1. Cultural Competency in Caring for Diverse Populations Fern R. Hauck, MD, MS Department of Family Medicine University of Virginia Health System September 11, 2006

2. 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 International Family Medicine Clinic

3. “I don’t think one can ever really know any but one’s own countrymen. For men and women are not only themselves; they are also the region in which they were born, the city apartment or farm in which they learned to walk, the games they played as children, the old wives’ tales they overheard, the food they ate, the schools they attended, the sports they followed, the poets they read, the god they believed in. It is all of these things that have made them what they are and these are the things that you cannot come to know by hearsay; you can only know them if you have lived them.” Somerset Maughan, The Razor’s Edge (Introduction) 1944.

4. Commonwealth Fund 2001 Healthcare Quality Survey 7,000 adults surveyed Communication problems reported more commonly for African Americans (Af A), Hispanics (H) and Asian Americans (As A) H and Af A adults highest uninsured rates H and As A patients had greatest difficulty understanding information from doctor Less than one half of limited English proficient patients always or usually had interpreters Af A, H, and As A more often felt that they had been treated disrespectfully or with little understanding of their culture

5. Commonwealth Fund 2001 Healthcare Quality Survey (continued) (www.cmwf.org) Three main factors in ensuring that minority populations receive optimal medical care:  Effective patient-physician communication  Overcoming linguistic and cultural barriers  Access to affordable health insurance Policy implications  Financing interpreters (few states only)  Training of clinicians and medical students in communicating and interacting effectively with patients from different cultures  Expanding health coverage and access to all

6. Definition of Cultural Competence “ The knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of the patient’s culture; and adaptation of skills.” AMA, Culturally Competent Health Care for Adolescents, 1994.

7. 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.

8. 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.

9. “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.

10. “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).

11. “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?

12. “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.

13. “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.

14. “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).

15. “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.

16. Some Features of Mexican Culture In 2001, Mexicans became largest minority population in the U.S. Value of family over individual or community needs Father or oldest male holds greatest power in most families Respect and formality common in interactions. Uncommon for Mexicans to be assertive in healthcare interactions Direct eye contact less common than among Anglos

17. Some Features of Mexican Culture (continued) A brusque, confrontational or loud provider may not learn of the problems from the patient and patient unlikely to return Physical or mental illness may be attributed to imbalance between the person and environment This may include an imbalance of “hot” and “cold” Curative care favored over preventive care Spirituality/religion important in family and community life Biomedical and folk health systems may be used simultaneously by people of all social backgrounds

18. Some Features of Mexican Culture (continued) Culture-bound syndromes are common :  Mal de ojo (Evil eye) – affects women and children  Susto: fright causes loss of soul, symptoms vague complaints – affects women more commonly  Ataque de nervios: sudden outbursts of negative emotion, in response to stressor

19. 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 Task Force on Community Preventive Services, 2002.

20. International Family Medicine Clinic

21. Goals Provide comprehensive, high quality, culturally competent care to the growing population of limited English proficiency (LEP) patients Develop systems to more efficiently care for patients, including better communication with community partners and standardized screening and evaluation Become a resource for the medical center and others who serve LEP patients Document, evaluate and advocate

22. Current Clinic Structure Started October 2002 5-6 half-day sessions 5 clinicians Interpreters New refugee patients scheduled after Health Department Screening Special forms, cultural profiles, and database Mental health: referral to Family Stress Clinic International Health Intern

23. Community Partners & Patients Served RefugeesImmigrantsLimited Visas Partners International Rescue Committee (IRC) Health Department English as a Second Language (ESL) ESL Blue Ridge Medical Center/Rural Health Outreach Project/ Lay Health Promoter Program ESL UVa International Studies Office Countries Middle East Afghanistan Eastern Europe (Bosnia-Herzegovina, Croatia) Africa (Togo, Liberia, Sudan, Congo) Somali Bantu Meshketian Turks Hill Tribes (Burma) Mexico Central and South America Other China Korea Central & South America Other

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

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

26. Video Scenarios