Cultural Competence in Patient Care

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Cultural Competencein Patient Care

• Carlos Estrada, MD, MS
• Associate Professor of Medicine
• Division of General Internal Medicine
• Funding NHLBI 1 K07 HL081373-01
• Improving Cultural Competency An Online Case
  Based Curriculum

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Why do we need cultural competence in the 21st
century?

• Immigration will impact demographics
• Growth of minority population
• Important tool to help reduce disparities

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Cultural CompetenceDefinition

• The understanding of diverse attitudes, beliefs,
  behaviors, practices, and communication patterns
  attributable to a variety of factors
• Factors race, ethnicity, religion, SES,
  historical and social context, physical or mental
  ability, age, gender, sexual orientation,
  generational acculturation status

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Definitions

• RACE
• A local geographic or global human population
  distinguished as a more or less distinct group by
  genetically transmitted physical characteristics.
• A group of people united or classified together
  on the basis of common history, nationality, or
  geographic distribution

• ETHNICITY
• Of, relating to, or characteristic of a sizable
  group of people sharing a common and distinctive
  racial, national, religious, linguistic, or
  cultural heritage

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Cultural Competence inHealth Care

• A health care provider is cultural competent when
  he/she is able to deliver culturally appropriate
  and specifically tailored care to patients with
  diverse values, beliefs, and behaviors

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LEARN Model

• L isten
• E xplain
• A cknowledge
• R ecommend
• N egotiate
• 
  Berlin Fowkes, 1983

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Changing Demographics

• Aging of the population
• Growing majority of women
• Nations growing racial and ethnic diversity

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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implement policies and procedures
• Value diversity
• Perform a cultural assessment
• Question self-desire and motivation for positive
  change

Bigby, J. Cross-Cultural Medicine. 2003
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Video

• Observe, pay attention
• Write 1-2 short comments
• Any observations?
• Anything impressed you?

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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implementation of policies and procedures
• Value Diversity
• Perform a cultural assessment
• Question self-desire and motivation

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Dynamics of Difference

• Differences among patients and providers
• Avoid cultural blindness
• Belief that color or culture makes no difference
• All people are the same
• Difference in quality of care
• Over 600 disparities documented
• Institute of Medicine 2002

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Disparities in Care

• Cardiovascular disease Differential treatment
  after coronary arteriography, even controlling
  for disease severity (Schneider, 2001)
• Cancer Racial differences in mortality rates,
  analgesia, diagnostic tests and treatment

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Age-Adjusted Prevalence of Diabetes Mellitus in
U.S. Population1988-1994
1999 Heart and Stroke Statistical Update, AHA.
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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implement policies and procedures
• Value Diversity
• Perform a cultural assessment
• Question self-desire and motivation

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Incorporating Cultural Competency into Healthcare
Systems

• Community engagement
• Cultural perspectives
• Reciprocal transfer of knowledge and skills
• Healthcare organizations
• Consensus statements
• Call for action and research
• Accreditation
• Develop competencies and curricula

Taylor, 1997
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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implementation of policies and procedures
• Value Diversity
• Perform a cultural assessment
• Question self-desire and motivation

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Value Diversity

• Lack of diversity in leadership
• Improve early education
• Recruitment and retention
• Mentoring
• Workforce diversity
• Different perspectives
• Improve communication
• Comfortable environment

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Value of Diversity

• Concordance in race is associated with
• Greater participation in care process
• Higher satisfaction rates
• Greater adherence to care (Cooper and Patrick et
  al, 1999)
• Racial and ethnic minorities
• More likely to serve in underserved areas
• (Komoromy et al, 1999)

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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implementation of policies and procedures
• Value Diversity
• Perform a cultural assessment
• Question self-desire and motivation

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Cultural Assessment

• Individual
• Awareness of ones own culture
• Ethno-culture of medicine
• Institution
• Language barriers
• Operational issues
• Patient
• Performed over several visits

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Cultural Assessment for Patients
Adapted from Kleinman, 1978
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Cultural CompetencyFundamental Elements

• Understand the dynamics of difference
• Implementation of policies and procedures
• Value Diversity
• Perform a cultural assessment
• Question self-desire and motivation

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Internal Motivation andSelf-Awareness

• Recognize biases, management decisions influenced
  by race and ethnicity
• Physicians less likely to recommend
  catheterization for black females (Schulman,
  1999)
• Male physicians prescribed more analgesia for
  white patients vs. blacks (Wiese, 2002)

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What provider behaviors contribute to disparities?

• Provider perceptions of
• Symptoms
• Worthiness of patient
• Provider misunderstanding of racial and ethnic
  differences
• Poor communication skills

Bigby, 2003
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Experienced Bias or Disrespect
Kaiser Family Foundation Survey of Race,
Ethnicity, and Medical Care, 1999
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Consequences of Patients Experiences of Bias in
Health Care Setting

• Hold negative assumptions about providers
• Interpret provider behavior from baseline of
  mistrust
• Withhold important information
• Delay presentation for care
• Dont follow recommendations

Bigby, 2003
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Cultural CompetenceA Developmental Process
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LEARN Model

• L isten
• E xplain
• A cknowledge
• R ecommend
• N egotiate
• 
  Berlin Fowkes, 1983

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Cultural competence is a means, not an end
Bigby, J. Cross Cultural Medicine. 2003
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Cultural Competence

• a set of congruent behaviors, attitudes, and
  policies that come together in a system, agency
  or professional and enables that system, agency
  or professional to work effectively in
  cross-cultural situations.
• Cross TL et al Toward a Cultural Competent
  System of Care A Monograph on Effective Services
  to Minority Children Who Are Severely Emotionally
  Disturbed. Washington, DC Georgetown University
  Child Development Center, CASSP Technical
  Assistance Center, 1989

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What is Cultural Competency?

• a set of academic and personal skills that
  allow us to increase our understanding and
  appreciation of cultural differences between
  groups.

Archbold, 1996
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Key Concepts

• RACE
• Not a biological construct, a sociopolitical
  dimension
• Born with a heritage
• Assigned a race
• ETHNICITY
• Connectedness based on commonalties (religion,
  nationality, regions), cultural patterns shared
  over time
• Robinson, TL Howard-Hamilton, MF, 2000