What Culture Does Your Patient Hurt In? Cultural Competency in Caring for Diverse Populations Fern R. Hauck, MD, MS Department of Family Medicine University of Virginia Health System POM-1, September 10, 2007

Goals of This Talk  Define cultural competency (culturally responsive healthcare, cultural humility)  Describe differences in cultural norms between dominant U.S. culture and other cultures  Discuss ways to provide high quality, culturally competent care  Describe what UVA is doing to address patient care and training

Patient KI: 40 year old female, Somali refugee, who has been in Charlottesville 4 years. Developed gestational diabetes with last pregnancy (here) and continues to have diabetes mellitus. Most recent hemoglobin A1C 18. On maximum therapy orally, refuses insulin. Frequently “noncompliant” with oral medications and other treatment advice.

What is your reaction? How does this patient make you feel? What kinds of issues are involved in her care? How would you approach her in trying to reach the best outcome for her health?

What is culture? The function of culture is to ensure the survival and well-being of its members. Cultures are dynamic, responsive, coherent systems of beliefs, values and lifestyles that have developed within particular geographic locations; they evolve and are passed on from generation to generation. The resulting lifestyle (cultural) patterns of each group -such as diet, marriage rules, and means of livelihood- influence gene expression, health status and disease prevalence.

Components of Culture Environment Economy Technology Religion/world view Language Social structure Beliefs and values (Hammond P, 1978)

Definition of Cultural Competence Having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented, by patients and their communities. Why is this important??? Ever-increasing diversity of the population of the United States Strong evidence of racial and ethnic disparities in health care  Barriers in access to care  Lack of proportional representation of minorities in the health professions  Low levels of cultural competence among health care professionals

Liaison Committee on Medical Education (LCME): Setting the Standard “The 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 treatments. Medical students should learn to recognize and appropriately address gender and cultural biases in health care delivery, while considering first the health of the patient.” (LCME, 2000)

States are Following New Jersey will be the first state to require that physicians have education and training in cultural competence for medical licensure (to take effect in 2008). Other states are considering similar legislation.

Myths and the Misuse of the Concept of Culture 1. Culture is not race 6 racial/ethnic categories by OMB intended to monitor political allocation of resources, not as scientific evidence of genetic differences Greater genetic within-group variation than between Each category contains multiple national groups & multiple ethnic groups within each national group, each with its own culture or subculture

Myths and the Misuse of the Concept of Culture 2. Cultures are not homogeneous Various levels of acculturation, assimilation, age, education, family structure, gender, wealth, refugee or immigrant status all modify the degree to which one’s cultural group membership may influence health practices and health status Each cultural group is continually undergoing change

Myths and the Misuse of the Concept of Culture 3. The Western biomedical model and European-American lifestyle are not the only ways to ensure health Research indicates that prevalence of some illnesses much lower in immigrants’ countries of origin than after settling in the U.S. (e.g., diabetes, breast cancer)

Comparisons of Cultural Norms and Values Aspects of CultureMainstream American Culture Other Cultures Communication and language Explicit, direct communication. Emphasis on content -- meaning found in words. Implicit, indirect communication. Emphasis on context – meaning found around words. Time and time consciousness Linear and exact time consciousness. Value on promptness – time=money. Elastic and relative time consciousness. Time spent on enjoyment of relationships.

Comparisons of Cultural Norms and Values ( continued) Aspects of CultureMainstream American Culture Other Cultures Relationships, family, friends Focus on nuclear family. Responsibility for self. Value on youth, age seen as handicap. Focus on extended family. Loyalty and responsibility to family. Age given status and respect. Values and normsIndividual orientation. Independence. Preference for direct confrontation of conflict. Group orientation. Conformity. Preference for harmony. Beliefs and attitudesEgalitarian. Challenging of authority. Individuals control their destiny. Gender equity. Hierarchical. Respect for authority and social order. Individuals accept their destiny. Different roles for men and women. Gardenswartz L, Rowe A. Managing Diversity: A Complete Desk Reference and Planning Guide, 1993.

Communicating in a Cross-Cultural Encounter The physician could work exclusively within the biomedical paradigm The patient and physician could function exclusively within each of their native cultures The physician could work within the patient’s cultural framework The physician and patient could negotiate between their concepts of the etiology of disease & the most appropriate means of treatment to reach mutually desirable goals (Kagawa-Singer M, 2003)

“Ethnic Mnemonic” E: Explanation T: Treatment H: Healers N: Negotiation I: Intervention C: Collaboration and Communication Developed by: Steven J. Levin, MD; Robert C. Like, MD; Jan E. Gottlieb, MD. Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School.

“Ethnic Mnemonic” – “E” E: Explanation  What do you think may be the reason you have these symptoms?  What do friends, family, others say about these symptoms?  Do you know anyone else who has had or who has this kind of problem?  Have you heard about/read/seen it on TV/radio/newspaper? (If patient cannot offer explanation, ask what most concerns them about their problem).

“Ethnic Mnemonic” – “T” T: Treatment  What kinds of medicines, home remedies or other treatments have you tried for this illness?  Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it.  What kind of treatment are you seeking from me?

“Ethnic Mnemonic” – “H” H: Healers  Have you sought any advice from alternative/folk healers, friends or other people (non-doctors) for help with your problems? Tell me about it.

“Ethnic Mnemonic” – “N” N: Negotiation  Negotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs.  Ask what are the most important results your patient hopes to achieve from this intervention.

“Ethnic Mnemonic” – “I” I: Intervention  Determine an intervention with your patient. May include incorporation of alternative treatments, spirituality, and healers as well as other cultural practices (e.g. foods eaten or avoided in general, and when sick).

“Ethnic Mnemonic” – “C” C: Collaboration and Communication  Collaborate with the patient, family members, other health care team members, healers and community resources.  Effectively use interpreters in encounters with patients with limited English proficiency.

Additional Tips 1.Don’t treat the patient in the same manner as you would want to be treated. 2.Begin by being more formal with patients who were born in another culture. 3.Don’t be “put off” if a patient fails to look you in the eye. 4.Don’t dismiss beliefs that are not held by our Western biomedical tradition. 5.Be cautious in relating bad news or in outlining detailed differential diagnoses. (Salimbene S, 2005)

Culturally Competent Healthcare Systems Interpreters or bilingual providers Cultural diversity training for staff Linguistically and culturally appropriate health education and information materials Tailored healthcare settings, such as refugee or immigrant health clinics (Task Force on Community Preventive Services, 2002)

International Family Medicine Clinic Started in October 2002 Collaboration between IRC, Health Department, and Family Medicine New refugee patients scheduled after Health Department screening Provide treatment of tropical, acute, chronic illnesses to refugee families Refer to specialists as needed, coordinate care 1000 patients from 50+ countries, speaking 30+ languages: Afghanistan Somalia Liberia Sudan Burma Uzbekistan

Community Outreach & Collaboration  ESL program/health literacy presentations and role plays  Health fairs

UVA Services Interpreters: In-house or via contracted providers; CyraCom phone Cultural diversity training for staff: culture fairs, CultureGrams Linguistically and culturally appropriate health education and information materials (Spanish mostly)

Course Offerings International, Tropical and Cross-Cultural Medicine (Elective)  1415 (Family Medicine and Internal Medicine)  4 week elective  Drs. Houpt and Hauck, course directors

Patient KI: 40 year old female, Somali refugee, who has been in Charlottesville 4 years. Developed gestational diabetes with last pregnancy (here) and continues to have diabetes mellitus. Last hemoglobin A1C 18. On maximum therapy orally, refuses insulin. Frequently “noncompliant” with oral medications and other treatment advice.

What is your reaction? How does this patient make you feel? What kinds of issues are involved in her care? What else would you like to know about KI? How would you approach her in trying to reach the best outcome for her health?

Questions or Comments?