culturally responsive obstetrical and gynecological care Jean Gilbert, PhD Geri-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 a H.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 a H.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. Labor Pains • Asian women tend to be stoic. • African American women may be either. Labor Pains • Iranian women tend to be expressive. • Mexican women also tend to be expressive. 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 a H.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 inlaws; At childbirth, both mother and baby are considered especially vulnerable to malevolent spirits. Video: Female Circumcision QuickTime™ and a H.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. Female Circumcision (aka Female Genital Mutilation) . Normal Female Anatomy Modified Sunna Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein Female Circumcision (aka Female Genital Mutilation) . Infibulation Infibulation Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein 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 Bonding and Baby Naming SERENA: serene Kabira: powerful Taci: washtub Radman: joy CALEB: devotion to God Duranjaya: a heroic son CHAN JUAN: the moon; graceful; ladylike 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?