, and practices about oral care of Latinx parents/caregivers of children with or without autism spectrum disorder (ASD) to identify gaps to focus future intervention.

Methods: Sixty English-speaking Latinx parents/caregivers who had a child between 4 and 14 years with or without ASD (n=31 ASD, n=29 typically developing [TD]) completed a questionnaire on oral health knowledge, practices, access to care, and demographics. Caregiver responses were compared, and gaps in knowledge and practices were identified.

Results: There were no significant differences in parent age, child age, income, insured status, or overall knowledge scores, only a significant difference in education (p=0.02), with the ASD group reporting less. Scores for knowledge, attitudes, access and practice were all nonsignificantly positively correlated, as was attitudes with access and practice. However, knowledge and attitudes were significantly negatively correlated. Additional significant findings were parents who had lower income and education, had lower oral knowledge scores, decreased frequency of dental visits, increased feelings of being discriminated against, children with increased fear of the dentist, and decreased ease of finding a dentist.

Conclusion: Factors such as income, education, ethnicity, and having a child with ASD can influence what Latinx parents and caregivers know about oral health and how their children experience receiving dental care. Latinx parents/caregivers of children with and without ASD report barriers to dental care, including difficulty attending visits or feeling stigmatized by their dental provider due to their ethnicity. Fear of the dentist is significantly correlated with ASD diagnosis and lower social demographics of the parent, and may contribute to a reduction in preventative oral care visits as well. Health care providers should consider these perspectives when providing care to this population to mitigate further oral health inequities.