It’s a moment Andrés Flores Fioravanti, MPH, won’t forget: At a meeting for Latino moms whose children have asthma, a guest speaker told the group that her teenage son was diagnosed with the incurable lung disorder at age 4, but she never gave him any of the prescribed medication to manage it.
Instead, she said proudly, she relied on her deep Christian faith and prayer.
The dilemma facing Fioravanti, an asthma expert who works with the American Lung Association of the Upper Midwest, was whether to interrupt the mom immediately and disagree with her about the value of medication, or wait until it was his turn to speak and address it in a way that did not embarrass her or dismiss her faith and culture.
He chose the latter option.
“At the end of the program, I took all the comments that I found a little bit misleading and I made sure to tackle them — but I generalized so that they blended in with what everyone had said, not just certain people,” he said. “This way, these moms don’t feel attacked and the message about proper treatment is still being delivered.”
Health care professionals like Fioravanti, who work with multicultural populations, often find themselves at the crossroads of cultural traditions and modern medicine. It’s a difficult place to be. Providers want their patients to comply with the full treatment plan — from household changes to daily and rescue medication — yet they can’t risk alienating patients by discounting or denigrating traditions that have been handed down for generations.
These are not rare encounters for health care providers. Consider these asthma facts:
- About 26 million Americans have asthma: about 7.4 percent of U.S. adults and 6.6 percent of U.S. children.
- Of those, about 3 million are Hispanic, 2.4 million are African-American and 218,000 are American Indians/Alaska Natives.
- The asthma rate among Puerto Ricans is 80 percent higher than it is for Caucasians and the highest compared with all ethnic groups.
- Although data on asthma conditions for American Indians/Alaska Natives is limited, children from that group are 30 percent more likely to have asthma than Caucasian children.
Knowing the prevalence of asthma among certain ethnic groups, how do providers create a plan for culturally sensitive, effective treatment? Start with common ground, Fioravanti says.
He often tells audiences about his childhood in Costa Rica, when his sister was given a Chihuahua because of a traditional belief in some Latino cultures that the dogs can cure asthma by “taking on” the illness from its owner. Now that Fioravanti has a son with asthma, he tells families that he does not believe in the Chihuahua theory but he does pray for his son to be healthy while still relying on his prescribed medication.
“I tell them, ‘If you believe that God is helping you, I have no doubt about that,’” he said. “But at the same time, I let them know that God is helping us to provide this medicine that has been proven to help if they use it every day.”
Show, Don’t Just Tell
Kristina Gutierrez-Barela, MD, is a pediatrician at ABQ Health Partners in Rio Rancho, New Mexico, a suburb of Albuquerque. The patient base is primarily Hispanic, American Indian and Caucasian, mirroring the demographics of the area. The metro area is about 49 percent Hispanic/Latino, almost 40 percent Caucasian and a little more than 5 percent American Indian or Alaska Native.
Dr. Gutierrez-Barela, a Mexican-American who is fluent in Spanish, often sees patients who only speak Spanish, or American Indians who make the 30- to 50-mile trek from their pueblos to the office. She says it’s important to her that all patients she treats feel comfortable and respected, no matter their culture. This, in turn, helps motivate them to comply with their care plan.
“I am bilingual so I can speak to our Spanish-speaking patients in their own language,” she said. “I want to provide information and handouts and explain things in a language they understand. Whatever we have in English, I make sure we have in Spanish.”
When she learns of a living situation that does not support good asthma care — such as using wood-burning stoves or treating asthma with a family herbal remedy — she tries to diffuse the situation by offering alternatives gently and without judgment. She also finds it effective to do the pulmonary function test before and after administering medication, to show the impact the treatment has.
“A family member may have other ideas about treatment, but a big part of what I do and what makes our practice successful is the doctor-patient relationship,” she said. “A lot of our patients put their trust in me, so they are much more likely to buy into what I say.
“We are trying to make it patient-centered. It’s not me saying ‘You need to do this.’ It’s looking at barriers to this patient and family that prevent them from getting medication and buying into the belief their child has asthma.”
The Rural Culture
James A. Lewis, MD, also cares for an American Indian population as a pediatrician with Cherokee Nation W.W. Hastings Health Center in Tahlequah, Oklahoma. But he finds their asthma treatment is affected much more by the very rural location than by culture. It can be difficult for patients to get in to see him — and for him to be sure they are complying with their treatment plan. Often, they will just figure it out themselves rather than make the trip in to his office.
“There isn’t a big difference between rural Oklahoma and Cherokee clients,” Dr. Lewis said. “The biggest issue for both is compliance and making sure they are following through with controller medications. Very often, these patients will use their rescue medicine only and when they get very bad they come to the ER. So it really has to do with their age and the fact they live in rural Oklahoma, more than being part of the Cherokee Nation or not.”
He tries to address this by going over medications with patients and their parents and explaining the use and necessity of everything that is prescribed. That’s usually enough for preteens, but not for teenagers. They become “symptom tolerant,” Dr. Lewis says, meaning they don’t worry about minor wheezing, even though it’s an asthma symptom. So he often doesn’t see them until they are in the emergency room with an asthma flare-up — and he offers them some stern words.
“I tell them breathing is not like a car, where you can choose what kind of options you want,” he said. “Breathing is not optional and needs to be the best it can be at all times. It’s just a matter of them realizing that, but nobody wants to admit they are different.”
Partnering with providers to support efforts to improve asthma treatment is one way Blue Cross and Blue Shield of Texas is Taking on Asthma. Learn more about the initiative at bcbstx.com/taking-on-asthma.