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Cultural Competence And Global Health Workers
- 1. Cultural Assets and Cultural Needs Enhancing the contributions of global health workers Julia Puebla Fortier Director Resources for Cross Cultural Health Care
Editor's Notes
- Global health workers, by definition, are people who come from a national, cultural, and frequently linguistic background that is different from that of the institution and community they are going to work in. These differences – especially the cultural and linguistic ones, have profound effect on many different levels: how they feel as an individual and a professional; how they interact with the staff and systems of the institution they work in, and how they interact with patients, families and communities. In order to make an effective contribution, health workers need to feel comfortable and confident about themselves and about their interactions with others. By actively acknowledging the role that language and culture play in health care interactions, health care institutions can play an important role in easing the integration of global health workers into their organizations, and can harness their deep cultural knowledge to improve the quality of care for the increasing number of patients who come from other countries and cultural and linguistic backgrounds. My name is Julia Puebla Fortier, director of RCCHC. I have worked in health care policy in the United States for nearly 20 years, working especially with government agencies and health care organizations to improve quality of care for diverse and disadvantaged populations. While there are many deficiencies in the US health care system, I can say that great strides have been made over the last 10 years in developing creative models for bridging the cultural and linguistic gap between health care institutions and culturally diverse communities. I’d like to share some of these models with you today.
- Our society in the 21 st century is characterized by great movements of people, cultural institutions, business. I don’t need to say much the movement of health professionals globally – you know this data, and that’s why you’re here. Let me say a little about an equally important phenomena, which is that the movement of people means that health care institutions must really come to terms with an increasingly diverse patient population. (see demog sheet) What are the challenges health care organizations face when dealing with increasing diversity? Linguistic barriers that arise when patients can’t communicate with hospital staff or clinicians, can lead to a host of problems, ranging from not being able to find your way around the institution to misunderstandings about symptoms, disease course, diagnosis, treatment possibiliies, taking medication, etc. Cultural barriers can range from misunderstandings about dietary restrictions, issues of cultural/religions modesty, to differences in how to discuss terminal illnesses and death. Sometimes these barriers result in patients or communities that are unhappy with or mistrustful of a health care institution, and avoid using it, even at the expense of their health. Sometimes these barriers and misunderstandings have serious clinical consequences, including disability and death.
- So, how do we effectively care for diverse patient populations, and what role do global health workers have in this task? I’d like to take just a few minutes to describe the framework of cultural competence, because I believe that it offers us the possibility of using the cultural assets of global health workers to address the cultural needs of diverse patient populations. Cultural competence, cultural sensitivity, multicultural health – there are many different terms, but they essentially refer to the same objective: the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter. Patients who receive culturally competent health care know that they will be able to communicate effectively with staff and clinicians, that they will be treated with respect, that their unique personal and cultural background and attitudes will be acknowledged and integrated into treatment programs, and that the institution has already recognized and planned for how to address the cultural diversity issues that may arise, ideally in consultation with the community. The execution of this cultural competence agenda varies around the world: parts of Australia have been a pioneer in explicitly addressing these issues through government policy and targeted health programs and interventions. The US has take a more grass-roots, bottom up approach to developing model programs, which have then become the basis for policy formulation, in national, state and quality accreditation frameworks. And Europe has recently been the site of 12-country policy and practice research project that was quite successful, although the practice and integration of these lessons across the mainstream has only just begun.
- In practice, addressing culture and language in health care would ideally touch on improving interpersonal interactions, strengthening the ability of institutions to assess, plan for, and improve services that are used by diverse populations, and putting into place policy structures and funding that support the mechanisms needed to effectively address diversity. In the U.S, this has been outlined and promoted through the National Standards for Culturally and Linguistically Appropriate Services in health care, or the CLAS standards (ref. to handout) Specific strategies that focus on improving interpersonal interactions in the context of cultural and linguistic differences, and all of these tasks are frequently taken on by global health workers, whether explicitly as part of their job description, or on an ad hoc basis. They include:
- I’d like to say a little more the last strategy, which is also known as cultural bridging. This is the ability of a person or a program to use their knowledge of two cultures, that of the patient, and that of the health care system, to act as a bridge between patient and institution to improve communication, comfort and the quality of health care delivered. Many times nurses, doctors and other staff do this as a matter of course. However there are also specific roles that involve cultural bridging include: CHWs are usually from the community and work in the community on disease prevention and health promotion. C Case Managers usually work within an institution to not only manage the care of a patient, but also to serve as a liaison (linguistic or cultural) between the patient and the institution. Cultural navigator is another term for this work. And finally, staff from other countries or particular religious/ cultural background can serve as a resource to other staff, answering questions, providing education, serving as a intermediary when cultural issues are complex and difficult to manage.
- Challenges: Role confliscts Different approaches to patient care (IMGs less likely to have formal coursework in skill areas) Jacobs Particularly critical in countries where increasing push for patient centered care model, partnership rather than paternalism, don’t do psychosocial histories, negotiate with patients Fiscella Diagnoistic and treatment options will be influences by home country values (homosexiuality, marital distress, sex, alcohol and drug use *Steinert) Transcultural challenges: lifestyle, sex-role, discrimination, change in status, geneder hierarchy, power Same country is not same understanding – diff ethnic groups, social classes, educational levels. In small communities and countries, tension can be created by people from on different sides of conflicts Bernstein: do IMGs want to be seen as representatives of their own culture… some have sought to avoid being perceived in this role.
- We’ve seen the ways in which global health workers can be assets, and we have seen what personal needs and challenges they face integrating into a new culture and health care system. How do we find the right synergy between the their needs and what they can offer to patients who are themselves from diverse cultural backgrounds. The models I’m about to describe point to 3 main activities: (bullets)
- All listed on resource sheet On the training end of the spectrum, a recent program has been developed in Canada that provides teaching modules for those involved in training or educational programs with foreign trained health workers. It has modules to orient teachers/staff to the world of the IMG, explain the Canadian health system, how to work in the context of cultural diversity, how to deliver patient-centered care and improve communication. It also offers a toolkit to adapt the material to a variety of teaching situations Welcome Back. Recognizing the reality of many professional trained immigrants in CA who could not practice due to relicensing difficulties, and the overwhelming need in many health care institutions for bilingual/bilcultural staff. The Welcome Back program attempts to serve both ends of the cultural needs equation in health care. Targeting indviduals who have been trained in other countries, but are not working in health care now for whatever reason, this program offers an extremely comprensive and wellthougt out ptraom of individual assessment, counseling, case management, referreal, and educational services. The educational offerings alone are quite indicative of the needs that many IMGs have english in health care, study groups, exam preparation, health care system. In addition, the outcomes of this program are quite impressive: 773 have found employment in the health sector: as nurses, nurse assistants, Pas, techs, In a practicing hospital setting, At the AEMC, in Philadelphia, a 3-year course is required for all IMG residents, called Comunication and Cultural Competence. There is also a special orientation program for IHWs with distinct opportunities for these staff to talk about their own integration processes, and how they feel about being representatives of their own culture. Often they find that their own personal knowledge of cultural issue: the experience of being an immigrant, understanding the context of female circumcision, etc. gives them an opportunity to be helpful to other staff who must care for patients from that culture. Harborview Cultural Case Manager ProgramTo be fully effective, cultural mediation is combined with case management. The interpreter follows a family or patient over a period of time, becoming fully aware of the family’s needs, problems, and strengths. A case management approach enables the interpreter to provide cultural interpretation and mediation, and to advocate for appropriate treatment based on a more thorough understanding of the patient. The interpreter can thus communicate cultural facts and social/familial histories to the health provider, offering the provider a way to gain valuable insights which can positively impact patient care. Problems such as poor housing, lack of child care or support for new parents, depression, isolation, and mental health problems can be identified and addressed using the interpreter cultural mediator approach. While the interpreter cultural mediator cannot solve all the problems a family may contend with, avenues for communication are vastly broadened and cultural gaps in information more easily bridged when an ICM is involved in patient care.