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As this nation of 323,127,513 people13 interact with and attempts to assimilate 1 million new Hispanic arrivals each year, some dental practices may choose to become more aware of an unfamiliar language and culture. Hispanics now comprise more than 17.8% of the U.S. population. Between 2000 and 2010, the Hispanic population increased by 43%, a percentage that is expected to increase.14 Creating a dental office in which Hispanics are comfortable and well served will be very important to future growth for some dental offices. And all dental practices are likely to find that treating patients with language and cultural differences is much easier if the dental team is prepared.
A quick test can help a dental team decide if its office should consider taking steps to help it become more culturally aware of this large population of potential patients. Have any of these situations occurred in your dental practice?
1. A patient walks into your office and feels uncomfortable because no one understands him/her in Spanish, then becomes frustrated.
2. The mother of a young patient who doesn't speak English becomes confused, then becomes upset because she is told to wait outside while her son is being treated.
3. While attempting to make an appointment, a prospective patient is turned away because no one can effectively communicate in Spanish over the phone.
The above scenarios send a message that dental practices should take steps so that they can provide better treatment for Hispanic patients.
With minimal effort, dental teams can attain enough knowledge of the Hispanic cultural background to make members of this fast-growing population feel more comfortable in the office. The aim is not to give up the existing culture in the dental office, but rather to ensure that the dental practice demonstrates a friendly, competent, helping attitude to all patients. By understanding certain nuances of the Hispanic culture, dental teams can welcome Hispanics and help them navigate, as the pilgrims they are.
On a personal note, the author of this course would like to state that this course has been greatly influenced by her own background and experiences. Much of the content has been inspired by personal experiences rather than by any position taken by the ADAA.
Most Hispanic immigrants to the United States are from Mexico, although there are many other cultures represented as well. According to the 2010 US Census, Mexican Americans represented 63% of the total Hispanic population, followed by Central and South Americans (16.2%), Puerto Ricans (9.2%), Cubans (3.5%), Spaniards (1.3%), and other Hispanics (6.8%)."15As recently as ten years ago, little emphasis was placed on translating informational literature and standardized forms from English to Spanish. Today, it is common to see forms of written communication, from state drivers' license applications to new patient history forms, offered in both English and Spanish.
Moreover, most companies now have automated telephone answering messages that first prompt the caller to select either Spanish or English. The demand to diversify has arrived. The ebb and flow of immigration policy and the assimilation into the American culture of Hispanics will determine if these trends continue to grow.
Hispanics place great importance on retaining the Spanish language and passing it on to future generations. In fact, the Hispanic family commonly attempts to preserve the Spanish language in the home, considering it a disgrace or embarrassment to the family when a Hispanic son or daughter does not speak Spanish. "Preserving the Spanish language within the family is a common practice in most Hispanic homes."1 Although most Hispanics, particularly second and third generation, speak English, Spanish remains an important language to those choosing to preserve cultural roots. This effort at preservation is not always successful. However, dentists need to recognize this family tradition and prepare effectively for it.
Spanish has become the second language of choice for middle school and high school students. The majority of students choose to enroll in Spanish, followed by French and German. As of the fall of 2009, course enrollments were highest in Spanish, increasing by 5.1% since 2006. However, the proficiency of actually speaking and writing the language has not been verified due to difficulty in receiving reliable test data.17,18
Good communication skills are an essential part of delivering quality care in the dental office, but formulating explanations, instructions, and questions to Spanish-speaking patients can be a challenge for most non-Spanish speaking staff. Some dentists address this issue by hiring Spanish-speaking staff, while others opt to learn the Spanish language themselves. Not every dental office is fortunate enough to have Spanish-speaking staff, but basic dental Spanish can be learned with a few vocabulary words commonly used in the dental office. Even if a person has a limited understanding of Spanish, some basic Spanish words will prove to be very valuable tools during the initial greeting of a patient, recording the patient's history, assessing the patient's overall health and oral health, and discussing any kind of dental procedure. Some of the most commonly used Spanish words in dental practices are listed in Table 1.
Thoroughly learning and using these words would give a person a reasonable foundation to communicate with a Spanish-speaking patient. Learning just 25 or 30 words may be adequate. Spanish-speaking patients are more apt to feel comfortable when the dentist or the staff is at least somewhat conversant in their language, feeling confident that the dentist will diagnose and treat skillfully. Learning to pronounce Spanish correctly is not difficult. This is greatly appreciated because Hispanics identify closely with the language itself. There are numerous dialects but basic sounds are the same. Most Spanish speakers are very helpful to people attempting to learn the sounds of the language. The issue of formal/informal language is not all that important in most situations, particularly with English speakers. A sense of humor and friendly smiles are good ways to deal with attempts at using Spanish.
Communication is the key. Some may define a "successful" dentist as one who exhibits excellence in clinical skills. Yet, if the dentist cannot communicate well with patients, then how successful can the dentist really be? "Consider that it's not good enough to be an extremely talented dentist if you can't communicate and make patients feel comfortable regardless of their ethnic or culture backgrounds."5 While many dentists strive to perfect their clinical skills, most patients don't know the difference between a good margin and an open margin. Oddly enough, "90 percent of dentistry is about communication, while the other 10 percent is getting a good margin on the tooth."5 This is not to suggest that a dentist should not strive for excellent clinical skills, but simply suggesting that dental teams not lose sight of the importance of good communication skills with patients and how these skills benefit a dental practice. For a non-Hispanic person, a well-developed vocabulary and understanding of the nuances of the Spanish language and culture is unlikely, but if the dental team approaches Hispanic patients with sensitivity and a fundamental knowledge of vocabulary and culture, patients will know the dentist is trying to help them.
Potential language difficulties between patients and dental teams can be a barrier to communication and good dental care. "Poor communication may be a deterrent to effective interaction between patients and health care providers. Having limited English skills may make it difficult for people to establish a dental home by inhibiting communication between the dentist and patient."4 It is one thing for a successful practice to attract new patients, but it is another thing to communicate effectively on all levels so as to retain those patients in the practice. In reality, even most first-generation Hispanics understand very basic English, a fact which helps lessen the communication barrier.
Fear and Anxiety
Many say that fear is the number one reason why patients break appointments and avoid going to the dentist. "Dental anxiety has been highlighted as being one of the most important barriers with regard to dental attendance. There is the view that anyone who presents with fear of dental treatment experiences an equivalent intensity of emotion or affect which results in the avoidance of dental care."6 If this is true, then any steps towards reducing the fear factor are a wise investment of time for the dental practice. A fundamental knowledge of language and culture will help the patient with dental anxiety.
Trust is the single most important aspect of any ongoing relationship and starts with truthful information and respect. The misunderstanding of others' customs can create a breach of the trust that is needed between a patient and dentist for effective care. The more comfortable a dental team can make patients feel, the more likely these patients will trust the dental team and accept treatment. Recognizing and adjusting to different cultures is an important task for dental teams across the U.S.
Hispanics are not open to sharing personal information until a high level of trust is established. Often they will respond with the answer that is expected - in a way to remain polite and respectful. This may depend on the socio-economic level of the patient because they generally respect those with education and authority.
Simply by observing language, voice tone, and body language, the dentist can learn valuable information. Listening intently to patients can provide dentists with helpful information to confirm whether or not the patient understands his or her dental condition and the reasons for the recommended treatment plan. In addition, it is possible that patients view active listening as a sign that the dentist is interested in their welfare and, therefore, conclude that he or she may be more likely to provide high quality care. Thus, the quality of communication between the dentist and patient may influence the patient's decision about whether to follow through with the recommended treatment. Trust is a critical factor in how the patient perceives the dental team.
Perception can be altered by culture. It is important to understand different perceptions of oral health in order to manage trans-cultural barriers that may arise during the utilization of oral healthcare services. Even when treating patients of a familiar culture, it is sometimes difficult to understand the reasons behind a patient's actions or reactions. As new immigrants flock to the U.S. each year, it becomes even more challenging for health care professionals to understand and adjust to cultural traditions different from their own. For example, the traditional Hispanic female will defer to male family members in most cases and not be confrontational in public.
As many have already experienced, fear and anxiety exaggerate or alter behavior. Paying attention to various backgrounds and differences can give someone outside that culture a better chance of understanding. Ignoring these factors can get an unsuspecting dental team into an awkward situation or even a conflict. Lack of cultural preparation has many levels of impact, from an embarrassing moment, to a breakdown in inter-office communication. The price of inadequate cultural awareness can be significant but can easily be avoided with proper preparation.
Most first-generation Hispanics do not divorce themselves from their country of origin or basic cultural beliefs. They usually continue to embrace that culture, which ultimately affects their belief system and the way they approach many things, including healthcare.
According to Bonta and Arteaga, Hispanic families tend to put immediate family needs first and, therefore, save medical and dental treatments for emergency situations. Knowing this, the dental team should understand this situation is not just a monetary situation, but also a cultural one.16
Hispanic parents have passed on a tradition of "family" and home remedies to their children and grandchildren. Many Hispanics retain a belief in folk diseases and the power of home remedies and even "healers."12
Although Anglos and Hispanics seem to share the same major health concerns, including cancer, diabetes, and heart disease, Hispanics approach healthcare issues in a different way. Hispanics, in general, differ from Anglos in that they rely more on home remedies and over-the-counter medications as well as strongly relying on advice from friends and family members on medical related matters. "An individual who becomes sick will turn first to family members, especially elders, for support and advice. They may recommend safe, simple home remedies."7 Hispanics also tend to self-diagnose and self-treat initial symptoms (using home remedies/over-the-counter medication) and usually will only seek professional advice if symptoms persist. Many times, they will first try a recommended home remedy before consulting a doctor. This traditional practice may stem from the culturally accepted methods used in Mexico today when obtaining medication. Currently in Mexico, a person does not need to have a prescription in order to fill prescribed medication.
Having the hiccups does not require professional help, but it provides a good example of a Hispanic home remedy. A simple remedy is commonly used to cure a child's or even a grownup's hiccups. This remedy involves wetting a small ball of red thread with saliva and putting this on the forehead of the person with hiccups. Supposedly, this is a quick and easy cure for the hiccups!
Hispanics tend to be very polite, which can be interpreted by Anglos as being subservient or servile. Phrases like "a sus órdenes" (at your command), "para servirle" (at your service), "mi reina" (my queen), or "mi rey" (my king) are often used in the daily repertoire of Hispanic expressions. Also, when one is invited to a Hispanic person's home, the Hispanic hostess traditionally says: "mi casa es su casa" (my house is your house) which is not to be taken literally but means "you are always welcome in my house."
Hispanics are often described by doctors as "more emotional" and tend to self-medicate and self-prescribe more often than the average Anglo patient. Some view Hispanics as "far more emotionally expressive."7
Hispanics tend to be formal in their greetings towards one another. They tend to show affection through touching. Greeting practices used by many Hispanics range from a firm handshake to a kiss on the cheek. Be aware that the physical distance between Hispanics when holding a conversation is much closer than in other cultures. "Anglos communicate with each other, usually maintaining a distance of 36-48 inches, while Hispanics tend to stand closer to each other at about 18 inches."8 Within the Hispanic culture, a hug and a light kiss on the cheek are common greeting practices between women, as well as men and women who are close friends or family. Some cultures may view this greeting as "too close for comfort," while Hispanics practice this as if it were second nature to them. This custom has somewhat influenced Anglo behavior in recent years.
Hispanics also tend to make more eye contact, face each other more, and touch more when they speak. "Hispanics view direct eye contact as a show of concern and attentiveness."9 Eye contact is an important factor for them when engaged in a conversation, formal or informal. Consequently, when consulting with a Hispanic patient, it would not be wise to communicate with the patient while turned around or facing the opposite direction, especially at a distance.
In non-formal settings, conversations between Spanish speakers are usually loud, fast, and adorned with animated gestures and body language to better convey points. A person who is not familiar with this tradition may perceive those who are speaking loudly to be rude or insensitive to the quiet environment of the dental practice. In reality, this behavior is their way of life and a common daily practice for them. Most likely, they do not mean to be disrespectful in any way and will conform to your "quiet culture" if reminded that the doctor must have a quiet office to perform well.
Family is very important to the Hispanic. Children are often pampered in comparison to non-Hispanics. This comes from the thought that life is to be enjoyed and may be cut short or become difficult at a young age by socio-economic status.
Hispanics are known to place great importance on looks and appearance as a sense of dignity and pride. In many cultures, not only Hispanics, going to a dental appointment is considered an event and they will dress up for the occasion.16
Hispanics also tend to be more relaxed and flexible about time and punctuality than others. Economic realities often cause families to join together in sharing housing and transportation. This will have a bearing on how they get to and from appointments and who actually appears in the reception area. A dental practice should prepare for such scheduling conflicts. There are scheduling techniques that a practice could use to avoid such potential scheduling conflicts.
One of the easiest and most effective techniques that a dental team could implement is the "30-second added value speech" which means that the staff take a few seconds to clearly emphasize to patients that the appointment is reserved specifically for them. They need to know that the practice sees patients by appointments so that the doctor can treat all patients, accordingly. The patients need to also understand the clinical value of the upcoming appointment. If a patient places no value to his/her appointment (based on our communication or feedback), then other commitments may very well take priority over the dental appointment. This rule of thumb takes roughly 30 seconds to convey and is preached by many practice management consultants and has proven very effective.
Home remedies, the "polite" aspects of the Spanish language, the emphasis on family, formal greetings, appearance, and a different attitude about time are some of the very intriguing and charming differences between the American and Hispanic cultures.
For those dental practices wanting to penetrate the Hispanic market, it may be a wise investment of time to become involved in various Hispanic community events and become familiar with cultural practices in order to understand our Hispanic neighbors and patients. "'Becoming a culturally competent dental professional will become increasingly essential for the survival and success of a dental practice,' says Dr. Erlich, a psychologist and author."11 A person may find his/her own horizons broadened and a basic understanding of people improved.
The American culture is so powerful and pervasive that even in deep South Texas, what some term "the front lines of Mexican immigration," there are many families that have been here for three generations and have children that have Hispanic surnames, but the children cannot speak Spanish. They may say that they understand it, but they cannot speak it. In the Spanish name system, there may be two last names. The first is the male family line and the second name comes from that individual's mother. Record keeping can become very confusing.
Our American culture is already absorbing the Hispanic culture in many ways. The Hispanic culture is very beautiful in its music, art, and language. It also has very interesting history and politics. It may be inevitable that it will blend and dissolve with the American culture but now is the time for the dental profession to consider preparing practices to welcome those pilgrims of the Hispanic culture - one million new immigrants each year.
Will America be overwhelmed by the Hispanic culture or will new Hispanic citizens become completely absorbed by American culture? America will have an answer to this question in 50 years or so. A practice may want to consider preparing for Hispanic patients now based on humanitarian and economic motivation.
The differences between cultures are real and can add richness to the fabric of life. People everywhere have much in common, such as a need for affiliation, love, participation, and contribution. When the exterior is peeled off, there are not so many differences after all. Many practices across the U.S. will get to know and experience the Hispanic culture for all its beauty inside and out.
The ethnic make-up of the U. S. population is changing - and changing fast. Over the past 30 years, the Hispanic population has exhibited tremendous growth in the United States and is creating challenges for many "unprepared" dental practices. The Hispanic patient may need a different approach from the average patient. Treating patients with language and cultural barriers can prove difficult if the dental team is not prepared. Language barriers and the lack of cultural knowledge preparation can affect a dental practice in many ways; these potential problems can be easily avoided with minimal effort. Dental teams need to understand certain nuances of the Hispanic culture and make their practice a culturally affirming environment.12
Several online resources exist to aid practitioners in communication with Spanish-speaking patients. The following link is one example and has audio pronunciation links to help dental professionals - http://www.123teachme.com/learn_spanish/dentists_dental_hygienists.
1. Clutter, Ann, et. 2l. "Understanding the Hispanic Culture." Ohio State University Fact Sheet. Ohio State University. (8 Oct. 1997) Accessed at http://www.ohioline.ag.ohio.edu.
2. Pew Hispanic Center, 2005. (Reference removed when version was update in 2011.)
3. "Latino Oral Health Issues - A Research Agenda for the 21st Century." Hispanic Dental Association (2005) Accessed at http://www.hdassoc.org/site/epage/29724_351.htm.
4. Graham, Michelle A., et al. "Perceived social status, language and identified dental home among Hispanics in Florida." The Journal of the American Dental Association 136.11 (2005) 1572-1582.
5. Garvin, Jennifer. "Diversity in Dentistry." Academy of General Dentistry. 2004. Accessed at http://www.agd.org/library/2004/june/garvin.asp.
6. Freeman, Ruth. "Barriers to accessing dental care: patient factors." British Dental Journal. 187.3 (1999): 1-7.
7. "The Hispanic American Community." Transcultural Nursing. Accessed at http://www.culturediversity.org/hisp.htm
8. "Deep Culture." Teaching from a Hispanic perspective: A handbook for non-Hispanic adult educators. Accessed at http://www.literacynet.org/lp/hperspectives/deepcult.html
9. "Transcultural Barriers to Implications of Oral Health Messages." The Journal of Contemporary Dental Practice. 8.4 (2007): 5-6.
10. Hispanic Research, Inc. 2006. Accessed at http://www.hispanic-research.com/home/family.htm.
11. Furlong, Arlene. "Cultural Competence." American Dental Association News 3 Sept. 2007.
12. Herring, Roger D. "Counseling Diverse Ethnic Youth", Harcourt Brace & Co. 1997.
13. US Census Bureau; State and Country Quick Facts from the 2010 Census. https//www.census.govquickfacts/fact. Accessed on Accessed September 1, 2017.
14. US Census Bureau; 2010 Census Shows Nation's Hispanic Population Grew Four Times Faster Than Total U.S. Population. http://2010.census.gov/news/releases/operations/cb11-cn146.html. Accessed August 19, 2011.
15. The Hispanic Population: 2010; Census Briefs Issued May 2011. http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf. Accessed August 19, 2011.
16. Bonta, Yolanda, & Arteaga, Sarita. (August 2011) "Bridging The Gap." First Impressions, pg. 24.
17. Modern Language Association (December 2010) "Enrollments in Languages Other than English in the United States Institutions of Higher Education, Fall 2009." http://www.mla.org/pdf/2009_enrollment_survey_pr.pdf. Accessed on September 2, 2011.
18. National Education Writers Association. http://www.ewa.org/site/PageServer?pagename=resources_k12_foreign. Accessed on September 2, 2011.
Anglo - a non-Hispanic white person; an English-speaking white person in the United States who is not of Hispanic origin.
Body language - non-verbal communications, such as gestures, postures, and facial expressions that can be interpreted as unconsciously communicating somebody's feelings or psychological state.
Culture - the beliefs, customs, practices, and social behavior of a particular nation or people.
Diversity - a variety of something, such as opinion, color, or style.
Ethnic - relating to a person or to a large group of people who share a national, racial, linguistic, or religious heritage, whether or not they reside in their countries of origin.
Hispanic - relating to people descended from Spanish or Latin American people or their culture.
Immigrants - relating to those who have come to settle in another country.
Minority group - a smaller, socially defined group of people within a society, whose members have different ethnic, racial, national, religious, sexual, political, linguistic, or other characteristics from the rest of that society.
Trans-cultural - extending across cultures or involving more than one culture.
About the Author
Cynthia Sellers, RDA
Cynthia Sellers, RDA, has been leading dental teams as an effective Practice Administrator of two large dental practices for over 15 years. She has a degree from the University of Texas in English with minors in Spanish and Reading. Cynthia was born in the U.S., but spent some time growing up in Monterrey, Mexico, where she learned about the culture across the border. In addition to dentistry, her background includes teaching high school English and public speaking as a Certified Texas Hospitality Instructor for various resorts and restaurants.
Her passion is to lead practices to the top by focusing on 5-Star patient care. Cynthia excels at motivating dental teams, utilizing the Linda Miles practice management model, while training them to manage by the numbers for a more efficient and profitable practice. Implementing systems that offer less stress for the dental team is her ultimate goal. With effective marketing, practices can climb to the top 5%. Cynthia is an international speaker, speaking fluent English and Spanish.
This course has been "Approved by the Hispanic Dental Association"