Physician Interaction and Counseling of Filipino Patients

1. Physician Interaction and Counseling of Filipino Patients • Filipino American Cardiovascular Health Conference • National Harbor, MD • July 8, 2011 • PotriRankaManisQueanoNur, MA, RN • Kalusugan Coalition, Inc.

2. Objectives • To cite situations of Filipino Americans that may help explain underlying behaviors, attitudes, and perceptions of health and determine health outcomes and health disparities. • To describe socio-cultural factors impacting Filipino Americans non-adherence to medication • To examine cases of physician interaction and counseling of Filipino patients • To highlight the importance of understanding various barriers Filipinos encounter when it comes to medication adherence and the best way to communicate without labeling a patient as "non-compliant".

3. The Clinical Encounter • Patient’s Barrier: Lack of health insurance/coverage --> Association of clinical encounters with cultural stigma (i.e. death, high costs, poor self-care) • “Is it hiya, or just fatalism…? ‘God take me’, they say… They know they’re sick and have high blood, but going to the doctor is just going to lead to high costs and things getting worse, not better… and more disruption with other parts of their life, like work, church, family, social functions.” - AsPIRE Community Health Worker

4. Case Study • Perry is 57/female years old. She was an architect in the Philippines. Currently working as a manager of a nurse staffing agency. • " I was in the ER last week. My blood pressure went up to 200/110. I thought I will die. I am in medication but it makes me cough. I went to see my doctor, she gave me cough medication. She was so in a hurry that I was not able to ask her more questions that is related to what I am feeling. I stopped taking the medication. I saw her in a party and I thought I can speak to her about me but when I told her I have a headache and a backache she said I needed an MRI. I stopped seeing that Doctor. Right now I am just taking the medicine when I feel my BP is high.”

5. Physician-Patient Communication in the Primary Care Office: systematic Review Rainer Beck, MD,et al • According to Dr. Beck, et al study, Physician-patient communication has frequently been judged to be inadequate. • According to Dr. Mcbride et al study it was found that patients considered communication to be one of the top three competencies a physician should possess, yet they frequently rated their own physicians' communication skills to be unsatisfactory.

6. Qualitative Studies on Filipino Americans & Medication Adherence • The Role of Sociocultural Factors on Medication Adherence and Control of Hypertension Among Filipino Americans: A Qualitative Study - Gregory S. Calip, PharmD, MPH, 2009 • The Illness beliefs, perceptions, and practices of Filipino Americans with Hypertension – FelicitasDela Cruz, 2007 • Nonadherence due to forgetfulness because of multiple family responsibilities and time constraints.

7. Environmental Characteristics • Patient barriers: • Immigration status and recent migration • Lack of time for self care • Prioritization of employment versus health status • Cultural perception of health

8. Immigration Status and recent migration Immigration status. Displacement of status. • It can be silent in the written survey that most of the domestic workers are teachers, accountants, engineers, lawyers, nurses, even doctors in the Philippines. One of the recent encounters in a recent health screening, the client was a Mayor in his town in the Philippines.

9. Lack of time for self-care • Most Filipino immigrants have 2-3 jobs to meet the economic demands here plus the demands of their family/extended family back home in the Philippines. • “Managing high blood among my clients is only possible if they knew they had the time/ability to work, send money home to the Philippines, and then… take time to see the doctor.” AsPIRE CHW

10. Prioritization of employment versus health status • Filipino immigrants/recent immigrants who work 2 jobs and 7days a week often note they have no time to go to health providers for their health care needs.

11. Cultural Perceptions of Health • There are those who stop when they feel better or their blood pressure becomes normal and mistakenly believe that they no longer need the medication or that they thought they were cured. Some just simply forget taking their medication.

12. Cultural Characteristics • Chronic nature of hypertension management • Cultural perception of well being • “Folks in our community can’t FEEL their high blood pressure they tell me they feel fine if they have time to work and don’t see the bigger picture until someone they know gets sick or dies.” Community Health Worker, Jersey City, NJ

13. Lack of understanding and Information • Low awareness of treatment: Risk factors, Characteristics, Complications • Most knowledge acquired from sources other than health providers • Long term use of medication drug-taking contingent to symptoms • “Clients of mine receive medications from family members or doctors in the Philippines because they’re cheaper. They share them because they think it worked well for their relative. They might know they have high blood from a screening, but never saw a doctor because they couldn’t pay.” Community Health Worker, Queens, NY

14. Physician as a Patient Educator (Diane Florde McCANN, EdD, et al.) A Establish rapport by eliciting patient’s ACTIVE INVOLVEMENT D Assess needs by listening carefully as a patient DISCUSSES CONCERNS U Develop a plan by promoting an UNDERSTANDING OF THE ISSUES L Implement the plan by offering patient opportunities to LEARN NEW BEHAVIORS T Evaluate the plan by identifying strategies for TRACKING PATIENT’S PROGRESS

15. Art of Communication • Judgmental Feedback • Language Barriers • Trigger defensiveness, aggression, or resistance • Example: • “You’re 35 years old. You should be pregnant by now.” • ~ spoken by a Filipina OB/GYN doctor to a Filipina patient.

16. Art of Communication Keys to Active Listening Seven Levels of Listening • Block out obstacles to listening such as noise • Full attention – not on the cellphone; Maintain eye contact (remember cultural variations) • No interruptions – allow the person to speak, nodding is acceptable • Ask the person to repeat in the event you don’t understand • Acceptable to take brief notes to keep track of details • Non-listening – too busy thinking about your own response or feelings • Avoiding – tuning out what we don’t want to hear • Blaming – ‘The blame game’ • Negating – “You should not feel that way” • Top This – “Let me tell you…” • Interest – “Tell me more…” • Reflective – “What I hear you say is…”

17. CHW/Adjunctive Instructions • Egbert and colleagues were among the first investigators to report the positive effects of adjunctive patient instruction by members of an interdisciplinary health team. • Combination of cognitive and motivational and skill-building education and reinforcement from the community health worker • Community health workers can be part of a team approach to patient education as an adjunct to personal physician education through regular physician visits

18. THANK YOU! • For more information please contact: • Potri Ranka Manis Queano Nur, MA, RN • 39-04 63rd Street • Woodside, NY 11377 • Phone | 718.426.7600 • Fax | 718.426-7609 • Email | info@kalusugancoalition.org • Website | www.kalusugancoalition.org • Facebook |www.facebook.com/kalusugancoalition • Twitter |www.twitter.com/kalusugan