Disparities in healthcare: Spanish-speakers at a pediatric clinic in Houston, Texas

Introduction

Background

Social determinants of health are the conditions influencing health outcomes, encompassing environmental, behavioral, economic, and socio-cultural factors, including access to quality healthcare (1,2). This paper addresses structural and socio-cultural factors impacting the quality of care for the Latino or Hispanic pediatric population in the US. Despite the diverse population in the US, social dynamics often lead to stratification, hindering access to healthcare due to language and cultural barriers (3). Globalization has led to an increase in migration particularly, leaving migrants socially vulnerable without adequate tools for adaptation (4). Multiple definitions for Latino and Hispanic terms exist rooted in genetic, cultural, or environmental factors, affecting how individuals identify themselves or are identified externally (5). Houston, Texas is the fourth largest city in the US and has historically been one of the most Spanish-speaking cities in the country. In 2019 the Latino population accounted for 45.8% of the city’s total population (6). Following English, Spanish is the most spoken language in this metropolis (7). It is considered that half of the city’s Latinos speak English “less than very well” which is equivalent to a “Limited English proficiency” (LEP) (8). In this sense, patients of Hispanic origin are disadvantaged by the language barriers imposed by the health system (9).

In addition to language, socialization of origin plays a determining role in the resources of action that people have when interacting in social dynamics. Ethnicity is defined as the racial characteristics of a specific nation determined by birth (6). Culture, on the other hand, is much broader, as it also covers the beliefs, linguistic expressions, norms of behavior and styles of communication that a group of people have (10). Thus, in addition to the language barriers the migrants may experience, culture and its expression in interpersonal relationships (tone of voice, attitude towards health personnel, traditions, myths, etc.) affect the doctor-patient relationship. Latinos, for example, perceive primary care professionals as figures of authority, and this perception may inadvertently affect the interpersonal component of their health care (11). In the context of migrant children, it is important to analyze the disparities that they could face, which is why this study aims to identify and analyze (I) access or the possibility of timely attending the service; (II) the quality of communication and understanding (III) the treatment you experience according to a quality standard in medical care.

Regarding access, children with special needs who are children of immigrant families are more likely to be uninsured, lack a regular source of care, report a delay in medical care, and not see a doctor in the past year. They are also less likely to have gone to emergency facilities during the last year (12). Additionally, the lack of understanding of how the US health care system works constitutes an additional barrier to accessing health (13,14). In terms of communication effectiveness, disparities in health care accentuated by language barriers are a recognized problem. One of the main concerns has to do with the risk of misinterpretation in medical management, being the most common omission error, increasing the incidence of adverse clinical events (15,16). Disparities in relation to ethnicity are largely explained by differences in English fluency (17), and children represent an even more vulnerable group since parents of children born in the US may face this difficulty (18). In addition to the risks mentioned, these socio-cultural barriers reduce patient satisfaction and provider satisfaction (16).

When it comes to the standard of treatment, first-contact physicians have been found to make suboptimal treatment decisions with the migrant population, in addition to the fact that the time they spend in their consultation is less and their treatments are often biased (19), one of the proposed solutions to mitigate these barriers is the anti-discrimination clause VI of the US Civil Rights Act, which instructs federal agencies to implement a mandatory system that allows people with LEP to access health services provided by those agencies (20). Given these circumstances, it is important to explore how physician-patient relationships are developed with people who have a limited command of the English language, to empirically characterize possible expressions of barriers identified in the literature that include access to care, the quality standard, and the treatment received by health providers in the Hispanic population in the US.

Rationale and knowledge gap

Understanding doctor-patient relationships in pediatric patients with language barriers, is crucial for ensuring effective communication and addressing healthcare disparities. It is particularly important in the Hispanic population in the US, where language barriers impact access to care and treatment quality. Despite recognition of the significance, empirical research in this area is lacking. While literature acknowledges language barriers’ impact, there is a lack of comprehensive studies examining their interplay with cultural factors and disparities, especially in pediatric settings. Research is needed to understand these dynamics better and develop strategies to improve healthcare outcomes for patients or caregivers with LEP.

Objective

Essentially, it is important to explore the dynamics of doctor-patient relationships, particularly concerning pediatric patients who have or whose caregiver has LEP in order to empirically characterize the language barriers delineated in current literature. which include access to care, quality standard and treatment received by health providers in the Hispanic population in the US. Through empirical examination of these issues the goal is to clarify the interaction between language barriers, cultural influences and healthcare disparities.

Methods

This is a hybrid study with a predominantly qualitative approach. For data collection, the methodology of participant observation was used in which the researcher played an active role in the interactions with the group that is the object of her study (21). The researcher, a bilingual medical student, occupied the role of medical office assistant, witnessing and participating in pediatric general consultations at a private outpatient clinic in Houston, Texas.

Observations were collected in February 2022, with the observed cases corresponding to the first 6 patients who attended a 1-month consultation with the same pediatrician (N=157).

With regards to ethical considerations, this study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was purely observational; hence no intervention was made. No personal information was gathered, respecting patient confidentiality thus the Institutional Review Board approval is waived.

Statistical analysis

Quantitative variables included the recording of (I) consultation time, (II) reason for consultation, (III) diagnosis, (IV) number of questions posed to the physician by the patient or family member, and (V) number of questions posed to the patient or family member by the physician. Race/ethnicity and gender variables were recorded. These data were reported using descriptive statistics and were analyzed for possible correlations with Rstudio software. However, no relationship was found between the severity of diagnostic suspicion and the patient’s ethnic classification. Similarly, no significant relationship was found between the level of interaction and ethnic classification.

The reason for consultation was categorized according to severity based on diagnostic suspicion to distinguish between patients who attended for (I) well-child consultation (II) non-severe diagnostic suspicion (III) moderately severe diagnostic suspicion and (IV) severe diagnostic suspicion. Another conjugated variable was also established with an interaction scale ranging from 1 to 5, with 1 indicating minimal interaction and 5 indicating significant engagement, including discussions about family and future plants.

For the ethnic identification of the patients, an indirect method was used, which consisted of categorization by the researcher based on the language and cultural traits observed during the consultation as well as from medical notes and comparison of surnames. All patients classified as Latino spoke Spanish during the consultation, sometimes among themselves, mixing simple words and phrases, and other times to the health professionals, throughout the consultation.

Results

At this outpatient clinic, the majority of the regular patient population consisted of Hispanic individuals and all patients had to pay out of pocket. There were several multicultural aspects of interest considering the human resources. At the time of data collection, 6 students occupied the role of assistants in the office: 2 of them spoke only English and the rest were bilingual, handling in addition to English, Romanian, Portuguese, Hindi, or Spanish. This reinforces the palpable globalization environment in the field of professionalization. Of the 6 assistants (women) who performed administrative and nursing tasks, half spoke both English and Spanish. In contrast, the 4 pediatric physicians (3 men and 1 woman) spoke only English.

During the month in which data were collected, a total of 157 consultations were recorded (n=157), consistent with the first 6 records of each day Monday through Friday, seeking to equalize circumstances for comparison. Physicians saw approximately 16 patients in a workday. The average consultation time was 4 minutes 53 seconds, including physical examination and questioning. The longest consultation was 12 minutes 25 seconds and involved a child with a first-time foster mother who presented many concerns. In contrast, the shortest consultation of a healthy child lasted only 1 minute and 47 seconds.

The indirect ethnic classification resulted in the following distribution: Latinos (45.22%), whites (30.57%), Afro-descendants (22.93%), and Asians (1.27%), represented by only 2 patients. In this sense, the proportion of Latino patients is consistent with the 45.8% reported by the US Census in 2019.

Access

To explore whether there was any distinction in access or severity threshold that causes patients to come for consultation according to ethnicity, the reason for consultation was documented and a severity level scale was established. Well-child consultation included those who attended for preventive reasons only. Non-severe patients included those who had a non-severe illness (e.g., non-severe respiratory tract infection). Moderately severe diagnostic suspicions included those with a more serious illness (e.g., complicated urinary tract infection) and severe patients were classified as those who had an urgency (e.g., head trauma) (Table 1).

Most of the patients (62.90%) who went to the outpatient clinic came for a general check-up without being ill. A higher proportion of white patients came for preventive consultation (75%), while patients of African descendance were the least likely to come for consultation without being ill (53.33%). In the sample collected, no significant correlation was found between the severity of the diagnostic suspicion and the racial/ethnic classification of the patient.

Communication and language fluency

No difficulty was observed in communicating in English for white, Afro-descendant, or Asian patients. Instead, out of the 46 Latino patients, 9 were found to have limited English language proficiency. In this work, LEP patients were defined as those who could not fluently communicate and relied solely on basic English when interacting with their healthcare providers. All 9 cases were women, who represented 5.73% of the total population and 12.68% of the total Latino patient population, highlighting the vulnerability of this specific group.

The percentage of Latinos with limited language proficiency in this sample is well below the 50.4% that exists in the city. This underrepresentation could be a result of this specific group not having access to a clinic with these characteristics, either for economic, cultural, social and/or migratory reasons. It was observed that the clinic has access to interpreters paid by an agreement with a medical center who provides service through smart tablets to outpatient physicians; however, it is noteworthy that despite the existence of a formal translation service, this was not requested on any occasion, neither by the physician nor by the patients.

It is also noteworthy that the bilingual assistants who were available at the clinic did not, in any case, offer support in patient-physician communication, despite being aware of some cases in which there was a clear difficulty of understanding between the two parties.

While no interviews were conducted in this study, one patient reported that she had previously requested an interpreter. She commented that her physician refused this option, stating he was available “to help her learn to speak English”, without being prompted. The two patients who asked the most questions (3) were individuals without English language limitations. Given the obvious language discordance that occurs when the patient and the health professional are not fluent in the same language(s) (22), the lack of use of an interpreter even when one was available stands out.

Bedside manner

To explore whether there was any distinction in bedside manner, the following was considered: consultation time, the number of questions asked at the physician’s initiative, the number of questions asked at the patient’s initiative, and the level of interaction (Table 2). These variables were crossed with the concept of diagnostic severity, so that the comparison could be comparable. It was identified that the level of physician-patient interaction was not modified according to their racial classification, so no difference in treatment was detected in this aspect. Regarding the doubts that patients expressed to their physicians, 81% of Hispanic patients had doubts about their condition, while only 44% of white patients asked their health care provider any questions. At the end of the consultation, 56% of Caucasian patients were asked by the health professional if they were left with any questions while only 19% of Hispanic patients were asked this same question (Table 3). The other difference observed involved a different standard of preventive management of fever or malaise in patients who received vaccines. The physician prescribed an antipyretic medication more frequently to non-Hispanic patients. It is striking that only 2 people of the 157 observed asked more than one question to their physician. The rest ended the consultation having asked 1 or no questions to the physician.

Discussion

Key findings

The barriers to adequate medical care are structural. They are expressed in the length of the consultation, reflected in the professional hierarchy where physicians speak only English, and assistants speak only Spanish. They are reflected in a culture that minimizes the risks of communication errors by not invoking translation services, while justifying it “so that (the patient) learns English”.

Comparison with similar research

Barriers to the use of translation services are observed in this study as described in previous literature. Physician resistance to their use has been identified, including cost and lack of knowledge about how to organize interpreter interventions (23). The reasons why translation resources were not used in this pediatric facility remain to be interpreted. Literature suggests that clinical encounters with language discordance can seriously compromise the quality of patient care and health outcomes (22). Underlying these could be a disinterest toward other cultures as an attributing factor, or a conscious or unconscious bias that minimizes the need.

Explanations of findings

In terms of access or the possibility of timely access to services, since the population studied had the economic stability to pay for a $150 USD outpatient visit, a significant portion of the population that does not have the economic capacity to access these services, as well as the reflection of minorities in this area, has not been studied.

To circumvent the cost barrier, many physicians and health facilities employ bilingual nurses instead of hiring trained medical interpreters (24), however in this case the nurses did not take on that role. The extent to which the nurses’ professional position mitigates their willingness to identify and explain points of confusion or medical conflicts to health care professionals is unknown. (24). The problem of short consultation length is apparent worldwide, 50% of the population accesses 5-minute consultations, however in the US, consultation time has increased from little to over 20 minutes on average (16). This data contrasts with what has been observed in this context where the average consultation time is close to 5 minutes. Even 10-minute consultations in primary care have been considered inadequate by 92% of physicians in the United Kingdom (25). The inadequate length of the consultation, which appears to be an imposition from the system, contributes to structural exclusion because it will affect to a greater extent those who would require extra time to consider the translation service or ask questions to clarify their needs.

The very short duration of consultations observed in this study maintains the paradigm of a medicine physician-centered medicine, on his or her time or lack thereof, conditioned at the same time by a system that is not sensitive to the needs of patients. Patient-based medicine should be allowed to center on the individuals, ensuring that there is no limitation for translation services or for inviting clarification questions at the end. It is known that having more consultation time, improves patient education, allows psychosocial problems to be recognized and addressed, decreases physician-patient stress (9), and improves patient satisfaction (26). In contrast, a rushed environment contributes to poor care and the perception of poor communication (27).

In relation to interaction, the fact that patients who required the interpretation service did not request it may be in relation to a cultural cue, in which a positive personal relationship is sought by avoiding interactions that could be perceived as discourteous (27). This could also explain why they ask a maximum of one question despite the short consultation time and possible doubts that may arise by those who speak English less than very well.

It can be inferred that patients with language limitations would ask more questions to their health care provider if they had the appropriate tools to communicate, although there is also a cultural cue of power asymmetry that could interfere with confidence in questioning the provider. The lack of interpreters increases the risk of misdiagnosis and serious treatment errors even in settings where it is common to care for patients with LEP (28).

Most Hispanic patients attending this clinic sought preventive care, general checkups, or treatment for minor conditions. Differential treatment of Hispanic patients was observed, as they were prescribed prophylactic post-vaccine antipyretic medication less frequently than non-Hispanic patients. Other authors have identified a differential standard of care in the follow-up of chronically ill patients (29).

These observations could be explained by a conscious or unconscious bias of the physician who avoids incurring more conversation with Latino patients by not asking if they have any questions, and not prescribing the prophylactic medication. The omission of the prescription could be motivated by avoiding possible errors in the administration of a drug that is not intended to cure and that seems dispensable. Secondarily, it could be due to a reluctance to delay further consultation.

The observer, as a bilingual Hispanic female medical student, found herself in a uniquely insightful position. Being bilingual provided a deep understanding of the challenges faced by patients who were not proficient in the dominant language of their healthcare system. This understanding allowed her to empathize more readily with patients who encountered language barriers and to recognize the nuances of communication breakdowns in medical settings.

Additionally, as a member of the Hispanic community herself, she brought a heightened awareness of cultural nuances, beliefs, and practices that could impact healthcare interactions. She was more attuned to the cultural factors that influenced health-seeking behaviors and patient-provider communication within her community, which was invaluable in designing interventions or policies to address language barriers effectively. However, her unique position also came with its own set of preconceptions and biases. Despite her bilingualism and cultural background, she may have held unconscious biases or assumptions about language proficiency, cultural norms, or healthcare practices that could have influenced the research approach or interpretation of data. It was crucial for her to remain mindful of these biases and actively work to mitigate them through reflexivity, seeking diverse perspectives, and engaging in critical self-reflection throughout the research process. Overall, this multifaceted position afforded both insights and challenges.

Strengths and limitations

One limitation of this study has to do with the fact that the observation was documented in a single clinic and with a single provider. Personal biases are another limitation, especially in determining patient ethnicity. In the future, correlation of this technique with patient interviews could be considered. An objective method of determining patient ethnicity is also recommended. In terms of strengths, the intersectional approach of this study and its relevance to healthcare equity contribute to the development of more equitable healthcare practices.

Implications and actions needed

The present study did not document patient perceptions, which could complement the view on this passive role, and determine whether it coexists with a perception of discrimination related to their ethnicity, which is associated with distrust in the provider, discontinuation of indicated treatments, and dissatisfaction with the services provided (2). On the other hand, it is essential to understand the vision of health care providers on what they consider adequate standard of care in terms of time and objectives of the consultation, as well as to delve into the resistance in the use of translation services.

Conclusions

Despite technological advances and the exponential growth of migration, language barriers remain a tangible and prevalent problem in obtaining quality health care. Although in theory there was access to interpretation services and bilingual staff within the population studied, there was no attempt to mediate in this aspect, which denotes a lack of empathy and poor awareness of the risks that exist from bad communication in medical interaction.

Short consultation time is a major concern that may be impeding quality of care as well as worsening barriers with multicultural patients, this system limits patient-centered care that can address other social determinants of health and produce better therapeutic outcomes. In relation to the treatment that the patient experiences according to a quality standard in medical care, health professionals must be notified of the exercise of this type of violence that may be conscious or unconscious since the provision of culturally sensitive health care can improve patients’ health status (30). One way to achieve this is to ensure that patients are informed about the availability of translation services when they are needed. Other ways to achieve this should be explored. More research is needed in this area and qualitative interviews are recommended for patients with LEP and their health care providers as the next step.

It is necessary to educate future health professionals beyond giving them the skills to make a correct diagnosis and treatment of diseases. Multicultural skills should be part of the curriculum of today’s medical schools, and should convey to their future professionals that sensitivity and empathy towards vulnerable patients are indispensable tools for good practice.

Systems must be designed that do not hinder the quality of care conditioned by a misunderstood logic of effectiveness. This includes consultation time, which should be sufficient to educate the patient by clarifying his doubts about diagnosis and treatment to ensure a quality consultation. It is essential to give patients information about their pathology and their rights to empower them and have the necessary knowledge so that in any case they can demand an interpreter or report in case they are denied.

Since structural determinants are identified, advocacy to change this problem must come from several fronts, underpinning the education of all actors, but also a design of processes and regulations that align with the objectives in favor of the patient’s well-being as a focus.

Acknowledgments

The work of Kenia Urena-Barrera is acknowledged for her help on editing the English version of this paper.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Equity in Health: Findings from the APRU Global Health Conference 2023” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-49/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-49/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-49/coif). The series “Equity in Health: Findings from the APRU Global Health Conference 2023” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was purely observational; hence no intervention was made. No personal information was gathered, patient confidentiality was respected thus the need for Institutional Review Board approval is waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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