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POPULATION SPECIFIC
COMPETENCY
East Tennessee Children’s Hospital
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This module contains:
 Instructions for completion of module
 Definition of Population Specific Competencies
 Review of pediatric age-group specific
interventions
 ETCH population specific information
 Important resources you need to know
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Why?
 Population-specific staff competence is
CRITICAL to providing a safe environment
for our patients.
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What is it?
 Population-specific staff competence relates to
possessing the knowledge, skills, ability and
behaviors essential to providing care to a specific
population.
 At Children’s Hospital the pediatric age groups
served is a primary focus of our staff
competency. However, it does not address the
full spectrum of the population served.
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What is it?
 Beyond a patient’s age, their health care is
also affected by their socio-cultural and
geographical factors. Health care is also
influenced by our living situation, family
dynamics, diagnosis and acuity.
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ETCH Commitment
 As a pediatric healthcare facility, we are
committed to providing age-specific care.
Every element of our approach to healing –
from the specially trained staff to the
sophisticated equipment- is child and
family centered.
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Children are NOT small adults
 Age-specific interventions are the skills you
use to give care that meets each patient’s
unique needs.
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Every patient is an individual with
his or her own...




Likes and dislikes
Feelings
Limitations and abilities
Experiences
Everyone grows and develops in a similar way or stages that
are related to their age, BUT at their own pace.
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• Illness and hospitalization places
stress on our patients and families.
Some patients regress emotionally or
mentally when they are ill/hospitalized
• By following guidelines based on
age/developmental characteristics, we can
help reduce the stress of our patients and
families.
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Strategies to enhance coping &
Developmental Considerations:
 Newborns
– pacifier, blanket, soothing sounds, touch, music,
parental involvement when appropriate, stay in
infant’s line of vision, place parents in infant’s line of
vision, place familiar object with baby (stuffed animal,
etc.), provide safe/secure environment, cuddle, hug
after procedure, adequately hold during procedures.
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Strategies to enhance coping &
Developmental Considerations:
 Toddlers
– pacifier, blanket, favorite toy, holding a hand, party
blowers, blowing bubbles, pop-up books, toys, mobiles,
pre-post procedural play, play dough, emphasize being
still, let them know “It’s okay to cry”, utilize Child Life for
distraction (bubbles, musical toys, etc.), give toddlers one
direction at a time, explain procedure in relation to what
child sees, hears, etc. Use play by demonstrating on a doll
or stuffed animal, provide consistency with daily routines.
Use a firm and direct approach, involve child in procedure
by allowing him/her to play with equipment when
appropriate, allow toddlers a choice when possible.
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Strategies to enhance coping &
Developmental Considerations
 Preschoolers
– Party blowers, blowing bubbles, counting, pop-up
books, holding a hand, manipulative toys, computer
games, listening to music, singing songs, pre-post
procedural play, play dough, explain in simple terms,
demonstrate procedure, allow to play with
equipment/dolls, encourage child to talk; let them ask
questions to clarify, tell them “this is not punishment”“you haven’t done anything wrong”, enjoy
games/rewards/praise.
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Strategies to enhance coping &
Developmental Considerations
 School Age
– deep breathing exercises, music, hand-held games,
computer games, imagery/fantasy, pretending to be
in a favorite place or doing a favorite thing, pre-post
procedural play, squeezing nerf balls, explain using
correct terms, explain reasons – use simple diagrams,
allow to ask questions, prepare in advance, tell what is
expected, suggest breathing, counting, etc., include in
decision (where to get injection etc.), encourage
participation, provide privacy.
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Strategies to enhance coping &
Developmental Considerations
 Adolescents
- deep breathing exercises, music (head sets are
popular), computer games, imagery/fantasy, imagine
a favorite activity, squeezing a nerf ball, hand-held
games, explain and give reasons, encourage
questions, provide privacy, discuss “after effects”scars, etc., involve in decision making and planning,
accept regression and resentment of authority, allow
peer involvement
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Age-Specific Approaches to
Physical Examination
Developmental
Indicators
Positioning
Sequence
Prep
Infant
(0-1)
Stranger anxiety
begins at 7 mo. Peaks
at 9 mo. Resists
being restrained.
Responds to simple
commands by age
9mo. Separation
anxiety peaks at 13
mo.
Supine or prone, before
4 to 6 months, can be
placed on exam table.
After 6 mos. Sits alone,
uses this position
whenever possible in
parent’s lap, if on table
place with parent in full
view.
If quiet, ascultate heart, lungs,
abdomen. Palpate and
perscuss same areas. Proceed
in usual head-toe direction.
Perform traumatic procedure
last (eyes, ears, mouth [while
crying], rectal temperature [if
taken]). Elicit reflexes as body
part examined, elicit
generalized primitive reflexes
last.
Completely undress if room
temperature permits. Leave
diaper in place. Gain
cooperation with distraction,
bright objects, rattles,
talking. Smile at infant; use
soft high pitched voice.
Pacify with pacifier or sugar
water or feeding. Enlist
patent’s aid for restraining to
examine ears, mouth. Avoid
abrupt, jerky movements.
Toddler
Autonomy
important.
Egocentric stranger
anxiety decreases at
18 mo. Speech
begins. Negativism
present. Knows
several external body
parts. Separation
anxiety decreases at
2y.
Sitting on or standing
by parent. Prone or
supine in parent’s lap.
Inspect body areas
through play: “count
fingers”, “tickle toes”.
Minimize physical contact
initially. Introduce
equipment slowly.
Auscultate, percuss,
palpate whenever quiet.
Perform traumatic
procedures last (same as
for infant).
Have parent remove outer
clothing. Remove underwear
as body part examined.
Allow to inspect equipment.,
demonstrate use of
equipment usually effective.
If uncooperative, perform
procedures quickly. Use
restraint when appropriate;
request parent’s assistance.
Talk about exam if
cooperative; use short
phrases. Praise cooperative
behavior
Age
(1-3)
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Age-Specific Approaches to
Physical Examination
Developmental
Indicators
Positioning
Preschool
Child
(3-5)
Likes to “help”. More
cooperative, follows
simple instructions.
Knows most external
body parts, 3-5
internal parts. Fears
bodily harm
School
Aged Chld
(5-12)
Adolescent
(12-18)
Age
Sequence
Prep
Prefer standing or
sitting. Usually
cooperative. Prefer
parent’s closeness.
If cooperative
proceed in head to
toe direction. If
uncooperative,
proceed as
toddler.
Request self-undressing. Allow
to wear underpants if shy. Offer
equipment for inspection, briefly
demonstrate use. Make up story
about procedures. Use paper
doll technique. Give choices
when possible. Expect
cooperation; use positive
statements.
Industrious. Cause and
effect develops.
Increasing self control.
Understands simple
scientific explanations.
Knows 5-10 internal body
parts.
Prefers sitting.
Cooperative in most
positions. Younger age
prefers parent’s
presence. Older age
may prefer privacy.
Proceed in head to
toe direction.
Examine genitalia
last.
Request self-undressing. Allow
to wear underpants. Give gown
to wear. Explain purpose of
equipment and significance of
procedure. Teach about body
functioning and care.
Increasing independence.
Separates readily from
parents. Future oriented.
Knows basic anatomy and
physiology.
Generally prefer
privacy. Offer option
of parent’s presence.
Proceed in head to
toe direction.
Examine genitalia
last.
Allow to undress in private. Give
gown. Expose only area to be
examined. Explain findings
during exam. Matter of factly
comment about sexual
development. Emphasize
normalcy of development
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Additional resources

The following videos are available through the
Education department-541-8618 or
[email protected] for more review on Agespecific Competencies.
1.
Pediatric Physical Assessment – 3 tape series



Infants and Toddlers
Preschool and School Age
The Adolescent
2. Growth and Development – Whaley and Wong
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Appreciating Cultural
Differences
Are you culturally competent?
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This section will help you to:
 Consider the uniqueness of all your
patients and recognize cultural differences.
 Understand what skills are necessary to
respect a patient while giving care.
 Ensure appropriate communication and
confidentiality for all of your patients.
 Identify resources you can use for
developing these skills.
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Imagine yourself
 Waking in a hospital bed, in a strange room with other patients near by…
 Seeing unfamiliar faces and realizing they all speak a different language than
you…
 Having people talk to you and about you with no idea what is being said…
 Seeing looks, smiles, frowns, gestures that you think might be related to you,
but you are uncertain…
 Having people approach and touch you without a means to explain…
 Being injected, or washed, or any other private or invasive procedure without
being able to ask questions or state your preferences or limitations…
 Hearing discharge instructions and teaching in a foreign language while
someone points to a paper for you to sign…
 Hearing medical advice contrary to your deep religious beliefs…
 Not having enough money for medical care or food…
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If the shoe were on the other foot…
 Would you feel respected? Would you
consider that being treated in a dignified
manner?
 Would you trust your caretakers?
 How would you know what was wrong and
how to get better?
 Would you feel as though you had rights?
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Culture… defined:
The values, beliefs, norms
and practices of a
particular group that are
learned and shared and
that guide thinking,
decisions and actions in a
patterned way
Source: Dynamics of Diversity, Pollar & Gonzalez
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Diversity… defined:
 The Diversity Coalition
defines diversity as
encompassing the following
categories: ability &
disability, age, color,
ethnicity, religion, gender, job
category, class status,
national origin, race and
sexual orientation
Source: http://www.diversitycoalition.org/general_diversity_resources
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Important Terms to know to be
“culturally diverse”:
 Environmental
Control refers to
perceptions that a person
has about the ability to
direct factors in the
environment and the
systems and processes
that are part of it. Health
behaviors and disease
patterns differ with
cultural groups.
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How do I become “Culturally Competent?”
It is impossible to memorize all the specific information about every culture.
However, many resources exist at Children’s Hospital to help
you. Know what they are and how to use them:
 Cultural Care Guides and books – they provide information about
various groups and give practical and immediately useful advice
 Interpretive Services – know how to access and use both live and
telephone services (see CBL “Interpretive Services”)
 Language Services – printed materials, visual aids
 The Pediatric Medical Library
 Social Work and Pastoral Care Departments
 HIPAA Guidelines – each institution has specific guidelines that ensure
confidentiality for patients’ health information. All employees,
students, and volunteers are responsible for following these guidelines,
which state that confidentiality can be maintained by only sharing
MINIMUM information necessary.
 Outside Resources – accessed through Social Work
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Some Basic Tips for Overcoming Initial
Cultural or Communication Barriers
 Greet patients with their
names – avoid being too casual
or familiar
 Introduce yourself by pointing
to yourself and saying your
name
 Note and observe any
hesitations or special requests
(ie, no male caregivers for a
female patient)
 Determine understanding by
hearing person repeat or
demonstrate instructions
 Do not talk to other staff in
patient’s area using a language
he/she will not understand
 Do not make assumptions
about eye contact, space,
gender issues or any other
cultural factor based on your
opinions. Seek understanding
and resources!
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Tips for Overcoming Initial Cultural or
Communication Barriers
 Pay special attention to
any efforts made by the
patient or family to
communicate
 Use an available resource
to get a “quick glimpse”
into the patient’s culture
or language
 Use available visual aids
 If language barrier exists
that prevents this
communication, seek
interpretive services –
continual attempts will
only fail and add to
frustration
 Maintain confidentiality
by using “minimum
necessary information”
even with interpreter
 Continue to provide nonjudgmental care!
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Are there other Barriers?
 Religious preferences/differences can be a
barrier.
 Socio economic status as well as
educational level can be a barrier.
 Differences in family structure, function,
and composition are common barriers.
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Know about Family-Centered Care
 This is part of the special care we provide to
children.
 Our interventions are structured around the
entire family unit – with the patient as the center
 We must respect the various styles, abilities,
resources, communication patterns and values
that all families exhibit differently.
 Our goal is to Individualize patient care to best
support the family structure – without prejudice
or judgment on our part.
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R-E-S-P-E-C-T
 Find out what it means to YOU!
 Know yourself – your own attitudes,
beliefs, and even prejudices…
 Keep an open mind…
 Acknowledge and celebrate differences –
all cultures and groups have strengths and
weaknesses…
IT STARTS WITH YOU
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No Two People are Created Alike
What are some key cultural differences to think about?
– Communication – language, patterns, gestures and facial
expressions, decision-making
– Personal Space – how close is too close?
– Social Organization – how a group mourns, celebrates,
learns, lives, etc.
– Time – past, present, or future orientation
– Environmental Control – nature versus nurture
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Important Terms to know to be
“culturally diverse”:
 Communication and culture are
intertwined. Written and oral
language, gestures, facial expressions,
and body language are the means by
which culture is transmitted and
preserved. Patterns are developed
early and affect an individual’s entire
life. Healthcare providers should
recognize common cultural patterns,
but not assume that all members of a
cultural group use the same means of
expression.
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Important Terms to know to be
“culturally diverse”:
 Personal Space – is the
area surrounding a person’s
body. It includes the space
and objects within that
designated area. This
differs with culture and is
important to know and
respect when providing
physical care.
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Important Terms to know to be
“culturally diverse”:
 Social Organization
takes into account patterns of
behavior that people of various
cultures may exhibit during such
life events as birth, puberty,
childbearing, illness, disease, and
death. Healthcare workers need to
understand the profound impact
this can have. Beliefs, values, and
attitudes related to these events
result in traditions and rituals that
follow an individual through life.
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Important Terms to know to be
“culturally diverse”:
 Time –Time can be
perceived as concrete or
abstract. Cultural groups
may be differentiated
according to whether their
time orientation or behavior
is related primarily to the
past, the present, or the
future.
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Examples of Health Care Related Diversity
 Southern African Americans – health is considered a gift
from God and illness retribution for sin.
 Chinese believe that health is based on the balance of
female energy (yin) and male energy (yang.) Disharmony
between the two is thought to disturb the body’s
functioning.
 Mexican patients may believe in “hot” and “cold” forces
that may be thrown out of balance in illness.
 In many Western cultures, calling an elderly person by his
first name is considered rude. (Ask a patient how he
wishes to be addressed.)
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Examples of Health Care Related Diversity
 Some families especially in rural Appalachian areas, may be
challenged for basic necessities such as heat, water, and food.
 Native Americans or Southeast Asians may view expressions of
caring, such as hugging, as intrusions of personal space. They may
view it as discourteous to make direct eye contact or to stand too
close.
 Thais or Filipinos may nod their head in a “yes” manner, but it
does not necessarily mean they understand. People in these
cultural groups VALUE preserving harmonious relationships and
avoiding confrontation. They may nod to avoid offending or
embarrassing anyone.
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Examples of Health Care Related Diversity
 Jehovah’s Witnesses do not accept blood transfusions and
refuse to eat foods that contain blood.
 Muslim and Hindu patients may also follow religious dietary
restrictions.
 Muslims pray five times a day and must face east when
doing so
 Strictly observant Jews may obey dietary laws, that prevent
the mixing of milk and meat, and forbid pork or shellfish.
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Your Responsibility…

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Offer culturally competent care
Respect differences
Maintain confidentiality
Know and use your resources
Ensure patient appropriate communication
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More about our ETCH Child &
Family Population
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Demographic Changes in
Tennessee
7000000
6000000
5000000
Non-Latino
Population
4000000
3000000
Latino
Population
2000000
1000000
0
1990
2000
2008
2010
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Child Population Projection
2000 Population
2010 Projection
Age
Group
Tennessee Latino
Total
Percent Tennessee
of Total Total
Latino Percent
0-9
Years
770,693
24,563
3.2%
822,557
45,087 5.5%
10-19
Years
790,339
20,349
2.6%
845,487
37,526 4.4%
of Total
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Patient Population at ETCH
2003
Total
134,119
Latino
1,736
2004
Total
131,554
Latino
1,967
2005
Total
137,316
Latino
2,516
2006
Total
137,635
Latino
3,378
2007
Total
143,077
Latino
3,964
228% Increase in Spanish speaking population since 2003
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IMPORTANT INFORMATION ABOUT
OUR ETCH LATINO FAMILIES
It is important to understand the
family roles, family dynamics, and
the role faith plays within our Latino
families.
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FAMILY DYNAMICS
 Understanding “La familia”
– We must understand roles and relationships within
the Latino family to help foster positive
communication, patient/family cooperation and
interaction with ETCH staff. This understanding
will also assist compliance with treatment or
treatment outcomes.
 The importance of extended family
– Latino families believe it is valuable to have
extended family support and presence during
times of crisis.
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GENDER ROLES
 Mother’s Role
Determines when a family
member is ill and needs
care
“The Nurturer”
 Father’s Role
Holds the greatest
power in the majority
of Hispanic families
and gives the
permission to seek
treatment.
“The Decision Maker”
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FAITH, RELIGION AND TRADITION
 Faith and the Church are powerful sources of hope and
strength for many Hispanic families.
– This may also impact how they interpret and accept our help
 Roles of faith, religion, and tradition in healthcare
– Religious beliefs of a family may require practices that are
unfamiliar to ETCH staff. We must respect the families need to
uphold their belief while continuing to provide the best possible
care for our patients.
– There are many traditional religious home “treatments” that can
impact patient outcomes
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COMMUNICATION AND RESPECT
 Verbal and Nonverbal
Communication
– REFRAIN from hand gestures.
Different hand gestures can
have different meanings
across cultures.
– Please make eye-contact.
– Head nodding could mean
respect for authority not
necessarily understanding.
 Touch, Hugging
– Should be done only after
establishing a relationship
with a family.
 Authority
– Encourage questions.
Healthcare workers are
considered authority and asking
questions could be viewed as
disrespectful.
 Doctor/Patient Relationship
– Needs to be based upon mutual
respect.
– Once established will lead to
better treatment outcomes.
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CAUSES AND HOW ILLNESS IS
PERCEIVED
 Opposite Concepts Collide
– (Hot and Cold) For example, a culture could treat fever with blankets to
sweat it out, whereas our treatment is to remove layers to cool the body.
 “Mal de Ojo”- Strictly interpreted as “the evil eye”
– Be very careful how we look at patients. Can be interpreted as looking
down upon. Make other contact as well by talking or interacting.
 Safety
– Patients and families may use bracelets or beads as protection against the
“Mal de Ojo” (Evil Eye).
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APPROACHES TO TREATMENT
Can vary from culture to culture
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DIET AND ALTERNATIVE REMEDIES







What have they been using at home or here as their
treatment of choice?
Herbs
Vitamins
Fruits
Spices
Teas
Plants
Prayer
These are services often depended upon and may
be consulted after leaving ETCH





Healers
Herbalists
Midwives
Massage Therapists
Priests
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EXPLAINING TREATMENT AND
AVOIDING MISUNDERSTANDING
 Filtering Information to families
– When explaining treatments/medications, be extra careful to help
families understand what is happening and what to expect.
– Some families’ inability to read and write requires special labeling and
instructions for at-home treatment.
 Reactions of families with misunderstood expectations
– Compliance to discharge instructions is not certain. Sometimes families
will go back to home remedies initially or misunderstand treatment side
effects as ineffective treatment.
 Impact on the Family System when a misunderstanding
occurs
– Can breakdown established trust with healthcare staff when treatment
is unclear to the family and their expectations are not being met.
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BRIDGING THE GAP
Interpreters, Translators,
Advocates, and Resources
 For complete information regarding access to
Interpretive Services, all staff must complete the
Interpretive Services NetL CBL.
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IMPERFECT SCIENCE
 Interpretations and translations are not
always simple or clear cut.
 Religion, diet, family structure all play a
part in our interactions.
 We have to bridge the gap between us as a
hospital and healthcare providers and the
Latino community we serve.
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OTHER POPULATION-SPECIFIC
CONSIDERATIONS
APPALACHIAN HERITAGE
IMPORTANT BELIEFS AFFECTING
HEALTHCARE…
 Self-reliance activities and nature
predominate over people, many
believe that it is best to let nature
heal
 Bureaucratic forms foster fear and
suspicion of health-care providers
June 2008
55
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OTHER POPULATION-SPECIFIC…
APPALACHIAN HERITAGE
 For many, pain is something that is to be endured and
accepted stoically
 it is important for health-care providers to approach
individuals in an unhurried manner
 Slow pace is better received
June 2008
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OTHER POPULATION SPECIFIC
CONSIDERATIONS..
Patients and families with
Low Health Literacy
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HEALTH LITERACY
“The ability to obtain, process, and understand
basic health information and services needed
to make appropriate health decisions.”
Healthy People 2010
 Prevalence across 85 medical studies
– 26% low health literacy
– 20% marginal health literacy
Paasche-Orlow et al. (2005). J Gen Intern Med.
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19 000 US adults; 16 years;
residing in households or prisons
 Proficient
 Intermediate
 Basic
 Below Basic
can perform complex and
challenging literacy tasks
can perform moderately
challenging literacy tasks
can perform simple everyday
literacy tasks
cannot perform basic tasks
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HOW DO TENNESSEE ADULTS
COMPARE?
K in g s p o r t
C la r k s v ille
N o rris
C u m b e rla n d
75
Riv e r
155
N a s h v ille
40
K n o x v ille
M ississip p i
Riv e r
40
TENNESSEE
65
M e m p h is
Te n n e sse e Riv e r
24
81
La ke
40
Te n n e sse e
Riv e r
75
C h a tta n o o g a
54%* of adults function at
Below Basic or Basic
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LOW HEALTH LITERACY=PROBLEMS WITH


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

Pill bottles
Appointment slips
Informed consents
Discharge instructions
Patient/health education
materials
 Insurance applications
Medication
Take as directed
Dr. Literate
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PROPER USE OF ASTHMA INHALER
3.5
3
2.5
Correct Steps 2
of 6
1.5
1
0.5
0
Low
Adequate
Health Literacy Skills
Williams et al. (1998). Chest.
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MOTHERS WITH LOW LITERACY
 Less knowledge about adverse effects of
Arnold et al. (2001). Prev Med.
smoking
 Less breast-feeding
Kaufman et al. (2001). South Med J.
 Less able to read a thermometer
Fredrickson et al. (1995). Kan Med.
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COMMON MEDICAL WORDS
Common medical words that patients with limited
literacy may not understand:

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

Blood in the stool
Bowel
Colon
Growth
Lesion




Polyp
Rectum
Screening
Tumor
Davis et al. (2002). Cancer Invest.
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EDUCATIONAL ATTAINMENT
AND READING LEVEL
 Years of formal schooling tells us what people
have been exposed to, NOT what skills they have
acquired.” (Doak, Doak, & Root, 1996)
 Most American adults read 3-5 grade levels
lower than the highest grade level of schooling
completed.
– Average reading level in US=6-8th grade
Davis et al. (1996). Pediatrics.; Meade et al. (1994). Am J Pub Health.
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“AT RISK” GROUPS

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Elderly
Minority
Recent immigrants
Non-English speakers
Low-income
School drop-outs
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POSSIBLE INDICATORS OF
LOW HEALTH LITERACY
 Seek help only when illness is advanced.
 Have difficulty explaining medical concerns.
 Excuses: “I forgot my glasses.”
 Lack of follow-through with tests/appointments.
 Seldom or never have any questions.
 Identifies drugs by pill color and shape rather than by
name.
 Does not know purpose of each medication.
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HEALTH LITERACY SCREENING ITEMS
FOR PARENTS
3 items combined associated
with 6th grade parental
reading level:
–<12th grade completion
–nnot living with child’s
other parent
–Nnot reading for pleasure
2 items independently
associated with adequate
parent health literacy:
>10 adults’ books in the
home
>10 children’s books in the
home
Bennett et al. (2004). Fam Med.
Sanders et al. (2004). Ambul Pedriatr.
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STRATEGIES TO IMPROVE
COMMUNICATION
 Limit information (3-5 key points)


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
Use living room language
Be specific and concrete, not general
Demonstrate, draw pictures, use models
Use a “Teach Back” or “Show Me” approach (confirm
understanding)
 Be positive, respectful, caring, sensitive, empowering
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IN SUMMARY
 We are all advocates and professional
allies and our goal is to treat the patient
and help him or her achieve better health.
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IN SUMMARY
 Patient needs to trust you and believe what you
are telling them is true.
 Patient needs to understand you.
 There MUST be mutual respect among the
healthcare provider, the interpreter, and the
patient.
 Towards all patients, we ALWAYS remain neutral
and NEVER judgmental.
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IN SUMMARY
 Generalization is a beginning point and a
stereotype is an ending point.
 Focus on similarities rather than pointing out
differences.
 Do not allow cultural assumptions or prejudices
to interfere with treatment.
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"Because Children are Special...they deserve the
best possible health care given in a positive,
child/family centered atmosphere of
friendliness, cooperation, and support regardless of race, religion, or ability to pay."
At ETCH, providing Population Specific Competent
Care is essential to our vision of…
“Leading The Way To Healthy Children”.
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