culturally responsiveobstetrical and gynecological care

Jean Gilbert, PhDGeri-Ann Galanti, PhD

Los Angeles County Department of Health Services

Office of Diversity Programs

Who Thinks Cultural Competency is a Clinical Skill?

The Accreditation Council for Graduate Education (Residency Programs)

The Association of American Medical Colleges (Medical Schools)

The American College of Obstetrics and Gynecology

The Los Angeles County Department of Health Services: Cultural and Linguistic Competency Standards

Why This Recent Emphasis on Culture and Health Care?

Major changes in the composition of the U.S. population: 25% of the California population is foreign born.

Many immigrants are from non-Western nations with non-Western health concepts.

Increasing emphasis on patient-centered care within medicine.

Of the 1.7 million DHS patient visits over the last 6 months, about 779,000 were limited English

proficient, preferring services in 88 languages.

If You And Your Patient Hold Very Different Health Beliefs...

This may impact on their trust in you and their evaluation of your abilities.

It might impede understanding of your assessment and treatment plan.

It may make obtaining consent for procedures very difficult.

It might reduce willingness to comply with treatment and follow-up.

Culture is a Major Force in Shaping an Individual’s:

Expectations of a physician

Perceptions of good and bad health

Understanding of disease etiology

Methods of preventive care

Interpretation of symptoms

Appropriate treatment

Health care self-efficacy

In Understanding Cultures, a Little Knowledge is Dangerous

Don’t let cultural generalizations become stereotypes.

Generalizations are testable probabilities; we couldn’t do science without them.

Stereotypes attribute the central tendencies of groups to individuals… ignoring the bell curve!

Your patient is an individual, not a culture.

The Importance of Women’s Roles

Which one of these women is the model for your patient?

Acculturation is a Critical Factor in:

Family dynamics and gender roles

Knowledge of and access to public and private helping agencies.

Ability to speak and read English.

Experience with the U.S. health care system.

Video: Lupe’s Dilemma

QuickTime™ and aH.263 decompressor

are needed to see this picture.

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment .

Cultural Resistance to Breast Cancer, PAP and STD Screenings

Lack of orientation to preventive care

Fatalistic perspective

Fear and embarrassment about pelvic

examinations

Social shame, invasion of bodily privacy

Doctors “push” testing too early, endanger hymen

Video: A Big Baby is Coming

QuickTime™ and aH.263 decompressor

are needed to see this picture.

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment .

Gestational Diabetes

Gestational diabetes is the most common complication of pregnancy among Mexican Americans.

Lack of early prenatal care often prevents appropriate treatment.

Language issues often make appropriate education and treatment difficult.

• Asian women tend to be stoic.

• African American women may be either.

Labor Pains

• Mexican women also tend to be expressive.

• Iranian women tend to be expressive.

Labor Pains

Preferred Labor Attendants

Anglo American: Husband or Domestic Partner

Hispanic: Mother or Female Relative

Asian: Mother or Mother-in-Law

Video: Hmong Birthing Practices

QuickTime™ and aH.263 decompressor

are needed to see this picture.

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment .

Hmong Prenatal and Birthing Practices

Hmong women may resist napping and invasive prenatal testing;

Consent for prenatal and birthing procedures may have to be gotten from parents, husband, and in-laws;

At childbirth, both mother and baby are considered especially vulnerable to malevolent spirits.

Video: Female Circumcision

QuickTime™ and aH.263 decompressor

are needed to see this picture.

Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment .

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Normal Female Anatomy Modified Sunna

Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

Female Circumcision (aka Female Genital Mutilation)

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Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

Female Circumcision (aka Female Genital Mutilation)

Infibulation Infibulation

Breastfeeding

Colostrum

Postpartum Lying-in

Traditionally 30 - 42 days

Rest, stay warm, avoid bathing & exercise

Eat foods designed to restore warmth

Failure to follow custom is thought to result in aches & pains in later years

BondingBonding and Baby Naming

SERENA: serene

Duranjaya: a heroic sonCALEB: devotion to God

CHAN JUAN: the moon; graceful; ladylike

Kabira: powerful

Radman: joy

Taci: washtub

Menopause in Cultural Perspective

Although menopause is universal, the “symptoms” attributed to it are not.

Research suggests that the variety of ways menopause is experienced can be termed “local biologies.”

Cessation of the menses is looked upon very positively by women in many cultures.

Issues of Language Access in Health Care

DHHS guidance for language access under the Title VI, Civil Rights Act of 1964

MediCal contract regulations

DHS Cultural & Linguistic Standards

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes standards for cultural competence training and language services.

JCAHO Ruling

JCAHO views the provision of linguistically appropriate care as an important quality and safety issue.

JCAHO requires the inclusion of language and communication needs in the medical record.

Interpretation and translation must be provided for patients who need it.

DHHS says:

Assess patients’ language needs.

Try not to use family or friends or whoever you can grab.

Don’t use minors to interpret.

Try to use trained medical interpreters whenever possible.

Use telephonic interpreters for rare languages.

What Can You Do?

Honestly assess your own bilingual skills

Understand the pitfalls in using untrained interpreters

Use interpreters effectively

Use telephonic interpreters skillfully

Are your bilingual skills really adequate? Can you:

formulate questions easily?

ask a question in more than one way?

understand nuance and connotation in the patient’s response to questions?

understand regional variations?

know terms for anatomy and healthcare concepts?

convert biomedical terms into lay terms in the target language?

Pitfalls in Using Untrained Interpreters

Studies show that an average of 70% of the interpreted exchanges by ad hoc interpreters contain clinically important errors.

Family members, especially, are prone to edit both the clinician’s and patient’s utterances.

Children are frightened or intimidated if asked to interpret. There are ethical problems involved.

Confidentiality concerns must also be considered.

The Effective Use of Face-to Face Interpreters

Brief the interpreter first, if possible.

Introduce the interpreter to the patient.

Position the interpreter behind the patient or behind you.

Speak and look directly at the patient.

Use first person and expect the interpreter to do the same.

Avoid interrupting the interpretation.

Using Telephonic Interpreters

Use a speaker phone; do not pass a handset back and forth.

Remember that the interpreter is blind to visual

cues.

Let the interpreter know who you are, who else is

in the room, and what sort of patient encounter it is.

Let the interpreter introduce her/himself.

What You Need to Know to Connect

The language needed

Dial 0 for hospital operator

Tell operator to connect you with the Language Line.

Remember that the telephonic interpreter is bound by confidentiality regulations, just as any other health care personnel.

What Can You Do To Be More Culturally Competent?

Practice ways to build rapport

Ask tactful, nonjudgmental questions about their preferences and practices

Understand family roles in health care

Know something about the cultural beliefs of your patients, but don’t stereotype

Use interpreters and use them effectively, don’t “wing it.”

Consider:

Think back on your “difficult” patients.

May any of the challenges they presented be linked to their cultural beliefs or practices?

Would cultural competence skills have made a difference?