Are We on the Same Are We on the Same Page??:Page??:

Health BeliefsHealth Beliefsand Access to Careand Access to CareSusan Chauncey Horky, LCSW

University of FloridaPediatric Pulmonary Center

Bodily care Decision making Views of disability Time orientation Family priorities Definition of health

Parenting beliefs Spiritual beliefs

Communication

“Core Cultural Variables”

Insurance

TransportationAwareness of

Services

Ability to navigate systems

On-siteOn-sitefactorsfactorsHealthHealthBeliefsBeliefs

• Learn about the patient’s cultural environment

• Learn about the patient’s social environment

Get to know the

patient and family

What are “health beliefs” (and how What are “health beliefs” (and how do they affect client decisions about care?)do they affect client decisions about care?)

How can we work with How can we work with patients’ health beliefs ?patients’ health beliefs ?

Overview

•Get to know the patient and familyGet to know the patient and family•Understand how a patient weighs Understand how a patient weighs healthcare choiceshealthcare choices•Negotiate and compromiseNegotiate and compromise•Increase our own self awarenessIncrease our own self awareness

Broadly defined: health beliefs are the

considerations on which patients base decisions and choices about their

health care.

What areWhat are “ “health beliefs”?health beliefs”?

A Fable

Once upon a time a monkey and fish were caught up in a great flood. The monkey, agile and experienced, had the good fortune to scramble up a tree to safety. As he looked down into the raging waters, he saw a fish struggling against the swift current. Filled with a humanitarian desire to help his less fortunate fellow, he reached down and scooped the fish from the water. To the monkey’s surprise, the fish was not very grateful for this aid...

• Do I really think I am sick?

• If so, how bothered am I by my sickness

• Do I think something else would help more?

Factors weighed in healthcare choicesFactors weighed in healthcare choices

• How much do I think the doctors ideas will help?

• Am I concerned about unwanted effects of treatment?

FeelingsFeelings•PerceptionsPerceptions•ExperiencesExperiences•ExpectationsExpectations

KnowledgeKnowledge

BeliefsBeliefs

IndividualIndividual

FamilFamilyy

CultureCulture

Origins of BeliefsOrigins of Beliefs

Beliefs

SocialSocialEnvironmentEnvironment

Differential referrals

Environmental problems

Stresses

Cultural communicationbarriers Less prevention-

oriented

Different health beliefs

Hours care is available

Difficulty missing work

Difficulty navigating systems

Poor continuity of careTransportation problemsLack of childcare

No or poor insurance

Not aware of resources

Fewer minority cliniciansAnd researchers trained

Differential treatmentHealthcare not mostimmediate need

Language differences

Poor pt-provider relationship

MDs give differentmessages

Social Factors Affecting Health ChoicesSocial Factors Affecting Health Choices

Research conducted onmajority populations

Cultural Variables Affecting Health Choices

Cultural Variables Affecting Health Choices

Discipline/ Parenting beliefs

Explanatory models

Expectations for survival

Common-law marriage

Definition of family

Autonomy vs. group orientation

Decision making: who and how

Role of bio- medical healthcare

Time orientation

Views of health and illness

Gender roles and expectations

Communication styles

Views of disability

Attitudes towards giving up hope

Personal vs. institutional needs

Views on aggression

Views of authority

Private vs. public

Alternative treatments

Handling of emotions/coping

Explanatory Models

Paternalistic

((Individual or social)

God

Soul loss

Evil spirit

Soul theft

Curse

Spirit possession

Ghost

Breach of taboo

Sin

Evil eye

Witch

Naturalistic

Wet/Dry

Hot/Cold

Humoral imbalance

Emotional imbalance

Harmony/Disharmony

Hand gestures

Eye contactPhysical contactPersonal space

Verbal expressivenessVerbal responsivenessDirect or indirect style

Communication Variables

(Herbal or Folk Remedies for Asthma )

• Avoid triggers (including exercise)

• Avoid milk products

• Aloe tea

• Eucalyptus

• Mullein

• Milkweed

• Burn hornets nest and inhale smoke

• Inhale smoke from skunk cabbage root

Alternative treatments

• Hog hoof tea• Pillow made of staghorn

sumac• Dried, split skin of poisonous

snake, held to chest• Wild Plum bark tea• Break a hot loaf of bread

over child’s head• Cow dandruff, burned and

inhaled• Burn two wing feathers of a

buzzard

• Place clip of hair in tree

Latino Medicine

Yerbero

Sobrador

Partera

Curandero

Rich heritage of healers and healing

• For some Gypsies, it is important to use different bathing items (soap, towel, washcloth) for above and below the waste

• In many Gypsy families, older family members make (health and other) decisions, even if the individual is married and in his or her twenties

• Illnesses may be caused by lack of spiritual and moral cleanliness, leading to presence of the devil or bad spirits

• Emotions, including those in routine conversation, and those related to pain or death are often expressed loudly,

Gypsies (Roma)

African American Healthcare

Strong religious beliefs,prayer is a primary way of dealing with health problems

Health is a dynamic process of mind, body and spirit – not a mind/body dichotomy

Health and happiness are connected toliving a life that is pleasing to God.

Strong history of herbal medicine

African American HealthcareAfrican American Healthcare

African Americans have had many

harmful experiences in the healthcare system, as well as in society at

large

Arab Americans may speak loudly if they are stressing importance, and with a high intense pitch if they are angry

Mideastern families may appear “demanding” as a way of showing

caring for the patient

Arab childrearing may appear alternately permissive and restrictive

Mideastern Cultures

Cambodian healthcareTo show the bottom of one’s

feet to a Cambodian individual may be construed

as an insult

Cambodians may have great reluctance to sign forms,

due to cruelty and injustices during the

Khmer Rouge

Many Cambodians believe that the soul resides in the

head, so touching or performing procedures on

the head should be avoided

How do we work with client’s

health beliefs?

• Get to know the patient and family

• Understand how each patient weighs healthcare choices

• Negotiate and compromise

• Increase our own self awareness

• Create emotionally safe environment– Allow patient to talk

about feelings and stressors

– Show interest in the patient’s whole life

–Identify whether non-adherence results from poor coping, a social constraint or a belief system

Get to know the

patient and family

– Show respect– Listen– Validate and

legitimize– Ask open ended

questions– “Float” general

statements– Reflect and re-state

– Clarify and focus– Show an interest in

details– Allow silence– Summarize– Empathize– Avoid jargon– Attend to

intonation

“Incorporation of the patient’s perspective… will require a fundamental rethinking of medicine such that patients will define their own medical goals, actively participate in management and treatment considerations, and are considered expert in judging their own functioning and well-being.”

• Do you think you’re sick?

• How much does your sickness bother you?

• Do you think my ideas will help?

• Are you worried about side effects?

• Are there problems with my ideas?

• How important is your health, given everything else going on in your life?

Eliciting General Health Beliefs

Assessing cultural factors

• Where were you born? How long have you lived here?

• What language (s) do you feel most comfortable with?

• What role does religion play in your life?

• Do you have a support system?

• Is your income sufficient to meet your needs?

• What do you think caused your problem?

• Why do you think it started when it did?

• How does it affect your life?

• What worries you most about it?

• What do you think will help?

Eliciting Cultural Health Beliefs• What have you tried?

• How can I help you?

• What would you like from this visit?

• I know little about your culture. Are there things we’ve discussed that run contrary to your beliefs?

Understand how your patientbalances priorities

Am I sick?(And how bothered am I by my illness?)

Social stresses

Higher cultural priorities

Higher risk factors

Religious beliefs

My child’s illness…

…is a sign I haven’t prayed enough

…is a punishment for past sins

…will be cured by God

…is meant to be

…is a sign of specialness

…is a cross to bear

…is a test of faith

Will the doctor’s ideas help?Will the doctor’s ideas help?(Will something else help more?)(Will something else help more?)

Personal Experience

Home remedies may have worked well

Hospitals are untrustworthy, places to

die

Explanatory model

Naturalistic – imbalances

Paternalistic- God or spirits

Locus of Control

Patients feel little control

Depends on:

Are there unwanted effects of treatment?

“Unnaturalness” of medication

Intrusion into life

Side effects

Lack of spontaneity in life

Becoming “immune” to medication

Dependence on medication

Attempt to find lowest possible dose

“Over time, medical diagnoses and

recommendations were altered in ways that allowed them to fit in with the exigencies and constraints of the women’s daily lives…(such) alterations of treatment behavior were commonly accompanied by re-interpretations of the illness explanation that produced coherent rationale for the customized regime.”

Health problemHealth problem

LifeLife

LifeLife

Health Health ProblemProblem

The role of health problems in lifeThe role of health problems in life

What’s theminimum you could live with?

What’s themaximum clientwould manage?

What doesclient thinkwill help?

What do you think

will help?

Explain yourexplanatory

model

Elicit client’s explanatory

model

Negotiate and Compromise

• Talk about the patients condition; don’t struggle about whether the patient is taking the medications you recommend

• Present information in patient’s context

– “Tightening of the airways causes an asthma attack, but that is most likely to happen when airways are inflamed; without medication your airways are always inflamed even when you don’t feel it”

– “This medicine will allow your body to remain in balance”

• Don’t argue about harmless alternative treatments

• With children, know your bottom line

Self Awareness

What client behaviors make me uncomfortable?

How do I respond when I’m uncomfortable?

What are my own prejudices and biases?

What keeps me from truly putting myself in others’ shoes?

Do I really believe that other ideas are valid?

What are my own cultural beliefs

When I judge others, what am I feeling?

How do I feel when clients don’t do what I say?

Perhaps the most important thing that we cando is understand what keeps us from accepting

and respecting our patients’ views

How would I feel about simply accepting what the patient is doing?

Self Awareness

I really have to hurry...

I’ve got to seem knowledgeable and in charge

My bosswill be angryif I suggest

that we do whatthe client wants

I want to beempathic but I

just don’tunderstand howsomeone can

think that

This family seems hostile-I just want to get out of

the room

I feel souncomfortable,

I just don’tknow what

to say

I know what I shouldbe saying, but it feels awkward

What ifthis familydisdainsme?at

I understand his feelings, but my views are based on science

If I support the family the child won’t get good care

You’re just making excuses for them

I had toadapt, so

othersshould,

too

Access tocare

HealthBeliefs “Adhere

nce”

What is the relationship between:What is the relationship between:

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