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cross cultural.ppt
1. Cross Cultural Care and Education in
Geriatrics
Jerry Johnson, M.D.
Professor of Medicine
University of Pennsylvania
2. Objectives
Overall Goal: Preparation to Teach Cross Cultural
Aspects of Geriatrics
Anticipate predictable challenges
Relate your teaching content to the domains of cross
cultural interactions
Apply mnemonics for interactions with patients and
caregivers
Use diverse approaches to teaching
Identify resources for education and learning
3. Crossing the Quality Chasm
“The system by which health care is delivered
and financed must be designed to ensure that care
is safe, effective, efficient, equitable, timely, and
tailored to each individual’s specific needs and
circumstances.”
- Institute of Medicine Report, 2001
4. Cultural diversity
training
programs for
providers
Increase provider
sensitivity to attitudes
and beliefs which
marginalize ethnic
groups
Analytic Framework: Cultural Diversity
Training for Providers
Increase provider
knowledge of
culturally-based
beliefs and behaviors
Decrease differential
treatment due to
unconscious
discrimination
Increase use of
culturally appropriate
health care interventions
Improved
health status
outcomes
Greater
satisfaction
with care
Decrease ethic
differentials
in utilization
and treatment
Increase provider
abilities and strategies
for cross-cultural
interactions
Greater client
adherence to
care and treatment
recommendations
5. Challenges of Cross-cultural Care
Defining the concept of culture
Concern about stereotyping, relevance and legitimacy
Cross cultural care overlaps with other aspects of clinical
care: professionalism, humanism
Multiple levels of cultural competence
the health professional- patient relationship
the health system
the community
6. What is Culture?
Acquired attitudes, values and beliefs or “unwritten rules
of behavior.”
Caveats
Culture is not synonymous with race or ethnicity,
but...
“Culture is not a fixed, knowable entity that guides
individuals’ behaviors in linear ways” (see Gregg J.
Losing Culture on the Way to Competence: the use and misuse
of culture in medical education. Acad Med 2006: 81: 542-547).
Culture is mutable and multiple.
8. Relevant Cultural Constructs
• The culture of the patient
• The culture of the practitioner
• The culture of the practitioner’s profession:
e.g. medicine, nursing, and social work.
• The culture of the workplace: health
system, institution, or other entity
9. Relevance of Group Identities
Each individual’s identity is partly determined by
group affiliation: gender, ethnicity, religion....
Preservation of these group identities for many is
a matter of self esteem
Group identity partly determines how others view
us and interact with us
Cox, Taylor . Cultural Diversity in Organizations. 1993
11. Content Areas Relevant to Interactions
Self awareness
World view
Causation or explanatory models
Spirituality
Complementary alternative medicine
Help-seeking behavior (community and family)
Language and health literacy
Historical, social and economic factors
CREATE SOME REPRESENTATIVE CASES
12. Case Example: Explanatory Model
and Alternative Healing
Depression in a 75 yo man, self explained by the
patient, and treated outside the formal health care
system.
13. Case Example: Spirituality
Woman with multiple admissions for CHF
accompanied by markedly elevated BP, who
believes her faith, not medications, will treat
HTN.
Woman dying of metastatic breast cancer who
wants chemotherapy as an example of “being
strong” and maintaining faith.
14. Case Example: Language issues
Russian speaking man admitted with pain and gait
dysfunction
15. Case Example: social and economic
factors
Woman with large family, inadequate funds,
under significant stress
17. Conceptual Framework
Emphasis on the illness and its context:
Kleinman’s questions: Eisenberg et al. Culture, illness, and
care: clinical lessons from anthropologic and cross cultural
research. 1978
Carillo et al. Cross cultural primary care: a patient based approach. Annal Int
Med 130:829, 1999
Explore the meaning of illness
Conduct a social context “review of systems”
Negotiate management
18. Kleinman’s Questions
1 What caused it?
2 Why now?
3 How affects you?
4 How severe is it?
5 What treatment?
6 What results expected?
7 What chief problem?
8 What do you fear most?
9 What duration?
20. Mnemonics for Cultural Interactions
LEARN
BELIEF
RESPECT
ETHNIC and ETHNICS
BATHE
ADHERE
Others
21. LEARN
Listen with sympathy and understanding to the
patient’s perception of the problem
Explain your perceptions of the problem
Acknowledge and discuss the differences and
similarities
Recommend treatment
Negotiate treatment
Berlin E. Western Journal of Med 1983; 139: 934-938
22. BELIEF
Health Beliefs (What caused your illness ?)
Explanation (Why did it happen?)
Learn (Help me understand your belief/opinion)
Impact (How is this illness affecting your life?)
Empathy (This must be very difficult for you)
Feelings (How are you feeling?)
23. RESPECT
Respect: a demonstrable attitude
Explanatory model: patient explanation of cause
Social cultural context: gender, migration status,
sexual orientation, economic group, history
Power differential: acknowledge it
Empathy: put into words
Concerns and fears: eliciting them
Therapeutic alliance and trust
24. ETHNIC and ETHNIC(S)
Explanation : What do you think is the reason for your
sx?
Treatment: What kinds of treatment have you tried, what
kinds of treatment do you want?
Healers: Advice from alternative healers?
Negotiate: discuss options and expected results
Intervention. Determine an intervention
Collaboration
Spirituality or Seniors
Levin, S. Ethnic. Patient Care 2000; 34 (9): 188-189
25. BATHE
Background (what is going on in your life?)
Affect (How do you feel?)
Trouble (What troubles you most?)
Handling (coping)
Empathy (That must be very difficult)
26. ADHERE
Acknowledge (need for treatment and joint goals)
Discuss (potential treatments and alternatives)
Handle (questions)
Evaluate (health literacy and barriers to
adherence)
Recommend (treatment)
Empower (the patient by listening)
27. General Tips in Cross Cultural Care
Avoid idioms
Use titles such as Mr. and Miss
Yes does not always mean yes
Be cautious of touching
Use trained interpreters when available
29. Large Group Exercises
Aging Panel: Who are the elderly
Working with interpreters-film
Spirituality panel and case discussions
CAM presentation with practitioners
30. Small Group Activities
Discussion sessions following large groups, often
with guests (seniors, chaplains)
Self awareness exercises
Introduction to the Physical Community
part of a home visitation course
Narrated van tour of West Philadelphia
Resident and fellow presentations in community sites
31. Faculty and Preceptor Education
One or two orientation sessions per year
Materials prepared with key readings and
discussion questions for small groups
Debriefings after small group sessions
32. Evaluation
Students: one or two page description of an
experience with presentation to peers in a small
group
Focus groups of trainees
Critique of presentations and sessions: value,
lessons learned
33. References and Materials
Full Curricula
UCSF: Culture and communication in health care, a
curriculum
TACCT: Tool for assessing cultural competence
training : a project initially privately funded, now
adopted by the AAMC
34. References and Materials
Monographs and articles
Doorway Thoughts-American Geriatrics Society
Ham and Sloan: Cased Based Primary Care Geriatrics,
chapters on Ethnic and Cultural Aspects of Geriatrics
(4th and 5th editions). Jerry Johnson
35. Other Resources for Teaching
Stanford: stanford.edu/group/ethnoger
HRSA website: cultural and linguistic competence
education:
www.hrsa.gov/culturalcompetence/curriculumguide
The California Endowment website
Kaiser Foundation website
Manager’s electronic resource center (ERC) a cultural
competence quiz produced by Management Sciences for
Health
36. Summary
Cultural differences are common and germane.
The process of inquiry, rather than knowing a set of facts
about a group, is fundamental.
Knowledge of critical domains can direct the interaction.
Several mnemonics are available.
Discussions and interactive exercises work.
Extensive resources on cross cultural care are available.
Culture matters
Editor's Notes
Awareness of deficiencies in quality were brought to the public’s attention with a report that claimed that health care is often of a poor quality
That report made recommendations in five areas: safety, effectiveness, efficiency, equity, and patient centered care.
So, if the chief quality officer said, we have established measures in each of the areas and now we are thinking about equity. WHAT WOULD YOU SAY?