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effective Health Care: bridging Cultural gaps

effective Health Care: bridging Cultural gaps. Zorina M. Piña-Hauan , MSN, APRN-BC, FNP Debra Howenstine, MD Department of Family and Community Medicine. What is Culture?.

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effective Health Care: bridging Cultural gaps

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  1. effective Health Care: bridging Cultural gaps • Zorina M. Piña-Hauan, MSN, APRN-BC, FNP • Debra Howenstine, MD • Department of Family and Community Medicine

  2. What is Culture? • Full spectrum of values, behaviors, customs, language, race, ethnicity, gender, sexual orientation, religious beliefs, socioeconomic status, and other distinct attributes of population groups.” AAP Policy Statement 2004

  3. Many names, One Goal • Cultural Competency • Culturally Effective Health Care • Cultural Sensitivity • Cultural Humility • Cultural Responsiveness • Multicultural • Cultural Proficiency

  4. Why bridge the cultural gaps? • “Clinicians who are unaware of cultural influences may not only miss important medical implications for a patient but can also inadvertently exacerbate an often already tenuous therapeutic relationship.” New York Times, How Cultural Background Affects Health, by Tara Parker-Pope, July 16, 2009

  5. Why bridge the cultural gaps? • “There’s a rich cultural gap that sometimes needs to be crossed for patients to be able to feel that a provider understands them and that they can have hope.”New York Times, Bridging the Culture Gap by Pauline W. Chen, M.D., July 16, 2009

  6. Benefits of Culturally Effective Health Care • Responds to current and projected demographic changes in US. • Enhances overall communication and the clinical interaction between the patient and the provider. • Allows clinicians to obtain more specific and complete information to make an appropriate diagnosis.

  7. Benefits of Culturally Effective Health Care • Facilitates the development of treatment plans that are followed by the patient and supported by the family. • Reduces delays in seeking care and allows for improved use of health services. • Improved patient satisfaction. • Delivering Culturally Effective Health Care to Adolescents: http://www.ama-assn.org/resources/doc/ad-hlth/culturallyeffective.pdf

  8. What do we want to achieve in health care? • Seeing the patient as a unique person by taking into account how a person's culture, race, ethnicity, religion, gender, sexual orientation and socioeconomic situation influence their health, health care beliefs and access to services.

  9. Where do we begin? • Awareness of one’s personal beliefs and attitudes and how that may affect the perception of other cultures. • Respect differences of others beliefs and attitudes. • Efforts to acquire knowledge and information about the particular groups one is working with.ACHA Guidelines Cultural competency Statement, February 2011

  10. In my culture we... • What role did your families’ culture play in your early identity/who you are today? • Where do you find your cultural identity now? • What aspects of your culture are different from other members of the group? • As providers we bring our own cultural perspective to each encounter.

  11. In my culture we... • Throughout the day, many of us move between several cultures, often without thinking about it. • Home/family • Workplace • School • Social club • Religious organization, etc. • Are You Practicing Cultural Humility? The Key to Success in Cultural Competence , California Health Advocates , April 2007

  12. Conduct a cultural self-assessment • 40 Questions with answers A= Things I do frequently, B = Things I do occasionally, C= Things I do rarely or never • Physical Environment: Materials & Resources: I display pictures, posters, artwork and other decor that reflect the cultures and ethnic backgrounds of clients served. • Communication Styles: For individuals and families who speak languages or dialects other than English, I attempt to learn and use key words in their language so that I am better able to communicate with them during assessment, treatment or other interventions. • Values & Attitudes: I recognize that the meaning or value of medical treatment and health education may vary greatly among cultures. • Questionnaire from Improving Patient Care, Cultural Competence It’s not just political correctness. It’s good medicine. Family Practice Management 2000 Oct;7 (9):58-60

  13. Remember • There is great diversity within cultures. • 23 year old female from El Salvador. Recently arrived. Speaks essentially no English. Unable to read or write in Spanish. No extended family in this country. Had never had a regular primary care provider before coming to our clinic. • 42 year old female graduate student from South America. Here with her husband. Speaks three languages. Has been in the US for seven years, initially on the East Coast.

  14. Stereotype vs Generalizations • A stereotype is an ending point. No attempt is made to learn whether an individual fits the statement. • A generalization is a starting point; it suggests a common trend, but further information is needed to determine whether statement is true for a specific individual.

  15. Generalizations • Can serve as a guide to be accompanied by information gained through getting to know the patient and his/her family. • Ask the patient/parent rather than assume you know what patient needs and wants.

  16. Techniques for... • Verbal Communications • Non-verbal Communications • Culturally sensitive interviewing tools: LEARN, Kleinman’s 8 questions (Explanatory Model) • Use of Interpreters and the language lines

  17. Verbal Communications • Speech patterns • People vary greatly in • length of time between comment and response • speed of speech • willingness to interrupt

  18. Verbal CommunicationsImportant to acquire knowledge on... • Roles of language, speech patterns, and communications styles of patient populations. • Initial greeting sets tone. Many older people from traditional societies expect to be addressed formally. • Many patients from other languages or cultural backgrounds are less likely to ask questions. • Many patients are more likely to answer through narrative than with direct responses.

  19. Verbal Communications, what can we do? • Bridge cultural gaps by: • Tolerating gaps between questions and answers • Modifying your own speech to match volume and speed of patient's speech • Do not be offended if patient interrupts • Be aware of your own pattern of interruptions (especially if patient is older than you) • Be aware of current language/slang and be able to ask questions • Avoid questions that can be answered “yes” or “no” (Use “What questions do you have?” not “Do you have any questions?”).

  20. Non-verbal Communications • 70% of communication is non-verbal. • Eye contact and Body language can impact the success of communication more acutely than the spoken word.

  21. Non-verbal Communications • Eye Contact • The way people interpret various types of eye contact is tied to cultural background and life experience. • Euro-Americans tend to look people directly in the eyes; not doing so is sign of dishonesty/disrespect • For many other cultures, direct gazing is rude/disrespectful • Bridge cultural gaps by: Never forcing a patient to make eye contact

  22. Non-verbal Communications • Body languagE • The meaning of body language varies greatly by culture, class, gender, age. • In many cultures nodding is a form of respect and does not indicate either agreement or understanding. Candib, “Sí, Doctora.” Annals of Family Medicine, 2006

  23. Non-verbal Communications,Body Language, what can we do? • Bridge cultural gaps by: • Being conservative in your use of gestures • Asking about unknown gestures or reactions • Do not base impression of patients’ feelings or level of pain just on facial expressions • Being aware that some cultures may not allow for cross-gender touching (female heath care provider and male patient)

  24. Non-verbal CommunicationsBody Language, what can we do? • Bridge cultural gaps by: • Following patient’s lead on physical distance and touching • Spacial distance is culturally determined take your cue from patients and move closer or create distance as needed

  25. Culturally Sensitive Interviewing tools • LEARN Model: enables health care providers to overcome barriers in communication with the patient. Model developed on 1983 by Elois Ann Berlin and William C. Fowlkes. • Kleinman’s 8 questions(Explanatory Model)

  26. LEARN • Listen with sympathy and understanding to the patient’s perceptions • Explain your perceptions • Acknowledge and discuss the differences and similarities • Recommend treatment • Negotiate agreement

  27. Kleinman’s 8 questions (Explanatory Model) • Patients usually have • specific beliefs about the cause of their symptoms, • specific concerns, • specific expectations about potential treatments. • The patient’s overall understanding of the illness experience is called the explanatory model.

  28. Kleinman’s 8 questions (Explanatory Model) • What do you call your problem? • What do you think caused your problem? • Why do you think it started when it did? • What do you think your sickness does to you? How does it work? • (continued)

  29. Kleinman’s 8 questions (Explanatory Model) • How severe is your sickness? Will it have a short or a long course? • What kind of treatment do you think you should receive? What results do you hope to get from treatment? • What are the chief problems that your sickness has caused for you? • What do you fear most about your sickness?

  30. Why should you use an interpreter? • “Under Title VI of the Civil Rights Act of 1964, medical providers that accept federal funds — for treating Medicare or Medicaid recipients, for example — have to provide access to language services for patients who don't speak English well. But funding for such services can be problematic, since many insurers don't reimburse providers for them”.Trained Interpreters Can Help Prevent Medical Errors by Michelle Andrews

  31. Why should you use an interpreter? • University of Missouri’s policy on use of interpreters: “Physicians and other healthcare providers may see patients without an interpreter only if they have provided the Language Services Department with proof of completion of medical studies in both English and the target language (patient’s preferred language).  If other healthcare providers/team members, family or friends are present, an interpreter must also be present either on-site or telephonically.” Agreed upon by MU’s Patient Rights and Organizational Ethics Committee.

  32. Why should you use an interpreter? • “Linguistically and culturally appropriate care has a direct impact on quality and safety, and is a growing issue that is not going to go away.”http://xculture.org

  33. When should you use an interpreter? • Limited English Proficiency (LEP) “This means persons who are unable to communicate effectively in English because their primary language is not English and they have not developed fluency in the English language. A person with Limited English Proficiency may have difficulty speaking or reading English. An LEP person will benefit from an interpreter who will interpret to and from the person’s primary language. An LEP person may also need documents written in English translated into his or her primary language so that person can understand important documents related to health and human services”. www.hhs.gov

  34. When should you use an interpreter? • LEP patients should have appropriate language access at every point of contact • Check-in, update their demographic and insurance information • During vitals, medical histories, and exam • Check-out, make f/u appointments or f/u testing

  35. Bridging the gap with an interpreter... • Ideal Interpreter: Trained • Knowledge of two languages and cultural issues • Familiar with medical terminology • Able to convey messages with out interjecting opinions, beliefs, or prejudices • Not a family member or friend, (can compromise confidentiality)

  36. Bridging the gap with an interpreter...Tips for working with an untrained interpreter • Patient focused care: Introduce yourself to the patient first then interpreter • Get consent by patient to be able to use interpreter • Give a pre-session to interpreter: “I would like you to interpret exactly what the patient says as if you were the patient.” If the patient says, “My stomach hurts.” You say, “My stomach hurts.” Please don’t leave anything out or add anything. • Maintain eye contact with patient

  37. Tips for working with an untrained interpreter... • Maintain control: redirect if there are any side conversations • Use short sentences and simple concrete phrases • Use teach back method with treatment plan • Ask, “What questions do you have?” and don’t forget to discuss follow up if needed

  38. Language lines • Certified Languages International (CLI) • http://www.certifiedlanguages.com • * 180 languages • * Available 24/7 • *Connects on average in 18 seconds or less to a trained interpreter • * Services offered: Telephone, Onsite and Document Translation * Pricing for both sites : Must contact or request a quote

  39. Bridging the gap with an interpreter... • Language lines: • CYRACOM,http://www.cyracom.com • 200 languages • Available 24/7 • Connects on average in 15 seconds or less to a trained interpreter (Blue phones, Dual-handset ,Cordless blue phones or any phone) • Also has video remote interpretation for Sign Language or spoken language interpreters • CYRACOM MOBILE APP, Available free in your mobile APP store. Allows healthcare providers to connect to an interpreter with a mobile device, saving time in patient interactions. 

  40. Other resources... • Check with local pharmacies to see if prescriptions can be written in both English and patient’s preferred language. • Check with your institution to find out where your patient populations are coming from. • Check with local clinics and hospitals about their interpreting services. • Check on web for handouts in patients preferred language.

  41. Special thanks to... • Dr. Debra Howenstine for providing assistance with this presentation by sharing her expertise on this topic. And for her constant support, mentorship, and friendship throughout the years. • Grace Vega, UMCHC Coordinator of Language Services for her assistance with this presentation.

  42. Resources • Useful one page handouts for providers and office staff on enhancing cross cultural communication • Available through www.iceforhealth.org under approved ICE documents, Cultural and Linguistics Provider Toolkit, • Or copy and paste: http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10.pdf

  43. Resources • Patient-Focused Cultural Assessment Models , Gloria Kersey-Matusiak • http://www.xculture.orgThe Cross Cultural Health Care Program. Not for profit. Cultural competency training, interpreter trainings, many multilingual publications available. • http://erc.msh.orgProvider’s Guide to Quality and Culture. Designed to assist health care organizations throughout the U.S in providing high quality culturally competent services tomulti-ethnic populations. Access through above URL, then click on link for “Provider’s Guide to Quality and Culture.”

  44. Resources • http://minorityhealth.hhs.gov/assets/pdf/checked/toolkit.pdf • Physician Tool Kit and Curriculum: Resources to Implement Cross-Cultural and Clinical Practice Guidelines for Medicaid Practitioners, March 2004

  45. Thank You! Gracias! contact; zmp@hauan.org

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