Bridging the Gap: New Americans Culture

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Bridging the Gap New Americans Culture
American Health Care Experience

• Fozia Abrar, M.D, MPH
• Department Chair
• Occupational Medicine
• Regions Hospital

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The Effect of Health Beliefs on the Delivery of
Culturally Competent Care
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The effect of health Beliefs on the
Provider-Patient Relationship

• Providers lack the information to understand the
  influence of health belief on the clinic
  encounter
• Cultures define health, etiology of disease
  prescribe treatment
• Patients medical decisions are based on values
  and beliefs about health
• Patient-Family health beliefs influence health
  behavior outcome

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Five Pillars of Islam

• Shahadah Witnessing profession of Faith
• Salat Prescribed Prayers
• Zakah Wealth Cleansing Tax (almsgiving)
• Sawm Fasting the month of Ramadan
• Hajj Pilgrimage to Makkah

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Cultural Norms

• Family takes precedence over individual
• Same gender may walk hand in hand
• Touching is common in conversations
• Social structure is based on clan system

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Families in new Americans Culture

• The family is the central foundation upon which
  immigrant societies are built.

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Causes of Illness

• Diseases and medical conditions are caused by
  Allah.
• Some disease are believed to be caused by people
  or by spirits.
• Fozia Abrar, MD

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Causes of Illness

• Evil eye cast by someone else.
• Curses
• By other people/ things
• By parents (believed to be the worst and hardest
  to treat)
• Witchcraft Said to cause some diseases and
  medical conditions.
• Jiniis Believed to be cause of serious
  psychotic diseases. Fozia Abrar, MD

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Purpose/Cure of Illness

• Because illnesses are believed to be caused
• by Allah, suffering is believed to bring about
  forgiveness of sins by God.
• All suffering is not in vain but rather a ticket
  for the hereafter.
• Whatever the cause of the disease e.g. spirits,
  witchcraft or evil eye, it is still believed that
  these occur and can be treated only through the
  will of God. This is the case if the treatment is
  by traditional means or through western medical
  practice. Fozia Abrar, MD

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Health Beliefs of Somalis

• Some healing practices
• Magico-religious religious healing performed
  by religious persons mainly through the reading
  of the Koran. This is used to treat organic,
  psychic and magic. The religious person reads the
  Koran over the patient or water which is given to
  the patient to drink.
• Fozia Abrar, MD

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Health Beliefs of Somalis

• Cauterization believing that disease fixes on
  areas of the body, recovery is obtained by
  burning that sick part of the body.
• Fozia Abrar, MD
• Disease and fire do not stay together in the
  same place -Somali proverb

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Health Practices of Somalis

• Scarification and blood-letting this entails
  cupping by means of a horn placed on a part of
  the body in order to free the patient from
  spoiled blood.
• Bone Setting
• Surgery
• Use of herbal medication
• Fozia Abrar, MD

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What do you consider illness?

• Somali Participants Illness was a pain that
  could be located in the entire body.
• Illness was viewed as a departure from a normal
  or healthy state.

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Who do you consider a health provider?

• Most participants prefer to see a physician. Not
  familiar with the role of other providers in USA.

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Barriers to Preventive Screening Services

• Lack of awareness.
• Cultural.
• Language (confidentiality/role of translators)
• Attitude of health care providers.
• Dissatisfied with the care

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Cultural Barriers Identified by the East African
Women

• Going to Health care facility is for sick people
  (Somali Participant)
• When I am not sick, I am not going to be
  disobedient to God. God gave me health, so why
  should I go to places that you go when you are
  sick (Somali)
• When not sick, just say praise God and stay
  home (Oromo)

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Psychosocial and Attitudinal Variables

• Attitudes towards screening services (God brings
  diseases).
• Satisfaction with previous screening (positive
  experience).
• Attitudes toward health care providers, tests.
• Social support system.
• Fozia Abrar, MD

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Problems and Issues

• Accessing care
• Patients expectations (Meds, Imaging)
• Concept of time
• Culture of no Appointments
• Male/female roles
• Husband or extended family must agree to medical
  care or procedures
• Fozia Abrar, MD

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Problems and issues (contd.)

• Somatization
• Surgery
• Blood Draws
• Traditional Medicine
• Health Care Maintenance

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Undesirable outcomes

• Miscommunication ( role of translators)
• Inappropriate diagnosis and treatment
• Patient/provider alienation and frustration
• Poor utilization of services
• Non-compliance/ refusal of treatment

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Principles of Ethics

• Autonomy right to determine ones own life plan
  Member of a family or local imam.
• Beneficence Acting for the good of the patient(
  health care provider is obligated to familiarize
  the religious and cultural beliefs of the
  patient)
• Nonmaleficence Do no harm and remove harm
  information on the procedures
• Justice The wish and needs of the Somali patient
  and family member should be valued.

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Strategy to improve physician-Patient relationship

• Culturally informed communication is crucial to
  effective doctor-Patient relationship
• Ask about pertinent beliefs, practices, and
  values for patients and families
• Obtain a medical history, considering culture
• Perform a physical exam, to fit patients culture

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Cultural

• How do different cultures view illness and
  injury? How does this affect emergency care?
• Holidays Ramadan and fasting.
• Chronic disease and compliance.
• Diabetes, HTN, CHF, Poly-pharmacy
• Fozia Abrar, MD

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Language

• What Language ? What Dialect?
• Ability of patient to verbalize symptoms
• Cultural perspective of symptoms.
• I feel hot
• My left side feels hot
• I feel cold
• My head is light
• Family members as interpreters

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Attitude Toward Health Care

• Health Care Crisis
• No Primary Care Model
• Find doctors in hospital not in community

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Examples of cultural miscommunication

• Q The pt continually is fidgeting in the chair,
  moving about, speaks with a pressure speech and
  is obviously very anxious and tense.
• A Chronic Anxiety State
• Somali female on Prozac for not remembering
  Groceries
• Fozia Abrar, MD

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Cultural Competency

• In order to deliver accessible, relevant and
  high-quality health care, providers must gain a
  better understanding of the patients health
  beliefs and his/her approach to health care.
• Where is the patient coming from and will what we
  are saying and prescribing respond to their real
  needs?
• More importantly, will it be accepted?

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Hallmarks of the Cross Cultural Care and Service
Clinician - One of three 

• History and culture of patients country of
  origin
• Pertinent psychosocial stressors
• Family life and intergenerational issues
• Role of religion in health
• Differences between culturally acceptable
  behaviors and psychopathology
• Cultural beliefs regarding causes and treatments
  of disease
• Ethnic differences in disease prevalence,
  responses to medicines and other treatments
•  
• Source Evelyn Lee, Ph.D.

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Hallmarks of the Cross Cultural Care Service
Clinician - Two of three 

• Interview and assess patients in the target
  language or via appropriate use of
  bilingual/bicultural translator
• Communicate in a cross-cultural sensitive manner
• Avoid under or over diagnosing disease states
• Understand the patients perspective
• Formulate treatment plans, which are culturally
  sensitive
• Effectively utilize community recourses
• Act as a role model and advocate for
  bilingual/bicultural staff and patient
•   Source Evelyn Lee, Ph.D

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Ingredients to Successful Health Care Programs

• Professionally trained interpreters
• Health care providers with expertise in
• cross cultural health care
• mental health problems of new Americans
• Health beliefs of the communities being served
• removing structural barriers (transportation,
  access to care etc.) and
• RESPECT, CULTURAL HUMILITY, TRUST, COMPASSION,
  UNDERSTANDING AND FUN!

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Strategy to improve physician-Patient relationship

• Culturally informed communication is crucial to
  effective doctor-Patient relationship
• Ask about pertinent beliefs, practices, and
  values for patients and families
• Obtain a medical history, considering culture
• Perform a physical exam, to fit patients culture

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References

• Walker PF. Preventative Health Care in a
  Multicultural Society Are we Culturally
  Competent?. Mayo Clin Proc 199671519-521
• Abrar F. Barriers to preventative Care
  Unpublished
• Immigrant Health Task Force website
  http//www.health.state.mn.us/ihtf/ihtfmain.htm

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• Suggested Reading
• The Middle Of Everywhere
• Helping Refugees Enter The American Community by
  Mary Pipher

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Rule of Law in Public Health

• Provide regulations for the training and
  certification of interpreters
• Cultural Competency training for all providers
• Support research in the role of law in the
  provision of immigrant public health.

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Questions and Discussion