Practices of Culturally Sensitive Care.

WHAT IS CULTURAL COMPETENCE IN HEALTH CARE?

Individual values, beliefs, and behaviors about health and well-being are shaped by various factors such as race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. Practices of Culturally Sensitive Care.

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Cultural competence in health care is broadly defined as the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy. Some common strategies for improving the patient-provider interaction and institutionalizing changes in the health care system include:(20)

1. Provide interpreter services

2. Recruit and retain minority staff

3. Provide training to increase cultural awareness, knowledge, and skills

4. Coordinate with traditional healers

5. Use community health workers

6. Incorporate culture-specific attitudes and values into health promotion tools

7. Include family and community members in health care decision making

8. Locate clinics in geographic areas that are easily accessible for certain populations

9. Expand hours of operation

10. Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials. Practices of Culturally Sensitive Care.

Cultural competence is an ongoing learning process

In order to increase the cultural competence of the health care delivery system, health professionals must be taught how to provide services in a culturally com-petent manner. Although many different types of training courses have been developed across the country, these efforts have not been standardized or incorpo-rated into training for health profession-als in any consistent manner.(21) Training courses vary greatly in content and teaching method, and may range from three-hour seminars to semester-long academic courses. Important to note, however, is that cultural competence is a process rather than an ultimate goal, and is often developed in stages by building upon previous knowledge and experience.Practices of Culturally Sensitive Care.

TRAINING APPROACHES THAT TEACH FACTS ABOUT SPECIFIC GROUPS ARE BEST COMBINED WITH CROSS-CULTURAL SKILL-BASED APPROACHES THAT CAN BE UNIVERSALLY APPLIED

Approaches that focus on increasing knowledge about various groups, typically through a list of common health beliefs, behaviors, and key “dos” and “don’ts,” provide a starting point for health pro-fessionals to learn more about the health practices of a particular group. This approach may lead to stereotyping and may ignore variation within a group, however. For example, the assumption that all Latino patients share similar health beliefs and behaviors ignores im-portant differences between and within groups. Latinos could include first-generation immigrants from Guatemala and sixth-generation Mexican Americans in Texas. Even among Mexican Americans, differences such as generation, level of acculturation, citizenship or refugee status, circumstances of immigration, and the proportion of his or her life spent in the U.S. are important to recognize.Practices of Culturally Sensitive Care.

It is almost impossible to know everything about every culture. Therefore, training approaches that focus only on facts are limited, and are best combined with approaches that provide skills that are more universal. For example, skills such as communication and medical history-taking techniques can be applied to a wide diversity of clientele. Curiosity, empathy, respect, and humility are some basic attitudes that have the potential to help the clinical relationship and to yield useful information about the patient’s individual beliefs and preferences. An approach that focuses on inquiry, reflection, and analysis throughout the care process is most useful for acknowledging that culture is just one of many factors that influence an individual’s health beliefs and practices.(22)Practices of Culturally Sensitive Care.

GUIDELINES FROM PROFESSIONAL ORGANIZATIONS HELP PROMOTE CULTURAL COMPETENCE

Many professional organizations representing a variety of health professionals, such as physicians, psychologists, social workers, family medicine doctors, and pediatricians have played an active role in promoting culturally competent practices through policies, research, and training efforts. For example, the American Medical Association provides information and resources on policies, publications, curriculum and training materials, and relevant activities of physician associations, medical specialty groups, and state medical societies.(23)Practices of Culturally Sensitive Care.

Several organizations have instituted cultural competence guidelines for their memberships. For example, based on ten years of work, the Society of Teachers of Family Medicine has developed guidelines for curriculum material to teach cultural sensitivity and competence to family medicine residents and other health professionals. These guidelines focus on enhancing attitudes in the following areas:(24)

• Awareness of the influences that sociocultural factors have on patients, clinicians, and the clinical relationship.
• Acceptance of the physician’s respon-sibility to understand the cultural aspects of health and illness
• Willingness to make clinical settings more accessible to patients
• Recognition of personal biases against people of different cultures
• Respect and tolerance for cultural differences
• Acceptance of the responsibility to combat racism, classism, ageism, sexism, homophobia, and other kinds of biases and discrimination that occur in health care settings.Practices of Culturally Sensitive Care.

ACCREDITATION STANDARDS THAT ADDRESS CULTURAL COMPETENCE IN MEDICAL SCHOOLS HAVE THE POTENTIAL TO REACH MANY FUTURE PHYSICIANS

Accreditation standards are important tools that can have widespread effects on the cultural competence of medical students, health care professionals, and health care organizations. For example, the Liaison Committee on Medical Edu-cation (LCME) — the nationally recognized accreditation body for medical schools in the U.S. and Canada — recently mandated higher standards for curriculum material on cultural competence than were previously in place. As a result, medical schools must now provide students with the skills to understand how people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Students must also be able to recognize and appropriately address racial and gender biases in themselves, in others, and in the delivery of health care.(25)Practices of Culturally Sensitive Care.

Commitment to cultural competence is growing among health care providers and systems

Health systems are beginning to adopt comprehensive strategies to respond to the needs of racial and ethnic minorities for numerous reasons. First, there are increasingly more state and federal guidelines that encourage or mandate greater responsiveness of health systems to the growing population diversity. Second, these strategies may be seen as essential to meeting the federal government’s Healthy People 2010 goal of eliminating racial and ethnic health disparities. Third, many health systems are finding that developing and implementing cultural competence strategies are a good business practice to increase the interest and participation of both providers and patients in their health plans among racial and ethnic minority populations.Practices of Culturally Sensitive Care.

In addition to increasing the cultural competence of health care providers, organizational accommodations and policies that reduce administrative and linguistic barriers to health care are also important. Policies that strive to achieve cultural competence throughout the organization must address issues on all levels, from the organization’s top management to clinicians to office staff to billing and administrative staff. Organizational policies that address language and literacy barriers have been among the most successful efforts.Practices of Culturally Sensitive Care.

BILINGUAL AND BICULTURAL SERVICES ARE EFFECTIVE

Traditionally, community health centers that serve the Asian American or Latino communities have the most fully developed linguistic capabilities. For example, Asian Counseling and Referral Services (ACRS) in Seattle is a community-based mental health organization that effectively addresses language needs. Practices of Culturally Sensitive Care.They try to provide bilingual and bicultural clinicians that match the client’s background. When this is not possible, ACRS provides trained staff to act as co-providers with a licensed mental health professional. These trained individuals act not only as interpreters, but also help provide a cultural context for the client’s beliefs and practices. Stemming from 30 years of experience in this arena, ACRS has developed a training curriculum, “Building Bridges: Mental Health Interpreter Training for Interpreters of Southeast Asian Languages.” This curriculum will be used as a model for a national mental health interpreter training project to address the needs of limited-English speaking people. This national project includes training for interpreters, trainers, and health providers, as well as a mental health interpreter certification process.(26)Practices of Culturally Sensitive Care.

Within the Latino community, the use of promotoras, also known as peer edu-cators, is becoming increasingly popular. Promotoras are generally ordinary people from hard-to-reach populations who act as bridges between their community and the complicated world of health care. They learn about health care principles from doctors or non-profit groups, and share their knowledge with their com-munities. The peer education model is not only cost-effective, but also has been shown to be more effective in terms of reaching populations who find the information more credible coming from someone with a familiar background.(27)Practices of Culturally Sensitive Care.

ASSESSING LITERACY LEVELS CAN BREAK DOWN BARRIERS

Methods employed to assess literacy levels include the use of screening instruments that test for certain skills related to functional literacy or less formal tools that allow health care professionals to determine a person’s comfort level with various modes of communication. For example, at the To Help Everyone (T.H.E.) Clinic in Los Angeles, nurses and health care professionals speak individually with patients when they arrive at the health clinic to determine whether the patient prefers to learn by using written materials, pictures, verbal counseling, or some other technique. This method of assessment allows the patient to identify their own learning style preference without having to take a literacy test; it also reduces feelings of fear or humiliation that may occur when singled out.(28)Practices of Culturally Sensitive Care.

FEDERAL STANDARDS AND GUIDELINES FOR PROVIDING CULTURALLY AND LINGUISTICALLY APPROPRIATE CARE

1. The Department of Health and Human Services has provided important guidance on how to ensure culturally and linguistically appropriate health care services. The Office for Civil Rights published “Title VI Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency.” Very few states have developed standards for linguistic access. States that have developed such standards have focused on managed care organizations, contracting agreements with providers, and specific health and mental health services in defined settings.(29)Practices of Culturally Sensitive Care.

2. In August 2000, the Health Care Financing Administration (now Centers for Medicare and Medicaid Services) issued guidance to all state Medicaid directors regarding interpreter and translation services, emphasizing that federal matching funds are available for states to provide oral interpretation and written translation services for Medicaid beneficiaries.(30)Practices of Culturally Sensitive Care.

3. In December 2000, the Office of Minority Health of the Department of Health and Human Services issued 14 national standards on culturally and linguistically appropriate services (CLAS) in health care. These standards are intended to correct current inequities in the health services system and to make these services more responsive to the individual needs of all patients. They are designed to be inclusive of all cultures, with a particular focus on the needs of racial, ethnic, and linguistic population groups that experience unequal access to the health care system. The CLAS standards provide consistent definitions of culturally and linguistically appropriate services in health care and offer a framework for the organization and implementation of services. CLAS standards can be found at http://www.omhrc.gov/CLAS/Practices of Culturally Sensitive Care.

4. In 2002, two guides were developed to assist managed care plans with cultural and linguisti-cally appropriate services: “Providing Oral Linguistic Services: A Guide for Managed Care Plans” and “Planning Culturally and Linguistically Appropriate Services: A Guide for Managed Care Plans.” Both guides can be found at www.cms.gov/healthplans/quality/project03.asp Practices of Culturally Sensitive Care.

Conclusion

Cultural competence is not an isolated aspect of medical care, but an important component of overall excellence in health care delivery. Issues of health care quality and satisfaction are of particular concern for people with chronic conditions who frequently come into contact with the health care system. Efforts to improve cultural competence among health care professionals and organizations would contribute to improving the quality of health care for all consumers.Practices of Culturally Sensitive Care.

Reflective Journal Week 3: Practices of Culturally Sensitive Care

Last week’s reflection was on the current covid-19 vaccination drive at Kingston Healthcare in California where I work. I pointed out that the facility and the surrounding community has lately been battling rising cases of covid-19 infections. I also observed that healthcare employees at the facility were being affected by the novel coronavirus infection at higher rates than would be expected. This is what led to the educational intervention targeting the healthcare workers, especially nurses. They were taught how to properly put on and take off PPEs (donning and doffing). This may sound preposterous, but improper use of PPEs was identified as one of the causes of the rising staff infections at Kingston Healthcare. With the FDA approval for emergency use of the Pfizer/BioNTech and Moderna vaccines, however, the focus in the past two weeks has no shifted on covid-19 vaccination, patient education, and community awareness.Practices of Culturally Sensitive Care.

I noted in my last reflection last week that there was some resistance from some quarters against the covid-19 vaccination drive. I was specific that the African American community for instance is apprehensive about the coronavirus vaccination for tangible historical reasons. This means that our patient education efforts have to be in high gear so that we can dispel any rumors or misinformation about the vaccines. We are also creating awareness in the surrounding community so that the identified vulnerable groups identified can come to Kingston Healthcare to get vaccinated against coronavirus. We are aware that we need to do this in a culturally sensitive and competent manner. Practices of Culturally Sensitive Care.This means, for instance, that we must acknowledge the historical injustices that were committed against the Black community in the past in the guise of medical research. We must let the Black community know that their concerns are real and justified. After that, we have then embarked on a reassurance mission that the vaccine is safe. Lastly, we have been educating the community that getting vaccinated does not mean one is now non-infectious and cannot spread the virus. For this reason, we have been telling everyone who is vaccinated to continue wearing masks.     Practices of Culturally Sensitive Care.