CULTURAL COMPETENCY

1. CULTURALCOMPETENCY Keri Holmes-Maybank, MD March, 2013Medical University of South Carolina

2. Learning Objectives • Residents will learn the definition of cultural competency. • Residents will learn the importance of cultural competency. • Residents will learn questions to use to facilitate interviews in culturally diverse populations. • Residents will identify pitfalls to avoid when practicing cultural competency.

3. Key Messages • Minority populations receive a lower level of health care. • Successful care of minority populations requires cultural competency. • By recognizing cultural differences a respectful relationship between the provider and patient may begin. • It is important to avoid stereotyping when practicing cultural competency. • Culturally competent care leads to greater patient satisfaction and less errors.

4. Importance of Cultural Competence • Different languages • Different explanatory models of the cause and treatment of illness • Religious beliefs • Ways of understanding the experience of suffering and dying

5. Importance of Cultural Competence • Misperceptions secondary to lack of cultural competence lead to • Poor interactions • Mistrust • Anger with patients and their families • Unwanted clinical outcomes

6. US Diversity • Ethnic minorities ~30% of the population • >329 languages • 32 million do not speak English at home • Foreign-born: 50% Latin America, 25% Asia, 25% Europe, Canada, etc. • By 2050 ethnic minorities will be the majority

7. Health Care Disparities • Multi-factorial • Minority communities • More socioeconomically disadvantaged • Lower levels of education • Higher rates of occupational hazards • Greater environmental hazards • Overrepresented among underinsured • Higher rates of disease, disability, death

8. Health Care Disparities • Quality of Care - even when adjusted for access (insurance and income) • Utilization of cardiac diagnostic and therapeutic procedures • Analgesia for pain control • Surgical treatment of lung cancer • Referral for renal transplant • Treatment of pneumonia and congestive heart failure • Immunizations • Mammograms

9. Black Disparities • Cardiac procedures • Analgesic prescriptions • Cancer treatment • Depression anxiety treatment • HIV treatment • Renal disease • Asthma • Pharmacies in Black neighborhoods are less like to stock and fill narcotics

10. Cultural Barriers • Lack of diversity in health care providers • Systems of care poorly designed to meet needs of diverse patient populations • Poor communication between providers and patients of different racial, ethnic or cultural backgrounds • Lack of cultural competency

11. Need for Cultural Competence • Department of Health and Human Services’ Office of Minority health • Culturally and Linguistically Appropriate Standards of Services(CLAS) • Healthy People 2010 • Task Force on Community Preventative Services • Accreditation Council for Graduation Medical Education - “Tool for the Assessment of Cultural Competence Training” TACCT • Liaison Committee for Medical Education

12. LCME • “Faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatment.” • Cultural competence is a complex, life-long process.

13. Cultural Competence • Describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including delivery to meet pts social, cultural, and linguistic needs. • Cultural competence refers to knowledge, skills(communication, interpreters, attention to nonverbal communication), and cultural sensitivity.

14. Cultural Competence • Capacity to identify, understand, and respect values and beliefs of others • Consider how these factors interact at multiple levels of the health care delivery system • Devise interventions that take these issues into account • Expansion of cultural knowledge • Disease prevalence, incidence, and treatment outcomes

15. Cultural Sensitivity • Be aware of how culture shapes patient values, beliefs, and world views • Acknowledge that differences exist • Respect the differences • Maintain a non-judgmental attitude toward unfamiliar beliefs and practices • Be willing to negotiate and compromise when world views conflict

16. Culturally Incompetent Communication • Differences are not accepted, appreciated, explored, or understood = disagreements, difficult interactions, or decisions the physician does not understand • Creates barriers to accessing health care • Patients may delay or refuse care • Mistrust • Perceived discrimination • Negative experiences with health care system • Historical events (slavery and abuses in research

17. Culturally Competent Care • Comprehensive and compassionate care • Reduces unnecessary test • Reduces inappropriate use of services • Reduces the incidence of medical errors • Assures the provision of appropriate services • Improves health outcomes • Increases efficiency staff • Increases adherence • Greater patient satisfaction

18. Trust • Trust is critical to cross-cultural cooperation • Addressing and respecting cultural differences will likely increase trust

19. Culture: Definition • Integrated pattern of learned beliefs and behaviors • Language • Thoughts • Communication • Ways of interacting • Views on roles and relationships • Actions • Practices/Customs • Values

20. Socio-Cultural Factors • Race • Ethnicity • Nationality • Language • Gender • Sexual orientation • Socioeconomic status • Physical and mental ability • Occupation

21. Religion and Spirituality • Influenced by religious or spiritual concerns • Religious and medial perspectives are different and could come into conflict though they do not need to be contradictory • Religious beliefs and practices vary from individual within same religion or denomination • Only God has knowledge about and power over life and death

22. Culture in Health Care • Fundamentally shapes the way people make meaning out of illness, suffering and dying • How symptoms are identified and communicated • Beliefs about causality, prognosis, prevention, treatment options • Threshold for seeking care • Expectations of care • Adherence • Ability to understand the treatment strategy • Family, social, and cultural networks reinforce

23. Medicine as a Culture • Cultural system with specific language, values, and practices that must be translated, interpreted and negotiated with patient and families. • Biomedical world view of professional training creates values, perspectives, and biases. • Traditional H&P does not facilitate learning how patients make decisions

24. Patient Autonomy and Truth-Telling • Right of patient to be informed about condition, possible treatments, ability to choose or refuse life –prolonging medical care, advance directives • Truth-telling is not the norm in much of the world • Can be seen as cruel and potentially harmful • May lose hope and suffer unnecessary physical and emotional distress • Some believe hastens death

25. Disease and Illness • Disease is the objective, measurable pathophysiology that creates the illness • Illness includes the assumed etiology—be it natural (fall that breaks a bone), supernatural (God’s will, witches, or malevolent spirits), or metaphysical (bad airs or seasonal changes for which one is unprepared) • The assumed etiology establishes the groundwork for negotiating objectives of care

26. Cultural Competence Do’s • Develop communication skills • Aware of the specific beliefs and practices • Be sensitive cultural differences • Accept the patient values and world views as starting points for the MD-PT relationship • Humility and genuine concern • Friendly and helpful

27. Cultural Competence Do’s • Avoid medical jargon • Checking for understanding • Use translator • Ask specific questions - Inquire about values • Self-reflection to address own bias = barriers • Respect = trust = confide • Respectful emotionally supportive dialogue can overcome racial barriers

28. Cultural Pitfalls • Disregarding importance of culture to patient’s view and beliefs • “Cultural imperialism” - giving greater meaning to values and disregard patient’s • MD’s may misinterpret non-verbal cues without knowing cultural context • Family/untrained interpreters may misinterpret medical phrases, censor sensitive or taboo topics, or filter/summarize discussion

29. Cultural Pitfalls • Interrupting • Failing to maintain appropriate physical distance • Failing to listen • Assuming words mean the same to patient • Stereotyping • Appearing disrespectful

30. Stereotyping • Great diversity with in ethnic and cultural groups • Individuals w differ socio-cultural factors: • Gender • Socioeconomic class • Education • Immigrant status • Acculturation • Religion • Personal psychology • Life experience

31. Avoid Stereotyping • Elicit patient perspectives on illness and their expectations • Ask patient if they have a certain belief • Open-ended questions • Empathic comments

32. Cultural Competency Training • Increase awareness of racial and ethnic disparities in health and the importance of socio-cultural factors on health beliefs and behaviors • Identify the impact of race, ethnicity, culture and class on clinical decision-making • Develop tools to assess the community members’ health beliefs and behaviors • Develop human resource skills for cross-cultural assessment, communication and negotiation

33. Cultural Competency Training • Excellent evidence - improves knowledge of health care professionals • Good evidence – improves attitudes and skills of health professionals • Good evidence –impacts pt satisfaction • Poor evidence training impacts pt adherence • Poor evidence - training cost • No studies - health outcomes

34. Questions • What do you think caused your sickness? • Why do you think it started when it did? • What do you think your sickness does to you? • How severe is your sickness? • What are the biggest problems your sickness has caused for you? • What do you fear most about your sickness? • What are the most important results you hope to get from treatment? Kleinman

35. Questions • What do you think might be going on? • Would you like me to tell you the full details of your condition? • Is there someone else you would like me to talk to? • What language are you most comfortable speaking? • What are your greatest concerns now that you have this illness?

36. Questions • Who can help you with physical care, emotional support, transportation? • Where do you go for religious or spiritual strength, or solace? • What kind of assistance is available to you in your community that might be helpful during this time? • Where were you born and raised? • When did you emigrate to the U.S.?

37. Does Not Prevent All Conflicts • Understanding patients as individuals in context of culture does not prevent conflicts over differing beliefs, values, or practices • Does serve to identify areas of negotiation and create atmosphere of mutual respect

38. Examples of Cultural Context • Ventilation and cardiopulmonary resuscitation hasten death • Nodding indicates politeness and respect not agreement • May seek aggressive treatment bc value sanctity of life not bc misunderstand limits of technology • History of poor access to care may feel palliative care = giving up or poor care

39. Religion - Specific Cultures • American Islamics expect broader issues of faith and belief to be addressed in clinical encounter • Black women who think God is controlling health less likely to get mammograms • Some black communities believe suffering is redemptive, must be endured, stopping life support to avoid pain and suffering may be seen as failing a test of faith

40. Asian • Family is decision maker - responsibility to protect the sick from burden • Hospice is failure of the caretaker • Filial piety – expectation children will care for their parents • How well fulfill their filial duties is open to community scrutiny and judgment • Reflect poorly on parenting abilities

41. Asian • “Face” – indirect communication • never put pt in a position of embarrassment or loss of honor by directly asking a sensitive questions • preservation or family and community honor (Chinese American) • Allows ambiguity and allows to save face and possibility of hope • Can offer patient opportunity to know “informed refusal”

42. Navajo • Statements of family are indirect questions – acknowledges families fears, respects need for indirect discussion, invites further questions • Feel western MD seems to be giving negative info through informed consent, truth telling, advance care planning

43. Blacks • Home or natural remedies • Religion is a source of enormous emotional support • More likely to want aggressive care at end of life • Less likely to have DNR and advance care plans • Less likely to trust the motives of md • Mistrust is a barrier to organ donation • Mistrust is barrier to participating in medical research • More blacks fear inadequate medical care • Feel many unmet needs for communication • Want to be informed of dx and prognosis to make informed decisions

44. References • Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J, the Task Force on Community Preventative Services. Culturally competent healthcare systems. A systematic review. Am J Prev Med 2003;24(3S):368-379. • Back A, Arnold R, Tulsky J. Mastering Communication with Seriously Ill Patients. Balancing Honesty with Empathy and Hope 2009. Cambridge University Press. • Beach MC, Price EG, Gary TL, et al. Cultural competency: A systematic review of health care provider educational interventions. Med Care. 2005 April;43(4):356-373. • Betancourt JR, Green AR, Carrillo. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. The Commonwealth Fund, Field Report 2002. • Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Define cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports July-August 2003;118:293-302. • Betancourt JR, Green AR, Carrillo E, Park ER. Cultural competence and health care disparities: Key perspectives and trends. Health Aff March 2005;24:499-505. • Carrese JA, Rhodes LA. Bridging cultural differences in medical practice. The case of discussing negative information with Navajo patients. J Gen Intern Med 2000;15:92-96. • Crawley LM, Marshall PA, Lo B, Koenig BA. Strategies for culturally effective end-of-life care. Ann Intern Med 2002;136:673-679. • Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of life. “You got to go where he lives”. JAMA 2001;286(23):2993-3001. • Kleinman A. Patients and Healers in the Context of Culture. Berkeley, California: University of California Press, 1980. • Levin SJ, Like RC, Gottlieb JE. ETHNIC: A Framework for culturally competent clinical practice. In: Appendix: Useful Clinical Interviewing Mnemonics. Patient Care 2000;34(9)188-9. • Mull JD. Cross-cultural communication in the physician’s office. West J Med 1993;159:609-613. • Steiner RP, Rubel AJ. Recommended core curriculum guidelines on culturally sensitive and competent health care. Fam Med 1996;27:291-297.

45. RISK • R Resources for patients and families • I Individual identity and acculturation • S Skills of patient and family to adapt to disease • K Knowledge ab health beliefs, values, practices, and cultural communication etiquette

46. RISK’’ Reduction Assessment to Ascertain Level of Cultural Influence

47. ABCDE • A Attitudes • B Beliefs • C Context • D Decision making • E Environment

48. ETHNIC • E Explanation • T Treatment • H Healers • N Negotiate (mutually acceptable options) • I Intervention (mutually acceptable) • CCollaboration (patient, family, healers) • S Spirituality

49. BELIEF • BBeliefs What caused your illness/problem? • E Explanation Why did it happen at this time? • L Learn Help me to understand your belief. • I Impact How is this impacting your life? • E Empathy This must be very difficult for you. • F Feelings How are you feeling about it?

50. LEARN • L Listen to the patient's perspective • E Explain and share MD’s perspective • A Acknowledge differences • R Recommend a treatment plan • N Negotiate a mutually agreed upon plan