MAPS Conferences

Workshop I

Healthy Mind, Healthy Body
Traditional and Alternative Healing Practices in Contemporary Portuguese-speaking Communities

Western Medicine: Beliefs and Compliance in the Treatment of Medical Issues

Chair & Moderator
João Baptista Soares, MD, MPH
Director, Health Division, Massachusetts Alliance of Portuguese Speakers (MAPS)
Read conference synopsis

Maggie Curtin, RNC, FNP, MSN
Family Nurse Practitioner, East Cambridge Health Center, Cambridge Health Alliance Clinical Faculty at Primary Care Program, Northeastern University

Panelists
Helena Santos, MD
Internal Medicine, East Cambridge Health Center, Cambridge Health Alliance
Clinical Instructor in Medicine, Harvard Medical School

Coronary atherosclerotic heart disease is the most common cause of cardiovascular disability and death in the USA. Diabetes mellitus affects an estimated 16million people in the USA. Many statistics are available concerning the US population in general however little is known regarding these diseases in the Portuguese-speaking communities living in the USA. The lack of data is also true for hypertension, hyperlipidemia as well as for many other chronic diseases. So far, health providers have extrapolated the US statistics available and have applied them to Portuguese-speaking patients. Some information and education materials have also been translated into Portuguese to facilitate the patients’ understanding of their medical conditions. However, simple and direct translations of materials from English to Portuguese, even if available do not transmit their message effectively if they are not culturally sensitive. For example, nutritional advice, which is an extremely important aspect in the treatment and management of diabetes and coronary heart disease, is often misunderstood and times confusing to many Portuguese-speaking patients. If the advice given is not culturally sensitive it loses its effectiveness in sending the proper message. This is further complicated by the fact that the Portuguese-speaking community is actually comprised of several different cultural communities, such as the Portuguese (further subdivided into continental Portuguese and Portuguese from the Islands – Azores and Madeira), Brazilian and Cape Verdean, just to name a few. Also different are the views on the use of alcohol, tobacco and lifestyle, along with myths regarding the above named diseases. It becomes utterly important to understand the cultural beliefs and differences in order to develop culturally sensitive information materials for patients, as well as to develop adequate education programs for healthcare providers. Concomitantly, strong efforts should be pursued to obtain official statistics pertaining to chronic diseases in the Portuguese-speaking community. Only then can we deliver truly excellent care and make a difference in the outcome of our patients’ health.

Fernando Santos, MD, PhD
Private Practice of Internal Medicine, Salem, New Hampshire

Depression

1. Introduction: Depression is a serious disease. It may be life threatening if not properly treated.

2. Depression is a severely depressed mood resulting in a feeling of sadness. Loss of pleasure and interest in the usual activities is also present. It must be accompanied by at least five of the following symptoms including the two above. These symptoms must be present for at least 2 weeks:

• Fatigue or loss of energy almost every day
• Decreased ability to think or concentrate
• Repeated thoughts of death
• Insomnia or hypersomnia
• Weight loss or weight gain
• Agitation or retardation as observed by others
• Feeling of worthlessness

This type of depression is called Major Depression or Major Depressive Disorder. Major Depression can also be associated with manic episodes. It is then called Manic Depressive Disorder or Bipolar I disorder.

3. A typical case of a patient with Major Depression: “A 35 year-old woman who comes to the doctor’s office because she feels sad. She has thoughts of suicide and no energy for anything. She has no motivation, no appetite, and sleeps until late in the morning. She has missed work several times. There is no interest in Any type of social life.”

4. Somatic symptoms: They usually mask the real problem that brings the patient to the doctor.

5. Prevalence factors to Depression in a medical practice. It is at least 5 to 10 per cent. Women are more affected than men (twice as much).

6. Suicide in Major Depression. Risk of suicide is much greater in untreated patients.

7. Predisposing factors to Depression. Divorce, loss of a job, death of a loved one, etc may start a chain of events leading to Depression.

8. Treatment. Psychotherapy, drug therapy and electroconvulsive therapy (ECT) are the main stem of a treatment. Psychotherapy can be used alone when Depression is associated with reactive disorders as long as symptoms are not severe. Drug therapy is a must if the symptoms meet the criteria for Major Depression. ECT is indicated when drug therapy does not work. Antidepressant drugs may be classified into 3 groups: 1) trycyclic and similar compounds; 2) Serotonin-selective reuptake inhibitors (SSRIs); 3) Monoamine oxidase inhibitors (MAO).

Patrice Alves, MD, MPH
Adult Primary Care Physician, Boston Medical Center and Upham's Corner

Health Center Some salient points of the health care delivery in the Cape Verde Islands and how Cape Verdean immigrants react and adapt to the U. S. medical system. Strategies to adopt and pitfalls to avoid when caring for Cape Verdean patients, to maximize compliance and minimize non- adherence to prescribed medical regimens. Overview of major health issues in the Cape Verdean community.

Dr. Helena Santos introduced the latest statistics for diabetes and heart disease; their significance and prevalence in the general population as devastating diseases. The mortality of CAD and DM vary by gender and DM also is impacted by race/ethnicity. She then pointed out the lack of specific data and the difficulty in obtaining it in regard to the Portuguese-speaking populations. Therefore, the data is extrapolated from the general population, although data based out of New Bedford and Fall River, MA, which contain a large percent of Portuguese speakers, suggests that diabetes may be possibly higher than the general population.

As well, the complications of the disease may be higher in minority populations because of a variety of reasons: barriers to healthcare they face and subsequent delay in seeking care secondary to legal and insurance issues, language, and their own beliefs about these diseases, and lack of lifestyle modification.

This leads to the question of what healthcare providers can do for these patients. Healthcare providers can intervene in the arena of controllable factors such as lifestyle (ETOH, smoking), diet, exercise, medicine and insulin administration via patient education. Effective patient education goes beyond mere translation. It addresses core beliefs and gives specific suggestions to diet that are recognizable and culturally acceptable to the patient. It also has to be multifaceted to cover those people who are illiterate and/or disabled, and encompass a variety of individual learning styles. Ideally, it would be available in the patient's primary language in written and audio versions, and in 1:1 and group teaching sessions.

Effective patient education that could cross the cultural gap and help patients modify their controllable disease risk factors could significantly reduce the mortality and morbidity where it is the highest. This could be furthered by enhancing the data which already exists and then creating appropriate models for teaching healthcare workers who work with these populations as well as teaching the patients themselves.

Dr. Fernando Santos: Depression in Primary Care Among Immigrants

Dr. Fernando Santos started his presentation by telling a personal tale of a Brazilian colleague who was head of the Dept. of Psychiatry who committed suicide. He drove home the point that anyone could be susceptible to depression and suicide, given a combination of overwhelming stressors. An estimated 5 to 10% of the general population who visit a doctor's office are depressed. It is generally accepted that the prevalence of depression in immigrant populations is even significantly higher than that for a variety of factors:

1. They are separated from their families and social supports.
2. Conversely, they are anxious over family members they have left and are unable to help.
3. Increased financial stress and financial support of other dependent family members.
4. Increased work and subsequent decreased socialization and rest.
5. Feeling "out of synch" with the dominant culture they are assimilated into.
6. Previously untreated and/or unresolved psychological issues are unmasked under a new set of strains.
7. Shame around a psychiatric diagnosis can delay diagnosis and treatment. The healthcare provider then must be first aware of the high prevalence of depression among immigrants, and interview directly about it. They must also be aware of multiple somatic complaints as another face of depression. They must also be aware of the transference of the feeling of depression from the patient to the caregiver in order to successfully continue to provide this valuable service.

Dr. Patrice Alves: Beliefs and Compliance in the Treatment of Medical Issues: Health Issues in the Cape Verdean Community

Dr. Patrice Alves started with the recognition that "disease is the same all over the world, but what is different is the patient's response to it." The patient's response to the disease, as well as the healthcare providers' management of the patient is different based on their culture and a web of other socioeconomic factors. In order to have maximal impact in their suggestion of treatments, the healthcare provider must understand the specifics of the patient's culture. The patient's experience often reflects what is going on in their country of origin.

Dr. Alves gave a brief overview of the Cape Verdean Islands' history and diversity even one from the other, which is reflected in the population. He gave an overview of the healthcare delivery system in Cape Verde and how Cape Verdean immigrants adapt and react to the US healthcare system. The suggestions and pitfalls he outlined for providers included:

1. Use of a professional translator, as there are many internal dialects and C.V. Creole is different than Portuguese, although some patients may also recognize and speak this.
2. It is best if the translators are professional, as patients have doubts and fears regarding the confidentiality of the information if the staff are from the community. They may also censor information out of shame and/or embarrassment.
3. Instructions must be very clear, especially about referrals and/or screening procedures, as well as medicines. Encouraging the patient to bring their medicines to every visit will help enlighten the actual usage of the medicines vs. the prescribed use.
4. Longstanding issues (like HTN) may be minimized because they are asymptomatic, while acute mild symptoms may be stressed. This is based on a belief that lack of symptoms means lack of disease.

In short, the more the healthcare provider understands about the patients' beliefs and frame of reference, the more precise the communication can be, and the more efficient intervention he/she can make.
Back to top.

Copyright © 2002 Massachusetts Alliance of Portuguese Speakers, Inc. All rights reserved.