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Cross Cultural Care and Education in Geriatrics

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Cross Cultural Care and Education in Geriatrics Jerry Johnson, M.D. Professor of Medicine University of Pennsylvania References and Materials Monographs and articles ... – PowerPoint PPT presentation

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Title: Cross Cultural Care and Education in Geriatrics


1
Cross Cultural Care and Education in
Geriatrics
  • Jerry Johnson, M.D.
  • Professor of Medicine
  • University of Pennsylvania

2
Objectives
  • Overall Goal Preparation to Teach Cross
    Cultural Aspects of Geriatrics
  • Anticipate predictable challenges
  • Relate your teaching content to the domains of
    cross cultural interactions
  • Apply mnemonics for interactions with patients
    and caregivers
  • Use diverse approaches to teaching
  • Identify resources for education and learning

3
Crossing the Quality Chasm
  • The system by which health care is delivered and
    financed must be designed to ensure that care is
    safe, effective, efficient, equitable, timely,
    and tailored to each individuals specific needs
    and circumstances.
  • - Institute of Medicine Report, 2001

4
Analytic Framework Cultural Diversity Training
for Providers
Increase provider sensitivity to attitudes and
beliefs which marginalize ethnic groups
Decrease differential treatment due
to unconscious discrimination
Cultural diversity training programs for providers
Improved health status outcomes
Increase provider abilities and strategies for
cross-cultural interactions
Greater client adherence to care and
treatment recommendations
Decrease ethic differentials in utilization and
treatment
Increase provider knowledge of culturally-based
beliefs and behaviors
Increase use of culturally appropriate health
care interventions
Greater satisfaction with care
5
Challenges of Cross-cultural Care
  • Defining the concept of culture
  • Concern about stereotyping, relevance and
    legitimacy
  • Cross cultural care overlaps with other aspects
    of clinical care professionalism, humanism
  • Multiple levels of cultural competence
  • the health professional- patient relationship
  • the health system
  • the community

6
What is Culture?
  • Acquired attitudes, values and beliefs or
    unwritten rules of behavior.
  • Caveats
  • Culture is not synonymous with race or ethnicity,
    but...
  • Culture is not a fixed, knowable entity that
    guides individuals behaviors in linear ways
    (see Gregg J. Losing Culture on the Way to
    Competence the use and misuse of culture in
    medical education. Acad Med 2006 81 542-547).
  • Culture is mutable and multiple.

7
Cross cultural education is relevant because
health care is delivered in a cultural context.
8
Relevant Cultural Constructs
  • The culture of the patient
  • The culture of the practitioner
  • The culture of the practitioners profession
    e.g. medicine, nursing, and social work.
  • The culture of the workplace health system,
    institution, or other entity

9
Relevance of Group Identities
  • Each individuals identity is partly determined
    by group affiliation gender, ethnicity,
    religion....
  • Preservation of these group identities for many
    is a matter of self esteem
  • Group identity partly determines how others view
    us and interact with us

Cox, Taylor . Cultural Diversity in
Organizations. 1993
10
Content Areas or Domains of Cross- Cultural Care
11
Content Areas Relevant to Interactions
  • Self awareness
  • World view
  • Causation or explanatory models
  • Spirituality
  • Complementary alternative medicine
  • Help-seeking behavior (community and family)
  • Language and health literacy
  • Historical, social and economic factors

CREATE SOME REPRESENTATIVE CASES
12
Case Example Explanatory Model and Alternative
Healing
  • Depression in a 75 yo man, self explained by the
    patient, and treated outside the formal health
    care system.

13
Case Example Spirituality
  • Woman with multiple admissions for CHF
    accompanied by markedly elevated BP, who believes
    her faith, not medications, will treat HTN.
  • Woman dying of metastatic breast cancer who wants
    chemotherapy as an example of being strong and
    maintaining faith.

14
Case Example Language issues
  • Russian speaking man admitted with pain and gait
    dysfunction

15
Case Example social and economic factors
  • Woman with large family, inadequate funds, under
    significant stress

16
Negotiating with Patients and Families
17
Conceptual Framework
  • Emphasis on the illness and its context
  • Kleinmans questions Eisenberg et al. Culture,
    illness, and care clinical lessons from
    anthropologic and cross cultural research. 1978
  • Carillo et al. Cross cultural primary care a
    patient based approach. Annal Int Med 130829,
    1999
  • Explore the meaning of illness
  • Conduct a social context review of systems
  • Negotiate management

18
Kleinmans Questions
  • 1 What caused it?
  • 2 Why now?
  • 3 How affects you?
  • 4 How severe is it?
  • 5 What treatment?
  • 6 What results expected?
  • 7 What chief problem?
  • 8 What do you fear most?
  • 9 What duration?

19
Mnemonics
20
Mnemonics for Cultural Interactions
  • LEARN
  • BELIEF
  • RESPECT
  • ETHNIC and ETHNICS
  • BATHE
  • ADHERE
  • Others

21
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 treatment

Berlin E. Western Journal of Med 1983 139
934-938
22
BELIEF
  • Health Beliefs (What caused your illness ?)
  • Explanation (Why did it happen?)
  • Learn (Help me understand your belief/opinion)
  • Impact (How is this illness affecting your life?)
  • Empathy (This must be very difficult for you)
  • Feelings (How are you feeling?)

23
RESPECT
  • Respect a demonstrable attitude
  • Explanatory model patient explanation of cause
  • Social cultural context gender, migration
    status, sexual orientation, economic group,
    history
  • Power differential acknowledge it
  • Empathy put into words
  • Concerns and fears eliciting them
  • Therapeutic alliance and trust

24
ETHNIC and ETHNIC(S)
  • Explanation What do you think is the reason for
    your sx?
  • Treatment What kinds of treatment have you
    tried, what kinds of treatment do you want?
  • Healers Advice from alternative healers?
  • Negotiate discuss options and expected results
  • Intervention. Determine an intervention
  • Collaboration
  • Spirituality or Seniors

Levin, S. Ethnic. Patient Care 2000 34 (9)
188-189
25
BATHE
  • Background (what is going on in your life?)
  • Affect (How do you feel?)
  • Trouble (What troubles you most?)
  • Handling (coping)
  • Empathy (That must be very difficult)

26
ADHERE
  • Acknowledge (need for treatment and joint goals)
  • Discuss (potential treatments and alternatives)
  • Handle (questions)
  • Evaluate (health literacy and barriers to
    adherence)
  • Recommend (treatment)
  • Empower (the patient by listening)

27
General Tips in Cross Cultural Care
  • Avoid idioms
  • Use titles such as Mr. and Miss
  • Yes does not always mean yes
  • Be cautious of touching
  • Use trained interpreters when available

28
TRAINING TOOLS AND APPROACHES
29
Large Group Exercises
  • Aging Panel Who are the elderly
  • Working with interpreters-film
  • Spirituality panel and case discussions
  • CAM presentation with practitioners

30
Small Group Activities
  • Discussion sessions following large groups, often
    with guests (seniors, chaplains)
  • Self awareness exercises
  • Introduction to the Physical Community
  • part of a home visitation course
  • Narrated van tour of West Philadelphia
  • Resident and fellow presentations in community
    sites

31
Faculty and Preceptor Education
  • One or two orientation sessions per year
  • Materials prepared with key readings and
    discussion questions for small groups
  • Debriefings after small group sessions

32
Evaluation
  • Students one or two page description of an
    experience with presentation to peers in a small
    group
  • Focus groups of trainees
  • Critique of presentations and sessions value,
    lessons learned

33
References and Materials
  • Full Curricula
  • UCSF Culture and communication in health care, a
    curriculum
  • TACCT Tool for assessing cultural competence
    training a project initially privately funded,
    now adopted by the AAMC

34
References and Materials
  • Monographs and articles
  • Doorway Thoughts-American Geriatrics Society
  • Ham and Sloan Cased Based Primary Care
    Geriatrics, chapters on Ethnic and Cultural
    Aspects of Geriatrics (4th and 5th editions).
    Jerry Johnson

35
Other Resources for Teaching
  • Stanford stanford.edu/group/ethnoger
  • HRSA website cultural and linguistic competence
    education www.hrsa.gov/culturalcompetence/curricu
    lumguide
  • The California Endowment website
  • Kaiser Foundation website
  • Managers electronic resource center (ERC) a
    cultural competence quiz produced by Management
    Sciences for Health

36
Summary
  • Cultural differences are common and germane.
  • The process of inquiry, rather than knowing a set
    of facts about a group, is fundamental.
  • Knowledge of critical domains can direct the
    interaction.
  • Several mnemonics are available.
  • Discussions and interactive exercises work.
  • Extensive resources on cross cultural care are
    available.
  • Culture matters
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