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Do You Speak the Other Guy’s Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston, MA Shani A. Dowd, B.A., L.C.S.W. Dir., Clinical Cultural Competency Training Harvard Pilgrim Health Care Boston, MA
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Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

Mar 27, 2015

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Page 1: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

Do You Speak the Other Guy’s Language: Culture, Diversity and

the Bottom Line

Dr. Paul Mendis,M.D., Chief Medical Officer

Neighborhood Health Plan

Boston, MA

Shani A. Dowd, B.A., L.C.S.W.

Dir., Clinical Cultural Competency Training

Harvard Pilgrim Health Care

Boston, MA

Page 2: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

US Population by Race/Ethnicity2000

White 69.1%

African Amer. 12.3%

Amer. Ind. 0.9%

Asian 3.6%

Pacific Is. 0.1%

Latino 12.5%

Two or More 2.4%

Page 3: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Racial and Ethnic Distribution of the Population of the US:

Projected 2030

White, Non-Hisp.60.5%

African American13.1%

Hispanic 18.9%

Asian/ Pacific Is.6.6%

American In./AlaskaNat. 0.8%

Bureau of the Census, Statistical Abstract of the U.S. 1997.

Page 4: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Leading Causes of Death, by Race and Ethnic Group, 1996

RankWhite, non-

HispanicAfrican

AmericanLatino

NativeAmerican

AsianAmerican

Cause of

Death

1Heart

DiseaseHeart

DiseaseHeart

DiseaseHeart

DiseaseHeart

Disease

2 Cancer

CVD

Chronic lungDisease

AUI

3

4

5

Cancer Cancer Cancer Cancer

CVD AUI AUI CVD

HIV/AIDS CVD Diabetes AUI

AUI HIV/AIDS CVDPneumonia and

Influenza

AUI =accidents and unintentional injuriesCVD=cerebrovascular disease (stroke, etc.)

Source: DHHS, Health, United States,1998

Page 5: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Health Care Disparities: Asthma

7% of all children in US have asthma

African American children are:

twice as likely to have asthma

Three times more likely to be hospitalized with asthma

six times more likely to die from asthma

Source: Kaiser Family Foundation www.kff.org

Page 6: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Health Care Disparities: AsthmaAmong Latinos, asthma prevalence varies by ethnicity:

Puerto Ricans have the highest rates: 11%

Mexican American children have the lowest rates among Latinos: 3%

Kaiser Family Foundation www.kff.org

Page 7: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Health StatusWhile 16% of white Americans self-report indicated that they believed they were in only fair or poor health, :

% of Asians reporting fair or poor health

40% of Vietnamese

29% Korean Americans

11% of Chinese

Kaiser Family Foundation www.kff.org

Page 8: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Chronic or Poor Health:

51% of all African Americans have been diagnosed with at least one of the following

within the past 5 years:

Asthma

Cancer

Heart Disease

Diabetes

High Blood Pressure

Obesity

Anxiety/depression

Source: Commonwealth Fund

Page 9: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Health Care Disparities:HIV/AIDS Treatment

African Americans are twice as likely as whites to NOT receive triple drug antiviral therapies.

African Americans are 1.5 as likely to not get prophylaxis for PCP

Latinos are 1.5 times as likely as whites to NOT get triple drug antiviral therapies

Kaiser Family Foundation www.kff.org

Page 10: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Diabetes-Related Death Rate, 1996

11.6

28.8

18.8

8.8

27.8

0

5

10

15

20

25

30

35

White Black Hispanic Al/An Asian/Pl

Racial/Ethnic Disparities in Health: Diabetes Outcomes

Page 11: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Health Care Disparities: Treatment for Cardiac Care

Among Medicare Beneficiaries:

African Americans are 60% LESS likely than whites to received heart bypass surgery, even when controlled for income, insurance status and place of treatment

Kaiser Family Foundation www.kff.org

Page 12: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Racial/Ethnic Disparities in Health:

Cardiovascular Procedures

Differential use based on race of:

Cardiac catherization and angioplasty (Harris et al, Ayanian et al.)

Coronary artery bypass graft (Peterson et al.)

Treatment of chest pain (Johnson et al.)

Referral to cardiology specialist care (Schulman et al.)

Page 13: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Life Expectancy (in years) at birth and by race and sex, United States, 1998

62

64

66

68

70

72

74

76

78

80

WhiteMales

BlackMales

WhiteFemales

BlackFemales

Life Expectancy inYears

Source: Health United States, 2000. Bureau of Primary Health Care

Page 14: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

10 Health Conditions with Greatest Disparities Between Whites and Members

of Ethnic Communities

COPD

Cancer

Cardiovascular Disease

Infant Mortality Rates

Diabetes

HIV/AIDS

Child and Adult Immunizations

Pneumonia

Stroke

Tuberculosis

Page 15: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Percentage of Adults Reporting Problems with Communication with MD

33% of all Latinos

27% of all Asians

23% of all African Americans

16% of all white, non-Latinos

Source: Commonwealth Fund (www.cwf.org)

Page 16: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Communication Problems with MD

Of those reporting problems, one or more of the following were reported:

MD did not listen to everything that pt. said

Patient did not fully understand MD

Had questions but did not feel comfortable asking

Source: Commonwealth Fund www.cwf.org

Page 17: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Latinos Reporting Communication Problems

43% report Spanish as their primary language

26% report English as their primary language.

Source: Commonwealth Fund \\www.cwf.org

Page 18: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Patient Satisfaction

Patient satisfaction increases when clinician uses psychosocially-oriented interview

Psychosocially oriented interview was LEAST frequently used

Perception among physician that takes more time

BUT: Study found that psychosocial interview did not significantly increase time of the clinical encounter

Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.

Page 19: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Malpractice and Physician-Patient Communication

Specific communication problems were identified in a sample of malpractice claims. Physicians with no claims against them were more likely to:

orient patients to the process of the visit

use facilitative statements more, e.g. “Go on, tell me more”

ask patients’ opinions about their medical problems

use humor, indicated warmth and friendliness

Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.

Page 20: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Malpractice and Physician-Patient Communication

Four problematic themes emerged when plaintiffs depositions were reviewed:

Deserting the patient 32%

Devaluing the patient or family views 29%

Delivering information poorly 26%

Failing to understand the patient

and/or family perspective 13%

Beckman, HB, Markakis, KM, Suchman, AL and Frankel, RM. (1994) The Doctor Patient Relationship and malpractice: Lessons from Plaintiff Depositions. Arch. Internal Med., 154: 1365-1370.

Page 21: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Malpractice and Physician-Patient Communication

While 1% of hospitalized patients suffer a significant injury due to negligence, fewer than 2% of these patients initiate a malpractice claim.

Patient dissatisfaction is the key element in the decision to initiate a malpractice claim.

Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.

Page 22: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

The New Millennium (Health Care Environment)

Health care entities are fewer in number, but larger & more complex in size, product offerings & geography

E-Health will play an increasingly important role in health care industry

Loyalty to skill/profession, work group, colleagues is shifting for many providers

Rapid change (revolutionary)

Page 23: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Motivations for Addressing Cultural Issues in Health Care in the United States

Changing demographics

Increasing globalization of US economy

Rising advocacy of health care consumers

Increasing regulatory requirements

Continuing documentation of inequities in access to health care and health care information and in health outcomes

Page 24: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Meeting Regulatory and Accreditation Guidelines

NCQA

JCAHO

Office of Minority Health

Department of Medical Assistance

Employer Request for Proposals

Licensure Requirements

Page 25: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Meeting Regulatory and Accreditation Guidelines

Physicians and hospitals who wish to participate in federally funded medical programs, specific requirements are articulated in the language of the contract relating to cultural issues, such as linguistic access:

• Balanced Budget Act of 1997

• Medicare

• Medicaid

Page 26: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Commercial Insurers

Increasingly, large employer groups are finding that their workforces are increasingly diverse in

languages spoken

ethnic cultures

racial groups

religious groups

gender

disabilities

Page 27: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

What is Cultural Competence?

It is the ability to deliver effective medical care to people from different cultures.

By understanding, valuing and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health providers deliver more effective and cost-efficient care.

Page 28: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

What is Cultural Competence?

“…the demonstrated awareness and integration of three population-specific issues:

health-related beliefs and cultural values,

disease incidence and prevalence, and

treatment efficacy.”

Risa Lavisso-Mourey, MD, MBA & Elizabeth Mackenzie, PhD

Page 29: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Diversity and Its Stumbling Blocks

•Literacy and Language•Class-related values•Culture related values•Communication•Stereotypes•Racism•Ethnocentricity

Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)

Page 30: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Patient Cultural FactorsThese factors are shown to facilitate immigrants positive adjustment to medical care in the US: A relatively high level of formal education

Greater generational removal from immigrant status

Low degree of encapsulation within an ethnic and family social network

Experiences with medical services that incorporate patient

education

Page 31: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Facilitating Cultural Factors (Cont’d)

Previous experience with particular diseases in the immediate family

Immigration to host culture at an early age.

Urban, as opposed to rural origin.

Limited migration back and forth to the home culture.

Harwood, A. (1981) Ethnicity and Medical Care. Cambridge, MA: Harvard Univ. Press.

Page 32: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Literacy

40 to 44 million adult Americans are functionally illiterate

50 million have only marginal literacy skills

72 million cannot read technical reports or news magazines

Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)

Page 33: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Literacy

One-half of the adult population of the U.S. has basic literacy deficits:

• 21-23% read no more than 4th grade level

• Unable to read newspaper, follow written instructions

• 25-28% of adult Americans read at about 8th grade level

Greatest number of low-literate adults are native born whites.

Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture)

Page 34: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Written Medical Material

Literacy levels vary enormously across class, gender and age.

Bilingual people often have widely different literacy levels in the languages they speak

Literate readers may encounter difficulty translating diagrams which inevitably make use of culturally “normal” visual concepts

Page 35: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Literacy and Gender

Among the Sudanese over 15 years of age:

34.6% of all females are literate

57.7% of all males are literate

Among the Congolese, over 15 years of age:

67.2% of all females are literate

83.1% of all males

Page 36: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Written Medical Information

Speakers of the same language may vary in idiomatic language use based on gender, age, nationality and class.

How the information is dispersed may signal authenticity in a given culture.

Page 37: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Written Medical Material

Literate readers may encounter difficulty translating diagrams which inevitably make use of culturally “normal” abbreviations.

Readers may have cultural barriers to receiving certain kinds of information in writing, or in possessing certain kinds of written information.

Page 38: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Developing Written Materials in Languages other than English

Do not assume that highly educated bi-lingual staff, including physicians, are as literate in their firsat language as they are in English.

Do research (focus groups) to determine which dialects should be used.

Use simple language, and where possible, easy to communicate basic concepts.

All literature must be “back translated”.

Page 39: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Back Translation

Material is translated from English to target language and target dialect.

Independent translator who speaks target language and target dialect translates document back to English.

Independent translator re-translates document.

Translation errors are corrected and errors in idiomatic expression are corrected.

Page 40: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Translation of Clinical Condition: Rheumatoid Arthritis

English:

Rheumatoid arthritis can be acute or chronic. Acute rheumatoid arthritis is more common during adolescence. The cause is believed to be due to an over-sensitive reaction of the joints to the Beta Hemolytic Streptococcus. The most common sites of infection are the throat and tonsil.

English to Chinese to English:

Wet Wind Style Joint inflammation has fast and slow type. The fast type sees more at small year time. The reason for its up believes to be the joint’s over-sensitive reaction to the blood-dissolving chain-ball bacteria. And the affecting path is most frequently the swallow tube and the flat-peach gland.

Page 41: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Heterogeneity: Chinese

Majority of elderly speak Toisenese; most of them also understand Cantonese.

Mandarin speakers are likely to be students or professionals who probably also speak English (except for the elderly). They tend not to speak Cantonese.

Cantonese-speaking Chinese also speak Mandarin if they are educated.

Page 42: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Written Medical Material

Materials providing medical instructions need to be carefully written to avoid dangerous misunderstandings

For Example:

“three times a day”

“insert suppository”

“take with food”

Page 43: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Case Example

A fifty-nine year old bilingual Vietnamese immigrant who had been a farmer in Vietnam and was poorly educated prior to immigration, interpreted the direction, “Take with meals,” to mean he should carry the medication in his lunch pail. He did not actually take the medication at the time he ate, as he did not want anyone to know he was ill.

Page 44: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

The lower the patient satisfaction with the interaction, the greater the

likelihood of non-adherence

Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 45: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Perceptions of Time

•How does the patient perceive or organize time?

Patients who are not regularly employed outside the home are usually less “clock-bound” in their perceptions of and organization of time.

Some patients organize time by tasks, rather than by clock time.

In many communities of color, time is organized in a more fluid and phenomenological manner.

Page 46: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Perceptions of Time

• Medications requiring rigid dosing by “clock time” must be carefully discussed and reviewed.

• The provider should attempt to determine how the patient understands time.

Page 47: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Perceptions of Time

In some cases it may be necessary to tie dosing to an activity or to an event rather than to “clock time”:

e.g. “Take the medication about the time your children would come home from school.”

Page 48: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Employ Positive Non-Verbal Behaviors

Lean forward

Silence - LISTEN

Appropriate eye contact

Warm expression

Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 49: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

The Popularity of

Alternative Medicine More than 4 out of 10 people in the United States visited alternative

medicine practitioners in 1997.

Sharp increase in the number of Americans using it, from 61 million in 1990 to 83 million in 1997, even though many alternative therapies aren’t covered by insurance.

Patients’ spending on alternative therapies nearly doubled from 9.4 billion dollars in 1990 to 17 billion dollars in 1997.

(1998)Trends in Alternative Medicine Use in the United States, 1990-1997, JAMA , 280: 1569-1575.

Page 50: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Demographic Profile of People Using Alternative Medicine

In addition to patients from many ethnic groups:

•People who are ages 35 – 49

•Very well-educated

•Incomes of about $50,000 a year

•People who are sick:

In fact, 7 out of 10 cancer patients turn to an alternative therapy

as a means of maximizing their hopes of seeing a cure.

Page 51: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Use of Herbal treatments

Most patients tend to think of herbal treatments as “natural” and “safe”…

However a small scale study examining the effects of St. John’s Wort (n=5) reported:

That patients taking St. John’s Wort & Camptosar (a chemotherapy agent) showed a 40% reduction in blood levels of Camtosar

Suppressant effect may last for at least 3 weeks after discontinuing St. John’s Wort

Source: Boston Globe, April 9, 2002

Page 52: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Lack of Trust

In many ethnic communities, there is a distinct lack of trust of medical institutions: African Americans recall the infamous Tuskeegee study

which affected hundreds of African american families.

Forced sterilization of ethnic minority women was a fairly common event well into the 1960’s

In many American medical institutions, ethnic minorities and poor whites were used as experimental subjects without their consent.

Page 53: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Lack of Trust•Many ethnic minority patients find it easy to believe that a provider is experimenting on them

•Many believe that medications used to treat whites are “too strong for the system” of ethnic people.

•Patients who are being treated for diseases with no apparent symptoms, find it hard to be compliant with treatment regimens, especially in the context of abuses in the medical care system.

Page 54: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Provide Information

•Be persuasive as opposed to commanding•Describe use•Inform about side effects:

Research shows: This does NOT increase

side effects•Tell when and how medication will help•Avoid being too complicated or detailed•Use “plain” English, avoid technical terms•Avoid anxious mannerisms (e.g. touching self, shuffling papers, looking at watch). These may be interpreted as a lack of truthfulness or honesty.

Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 55: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Determine the Patient’s View of the Medication Regimen

Ask the person: Do you think there will be any problems with the medication?

Have you taken a medication similar to this in the past?

• Provide Information

• Provide Strategies

Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 56: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Causes of Non-AdherenceHealth Beliefs:

Person’s perceptions of• Seriousness of the illness

• Outcomes of non-treatment

• Perceived ineffectiveness of treatment

Lack of social support

Social discouragement

Adverse effects

Lengthy or complicated treatment regimensSource: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 57: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Causes of Non-Adherence

Poor Communication• Minimal medical supervision• Insufficient instruction• Poor Feedback• Interactions with health professional

perceived as unfriendly

perceived as unconcerned

little interaction

unilateral interaction

Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)

Page 58: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Patient Satisfaction Patient satisfaction increases when clinician uses

psychosocially-oriented interview

Psychosocially oriented interview was LEAST frequently used

Perception among physician that takes more time

BUT: Study found that psychosocial interview did not significantly increase time of the clinical encounter

Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.

Page 59: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

Many languages lack terms equivalent to our medical terminology:

When interviewed in English, patients sometimes responded positively to questions, even when they were confused by the terminology used in the interview.

When interviewed in their language of origin, lack of understanding was more readily identified.

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys, Public Health Reports, Supplement 1, Vol. 116:223-243

Page 60: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

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Linguistic Access: Eliciting Clinical Information

Questions that created problems for respondents included those in which:

The concept or wording was unclear

The translation was difficult

The concept or wording was culturally inappropriate

The request for sensitive information led to untruthful responses

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 61: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

Questions which worked better were those which:

used clearly defined concepts

used clear and simple language

asked for factual information

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 62: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

Survey questions which were identified as most problematic were those which attempted to elicit:

socio-demographic information

preventive behaviors

attitudes and beliefs

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 63: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

Consider the question “When did you have your last check-up?”

Focus groups were conducted in Spanish, English, Cantonese and Vietnamese.

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 64: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

“When did you have your last check-up?”

Focus group feedback revealed:

Latinas felt that most Latina respondents would lie, because they knew they were “supposed” to get check-ups, whether they did or not.

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 65: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Linguistic Access: Eliciting Clinical Information

Focus Group feedback: “Last Checkup?”

Chinese women wondered why one would go to a doctor if one was healthy. They felt that Chinese respondents might associate regular check-ups with a presumption of illness, may not answer truthfully, even if they did indeed have a check-up.

Vietnamese women had trouble understanding the concepts of “routine” and “check-up” though most answered the question in the affirmative when interviewed in English.

Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,

Public Health Reports, Supplement 1, Vol. 116:223-243

Page 66: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

© Harvard Pilgrim Health Care, Inc

Communication: Soliciting the Patient’s Concerns

Communication is at the heart of the clinician patient encounter:

Physicians actively solicited patient concerns in 75.4% of interviews

Patients’ initial statement of concerns was completed in only 28% of interviews.

In 24.6% of visits, the physician did not ask the patient about his/her concerns.

Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287

Page 67: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

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Communication

The average visit length was 15 minutes.

The average patient who came with one or more concerns used only 32 seconds to complete their review of concerns.

No patient used more than 129 seconds.

Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287

Page 68: Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line Dr. Paul Mendis,M.D., Chief Medical Officer Neighborhood Health Plan Boston,

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Communication

When patients were allowed to complete their initial statement of concerns, there were fewer spontaneous statements of concerns which occurred after the history taking portion of the interview (14.9% vs. 34.9%)

Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we improved? JAMA, 281(3):283-287