194 ACADEMIC EMERGENCY MEDICINE MAR 1996 VOL 3/NO 3

A Challenge in Injury Prevention-The Hispanic Population

Ricardo Martinez, MD, Richard A. Veloz, MPH, JD

TRAFFIC SAFETY PROBLEMS IN HISPANIC COMMUNITIES

As noted by Lee et al.’ in this issue of Academic Emergency Medicine, traffic safety is an emerging priority for Hispanic communities. The His- panic population in the United States is growing seven times faster than is the U.S. population as a whole. His- panics are projected to compose at least 11% of the U.S. population by the year 2000, and 22% by 2050, be- coming the nation’s largest minority group.2 This rapid population growth also means that Hispanics will con- stitute an increasing proportion of crash injuries and fatalities. More- over, Hispanics may be at greater crash risk than are other segments of the population. Data collected by the National Vital Statistics System show that between 1988 and 1990, the death rate among Hispanics from motor vehicle crashes (MVCs) sur- passed the death rates for blacks and for whites (Table 1).

The National Highway Traffic Safety Administration (NHTSA) re- cently conducted a study to identify issues and strategies regarding high- way safety in US. Hispanic com- munitie~.~ Specific objectives of the study were: 1) to identify the high-

way safety needs of Hispanic com- munities in the United States; and 2) to explore methods for promoting safety issues in those communities. The project involved discussions with representatives of agencies and organizations actively engaged with Hispanic communities in California, Colorado, Texas, Florida, the District of Columbia, and the New York Citymew Jersey area. These discus- sions were followed by nearly 50 fo- cus groups conducted with Hispanic community members across the six regional sites.

In general, the agency and orga- nizational representatives believed that traffic safety issues tend to get lost amid more pressing social con- cerns in their communities, such as housing, health care, unemployment, and crime. Yet the community mem- bers in the focus groups were quite concerned about traffic safety prob- lems. They described unsafe behav- iors by drivers and pedestrians, as well as perceived infrastructure dis- parities in their neighborhoods when compared with other, perhaps more affluent, environs.

Table 2 lists the highway safety problems mentioned most frequently by the study participants. Drinking and driving emerged as the leading concem. Key issues related to alco-

hol consumption by the study par- ticipants included the following: consumption of alcohol as proof of manhood; lack of knowledge re- garding the effects of alcohol on driving ability; willingness of pas- sengers to ride with a driver who has been drinking; lack of clarity about the role of the designated driver; the prevalence of underage drinking, particularly in rural and border com- munities; the manner in which the alcohol retail industry targets minor- ity communities; use of drugs in ad- dition to alcohol, especially mari- juana; use of alcohol to relieve anger and stress; and weak laws and en- forcement related to drinking and driving.

Nonuse of safety belts ranked second in concern among the study participants. Even among the com- munity members participating in the study, safety belt use was not uni- versally accepted. Reasons for non- use of safety belts included: discom- fort associated with their use; the belief that they are unsafe; the ab- sence of safety belts in some older vehicles; a sense of fatalism among some Hispanics; and the belief that safety belts are unnecessary for short distances or for passengers in the back seat.

The agency and organization rep- resentatives were far more likely than the community members to mention nonuse of child safety seats as a problem. Several factors were cited for nonuse, including: resis-

I TABLE 1 Death Rates from Motor Vehicle Crashes (Deaths per 100,OOO Resident Population)* ............................................................................................................................................................... . ... Hispanics Blacks Whites

~~ ~~ ~~~ ~~~ ~ ~ ~~

1985- 1987 1988-1990 1985 - 1987 1988- 1990 1985-1987 1988- 1990

A11 ages 16.8 19.7 17.9 18.7 19.6 19.2

1 - 14 years 5.8 6.4 7.6 7.4 6.9 6.4 15-24 years 28.4 32.0 21.7 23.4 40.1 38.1 25-44 years 19.3 23.0 22.7 23.2 20.8 20.6 45-64 years 16.1 19.1 19.8 20.6 14.9 15.3 65+ years 20.3 25.0 20.8 22.8 22.3 23.5

*Adapted from Health United States 1992, Department of Health and Human Services.’ Data are shown only for states with a Hispanic- origin item on their death certificates. The 1990 reporting area for Hispanic origin included 45 states and the District of Columbia. Based on data from the Bureau of the Census, the 1990 reporting area encompassed an estimated 88% of the US. Hispanic population.

~

Injury Prevention for Hispanics, Martinez, Veloz 195

I TABLE 2 Highway Safety Problems Identified by the Study Participants .......................................................................................................

Mentioned Most Often by Agency and Mentioned Most Often by Organization Representatives Focus Group Participants

1. Drinking and driving 2. Seat belt use 2. Seat belt use 3. Child safety seat use 4. Old unsafe vehicles 4. Inattention 5. Crowded vehicles 6. Unlicensed and uninsured drivers 7. Speeding 8. Elderly drivers 9. Disregard for signs and signals

1. Drinking and driving

3. Speeding

5. Disregard for signs and signals 6. Elderly drivers 7. Child safety seat use 8. Unlicensed and uninsured drivers 9. School buses

10. Inattention 10. Old unsafe vehicles

tance of the child; inadequate space in the vehicle, particularly with large families; the expense of the seat; and the belief by some Hispanics that it is better to hold the child in their laps. Parents in the study who said that they did use safety seats with their children gave as their reasons a concern for safety, an awareness of local laws, and the presence of com- munity programs that provided ac- cess to safety seats accompanied by instruction in their use.

The study participants identified young male drivers as the segment of the Hispanic community with the greatest safety problems. While young males would probably be sin- gled out in any ethnic or racial group, the problem may be com- pounded in the Hispanic community by cultural factors related to the proof of manhood. In living up to their masculine ideals, all men, but young men especially, may engage in behaviors that have undue risks. The study participants also fre- quently mentioned vehicular and pe- destrian safety problems among recent immigrants. Their unsafe be- haviors were largely attributed to habits brought from their countries of origin, combined with lack of fa- miliarity with the more complex sys- tem in the United States.

Socioeconomic status was a common theme in discussions of traffic safety problems. Many of the sampled communities were com- posed of large proportions of persons

at lower socioeconomic levels. The study participants agreed that socio- economic status can affect access to and use of safe vehicles, safety belts, and child safety seats. It also can af- fect access to information and edu- cational programs that are designed to enhance community awareness.

CHALLENGES TO ORGANIZATIONS IN PROVIDING SERVICES In attempting to address highway safety issues in Hispanic communi- ties, one must first consider the chal- lenges faced. Those identified in the NHTSA study included the follow- ing:

1. Language-The communication challenge includes some Hispanic community members’ lack of knowledge of English as well as their level of literacy in Spanish. Many people who speak Spanish cannot read or write it. Inade- quate translations of English ed- ucational materials and lack of Spanish-speaking staff impede educational outreach programs.

2. CuZturat dzpemmes- Within such a diverse group as the Hispanic population, there are various sub- cultures with unique values and norms. Differences within Hispanic communities make it inappropriate to address all members as a single group when devising prevention

programs. Sensitivity to intra- as well as intergroup differences is needed.

3. Socioeconomic issues-For many Hispanics, socioeconomic factors associated with low income con- tribute to an orientation to the present, with low expectations for the future. This means that pro- grams have to reach them in the now. For example, they may not accept the message that the drink- ing they are doing now will affect them when they are driving later. The impact of socioeconomic status on access to safety equip- ment and information, noted in the previous section, is another series of issues to consider. Per- haps the most daunting economic challenge for organizations is their own limited resources to provide services to everyone in need.

4. Patterns of alcohol consump- tion-Heavy use of alcohol within many Hispanic communi- ties, lack of knowledge of the im- pact of alcohol on driving, and confusion over alcohol laws all contribute to drinking and driving problems.

5. Immigration patterns-Large numbers of recent immigrants who arrive within a short period of time can strain the resources of highway safety organizations. Many recent immigrants cannot read signs, do not know or ac- knowledge the laws, and do not have driver’s licenses. The United States has a complex driv- ing system that requires more so- phisticated decision making com- pared with that to which new arrivals are accustomed.

6. Lack of emphasis on preven- tion-The health maintenance concept of recent Hispanic im- migrants often does not include preventive care as practiced in the United States, to avoid illness or

196 ACADEMIC EMERGENCY MEDICINE MAR 1996 VOL 3/NO 3

injury. Therefore, safety issues are not always readily accepted by this population.

7. Data collection-A major chal- lenge that exists is that the ma- jority of traffic safety information systems do not collect and report data for specific racial and ethnic populations. The database as it exists is therefore limited.

Professionals in emergency med- ical services (EMS) may confront additional challenges when treating Hispanic community members. As in other fields, language is a princi- pal challenge for EMS personnel in working with Hispanic community members because of a lack of bilin- gual staff. In addition, the reactions of some Hispanics during emergen- cies may differ from the behavior to which EMS workers are accustomed. A lack of understanding of behav- ioral differences can pose problems when trying to calm family members during an emergency. EMS staff also may experience situations in which a Hispanic patient has overdosed on some medicine or remedy brought from his or her country of origin to the United States. Lack of familiarity with the drug and its side effects could delay the response to the reaction.

STRATEGIES TO IMPROVE HIGHWAY SAFETY

Agencies and organizations have worked to overcome these obstacles through a variety of outreach activ- i ties that communicate information, establish the organization’s presence in the community, and approach community members in a nonthreat- ening and culturally sensitive man- ner. For example, efforts to increase access to EMS have included the presence of bilingual staff and the use of interpreters and translators, the distribution of brochures and other print materials, public service announcements on radio and tele-

vision, and participation in com- munity events such as health fairs. There also have been presentations in Spanish in elementary schools, teaching children how to dial 9-1-1 and what to say and do in an emer- gency situation. Not only is this method designed to educate the chil- dren, but it is also expected that the children will act as intermediaries and carry the information to their parents.

The NHTSA study asked partic- ipants to recommend approaches for developing and implementing traffic safety programs targeted toward His- panics. Community members in the focus groups were emphatic about the need to develop central themes that have some relationship to their lives. They called for graphic and explicit depictions of MVCs and the impact on families. Study partici- pants agreed that the family is one of the most powerful symbols in the Hispanic community. They empha- sized that any public awareness cam- paign for the Hispanic community must feature the family. According to one Texas participant, anything that is viewed as dangerous for the family reaches the entire community.

The agency and organization representatives emphasized the impor- tance of personal contact and estab- lishing relationships within the com- munity. Building trust and confidence is integral to obtaining the commu- nity’s involvement and commitment The representatives stressed that if an intervention is seen as coming from the community and for the commu- nity, the intervention is more accept- able. If it is perceived as coming from some distant governmental body that has decided what is good for the com- munity, the message will not be re- ceived well. These comments were echoed by the community members, who indicated that the element of trust in agencies is the most important cri- teria for seeking services and choosing where to go for them.

The study participants pointed

out several strategies to avoid in working with Hispanic communities. They advised against impersonal ap- proaches, use of aggressive or en- forcement-oriented messages, and assumptions that all Hispanics are alike. Presentations that could be construed as disrespectful or conde- scending must be avoided. For ex- ample, machismo behavior should not be attacked or insulted; elders and women should be shown re- spect. Excluding key members of the community is another ingredient for failure, as this seriously undermines credibility.

Inattention to language issues creates added problems. Service pro- viders should avoid communicating in English when Spanish is more ap- propriate and needed. Moreover, di- rect translation of materials from English to Spanish is frequently in- correct, and embarrassing. For ex- ample, one airline’s promotional theme “Fly in Furs” was translated to Vuele en Cuero, which means “fly naked.” Program planners require someone in the translation process who understands the nuances of the language, and local usage.

NHTSA OUTREACH Recognizing the need to target activ- ities to reach the Hispanic popula- tion, NHTSA has actively worked in developing and implementing activ- ities to build local traffic safety in- frastructures to reach Hispanic com- munities with traffic safety mes- sages. One ongoing effort is between NHTSA and the National Coalition of Hispanic Health and Human Ser- vices Organizations, a private, non- profit membership organization that represents community-based agen- cies serving Hispanics nationwide? “ T S A has provided funding for this multiyear program. This pro- gram is being piloted in seven com- munities throughout the United States to test strategies to reach the diverse Hispanic communities. A sample of activities include: 1) a

Injury Prevention for Hispanics, Martinez, Veloz 197

campaign involving youth to collect information about knowledge of, be- liefs about, and attitudes toward traf- fic safety issues among their peers, and using youth to conduct outreach programs on traffic safety issues in Boston; 2) traffic safety outreach ac- tivities by senior citizens in the Miami area; 3) traffic education pro- grams, especially child passenger safety, incorporated into prenatal classes in San Diego; 4) the devel- opment of an educational videotape on traffic safety in the Washington, DC, area; 5 ) community education activities through festivals and par- ent education classes in the Chicago area to emphasize traffic safety; 6) traffic safety programs on a variety of issues, with a special focus on pickup trucks, in the Rio Grande Valley; and 7) a focus on traffic safety issues for all ages in New York City (a new site), where posters and brochures in Spanish are dissem- inated throughout the Hispanic communities.

CONCLUSIONS

Changing population demographics are placing increasing demands on organizations involved in safety is- sues. Rapid population growth

among Hispanics can be expected to cause accelerated growth in traffic safety problems in Hispanic com- munities unless serious attempts at prevention are made. This requires improved program strategies to over- come the gaps in knowledge, the so- ciocultural influences, and the socio- economic influences that are re- sponsible for problem behaviors. Better data that extend the work of Lee et al.' are needed for making tar- geting and other program decisions. In addition, a greater understanding of Hispanic culture and diversity needs to be incorporated into pro- grams for them to be meaningful to their targets. One way of accom- plishing this is to involve commu- nity members in each of the different steps of the development process. Overall, safety professionals would be well-advised to follow three basic principles in carrying 01 c program activity: show respect for the target audience, show commitment, and develop trust.

Dr. Martinez is Administrator and Dr. Veloz is Special Assistant, Department of Transpor- tation, National Highway Traffic Safety Ad- ministration, Washington, DC.

Received: October 12, 1995; accepted: Oc- tober 18, 1995.

Address for correspondence and reprints: Ri- cardo Martinez, MD. National Highway Traf- fic Safety Administration, 400 7th Street, SW. Room 5220, Nassif Building, Washing- ton, DC 20590. Fax: 202-366-2106; e-mail: rmartinez@nhtsa.dot.gov or rvelozanhtsa. dot.gov Key words: injury; preventive medicine; Hispanic; ethnicity; race; motor vehicle trauma.

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