PatientCentered Care Becoming Culturally Humble When Working with Refugees, Migrants and Immigrant Y

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

• Maxine Proskurowski
• Eugene, OR School District

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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

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CULTURAL COMPETENCY

• Describes a set of skills, knowledge and
  attitudes that enhances a clinicians ability to
• Understand and respect the patients values,
  beliefs and expectations
• Be aware of ones own assumptions and value
  systems, and those of the American medical
  system
• Adapt care to be acceptable to the patients
  expectations and preferences

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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

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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

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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 nations population clock
  records a net increase of one more
• American overall

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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

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Alteration of Americas racial and ethnic dynamic

• For the first time African Americans are no
  longer the nations 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

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Children of Immigrants by region of origin,
1910-2000
www.futureofchildren.org
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Dispersion of Immigrant families between 1990 and
2000
www.futureofchildren.org
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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

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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

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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

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Challenges faced by immigrant families

• Less educated parents
• Low wage work with no benefits
• Language barriers
• Discrimination and racismracial profiling
• Poverty and multiple risk factors
• Lack of social supports

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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

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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

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Health profile of immigrants

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

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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.

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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.

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Richard Rothsteins 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 programs
• 2. After school programs
• 3. Fully staffed health clinics in schools
  serving low income children.

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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 disparitiesunequal quality of care
• 2006 Center for the Health Professions,
  University of California, San Francisco

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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

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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
  physiciancould be the result of subconscious
  perceptions rather than deliberate actions or
  thoughts.
• Schulman, 1999.

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Biases and Assumptions

• An inherent human traitwe 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 1999340-61826

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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

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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

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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?

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Linking health disparities and cultural competence

• Culture matters in health careaffects 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

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Eliciting Health and Healing Beliefs

• Communication is culture-bound
• Explanatory frameworks can be used to help bridge
  cross-cultural communication
• Examples of frameworks
• LEARN
• Kleinmans questions

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Framework for Eliciting Health Beliefs

• LEARN
• Listen with sympathy and understanding to
• the patients 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

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Kleinmans 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

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Applying Models to Elicit Patients Experience of
Illness

• The best way to learn about something is to
  play about it.
• Mr. Rogers

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Role of Culture in Health, Illness and Healing

• Culture is societys 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

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Worlds apart a Laotian child

• Film about Laotian child raises issues around
• Understanding the familys health and illness
  beliefs
• 2. Family decision-making and authority figures
• Traditional/alternative medical practices
• Cross-cultural negotiations
• Barriers to effective communication

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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?

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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 clinicians explanation and recommended
  treatment must be at least consistent with the
  patients point of view.
• Moira Stewart, 1995 Patient Centered Medicine

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Evolution of Health Care

• 2000 BC Here, eat this root.
• 1000 BC The root is heathen. Say this prayer.
• 1850 AD That prayer is superstition. Here,
• drink this potion.
• That potion is snake oil. Here, take this
• antibiotic.
• 2000 That antibiotic does not work. Here, eat
  this root.
• Source unknown

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Culturally Humble Care

• Understanding a patients 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