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culturally responsive obstetrical and gynecological care. Jean Gilbert, PhD Geri-Ann Galanti, PhD. Los Angeles County Department of Health Services Office of Diversity Programs. Who Thinks Cultural Competency is a Clinical Skill?.

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culturally responsiveobstetrical and gynecological care

Jean Gilbert, PhD

Geri-Ann Galanti, PhD

Los Angeles County

Department of Health Services

Office of Diversity Programs

Who Thinks Cultural Competency is a Clinical Skill?

  • The Accreditation Council for Graduate Education (Residency Programs)

  • The Association of American Medical Colleges (Medical Schools)

  • The American College of Obstetrics and


  • The Los Angeles County Department of Health Services: Cultural and Linguistic Competency Standards

Why This Recent Emphasis on Culture and Health Care?

  • Major changes in the composition of the U.S. population: 25% of the California population is foreign born.

  • Many immigrants are from non-Western nations

    with non-Western health concepts.

  • Increasing emphasis on patient-centered care

    within medicine.

  • Of the 1.7 million DHS patient visits over the last

    6 months, about 779,000 were limited English proficient, preferring services in 88 languages.

If You And Your Patient Hold Very Different Health Beliefs...

  • This may impact on their trust in you and their evaluation of your abilities.

  • It might impede understanding of your assessment and treatment plan.

  • It may make obtaining consent for procedures very difficult.

  • It might reduce willingness to comply with treatment and follow-up.

Culture is a Major Force in Shaping an Individual’s:

  • Expectations of a physician

  • Perceptions of good and bad health

  • Understanding of disease etiology

  • Methods of preventive care

  • Interpretation of symptoms

  • Appropriate treatment

  • Health care self-efficacy

In Understanding Cultures, a Little Knowledge is Dangerous

  • Don’t let cultural generalizations become stereotypes.

  • Generalizations are testable probabilities; we couldn’t do science without them.

  • Stereotypes attribute the central tendencies of groups to individuals… ignoring the bell curve!

  • Your patient is an individual, not a culture.

The Importance of Women’s Roles

Which one of these women is the model for

your patient?

Acculturation is a Critical Factor in:

  • Family dynamics and gender roles

  • Knowledge of and access to public and private helping agencies.

  • Ability to speak and read English.

  • Experience with the U.S. health care system.

Video: Lupe’s Dilemma

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

Cultural Resistance to Breast Cancer, PAP and STD Screenings

  • Lack of orientation to preventive care

  • Fatalistic perspective

  • Fear and embarrassment about pelvic


  • Social shame, invasion of bodily privacy

  • Doctors “push” testing too early, endanger hymen

Video: A Big Baby is Coming

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

Gestational Diabetes

  • Gestational diabetes is the most common complication of pregnancy among Mexican Americans.

  • Lack of early prenatal care often prevents appropriate treatment.

  • Language issues often make appropriate education and treatment difficult.

Labor Pains

  • Asian women tend to be stoic.

  • African American women may

  • be either.

Labor Pains

  • Iranian women tend to be

  • expressive.

  • Mexican women also tend to be

  • expressive.

Preferred Labor Attendants

Anglo American: Husband or Domestic Partner

Hispanic: Mother or Female Relative

Asian: Mother or Mother-in-Law

Video: Hmong Birthing Practices

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

Hmong Prenatal and Birthing Practices

  • Hmong women may resist napping and invasive prenatal testing;

  • Consent for prenatal and birthing procedures may have to be gotten from parents, husband, and in-laws;

  • At childbirth, both mother and baby are considered especially vulnerable to malevolent spirits.

Video: Female Circumcision

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.


Female Circumcision

(aka Female Genital Mutilation)

Normal Female Anatomy

Modified Sunna

Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein


Female Circumcision

(aka Female Genital Mutilation)



Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein



Postpartum Lying-in

  • Traditionally 30 - 42 days

  • Rest, stay warm, avoid bathing & exercise

  • Eat foods designed to restore warmth

  • Failure to follow custom is thought to result in aches & pains in later years


Bonding and Baby Naming

SERENA: serene

Kabira: powerful

Taci: washtub

Radman: joy

CALEB: devotion to God

Duranjaya: a heroic son

CHAN JUAN: the moon; graceful; ladylike

Menopause in Cultural Perspective

  • Although menopause is universal, the “symptoms” attributed to it are not.

  • Research suggests that the variety of ways menopause is experienced can be termed “local biologies.”

  • Cessation of the menses is looked upon very positively by women in many cultures.

Issues of Language Access in Health Care

  • DHHS guidance for language access under the

    Title VI, Civil Rights Act of 1964

  • MediCal contract regulations

  • DHS Cultural & Linguistic Standards

  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes standards for cultural competence training and language services.

JCAHO Ruling

  • JCAHO views the provision of linguistically appropriate care as an important quality and safety issue.

  • JCAHO requires the inclusion of language and communication needs in the medical record.

  • Interpretation and translation must be provided for patients who need it.

DHHS says:

  • Assess patients’ language needs.

  • Try not to use family or friends or whoever you can grab.

  • Don’t use minors to interpret.

  • Try to use trained medical interpreters whenever possible.

  • Use telephonic interpreters for rare languages.

What Can You Do?

  • Honestly assess your own bilingual skills

  • Understand the pitfalls in using untrained interpreters

  • Use interpreters effectively

  • Use telephonic interpreters skillfully

Are your bilingual skills really adequate? Can you:

  • formulate questions easily?

  • ask a question in more than one way?

  • understand nuance and connotation in the patient’s response to questions?

  • understand regional variations?

  • know terms for anatomy and healthcare concepts?

  • convert biomedical terms into lay terms in the target language?

Pitfalls in Using Untrained Interpreters

  • Studies show that an average of 70% of the interpreted exchanges by ad hoc interpreters contain clinically important errors.

  • Family members, especially, are prone to edit both the clinician’s and patient’s utterances.

  • Children are frightened or intimidated if asked to interpret. There are ethical problems involved.

  • Confidentiality concerns must also be considered.

The Effective Use of Face-to Face Interpreters

  • Brief the interpreter first, if possible.

  • Introduce the interpreter to the patient.

  • Position the interpreter behind the patient or behind you.

  • Speak and look directly at the patient.

  • Use first person and expect the interpreter to do the same.

  • Avoid interrupting the interpretation.

Using Telephonic Interpreters

  • Use a speaker phone; do not pass a handset back and forth.

  • Remember that the interpreter is blind to visual


  • Let the interpreter know who you are, who else is

    in the room, and what sort of patient encounter it is.

  • Let the interpreter introduce her/himself.

What You Need to Know to Connect

  • The language needed

  • Dial 0 for hospital operator

  • Tell operator to connect you with the Language Line.

  • Remember that the telephonic interpreter is bound by confidentiality regulations, just as any other health care personnel.

What Can You Do To Be More Culturally Competent?

  • Practice ways to build rapport

  • Ask tactful, nonjudgmental questions about their preferences and practices

  • Understand family roles in health care

  • Know something about the cultural beliefs of your patients, but don’t stereotype

  • Use interpreters and use them effectively, don’t “wing it.”


  • Think back on your “difficult” patients.

    • May any of the challenges they presented be linked to their cultural beliefs or practices?

    • Would cultural competence skills have made a difference?

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