IMPORTANCE OF USING CULTURALLY SENSITIVE TOOLS FOR ACQUIRING PERCEPTIONS OF HEALTH

1. IMPORTANCE OF USING CULTURALLY SENSITIVE TOOLS FOR ACQUIRING PERCEPTIONS OF HEALTH

2. The Art of Communication

3. Our Best Tool The patient’s voice on the perception of their health

4. Background • As early as the 1920’s, it was suggested that individual perceptions of health could be indicators to the onset of disease • Established standards and empirical results have underscored the importance of incorporating measurement of health perceptions in studies that assess an individual’s health, illness, or disease impact.

5. Perceptions of health are internal and subjective within individuals At the individual level, they may channel actions At the societal level, they may channel policy for change

6. Often individuals’ perceptions of health are categorized as: EXCELLENT GOOD FAIR POOR VERY POOR Used by the Behavioral Risk Factor Surveillance System and the National Health Interview Survey

7. Although this is a validated method for obtaining individuals’ perceptions of health; the cultural meaning of health can be lost

8. How is health defined within the culture? • What values are placed on health? • What is the contextual placement of good, fair, or poor? • What senses and experiences are dominating that culture to form the perception? These are important questions to ask the individual

9. Need to go back to foundational experiences of people, and the medical anthropological understanding of disease and illness where culture is embedded and sustained over a period of lifetimes; followed by providing the individual the measurement tool which will help to categorize perceptions of health

10. Qualitative Surveys Qualitative Surveys • World Health Organization Quality of Life Survey (WHOQOL) Believed that the “missing element of health” was the humanistic element • Health Perceptions Questionnaire Form II (1976) • Nottingham Health Profile (1985) • EQ-5D (EuroQol Group) 1990 • SF-36 Health Survey Questionnaire (1992)  Medical Outcome Survey Lost its most meaningful context SF  36 MOS  20 MOS  12

11. Qualitative Research Methods • Reveal underlying meanings and patterns of relationships within a culture • Provides contextual description of how people experience health • Identify intangible factors such as : • social and cultural norm • beliefs, rituals and values • socioeconomic status • gender roles • ethnicity • religion • THEY BRING THE PATIENTS VOICE TO THE FOREFRONT

12. Methods of Obtaining Qualitative Information Focus Groups One-to-One Interviews Participant Observations Field Work Observations

13. New Tools 1. Better Communication, Better Care: Provider Tools to Care for Diverse Populations AHRQ Healthcare Innovations Exchange website: http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10 .pdf 2. AHRQ Health Literacy Toolkit AHRQ Pub. No. 10-0046-EF Citation: DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010. H

14. In addition: Knowledge of: › the cultures’ history › ethnic composition › past religious, political, and social forces This rich experiential data can help to retain and sustain culture within the health perceptions measurement tool

15. Preliminary information regarding: demographics, social and economic variables, vital statistics, and chronic disease factors can be obtained through: Country websites: United States www.factfinder.census.gov WHO website: http://www.who.int/whosis/en/index.html United Nations website: http://unstats.un.org/unsd/default.htm

16. CAUTION!!!!!! The use of information must be carefully considered because often the information is from an aggregate population, not the subgroup. They may yields very different profiles

17. EXAMPLES OF CULTURAL VARIATIONS IN PERCEPTIONS OF HEALTH

18. SRI LANKA SRI LANKA

19. History of Medicine 4 ancient periods 1. Medicine under Sri Lankan kings 2. The Portuguese period 3. The Dutch period 4. British period

20. Health Care Systems in Sri Lanka 1. Alophatic: dominates Sri Lanka; (basically western medicine) yet people retain some components of the other two systems in their belief when they define health 2. Ayurveda: originated in India; individuals would maintain that illness and suffering are due to change in Wa (air), Pith (bile), and Sem (mucus) 3. Indigenous: developed within the context that the king and others should do their best to reduce suffering due to illnesses. This teaching helps people tolerate suffering such as pain

21. The majority of Sri Lankans are Buddhists. The Buddhist philosophy defines health as wealth; yet it also says that people get sick because of their “Karma”. Elimination of suffering can only be achieved through the person by elimination of any attachment it may have to the subconscious body

22. Other considerations 95% of people can read and write this will affect your tool design when considering time and budgeting

23. MEXICO MEXICO

24. In most homes, health is seen as a luxury • Little value is placed on prevention of disease • Class separation is very visible/the poor are left uninsured and without care

25. Mexicans value Familismo(the family unit)

26. High value placed on religion, with illness placed in the hands of God • Curanderos (spiritual healers) are very important in Mexico with their holistic approach to healing

27. The Mexican government plays a role; due to corruption, pharmacies are able to sell medicine with little regulation • Mexicans are taught not to complain; most will answer “good” when asked the question…..How are you feeling? • Mexican use many different dialects and different words in various parts of the country

28. Cambodia

29. Misconception • Often Asians in the aggregate present a picture of good health, higher levels of income, and higher family income (Koch-Weser S, Liang SL, Grigg-Saito DC)

30. In Cambodia • March 2008: United Nations reports population at 13,388,910 • Life expectancy at birth: 59 yrs. old for men 63 yrs. old for women • Literacy rate in 2004: 73% • Infant mortality rate in 2006: 66 per 1,000 births

31. Cambodians have struggled with poverty, corruption and the aftermath of the Khmer Rouge war

32. Many people struggle on a daily basis to have a small meal whether they find it, grow it, or buy it with the small income they receive • Hunger may be a variable of perceptions of health

33. Most hospitals and clinics are located in Phnom Penh. Many have no means of transportation; the village healer is utilized

34. There is no form of health insurance in Cambodia • When speaking to a Cambodian, they will say “ This is the life we live, what options do we have?” • This is the unfortunate reality of the lifestyle in Cambodia

35. Conclusion Various cultures provide for important variations in: • The definition of health • Values placed on health • The contextual and experiential placement of good, fair, or poor • What senses dominate the perceptions ========================================== ALL WHICH AFFECT PERCEPTIONS OF HEALTH

36. Importance of • Conceptual clarity: provides common definitions within the culture that guides the tool • Operating from an understanding of the cultures contextual conditions to assure that all questions are locally, culturally, and developmentally appropriate Unites the caregiver with the voice of the individual = Improved service satisfaction

37. Importance of Culturally Sensitive Measurement Tools • Key component to formulation qualitative data into quantitative data which my initiate change • Healthcare reform is now at the forefront of Congressional committees in the U.S. • Ranked as high priority is the improvement of health of underserved population

38. “The Measurement of Health is an Essential Requirement for the Evaluation of Health Policy, Assessment of Intervention Effectiveness, and Measurement of the Efficiency of Health Systems” (McDowell, Ian) The Patient’s Voice is Our Greatest Ally

39. Thank you Bohoma Sthu-thee-yi Gracias Ar kun