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Caring for the Caring for the Southeast Asian PatientSoutheast Asian Patient

Lynne H. Nguyen, M.P.H.Lynne H. Nguyen, M.P.H.Board VP, Asian American Health CoalitionBoard VP, Asian American Health Coalition

Director, Minority & Women Clinical Trials Recruitment, Director, Minority & Women Clinical Trials Recruitment, M. D. Anderson Cancer CenterM. D. Anderson Cancer Center

Who Are they?Who Are they?

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Identification of Southeast AsiansIdentification of Southeast Asians

Classification complicated due to diversityClassification complicated due to diversityMost common languages in Houston: Vietnamese, Most common languages in Houston: Vietnamese, Hindi/Gujarati/Urdu, Chinese (Cantonese/Mandarin), Hindi/Gujarati/Urdu, Chinese (Cantonese/Mandarin), KoreanKoreanReligion: Christianity, Buddhism, Hinduism, IslamReligion: Christianity, Buddhism, Hinduism, IslamCultureCulture

Asian data is often presented in the aggregate, Asian data is often presented in the aggregate, applied to the group as a whole. This may mask applied to the group as a whole. This may mask important differences among different important differences among different subgroups subgroups

Establishing a Foundation Establishing a Foundation for Understandingfor Understanding

Culture is best used to Culture is best used to understandunderstand behavior, rather behavior, rather than to than to predictpredict it, since variation it, since variation within a culture is usually greater within a culture is usually greater than that between cultures than that between cultures –– G. G. GalantiGalanti

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Your ResponsibilityYour Responsibility

Cultural competence requires individual Cultural competence requires individual providers at a minimum to providers at a minimum to Acknowledge cultural differences Acknowledge cultural differences Understand your own culture Understand your own culture Engage in selfEngage in self--assessment assessment Acquire cultural knowledge & skills Acquire cultural knowledge & skills View behavior within a cultural context View behavior within a cultural context

Cross et al, 1989

Stereotype vs. GeneralizationStereotype vs. Generalization

Yuko grew up in Japan. She must know karate.

Yuko grew up in Japan. Yuko, did you ever study karate?

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PatientPatient--Focused Care: Focused Care: Key Components of World ViewKey Components of World View

ME

Family Background

Ethnic Heritage

AgeIm

port

ant

Valu

es

Sexual Orientation

Gend

er

Regional Background

Soci

al C

lass

Mental/Physical Disabilities Occupation

Lang

uage

Travel Experiences

Relationship Status

Educational ExperiencesRace

Religious Tradition

Cult

ure

Group Membership

Nat

iona

lity

Econom

ic Stat

us/Clas

sPo

litica

l Aff

iliatio

ns

Chaplain David F. Berg, MA, MDiv & Doretta E. Stark, MA, LICSW

A ProfileA Profile

90% of Asian adults in Harris 90% of Asian adults in Harris County are firstCounty are first--generation generation (from Vietnam, Cambodia, (from Vietnam, Cambodia, Laos, China, India, Pakistan, Laos, China, India, Pakistan, the Philippines, Korea, or the Philippines, Korea, or other API nations)other API nations)67% grew up in their native 67% grew up in their native lands, and came to the U.S. lands, and came to the U.S. as adultsas adults47% came to Houston 47% came to Houston directly from abroad, without directly from abroad, without having lived anywhere else having lived anywhere else in Americain America

Steven Klineberg, 2003

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A Closer LookA Closer Look

Vietnamese are significantly Vietnamese are significantly more likely to not have more likely to not have graduated from high schoolgraduated from high schoolFilipinos are most likely to Filipinos are most likely to have college degreeshave college degreesS. Asians and Filipinos are S. Asians and Filipinos are most likely to have post most likely to have post graduate degreesgraduate degrees28% of Vietnamese work in 28% of Vietnamese work in production or day labor jobsproduction or day labor jobsSE Asians are more likely to SE Asians are more likely to not have insurance and to not have insurance and to report problems getting report problems getting groceries for their families. groceries for their families.

Steven Klineberg, 2002

The Model MinorityThe Model Minority

59% have college degrees59% have college degrees24% have done post graduate work 24% have done post graduate work beyond collegebeyond collegeStable families, lower divorce rates, Stable families, lower divorce rates, polite, wellpolite, well--behaved childrenbehaved children

Steven Klineberg, 2003

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Conditions/Diseases to NoteConditions/Diseases to NoteCancersCancers

BreastBreastLungLungColonColonProstateProstateLiverLiverStomachStomachCervicalCervicalThyroidThyroid

Cardiovascular diseasesCardiovascular diseasesStrokeStrokeHeart attackHeart attack

Other risksOther risksDiabetesDiabetesMental healthMental healthTobacco useTobacco useTuberculosisTuberculosisHepatitis B Hepatitis B ThalassemiaThalassemia

Asian and Pacific Islander American Health Forum (www.apiahf.org)

NonNon--Verbal CommunicationVerbal Communication

Note: Note: Eye contactEye contactPersonal spacePersonal spaceTouchTouchHand gesturesHand gesturesNoddingNoddingSmiling, shruggingSmiling, shruggingStoicism (pain, mental health)Stoicism (pain, mental health)Time orientationTime orientation

Approaches:Approaches:Avoid hand gestures. Use both Avoid hand gestures. Use both hands to give somethinghands to give somethingObserve spatial needsObserve spatial needsExplain procedures before Explain procedures before physicalphysicalAssess pain/discomfort, offer Assess pain/discomfort, offer solutionssolutionsCalm, unhurried demeanorCalm, unhurried demeanorEmphasize time focus, explain, Emphasize time focus, explain, remindremind

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Verbal CommunicationVerbal CommunicationNote: Note:

““YesYes””Saving faceSaving faceHe said, she saidHe said, she saidTone of voiceTone of voiceIndirect styleIndirect styleTranslationsTranslations

Approaches:Approaches:Avoid jargonAvoid jargonFocus on the highest priorities: Focus on the highest priorities: informed consent, selfinformed consent, self--care skills, care skills, how to recognize problems and how to recognize problems and know how to respond, and know how to respond, and answering questions.answering questions.Be explicit on next steps. Assess Be explicit on next steps. Assess

understanding through understanding through demonstration or explanationdemonstration or explanationAsk openAsk open--ended questionsended questionsClarifyClarifyEstablish trust before discussing Establish trust before discussing personal issuespersonal issuesFormal approach, address elders Formal approach, address elders first, use titlesfirst, use titlesAllow longer response timeAllow longer response timeBeware of family translators Beware of family translators

Desire for Information & Desire for Information & DecisionDecision--MakingMaking

Note: Note: Patriarchal view of Patriarchal view of medicinemedicineFamily may prefer Family may prefer patients not receive bad patients not receive bad newsnewsRespect for ageRespect for ageRespect for education Respect for education and wisdomand wisdomRespect for harmonyRespect for harmonyFear of technologyFear of technology

Approaches:Approaches:Provide options, but also Provide options, but also recommendationsrecommendationsAsk who should be Ask who should be included in medical included in medical decisionsdecisionsFormal and warm styleFormal and warm styleAppropriate dress Appropriate dress Share information/ Share information/ resourcesresources

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Health Beliefs & PracticesHealth Beliefs & Practices

Note:Note:““HotHot”” and and ““ColdCold””Traditional medicinesTraditional medicinesCauses of illnessCauses of illnessBody imageBody imageHome remediesHome remediesEfficacy of western medicinesEfficacy of western medicinesPrevention and prophylacticsPrevention and prophylacticsRespect for propriety & harmonyRespect for propriety & harmonyFear of technology. Fear of technology. Hospital/hospice seen as last Hospital/hospice seen as last resortresortYour numberYour number’’s ups up

Approaches:Approaches:Suggest balanced dietSuggest balanced dietAsk about herbal medicine use. Ask about herbal medicine use. Check for drug interactions. Check for drug interactions. Tamp down emotions. Ask, clarifyTamp down emotions. Ask, clarifyCheck medication regime, get Check medication regime, get relativesrelatives’’ observations, repeat observations, repeat instructions, explaininstructions, explainHave same gender person present Have same gender person present during physical examsduring physical examsExplain procedures before and Explain procedures before and duringduringAccommodate patientAccommodate patient’’s preference s preference when possiblewhen possible

Working with InterpretersWorking with Interpreters

Remember that a translated Remember that a translated conversation takes twice as longconversation takes twice as longLook at your client, not the Look at your client, not the translator. Dontranslator. Don’’t say, t say, ““Tell her Tell her thatthat…”…”. Speak directly to the . Speak directly to the clientclientDO NOTDO NOT use family members use family members --especially children especially children -- as as interpreters unless client interpreters unless client specifically requests thatspecifically requests thatTranslators and interpreters are Translators and interpreters are highly trained professionalshighly trained professionals

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Undocumented Immigrants,Undocumented Immigrants,Refugees, Refugees, AsyleesAsylees

Utmost sensitivity is required. They may have experienced treatmUtmost sensitivity is required. They may have experienced treatment ent at the hands of at the hands of official institutionsofficial institutions that one could hardly imagine, that one could hardly imagine, such as torture and trauma, execution or kidnapping of family such as torture and trauma, execution or kidnapping of family members, forced separations, members, forced separations, harrassmentsharrassments, etc. . . , etc. . . Giving out any identifying information, including names or coGiving out any identifying information, including names or co--residents and location of relatives, can be threateningresidents and location of relatives, can be threateningYou may be perceived as an You may be perceived as an ““authority figureauthority figure”” and therefore not to and therefore not to be trusted. be trusted. Questionnaires, forms, informed consents. . . Can be anxietyQuestionnaires, forms, informed consents. . . Can be anxiety--provokingprovokingEmotional and mental illness, often covert, are especially prevaEmotional and mental illness, often covert, are especially prevalent lent among refugees and among refugees and asyleesasylees. Often the symptoms, if expressed at . Often the symptoms, if expressed at all, are expressed physically. Many will deny a problemall, are expressed physically. Many will deny a problemCertain health problems such as TB and parasites can be prevalenCertain health problems such as TB and parasites can be prevalentt

Carrie Cameron, Ph.D.

Working with Other Cultures: Working with Other Cultures: Skills SummarySkills Summary

Think about acculturation level Think about acculturation level and SESand SESRemember, culture is often Remember, culture is often behind wellbehind well--meaning clashes meaning clashes over ethical & unethical, over ethical & unethical, professional & unprofessional, professional & unprofessional, etc.etc.Identify and use culture Identify and use culture brokersbrokersUse the strengths of the Use the strengths of the culture youculture you’’ve learned about to ve learned about to build a bridge build a bridge -- BUT you donBUT you don’’t t have to change your behavior have to change your behavior for each type of clientfor each type of client

Develop the ability to tolerate Develop the ability to tolerate your emotions and reactions your emotions and reactions without acting on themwithout acting on themDonDon’’t put too much pressure t put too much pressure on yourself to be on yourself to be ““correctcorrect””. . Learn as you goLearn as you goAlways be on the lookout for Always be on the lookout for the missing piece of the the missing piece of the puzzle. There is usually a puzzle. There is usually a reason why people act and reason why people act and feel the way they dofeel the way they doAlways strive for a creative Always strive for a creative third solutionthird solution

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LEARN to Become LEARN to Become Culturally CompetentCulturally Competent

LListen with sympathy and understanding to the isten with sympathy and understanding to the patient's perception of the problem patient's perception of the problem EExplain your perceptions of the problem and your xplain your perceptions of the problem and your strategy for treatment. strategy for treatment. AAcknowledge and discuss the differences and cknowledge and discuss the differences and similarities between these perceptions. similarities between these perceptions. RRecommend treatment while remembering the ecommend treatment while remembering the patient's cultural parameters. patient's cultural parameters. NNegotiate agreement. It is important to egotiate agreement. It is important to understand the patient's explanatory model so understand the patient's explanatory model so that medical treatment fits in their cultural that medical treatment fits in their cultural framework. framework.

Berlin & Fowkes

8 Questions to Ask8 Questions to Ask1.1. What do you call the problem?What do you call the problem?2.2. What do you think caused this problem?What do you think caused this problem?3.3. Why do you think it started when it did?Why do you think it started when it did?4.4. What do you think the sickness does? How does it work?What do you think the sickness does? How does it work?5.5. How severe is the sickness? Will it have a short or long How severe is the sickness? Will it have a short or long

course?course?6.6. What kind of treatment do you think the patient should What kind of treatment do you think the patient should

receive? What are the most important results you hope receive? What are the most important results you hope she receives from this treatment?she receives from this treatment?

7.7. What are the chief problems the sickness has caused?What are the chief problems the sickness has caused?8.8. What do you fear most about the sickness?What do you fear most about the sickness?

Arthur Kleinman et al, 1978

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When Communications Go AwryWhen Communications Go Awry

When Communications Go AwryWhen Communications Go Awry

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The New Golden RuleThe New Golden Rule

Treat others as Treat others as THEYTHEYwould like to be would like to be

treatedtreated