Ensuring Culturally Competent

TB Program Staff

Bill Bower, MPH Charles P. Felton National Tuberculosis Center

Sponsored by the Northeastern Regional Training and Medical Consultation Consortium

Session Objectives

• Explain why cultural and linguistic competency are important for TB control

• Describe the difference between culture and ethnicity

• Name at least one area of knowledge, one skill, and one attitude necessary for developing cultural competency

• State at least three questions to start two-way dialogue about TB patient education

• Discuss strategies to ensure culturally competent staff

Resources

• Core competencies for public health professionals related to cultural competency

• Stages of cultural competency development

• Cultural Dynamics Influencing the Clinical Encounter

• Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It

• Tools for assessing staff and programs

• Cultural competency newsletters from the New Jersey Medical School Global TB Institute

• Cultural Competency and Tuberculosis Care: A guide for self-study and self-assessment

“To learn every aspect of each culture that could

influence the patient encounter is impractical, if

not impossible”

Carillo J, Green A, Betancourt J. Cross Cultural Primary Care: A Patient-Based Approach.

Annals of Medicine, 18 May 1999. 130:829-834.

Culture-General vs. Culture-Specific Approach

GENERAL

• Broad concepts

• Generalizable principles

• Focus on learner

• Emphasis on attitude

SPECIFC

• Assumptions/fixed ethnic traits

• Reduced to skills

• Cookbook

• Do’s/Don’ts

• Can lead to stereotyping

General First, then Specific

…while 'the specific features of the cultural values and practices of particular ethnic communities constitute one challenge to providing appropriate care', there nonetheless needs to be developed 'a general personal adaptability to inter-ethnic contacts' otherwise culture specific knowledge is 'unlikely to be employed sensitively and appropriately' Gerrish (1996:12).

Gerrish, K., Husband, C. and Mackenzie, J. (1996) "Ethnicity, the minority ethnic community and health care delivery", in Nursing For A Multiethnic Society, Buckingham: Open University Press.

“The body of learned beliefs, traditions, principles, and guides for behavior that are commonly shared among members of a particular group. Culture serves as a roadmap for both perceiving and interacting with the world.”

Increasing Multicultural Understanding: A Comprehensive Model, Don Locke, SAGE Publications, 1992

What is Culture?

What is Ethnicity?

Refers to particular social groups in complex societies; groups differentiated not only on the basis of shared cultural content, but also on the basis of social attitudes and economic and political considerations.

Working with Latino Youth: Culture, Development and Context. Joan D. Koss-Chioino and Luis A. Vargas

How is Culture Important in Healthcare ?

• Cultural forces are powerful determinants of health-related behavior

• A lack of knowledge of or sensitivity to health beliefs and practices of different cultures can limit one’s ability to provide quality healthcare

Core Competencies for Public Health Professionals

Council on Linkages Between Academia and Public Health Practice.Funded by the Health Resources and Service Administration, Aug 2005

Cultural Competency Skills• Utilizes appropriate methods for interacting sensitively, effectively, and professionally with persons from diverse cultural, socioeconomic, educational, racial, ethnic and professional backgrounds, and persons of all ages and lifestyle preferences

• Develops and adapts approaches to problems that take into account cultural differences

• Understands the dynamic forces contributing to cultural diversity (attitude)

• Understands the importance of a diverse public health workforce (attitude)

Core Competencies for Public Health Professionals

Cultural Competency

CLAS Standards

National Standards for Culturally and

Linguistically Appropriate Services in Health Care

Developed by the Office of Minority Health

Culturally competent care, organizational supports for cultural competence and organizational structure and policies

U.S. Department of Health and Human Services, Office of Minority Health, March 2001

What are CLAS Standards?

1. Understandable and Respectful Care2. Diverse Staff and Leadership3. Ongoing Education and Training4. Language Assistance Services5. Right to Receive Language Assistance Services6. Competence of Language Assistance7. Patient-Related materials8. Written Strategic Plan9. Organizational Self-Assessments10. Patient/Consumer Data11. Community Profile12. Community Partnerships13. Conflict /Grievance Processes14. Implementation

U.S. Department of Health and Human Services, Office of Minority Health, March 2001

Importance of Culture to TB

Tuberculosis in the United States – 2007 Surveillance Slide Set -- CDC

Tuberculosis in the United States – 2007 Surveillance Slide Set -- CDC

• Experience of psychological distress, description of symptoms – and communication about these

• Perceived causes of illness, understanding of ‘infection’, ‘transmission’ and who ‘contacts’ are

• Health-seeking behavior

• Understanding of disease process, treatment expectations and decisions

• Interaction with health care system and health care professionals, communication styles

• Attitudes towards helpers, authorities, revealing contacts

• Names and relationships of contacts

Culture can affect . . .

What is Cultural Competence?

“A set of congruent behaviors, attitudes, and policies which come together in a system, agency, or amongst professionals to work effectively in cross-cultural situations.”

“The state of being capable of functioning effectively in the context of cultural differences.”

Towards a Culturally Competent System of Care. Cross et. al., 1989, Georgetown University Child Development Center

Cultural CompetencyContinuum

Advanced Cultural Competence

Basic Cultural Competence

Cultural Pre-competence

Cultural Blindness

Cultural Incapacity

Cultural Destructiveness

Cross Model of Cultural Competency by Terry Cross, 1988

Handout Summary

“Western” Culture• Fix it

• Control nature

• Do something now

• Strong measures

• Plan ahead

• Standardize ) treat everyone the same)

“Other” Cultures• Accept it

• Balance with nature

• Wait and see

• Gentle approach

• Take life as it comes

• Individualize

Office of Minority Health’s Cross Cultural Physician Toolkit.

Four Elements

1. Awareness of one’s own cultural values– Are you attentive your own preconceived notions of

other cultural groups?

2. Awareness and acceptance of cultural differences– Do you look for opportunities to meet and interact with

individuals who are from cultures other than your own?

3. Development of cultural knowledge– Are you familiar with the worldviews of cultural groups

other than your own?

4. Ability to adapt practice skills to fit the cultural context of the client

– Do you have the know-how to navigate cross-cultural patient interactions?

Explanatory Models Approach

• What do you call this problem?

• What do you believe is the cause?

• What course do you expect it to take? How serious is it?

• What do you think TB does inside your body?

• How does TB affect your body and your mind?

• What do you most fear about this TB?

• What do you most fear about TB treatment?

Kleinman, Arthur Concepts and a model for the comparison of medical systems as cultural systems Social Science and Medicine 1978

For your program’s consideration

• What cultures are predominantly represented in your program?

• What are the values, beliefs, traditional concepts particular to these groups?

• Who are the “gatekeepers” of health within these groups?

• What is the group’s perception of health and illness?

• What is the relationship between health care providers and the community?

What do you want to find out from each client?

• Language and literacy level• Health knowledge, health beliefs• Health seeking behaviors• Daily routine activities (work, leisure)• Relevant relationships (contacts)• Visitors, travel• Decision making preferences• Perception of “western” medicine or our

health care system• Relevant incentives

Get to know the individual

• How do you prefer to be addressed?

• What country did you grow up in?

• Are you more comfortable reading information in [your native language] or in English?

• Tell me about how important healthcare decisions are made in your family…

• Are there certain health care procedures and tests which your culture prohibits?

Language Access Barriers

45 million people in the US speak a language other than English at home. Most of them are elderly.These impacts are the result:• Less likely to receive care• Less likely to understand care• Increased risk of medical errors• Reduced quality of care• Increased risk of unethical care• Less satisfied with care

Languages and Interpretation

• Do you find that interpretation is needed often during TB diagnosis? Treatment? Contact investigations?

• What settings? Purposes? Languages?

• How do you meet these needs?

• What laws or regulations affect interpretation?

Interpretation Skills

• Video and viewer’s guide

• Consecutive interpretation

• Simultaneous interpretation

• Sight translation

• Telephone interpreting

Naming SystemsA Common Difference

Latin America – 4 names are commonFirst name / Middle name / Dad’s last / Mom’s last

DAD Carlos Alfonso Gonzalez CastroMOM Sonia Salazar del CastilloMOM Sonia Salazar de GonzalezSON Carlos Javier Gonzalez Salazar

May go by “Javier Gonzalez”May not respond when you call out “Carlos Salazar”

How do you handle that on your forms? In a computer registry?How do you alphabetize? By Dad’s last name? Mom’s last name?

Naming SystemsA Common Difference

China – last name / first name

Zhang Wen Yi

In the U.S. may become Wen-Yi Zhang

“Wendy Chang”______________________________________

African – last name / first name

Managing Names

• Ask for names, nicknames, aliases

• Anticipate reasons not to give correct name

• Understand reasons to hide someone, not name them

• Enter names on forms, in registry

• Encourage health literacy: agree to give/use the same name every time

Use open-ended questions

• How do you feel about knowing you have TB? LTBI?

• How do you feel about knowing that you might have infected others with the TB germs?

• What matters most to you as you are being treated for TB? LTBI?

• So that I can be aware of and respect your cultural beliefs, can you tell me a little about….

• Tell me about any cultural considerations that may impact [your treatment], [our home visits], [this interview], etc.?

Questions for Determining Health Beliefs

• What information do you have about TB?• What do you think causes TB?• What problems will having TB cause you?• Why do you think you got sick when you did?• What does TB do to your body?• How severe do you think your illness is?• What treatment do you think you should receive for TB?• What are the most important results you hope to receive from

this treatment?• What are the main problems having TB has caused for you?

What do you fear about TB?• How do your family members or close friends feel about your

having TB?Adapted from: Cross- Kleinman, Eisenberg, and Good (1978), CDC (1994)

Cultural Competency at Program Level

• Assess cultural / linguistic competence

• Train existing staff (general and specific)

• Hire bi-cultural and bi-lingual staff to match your clients

• Manage a culturally diverse workplace

• Use interpreters or interpretation service

• Work with community based groups

• Provide TB educational materials for different cultures/languages

Background Documents

Core Competencies

for Public Health

ProfessionalsCouncil on Linkages

Between Academia and Public Health Practice

August 2005

TB ETN Resource Guide

• Developed by the Cultural Competency Working Group of TB ETN

• Includes a list of organizations, readings, and assessment tools associated with cultural competence and health.

• Updated constantly

www.findtbresources.org/material/CCGuide.pdf

Audio Visual Materials

• VA Dept. of Health Nursing Council Patient Education Committee in partnership with Health Roads Media

• Originally a series of 7 patient education pamphlets: – Do I Need a TB Test?– Just the Facts about BCG and TB– Stop TB Infection Before it Makes You Sick– TB Disease: You Need Treatment to Make You Well– TB & HIV: A Dangerous Partnership– What is a TB Test?– What you Should Know About Taking Tuberculosis Medicines

• Formats now include web-video and mobile video

Examples of Tech Options

Multimedia and Pamphlets

• Multimedia materials

healthyroadsmedia.org

VDH DTC pamphlets in 15 languages

vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/Tuberculosis/Patients/brochureLanguage.htm

Healthy Roads Mediawww.healthyroadsmedia.orgTel 406-556-5877

SNTC Country Profiles

Developed by the SE National TB Center & UAB Lung Health Center

• Country background

• Tuberculosis epidemiology

• Common misperceptions, beliefs, attitudes, and stigmatizing practices related to TB & HIV/AIDS

• General cultural courtesies

• Additional Notes

31 Country Snapshots

CambodiaDominican

RepublicEcuadorHaitiHondurasIndiaMexicoPhilippinesSomaliaVietnam

BangladeshEthiopiaIndonesiaKenyaNigeriaRussiaSouth AfricaThailandUgandaZambiaZimbabwe

BrazilChinaColumbiaCubaEl SalvadorGuatemalaSouth KoreaMyanmar (Burma)NicaraguaPeru

Birth countries most commonly reported by foreign-born patients treated in the Southeastern United States:

Cultural Competency and TB Care

• A guide for self-study and self-assessment

• Collaborative effort between NE RTMCC, SE National TB Center, Heartland National TB Center, and U. of Alabama Lung Center

• For the public health workforce and other healthcare providers

• Covers knowledge, skills, and attitudes necessary for the ongoing development cultural competency in TB control activities

• Includes self-assessment exercise and teaching cases

CDC Ethnographic Guides

• Mexican, Somali, Vietnamese, Hmong, and Chinese ethnographic guides designed to enhance effectiveness and cultural appropriateness of services by health care providers who serve these communities

• Content comes from CDC ethnographic study and from in-depth literature reviews

Remember

• Within-group diversity is often greater than between-group diversity

• There is no “cookbook approach”for treating or interacting with TB patients

• Avoid stereotyping and overgeneralization

• Maintain an assets- and strengths-based perspective

• You don’t have to know everything. Ask questions.

• Every encounter is a cross-cultural encounter!

Bring it home to your clinic

“If we were to reduce the … steps of culturally informed care to one activity that even the busiest clinician should be able to find time to do, it would be to routinely ask patients (and where appropriate family members)what matters most to them in the experience of illness and treatment.”

Kleinman A, Benson P (2006) Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Med 3(10): e294

Slide Credits

SLIDES 4-11, 14, 17-23, 32-33, 45:

SLIDES 26, 29, 30:

SLIDES 37-39:

Lauren Moschetta-Gilbert, MA NJMS Global Tuberculosis Institute

Sapna Pandya, MPH Center for Immigrant Health, New York Univ. School of Medicine

Jane L. Moore, RN, MHSA Virginia Department of Health