Cultural Competent Health Care

Agenda

• Questions & concerns

• Discussion on culture, race, ethnicity, & value

• Needs for cultural competent care

• Negotiation for dates for individual presentations

Shrink the Earth’s Population to 100

• 57 Asians

• 21 Europeans

• 14 North, Central and South Americans

• 8 Africans

• 70 would be non-white, 30 white

• 70 would be non-Christian, 30 Christian

Population in the U.S.

Year 2000

• Whites – 69.4%

• Black – 12.7%

• Hispanic – 12.6%

• Asian – 3.8%

Year 2050

• Whites – 50%

• Black – 14.6%

• Hispanic – 24.4%

• Asian – 8%

US Census Bureau, 2004

Registered Nurses in the U.S.(2000)

• 86.6% - non-Hispanic white

(US dept of Health & Human Service, 2003)

Population in San Jose (2000)

• Whites - 47.5% • Hispanic - 30.2%• Asian - 26.9% • Black - 3.5%

U.S. Census Bureau (2006)

Globalization :Q: How to define globalization?A: Princes Diana’s deathQ: How come?A: An English princess with an Egyptian boy-friend crashes in a French tunnel, in a German car with a Dutch engine, driven by a Belgian who was pissed on Scottish whiskey, followed closely by an Italian paparazzi, on Japanese motorcycles, treated by an American doctor, using Brazilian medicines.And this is sent to you by a Israeli, using Bill Gates’Technology which he stole from the Taiwanese.

Minorities Receive Lower Quality Health Care Than Whites

• Institute of Medicine, 100 studies reviewed over past 10 yrs.

• Full report www.nap.edu/books/030908265X/html• Minorities less likely to receive sophisticated Txs

for AIDS• More likely to have leg amputations for diabetes• Poorer relationships with MDs

Other Cultural Domains

• Folk beliefs/religion - can be confused with “religiosity”

• Stereotyping labels - avoid generalizations• Ethnopharmacology - genetic influence, effect,

metabolism• Herbal therapies - interactions with meds• Folk healers & treatment approaches, e.g..,

hysteria, psychosis

Cultural competence &impact on clinical outcomes

• Patients fear of being misunderstood or disrespected; • Providers are not familiar with the prevalence of

conditions among certain minority groups • Providers may fail to take into account differing

responses to medication • Providers may lack knowledge about traditional

remedies, leading to harmful drug interactions • Patients may not adhere to medical advice because they

do not understand or do not trust the provider; • Providers may order more or fewer diagnostic tests for

patients of different cultural backgrounds

ethnic disparities in health care

• African American women are more likely than European American women to die from breast cancer, despite having a lower incidence of the disease.

• Infant mortality rates are 2.5 times greater for African Americans and 1.5times greater for Native Americans than for European Americans.

• Influenza death rates are higher for African Americans and American Indian/Alaska Natives/Native Alaskans than they are for European Americans.

• Mortality for colorectal cancer is highest for African Americans, followed by Native Alaskans, and then Hawaiians.

Needs for cultural competence

• American nurses experienced a lack of cultural confidence in caring for culturally diverse populations - Coffman, Shellman, & Bernal (2004) and Hagman (2006)

• There were gaps in healthcare providers’ knowledge of other cultures and how to care for them in culturally sensitive ways - Jones, Cason, and Bond (2004)

Other evidences• Negative racial stereotypes - rate black patients as

more likely to abuse drugs and alcohol, less likely to comply with medical advice, and less likely to participate in cardiac rehab than white patients - Van Ryn and Burke (2000)

• Less Dx test - physicians were less likely to recommend catheterization procedures for black female patients than white or black male patients if they experienced the same kind of symptoms. Schulman et al. (1999)

cultural competence is a process

• American Nurses Association published its first guidelines on cultural diversity in nursing curricula in 1986 - understanding the concept of human diversity including cultural and racial variations

• The Board of Registered Nursing of California (2006) has required all nursing schools in California to include cultural diversity and competence into their curricula

Language barriers and disparity

• Utilization of health care services– Fewer doctor visit and less preventive services– More diagnostic test to compensate communication

problems• Satisfaction

– Less satisfied unless with interpreter• Adherence

– Miss the appointment or drop out• Outcomes• Patient education

Health Disparities

• President Clinton (1998) set the goal – reduce health disparities by the year 2010.

• Target areas: (NIH, 2003)– Infant mortality, – Cancer screening and management, – Cardiovascular disease, – Diabetes,– HIV/AIDS, – Immunization

Problems with Health Disparities- with cultural factors

Flaskerud, J. et al (2002) – a review of 79 articles in the past 5 decades:

– Ignorance of certain groups (indigenous peoples)

– Inappropriate lump together ie. Hispanic members of disparate groups with their own cultural identity eg., Puerto Ricans, Mexicans, Cubans, Dominicans

Aday’s 2010 Priorities Showcase – Needs within vulnerable population

• High-risk mothers & infants-of-concern• Chronically ill & disabled• Persons living with HIV/AIDS• Mentally ill & disabled• Alcohol & other substance abuses• Suicide- or homicide-prone behavior• Abusive families• Homeless persons,• Immigrants/refugees

Impact of Cultural Competency

• More successful patient education• Increases in pt’s health care seeking behavior• More appropriate testing and screening• Fewer diagnostic errors.• Avoidance of drug complications• Greater adherence to medical advice• Expanded choices and access to high-quality

clinicians.

Culture - Bound Syndromes

• A person living within a certain reality

• Learned way to interpret the world based on enculturation

• Recurrent, locality- specific patterns of aberrant behavior and troubling experiences that may not be linked to a DSM-IV diagnosis

Culture Bound Syndromes

Group Disorder Explanation

Caucasian Anorexia Preoccupied body wt. & image

Nervosa

Bulimia

Binge eating followed by vomiting

African American Low blood Insufficient blood or weakness of blood

High blood Blood that is too rich

Thin blood Susceptibility to illness

Culture Bound Syndromes Cont.

Group Disorder Explanation

Chinese/ Southeast Asian

Koro Fear that penis is retracting into body

Amok Acute reaction to loss,

Culture Bound Syndromes Cont.

Hispanic Disorder Explanation

Empacho Food clings stomach & intestines: pain

Mal ojo “evil eye” Stranger’s attention causes illness in children

Susto Anxiety, phobias

Culture Bound Syndromes Cont.

Group Disorder Explanation

Native American Ghost Hallucinations, terror

Japanese Wagamama Childish behavior

Korean Hwa-Byung Multiple somatic & psychological symptoms

Cambodian Koucharang “thinking too much”

Headaches, chest pain, palpitations, SOB, insomnia

Temporal Relations

• Time Orientation

• Past, present or future-oriented

• Punctuality

Negotiation Process

• Listen: to the client’s perspective• Teach: from your knowledge in language

appropriate for client & family• Compare: similarities & differences, disagree but

do not devalue client’s view• Compromise:

– if client treatment not harmful, promote

– If harmful, explain harm and suggest alternatives

Gorin, S. & Arnold, J. (1998). Health Promotion Handbook. St Louis: Mosby. P 92

The Health Promotion Matrix

Before Next Class• Take extra care of yourself and your family• Prepare by reading for class: get copies of articles• Decide on group presentation medium for

presentation; bring IBM compatible disk one week before if you want to use Power Point for your presentation; limit slides to 30

• Continue work on your group for presentation• Have a great week

The End