Cultural Competency in a Health Care Setting

Culture Culture is defined as: a group’s way of perceiving, judging & organizing the ideas, situations & events they encounter in their daily lives. It encompasses a sharing of values, traditions, customs, history, art, myths & superstitions of a people. These are passed down through the ages and become a culture that shapes an individual’s world. The result of varied cultures has a high impact on one’s health care beliefs and behaviors. “Culture” should not be generalized as one’s ethnic background.

Cultural Competency Awareness of cultural differences Sharing a dialect doesn’t always translate to sharing the same culture. Though there are 329 languages spoken in America, most Americans are English speaking. Do all share the same ideology, traditions, religions & values as other English-speaking people? Spanish speakers don’t necessarily speak the same Spanish. Vocabulary, pronunciation, & other facets of the Spanish language vary.

Cultural Competency Healthcare professionals need to have an awareness of and knowledge about cultural differences and their impact on health-related attitudes and behaviors. This requires sensitivity, understanding, and a non-judgmental approach to dealing with people whose culture is different from our own. Flexibility and skill are also necessary when responding and adapting to different cultural contexts and circumstances.

Culturally Competent Care Culturally competent care is defined as the knowledge, skills & attitudes required to provide quality care to patients from different cultural, ethnic & racial backgrounds. It involves tailoring delivery to meet patients' social, cultural and linguistic needs in an effort to improve outcomes and eliminate disparities in healthcare. Cultural competence does not require that individuals be treated by using the same methods used in their country of origin. However, cultural competency does create a compelling case for understanding the different ways people might act & for communicating to ensure the best possible outcome. Instead of presenting a way to limit care, cultural competence provides a way to deliver maximum care.

GOALS OF CULTURALLY COMPETENT CARE CULTURAL AWARENESS: Appreciating and accepting differences CULTURAL KNOWLEDGE: Deliberately seeking out various world views and explanatory models of disease. Knowledge can help promote understanding between cultures CULTURAL SKILL: Learning how to culturally assess a person to avoid relying only on written "facts;" explaining an issue from another's perspective; reducing resistance and defensiveness; and acknowledging interactive mistakes that may hinder the desire to communicate CULTURAL ENCOUNTERS: Meeting & working with people of a different culture will help dispel stereotypes and may contradict academic knowledge. Although it is crucial to gather cultural knowledge, it is an equally important culturally competent skill to be humble enough to remain open to the individuality of each person.

Cultural Differences Impact Behaviors Culture structures our daily lives This includes our approach to health, illness & healing. While no two cultures are the same, no two people are either. The succeeding presentation is not meant to stereotype any ethnicity, race or culture; rather, to offer a basis for understanding possible cultural behaviors that have, according to researchers, impacted health care encounters. Let’s take a look at some basic values & possible beliefs held by the following cultures:

Did you know… African Americans Spend 50% LESS time with their health care provider than Caucasians! WHY? At present, there is not a clear-cut answer. Based on this statistic, the question must be posed: What is the quality of interaction and information being shared with the patient who only gets half as much of the doctor’s time & attention? Health care professionals must make a conscious effort with African American patients to extend care in a manner identical to that given Caucasian patients.

African Americans There are immense differences within this ethnic group, based on age, income, education, & geography Decision to seek care is often delayed For some, fear and mistrust of mainstream institutions and providers of the dominant culture may exist. Hence, the decision to seek care is often delayed. Based on personal history and experience, many African Americans view receiving health care as a degrading, demeaning or humiliating experience. Some may even fear or resent health clinics, because of the long waits, medical jargon, feelings of racism or segregation, loss of identity, and a feeling of powerlessness and alienation in the system (Spector, 2000). Folk or home Remedies In some sects, folk or home remedies are used prior to any medical encounter.

African Americans Social & kinship network Church & religion Bringing family & neighbors into the decision-making process regarding serious illnesses is common Church & religion The frequency of church attendance has been found to impact the frequency of care received. It has been noted that for certain groups of elderly African Americans, friends and church members may be of great importance in decisions to seek care Showing Respect Particularly because of the experience of many African American elders who grew up with segregated health care and social service systems in which they faced continual discrimination, it is extremely important to show respect to them in clinical settings in order to put them at ease and establish rapport Provision of health care to older African Americans must give consideration to culture and tradition, with the acknowledgement that social and kinship networks, community, extended family, and the church are all significant players in the health care & support service system

Consult Tribal Leaders or Family Before Making Medical Decisions 4 million people identify themselves as Native Americans/Native Alaskans Present-Oriented American Indians tend to be “Present oriented” rather than “future-oriented.” Impact on preventive health? Consult Tribal Leaders or Family Before Making Medical Decisions As w/African Americans, there might be a historic mistrust from centuries of abuse & broken promises. Therefore, it is a common practice to consult with a tribal leader/family elder prior to making a medical decision.

Native Americans/Native Alaskans Holistic View/Folk remedies Holistic: spiritual, physical, mental & emotional harmony. Illness may signal a disharmony within the spirit. Folk remedies are likely used prior to medical encounter May Not Express Pain American Indian/Native Alaskans may have been taught to never express pain; may say “uncomfortable.”

Native Americans/Native Alaskans Appropriate Ways to Show Respect and Establish Rapport Listening is valued over talking by most older American Indians; calmness and humility are valued over speed or directness. Asking for the elder’s help in understanding the current situation and in planning the components of care are important aspects of showing respect for the elder’s experience. Conversational pace American Indian languages have some of the longest pause times, compared to other languages, and especially English. Silence is valued. Interruption of the person who is speaking is considered extremely rude, especially if that person is an elder. Non verbal communication a) Physical distance: several feet is usual comfort zone. b) Eye Contact: not direct or only briefly direct, gaze may be directed over the shoulder c) Emotional expressiveness: may be controlled, except for humor d) Body movements: minimal e) Touch: not usually acceptable except a handshake

Chinese Americans Widely differing range of cultural values, based on age, ethnic group, length of time away from China “Yin & Yang” out of balance In the Chinese culture, there are some who believe that natural illnesses are caused by yin and yang being out of balance— this differs widely from the Anglo-American emphasis on scientific reasoning Herbal remedies Many Chinese Americans use specific foods & herbs for healing, particularly in the early stages of an illness; therefore, they may present at a more advanced stage of disease Acupuncture Massage and acupuncture are traditional Chinese therapies used to restore the body to balance

Chinese Americans Avoid eye contact Father head of household Many Asian people are trained to avoid eye contact w/authority figures, such as physicians, as a sign of respect. The Chinese American patient may smile, nod, and say “yes”. This is acknowledgement that he/she has heard you, NOT necessarily signaling agreement or understanding of your words. Father head of household The father is the undisputed head of household and therefore, the decision-maker. Conservatism Generally, very conservative.

Chinese Americans Health Care Utilization Medications Family The degree of utilization is dependent upon acceptance by patient and family, and barriers such as mistrust, money, saving face, & family responsibilities. Medications High rate of non-compliance with medications. Family Culture emphasizes loyalty to family and devotion to traditions; may want to involve entire family in medical decisions.

Southeast Asian Cultures Philippines, Singapore, Thailand, Vietnam, Laos, etc. Shake Hands? In the Vietnamese culture, men shake hands but women don’t. Imbalance Illnesses are seen as an imbalance between the body & nature. Folk Therapies Folk remedies are frequently used before a southeast Asian will seek western medical attention Coin rubbing and skin pinching are 2 common folk remedies used to allow unwanted elements to escape the body. They are not harmful & many patients report feeling better afterwards.

Southeast Asian Cultures Avoid Eye Contact Many Asian people are trained to avoid eye contact with authority figures, such as physicians, as a sign of respect. As with the Hispanic patients, providers with limited knowledge of these cultures may assume that a patient is expressing mistrust or isn’t paying attention. Many Dialects Don’t make assumptions about language. These cultures have a wide variety of languages. The healthcare system may be very overwhelming, including the role of the PCP, needing a referral for a specialist, and understanding insurance & HIPAA forms, and obtaining a Durable POA for healthcare.

Southeast Asian Cultures Family Involvement Family is very important. hospitalized patients may want a family member there 24-7. allow it! Perhaps he/she will recover more quickly with family lending comfort and security? “Strong Medicine” Western medicine, is believed to be “too strong”. Southeast Asian patients will often cut the pills in half or stop taking the medication as soon as they begin to feel better. Spoons A teaspoon in an Asian household (demonstrate) may actually be about a tablespoon. Feminine Modesty Feminine modesty is a cultural belief.

Amish Must consider perception toward a female health care provider Elders Within the Amish and a few other communities nationwide, elders play an important role in health care decisions and may affect treatment plans, preventive health measures, patient education. Elders are revered. Male-dominated sect Must consider perception toward a female health care provider Religion Believe body is the Temple of God and that God is the one who heals. Limited contact w/mainstream including health care Preventive health issues Do use preventive or curative measures.

Latino & Hispanic Cultures Many countries comprising the Latino & Hispanic cultures vary in traditions and beliefs. Puerto Rico, Mexico, Columbia, Ecuador, Venezuela, Bolivia, Spain, Costa Rica, El Salvador, Cuba are just a few subcultures. The characteristics listed tend to be somewhat common to many Latino cultures. Eye Contact Many Latino people are trained to avoid eye contact with authority figures as a sign of respect. Nodding Nodding means the patient is listening, not necessarily agreeing with what is being said. Silence may mean lack of understanding or disagreement. Healthcare providers must ask questions to be sure the patient understands. Head of House Decision-makers The mother determines when it is time to see the doctor and the male head of household gives permission for family member to go.

Latino & Hispanic Cultures Folk & Home remedies Ask if patient has been using home remedies. Patient may try remedies from a folk healer or Curandero before med doctor. Female modesty Female modesty can be an issue; having female HCP may be less stressful. If not possible, woman may want to bring sister or other female relative with her. Family before patient (news) The family would prefer to hear about bad medical news before the patient is informed. Sometimes the family doesn’t tell the patient at all. If the patient does not want to make medical decisions, HIPAA law must be honored and a durable power of attorney for healthcare must be obtained so the Healthcare Provider can legally meet with the chosen family members. Religion Some cultures believe God determines outcome of illnesses, that they are the victim, and must remain passive when ill…may not take active part in care and recovery.

Russian Smiles are often not as frequent as Anglo Americans *Health care providers in the former Soviet Union did not smile nearly as much as their American counterparts. -- Could a Russian immigrant translate the easy and frequent smiles of an American physician as not taking their illness seriously? “Depression” more acceptable than “mental health” Depression is a much more acceptable term than “mental illness” or “mental health”. Genders are equal Both sexes treated equally. Decisions are made by parents or oldest child. Some individuals of Russian heritage may not want prescription meds and may wish to treat with OTC meds.

Russian Other factors to consider Many Russians believe their illness is caused by weather or social experiences, such as a family argument or having to deal with a lot of stress. Some individuals of Russian heritage may not want prescription medications and may wish to treat with over-the-counter medications.

C.L.A.S. Standards Culturally (&) Linguistically Appropriate Services Moving forward: Familiarize yourself with CLAS Standards. The Cultural and Linguistically Appropriate Services (CLAS) Standards are guidelines established by the federal Health and Human Services Department, Office of Minority Health. These standards are mandated for all health care organizations receiving federal funds. Link to C.L.A.S. standards:http://omhrc.gov/CLAS/

A Culturally Competent Health Care Professional HOW DO WE BECOME CULTURALLY COMPETENT? The road to cultural competency is long, but here are some suggested ways to begin. Berlin and Fowkes suggest the LEARN model guidelines. Listen--to the patient's perception of the problem with sympathy and understanding Explain--the problem & strategy for intervention. Acknowledge & discusses--differences & similarities between these perceptions (yours and a culturally different perception). Recommend treatment while remembering the individual's cultural parameters. Negotiate agreement-- It is important to understand the patient's culture so that medical treatment fits in their cultural framework.

Barriers to Culturally Competent Negotiation Health care providers cannot violate value, scientific/ethical practice or law There are medical, ethical barriers to culturally competent negotiation. As noted by the American College of Physicians, an ethical conundrum for providers is: "The physician cannot be required to violate fundamental personal values, standards of scientific or ethical practice, or the law." In some cases, might be impossible to resolve ethical dilemma For example, female circumcision may be regarded as wrong by a western doctor while it is often a cultural imperative with some African tribes. Concordance-- both provider & patient must be regarded as equals In these instances, seek not either or but compromise.

Conclusion It is imperative to understand diversity’s impact on the health care encounter All healthcare providers should be trained in diversity and cultural sensitivity

An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity. Martin Luther King, Jr.