Patient-Centered CareBecoming Culturally Humble When Working with Refugees, Migrants

and Immigrant Youth

Maxine ProskurowskiEugene, OR School District

Immigrants, Refugees and Migrants

• Demographic changes• Strengths and challenges for the new Americans,

and their health care needs• Culturally competent care

our own beliefs and assumptions

skills to provide culturally humble care

film and discussion around different cultural

beliefs

CULTURAL COMPETENCY

Describes a set of skills, knowledge and attitudes that enhances a clinician’s ability to:

• Understand and respect the patient’s values, beliefs and expectations;

• Be aware of one’s own assumptions and value systems, and those of the American medical system;

• Adapt care to be acceptable to the patient’s expectations and preferences

Rationales for cultural competence training

• Rapidly changing demographics calls for new skills, attitudes and knowledge to allow clinicians to work effectively with diverse racial, ethnic and social groups;

• By reflecting on our own assumptions and biases, we can develop a greater understanding and acceptance of beliefs that differ from our own

Demographic changes in the last 100 years

• More than 281 million people counted by the latest federal census in 2000

• four times the number in 1900

• double the population in 1950

• In the decade 1990-2000 the population grew by the biggest ten year numerical leap in the US history

The ticking clock

• Every 8 seconds a new American is born

• Every 12 seconds one dies

• As each 25 seconds ticks by there is a net gain of one immigrant from abroad

• Every 12 seconds the nation’s population clock records a net increase of one more

American overall

Immigrant profile

• 56 million Americans or 1 in 5 are foreign born or children of foreign born parents

• Foreigners keep coming to this country, as they have for hundreds of years:

• refugees: to escape discrimination, death• job availability• and most importantly, people seek the best

opportunity to improve their own lives and those of their children

Alteration of America’s racial and ethnic dynamic

• For the first time African Americans are no longer the nation’s biggest minority group

• Jose is • #1 name for baby boy in Texas

• #2 in Arizona

• #3 in California

• Smith remains the most common surname• Top 50 names include Garcia, Martinez,

Rodriguez, Hernandez, Lopez, Gonzalez, Perez

Children of Immigrants by

region of origin, 1910-2000

www.futureofchildren.org

Dispersion of Immigrant families between 1990 and 2000

www.futureofchildren.org

Distinguishing factors for the latest waves of immigrants

• Besides 6 major gateway states (California, New York, Texas, Florida, Illinois, New Jersey) 22 other states experienced immigration growth three times faster than the nation as a whole

• Limited English proficient population grew by 52% from 14 million to 21.3 million.Source: Pew Hispanic Center

Distinguishing factors for the latest waves of immigrants (cont)

Rise in undocumented immigration• between 1990 and 2002 the undocumented

population tripled from 3 to 9.3 million, by March 2003 increased another million and by March 2007 estimated 12 million

• Of the 17.9 million foreign born workers in the US – 5.2 million or 29% are undocumented

• 57% from Mexico, • 24% other Latin American countries, • 9% Asians.

Source: Pew Hispanic Center

Strengths of immigrant families

• Healthy, intact families• Strong work ethics and aspirations• Community cohesion• Children have high educational aspirations• Children are less likely to engage in risky

behaviors • Children spend more time doing homework• Do well in school during the early school years

Challenges faced by immigrant families

• Less educated parents

• Low wage work with no benefits

• Language barriers

• Discrimination and racism—racial profiling

• Poverty and multiple risk factors

• Lack of social supports

High poverty rate for immigrant children

• High poverty rate for immigrant children is a recent phenomenon.

• 2002 overview of immigrant children :– 29% live in families with incomes below

poverty level– 18% lack health insurance– 40% live in a family worried about affording

food

Restrictions on benefits for legal immigrants

Most legal immigrants are ineligible for benefits during their first five years in the United States:

– TANF (Temporary Assistance for Needy Families)

– Food stamps– Supplemental social security income– Health benefits-SCHIP and Medicaid

Health profile of immigrants

First generation children do well at early ages• healthy babies• high immunization rates

Adolescent health

• Adolescent well being declines the longer the families have lived in the United States.

• Foreign born youth report better health as compared to American born adolescents of the same ethnicity.

Educational challenges

While the majority of teens in immigrant families attend school, they are more likely to be behind grade level and not to graduate.

This is especially evident in those families with origins in Mexico, Central America, the Dominican Republic, Haiti and Indonesia, who together account for the majority of immigrant children.

Richard Rothstein’s recommendations for all children

Richard Rothstein, a researcher at the Economic Policy Institute, author of “Class and Schools: Using Social, Economic and Educational Reform to Close the Black-White Achievement Gap” calls for three programs:

1. Early education programs2. After school programs3. Fully staffed health clinics in schools

serving low income children.

Health Disparities

• Defined as racial or ethnic differences in the quality of health care.

• Differences result in worse clinical outcomes.• The differences persist after adjusting for known

factors, including economic and social class access to care Health disparities=unequal quality of care

2006 Center for the Health Professions, University of California, San Francisco

Healthy People 2010 Findings

• Women of Vietnamese origin in the U.S. have cervical cancer at nearly 5 times the rate of White women.

• 55% of reported AIDS cases are among African American and Hispanic populations.

• Infant mortality rates among American Indians and Alaskan Natives is almost double that of Whites.

• Pima Indians of Arizona have one of the highest rates of diabetes in the world.

• Evidence suggests that lesbians have higher rate of smoking and obesity than heterosexual women.

US. Department of Health and Human Services, 2001

Role of clinicians in health disparities

Clinical decision making study with standardized patients who were identical in all aspects except for race and gender:

• Videos shown to 720 physicians• African Americans 40% less likely to be referred for cardiac

catheterization• African Americans were rated as having lower income, despite the

same occupation.• Race and sex of patient affected decision to refer patient• Lowest referral rates were for African American women• Findings “may suggest bias on part of the physician…could be the

result of subconscious perceptions rather than deliberate actions or thoughts.”

Schulman, 1999.

Biases and Assumptions

• An inherent human trait—we all have biases and make assumptions. This is how our minds efficiently receive, file, store and retrieve information. Society also shapes our beliefs.

• We are more likely to make assumptions when time and information are limited.

• We may subconsciously discriminate on basis of race, gender, age.

Schulman K. NEIM 1999;340-618:26

Stereotypes

• A type of “mental shortcut” for taking in, processing and retrieving information.

• We use this to assign an individual to a category based on what we believe, consciously or unconsciously, about a general group to which the person belongs.

• Based on limited personal knowledge and/or experience

• More likely when time pressure, need for quick judgments, multi-tasking, and anxiety.

2006 Center for Health Professions, University of California, San Francisco

Generalizations

• Another type of “mental shortcut” for taking in, processing and receiving information.

• Based on a summary of common trends in beliefs or behaviors about groups

• Are a starting point; add knowledge, skills and practice to this base

First Memory of Difference

• Who were the messengers of difference?

• What people, or institutions were involved in your memory?

• What feelings did your memory evoke?

Linking health disparities and cultural competence

• Culture matters in health care—affects all aspects of life, including how we think about disease, health and healing

• Cultural causes of disparities can include: communication gaps between clinician and families health beliefs of patients biases and stereotypes among health professionals patients’ use of complementary or alternative healing traditions language barriers

Culturally competent care is care that is tailored to the linguistic and cultural needs of the patients

2006 Center for Health Professions, University of California, San Francisco

Eliciting Health and Healing Beliefs

• Communication is culture-bound

• Explanatory frameworks can be used to help bridge cross-cultural communication

• Examples of frameworks:

LEARN

Kleinman’s questions

Framework for Eliciting Health Beliefs

• LEARN

Listen with sympathy and understanding to

the patient’s perception of the problem

Explain your perceptions of the problem

Acknowledge and discuss the differences

and similarities

Recommend treatment Negotiate agreement Berlin, West J.Med 1983

Kleinman’s Questions

• What do you call this problem?• What do you think has caused the problem?• Why do you think it started when it did?• What do you think the sickness does? How

does it work?• How severe is the sickness? Will it have a

long or short course? Kleinman A. Ann.Intern.Med. 1978

Applying Models to Elicit Patients’ Experience of Illness

“ The best way to learn about something is to play about it.”

Mr. Rogers

Role of Culture in Health, Illness and Healing

Culture is society’s style, its way of living and dying. It embraces the erotic and the culinary arts; dancing and burial; courtesy and curses; work and leisure; rituals and festivals; punishments and rewards; dealing with the dead and with the ghosts who people our dreams; attitudes toward women, children, old people and strangers; enemies and allies; eternity and the present; the here and now and the beyond. Octavio Paz

World’s apart: a Laotian child

Film about Laotian child raises issues around:1. Understanding the family’s health and

illness beliefs2. Family decision-making and authority

figures;3. Traditional/alternative medical practices4. Cross-cultural negotiations5. Barriers to effective communication

Do Cultural Differences Exist?

In working with a patient/family

• What would prompt you to consider that there may be differences in the health beliefs or healing beliefs between you and the patient/family?

• What questions would you ask?

Working with Differences

Without some agreement about the nature of what is wrong, it is difficult for a clinician and a patient to agree on a plan of management acceptable to both of them. It is not essential for the clinician to actually believe that the nature of the problem is as the patient sees it, but the clinician’s explanation and recommended treatment must be at least consistent with the patient’s point of view.

Moira Stewart, 1995 Patient Centered Medicine

Evolution of Health Care2000 BC Here, eat this root.1000 BC The root is heathen. Say this prayer.1850 AD That prayer is superstition. Here, drink this potion.1940That potion is snake oil. Here, take this antibiotic.2000 That antibiotic does not work. Here, eat this

root.Source: unknown

Culturally Humble Care

Understanding a patient’s culture and beliefs not only helps us resolve purely medical complaints. Cultural competence brings solace and sustenance for the provider as well as the patient.

By leaving behind preconceived notions and opening our minds to other sets of values and beliefs, we embark on a voyage of spiritual discovery of our fellow human beings.

It is a voyage that can mature us and strengthen us for the rest of our lives.

Miguel Angel Corzo