Addressing Multiculturalism in Health Care Presentation


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Multicultural Conference on Resiliency and Living Strengths (10 November 2011) Handouts

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  • BK and JF Present as questions
  • JF
  • JF Jonathan and bukky give sandi questions and she enters them in here.
  • BK It’s old news that America’s diversity is increasing, with growth of Hispanics at the forefront (43% increase per Census 2010 vs. 2000; 4x growth of entire population which was 10%)-Hispanics (Mexicans, Puertoricans, now make up 16% of U.S. population
  • BK Despite our growing diversity, the presence of health care disparities reveal the challenges for multiculturalism in the U.S.A. Bronx Health Reach stated… Bronx Health REACH is a coalition of grass roots community organizations and churches dedicated to eliminating disparities in health care by 2010.
  • JF SANDI please reformat. The actors were comprised of 2 men, one black one white; 2 women, one black one white. They had the same insurance, presented with identical symptoms. Another interesting note is that not all of the docs were white.
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  • BK Given that a large body of research was continuously documenting disparities, Congress requested that Institute of Medicine conduct a study to assess differences in the kinds and quality of healthcare received by racial and ethnic minorities and non-minorities in the US. After reviewing more than 100 peer-reviewed studies, they found that it exists in different facets of health care, even after adjusting for socioeconomic differences and other healthcare access factors. They deemed it unacceptable due to its association with worst outcomes, i.e. death., Occurs in context of broader historic and current discrimination in many Sources contribute to it include health system, providers, patient and managers
  • BK Though present IOM clearly reported that this is supported only by small number of studies and Help-seeking behavior is influenced by cultural norms and preferences. Non-Hispanic White families - pursue formal avenues of support, e.g., mental health services, African American and Latino families are more likely to use informal supports, such as extended family or clergy. Stigma associated with mental health care Individuals or parents may experience guilt or shame about mental illness and therefore avoid or delay accessing services. Cultural mistrust of health professionals due to past history Past experiences of discrimination & racism (Tuskegee studies, Eugenics movement/Bell Curve)
  • BK Lack of resources, knowledge or institutional priority for interpretation/translation services; 1 of 5 latino report not seeking care due to language barriers Time pressures that limit physician’s accurate assessment of symptoms of minority patients, especially in face of cultural/language barriers Geographic availability of healthcare institutions- study showing opioid supplies available in 25% of pharmacies in a predominantly non-white neighborhood compared to 75% in white neighborhood
  • JF? IOS identified three factors that may be operating outside provider’s awareness. Though based on relevant theories and small body of research, some clear evidence show support for these variables.
  • These realities can feel disconcerting to providers given the values that bring us to the health care field, which are often altruistic. We enter into this field because… So it begets the question of how are we reconciling those values given our reality, i.e., the challenges we face with attending effectively to multiculturalism?
  • This begets the question- how are we reconciling those values given our reality of health care disparities, a clear indicator of the challenges we face with attending effectively to our multicultural society?
  • BK While the effects on clients are likely obvious. We must consider the impact disparities have for us. patient dissatisfaction (creates threat to your job/position) poor engagement or adherence to treatment protocols or premature termination of treatment (threatens our values/pursuit for effectiveness) poorer health outcomes of patients (contributes to growth of problems)
  • BK IOM described that “All members of a community are affected by the poor health status of its least healthy members and adeptly illustrated in the quote “infectious disease, for example knows no racial/ethnic or socioeconomic boundaries” Failure for patients to utilize services in cost effective way, i.e., minimal use of preventative services or treatment as prescribed and therefore rely on emergency services, which is most expensive form of treatment
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  • JF Belief/value in ethnocentric perspective Naïveté Belief in meritocracy Therefore unfair/unjust to even think about this Lack of knowledge of how to attend to it Inherent difficulty with making change
  • JF Our hope is to offer some ideas that will enable you to consider
  • JF Is this only relevant to micro level? Do we want to introduce this here? Should CC slide follow here?
  • JF Is this only relevant to micro level? Do we want to introduce this here? Should CC slide follow here?
  • JF Do we want to add the specific3- 4 domains here- awareness, skills, knowledge and behavior or according to Sue, D- (attitudes/beliefs; knowledge; skills
  • JF Need to stress willingness to learn . Explain that many cultural competency programs use racial/ethnic profiles which may actually reinforce stereotypes. Another way to point out the danger in using profiles may be to mention the Bell Curve, 60% fit the “norm” the remaining 40% is split on either side; almost half do not fit the “norm”. Making assumptions based on profiles and statistics prevents seeing the patient as an individual. However, some knowledge of the patient’s culture may be helpful. Refer to following slides
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  • BK Cultivating an environment that actively fosters the practice of cultural competence Continuously providing trainings Rewards practice of cultural competence
  • BK As providers and support staff are the implementers due to direct service provision, we are the real agents of change. For change to occur, providers and support staff will have to individually prioritize and practice the pursuit of cultural competency otherwise problems will unfortunately remain, regardless of how much institution policies support change
  • BK Because a s we all know, regardless of how much institution policies support and promote change, unless we individually and collectively become champions for making change, nothing will happen. as implementation is what counts & creates change!
  • BK Even more, how willing are you to being a game changer?
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  • JF Make these relevant for mental health audience; add Sue’s comments about non westerner’s perspectives on mental health
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  • BK A major benefit that comes with being a game changer is the sense of achievement of living in the path of your values, especially those that brought you into the field. We are hopeful that you will not only experience a generalized increase in your sense of effectiveness as a provider by engaging significantly more clients but also that you would feel the pride that comes with actively being a part of the solution of addressing major social problems of healthcare expenses and racism as a social change maker.
  • Addressing Multiculturalism in Health Care Presentation

    1. 1. ADDRESSING MULTICULTURALISM IN CLINICAL CARE Jonathan Fader, PhD Olubukonla (Bukky) Kolawole, PsyD
    2. 2. Objectives <ul><li>Why is multiculturalism relevant? </li></ul><ul><li>What problems are created when it’s not addressed? </li></ul><ul><li>Why is it daunting? </li></ul><ul><li>What would it mean for you to be a “game changer”? </li></ul>
    3. 3. Objectives <ul><li>Knowing is not enough; we must apply. </li></ul><ul><li>Willing is not enough; we must do. </li></ul><ul><li>-Goethe </li></ul>
    4. 4. Poll – Learning from each other
    5. 5. Multiculturalism in the U.S.A.
    6. 6. Healthcare disparities as threats to multiculturalism <ul><li>The higher incidence of disease, disability, and early death among African Americans, Latinos and other minority groups is what defines racial and ethnic disparities in health. </li></ul><ul><li>-Bronx Health REACH </li></ul>
    7. 7. Documenting racial disparities <ul><li>“ The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization” </li></ul><ul><li>Kevin A. Schulman MD, et al. </li></ul><ul><li>New England Journal of Medicine 1999; 340:618-626 </li></ul><ul><li>Actors portrayed clients in scripted interviews about their symptoms. 720 physicians reviewed recorded videotapes of these interviews. </li></ul><ul><li>Women were only 60% as likely to be referred for cardiac catheterization as men; Blacks were only 60% as likely to be referred for cardiac catheterization as whites. Black women were 40% as likely to be referred as white men. </li></ul>
    8. 8. Evidence of healthcare disparities <ul><li>Cancer </li></ul><ul><li>Asthma </li></ul><ul><li>Cardiovascular Disease </li></ul><ul><li>HIV/AIDS </li></ul><ul><li>Diabetes </li></ul><ul><li>Mental Illness </li></ul><ul><li>Children’s Mental Health </li></ul>
    9. 9. IOM’s findings on racial/ethnic disparities <ul><li>Occurs in context of broader inequality & discrimination </li></ul><ul><li>Major sources include variables by health system & providers </li></ul><ul><li>Minor source include client level variables </li></ul>
    10. 10. Client level variables <ul><li>Minorities are more likely to: </li></ul><ul><ul><li>Refuse recommended services </li></ul></ul><ul><ul><li>Adhere poorly to treatment plan </li></ul></ul><ul><ul><li>Delay seeking care </li></ul></ul><ul><li>Explained by: </li></ul><ul><ul><li>Cultural norms/preferences of help seeking behavior </li></ul></ul><ul><ul><li>Justified mistrust due to past history </li></ul></ul><ul><ul><li>Misunderstanding of instructions </li></ul></ul>
    11. 11. Health system variables <ul><li>Lack of resources for interpretation/translation services </li></ul><ul><li>Time pressures on providers, despite any cultural/language barriers </li></ul><ul><li>Geographic availability of healthcare institutions </li></ul>
    12. 12. Provider level variables <ul><li>Clinical uncertainty with minority clients </li></ul><ul><li>Bias/prejudice against minorities </li></ul><ul><li>Stereotypes about behavior/health of minorities </li></ul><ul><li>Disengagement in response to client’s mistrust/non-compliance </li></ul>
    13. 13. Why did we get into this? <ul><li>Providers typically enter field: </li></ul><ul><ul><li>To serve others </li></ul></ul><ul><ul><li>To promote the welfare of the sick and underserved </li></ul></ul><ul><ul><li>To make a meaningful difference </li></ul></ul><ul><li>Have values for: </li></ul><ul><ul><li>Altruism </li></ul></ul><ul><ul><li>Fairness </li></ul></ul><ul><ul><li>Equality </li></ul></ul><ul><ul><li>Effectiveness </li></ul></ul>
    14. 14. Food for thought: <ul><li>How are we reconciling our values for service, altruism, welfare and health given these disparities? </li></ul>
    15. 15. How do disparities impact providers? <ul><li>Pose threats to provider’s roles and values </li></ul><ul><ul><li>Client dissatisfaction </li></ul></ul><ul><ul><li>Poor client engagement or premature termination </li></ul></ul><ul><ul><li>Poorer client health outcomes </li></ul></ul>
    16. 16. What is the collective impact? <ul><ul><li>“ Infectious disease…knows no racial/ethnic or socioeconomic boundaries”- IOM </li></ul></ul><ul><ul><li>Drives up costs of healthcare/taxes </li></ul></ul><ul><ul><li>Maintains legacy of racial discrimination </li></ul></ul><ul><ul><li>“ Inequities in care, therefore” expose a threat to quality care for all Americans” – IOM </li></ul></ul>
    17. 17. What makes attending to multiculturalism so daunting?
    18. 18. What makes attending to multiculturalism so daunting? <ul><li>Belief/value in ethnocentric perspective </li></ul><ul><li>Belief in meritocracy </li></ul><ul><ul><li>Unfair/unjust to even think about this </li></ul></ul><ul><li>Lack of knowledge of how to attend to it </li></ul><ul><li>Inherent difficulty with making change </li></ul>
    19. 19. <ul><li>Fear </li></ul><ul><ul><li>Of embarrassment (i.e., saying wrong thing, being politically incorrect or “looking stupid”) </li></ul></ul><ul><li>Hopelessness </li></ul><ul><ul><li>“ This problem is so big and overwhelming. No point in even trying.” </li></ul></ul><ul><li>Helplessness </li></ul><ul><ul><li>“ I’m one person in the system, how can I make a difference?” </li></ul></ul>What makes attending to multiculturalism so daunting?
    20. 20. Finding the balance between stereotypes & generalizations <ul><ul><li>If you don’t consider generalizations about culture, you may miss important information </li></ul></ul><ul><ul><li>If you rely solely on generalizations (stereotypes), you risk providing inadequate treatment </li></ul></ul>
    21. 21. Finding the balance between stereotypes & generalizations
    22. 22. Cultural competency as a solution <ul><li>The ability to understand and use information about an individual’s cultural background to enhance the quality of your interaction with that person </li></ul>
    23. 23. Cultural competency: It’s a trip, not a destination <ul><li>There’s no such thing as Cultural Competence </li></ul><ul><li>different stages of development on this topic. always room for growth as long as there is willingness </li></ul><ul><li>Increase ability, desire and willingness to consider role culture plays in the health care of your clients </li></ul>
    24. 24. What if the solution requires a multi-pronged approach? <ul><li>Institutional level & Individual level </li></ul>
    25. 25. Institutions desiring change might consider: <ul><li>Diversification of workforce & decision makers </li></ul><ul><li>Fostering practice of cultural competency </li></ul><ul><ul><li>Continuously provide trainings </li></ul></ul><ul><ul><li>Reward practice of cultural competency </li></ul></ul>
    26. 26. What if the bigger impact for change lies in your hands? <ul><ul><ul><ul><li>Individual provider/support staff level: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Are the real agents of change </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Requires each individual to prioritize the pursuit of cultural competency </li></ul></ul></ul></ul></ul>
    27. 27. Implementation by staff is key for change <ul><ul><ul><ul><li>How willing are you to prioritize the practice of cultural competency? </li></ul></ul></ul></ul>
    28. 28. Key question How willing are you to being a game changer?
    29. 29. Being a game changer means… <ul><li>Changing our behavior to unbalance the status quo </li></ul><ul><li>Being more attentive to cultural issues in our patients/clients and practicing cultural competency in healthcare </li></ul>
    30. 30. Heart of cultural competency is respect of differences <ul><li>How willing are you to behave in a way that shows your respect for differences? </li></ul>
    32. 32. Case example <ul><li>Danesh is a 32 year-old carpenter of Guyanese descent who has lived in Brooklyn for the past 2 years. He comes referred by his MD. Danesh reports that he has been feeling “down” for two months. His counselor has not been able to find any medical etiology for Danesh’s symptoms. You believe his symptoms are related to a mood disorder. You believe he may be depressed. Upon further questioning, he tells you that he believes a neighbor put a “jumbie” on him and this is causing his low mood. </li></ul>
    33. 33. Recognize differences between cultural perspectives of health: Kleinman Model <ul><li>Difference between disease and illness </li></ul><ul><li>Disease “abnormalities in structure/function of organs or systems” </li></ul><ul><li>Illness “experiences of disvalued changes in states of being and social function; the human experience of sickness” </li></ul>
    34. 34. Kleinman model <ul><li>Illness shaped by cultural, social and psychological factors </li></ul><ul><li>For clients, illness may be the entire problem </li></ul><ul><li>Clinicans can view disease as whole problem </li></ul>
    35. 35. Kleinman questions: Why do we need them? <ul><li>Diverging explanatory models/clinical realities cause problems in care </li></ul><ul><li>Important to understand counselor’s and client’s models and how they conflict </li></ul><ul><li>Client feels understood and counselor gains critical information </li></ul>
    36. 36. Kleinman questions: Why do we need them? <ul><li>understanding leads to increased rapport, better alliance between counselor and client. </li></ul><ul><li>Puts counselor in a position where they can negotiate </li></ul>
    37. 37. Recognize that our treatment is not a universal norm <ul><li>Psychotherapy as a Western/Euro-American Norm </li></ul><ul><ul><li>Predominantly Euro-American perspective </li></ul></ul><ul><ul><li>May be culturally bound and not immediately applicable to culturally diverse groups </li></ul></ul><ul><li>(Sue, D & Sue, D, 2002) </li></ul>
    38. 38. <ul><li>“ It is more important to know what kind of patient has the disease than what kind of disease the patient has.” </li></ul><ul><ul><li>-Sir William Osler </li></ul></ul>GREAT! BUT HOW DO WE ASK?
    39. 39. Multicultural interviewing: Kleinman questions <ul><li>What do you think has caused your problem? </li></ul><ul><li>Why do you think it started when it did? </li></ul><ul><li>What do you think your sickness does to you? How does it work? </li></ul><ul><li>How severe is your (problem) sickness? Will it have a short or a long course? </li></ul>
    40. 40. Kleinman questions: <ul><li>What kind of treatment do you think you should receive? </li></ul><ul><li>What are the most important results you hope to receive from this treatment? </li></ul><ul><li>What are the chief problems your (problem) sickness has caused for you? </li></ul><ul><li>What do you fear most about (the consequences of your problem) sickness? </li></ul>
    41. 41. A framework for culturally competent clinical practice: E.T.H.N.I.C. <ul><li>E xplanation </li></ul><ul><li>T reatment </li></ul><ul><li>H ealers </li></ul><ul><li>N on-doctors </li></ul><ul><li>I ntervention </li></ul><ul><li>C ollaboration </li></ul>
    42. 42. Enhancing your cultural communication skills <ul><li>So that I might be aware of and respect your cultural beliefs ……………… </li></ul><ul><ul><li>Can you tell me what languages are spoken in your home and the languages that you speak? </li></ul></ul><ul><ul><li>Can you tell me about beliefs and practices including special events that you feel I should know? </li></ul></ul><ul><li>  </li></ul><ul><li>* Adapted from : University of Michigan’s Program for Multicultural Health </li></ul>
    43. 43. Negotiating conflict <ul><li>Ask yourself – does belief/practice affect care? </li></ul><ul><li>Allow for non-traditional healers </li></ul><ul><li>Attempt to incorporate client’s explanation/treatment into your plan </li></ul><ul><li>If cultural practice is dangerous—must advise client. </li></ul>
    44. 44. Privilege <ul><li>Skin color is one of the privilege variables that operates most often </li></ul><ul><li>Other variables that confer/deprive privilege: </li></ul><ul><ul><li>Gender </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Sexual Orientation </li></ul></ul><ul><ul><li>Economic Status </li></ul></ul><ul><ul><li>Disability Status </li></ul></ul><ul><ul><li>Religion </li></ul></ul><ul><ul><li>Immigration status </li></ul></ul>
    45. 45. Privilege <ul><li>Members of majority groups have certain societal benefits that members of minority groups do not have </li></ul><ul><li>More subtle than racism or prejudice </li></ul><ul><li>Can be invisible </li></ul><ul><li>Taken for granted </li></ul><ul><li>May operate outside of awareness </li></ul>
    46. 46. Racism, prejudice and privilege <ul><li>Raise awareness around issues of racism, prejudice and privilege </li></ul><ul><li>Examine our experience of these factors in ourselves </li></ul><ul><li>Begin to consider how these factors may play a role in the care we provide to clients </li></ul><ul><li>Practice strategies in diffusing tense client care situations related to these issues </li></ul>
    47. 47. Now what do I do? <ul><li>Understanding privilege is a good start </li></ul><ul><li>Examine the role of privilege in your interactions with colleagues, supervisors and clients </li></ul><ul><li>Developing this awareness works to dissolve barriers to care and bridges gaps between culturally different people </li></ul>
    48. 48. Now what do I do? <ul><li>Raise questions regarding difference and privilege </li></ul><ul><li>Continue to be respectful and curious about the impact of culture on your relationships with clients and on clinical care </li></ul>
    49. 49. What benefits might you enjoy as a game changer? <ul><ul><li>Increases in: </li></ul></ul><ul><ul><ul><li>Engagement of clients in treatment </li></ul></ul></ul><ul><ul><ul><li>Generalized sense of effectiveness </li></ul></ul></ul><ul><li>Pride of being a social change maker in major problem areas: </li></ul><ul><ul><li>Healthcare expenses and racism </li></ul></ul>