CULTURALCOMPETENCY

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

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.

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.

Different languages Different explanatory models of the cause

and treatment of illness Religious beliefs Ways of understanding the experience of

suffering and dying

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

Importance of Cultural Competence

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

US Diversity

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

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

Health Care 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

Black Disparities

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

Cultural Barriers

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

Need for Cultural Competence

“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.

LCME

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.

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

Cultural Competence

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

Cultural Sensitivity

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

Culturally Incompetent Communication

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

Culturally Competent Care

Trust is critical to cross-cultural cooperation

Addressing and respecting cultural differences will likely increase trust

Trust

Integrated pattern of learned beliefs and behaviors◦ Language◦ Thoughts◦ Communication◦ Ways of interacting◦ Views on roles and relationships◦ Actions◦ Practices/Customs ◦ Values

Culture: Definition

Race Ethnicity Nationality Language Gender Sexual orientation Socioeconomic status Physical and mental ability Occupation

Socio-Cultural Factors

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

Religion and Spirituality

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

Culture in Health Care

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

Medicine as a Culture

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

Patient Autonomy and Truth-Telling

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

Disease and Illness

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

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

Cultural Competence Do’s

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

Cultural Pitfalls

Interrupting Failing to maintain appropriate physical

distance Failing to listen Assuming words mean the same to patient Stereotyping Appearing disrespectful

Cultural Pitfalls

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

Stereotyping

Elicit patient perspectives on illness and their expectations

Ask patient if they have a certain belief Open-ended questions Empathic comments

Avoid Stereotyping

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

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

Cultural Competency Training

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?

Questions

Kleinman

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?

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.?

Questions

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

Does Not Prevent All Conflicts

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

Examples of Cultural Context

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

Religion - Specific Cultures

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

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”

Asian

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

Navajo

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

Blacks

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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.

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References

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

RISK

RISK’’ Reduction Assessment to Ascertain Level of Cultural Influence

Resources for patientsand families

Tangible resources that the family can draw on, such as:level of education, socioeconomic status (includinginsurance), social support networks, in-languagesocial service agencies, transportation, groceryshopping, etc.

What kind of assistance is available to you in yourcommunity that might be helpful during this time?’’‘‘Do you know others in your community who have facedsimilar difficulties?’’

Individual identity andacculturation/assimilation

Questions about the patient, the context of his or her life,and individual circumstances, including place of birth,refugee or immigration status, languages spoken, anddegree of integration within the ethnic community.

‘‘Where were you born and raised?’’‘‘When did you emigrate to the U.S. and how has yourexperience been coming to a new country?’’‘‘What languages do you speak and in which are you mostcomfortable talking?’’What are your most important concerns now that youhave this illness?Life history assessment: ‘‘What were other importanttimes in your life and how might these experienceshelp us to know you?’’

Skills available to thepatient and family toadapt to the diseaserequirements

The actual ability of the patient and the family to navigatethe health care system and cope with the demands ofthe disease itself—emotionally, physically, socially,and spiritually.

‘‘Who are the people in your support system that arehelpful or harmful?’’‘‘Who is there to help you with physical care, emotionalsupport, transportation, and care of loved ones.’’‘‘Who do you see or talk with, where do you go forreligious or spiritual strength, or solace?

Knowledge about theethnic group’s healthbeliefs, values,practices, and Cultural communication etiquette

Beliefs, values and practices associated with communication etiquette and health, including attitudes toward truth-telling, family-centered vs.individual-centered decision-making style, historical, social, and political issues that might affect relationships between the patient and elements of the dominant culture.

Knows the dominant ethnic groups in practice. Reads about the different cultures. Attends continuing education programs about each culture—the beliefs, values, and practices surrounding health, including truth-telling. What is the symbolic meaning of the disease?Learns about surrounding death and dying;Does the patient/family adhere these beliefs and practices?How are decisions made in this cultural group? Does this family adhere to traditional cultural guidelines or do they adhere more to the Western model?

A Attitudes B Beliefs C Context D Decision making E Environment

ABCDE

E Explanation T Treatment H Healers N Negotiate (mutually acceptable

options) I Intervention (mutually acceptable) C Collaboration (patient, family, healers) S Spirituality

ETHNIC

B Beliefs 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?

BELIEF

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

LEARN

Assessment – willing to participate in discussion

Preparation - disclose potentially upsetting information

Communication - caring, kind, respectful manner, do not rush, positive focus

Follow-through

APCE