Translating Cultural Competence into Patient

Adherence

Dr. Barbara Jones Warren, PhD, CNS-BC, PMH, FAAN

Disclosures

I have no conflicts of interest to disclose.

Objectives

• Identify the relevance of diversity and inclusion to patient adherence.

• Discuss the significance of incorporating culturally competent strategies into patient care in order to promote patient adherence.

• Describe specific assessment techniques that sustain the process of cultural competence.

Assessment Time

• What are you expecting from this session? • What are your aims for learning about culture, inclusion

and diversity as related to patient adherence and quality mental healthcare outcomes?

• What are you needing from me today?

Culture and Adherence

• Culture is fluid and dynamic. • Evidence-based recovery strategies need to

drive culturally competent education, practice and research approaches.

• Mental health providers’ use & understanding of culture and inclusion is critical for patient adherence & the promotion of positive outcomes.

Diversity and Inclusion… Just Culture…

Cultural Sensitivity… Cultural Humility…

Cultural Appropriateness… Cultural Competence…

Terminologies Related to Culture:

Diversity of Terms…

• Why do these exist? Why do we keep changing language?

• Do these terms take the place of previously used terms? If so, why? If not, why not?

• Are they more acceptable to persons. Again, if so, why?

• What do you think?

Ethno-Medical Web Sources

• Family history assessment tool through the Surgeon

General’s Ofc: www.cdc.gov

• Culture Clues • http://depts.washington.edu/pfes/CultureClues.htm

• Ethnomed http://ethnomed.org/ethnomed/index.html

Culturally Competent Mental Health Assessment, Interventions,

Evaluation Approaches

Cultural Variables for Everyone

Decade of birth Generation in U.S.

Class SES

Language Education

Origins Beliefs, Biases, Behaviors

• Assess understanding by using: – Teach back methods, verbally and demonstrations, pictures,

videos, diagrams, computer games – Use non-medical jargon as needed

• Tailor treatment and med schedules for clients'’ needs, involve pt. & sig. others – Color code meds, connect to daily events

• Slow down, listen to the use of the patient’s language, descriptions

• Be respectful, acknowledge cultural needs, practices. • Limit amounts of information @ visits.

Culturally Competent Skills

• “Set of congruent behaviors, attitudes, & policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations” (U.S. Office of Minority Health, 2012).

• New CLAS Standards are out. • www.ThinkCulturalHealth.hhs.gov

Culturally & Linguistically Competent Skills

Culture, Race & Ethnicity: How are they interrelated?

Race

– Previously thought of as genetic determinants within an individual’s biological make-up.

– However, the Surgeon General reports changed that:

• “Different cultures classify people into racial groups according to a set of characteristics that are socially significant. In fact, there is research that indicates there are greater genetic variations within a racial group than across racial groups.”

USDHHS, 2001, 1999

Ethnicity: Cultural Practices

Ongoing and continuing process of learning, appreciating, and acknowledging the importance of a person, group, population and/or community’s culture and then immersing this process into organizations & systems of care as well as individual areas of education, practice, & research.

Competence: ability, aptitude, skill.

Cultural Competence: An Ongoing Process

Recovery Processes=CC – Implies the person, group, community or population is

knowledgeable about their healthcare status, needs, and options available for them to utilize/seek appropriate care.

• A collaborative interaction and shared decision-making process with the healthcare providers who are working with them

– Implies that PMHNs are in a collaborative interaction with the individual, group, or community they are working with

• Are knowledgeable regarding the intersections of culture, recovery and cultural competence within & across education, care and research settings.

Culturally Competent Actions • See the individual client, know your perspectives. • Include value, guidance, challenge, support,

structure commitment • Use of caring, respect for diversity, responsibility,

integrity, professionalism • Promote positive cultural outcomes

– Growth, competence, confidence, empowerment • Encourage support of family, friends, significant

others in order to motivate and facilitate positive coping behaviors within clients Kossman, 2009; Pharris, 2009; Warren, 2011,2009

Incompetent Actions

• Use of stereotyping & marginalization toward clients

• Do not value the cultural perspectives & needs of clients

• Being indifferent to patient requests, beliefs, restricting or rejecting dialogues

• Being rigid, cultural bias Kossman, 2009; Warren, 2011, 2009

Outcomes of Cultural Incompetence

• Client frustration and lack of adherence • Provider frustration due to lack of patient

“compliance” • Lack of evidence-based delivery of care

poor outcomes

The Enculturation of the Process of Cultural Competence Genetics and Epigenetics

Ethno(psycho)pharmacology

Racial & ethnic genomic influences on the metabolism of medications

“Polymorphisms”

Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons. Munoz, Primm, Ananth, & Ruiz. (2007). Life in color: Culture in American Psychiatry. IL: Hilton Publishing. Warren, in press, 2011, 2010, 2009

Genetics

• Genome Project 1980s Now an NINH Institute: Dr. Francis Collins

• National Human Genome Center @ Howard University: Dr. Georgia Dunston

U.S. Human Genome Project Gene sequencing will lead to improvements in

Neuropsychopharmacology

Restructure of diagnostic, treatment approaches

Migration out of Africa (birthplace) has created genetic similarities within geographic regions. 99.9% similarity, however that 0.1% difference is critical to

understanding what is needed for patients. (1/1000th entire genome)

Geographic regions determine the f’s of alleles or differences Collins, F., et al. (2006). Race, genetics, and healthcare: What we know and

what it means for your practice. National Human Genome Research Institute Dunston, G. (2012). Presentation on genetics and healthcare disparities. The Ohio State University. Cols, OH

Genetics Vs. Genomics

Genetics: The science of inheritance Genetic Code: DNA structure and function

Genomics: The field within genetics

concerned with the structure and function of the entire

DNA sequence of an individual or population

Epigenetics: Environment

• ‘Epi’genetics - ‘On’ or ‘over’ the genetic information encoded in the DNA

Epigenetics and Different Aspects of Life

• Development of multicellular organism • Environment-organism interaction For examples: Nutrition supplements and environmental toxins

Image: Randy Jirtle

• Pathogenesis of diseases

Interplay of Culture

Genomics comprises racial components through genetic loading. Other variables also affect adherence in persons from different cultural groups.

• Ethnicity: cultural practices • Stressors: internal & external • Psychosocial variables and level of functioning • Environmental Factors Cultural variables of the clinician and patient

U.S. Human Genome Project

• Races: biological with mathematical criteria of biological divergence below the species.

• Variation is consistent around the world overlapping. – Nested pattern of variation – Hence, Africa has the most variation – In other Ns variations are a subset: 90% of

variations are found in these Ns Collins, F., et al. (2006). Race, genetics, and healthcare: What we know and what it means for your practice. National Human Genome Research Institute

U.S. Human Genome Project

• Benefit for variants (e.g. malaria) • Spelling errors differences in DNA

sequence • Mutation in a single gene (i.e., G6PD)

sickle cell, prostate Ca, factor 5 thromboembolic,

resistant to activated protein disease • Multiple mutations asthma, hypertension

Collins, F., et al. (2006). Race, genetics, and healthcare: What we know and what it means for your practice. National Human Genome Research Institute

Healthcare Literacy: Connection to Cultural Competence

“What is most important to me must be spoken, made verbal, even at the risk of having it bruised

or misunderstood” (Andre Lorde)

Brown, 2011

Definitions of Healthcare Literacy

• “The ability to read, understand and act on healthcare information.”

• Healthy People 2012: – “The degree to which individuals have the capacity to

obtain, process and understand basic health information & services needed to make appropriate health decisions”(Objective, 11-2).

• AMA Council of Scientific Affairs: – “The ability to read and comprehend Rx bottles,

appointment slips & other essential health-related materials required to successfully function as a patient.”

http://www.agingsociety.org/agingsociety/

publications/fact/fact_low.html http://www.askme3.org

Web Sources: Health Literacy

Statistics on Health Literacy

• 44 M aged >16 years (23% of all adults): functionally illiterate.

• 53.5 M or 28% more are only marginally @ reading and math skills

• $32 – $58B in costs. • Increased provider visits and prescriptions.

National Adult Literacy Survey, 2001

Who Pays for the Cost?

Clients 14% Employers 14% Medicare 19% Medicaid 47%

Who Are Those Who May Be At Risk?

• Elderly persons. • Diverse persons. • Immigrant populations. • __________________________________

• Lower socioeconomic class. • Environmentally unhealthy neighborhoods • Chronic mental &/or physical disorders.

Perhaps Some Vulnerable Populations

• Lower education level. • Learning disabilities. • Cognitive losses. • Continued use of reading skills.

Vulnerable Populations

• Improve quality healthcare outcomes. • Reduce healthcare costs. • Improves patient involvement • Directly related, in fact dependent on the

provision of culturally competent care

Positive Outcomes of Health Literacy

• Failure to understand written information leads to inappropriate implementation of healthcare. – Higher healthcare costs

• Longer stays & more procedures, tests, prescriptions

– Publicly financed healthcare systems – Client frustration – Poorer quality healthcare for dx and tx – Chronic disease

Negative Outcomes of Illiteracy

Processes Within Health Literacy

Visually Literate

Computer Literate

Information Literate

Numerically Literate

• Discuss, describe symptoms. • Ask questions. • Understand healthcare advice. • Use shared decision-making skills. • Able to use & evaluate internet if available.

Language Help Skills for Clients

• Suitability Assessment of Materials, Medicaid Checklist – Readable, understandable – Evaluate stimulation of learning, motivation, cultural

competence

• Levels of competence – Easy (5th, 6th) – Average (8th ) – Difficult >8th

Assessment, Reading Skills

Doak, et al., 1996; McGee, 1999

• Flesch-Kincaid Grade Level and Flesch Ease Score – # of syllables per word, words per sentence – Interfaces with Word

• SMOG (simple measure of gobbledygook) – Average sentence length, # of words with 3 or more

syllables

Assessment, Reliability Skills

Doak, et al., 1996; McGee, 1999

• REALM (rapid estimate of adult literacy in medicine), 1-2 min. – Recognition, pronounce terms

• TOFHLA (test of functional health literacy in adults), 20-25 min.

Assessment, Validation Tools

Doak, et al., 1996; McGee, 1999

Culture-Bound Syndromes

A WAY TO DEFINE AND MAKE SENSE OF BEING UNWELL Diagnostic & Statistical Manual of Mental Disorders-IV-TR, 2000

Recovery Processes: A Biopsychosocial Approach

Strategies

• Think of cultural competence as a journey, narrative – Use of literature, case exemplars, voices of all – Fluid and dynamic process, contextual (includes cultural

perspectives, genetics, genomics, epigenetics) • There is literature and research that backs the use of

these techniques and the importance of teaching the process of cultural competence. It is not just a warm and fuzzy learning approach. It takes knowledge, skill, experience, expertise, commitment. Kossman, 2009; Nairn, 2009; Warren, 2011, 2009

• Anatomy of person • Physiology of person • Environment (s) for person • Cultural beliefs & practices of person,

community

Culture, Recovery, Genomics, Biopsychosocial Perspectives

Complimentary & Alternative Therapies (CAM)

• Began in 1991 NIH Office of Alternative Medicine (OAM).

Cultural Rationale for Disease

• Loss of the soul (whole, part) • Spirit possession • Intrusion of supernatural force • Intrusion of an illness-causing spirit • Taboo violations (ancestors) • Spirit attacks • Homeopathic &/or contagious magic • Disturbances or violations of social rules &

relationships

What are CAM Therapies?

• Use and practice of therapies or diagnostic therapies not are not always considered part of Western medicine care.

• Emphasis is on prevention and treatment through mind-body-spirit.

• Alternative: instead of traditional therapies. • Complementary: in addition to existing treatments

(e.g., biofeedback, relaxation, yoga, tai chi, etc.,) • Higher in other countries than in the U.S. (40% -

50%) – U. S. persons aged 25-49 years

CC Recovery Healing Model

• Persons are healed within the context of meaning for them not on the diagnosis.

• Persons are autonomous not peripheral. • Based on the first 2, healing is always possible. Self-

healing is possible. • Persons are components of energy, balance, &

interactive processes. • Treatments can be variable. • Shared decision-making is an essential component. • Caring & therapeutic communication are critical to the

recovery process. Warren, 2008,

Fontaine, 2011

Components of Alternative Therapy

• Balance – Cyclic rhythms – Musical rhythms

• Spirituality • Energy

– Chakras (7 electromagnetic, circulation) – Auras (energy around us)

Components of Alternative Therapy

Energy (continued) – Meridians (networks of energy circuits) – Energy concentration – Grounding & centering

• Breath

Regulated by Law: Scope of Practices Defined

• Acupuncture – 356 vital points: follow yin to draw out yang – Right hand for left side of the body – Left hand for right side of the body

• Homeopathy – Substances of animal, vegetable, mineral orgins pharmacology

• Massage – Maintain good health, muscle tone reducing stress

• Naturopathy – Acupuncture, biofeedback, non-prescriptive

medications

One Exemplar

• Balance between yin and yang – Breakdown leads to illness – Excessive yin: depression – Excessive yang: mania

• Observation, listening, questioning, recording

• Six Pulses within Chinese medicine: – Left radial pulses: heart, liver, kidney – Right radial pulses: lung, spleen, kidney – 28 qualities to examine

Health Traditions

Maintaining •Protecting HEALTH •Restoring

•Physical, mental, spiritual

Health Tradition

Maintenance: active qd ways

Protection: Objects, substances ingested or worn, hung

Choices: philosophies

Restoration: remedies

Ethnopharmacology: Side Effect Profiles

Influenced by genetic patterns (CYP2D6) Polymorphisms

Influenced by dietary practices

Corn intake

Influenced by use of herbal preparations

Use of St. John’s Wort

Influenced by healthcare beliefs and practices Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.

Health Care Choices/ Philosophies

Allopathic: body & mind: US

Homeopathic: holistic approach.

Homeopathic Care complementary/alternative & culture bound

Aromatherapy

Biofeedback

Hypnotherapy

Macrobiotic Massage therapy

Reflexology

Evaluation/Evidence of CAM Therapies

• Experimental: Is the practice efficacious when examined experimentally?

• Clinical practice: Is the practice efficacious when used clinically?

• Safety: Is the practice safe? • Comparative: Is this the best practice for the

healthcare issue? • Summary: Is this practice known and evaluated? • Rational: Is this practice rational, progressing,

contributing to medical practice?

Evaluation/Evidence of CAM Therapies

• Demand: Do consumers and practitioners want the practice?

• Satisfaction: Is the practice meeting the expectations of consumers and practitioners?

• Cost: Is the practice inexpensive and cost-effective?

• Meaning: Is the practice the right one for the consumer?

Some Areas of Current Study

• Asthma and allergies • Cardiovascular diseases • Diabetes • Cancer • Neurologic diseases • Psychiatric diseases • Pain • Across the lifespan examinations

Culture-Bound Healthcare

Ayurvedic: India, diet Curanderismo: Hispanic holistic practices Herbals: natural environmental substances Powwow: German, PA Dutch Santeria: African and Catholic beliefs (Puerto Rican, Dominican) Voodoo: Christian & African Yoruba religious beliefs

Magico-Religious Healing Traditions

Birth, marriage, death Religion & Healing

Person-Spirit Relationships

Mind, Body, Spirit

Recovery/Cultural Competence

• Preservation: keep

• Negotiation: listen

• Repatterning: keep,

negotiate, good health care practices

Leininger & McFarland, 2008

Resources

• National Center for complementary and Alternative Medicine (NCCAM) Clearinghouse

• http://nccam.nih.gov

CAM Therapies

• Often more acceptable to patients than Western

• Medicine alone.

Knowledge: Drugs Today

• Biological basis for these differences or variations – Genomics and polymorphism in drug metabolism – Multiple disease states – Drug-drug interactions

• Environmental – Diet, smoking, pregnancy, stress, diurnal rhythms, etc…

• Cultural – Attitudes, beliefs, family influences, genomics, therapy

expectations

Culture & Healthcare Inequities

• Inequities versus disparities.

• Healthcare literacy. • Genetics and social

determinants. • Cultural perspectives. • World views.

World Views represents what a person values & how they function

Analytic (systematic): OUTCOME ORIENTED Relational (interactions with others):

RELATIONSHIP-BASED Community (needs of the group):

GROUP-MOTIVATED

Ecology (connection with the earth): ECOLOGY-BASED

Warren, B. J. (2002). The interlocking paradigm of cultural competence: A best practice approach. Journal of the American Psychiatric Nurses Association, 8 (6), 209-213.

Warren, 2011, 2010, 2009, 2008, 2007

Interlocking Paradigm of Cultural Competence

THERAPEUTIC FACTOR

VALUE FACTOR

Patient & Provider

ORIENTATION FACTOR

Patient, provider, systems

PROCESS FACTOR

Person/patient, systems

WORLD-VIEW FACTOR

Patient & Provider

Copyright B. J. Warren, 2001

Communities

World

Other Persons’ World Views

Cultural Interviewing Suggestions

Assess client’s cultural perspectives regarding: •What they need from you, not just what you think

they need

•Meaning of wellness & distress.

•How s/he describe the symptoms of current distress. •Feelings about seeking healthcare, issues of stigma. •How others who are important to the client feel about s/he seeking help for illness/ distress.

•Cultural practices for treating illness/ distress.

Gaw, 2001; Munoz & Luckmann, 2005

Cultural Assessment of Client Adherence

•Symptoms of their disorder •Treatment action and side effect profiles •Influence of herbal preparations with prescribed treatment •Daily schedule (e.g., dietary practices, work, sleep, etc.) •Role & use of support systems (e.g., healthcare professionals, family, significant others) •Through individual &/or group sessions

(Warren, 2011, 2009, 2008)

Kleinman’s Assessment Questions

What do you think has caused your problem? Why do you think it started when it did? What do you think your sickness does to you? How

does it work? How severe is your sickness? What kind of treatment do you think you should

receive? What results do you hope for from the treatment?

Kleinman’s Assessment Questions (con’t)

What are the chief problems your sickness has caused?

What do you fear most about your sickness?

Kleinman, 1986

Adaptation & Systems

“Each (person) is a dynamic and self-reflective system in continuous interaction with the environment.”

Y. Y. Kim, (2001), Becoming Intercultural

4 Domains Model: Causes of Illness

Natural Social Supernatural Personal

(Culhane-Pera, 2003)

Use of the 4 Domain Model

• Get cultural information for each domain of your target population. – Based upon your knowledge and the cultural group, you

might incorporate an example like this one: What do you think has caused your problem? – Is your body is out of balance? – Are there problems with your family? – Have you been struggling with bad spirits? – Did you eat unclean foods before you got sick? – Is there anything else that might have happened?”

Evidence-Based CC Assessment and Components of the Psychiatric History and Mental Status Exam

Screening = Briefly estimate severity of problem

Determine need for further assessment

Assessment = Identify strengths and needs

Measure baseline and changes over time

Accurately identify adults in need of treatment

Screening vs Assessment

Mental Status Exam (MSE)

• It describes the mental state and behaviors of a client education, social, culture.

• Includes objective observations by the clinician and subjective descriptions provided by the patient.

• Snapshot in time assessment, diagnosis, treatment.

• Can use to compare client’s status over time.

Components of the MSE

• Appearance • Behavior • Speech • Mood • Affect • Thought process • Thought content • Cognition • Insight/Judgment

Appearance: See & Is?

• Build, posture, dress, grooming, prominent physical abnormalities

• Level of alertness: Sleepy, alert • Emotional facial expression • Attitude toward the clinician: Cooperative,

uncooperative

Behavior: Differences are Acceptable

• Eye contact: this can be different for persons from different cultural groups.

• Psychomotor activity: slow , agitated • Movements: any tremor, abnormal

movements, gait/walking

Speech: Cultural Issues

• Rate: increased/pressured, decreased/slow

• Rhythm: monotone, slurred • Volume: loud, soft, mute • Content: fluent, talkative, quiet, reserved

Mood: May Be Culturally Framed

• Examples: “wonderful, sad, depressed, anxious, stressed, mad, angry, irritable, good, ok”

Affect: Cultural Nuances • What you see, observe:

–Type: (normal mood), (depressed, irritable, angry), (elevated, elated) anxious

–Range: full vs. restricted, blunted or flat, labile

–Stability: stable vs. labile

Thought Process

• Rate of thoughts, flow and connection • Logical, coherent, goal directed • Associations unclear, disorganized,

incoherent. Examples: tangential, loose, flight of ideas, word salad, rhyming, thought blocking.

Thought Process

• Circumstantial: provide unnecessary detail but eventually get to the point

• Tangential: Move from thought to thought that relate in some way but never get to the point

• Loose: Illogical shifting between unrelated topics

Thought Process

• Flight of ideas: Quickly moving from one idea to another- see with mania

• Thought blocking: thoughts are interrupted • Perseveration: Repetition of words, phrases or

ideas • Word Salad: Randomly spoken words

Thought Content

• Themes for client’s thoughts, perceptions

• Examples: preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions

Thought Content

• Suicidal or homicidal ideation • Illusions: misinterpretations of existing

environment • Ideas of Reference (IOR):

Misinterpretation of incidents and events in the outside world having direct personal reference to the patient

Thought Content

• Hallucinations: sensory alterations of the five senses: auditory, visual, tactile, taste, olfactory

• Derealization: environment feels unreal • Depersonalization: client feels unreal

Thought Content

• Delusions: fixed, false beliefs – Control: outside forces are controlling

actions – Grandiose: inflated sense of self-worth,

power or wealth – Somatic: patient has a physical defect – Reference: unrelated events apply to them – Persecutory: others are trying to cause

harm

Cognition

• Level of consciousness • Attention and concentration • Memory: immediate, short and long

term • Mini-Mental State Exam

Folstein Mini-Mental State Exam

• 30 item screening tool • Useful for documenting serial

cognitive changes an cognitive impairment

• Document not only the total score but what items were missed on the MMSE

Insight/Judgment

• Insight: client is aware of what is causing his or her symptoms, problems

• Judgment: client can anticipate the consequences of his or her actions and make appropriate decisions to take care of self.

Recovery Process Considerations for Adults

Culturally Competent Care with Patients and Significant Others

The most important thing I know about teaching is that the teacher is also learning Don’t think you have to know it all Nikki Giovanni, Don’t Think,

2002, p.109

Connections of Culture and Recovery: Anatomy of person

Physiology of person Environment (s) for person

Cultural beliefs & practices of person, groups, community

Summary

• Remember to keep in mind your cultural beliefs and value systems as well as the client’s when conducting an assessment.

• You are observing, thinking, evaluating and interacting with the client and others important to he or she during the assessment. They also assess you.

• Remember that each client has their own accepted behaviors and thoughts!

One Never Travels the Cultural Journey Alone

Thanks to Dr. Dr. Theresa Mason

Implications, Case Exemplars Points of Clarification, Questions?

Thank you, please continue the journey through dialogues grounded in cultural competence and recovery processes