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TB Nurse Case ManagementLisle, Illinois

April 27 28 2010April 27-28, 2010

Cultural Competency for TB Workers

Jessica Quintero BAASJessica Quintero, BAAS

April 28, 2010

Cultural Competency

Jessica Quintero, BAASHeartland National TB Center

April 28, 2010

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Objectives

• Discuss cultural and linguistic competency issues and their impact on health

• Identify strategies and resources to promote awareness of cultural / social issuesissues

What is culture?

“Culture is defined as the learned and

shared values, beliefs and meanings that

form the lens or perspective through

which an individual understands and

interprets their experience.”

Adapted from: Fitzgerald MH, Mullavey-O’Byrne C, Clemson L. Culturalissues from practice. Aus Occ Ther J. 1997; 44: 1-21. and Helman CG.Culture, health and illness. 4th ed. New York: Oxford University Press; 2001.

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Culture is…

• Language, thoughts, communication, actions, beliefs, values, traditions, norms, taboos, history, folklore, and institutionsinstitutions

• An overarching group identity

• Influenced by sociopolitical factors, poverty, oppression, prejudice, and racism

• Not necessarily connected to solely race ethnicity or• Not necessarily connected to solely race, ethnicity, or national origin

• A part of all of us

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So what does this mean to you?

Ask yourself:

Which individuals or groups of people are socially and medically segregated from those who have successfulthose who have successful

health outcomes?

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Patient Culture

• Core health beliefs

Definition of healthDefinition of health

Cause of illness

Diagnosis / treatment

• Health seeking practices

St f ill Stage of illness

Where to seek care

From who

Patient Culture (cont.)

• Norms, values, customs

• Communication stylecustoms

– Group / individual identity

– Control of destiny

F il d i

style

– Greetings

– Personal space

– Gestures

– Eye contact• Family dynamics

– Interests

– Decision making

Eye contact

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Culture of the Health Care Staff

• Biomedical background and beliefsg

• Often government affiliated when working in TB field

• Personal culture / belief system of the health• Personal culture / belief system of the health care provider that can lead to assumptions, stereotypes, and judgment

Health Literacy:

The degree to which individuals can obtain,individuals can obtain, process, and understand the basic health information and services they need to make appropriatemake appropriate health decisions.

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Possible Indicators of Low Health Literacy

• Seek help only when illness is advanced• Seek help only when illness is advanced

• Have difficulty explaining medical concerns / limited descriptive abilities

• Have difficulty completing forms

• Use excuses

• Lack of follow-through with tests and appointments

• Seldom or never have any questions

Health Disparities

• It is crucial to determine potential barriers toIt is crucial to determine potential barriers to health-seeking behavior and treatment adherence

• Conversely, it is important to self assess barriers to TB guideline adherence

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Chicago Heights city, IllinoisEstimate Margin of Error

Total: 30,996 +/-1,798

White alone 14,081 +/-1,282

Black or African American alone 13,505 +/-1,869

American Indian and Alaska Native alone 36 +/-58

Asian alone 100 +/-100

Native Hawaiian and Other Pacific Islander alone 39 +/-67

Some other race alone 2,387 +/-796

Two or more races: 848 +/-445

Two races including Some other race 533 +/-384

Two races excluding Some other race, and three or more races

315 +/-226

Chicago city, IllinoisEstimate Margin of Error

Total: 2,725,206 +/-11,581

White alone 1,086,524 +/-11,605

Black or African American alone 944,152 +/-8,566

American Indian and Alaska Native alone 5,946 +/-898

Asian alone 134,736 +/-4,611

Native Hawaiian and Other Pacific Islander alone 1,316 +/-592

Some other race alone 506,100 +/-10,936

Two or more races: 46,432 +/-3,250

Two races including Some other race 19,504 +/-2,400

Two races excluding Some other race, and three or more races

26,928 +/-2,307

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North Chicago city, IllinoisEstimate Margin of Error

Total: 27,446 +/-1,495

White alone 12,533 +/-1,321, ,

Black or African American alone 9,001 +/-1,088

American Indian and Alaska Native alone 38 +/-65

Asian alone 950 +/-412

Native Hawaiian and Other Pacific Islander alone 0 +/-151

Some other race alone 4,095 +/-1,145

Two or more races: 829 +/-358

Two races including Some other race 342 +/-290

Two races excluding Some other race, and three or more races

487 +/-246

West Chicago city, IllinoisEstimate Margin of Error

Total: 27,389 +/-1,971

White alone 21,293 +/-1,805

Black or African American alone 479 +/-328

American Indian and Alaska Native alone 0 +/-151

Asian alone 2,183 +/-533

Native Hawaiian and Other Pacific Islander alone 0 +/-151

Some other race alone 3,042 +/-1,164

Two or more races: 392 +/-284

Two races including Some other race 244 +/-233

Two races excluding Some other race, and three or more races

148 +/-158

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“Throughout the world, those least likely to comply

are those least able to comply.”

P l F-Paul Farmer

What can we do to address these issues?

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STRATEGIES…

Cultural Competence Is…

“Having the capacity to function effectively

as an individual and an organization within

the context of the cultural beliefs, behaviors

and needs presented by consumers and

their communities”

Source: HHS, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report, March 2001

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Cultural Sensitivity

Cultural competence encompasses cultural

iti it “th bilit t b i t lsensitivity: “the ability to be appropriately

responsive to the attitudes, feelings, or

circumstances of groups of people that share

a common and distinctive racial nationala common and distinctive racial, national,

religious, linguistic or cultural heritage”

Source: HHS, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report, March 2001

In a Culturally Competent Environment…

• The clinician / health care worker recognizes the cultural / social context of the encounter and cancultural / social context of the encounter and can negotiate among potential conflicting interpretations, expectations, and beliefs

• Health care staff are better able to provide optimal care to the patient and family

• Inequalities in health outcomes can begin to be addressed

Adapted from: Kagawa-Singer M, Kassim-Lakha S. A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Academic Med. 2003; 78: 577-587.

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Cultural Competency Key Points:

• We can not make assumptions about other cultures based on our own belief system

• Ask questions to find out what is important to the patient

• Care should be provided in a manner compatible with the patient’s cultural health beliefs and practices and p ppreferred language

• Negotiating and cultural brokering is necessary for a successful outcome

“Against boredom, even the gods themselves struggle in vain.”gg

−Friedrich Nietzsche

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Developing Cultural Competence

• Systemic approaches

• Individual approaches

• Tools and resources

Patient Centered Care Models

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Elements of Case Management

• Case finding

• Assessment• Assessment

• Problem identification

• Development of a plan

• Implementation

• Variance analysis• Variance analysis

• Evaluation

• Documentation

In Addition to…

• Recognizing the extent of the problem

• Offering staff training

• Making resources available

• Fostering a shame-free environmentenvironment

• Keeping forms simple and improve signage

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Individual Staff

• Commitment to developing skills, in order to become culturally aware and knowledgeabley g Self-awareness Acceptance Respect Cross-cultural communication

• Cultural brokering is the act of bridging, linking,Cultural brokering is the act of bridging, linking, or mediating between groups or persons of differing cultural backgrounds for the purpose of reducing conflict or producing change

Eliciting Health Views:LEARN

• Listen: listen with sympathy andListen: listen with sympathy and understanding

• Explain: explain your perceptions of the problem

• Acknowledge: acknowledge and discuss differencesdifferences

• Recommend: recommend treatment

• Negotiate: negotiate treatment

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Treatment Adherence: ADHERE

• Acknowledge: acknowledge the need for t t ttreatment

• Discuss: discuss potential treatment strategies

• Handle: handle any questions or concerns

• Evaluate: evaluate the patient’s understanding

R d d d i t t t• Recommend: recommend and review treatment regimen

• Empower: empower by engaging patient

Communication Skills

• Focus on key messages and repeat

• Speak slowly and clearly with non-technical language

• Utilize written or audiovisual materials

• Confirm patient comprehension

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Communication Skills

• Acknowledge the sensitivity of some issues

• Affirm the patient’s beliefs

• Ask open-ended questions

• Listen

• Assess your own communication style / abilities

Tips for Working with Interpreters

• DO NOT use untrained interpreters, family members, or minors

• Speak directly to and sit it facing the patient

• Don’t let the interpreter’s presence change your role in the interview

• If the patient does not understand it is the health care worker’s responsibility to explain more simply

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Resources• Cultural Competency:

– www thinkculturalhealth org– www.thinkculturalhealth.org– www.multi-culturalhealth.org– Office of Minority Health: www.omhrc.gov– National Standards for Culturally and Linguistically

Appropriate Services in Health Care: http://www.omhrc.gov/assets/pdf/checked/finalreport.pdfp

– Cultural Competency Resource Guide:http://www.findtbresources.org/material/CCGuide.pdf

Resources

• Language and Communication Barriers:– www.plainlanguage.govp a a guage go– http://www.languageline.com/– American Translators Association:

http://www.atanet.org/divisions/– Medline: How to Write Easy to Read Health Materials:

http://www.nlm.nih.gov/medlineplus/etr.html– Institute for Health Care Communication:

http://www healthcarecomm org/http://www.healthcarecomm.org/– National Health Law Program Language Services

Resources Guide:http://www.healthlaw.org/library.cfm?fa=download&resourceID=89928&appView=folder&print

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Additional Reading

• Farmer, Paul. Infections and Inequalities

• Whitaker, Elizabeth D. Health and Healing in Comparative Perspective

• Fadiman, Anne. The Spirit Catches You and You Fall Down

“What the social world has made, the social world, armed with knowledge, can undo.”

- Pierre Bourdieu- Pierre Bourdieu

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References

• Fitzgerald MH, Mullavey-O’Byrne C, Clemson L. Cultural issues from practice. Aus Occ Ther J. 1997; 44: 1-21. and Helman CG. Culture health and illness 4th ed New York: Oxford UniversityCulture, health and illness. 4th ed. New York: Oxford University Press; 2001.

• HHS, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report, March 2001

• Kagawa-Singer M, Kassim-Lakha S. A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Academic Med. 2003; 78: 577-587.

• Cultural Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment. New Jersey Medical School Global Tuberculosis Institute website. Available at: http://www.umdnj.edu/globaltb/products/tbculturalcompguide.htm

References

• Beyond Diversity: A Cultural Competency Journey. Heartland National TB Center.

• Physician Toolkit and Curriculum: Resources to Implement Cross-Cultural Clinical Practice Guidelines For Medicaid Practitioners. University of Massachusetts Medical School, Office of Community Health. 2004

• Carson, S. Cultural Competence in TB Case Management. TB Education Center.

• Granillo, J. Culturally Competent Care. Heartland National TB Center and Arizona Department of Health Services: 2008.p