Bridging the Gap: New Americans Culture & American Health Care Experience

Fozia Abrar, M.D, MPH Department Chair Occupational Medicine Regions Hospital

The Effect of Health Beliefs on the Delivery of Culturally Competent Care

The effect of health Beliefs on the Provider Patient Relationship” • • • • Providers lack the information to understand the influence of health belief on the clinic encounter Cultures define health, etiology of disease & prescribe treatment Patients medical decisions are based on values and beliefs about health Patient-Family health beliefs influence health behavior & outcome

Five Pillars of Islam • Shahadah: Witnessing profession of Faith • Salat: Prescribed Prayers • Zakah: Wealth Cleansing Tax (almsgiving) • Sawm: Fasting the month of Ramadan • Hajj: Pilgrimage to Makkah

Cultural Norms • • • • Family takes precedence over individual Same gender may walk hand in hand Touching is common in conversations Social structure is based on clan system

Families in new Americans Culture • The family is the central foundation upon which immigrant societies are built.

Causes of Illness • Diseases and medical conditions are caused by Allah. • Some disease are believed to be caused by people or by spirits. Fozia Abrar, MD

Causes of Illness • • • • ‘Evil eye’ cast by someone else. Curses: • • By other people/ things By parents (believed to be the worst and hardest to treat) Witchcraft: Said to cause some diseases and medical conditions.

‘Jiniis’: Believed to be cause of serious psychotic diseases.

Fozia Abrar, MD

Purpose/Cure of Illness • • • Because illnesses are believed to be caused by Allah, suffering is believed to bring about forgiveness of sins by God.

All suffering is not in vain but rather a ticket for the hereafter.

Whatever the cause of the disease e.g. spirits, witchcraft or evil eye, it is still believed that these occur and can be treated only through the will of God. This is the case if the treatment is by traditional means or through western medical practice. Fozia Abrar, MD

Health Beliefs of Somalis • Some healing practices: – *Magico-religious: religious healing performed by religious persons mainly through the reading of the Koran. This is used to treat organic, psychic and magic. The religious person reads the Koran over the patient or water which is given to the patient to drink. Fozia Abrar, MD

Health Beliefs of Somalis – *Cauterization: believing that disease fixes on areas of the body, recovery is obtained by burning that sick part of the body. Fozia Abrar, MD “Disease and fire do not stay together in the same place” -

Somali proverb

Health Practices of Somalis • • • • Scarification and blood-letting: this entails cupping by means of a horn placed on a part of the body in order to free the patient from spoiled blood.

Bone Setting Surgery Use of herbal medication Fozia Abrar, MD

What do you consider illness?

• • Somali Participants: Illness was a pain that could be located in the entire body.

Illness was viewed as a departure from a normal or healthy state.

Who do you consider a health provider?

• Most participants prefer to see a physician. Not familiar with the role of other providers in USA.

Barriers to Preventive Screening Services • • • Lack of awareness. Cultural. Language (confidentiality/role of translators) • • Attitude of health care providers.

Dissatisfied with the care

Cultural Barriers Identified by the East African Women • • • “Going to Health care facility is for sick people (Somali Participant)” When I am not sick, I am not going to be disobedient to God. God gave me health, so why should I go to places that you go when you are sick” (Somali) “When not sick, just say praise God and stay home” (Oromo)

Psychosocial and Attitudinal Variables • Attitudes towards screening services (God brings diseases).

• Satisfaction with previous screening (positive experience).

• Attitudes toward health care providers, tests.

• Social support system.

Fozia Abrar, MD

Problems and Issues • • • • • • Accessing care Patients expectations (Meds, Imaging) Concept of time Culture of no Appointments Male/female roles Husband or extended family must agree to medical care or procedures Fozia Abrar, MD

Problems and issues (contd.) • • • • • Somatization Surgery Blood Draws Traditional Medicine Health Care Maintenance

Undesirable outcomes • • • Miscommunication ( role of translators) Inappropriate diagnosis and treatment Patient/provider alienation and frustration • • Poor utilization of services Non-compliance/ refusal of treatment

Principles of Ethics • • • • Autonomy: right to determine ones own life plan; Member of a family or local imam.

Beneficence: Acting for the good of the patient( health care provider is obligated to familiarize the religious and cultural beliefs of the patient) Nonmaleficence: Do no harm and remove harm: information on the procedures Justice: The wish and needs of the Somali patient and family member should be valued.

Strategy to improve physician Patient relationship • • Culturally informed communication is crucial to effective doctor-Patient relationship • • Ask about pertinent beliefs, practices, and values for patients and families • Obtain a medical history, considering culture Perform a physical exam, to fit patients culture

Cultural • • How do different cultures view illness and injury? How does this affect emergency care?

Holidays: Ramadan and fasting.

Chronic disease and compliance.

Diabetes, HTN, CHF, Poly-pharmacy Fozia Abrar, MD

Language • • • • What Language ? What Dialect?

Ability of patient to verbalize symptoms Cultural perspective of symptoms.

“ I feel hot” “ My left side feels hot” “ I feel cold” “ My head is light” Family members as interpreters

Attitude Toward Health Care • • • Health Care = Crisis No Primary Care Model Find doctors in hospital not in community

Examples of cultural miscommunication • • • Q: The pt continually is fidgeting in the chair, moving about, speaks with a pressure speech and is obviously very anxious and tense.

A: Chronic Anxiety State Somali female on Prozac for not remembering Groceries Fozia Abrar, MD

Cultural Competency • In order to deliver accessible, relevant and high-quality health care, providers must gain a better understanding of the patient’s health beliefs and his/her approach to health care. – Where is the patient coming from and will what we are saying and prescribing respond to their real needs?

– More importantly, will it be accepted?

Hallmarks of the Cross Cultural Care and Service Clinician - One of three • • • • • • • History and culture of patient’s country of origin Pertinent psychosocial stressors Family life and intergenerational issues Role of religion in health Differences between culturally acceptable behaviors and psychopathology Cultural beliefs regarding causes and treatments of disease Ethnic differences in disease prevalence, responses to medicines and other treatments Source: Evelyn Lee, Ph.D.

Hallmarks of the Cross Cultural Care & Service Clinician - Two of three • • • • • • • Interview and assess patients in the target language or via appropriate use of bilingual/bicultural translator Communicate in a cross-cultural sensitive manner Avoid under or over diagnosing disease states Understand the patient’s perspective Formulate treatment plans, which are culturally sensitive Effectively utilize community recourses Act as a role model and advocate for bilingual/bicultural staff and patient

Source: Evelyn Lee, Ph.D

Ingredients to Successful Health Care Programs • • Professionally trained interpreters Health care providers with expertise in: – cross cultural health care – mental health problems of new Americans – Health beliefs of the communities being served – removing structural barriers (transportation, access to care etc.) and –

RESPECT, CULTURAL HUMILITY, TRUST, COMPASSION, UNDERSTANDING AND FUN!

Strategy to improve physician Patient relationship • • Culturally informed communication is crucial to effective doctor-Patient relationship • • Ask about pertinent beliefs, practices, and values for patients and families • Obtain a medical history, considering culture Perform a physical exam, to fit patients culture

References • • • Walker PF. Preventative Health Care in a Multicultural Society: Are we Culturally Competent?. Mayo Clin Proc 1996;71:519 521 Abrar F. Barriers to preventative Care: Unpublished Immigrant Health Task Force website: http://www.health.state.mn.us/ihtf/ihtfmain.

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Suggested Reading • • The Middle Of Everywhere Helping Refugees Enter The American Community by Mary Pipher

Rule of Law in Public Health  Provide regulations for the training and certification of interpreters  Cultural Competency training for all providers  Support research in the role of law in the provision of immigrant public health.

Questions and Discussion