Cultural Competency in a Health Care Setting. Culture Culture is defined as: a group ’ s way of perceiving, judging & organizing the ideas, situations.

Cultural Competencyin 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 healthcare 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 delayedFor 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 RemediesIn some sects, folk or home remedies are used prior to any medical encounter.

African Americans

Social & kinship networkBringing family & neighbors into the decision-making process regarding serious illnesses is common

Church & religionThe 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 RespectParticularly 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

4 million people identify themselves as Native Americans/Native Alaskans

Present-OrientedAmerican Indians tend to be “Presentoriented” rather than “future-oriented.”Impact on preventive health?

Consult Tribal Leaders or Family Before Making Medical

DecisionsAs w/African Americans, there might bea 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 remediesHolistic: 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 PainAmerican 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 RapportListening 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 paceAmerican 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 shoulderc) Emotional expressiveness: may be controlled, except for humord) Body movements: minimale) 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 balanceIn 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 remediesMany 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

AcupunctureMassage and acupuncture are traditional Chinese therapies used to restore the body to balance

Chinese Americans

Avoid eye contactMany 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 householdThe father is the undisputed head of household and therefore, the decision-maker.

ConservatismGenerally, very conservative.

Chinese Americans

Health Care UtilizationThe degree of utilization is dependent upon acceptance by patient and family, and barriers such as mistrust, money, saving face, & family responsibilities.

MedicationsHigh rate of non-compliance with medications.

FamilyCulture emphasizes loyalty to family and devotion to traditions; may want to involve entire family in medical decisions.

Southeast Asian CulturesPhilippines, Singapore, Thailand, Vietnam, Laos, etc.

Shake Hands?In the Vietnamese culture, men shake hands but women

don’t.

ImbalanceIllnesses are seen as an imbalance between the body &

nature.

Folk TherapiesFolk 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 ContactMany 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 DialectsDon’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 InvolvementFamily 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.

SpoonsA teaspoon in an Asian household (demonstrate) may actually be about a tablespoon.

Feminine ModestyFeminine modesty is a cultural belief.

Amish

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 sectMust consider perception toward a female health care provider

ReligionBelieve body is the Temple of God and that God is the one who heals.

Limited contact w/mainstream including health care

Preventive health issuesDo use preventive or curative measures.

Latino & Hispanic Cultures

Many countries comprising the Latino & Hispanic culturesvary 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 ContactMany Latino people are trained to avoid eye contact with authority figures as a sign of respect.

NoddingNodding 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-makersThe 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 remediesAsk if patient has been using home remedies. Patient may try remedies from a folk healer or Curandero before med doctor.

Female modestyFemale 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.

ReligionSome 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 equalBoth 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 ServicesMoving 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 understandingExplain--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 lawThere 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 dilemmaFor 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.