Understanding cultural differences is a key to improving health care in the border region
by Duncan Hayse
Rising health care costs and increasingly sophisticated medicines, diagnoses and technologies for treatment of disease are familiar themes in the story of health care anywhere in the United States.
But the health care story along the U.S.-Mexico border differs significantly. It is as much about the barriers to health care that people face as it is about successfully receiving health care.
Daryl Smith and his colleagues spend their time trying to dismantle the barriers to good health in southern New Mexico’s culturally and ethnically mixed border area. Smith, program coordinator at NMSU’s Southern Area Health Education Center (AHEC), is using a model of applied research that acknowledges the existence of various types of barriers and attempts to overcome them in an effort to improve the overall health and well being of communities.
“When we discuss health issues along the border,” Smith explains, “one of the biggest issues we face is cultural differences. The issue of cultural understanding between the health and social service providers and their clientele is not limited to just language barriers, but also involves cultural beliefs and norms that define health and illness differently, and so the roles of the health provider and of Western medicine itself become barriers.”
According to the non-profit Harvard Pilgrim Health Care, “Culturally competent care welcomes both the culture of the patient and that of the clinician. It borrows from the strengths of both to create a dynamic engagement and mutually acceptable outcomes through the actions of both individuals and organizations.” Health providers must be able to understand the unique needs and points of view of individuals and communities. As Smith says, “It is important that health providers be trained to recognize that the perceived health issues identified by the provider are not necessarily seen the same way by many of their clientele.”
The unique health issues and barriers to health care are the result of a combination of factors. The border region, defined as the area 60 miles on both the U.S. and Mexico sides of the nearly 2,000 mile-long boundary, is experiencing rapid population growth, with a population estimated at nearly 12 million that is expected to nearly double by 2030. In southern New Mexico – as elsewhere on the border – poverty, substandard housing, and air, water and soil pollution are major issues, as is the absence of effective and safe water, garbage and sewage treatment systems.
The federal Health Resources and Services Administration gives this picture of health-related challenges along the border: “If made the 51st state, the border area would rank last in access to health care, second in death rates due to hepatitis and third in deaths related to diabetes. Tuberculosis, which is becoming drug resistant, is six times the national rate, and vaccine-preventable measles and mumps are twice the national rate. In addition, HIV/AIDS is spreading rapidly, especially in large to mid-sized U.S.-Mexico sister cities and among farm workers. As a state, the border area also would rank last in per capita income, first in the number of school children living in poverty and first in number of children who are uninsured.”
In southern New Mexico, many residents of border communities are recent immigrants, primarily Spanish speaking, and some may be in the United States temporarily, as migrant workers, for example. New or temporary residents are less likely to be familiar with the variety of health care services offered, let alone with how to access them. A culturally competent view must also take into account the cultural viewpoints of Native Americans, who make up a small but significant percentage of southern New Mexico’s population.
Award-winning work on home health and safety
Two projects show how Smith and his colleagues at Southern AHEC are overcoming language and cultural obstacles in an effort to deliver information about health and disease to residents of border communities.
In 1999 they began the Environmental Health Education and Home Safety Project, which relies heavily on bilingual community health promoters (promotoras) to deliver culturally competent information about home safety and the relationship between the environment and family health.
They recruited community members using the criteria that the trainers must be bilingual and bicultural, well respected in their communities and committed to helping others. The promotoras were then trained in how to recognize home health and safety hazards, asthma and allergies, pesticides, food safety, gas safety, lead, hazardous household products, and fire and other emergencies.
Since their training, the promotoras have visited more than 1,000 homes and given more than 400 community presentations. In the majority of cases they develop an education plan based on their findings during the first visit and then conduct follow-up visits. Attesting to the success of this health promotion strategy, in 2003 the project received a Border Models of Excellence Award, given by the U.S.-Mexico Border Health Commission in recognition of programs that improve the health and well-being of communities along the border.
“If made the 51st state, the border area would rank last in access to health care, second in death rates due to hepatitis and third in deaths related to diabetes.”
Another project seeks to address the already severe and still increasing incidence of Type II diabetes. Southern AHEC began a Diabetes Prevention Initiative in 2003 that is similar to the home safety project in its efforts to build local capacity by training community residents to educate their peers.
Roger Garza, coordinator of the initiative, points out one vital reason for the initiative. “Of all children born in the year 2000, it is expected that about one third will get diabetes,” he says. The rising incidence of diabetes is especially alarming along the border, as studies have shown that many Native Americans and Hispanics have a genetic susceptibility to Type II diabetes.
As a community health strategy, Garza says, it is very important that we begin to teach children as early as possible about the need for physical activity, how to measure food portions and about good nutrition.
In the Diabetes Prevention Initiative, a core group of bilingual trainers receives diabetes training, including information about the causes of diabetes and about obesity, nutrition and physical activity. This core group will then begin educating – individually and through workshops – others who will then become diabetes trainers in their own communities.
As these diabetes educators spread out into their own communities, Southern AHEC plans to work with area public high schools to give student peer educators similar kinds of diabetes training. These older students will, in turn, teach fourth and fifth graders about diabetes. As Garza says, “We’re teaching a community about diabetes. The trainers are talking to the parents and to community leaders. We want to encourage young children to teach their parents, and we’ve come full circle.”
Full circle, that is, because the hope is that communities will become more aware of the issues affecting their own health. “Diabetes is a community health issue,” Smith concludes. “Like the other health problems we face in these border communities, the best solution is prevention, starting with educating young people and working our way up to reach all community members.”
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