culturally responsive obstetrical and gynecological care

1
culturally responsiveobstetrical and
gynecological care

• Jean Gilbert, PhD
• Geri-Ann Galanti, PhD

Los Angeles County Department of Health Services
Office of Diversity Programs
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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

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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.

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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.

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Culture is a Major Force in Shaping an
Individuals

• 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

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In Understanding Cultures, a Little Knowledge is
Dangerous

• Dont let cultural generalizations become
  stereotypes.
• Generalizations are testable probabilities we
  couldnt 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.

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The Importance of Womens Roles

• Which one of these women is the model for
• your patient?

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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.

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Video Lupes Dilemma
Video is part of the Multicultural Health Series,
a community service project of Kaiser Permanente
and The California Endowment.
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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

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Video A Big Baby is Coming
Video is part of the Multicultural Health Series,
a community service project of Kaiser Permanente
and The California Endowment.
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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.

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Labor Pains

• Asian women tend to be stoic.

• African American women may
• be either.

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Labor Pains

• Iranian women tend to be
• expressive.

• Mexican women also tend to be
• expressive.

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Preferred Labor Attendants
Anglo American Husband or Domestic
Partner Hispanic Mother or Female
Relative Asian Mother or Mother-in-Law
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Video Hmong Birthing Practices
Video is part of the Multicultural Health Series,
a community service project of Kaiser Permanente
and The California Endowment.
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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
  in-laws
• At childbirth, both mother and baby are
  considered especially vulnerable to malevolent
  spirits.

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Video Female Circumcision
Video is part of the Multicultural Health Series,
a community service project of Kaiser Permanente
and The California Endowment.
19
.
Female Circumcision (aka Female Genital
Mutilation)
Normal Female Anatomy
Modified Sunna
Illustrations from Prisoners of Ritual, (1989) by
Hanny Lightfoot-Klein
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.
Female Circumcision (aka Female Genital
Mutilation)
Infibulation
Infibulation
Illustrations from Prisoners of Ritual, (1989) by
Hanny Lightfoot-Klein
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Breastfeeding
Colostrum
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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

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Bonding
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
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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.

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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.

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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.

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DHHS says

• Assess patients language needs.
• Try not to use family or friends or whoever you
  can grab.
• Dont use minors to interpret.
• Try to use trained medical interpreters whenever
  possible.
• Use telephonic interpreters for rare languages.

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What Can You Do?

• Honestly assess your own bilingual skills
• Understand the pitfalls in using untrained
  interpreters
• Use interpreters effectively
• Use telephonic interpreters skillfully

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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
  patients response to questions?
• understand regional variations?
• know terms for anatomy and healthcare concepts?
• convert biomedical terms into lay terms in the
  target language?

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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 clinicians and patients utterances.
• Children are frightened or intimidated if asked
  to interpret. There are ethical problems
  involved.
• Confidentiality concerns must also be considered.

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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.

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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.

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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.

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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 dont stereotype
• Use interpreters and use them effectively, dont
  wing it.

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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?