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Cultural and Linguistic Competency & Health Literacy for Primary Health Care Providers Kentucky Primary Care Association October 19, 2010 Torrie T.

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Presentation on theme: "Cultural and Linguistic Competency & Health Literacy for Primary Health Care Providers Kentucky Primary Care Association October 19, 2010 Torrie T."— Presentation transcript:

1 Cultural and Linguistic Competency & Health Literacy for Primary Health Care Providers Kentucky Primary Care Association October 19, 2010 Torrie T. Harris, Dr.P.H., M.P.H. Director, Health Equity Branch, Commissioner of Public Health Office, KY Dept. For Public Health

2 Workshop Objectives Define Health Disparities and Health Equity
Define Cultural and Linguistic Competency and the rationale for practicing as a culturally and linguistically competent healthcare professional. Implement/practice strategies for reducing practitioners’ own biases and misconceptions when encountering patients of a differing cultural background

3 Workshop Objectives Identify when a language barrier is present and an interpreter is needed Recognize the advantages and disadvantages of trained vs. untrained interpreters Identify resources to assess individual and organizational cultural and linguistic competency

4 Workshop Objectives Discuss the link between health reform, cultural and linguistic competency.

5 Resources Agency for Healthcare Research and Quality
US DHHS Office of Minority Health MedScape Internal Medicine: Cultural Competency in Healthcare: A Clinic Review and Video Vignettes From the National Medical Association Georgetown Center for Cultural Competence Google or Bing it: “Cultural and Linguistic Competence”

6 Background KY has seen unprecedented growth in the diversity of their demographics. The rate of population increase is higher for communities of color. According to the Census from 1990 to 2000 there was a 172.6% growth of the Hispanic/Latino population. There was a 49.3% growth of American Indian/Alaska Native; 75.1% growth of Asians; and a 76.1% growth of Native Hawaiian and Other Pacific Islanders.

7 Background

8 Background The African American population grew by 12.6% while the White, non-Hispanic population grew by 6.8%. In 2000, More than 29,000 Kentuckians had limited English proficiency, and the number is expected to increase. Gonzalez indicated that U.S. residents will speak an estimated 329 languages, and 32 million will speak a language other than English at home within the next decade.

9 Health Equity Branch KY Dept. for Public Health
Established in Fall 2008 Funded by the U.S. DHHS, Office of Minority Health and the KY Dept. for Public Health Overarching Goals: To eliminate health disparities among racial and ethnic minorities, rural and low income populations in the state of KY. To promote health equity in the state of KY.

10 Health Equity Branch Activities
Obtained an Administrative Order from Secretary Miller to officially establish the Branch. Obtained $420,000 over the course of 3 years from the US DHHS Office of Minority Health to focus on: Cultural and Linguistic Competency Hispanic Health Programming Research and Evaluation

11 Health Equity Branch Activities
Cultural and Linguistic Competency Assessment of Local Public Health Depts. in KY. Promoting Health Equity Mini-Grants Healthy People 2020 Infant Mortality Health Disparities Diabetes/Obesity Collaborative Environmental Health Disparities Lex-Fayette Health Equity Network

12 Definitions Health Disparities or Health Inequalities: Empirically evident differences that exist in the quality of health and health care across racial, ethnic, sexual orientation, and socioeconomic groups. US DHHS sees health disparities as “population-specific differences in the presence of disease, health outcomes, or access to health care. across different social groups in a society (Peter, 2000). Health Inequities: are a subset of health inequalities or disparities involving circumstances that may be controlled by a policy, system, or institution so that the disparity is avoidable. These kinds of health disparities may include health and healthcare disparities. SOURCE: Center for Health Equity, Louisville Metro Public Health & Wellness, Overview & Key Ideas, Retrieved Januray,12, 2009 online at:

13 Health Disparities & Healthcare
Low socioeconomic status (SES) has been specifically linked to racial/ethnic disparities in access to quality health care. Agency for Healthcare Research and Quality (AHRQ) 2006 National Health Disparities Report stated that 73% of Afr-Am and 77% of Hispanic received worse quality healthcare than their counterparts or reference groups, partially attributed to provider or health system biases. SOURCE :U.S. DHHS (2005) National Healthcare Disparities Report. Agency for Healthcare Research and Quality. Rockville, MD. Retrieved online June 25,2009 at

14 Health Disparities: Infant Mortality Rates
Health Disparities: Infant Mortality Rates* by Race; Kentucky 1993, & **Background

15 White African American
Health Disparities in the Leading Causes of Death in Kentucky 2005 Age-Adjusted Rate per 100,000 Population White African American Heart Disease Heart Disease Cancer (all sites) Cancer (all sites) Stroke Stroke Diabetes Diabetes

16 Examples of Health Disparities

17 Causes of Health Disparities
Multifactoral Sociocultural Genetics Economic Healthcare delivery systems Systems of Care Patient and Communities Healthcare providers

18 Social Determinants of Health

19 Social Determinants by Populations

20 Social Determinants by Population

21 Definitions Health Equity: When everyone has the opportunity to “attain their full health potential” and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance. SOURCE: Whitehead M, Dahlgren G. Leveling Up (Part 1): A Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health. World Health Organization. Available at e89383.pdf.


23 Strategies for Achieving Health Equity
Awareness: Increase significance of health disparities, their impact on the nation, and actions necessary to improve health outcomes. Leadership: Strengthen and broaden leadership for addressing health disparities at all levels. Health and Health System Experience: Improve health and healthcare outcomes for racial and ethnic minorities and for underserved communities. Cultural and Linguistic Competency: Improve competency. Research and Evaluation: Improve coordination and utilization of research and evaluation outcomes.

24 Health Reform & Health Disparities
Data Collection Directs new Assist. Sec of Health Information to Set standards for data collection Coordinate analysis of data on health disparities with HHS Language Access and Cultural Competence Qualified health plans have appropriate communication and services Test models and curricula that train health professionals Require a study on how Medicare can reimburse health professionals providing language services and create a 3 yr grant program to test Extend matching rates for states that provide language services to for Medicaid beneficiaries not just children. Workforce Diversity Permanent advisory committee Increase funding and scholarships for disadvantaged students, with special consideration to institutions with a track record of training individuals from minority communities.

25 Achieving Health Equity

26 Achieving Health Equity Strategy: Cultural and Linguistic Competency
Workforce Training: Develop and support broad availability of cultural and linguistic training Diversity: Increase diversity and competency of the healthcare and administrative workforces through recruitment and retention of racially, ethnically, and culturally diverse individuals through leadership by healthcare organizations and systems Standards: Require Interpreters and bilingual staff providing services in languages other than English to adhere to National Council on Interpreting in Health Care (NCIHC) Code of Ethics and Standards of Practice Interpretation Services: Improve financing and reimbursement for medical interpretation services

27 Definitions Cultural Competence: A set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework. Linguistic Competence: Providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/cultural staff, trained medical interpreters, and qualified translators. SOURCE: Cross et al Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

28 Definitions Cultural and Linguistic Competency: The ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter. SOURCE:2 U.S. Department of Health and Human Services, Office of Minority Health Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda. Accessed January 17, 2003.

29 Background In 1994, Congress recognized the need to address the impact of cultural and linguistic competency on health disparities and mandated the Office of Minority Health, USDHHS to develop to capacity of health professionals to eliminate barriers to health care delivery and access to health care for limited English-proficient people.

30 Cultural and Linguistic Competency
As a result of the 1994 legislation, the Center for Cultural and Linguistic Competence in Health care was created. The National Standards on Culturally and Linguistically Appropriate Services (CLAS) were developed to help guide health care delivery organizations towards a competent workforce.

31 Cultural Competency Joseph Betancourt defines a culturally competent health care system as one that “acknowledges and incorporates-at all levels-the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaption of services to meet culturally unique needs. “

32 What does it mean to be culturally and linguistically competent?
Awareness of one’s own cultural worldview’ Attitude toward cultural differences Knowledge of different cultural practices and worldviews; and Cross-cultural skills

33 Cultural and Linguistic Competency: Scientific Studies
Dilworth-Anderson discovered that a provider’s awareness about their own biases has influence on providing culturally appropriate care. Many studies indicated that physicians tend to display less emotion and communication when dealing with ethnic minority patients, which translated to shorter consultation time and empathy. Gao, Burke, and Sumkin, discovered in their study of culture in physician patient communication during colorectal screening, that interpersonal relationships were common themes that determined whether or not a patient was referred for screening.

34 Competent Healthcare Organizations
Clinical (Provider-patient encounter): Interventions that include equipping individual clinicians with the skills to effectively provide care to diverse patient populations. Organizational (Leadership/Workforce): Recruiting a diverse workforce and leadership that represents the diversity of the community that it serves. Structural (Processes of care) Developing processes of care that facilitate access for underrepresented communities and cultures.

35 Competent Healthcare Organizations
Diverse workforce reflecting patient population. Convenient facilities Language assistance for patients with LEP Ongoing staff training regarding delivery of CLAS. Quality of care tracked across racial, ethnic, and cultural subgroups. Community included in setting priorities and planning, delivery, and coordination of care.

36 Competent Provider-Patient Interpersonal Interaction
Explores and respects patients beliefs, values, meaning of illness, preferences, and needs. Builds rapport and trust Establishes common ground Is aware of own biases or assumptions Maintains and is able to convey unconditional positive regard Is knowledgeable about different cultures Is aware of health disparities and discrimination affecting minority groups Effectively uses interpreter services when needed.

37 The Impact of Unconscious Bias and Stereotypes
Healthcare providers may: Lack recognitions of nonverbal cues when dealing with patients of different cultural backgrounds; Biases; Stereotypes

38 Strategies to Address Unconscious Bias
Awareness training of bias and stereotypes and their effect on clinical decision-making Self-reflection practices Individuation vs. categorization Perspective-taking and affective empathy Partnership building

39 Patient-Provider Communication
Minority patients report lower satisfactions with medical encounters, less partnership with healthcare providers, and less involvement in medical decision making. Minority patients also tend to perceive a lack of respect for their preferences compared with similar white patients. Minority patients may also be distrustful of the healthcare system due to personal experiences or the experiences of people they know.

40 Patient-Provider Communication
Minority patients may feel better with “Setting Talk”: Discussions centers on topics of immediate context, such as the surrounding environment, the clothes one is wearing or daily activities. Healthcare providers may feel more comfortable with “Categorical Talk”: Openly inquiring about another person’s age, occupations, place of residence-things which may be considered private or personal.

41 Patient-Provider Communication
Differences in Expectations of Treatment and Outcomes Differences in Expectation With regard to respective roles Appropriateness of asking questions and receiving info Level of family involvement Differences in Explanatory Models Understanding the connection between symptoms and the underlying disease process or causes of illness May lead to poor patient compliance

42 Selected Behaviors/Perspectives of Various Groups That May Impact Treatment-Seeking Behaviors
Culture Behaviors/Perspectives Mexicans Health is a gift from God and a reward for good behavior Health results from maintaining balance in the universe between “hot” and “cold” forces, illness in an individual body is considered a punishment meted out for wrong doing. Haitians Health is a state of harmony with nature. Illness is a state of disharmony and is also caused by movement of blood, problems with gas, imbalance between “hot” and “cold” forces, and voodoo or a spell placed on a person. To maintain health, the spirit and body must be linked together by the soul. May not feel comfortable discussing their spirit and soul with a medical practitioner for fear that their explanation may be misunderstood Native Americans Health is a state of total harmony with nature; human beings have an intimate relationship with nature. Illness is considered a price paid for something that happened in the past or that will happen in the future. Illness may also be due to evil spirits. Southern Blacks May feel that their illness is due to sin or evil. May feel that illness such as a cold is due to weather rather than a microbiologic factor (e.g. going out in the cold weather will cause one to a catch a cold.) SOURCE: Data from Giger, J.N., & Davidhizar, R.E. (1991). Transcultural nursing, assessment and intervention. St. Louis, MO: Mosby Year Book.

43 Strategies to Improve Patient-Provider Communication
Explore the respective expectations of an encounter Open discuss interpretation of nonverbal cues Use models of cross-cultural communication Use shared decision-making

44 Models of Cross-Cultural Communication
Tool Question or Approach Kleinman’s questions What do you think has cause your problem? What do you think your sickness does to you? How severe is your sickness? Will it have a short or long course? What kind of treatment to you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness? LEARN Listen with sympathy and understanding to the patient’s perception of the problem Explain your perceptions of the problem Acknowledge and discuss the differences and similarities in perceptions Recommend treatment Negotiate treatment

45 Overcoming Language Barriers
Limited English Proficiency Patients are more likely to: Receive Preventive Care Have consistent source of primary care Receive timely eye, dental, and physical examinations Receive error-free medical care Visit their clinician Return for follow-up visits after being an ER patient

46 Overcoming Language Barriers
Gold Standard: Bilingual-Bicultural Provider who is fluent in the patient’s language and culture and who expects patients to communicate their needs in English only if they have adequate English language skills. Provider should also have the necessary communication proficiency and an understanding of the patient’s language to be able to explain medical concepts in lay terminology.

47 Selecting an Interpreter
Title VI of the 1964 Civil Rights Act says that “requiring, suggesting, or encouraging” a patient to bring his or her friends, minor children, or family members to serve as an interpreter infringers on the patients civil rights. It is also considered illegal if the institution receives federal funds.

48 Interpreters Professionally Trained Interpreters at no cost to patient: Staff Interpreters Agency Interpreters Volunteer Interpreters Telephone Interpreters Bilingual staff is Ok, but not preferred IF patient insists on family member or friend: please honor the request after full disclosure of options Have patient sign waiver, releasing institution of liability.

49 Interpreters Interpreters should be able to do the following:
Be faithful in communicating the patient’s own words to the provider Maintain confidentiality Be trained in memory, note-taking, language transposition Skills that go beyond proficiency in speaking language

50 Friends and Family Compromise of confidentiality
Family member or friend may filter info Level of comfort may be lost Comprehension Children may lack the vocab. Or be embarrassed to discuss sensitive topics.

51 Conducting a Triadic Interview
Provider briefs Interpreter before patient encounter, concerns, expected duration Interpreter may indicate when he/she does not know how to translate or may feel uncomfortable Provider should ask direct questions to patient and observe patient, not the Interpreter Provider should use lay terminology Open to feedback Debrief Be aware of potential problems b/w the patient and Interpreter

52 Contact Info Torrie T. Harris, Dr.P.H. Director, Office of Health Equity KY Dept. for Public Health ext 4027 Maria Gomez, MPH, Doctoral Candidate

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