cultural communication...terms race = a tribe, people, or nation belonging to the same stock; a...

CULTURAL COMMUNICATIONCULTURAL COMMUNICATION

CULTURE

A system of shared beliefs, values, customs, behaviors, and artifacts that members of society use to cope with their worlds and with one another.their worlds and with one another.

It is passed down from generation to generation through learning.

Fratkin Bates, Cultural Anthropology, 2002.

CULTURE

Provides us with:

A sense of belonging.A sense of identity.A sense of identity.A feeling of cohesiveness.A sense of connectedness to those who came before and to those who will come after.

M.K. Moos, Cultural Competence in the Care of Childbearing Families, March of Dimes Birth Defects Foundation, 2003.

TermsRace = A tribe, people, or nation belonging to the same stock; a division of humankind possessing traits that are transmissible by descent.

National Center for Cultural Competence

Ethnic = Large groups of people classed according to common ancestry and national, Ethnic = Large groups of people classed according to common ancestry and national, religious, tribal, linguistic, or cultural origins.

Ethnicity = A sense of identity an individual has. How one sees oneself and how one is seen by others as part of a group on the basis of presumed ancestry and sharing a common destiny.

Institute of Medicine (IOM) 1999 Report

Cultural DiversityAccording to the 2000 U.S. Census Data:

16.7% of Florida residents were foreign born (up from 12.9% in 1990)

Region of birth of foreign born:72.8% Latin America13.3% Europe8.7% Asia3.8% Northern America1.3% Africa0.2% Oceania

Cultural Diversity

2000 U.S. Census Florida Data:

78% White 14.6% Black or African American14.6% Black or African American1.7% Asian0.3% American Indian0.1% Native Hawaiian/ Pacific Islander3.0% Other2.4% Multi-racial16.8% Hispanic or Latino origin

Cultural Diversity

According to the 2000 U.S. Census Florida Data:

23.1% of total Florida respondents stated a language other than English spoken at a language other than English spoken at home. (Up from 17.9% in 1990.)

10.3% of the total respondents from Florida answered that they speak English “less than very well.” (Up from 7.9% in 1990.)

Acculturation

Changes or adaptations in cultural beliefs, values, and traditions resulting from contact with other cultures over time. cultures over time. Borrowing of certain traits by one culture from another.Can have negative or positive effects.

What is Cultural Competence?What is Cultural Competence?

Cultural Competence

Requires that organizations have a defined set of values and principles, defined set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally

Developmental Disabilities and Bill of Rights Act of 2000

Elements of Cultural Competence

Value diversity.Conduct cultural assessment of self and system.Manage the dynamics of difference.Manage the dynamics of difference.Acquire and institutionalize cultural knowledge.Adapt to diversity and cultural contexts of the communities served.

The National Center for Cultural Competence, 2004.

Cultural Competence

Extends beyond addressing language barriers and providing translation services.services.

Extends beyond simply hiring staff of diverse racial backgrounds.

Culturally Competent Services

Services provided in a manner that demonstrates respect for individual dignity, personal preference, and dignity, personal preference, and cultural differences.

Developmental Disabilities and Bill of Rights Act of 2000

Cultural competency is:

A process not an event;

A journey, not a destination;

Dynamic, not static;

And involves the paradox of knowing .

Dr. Josepha Campinha-Bacote, Ph.D., A.P.R.N., B.C., C.N.S., C.T.N., F.A.A.N., President and Founder of C.A.R.E.

Associates of Cincinatti, Ohio.

Why do we Need to Be Culturally Competent?

1) Improve the quality of services.2) Meet legislative and accreditation

mandates.mandates.3) Gain a competitive edge in the

marketplace.4) Decrease the likelihood of liability

and malpractice claims.

Georgetown University Center for Cultural Competence

Public Health Providers

Our main focus is to improve health outcomes.

Health Promotion = The process of Health Promotion = The process of enabling people to increase control over the detriments of health and thereby improve their health.

World Health Organization 1998

Health Promotion Involves:

Actions directed at strengthening skills and capabilities of individuals.

Actions directed toward changing social, environmental, and economic conditions so as to alleviate their impact on public and individual health.

World Health Organization 1998

To accomplish the goal of improving health outcomes we must first understand:

Barriers to health improvement.Barriers to health improvement.Motivators to health improvement.The relevance of our methods.Effective ways to empower individuals.

Partnership for Clear Health Communication

Terms

Literacy = An individual’s ability to read, write, speak in English, compute, and solve problems at levels of proficiency necessary to compute, and solve problems at levels of proficiency necessary to function on the job, in the family, and in the society.

Workforce Investment Act of 1998

Terms

Health Literacy = The degree to which individuals have the capacity to obtain, process, and understand basic health information and services health information and services needed to make appropriate health decisions.

Healthy People 2010

Agency for Health Care Research and Quality (AHRQ) found a positive, significant relationship between literacy level and a participant’s knowledge of health issues.

People with low health literacy are People with low health literacy are more likely to report poor health, have an incomplete understanding of their health problems and treatment, and be at a greater risk of hospitalization.

AHRQ Evidenced Based Practice Program

Magnitude of Health Literacy

A national adult literacy study, done in 1993, found that 48% of adults do in 1993, found that 48% of adults do not have the literacy skills necessary to function adequately in society.

Cost of Low Health Literacy

The direct medical costs of low, functional literacy are financed through additional hospital and through additional hospital and office visits, longer hospital stays, extra tests, procedures, and prescriptions.

Center For Health Care Strategies, Inc.

Cost of Low Health Literacy

Center For Health Care Strategies, Inc. Source: Estimates from 1998 Medical Expenditure

Survey by the Center on an Aging Society

“Often, the people with the greatest health burdens, have the least access to information.”

“Even with access to information “Even with access to information and services, disparities still exist because many people lack health literacy.”

Healthy People 2010

“Ask Me 3”

An initiative developed by the Partnership for Clear Health Communication.

Identifies the three (3) most important questions a patient can ask to help understand their health status.

Terms

Limited English Proficient (LEP) =An individual who is unable to speak, read, write, or understand the English language at a level that English language at a level that permits him or her to interact effectively with health and social services agencies and providers.

Terms

Linguistic Competence = The capacity of an organization and its personnel to effectively communicate with persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities.

Potential risks/losses when languageservices are not provided:

Client unable to access eligible services or programs.

Client unable to exercise important rights, including informed consent.

Client unable to comply with provider requirements and requests.

Lost opportunities to decrease disparities/outreach on important health issues affecting LEP communities.

FL DOH Bureau of TB and Refugee Health

Longer “contact” times equal ineffective time management; productivity is affected.

Frustration on both sides impairs relationship building with clients and their community, decreases credibility of programs/staff.decreases credibility of programs/staff.

Incurring “hidden” costs due to unnecessary testing and diagnostics, over-prescribing, and repeat visits, etc.


Who Can You Use As An Interpreter?

Individuals who have had theirlanguage skills assessed, who arelanguage skills assessed, who aretrained and successfully evaluated inthe skills, modes, and ethics ofinterpreting.


Language Assistance OptionsTrained bi-lingual staff (other primary tasks with interpreter duties as adjunct).

On-staff interpreters (employees of the organization with specific interpreter duties only).

Contract interpreters (contractors paid by the encounter, not employees, on an on-call basis).

Telephone interpreters (contracted agency specializing in the provision of interpreter services via phone).


Least Preferred Options For Providing Language Services

Family or friends

Minor ChildrenMinor Children

Volunteers

Patients/clients waiting in the office


The Journey

To learn every aspect of each culture that could influence a medical encounter would be impractical if not impossible.

Simply relying on knowledge about particular aspects of specific groups may in fact lead to stereotyping and categorization of a culture.

What should we do?What should we do?

Step One: Self-Assessment

Cultural knowledgeBiasesBiasesStereotypingHealth care beliefs

Self-Assessment

“Who we are determines how we see others.”

“It is not what is around us but rather what is within us that determines what we see”

John Maxwell – The Lens Principle

Step Two: System Assessment

Collect, analyze, and report on the diversity in your patient population.

Use a standardized tool to annually assess the understanding and effectiveness of the care delivery system.

System Assessment

“Evidence suggests that a lack of diversity in the leadership and workforce of health care organizations results in structural policies and results in structural policies and procedures, and delivery systems inappropriately designed or poorly suited to serve diverse patient populations.”

Health Forum Journal 1999; 42:22.

System Assessment

Individuals will encounter the “front desk staff” prior to seeing a health care provider.

The encounter of a patient with the “front desk staff” can have a greater affect on the patient and their family than the encounter they experience by the health care provider.

System Assessment

It is vital to have all staff who encounter clients to participate in the organizations cultural competency training.competency training.

“Cultural Competence: It All Starts at the Front Desk,” National Center for Cultural Competence.

Step Three: Cultural Desire

Having a commitment and passion for caring.

Motivation of the health care provider Motivation of the health care provider to “want” to engage in the process of cultural competence.

Dr. Campinha-Bacote The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care.

Journal of Transcultural Nursing. 2002; 13:181-184.

Step Four: Cultural Attitude

Remain open to learning.Respect differences. Get involved with your community.Get involved with your community.Attend periodic, cultural training programs.Remain flexible and be willing to adapt.

Cultural AttitudeAttitudes important in effectively engaging in cross-cultural care are:

HumilityEmpathyCuriosityCuriosityRespectSensitivityCompassion AuthenticityOpennessAvailability.

Academic Medicine (2003) 78: 560-569.

Step Five: Communication Skills

Communication is the foundation of all relationships.

Research has shown that how patients perceive their connection patients perceive their connection with their health care provider significantly influences their sense of satisfaction and level of concern about their health.

Communication Behaviors and Being in Relation. Family Medicine. 2002; 34:319-324.

Terms

Health Communication = The study and use of communication strategies to inform and influence individual and community decisions that enhance health.

Communication Skills

Social and cultural factors determine differences in expectations, agendas, concerns, meanings, and values between patients and provider.patients and provider.

Surveys show that minority patients feel they are judged unfairly based upon race and how well they speak English.

Racial & Ethnic Differences in patient perceptions of bias and cultural competence in health care. Journal Gen Intern

Med. 2004; 19-101-110.

Communication SkillsProviders need to assess what is the patient’s perspective on their disease or illness.

Does the patient believe they have a problem?Do they perceive a need to make a change?Do they understand and “buy into” the treatment plan?


Folk Illness : Culturally-constructed disease or illness commonly recognized by an ethnic group, oftenin conflict with biomedical paradigms.

Sometimes the treatments for folk illnesses may cause harm.

Annals of Internal Medicine 1999; Volume 130;10:829-834.

Empacho = A condition in which it isbelieved that a substance gets stuck to thewalls of the stomach.

Symptoms include: diarrhea, vomiting, stomach cramps, and bloating. Patients will frequently consult a folk healer who performs special massage, prayers, and dietary modification.who performs special massage, prayers, and dietary modification.Multiple cases of lead toxicity have been documented among children whose empacho was treated with a folk remedy called greta, azarcon, or albayaldecontaining high levels of lead oxide.

Arch Pediatric Adolescent Medicine 1995; 149:978-981


Providers must learn to communicate in an open, sensitive, and non-judgmental manner.judgmental manner.

How we say something is equally, if not more important, than what we are saying.


Involves using a variety of tools and techniques to convey the message.

Recognize that culture, environment, Recognize that culture, environment, poverty, and education all influence how a message is perceived.

Involves both verbal and non-verbal communication methods.

Non-Verbal Communication

Facial ExpressionsGesturesPersonal DistancePersonal DistanceSense of TimeSeating Arrangements

Non-Verbal CommunicationFacial Expressions

Some elements of non-verbal communication may be consistent across cultures such as the emotions across cultures such as the emotions of fear, anger, sadness, and surprise.In some cultures, a nod or smile simply means that they heard you – it may not signify an understanding or agreement.

Non-Verbal Communication

Eye Contact

In Western culture, direct eye contact is viewed as a positive communication is viewed as a positive communication skill.

Eye contact in certain Asian and Hispanic cultures is not appropriate.

Gestures

Personal Space

How close is too close?

Touch – When is it appropriate?

Sense of Time

Is time considered precise or relevant?

Be mindful of clinic hours in relation to Be mindful of clinic hours in relation to cultural beliefs and occupations.

Seating ArrangementsThe position the provider takes when speaking with a patient caninfluence the effectiveness of the communication.communication.

Do you face the patient?Are you standing over or sitting higher than the patient?In a group setting – sitting in a circle is more conducive to sharing than sitting classroom style.

Communication StylesCultures may vary in standards for:

GenderLoudness of speechLoudness of speechSpeed of delivery SilenceAttentivenessTiming of when to enter a conversationDecision making

Invite, Listen, and Summarize

An innovative method for teachingcommunication skills to medicalresidents at the University of ColoradoSchool of Medicine.School of Medicine.

Emphasizes the techniques of:Asking open-ended questions.Showing empathy.Using engagement to gather data.

Communication SkillsOpen-Ended Questions :

Ask the patient to explain, in their own words, what their illness or problem is.Ask them in what ways their illness or Ask them in what ways their illness or problem is affecting their life.Give careful explanations and rationale for your treatment plans.After giving instructions or a treatment plan, have them explain it back to you.


Empathetic Listening

Active listening with the intention and commitment of truly and commitment of truly understanding the other person before seeking to be understood.


Engagement

Utilize members of the community and local partnerships to serve as and local partnerships to serve as teachers and experts of their particular cultures.

Patient Education

All materials must be culturally and linguistically competent.

Our goal should be to consider the patient Our goal should be to consider the patient a partner in care.

Rather than “telling” the patient the best action to take - empower them to learn about their health and encourage them to take steps to improve.

Patient Education

Two (2) main principles:

SimplicitySimplicityReinforcement

Patient EducationSimplicity

Verbal patient education should be given in a language the patient understands.

Information should be written at appropriate readability levels. (Average adult in the U.S. reads at a 6th-8th grade reading level.)

Avoid medical terminology whenever possible.

Patient EducationReinforcement

Teach the most important concept first and repeat it at the end.Ask clients to re-state what you have Ask clients to re-state what you have taught them.Use a variety of media in the educational process.Always supply written information for the patient to take home.

All communication is cultural – it draws on ways we have learned to speak and give non-verbal messages.

Culture is central to what we see, how we perceive, and how we express ourselves.

Learn from generalizations but do not use

Points to Remember

Learn from generalizations but do not use them to stereotype.

Do not assume all English speaking clients have the same belief system concerning health care.

Do not assume there is a right way to communicate (yours)!

Thank you!

cultural communication...terms race = a tribe, people, or nation belonging to the same stock; a...

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