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NEREIDA CORREA, MD ASSISTANT PROFESSOR

CULTURAL COMPETENCE : RACE AND ETHNICITY. NEREIDA CORREA, MD ASSISTANT PROFESSOR OBS/GYN & FAMILY PRACTICE ALBERT EINSTEIN COLLEGE OF MEDICINE JANUARY 24, 2001. CULTURE. INTEGRATED PATTERN OF HUMAN BEHAVIOR INFLUENCES THOUGHT, ACTIONS, CUSTOMS, BELIEFS AND VALUES

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NEREIDA CORREA, MD ASSISTANT PROFESSOR

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  1. CULTURAL COMPETENCE : RACE AND ETHNICITY NEREIDA CORREA, MD ASSISTANT PROFESSOR OBS/GYN & FAMILY PRACTICE ALBERT EINSTEIN COLLEGE OF MEDICINE JANUARY 24, 2001

  2. CULTURE • INTEGRATED PATTERN OF HUMAN BEHAVIOR • INFLUENCES THOUGHT, ACTIONS, CUSTOMS, BELIEFS AND VALUES • RELATED TO ETHNIC, RACIAL RELIGIOUS OR SOCIAL GROUP

  3. CULTURES IN THE BRONX • WHITE -ALL ETHNIC GROUPS • BLACK- ALL ETHNIC GROUPS • ASIAN - ALL ETHNIC GROUPS • INDIAN- EAST AND WEST • HISPANIC- MOST GROUPS

  4. COMPETENCE • ACQUISITION OF KNOWLEDGE • DEVELOPMENT OF SKILLS • EXPERIENCE • APPLIED TOWARDS INTERVENTIONS ADAPTIVE TO THE DIFFERENT GROUPS SERVED

  5. CULTURAL COMPETENCE • CONGRUENT BEHAVIORS, ATTITUDES AND POLICIES • COME TOGETHER TO WORK EFFECTIVELY IN CROSS CULTURAL SITUATIONS • SERVICES PERCEIVED AS RELEVANT AND HELPFUL

  6. DIVERSITY TRAINING • ACCEPTANCE AND TOLERANCE • LOWERS PREJUDICE • DEVELOPS CULTURAL AWARENESS AND SENSITIVITY • IS A BEGINNING TOWARDS SHOWING THE DIFFERENCES BUT DOES NOT GIVE TOOLS

  7. COMPETENCY TRAINING • PROMOTES SKILLS AND KNOWLEDGE • CONTENT BASED • DIFFICULT TO TEACH • INDIVIDUALIZED TRAINING • DEVELOPS PRACTICAL SKILLS

  8. CULTURAL AWARENESS • GENDER • AGE • ETHNIC IDENTITY • RACE • SOCIAL STATUS • ROLES

  9. CULTURAL ASSESSMENT • BIRTH PLACE AND ETHNICITY • SUPPORT FAMILY MEMBERS • LANGUAGES AND NONVERBALS • RELIGION AND PRACTICES • ECONOMIC SITUATION • HEALTH/ILLNESS BELIEFS • BIRTH/DEATH BELIEFS

  10. COMMUNICATION • INTERPRETORS • CONVERSATIONAL STYLE • PERSONAL SPACE • EYE CONTACT • TOUCH • TIME ORIENTATION

  11. DIVERSITY ISSUES • MIGRATION STATUS • ETHNICITY/RACIAL GROUP • SOCIOECONOMIC STATUS • SEXUAL ORIENTATION • DISABILITY

  12. BELIEFS • HEALTH AND WELLNESS • BIRTHING PRACTICES • USE OF ALTERNATIVE SYSTEMS • DEATH AND DYING • BEHAVIOR WITH HEALTH WORKERS • RESPONSE TO HISTORY TAKING

  13. NYC POPULATIONS • BLACK AMERICAN 2.8 M • PUERTO RICAN 1.O M • RUSSIAN 455 K • WEST INDIAN 452 K • CHINESE 285 K • EAST INDIAN 133 K

  14. POPULATION UNDERCOUNTING • IMMIGRANT GROUPS GREATLY UNDERCOUNTED • SELF DESCRIPTION VS ASSIGNED GROUP • STATE NET UNDERCOUNTING : 272K ADULTS, 113 K CHILDREN IN ‘90 • BY GROUP: 1.9K WHITE, 186K BLACK, 136K HISPANIC, 23K ASIAN,

  15. NYS UNDERCOUNTING • NET UNDERCOUNT 272,036 • NET CHILDREN 113,486 • WHITE 1,972 • BLACK 185,873 • HISPANIC 136,010 • ASIAN 22,760 • NATIVE AMERICAN 1,763

  16. LEARN • LISTEN WITH EMPATHY • EXPLAIN YOUR PERCEPTION • ACKNOWLEDGE • RECOMMEND TREATMENT • NEGOTIATE TREATMENT MODALITIES

  17. DISPARITIES • MATERNAL AND INFANT MORTALITY • ACCESS TO HEALTH CARE • EMPLOYMENT • EDUCATION • PREVALENCE OF DISEASES RELATED TO DIET AND EXERCISE • HOMICIDE AND SUICIDE

  18. HEALTH PROFILE ON MINORITIES • BREAST CANCER INCREASED 3.9% FOR BLACK WOMEN • TUBERCULOSIS INCREASED BY 51% FOR ASIAN AMERICANS AND 30% FOR HISPANICS • AIDS/HIV DISEASE INCREASED FOR BLACKS, HISPANICS, ASIANS AND NATIVE AMERICANS

  19. HEALTH PROFILE • INFANT MORTALITY RELATIVE INCREASE • LIFE EXPECTANCY 6.6 YEARS LESS • HEART ATTACK DEATH DECLINED 21% FOR BLACKS VS 29% FOR WHITES • DEATH FROM HIV DECLINED 13-22% VS 32% FOR WHITES

  20. HEALTH PROFILE • HOMICIDE AND SPINAL CORD INJURY • DOMESTIC VIOLENCE • EXPOSURE OF CHILDREN TO DRUGS • CIGARETTES AND ALCOHOL • TEEN PREGNANCY • SCHOOL FAILURE AND DROP-OUT

  21. INTERVENTION STRATEGIES • INVOLVEMENT IN COMMUNITY GROUPS • INVOLVEMENT IN LEADERSHIP OF PROFESSIONAL GROUPS • MENTORING OF YOUTH • POLITICAL ACTIVISM • RESEARCH

  22. VIGNETTES

  23. RACE AND ETHNICITY PRACTICE VIGNETTES

  24. PRACTICUM: RISKS • Stereotyping can occur • Oversimplification of true values • May be misinterpreted • May offend members of the group

  25. PRACTICUM: BENEFITS • Increases awareness of behavior • Inculcates sensitivity • Promotes understanding between groups • Develops strategies in practitioners that will help them to give care to diverse populations

  26. OBJECTIVES • Demonstrate by illustration how culture impacts on the physician-patient interaction • Provide examples of various ethnic groups in the Bronx and some common beliefs with in the culture • Explore the impact of a lack of understanding on the therapeutic relationship

  27. ETHNIC GROUPS • African-American • Arab • Haitian • Mexican • Puerto Rican • Vietnamese • West Indian

  28. A 14 year old teenage boy is brought in for a routine physical exam His mother wants routine exams done and is concerned about school performance Beliefs: Strong family links; demanding of respect Issues around gender identity, expected roles and independence AFRICAN-AMERICAN

  29. AFRICAN-AMERICAN • Assess developmental level and institute age appropriate counseling regarding safety issues, sex and pregnancy prevention, career issues • Provide flexible access for questions • Appreciate gestures such as lack of eye contact and looking down related to respect

  30. A 24 year old woman pregnant for the first time Visit with her husband Establishing plans for her care Beliefs Concerns Outcomes ARAB

  31. ARAB • Beliefs: Birth is a natural process • Modesty to be conserved-privacy, veils • Husband, father, brother make decisions • Children are sacred

  32. ARABS • Concerns: • Usually requesting female provider • Male family member to be involved in decision making • Prefer natural delivery, will accept pain medication • Prayer time essential for strict Moslems • Amulets: blue stone to ward off evil eye

  33. ARAB • Prenatal care with female providers • Delivery plan made with negotiations regarding the need for some male practitioners • Actual delivery with husband present-involved in decisions • Patient wore veils and robes when in halls

  34. Couple seen for evaluation of infertility Partner has one child from previous marriage Suspicion is male factor infertility Beliefs: Male sexual productivity is indication of masculinity Concerns: Inability to impregnate partner can be interpreted as loss Outcomes PUERTO RICAN

  35. PUERTO RICAN • Assurance of language competence and use of translator if needed, not family member • Presentation of data on infertility and the facts related to male factor • Reassurance that there is no correlation with sexual performance • Privacy

  36. A 5 year old girl brought in for fever and a cold Bruising noted on chest wall in reddish streaks Several cup marks seen on her back Beliefs: Hot and cold theory of medicine and use of alternative medicines; illness related to sins of past life Concerns: Distinguish injury to child VIETNAMESE

  37. VIETNAMESE • Assurance of language competency; use of translator unless fluent in English • History taking to include beliefs and practices in an open-ended way • Negotiate plan to include parental belief to improve compliance • Help family to deal with guilt at illness

  38. A 50 Year old man diagnosed with cancer of the stomach Has experience gradual illness and now is dying Beliefs:Illness a continuum Kompa bon Moin malad moin malad anpil moin pap refe bon die vs loa HAITIAN

  39. HAITIAN • Assurance of language competency • Discuss beliefs about illness and death; believer in spiritualism, or catholic or both • Allow space for as much family as possible • Final bath given by family member • Prefer to die at home

  40. 35 Year old woman with new diagnosis of hypertension Sees herself as healthy, has no pain Told to avoid salt and fatty foods in diet Beliefs: Diet with strong broths and organ meats will build up the body Fatigue and pain are symptoms of disease Hot and cold foods WEST INDIAN

  41. WEST INDIAN • Nutritional interventions with cultural beliefs in mind; hot and cold combinations and restrictions • Discussions regarding asymptomatic nature of her diagnosis and the need for preventive interventions • Regard for issues of respect, eye contact and touching

  42. A 15 year old girl brought in by her mother for amenorrhea History of recent arrival to city Concerns regarding pregnancy Beliefs: Family loyalty, concerns regarding respect, family reputation Curanderos: Maladies such as mal de ojo, susto. Empacho, caida de mollera, antojos MEXICAN

  43. MEXICAN • Assurance of language competency • Including mother in the interview • Speaking to the teenager alone • Exploring cultural beliefs and issues • Providing interventions and bridging cultural gap

  44. UNIFYING PRINCIPLES • Diversity vs. Similarity • Language competency essential • Respectful Inquisitiveness • Negotiation to improve compliance • Non-verbal communication is universal

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