In a study titled The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization published in the New England Journal of Medicine in 1999, physicians referred hypothetical white males, black males, and white females at the same rate but were less likely to refer black females. NEJM 1999;340:618
We cannot force people to change their beliefs because we think ours are better.
It requires an honest assessment of our positive and negative assumptions about others.
A set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.
It is apparent from these statistics that physicians will have to adapt to accommodate a larger and more diverse patient population. Working with patients from different cultures can make patient education a greater challenge and this can contribute to disparities in health care. In Connecticut alone, there was an almost 10% increase of Hispanic or Latino population from 2000 to 2010 according the US Census.
Racial and ethnic disparities are linked to poorer health outcomes and lower quality care. Language and cultural issues can have a significant impact on these disparities. Healthcare providers are in a position to have the opportunity to advance culturally competent care.
Our nation is aging. We are going to have many older patients with chronic conditions and disabilities who also have to be treated in a culturally competent manner.
Providing culturally competent care can help decrease barriers to health and reduce health disparities.
May feel providers have a higher status so will expect the provider to take charge. May use traditional medicine like cupping or coining.
Often Hispanic culture may be uncomfortable about seeing a social worker or mental health specialist and think that people will think there is something wrong with the family so they want to take care of it themselves.
Some individuals believe illness is caused by supernatural or by environmental factors like cold air. Do not dismiss as they play an important role in some people’s lives.
There is no way you can learn about every culture, but you can learn about certain taboos in different cultures. Some cultures are gender sensitive, for example. You can educate yourself about the main cultures in our community and become familiar with their cultural norms. Be sensitive: Cultural competence starts at the front desk.
Before meeting treatment needs, effective communication with the patient is needed to understand how the patient understands the problem and how they wish to address it. These are 8 questions a healthcare provider can comfortably ask a patient of another culture. You don’t have to ask all the questions or ask them in this order. You also don’t have to know about the patient’s culture, but you can learn about the culture through how it is reflected in the patient’s answers.
Build a foundation: Culture and language considerations should be included in any organizations missions and visions. Organizations wide policies that integrate cultural competence and support better care for diverse populations. Target Minorities: target culturally competent initiatives to specific population. This includes staff training and education as wellness as patient education. I know when building the new tower there will be more private rooms so people can have all their family members because as we saw different cultures have a much bigger emphasis on family involvement. But one thing I have noticed, signage is awful and in only one language so we need to change that. Establish Internal and External collaborations Work with community organizations to share info and resources to meet the needs of diverse populations Collect and use data: Review data to assess community needs before implementing services. Track current services to see how they are being used, services such a religious and spiritutal care, dietary requests
Role playing, study discussion, having a period once a month where you all bring in foods from your culture and ask a speaker to attend, maybe someone from your own unit or a physician or a clinical person who can talk about health care in their culture. That does happen on some of the units. Caring for Cultures day It is not a simple task. Becoming culturally competent is an attribute that takes time and patience. Simply learning facts about different culture does not necessarily deem individuals culturally competent It is not possible to learn everything about all minority groups, but having a knowledge base can be reduce anxiety and improve patient outcomes
Cultural Competence andPatient-Centered CareHorblit Health Sciences Library
ObjectivesAt the end of this presentation, you will be able to:1. Define culture2. Define cultural competency3. Identify how cultural competency can improve health communication4. Identify the cultural factors that influence cross- cultural patient-provider interactions5. List ways to develop cultural competence and to assess your own cultural competency development
Why Learn About Cultural Competence?• Patients bring many varied and cultural backgrounds, beliefs, practices, and languages, requiring culturally competent communication to maximize the quality of care they receive.• Providers also bring their own cultural backgrounds, values and beliefs, and biases to health care encounters. Culturally competent providers take into account how their own cultural orientation and background influence their perceptions and behaviors.
Cultural Bias is Everywhere• A review in Family Medicine found evidence that race, ethnicity, and language impact the quality of the patient- provider relationship.• Patients who are culturally different from their providers, especially those who are not proficient in English, are less likely to: – Have providers identify with and understand their situation – Establish a connection and trust with providers – Receive sufficient information – Be encouraged to participate in medical decision-making
What is Culture?• Most people think of culture in terms of race, nationality, and religion, but culture is broader than that.• Culture includes groups that we are born into, such as gender, race, national origin, sexual orientation, class, and religion.• It also includes the social groups that influence our identity, including age, disability, social and economic status, and even career.
Characteristics of Culture• Two people my have exactly the same cultural background but may respond differently to a given situation and have different values on similar issues.• Culture may be affected by many factors, including: – Personality – Experience/time – Gender – Level of ability (physical and – Age mental) – Sexual orientation – Spirituality/religion – Social and economic status
What Does Culture Encompass/Impact?• Communications • Customs• Language • Family obligations• Art • Illness and death• Religion • Preventive care• Diet • Gender roles• Environment • Social groups
These are Cultural Groups, Too• Gay/Lesbian • Visually impaired• Transgender • Mentally ill• Disabled
The Importance of Culture• Culture is a central issue in people’s lives. It influences their beliefs, values, attitudes, and behavior.• Although people may share the same culture, the way in which that culture is expressed will differ from person to person and will vary over time.
Culture and Health CareA person’s culture can affect:• What is considered to be a health problem• How symptoms and concerns about the problem are expressed• Who provides the treatment for the problem• What types of treatment should be given• How and when health care information is received
Culture and Health Communication• Patients may choose not to seek needed services• Providers may make errors in diagnosis because of miscommunication• Patients may not follow medical advice because they do not trust or understand the provider• Providers may order fewer or more diagnostic tests for patients because they may not understand or believe the patient’s description of symptoms HRSA
Social StructureEgalitarian Hierarchical• All are equal • Top down – All competent adults – Husband makes make decisions for their decisions own health care – Patriarch makes decision – Provider may be expected to make decision
What is Cultural Competence?• Developing an awareness of one’s own thoughts, attitudes, and environment without letting it influence those from other backgrounds.• Demonstrating understanding of a client’s culture. Understand the cause and control of specific diseases and the effectiveness of treatments in different populations.• Accepting and respecting cultural differences.• Adapting care to accommodate the client’s culture. HRSA
What is Cultural Competence?The ability to acquire and use knowledge of the health- related beliefs, attitudes, practices, and communication of patients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.
What is Cultural Competence?• It begins with an honest desire not to allow biases to keep us from treating every individual with respect.• Learning to evaluate our own level of cultural competence must be part of our ongoing effort to provide better health care.
What is Cultural Competence?Culturally competent providers consistently andsystematically:•Understand and respect their patients’ values, beliefs,and expectations•Understand the cause and control of specific diseasesand the effectiveness of treatments in differentpopulation groups•Adapt the way they deliver care to each patient’sneeds and expectations
Why Provide Culturally Competent Care?• Every patient-provider encounter is a cross-cultural encounter.• Even patients with appearance and background similar to yours can be culturally different due to life experiences, personalities, interests, careers, etc.
Benefits of Culturally Competent Care• Reduced health care disparities• Improved health communication and health outcomes• Providing culturally competent care allows you to develop trust and create partnerships with your patients, and helps to ensure effective, understandable, and respectful care for all patients.
Cultural Factors Influencing Patient- Provider CommunicationThere are several cultural factors that can influence thequality of patient-provider communication, including:•Personal biases•Nonverbal communication•Patients’ families and dynamics•Cultural values and beliefs
Why is Cultural Competence Important? Population ChangesHispanic populations Increase to 23% by 2050Asian populations Increase to 10% by 2050African American Double in size to 15.7% (62m)Non-Hispanic Whites Decline by 20% by 2050 www.census.gov, Population projections 2008
Why is Cultural Competence Important? Languages• Over 44 million Americans speak a language other than English at home.• Over 300 different languages are spoken in the U.S.• Over 48 languages are spoken in Danbury www.usinfo.gov Language Use and English-Speaking Ability: 2000
Aging and HealthNumber of people over the age of 65 2008 38.7 million 2050 88.5 million• Over age 65: up to 3 chronic conditions• Over age 85: at least one disability www.census.gov 2008 age projections; National Academy on an Aging Society 1999
What can culture influence?• Health, healing and wellness belief systems• How patient and consumer perceive illness, disease, and their causes• Patients’ behaviors seeking health care and their attitudes to healthcare providers• The delivery of services by the provider who looks at the world through his or her values• Compliance to medication and treatment plan HRSA
Healthcare Disparities• Health disparities and minority and foreign-born populations are increasing• African Americans’ infant mortality rates are 2 – 5 times higher than for European Americans• Influenza death rates are higher for African Americans than for European Americans HRSA
The Asian American Patient• Diverse population – Chinese, Filipino, Vietnamese, Korean, Japanese• Traditional definition of causes of illness is based on harmony: balance of hot and cold states or elements• Modesty highly valued• May be too polite to disagree• Communication based on respect; familiarity is unacceptable• Eldest male is head of family and may take the lead in health decision making
Hispanic Health Beliefs and Practices• Preventative care may not be practiced.• Illness is God’s will and recovery is in His hands.• Hot and Cold Principles apply.• Expressiveness of pain is culturally acceptable.• Obesity may be seen as a sign of good health and well being.• Diet is high in salt, sugar, starches and fat.• High respect for authority and the elderly.• Provide same sex caregivers if at all possible.
Cultural Groups• Anglo American • Native American – Direct eye contact – Anecdotes/metaphors – Informed about details – Avoid eye contact – Aggressive approach – Don’t speak to loudly – Killing germs – Traditional healing very – Antibiotics even when important unnecessary – Never touch or casually – Belief in technology admire a ritual object.
No Stereotyping• Culture is expressed through the individual• Not all members of a cultural group will believe the same thing• Variation within cultural groups.
Basic Strategies• Speak clearly and slowly without raising your voice, avoid slang, jargon, humor, idioms.• Use Mrs., Miss, Mr. Avoid first names which may be considered discourteous in some cultures.• Avoid gestures – they may have a negative connotation.• Many carry or wear religious symbols – Sacred threads worn by Hindus, native Americans-medicine bundles. DO not touch them.
How would you make your practice culturally competent?
Culturally Competent Care• Treat people uniquely • Know your comfort• Listen respectfully level• Gender sensitivity • Establish trust• Educate yourself• Be aware of different cultures
ScenarioA nurse, working as a community case manager, visited thehome of a toddler with severe physical and developmentaldelays. She explained to the parents that with their consent shewould refer the child to a physiotherapy and occupationaltherapy program that would help the child be moreindependent. The parents refused, saying that it was their dutyto care for their child because the child’s condition ispunishment for having conceived before they were married.They were not supportive of a program to increaseindependence. The nurse was upset and felt the parents werenot acting in the child’s best interests.
DiscussionThe nurse did not understand the family’s initial refusal oftreatment. After reflection and discussion with colleagues, sherealized that her personal and professional values ofindependence were causing her to feel upset with the parents’refusal. She decided to explore with the family their goals fortheir child. In doing this, she learned that the parents wantedtheir child to become stronger and have fewer infections. Whenthe same therapies were described as a means of meeting thesegoals, the parents were quite willing to participate. Theprogram was developed to meet the goals that the familyidentified as important.
ScenarioA couple comes to a walk-in clinic with a young child who iscrying and tugging at his ears. The couple has recently arrived inthe country but understands English well enough that the nursefeels language is not an issue. An assessment reveals that thechild has an infection in both ears, and the couple is given aprescription for an antibiotic and Tylenol drops for fever andpain. The situation is fairly routine, and an interpreter is notconsidered necessary. The parents are informed about thediagnosis and treatment, and they nod in understanding.
Scenario, continuedThe next day the couple returns with the child whose conditionseems to have worsened. There is now a pink discharge fromboth ears, and the entire family is in distress. An interpreter iscalled to assist. Through the interpreter, the nurse learns thatthe parents had the prescription filled promptly, and theyunderstood the child was to be given the medicine every 4hours. They had been administering the antibiotic orally, butsince they had treated previous infections with ear drops, theyhad administered the Tylenol drops in the child’s ears.
DiscussionThis example illustrates the importance of confirmingthat accurate communication has been achieved. Toreduce the chance of confusion, the nurse could havedemonstrated how to measure, and then administer,both medications. Culturally appropriate clienteducation materials would also have been helpful.
ScenarioA woman, 35, is admitted to the general medical unit.While in the hospital, she expresses concern about herpartner’s ability to care for her children. She alsoappears worried about how she will manage at homeafter she is discharged. The nurse suggests thatperhaps a family meeting is necessary and offers tocontact her husband. The nurse further suggests thatmaybe the patient’s mother, who has called often toinquire about her daughter, should be involved in themeeting.
DiscussionThe nurse has made an assumption that the patient’spartner is male and that the relationship with themother is one that will be supportive to the entirefamily. For many couples in a same sex relationship,the issue of family can be sensitive. For some people,“family” is often their chosen family as opposed to kin.By using the word “partner,” and asking the patientwho would be appropriate for a family meeting, thenurse shows openness and a nonjudgmental attitude.
ScenarioA nurse is providing direct care to an elderly womannewly diagnosed with angina. She has been prescribednitroglycerine to manage her angina attacks. Thepatient reveals to the nurse her firm belief that herillness is caused by the “evil eye,” a glance cast uponher by another to cause this condition. She shows thenurse her own remedy, which she claims will life thecurse of the evil eye and cure her.
DiscussionThe nurse assesses the patient’s remedy for possiblehealth risks, such as high sodium content. As well, thenurse negotiates with the patient to take thenitroglycerine. In doing so, the nurse will need to bevigilant to the potential objections the patient mayhave to taking the medication. The goal is to have aplan of care that includes the remedy for the evil eye,but also includes the appropriate use of thenitroglycerine. The nurse and the patient may not fullyunderstand each other’s preferences, but are willing toaccommodate both interventions.
The 4 C’s• What do you call your problem?• What do you think caused your problem?• What have you done to cope with your problem?• What concerns do you have about your problem, about my recommendations?
Kleinman’s 8 Questions1. What do you think caused the problem?2. Why do you think it started when it did?3. What does your sickness do and how does it work?4. How severe is your sickness/ How long do you expect it to last?5. What problems has the sickness caused you?6. What do you fear about your sickness?7. What type of treatment do you think you should receive?8. What are the most important results you hope to achieve from this treatment? Kleinman et al 1978
Benefits of Cultural Competence• Greater patient compliance• Fewer harmful drug interactions• More appropriate testing and screenings• Increased likelihood that minorities will seek health care• More successful patient education
Developing Cultural CompetenceAttitude/skill-centered approach• Recognize your own biases; understand how race, ethnicity, gender, etc. play a role in healthcare delivery and perception of health care. https://implicit.harvard.edu/implicit/• Acquire and apply culturally competent skills.
Developing Cultural CompetenceFact-centered approach• Learn specific information, such as an ethnic groups’ history, their concepts of illness and disease, their health-seeking behavior, disease patterns, etc.
Developing Cultural CompetenceOrganizational• Build a foundation• Collect and use data to improve services• Accommodate the needs of special populations• Establish internal and external collaborations
Developing Cultural CompetencePhysician-specific• Key stakeholders• Programs and training• Agents of change
Developing Cultural CompetenceEducational Opportunities• Films/videos and CDs• CMEs• Lectures• Presentations on specific cultures• Unit cultural gatherings
ReferencesAmerican Academy of Pediatrics. Plain Language Pediatrics. 2009. ElkGrove Village, IL: American Academy of Pediatrics.Arnold TL, Davis TC. Frempong JO et al. 2006. Assessment of newborn screening parent education materials Pediatrics 117(5pt2): S341-s345.HRSA Unified Health Communications Addressing Health Literacy, Cultural Competency, and Limited English Proficiency.Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251-258.Lenningert, M., & McFarland, M.R. (2002). Transcultural Nursing: Concepts, theories, research & practice (3rd ed).New York: McGraw-HillNational Academy on an Aging Society. Chronic Conditions : A challenge for the 21st century, November 1999.Pew Research Center.US Populations Projections 2005-2050.