What Culture Does Your Patient Hurt In?

Cultural Competency in Caring

for Diverse Populations

Fern R. Hauck, MD, MS

Department of Family Medicine

University of Virginia Health System

POM-1, September 10, 2007

                        

                        

                       

                                         

                                        

           

                                   

                

                                         

Goals of This Talk

Define cultural competency (culturally responsive healthcare, cultural humility)

Describe differences in cultural norms between dominant U.S. culture and other cultures

Discuss ways to provide high quality, culturally competent care

Describe what UVA is doing to address patient care and training

Patient KI:

40 year old female, Somali refugee, who has been in Charlottesville 4 years. Developed gestational diabetes with last pregnancy (here) and continues to have diabetes mellitus. Most recent hemoglobin A1C 18. On maximum therapy orally, refuses insulin. Frequently “noncompliant” with oral medications and other treatment advice.

What is your reaction?

• How does this patient make you feel?• What kinds of issues are involved in her

care?• How would you approach her in trying to

reach the best outcome for her health?

What is culture?

• The function of culture is to ensure the survival and

well-being of its members.

• Cultures are dynamic, responsive, coherent

systems of beliefs, values and lifestyles that

have developed within particular geographic

locations; they evolve and are passed on from

generation to generation.

• The resulting lifestyle (cultural) patterns of each group

-such as diet, marriage rules, and means of livelihood-

influence gene expression, health status and disease

prevalence.

Components of Culture

• Environment

• Economy

• Technology

• Religion/world view

• Language

• Social structure

• Beliefs and values

(Hammond P, 1978)

Definition of Cultural Competence

Having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented, by patients and their communities.

Why is this important???• Ever-increasing diversity of the population of the United States• Strong evidence of racial and ethnic disparities in health care

Barriers in access to careLack of proportional representation of minorities in the health

professionsLow levels of cultural competence among health care

professionals

Liaison Committee on Medical Education (LCME): Setting the Standard

“The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases and treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in health care delivery, while considering first the health of the patient.”

(LCME, 2000)

States are Following

New Jersey will be the first state to require that physicians have education and training in cultural competence for medical licensure (to take effect in 2008). Other states are considering similar legislation.

Myths and the Misuse of the Concept of Culture

1. Culture is not race• 6 racial/ethnic categories by OMB intended

to monitor political allocation of resources,

not as scientific evidence of genetic differences• Greater genetic within-group variation than between• Each category contains multiple national groups &

multiple ethnic groups within each national group,

each with its own culture or subculture

Myths and the Misuse of the Concept of Culture

2. Cultures are not homogeneous • Various levels of acculturation, assimilation,

age, education, family structure, gender, wealth,

refugee or immigrant status all modify the degree

to which one’s cultural group membership may

influence health practices and health status• Each cultural group is continually undergoing

change

Myths and the Misuse of the Concept of Culture

3. The Western biomedical model and European-American

lifestyle are not the only ways to ensure health• Research indicates that prevalence of some illnesses

much lower in immigrants’ countries of origin than after settling in the U.S. (e.g., diabetes, breast cancer)

Comparisons of Cultural Norms and Values

Aspects of Culture Mainstream American Culture

Other Cultures

Communication and language

Explicit, direct communication. Emphasis on content --meaning found in words.

Implicit, indirect communication. Emphasis on context – meaning found around words.

Time and time consciousness

Linear and exact time consciousness. Value on promptness – time=money.

Elastic and relative time consciousness. Time spent on enjoyment of relationships.

Comparisons of Cultural Norms and Values( continued)

Aspects of Culture Mainstream American Culture

Other Cultures

Relationships, family, friends

Focus on nuclear family. Responsibility for self. Value on youth, age seen as handicap.

Focus on extended family. Loyalty and responsibility to family. Age given status and respect.

Values and norms Individual orientation. Independence. Preference for direct confrontation of conflict.

Group orientation. Conformity. Preference for harmony.

Beliefs and attitudes Egalitarian. Challenging of authority. Individuals control their destiny. Gender equity.

Hierarchical. Respect for authority and social order. Individuals accept their destiny. Different roles for men and women.

Gardenswartz L, Rowe A. Managing Diversity: A Complete Desk Reference and Planning Guide, 1993.

Communicating in a Cross-Cultural Encounter

• The physician could work exclusively

within the biomedical paradigm• The patient and physician could function

exclusively within each of their native cultures• The physician could work within the

patient’s cultural framework• The physician and patient could negotiate between

their concepts of the etiology of disease & the

most appropriate means of treatment to reach

mutually desirable goals

(Kagawa-Singer M, 2003)

“Ethnic Mnemonic”

E: ExplanationT: TreatmentH: HealersN: NegotiationI: InterventionC: Collaboration and Communication

Developed by: Steven J. Levin, MD; Robert C. Like, MD; Jan E. Gottlieb, MD. Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School.

“Ethnic Mnemonic” – “E”

E: ExplanationWhat do you think may be the reason you have

these symptoms?What do friends, family, others say about these

symptoms?Do you know anyone else who has had or who

has this kind of problem?Have you heard about/read/seen it on

TV/radio/newspaper? (If patient cannot offer explanation, ask what most concerns them about their problem).

“Ethnic Mnemonic” – “T”T: Treatment

What kinds of medicines, home remedies or other treatments have you tried for this illness?

Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it.

What kind of treatment are you seeking from me?

                                          

         

“Ethnic Mnemonic” – “H”

H: HealersHave you sought any advice from

alternative/folk healers, friends or other people (non-doctors) for help with your problems? Tell me about it.

“Ethnic Mnemonic” – “N”

N: NegotiationNegotiate options that will be mutually

acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs.

Ask what are the most important results your patient hopes to achieve from this intervention.

“Ethnic Mnemonic” – “I”

I: InterventionDetermine an intervention with your patient.

May include incorporation of alternative treatments, spirituality, and healers as well as other cultural practices (e.g. foods eaten or avoided in general, and when sick).

“Ethnic Mnemonic” – “C”

C: Collaboration and CommunicationCollaborate with the patient, family members,

other health care team members, healers and community resources.

Effectively use interpreters in encounters with patients with limited English proficiency.

Additional Tips

1. Don’t treat the patient in the same manner as you would want to be treated.

2. Begin by being more formal with patients who were born in another culture.

3. Don’t be “put off” if a patient fails to look you in the eye.

4. Don’t dismiss beliefs that are not held by our Western biomedical tradition.

5. Be cautious in relating bad news or in outlining detailed differential diagnoses.

(Salimbene S, 2005)

Culturally Competent Healthcare Systems

• Interpreters or bilingual providers• Cultural diversity training for staff• Linguistically and culturally appropriate

health education and information materials

• Tailored healthcare settings, such as refugee or immigrant health clinics

(Task Force on Community Preventive Services, 2002)

International Family Medicine Clinic

• Started in October 2002• Collaboration between IRC, Health Department, and Family Medicine• New refugee patients scheduled after Health Department screening• Provide treatment of tropical, acute, chronic illnesses to refugee families• Refer to specialists as needed, coordinate care• 1000 patients from 50+ countries,

speaking 30+ languages:• Afghanistan• Somalia• Liberia• Sudan• Burma• Uzbekistan

Community Outreach & Collaboration

ESL program/health literacy presentations and role plays

Health fairs

UVA Services

• Interpreters: In-house or via contracted providers; CyraCom phone

• Cultural diversity training for staff: culture

fairs, CultureGrams• Linguistically and culturally appropriate

health education and information materials (Spanish mostly)

Course Offerings

• International, Tropical and Cross-Cultural Medicine (Elective) 1415 (Family Medicine and Internal Medicine) 4 week elective Drs. Houpt and Hauck, course directors

Patient KI:

40 year old female, Somali refugee, who has been in Charlottesville 4 years. Developed gestational diabetes with last pregnancy (here) and continues to have diabetes mellitus. Last hemoglobin A1C 18. On maximum therapy orally, refuses insulin. Frequently “noncompliant” with oral medications and other treatment advice.

What is your reaction?

• How does this patient make you feel?• What kinds of issues are involved in her

care? • What else would you like to know about

KI?• How would you approach her in trying to

reach the best outcome for her health?

                                      

     

           

                                         

                                        

Questions or Comments?