Clinical Applications of Culturally Competent Care

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Clinical Applications of Culturally Competent Care

• Denice Cora-Bramble, MD, MBA
• Professor of Pediatrics, George Washington
  University
• Executive Director
• Goldberg Center for Community Pediatric Health
• Childrens National Medical Center

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Clinical Cases Weaving Theoretical and Practical

• How does the patients' culture impact the
  diagnosis, treatment and clinical outcome?
• What can you apply to your practice?

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Clinical Case 1 Jose

• 7 y.o. Latino male presents with recurrent
  episodes of wheezing. Patient has been
  prescribed Albuterol and Flovent inhalers but
  mother uses only the Albuterol MDI during acute
  exacerbations. PMI positive for several asthma
  related hospitalizations in the last year.

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Discussion

• Next step?
• What else do you want to know?
• Therapeutic approach?

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Asthma

• Most common chronic disease of childhood
• Affects approximately 4.8 million children in US
• One of the most common reasons for pediatric
  hospital admissions

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Asthma and Latinos

• Half million Latino children have asthma
• 2/3 of them are Puerto Rican
• Flores G et al The Health of Latino Children
  Urgent Priorities, Unanswered Questions and a
  Research Agenda JAMA. Vol 288(1) 82-90 2003

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Asthma in Latino Sub-Populations

• Puerto Rican children have the highest prevalence
  of active asthma (11), exceeding by far the
  prevalence for African American (6) and Whites
  (3)
• Flores G et al The Health of Latino Children
  Urgent Priorities, Unanswered Questions and a
  Research Agenda JAMA. Vol 288(1) 82-90 2003

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Asthma DisparitiesMore than Access Barriers

• African American and Latino children enrolled in
  Medicaid managed care had worse asthma status and
  were less likely to be using preventive asthma
  medications than White children.
• This disparity persisted after adjusting for
  socioeconomic status.
• Lieu T et al. Ethnic Variation in Asthma Status
  and Management Practices Among Children in
  Managed Medicaid Pediatrics 109(5)
• 857-865 2002

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Persistence of Disparities

• The study suggests that even when financial
  access to health care is equalized by Medicaid
  managed care, variation in health care quality
  may persist.
• Lieu T et al. Ethnic Variation in Asthma Status
  and Management Practices Among Children in
  Managed Medicaid Pediatrics 109(5)
• 857-865 2002

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Understanding Health Disparities

• Contributing risk factors
• Race
• Income
• Insurance status
• Language culture
• Unknown factors?

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Sociocultural Determinants of Health

• Parental and child health beliefs
• Knowledge of asthma and asthma management
• Competition with other basic life needs
• Environmental factors
• Can parents afford to control the environmental
  triggers?
• Mansour M et al. Barriers to Asthma Care in
  Urban Children Parent Perspectives. Pediatrics
  106(3)512-519

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Sociocultural Determinants of Health

• Racial and ethnic differences in health beliefs
  and concepts of disease
• Differences in beliefs about the value of
  prevention
• Fears about steroids
• Lack of regularity in the life of the family
• Lieu T et al. Ethnic Variation in Asthma Status
  and Management Practices Among Children in
  Managed Medicaid Pediatrics 109(5)
• 857-865 2002

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Understanding Pediatric Asthma Disparities

• While the control and treatment for asthma is
  primarily based on medications, some parents have
  strong personal and cultural beliefs against the
  use of medications

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Belief Systems and Asthma

• 60 of Dominican mothers believed that their
  child did not have asthma in absence of symptoms
• 88 thought that medicines are overused in the US
• 72 did not use prescribed medicines but
  substituted traditional practices instead
• Bearison DJ et al. Medical Management of Asthma
  and Folk Medicine in a Hispanic Community. J
  Pediatr Psychol 24(4)385-3922002

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Traditional Practices Used in the Treatment of
Asthma

• Ethnomedical therapies
• Prayer
• Vicks VapoRub or alcanfor
• Siete jarabes
• Agua maravilla
• Te de manzanilla
• Pachter L et al. Ethnomedical (Folk) Remedies
  for Childhood Asthma in a Mainland Puerto Rican
  Community. Arch Pediatr Adolesc Med,
  Vol149(9)982-9881995

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Obtaining a Complete Cultural History

• Have you consulted anyone else about this
  problem? Traditional healers?
• Is your child taking any other medicines or home
  remedies?
• Was your child prescribed medicine that s/he is
  not taking?
• What do you think caused the disease?

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Cultural Clinical Pearls

• Anticipate resistance to steroids
• Incorporate harmless traditional practices

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Clinical Case 2When is it abuse?

• 18 mos old Laotian child presents with 2d h/o
  vomiting and diarrhea without fever
• Physical exam was positive for patterned skin
  discoloration streaking diagonally across childs
  abdomen
• Mother had similar findings on forehead

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Discussion

• Differential diagnosis?
• Treatment?
• Referrals?

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Differential Diagnosis

• Bruises secondary to coagulopathy
• Vasculitis
• Child abuse
• Traditional practices such as coining and cupping

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Southeast Asian Cultural Perspectives

• Traditional practices incorporates ritual
  healing, herbalism and dermabrasive techniques
• Coining shamans or healers repeatedly rubbing a
  coin over patients skin

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Benign vs Harmful Traditional Practices

• Lead-containing remedies for treatment of colic
• Greta
• Azarcon
• Treatment for mollera caida
• Risser A, et al. Use of Folk Remedies in a
  Hispanic Population. Arch Pediatr Adolesc Med,
  Vol 149(9) 978-981 1995

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Cultural Clinical Pearls

• Show respect for spiritual beliefs and
  traditional practices
• Families may not volunteer information regarding
  these practices
• Obtaining a cultural history is an important
  component of the clinical encounter (beyond idle
  curiosity or narrow criticism)

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Pediatric Case 3Just Say the Word Part I

• 16 y.o. Hispanic female patient is asked to serve
  as her parents interpreter as the neurosurgeon
  seeks to obtain informed consent the patient
  began to cry as she described the craniotomy
  procedure she would undergo

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Clinical Case 4Just Say the Word Part II

• 12 y.o. Haitian female interprets for her mother
  and explains to her in Creole that she has been
  raped by the mothers boyfriend

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Linguistic Barriers

• Studies have documented the multiplicity of
  adverse effects that language barriers have in
  health care including
• Impaired health status, nonadherence to
  medication regiments, higher resource use for
  diagnostic testing and others
• Flores G Dolor Aqui? Fiebre? Arch Pediatr
  Adolesc Med Vol156, 638-640 2002

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Linguistic Barriers

• One study identified language problems as the
  single greatest barrier to health care access for
  Latino children.
• Flores G and Abreau M Access Barriers to Health
  Care for Latino Children Arch Pediatr Adolesc
  Med, Vol 152(11), 1119-1125 1998

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Interpretive Services

• Medical interpreter as an essential component of
  effective communication between the limited
  English proficient (LEP) patient and health care
  provider
• Professional in-house, ad hoc, untrained family
  member, non-clinical hospital employee, stranger
• Untrained commit many errors
• Flores G et at. Errors in Medical Interpretation
  and Their Potential Clinical Consequences.
  Pediatrics Vol 111(1) 6-14 2003

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Clinically Significant Medical Errors

• Omissions
• Drug allergies
• Past medical history
• Chief complaint
• Substitutions
• Abx for 2 days instead of 10
• HC to entire body instead of lesion
• Flores G et at. Errors in Medical Interpretation
  and Their Potential Clinical Consequences.
  Pediatrics Vol 111(1) 6-14 2003

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Clinically Significant Medical Errors

• Editorializing
• Mother told to never answer questions about STDs
  and drug use
• Topical application of Amoxicillin in ear canal
  instead of oral
• Flores G et at. Errors in Medical Interpretation
  and Their Potential Clinical Consequences.
  Pediatrics Vol 111(1) 6-14 2003

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Vignette 5 Just 2 Tablespoons
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Clinical Picture

• 1-day history of
• Watery non-bloody diarrhea
• Decreased activity
• Labored breathing
• Mother gave 2 tablespoons of baking soda for
  upset stomach
• PE - dehydration
• Baby developed seizures
• Labs- Na 165, pH 7.83

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Case Discussion

• Baking soda used as home remedy to treat GI
  symptoms, URIs and diaper dermatitis
• ? Hypernatremic metabolic alkalosis
• Parents may not initially volunteer information
  regarding traditional practices, home remedies or
  folk illnesses

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Cultural Competence DefinitionWeaving the
Clinical Theoretical

• The ability of health care providers and health
  care organizations to understand and respond
  effectively to the cultural and linguistic needs
  brought by patients to the health care
  encounter.
• US DHHS, Office of Minority Health. National
  Standards for Culturally and Linguistically
  Appropriate Services in Health Care Final
  Report, 2001.

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Summary

• Impact of culture and language on the clinical
  encounter
• Cultural dialogue patient-centered and medically
  relevant inquiry that will aid practitioner in
  establishing diagnosis collectively developing
  a therapeutic plan
• Cora-Bramble D, Tielman F, Wright J Traditional
  Practices, Folk Remedies, and the Western
  Biomedical Model Bridging the Divide. Clin Ped
  Emerg Med.5102-1082004

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Summary

• Parental or patients beliefs regarding health
  may involve interactions of spiritual factors,
  internal balance inequities, and biological
  factors
• Families may combine diagnostic and treatment
  elements
• Cora-Bramble D, Tielman F, Wright J Traditional
  Practices, Folk Remedies, and the Western
  Biomedical Model Bridging the Divide. Clin Ped
  Emerg Med.5102-1082004

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Cultural Competence Continuum
Cultural Proficiency
Cultural Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destructiveness
National Center for Cultural Competence Adapted
and expanded from original work of Cross et al.
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Final Thoughts

• Cultural competence in clinical practice is best
  defined, not by an end point, but as a commitment
  and active engagement in a lifelong processwith
  patients, communities, colleagues and yourself.
• Community Activist

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Contact Information

• Denice Cora-Bramble, MD, MBA
• Executive Director
• Goldberg Center for Community Pediatric Health
• Childrens National Medical Center
• [phone]
• dcorabra_at_cnmc.org