Transcript Cultural Competence in Healthcare

Cultural Competency in Caring
for Diverse Populations
Fern R. Hauck, MD, MS
Department of Family Medicine
University of Virginia Health System
September 11, 2006
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 International Family
Medicine Clinic
“I don’t think one can ever really know any but
one’s own countrymen. For men and women are
not only themselves; they are also the region in
which they were born, the city apartment or farm
in which they learned to walk, the games they
played as children, the old wives’ tales they
overheard, the food they ate, the schools they
attended, the sports they followed, the poets they
read, the god they believed in. It is all of these
things that have made them what they are and
these are the things that you cannot come to know
by hearsay; you can only know them if you have
lived them.”
Somerset Maughan,
The Razor’s Edge (Introduction)
1944.
Commonwealth Fund 2001 Healthcare
Quality Survey
• 7,000 adults surveyed
• Communication problems reported more
commonly for African Americans (Af A),
Hispanics (H) and Asian Americans (As A)
• H and Af A adults highest uninsured rates
• H and As A patients had greatest difficulty
understanding information from doctor
• Less than one half of limited English proficient
patients always or usually had interpreters
• Af A, H, and As A more often felt that they had
been treated disrespectfully or with little
understanding of their culture
Commonwealth Fund 2001 Healthcare
Quality Survey (continued) (www.cmwf.org)
• Three main factors in ensuring that minority
populations receive optimal medical care:
 Effective patient-physician communication
 Overcoming linguistic and cultural barriers
 Access to affordable health insurance
• Policy implications
 Financing interpreters (few states only)
 Training of clinicians and medical students in
communicating and interacting effectively with patients
from different cultures
 Expanding health coverage and access to all
Definition of Cultural Competence
“The knowledge and interpersonal skills that
allow providers to understand, appreciate,
and work with individuals from cultures
other than their own. It involves an
awareness and acceptance of cultural
differences; self-awareness; knowledge of
the patient’s culture; and adaptation of
skills.”
AMA, Culturally Competent Health Care for Adolescents, 1994.
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.
“Ethnic Mnemonic”
E: Explanation
T: Treatment
H: Healers
N: Negotiation
I: Intervention
C: 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: Explanation
What 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: Healers
Have 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: Negotiation
Negotiate 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: Intervention
Determine 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 Communication
Collaborate 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.
Some Features of Mexican Culture
• In 2001, Mexicans became largest minority
•
•
•
•
•
population in the U.S.
Value of family over individual or
community needs
Father or oldest male holds greatest power
in most families
Respect and formality common in
interactions.
Uncommon for Mexicans to be assertive in
healthcare interactions
Direct eye contact less common than among
Anglos
Some Features of Mexican Culture
(continued)
• A brusque, confrontational or loud provider may not learn
•
•
•
•
•
of the problems from the patient and patient unlikely to
return
Physical or mental illness may be attributed to imbalance
between the person and environment
This may include an imbalance of “hot” and “cold”
Curative care favored over preventive care
Spirituality/religion important in family and community
life
Biomedical and folk health systems may be used
simultaneously by people of all social backgrounds
Some Features of Mexican Culture
(continued)
• Culture-bound syndromes are common:
Mal de ojo (Evil eye) – affects women and
children
Susto: fright causes loss of soul, symptoms
vague complaints – affects women more
commonly
Ataque de nervios: sudden outbursts of
negative emotion, in response to stressor
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
Task Force on Community Preventive Services, 2002.
International Family Medicine Clinic
Goals
• Provide comprehensive, high quality, culturally
competent care to the growing population of
limited English proficiency (LEP) patients
• Develop systems to more efficiently care for
patients, including better communication with
community partners and standardized screening
and evaluation
• Become a resource for the medical center and
others who serve LEP patients
• Document, evaluate and advocate
Current Clinic Structure
• Started October 2002
• 5-6 half-day sessions
• 5 clinicians
• Interpreters
• New refugee patients
scheduled after Health Department Screening
• Special forms, cultural profiles, and database
• Mental health: referral to Family Stress Clinic
• International Health Intern
Community Partners & Patients Served
Refugees
Immigrants
Limited Visas
Partners
International Rescue
Committee (IRC)
Health Department
English as a Second
Language (ESL)
ESL
Blue Ridge Medical
Center/Rural Health
Outreach Project/ Lay
Health Promoter
Program
ESL
UVa International
Studies Office
Countries
Middle East
Afghanistan
Eastern Europe
(Bosnia-Herzegovina,
Croatia)
Africa (Togo, Liberia,
Sudan, Congo)
Somali Bantu
Meshketian Turks
Hill Tribes (Burma)
Mexico
Central and South
America
Other
China
Korea
Central & South
America
Other
Community Outreach & Collaboration


ESL program/health literacy presentations and
role plays
Health fairs
Course Offerings
• International, Tropical and Cross-Cultural
Medicine
 1415 (Family Medicine and Internal Medicine)
 4 week elective
 Drs. Houpt and Hauck, course directors
Video Scenarios