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UNDERSTANDİNG CULTURAL DİFFERENCES AND THEİR EFFECT ON

HEALTHCARE

Bethany Berg, MPAS, PA-C

Nebraska Medicine, University Health Center UNL

OBJECTIVES:

•Define Cultural Disparities and Cultural Competency

•Explain examples of cultural differences regarding health care and the barriers these create

•Describe methods and practices to allow for delivery of optimal healthcare, despite cultural differences

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DISCLOSURES:

None

DEFINITIONS:

•Culture• “integrated patterns of human behavior that include the language, thoughts, communications, actions,

customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” from CDC.gov

•Cultural Disparities• “a particular type of health difference that is closely linked with social, economic, and/or

environmental disadvantage” according to Healthy People 2020

•Cultural Competence• "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among

professionals that enables effective work in cross-cultural situations"

• The ability to function effectively within an organization and as in individual with context of cultural beliefs, needs and behaviors of the patient and their community

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CULTURAL ELEMENTS:

•Age

•Cognitive ability or limitations

•Gender Identity

•Education Level attained

•Health Practices (traditional healer, etc)

•Language spoke or written

•Military affiliation and/or belief

•Occupations

•Socioeconomic status

•Sex and/or Sexual Orientation

•Religious and spiritual characteristics

•Political Beliefs

•Diet and Nutrition Beliefs

•Racial and ethnic groups

•Residence (urban, suburban, rural)

•Perceptions of family and community

•Composition of family and household

•Degree of acculturation

COMMON MISCONCEPTIONS

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BY THE PATIENT

•Assumed provider understanding of their cultural customs and beliefs• Traditional Medicines

• Religious Beliefs

• Temperatures of Foods with certain medical conditions

•Feelings of being insulted, unwelcome

•Confusion of appointments and/or treatment plans

BY THE PROVIDER:

•Basic understanding of illness symptoms• Definition of fever

• "The Flu"

•OTC Medications• Paracetamol

• APAP and NSAIDs

•Gender Expectations• Spousal contribution, equality, etc.

•Interpersonal Contact• Touching, hand shakes, etc.

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NEGATIVE EFFECTS ON HEALTHCARE

•Missed appointment• Lack of follow up

• Wasted appointment slots

•Lost to follow up

•Negative reputation• Patients with negative experiences more likely to tell others

•Patient complaints, grievance• Based on lack of understanding, misconception, etc.

STATISTICS

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NATIONWIDE

•More than 4 in 10 (41%) of nonelderly people in the US are people of color

•Non elderly Hispanics, Blacks, American Indian and Alaska Natives significantly more likely to be uninsured• Account for 55% of the uninsured

RATES OF INSURANCE COVERAGE BY ETHNIC BACKGROUND:

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UNIVERSITY OF NEBRASKA- LINCOLN

UndergraduateNon resident Alien

Hispanic/Latino

American Indian/AlaskaNative

Asian

Black/African American

Native Hawaiian/PacificIslander

White- Non Hispanic

Two or More Races

Unknown

GraduateNon Resident Alien

Hispanic/Latino

American Indian/AlaskaNative

Asian

Black/African American

Native Hawaiian/Pacific Islander

White- Non Hispanic

Two or More Races

Unknown

UNIVERSITY HEALTH CENTER

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EXAMPLES AT UNIVERSITY HEALTH CENTER:

EXAMPLES:

•Differences in sexual expectations• Need for clarification for all types of “sexual activity”

•Marriage Clearances• Often requires forms, sometimes with notary as well

• Labs and typically STD testing for the female

•Attitude towards women providers, with foreign male patients

•Dental care

•Desire to skip periods• Varying beliefs on contraception and periods

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EXAMPLES:

•Ramaadan• Rules of fasting

• Need to adjust or accommodate medication regimens

•Skin and acne expectation

•BMI variations across cultures• Lower BMI cutoff in Asian populations

•Diet• Rice and constipation

• Water intake

• Traditional cultural foods

EXAMPLES:

•Severity of Illness

•Temperature of Foods

•Illness vs Disease• Disease- medical diagnosis of condition (broken bone, measles, etc)

• Illness- can be disease as well, or can be more spiritually or psychologically based on “not well”

•Things “lost in translation”

•Typhoid and malaria history• Typhoid can remain in patient’s stool for a year after infection, as chronic carrier

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EXAMPLES:

•Vitamin D• High degree of suspicion in those from underdeveloped countries

• Lack of readily available fortified foods, etc.

EXAMPLES:

•Thalassemia• Prevalent in those of Mediterranean, African, Asian and Middle Eastern

descent

• Alpha or Beta• Can have major, intermedia, minor or trait

• Often found when patient has low MVC on labs, normal iron levels• If not diagnosed can get over treated with iron, which isn’t needed

• Important for patients to know in regards to passing on to offspring, etc.

•Infectious diarrhea and illness post travel to home country• Also for study abroad patients

• Dengue fever, Zika virus, Chikungunya, MERS

• Active TB and malaria

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H PYLORI

• Estimated 2/3 of world’s population infected

•Often have chronic symptoms but never tested

• Known to cause many health problems

METHODS FOR IMPROVEMENT

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CROSS CULTURAL COMMUNICATION

•Awareness of own cultural values

•Awareness and acceptance of cultural differences

•Development of cultural knowledge

•Adaptability of cultural context

CROSS CULTURAL COMMUNICATION

•Principles of Cultural Competence• Broad definition of culture

• Value and acknowledge your patient's own belief • Be aware of your own thoughts or possible barriers

• Recognize and adapt to cross cultural language interpretation

• Encourage learning and new education between staff and outreach• Constantly changing area

• Work with surrounding community population to address needs, culturally related

• Reach out to other organizations for collaborations

• Consider cultural and personal differences with hiring, ensure cultural acceptance and professionalism

• Make cultural competence a part of the work culture, standard accepted procedure

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ADAPTATIONS MADE AT UHC

•Handouts in other languages (Chinese, etc)

•Translation phone apps

•Written out patient instructions• Specific medications, frequency, etc (ibuprofen every 8 hours as needed)

•Cold Care Handouts

•Use of One Chart Portal Account

•Language Line via Phone

•ASK THEM QUESTIONS!!

COLD CARE HANDOUTS AT UHC

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AVAILABLE RESOURCES:

•Online• CDC.gov

• thinkculturalhealth.hhs.gov/• Online program for 9 hours of free CME!

•Statewide

•Campus and Community• Gaughn Center

• Multicultural Center

•Clinic Specific• Policies and Procedures

• KNOW YOUR OWN RESOURCES!

RESOURCES:

CDC.gov

https://npin.cdc.gov/pages/cultural-competence

https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

https://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/

https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1111/nyas.13968

http://www.cooleysanemia.org/updates/pdf/GuideToLivingWithThalassemia.pdf

https://www.gastrojournal.org/article/S0016-5085(17)35531-2/pdf

http://www.aafp.org/about/policies/all/cultural-diverse-populations.html

http://www.ahrq.gov/literacy

https://iea.unl.edu/dmdocuments/050_fall_2018_enrl_ethnic.pdf

https://iea.unl.edu/dmdocuments/050_fall_2018_enrl_grad_ethnic.pdf

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