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Diversity & Inclusion Beyond Competency: Striving for Cultural Safety in Latinx Health Equity
Beyond Competency: Striving for Cultural Safety in Latinx Health Equity
By Moises Gallegos, MD, MPH and Edgardo Ordoñez, MD, MPH on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine
As the push toward health equity and social justice continues to highlight opportunities for change in our health care systems, concepts of cultural competency, sensitivity, and inclusivity will make up many of the discussions. But what does it mean to achieve cultural competency? Surely, cultural competency has its critics, as one cannot expect that sporadic reading, lectures, or workshops can provide the knowledge, skills, and attitudes necessary to fully engage the various cultural drivers of health that influence the disease course for our patients. The cultural diversity that exists in our country is too wide-ranging to ever truly grasp the intricacies of the impact that culture — comprising language, faith/ religion, customs, behaviors, attitudes, etc. — has on health. As described by Curtis et al., the pursuit of cultural competency may be better described and thought of as striving to provide safe and respectful care. Cultural safety calls on us to create safe spaces that are responsive to our patients’ cultural, political, spiritual, and linguistic realities. The journey toward culturally safe, respectful, and inclusive care starts with awareness and develops through openness to learn about others. This article offers a glimpse of Hispanic and Latinx culture and highlights some key concepts and important considerations that demonstrate how eclectic communities that make up this cultural heritage are.
Cultural and Ethnic Identity
Hispanic vs. Latino/a
Hispanic and Latino/a originated in the political sphere during the civil rights movements of the 1950s and 60s. It’s important to understand that these terms describe ethnicity and culture, not race. Hispanic and Latino/a people can be Black, White, Asian, and Indigenous. For instance, some Black Latinos may identify themselves as Afro-Latino/a or Afro-Caribbean. Like race, these terms are also social constructs. There is also a difference in what Hispanic and Latino/a mean. Generally speaking, Hispanic means people who speak Spanish or are descendants from Spanish-speaking countries. Latino/a describes those that are from Latin American countries. Some prefer the word Latino/a over Hispanic due to the ties of the term Hispanic to colonialism. Additionally, many feel that the word Hispanic was imposed by the United States government, unlike the phrase Latino/a, which is seen as a word chosen by communities and grassroots organizations. There are many nuances, but the most important thing is demonstrating respect for how individuals identify.
What about Latinx and Latine?
If you are involved in diversity, equity, and inclusion (DEI) spaces, you have seen these iterations of the pan-ethnic labels of Hispanic and Latino/a. The Spanish language is known to be gendered. These terms are a newer, gender-neutral way to describe the Hispanic and Latino/a populations.
Outside of DEI spaces and academia, the words are foreign to many. Still, they have been established to introduce gender neutrality into languages and avoid the social construction of gender binaries. Their use is not yet been standard practice and has brought about a significant debate among those who identify as Hispanic and Latino/a. Critics will point to how they originated within American activist and corporate movements led by English speakers. Others will suggest that Latinx and Latine are gender and LGBTQ-inclusive terms that reflect a global movement in gender identity. So how does one navigate this? Using the gendered terms of the Spanish language is entirely acceptable but using the non-gendered words will allow those who value and seek inclusive environments to know they are in safe spaces that will respect their identity.
Cultural Drivers of Care
In discussing cultural drivers of health and social behaviors, it is important
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to acknowledge the shortcoming and pitfalls that may come with overgeneralization and limited consideration of the structural drivers of health. There is value in recognizing common beliefs and practices that may influence a medical encounter. At the same time, we must be cautious and understand that Hispanic and Latinx cultures are not monolithic. Many customs, traditions, and social norms will vary based on geography and ethnic makeup. Here we discuss two brief examples that may apply to certain Latinx communities, but not all.
Familismo
Familismo, a deep connection to family values, is a central aspect of several Latinx communities. Individuals may develop and carry a strong tie to family and a commitment to loved ones. As a result, many personal choices are influenced by the impact that they have on family members. This can manifest as a patient neglecting their own care to prioritize the well-being of others in the family. Delayed presentations for simple complaints now turned more complex may result. This may lead to patients presenting to the emergency department (ED) on holidays and weekends to avoid lost time at work and decreased income. Patients with delayed presentations of acute pathology perhaps would have wanted to come to the ED sooner but couldn’t due to their perceived responsibility to family.
Curanderismo
a core tenet of life for many Latinx countries. In several cultures, this extends to an interconnected relationship between medicine and faith-based healing. For example, the curandero from Latin America is a tradition that continues to exist in some U.S. cultures as an important community member for alternative healing practices. As a sobador, or masseur, the curandero is often sought after for musculoskeletal ailments. As a yerbero, or herbalist, they are often visited for relief from susto, fear,
or anxiety, or for a limpia espiritual, or spiritual cleansing. Patients may present first to a curandero due to ease of access, immigration status, or financial concerns, before seeking care in a clinic or hospital. The use of a curandero is not always out of distrust for modern or Western medicine. It represents a connection to faith and tradition and is often considered by patients as a supplement to their primary care providers. Patients inquiring if there might be a prescription to treat their coughs, aches, or pains may be familiar with receiving a homemade remedy or concoction and may be looking for a similar tangible takeaway from you in the ED.
While Spanish is the most common language spoken in Latin American countries, many other languages are present, including several Indigenous and Latin-derived languages like Creole and Portuguese. As part of the health care system, the ED must provide interpreter services to non-English speakers, which is mandated by Title VI of the Civil Rights Act for all health care organizations. Several studies have shown that patients who are non-English speaking do not receive equitable care. Causes of inequities can include improper informed consent and increased medical errors. Providing language-appropriate services includes 1) language concordance and 2) medical interpretation in the health care setting. Language concordance has been shown to improve patient satisfaction and improve patient outcomes. Medical interpreters also benefit patients when there is language discordance between patient and provider, but they are often underused. The National Standards for Culturally and Linguistically Appropriate Services exist to advance health equity for diverse communities regarding culture, language, and other communication needs, including individuals considered to have “limited English proficiency” (LEP).
As part of the social justice movement, language justice has promoted the idea that everyone has the right to communicate in the language in which they feel most comfortable. Language justice is a practice used to foster inclusion, develop collective power, and dismantle systems of oppression that have traditionally disenfranchised non-English speakers. The goal is to create multilingual spaces where there is language equity and resistance to the dominance of any one specific language. This framework is essential to consider, given how people have been reprimanded, discriminated against, and discouraged from using their native languages. Understanding these concepts can help us change the narratives intended to be well-meaning but not equity focused. In line with this thinking, let’s consider the use of the term LEP. Think about how this term centers privilege and power of dominant groups. In patient care, research, and work in our communities, we must make every effort to provide culturally safe spaces for everyone, including in the use of language. The terms “limited” and “proficiency” can be stigmatizing because it suggests a deficit. Instead, a more equity-focused alternative describes individuals having a language preference or a preferred language. If it must be specified that English is the primary language in the community, one can say non-English language preference. Reframing our perspectives on language and being intentional will help provide optimal care to our diverse patient population.
Final Thoughts
Beyond language, there exist cultural drivers of care that may influence how Latinx patients engage with the health care system. In the call to action for culturally safe, respectful, and inclusive care, awareness leads to understanding, understanding allows for personal growth, and personal growth results in betterinformed interactions with patients.
ABOUT THE AUTHORS
Dr. Gallegos is a clinical assistant professor of emergency medicine at Stanford School of Medicine and clerkship director in the department of emergency medicine. He is the development officer for the SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). Dr. Ordoñez is an associate professor of emergency medicine and internal medicine at Baylor College of Medicine and director of justice, equity, diversity, and inclusion in the Henry JN Taub department of emergency medicine. He is president of the SAEM Academy for Diversity and Inclusion in Emergency Medicine (ADIEM).
About ADIEM
The Academy for Diversity & Inclusion in Emergency Medicine (ADIEM) works towards the goal of diversifying the physician workforce at all levels, eliminating disparities in health care and outcomes, and insuring that all emergency physicians are delivering culturally competent care. Membership in SAEM's academies and interest groups is free. To participate in one more groups: 1.) log into SAEM.org; 2.) click “My Participation” in the upper navigation bar; and 3) click “Update (+/-) Academies or Interest Groups.”
