CULTURAL COMPETENCE : RACE AND ETHNICITY

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CULTURAL COMPETENCE RACE AND ETHNICITY

• NEREIDA CORREA, MD ASSISTANT PROFESSOR
• OBS/GYN FAMILY PRACTICE ALBERT EINSTEIN COLLEGE
  OF MEDICINE
• JANUARY 24, 2001

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CULTURE

• INTEGRATED PATTERN OF HUMAN BEHAVIOR
• INFLUENCES THOUGHT, ACTIONS, CUSTOMS, BELIEFS AND
  VALUES
• RELATED TO ETHNIC, RACIAL RELIGIOUS OR SOCIAL
  GROUP

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CULTURES IN THE BRONX

• WHITE -ALL ETHNIC GROUPS
• BLACK- ALL ETHNIC GROUPS
• ASIAN - ALL ETHNIC GROUPS
• INDIAN- EAST AND WEST
• HISPANIC- MOST GROUPS

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COMPETENCE

• ACQUISITION OF KNOWLEDGE
• DEVELOPMENT OF SKILLS
• EXPERIENCE
• APPLIED TOWARDS INTERVENTIONS ADAPTIVE TO THE
  DIFFERENT GROUPS SERVED

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CULTURAL COMPETENCE

• CONGRUENT BEHAVIORS, ATTITUDES AND POLICIES
• COME TOGETHER TO WORK EFFECTIVELY IN CROSS
  CULTURAL SITUATIONS
• SERVICES PERCEIVED AS RELEVANT AND HELPFUL

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DIVERSITY TRAINING

• ACCEPTANCE AND TOLERANCE
• LOWERS PREJUDICE
• DEVELOPS CULTURAL AWARENESS AND SENSITIVITY
• IS A BEGINNING TOWARDS SHOWING THE DIFFERENCES
  BUT DOES NOT GIVE TOOLS

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COMPETENCY TRAINING

• PROMOTES SKILLS AND KNOWLEDGE
• CONTENT BASED
• DIFFICULT TO TEACH
• INDIVIDUALIZED TRAINING
• DEVELOPS PRACTICAL SKILLS

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CULTURAL AWARENESS

• GENDER
• AGE
• ETHNIC IDENTITY
• RACE
• SOCIAL STATUS
• ROLES

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CULTURAL ASSESSMENT

• BIRTH PLACE AND ETHNICITY
• SUPPORT FAMILY MEMBERS
• LANGUAGES AND NONVERBALS
• RELIGION AND PRACTICES
• ECONOMIC SITUATION
• HEALTH/ILLNESS BELIEFS
• BIRTH/DEATH BELIEFS

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COMMUNICATION

• INTERPRETORS
• CONVERSATIONAL STYLE
• PERSONAL SPACE
• EYE CONTACT
• TOUCH
• TIME ORIENTATION

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DIVERSITY ISSUES

• MIGRATION STATUS
• ETHNICITY/RACIAL GROUP
• SOCIOECONOMIC STATUS
• SEXUAL ORIENTATION
• DISABILITY

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BELIEFS

• HEALTH AND WELLNESS
• BIRTHING PRACTICES
• USE OF ALTERNATIVE SYSTEMS
• DEATH AND DYING
• BEHAVIOR WITH HEALTH WORKERS
• RESPONSE TO HISTORY TAKING

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NYC POPULATIONS

• BLACK AMERICAN 2.8 M
• PUERTO RICAN 1.O M
• RUSSIAN 455 K
• WEST INDIAN 452 K
• CHINESE 285 K
• EAST INDIAN 133 K

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POPULATION UNDERCOUNTING

• IMMIGRANT GROUPS GREATLY UNDERCOUNTED
• SELF DESCRIPTION VS ASSIGNED GROUP
• STATE NET UNDERCOUNTING 272K ADULTS, 113 K
  CHILDREN IN 90
• BY GROUP 1.9K WHITE, 186K BLACK, 136K
  HISPANIC, 23K ASIAN,

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NYS UNDERCOUNTING

• NET UNDERCOUNT 272,036
• NET CHILDREN 113,486
• WHITE 1,972
• BLACK 185,873
• HISPANIC 136,010
• ASIAN 22,760
• NATIVE AMERICAN 1,763
  

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LEARN

• LISTEN WITH EMPATHY
• EXPLAIN YOUR PERCEPTION
• ACKNOWLEDGE
• RECOMMEND TREATMENT
• NEGOTIATE TREATMENT MODALITIES

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DISPARITIES

• MATERNAL AND INFANT MORTALITY
• ACCESS TO HEALTH CARE
• EMPLOYMENT
• EDUCATION
• PREVALENCE OF DISEASES RELATED TO DIET AND
  EXERCISE
• HOMICIDE AND SUICIDE

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HEALTH PROFILE ON MINORITIES

• BREAST CANCER INCREASED 3.9 FOR BLACK WOMEN
• TUBERCULOSIS INCREASED BY 51 FOR ASIAN AMERICANS
  AND 30 FOR HISPANICS
• AIDS/HIV DISEASE INCREASED FOR BLACKS, HISPANICS,
  ASIANS AND NATIVE AMERICANS

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HEALTH PROFILE

• INFANT MORTALITY RELATIVE INCREASE
• LIFE EXPECTANCY 6.6 YEARS LESS
• HEART ATTACK DEATH DECLINED 21 FOR BLACKS VS 29
  FOR WHITES
• DEATH FROM HIV DECLINED 13-22 VS 32 FOR WHITES

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HEALTH PROFILE

• HOMICIDE AND SPINAL CORD INJURY
• DOMESTIC VIOLENCE
• EXPOSURE OF CHILDREN TO DRUGS
• CIGARETTES AND ALCOHOL
• TEEN PREGNANCY
• SCHOOL FAILURE AND DROP-OUT

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INTERVENTION STRATEGIES

• INVOLVEMENT IN COMMUNITY GROUPS
• INVOLVEMENT IN LEADERSHIP OF PROFESSIONAL GROUPS
• MENTORING OF YOUTH
• POLITICAL ACTIVISM
• RESEARCH

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VIGNETTES
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RACE AND ETHNICITY

• PRACTICE VIGNETTES

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PRACTICUM RISKS

• Stereotyping can occur
• Oversimplification of true values
• May be misinterpreted
• May offend members of the group

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PRACTICUM BENEFITS

• Increases awareness of behavior
• Inculcates sensitivity
• Promotes understanding between groups
• Develops strategies in practitioners that will
  help them to give care to diverse populations

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OBJECTIVES

• Demonstrate by illustration how culture impacts
  on the physician-patient interaction
• Provide examples of various ethnic groups in the
  Bronx and some common beliefs with in the culture
• Explore the impact of a lack of understanding on
  the therapeutic relationship

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ETHNIC GROUPS

• African-American
• Arab
• Haitian
• Mexican
• Puerto Rican
• Vietnamese
• West Indian

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AFRICAN-AMERICAN

• A 14 year old teenage boy is brought in for a
  routine physical exam
• His mother wants routine exams done and is
  concerned about school performance

• Beliefs Strong family links demanding of
  respect
• Issues around gender identity, expected roles and
  independence

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AFRICAN-AMERICAN

• Assess developmental level and institute age
  appropriate counseling regarding safety issues,
  sex and pregnancy prevention, career issues
• Provide flexible access for questions
• Appreciate gestures such as lack of eye contact
  and looking down related to respect

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ARAB

• A 24 year old woman pregnant for the first time
• Visit with her husband
• Establishing plans for her care

• Beliefs
• Concerns
• Outcomes

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ARAB

• Beliefs Birth is a natural process
• Modesty to be conserved-privacy, veils
• Husband, father, brother make decisions
• Children are sacred

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ARABS

• Concerns
• Usually requesting female provider
• Male family member to be involved in decision
  making
• Prefer natural delivery, will accept pain
  medication
• Prayer time essential for strict Moslems
• Amulets blue stone to ward off evil eye

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ARAB

• Prenatal care with female providers
• Delivery plan made with negotiations regarding
  the need for some male practitioners
• Actual delivery with husband present-involved in
  decisions
• Patient wore veils and robes when in halls

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PUERTO RICAN

• Couple seen for evaluation of infertility
• Partner has one child from previous marriage
• Suspicion is male factor infertility

• Beliefs Male sexual productivity is indication
  of masculinity
• Concerns Inability to impregnate partner can be
  interpreted as loss
• Outcomes

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PUERTO RICAN

• Assurance of language competence and use of
  translator if needed, not family member
• Presentation of data on infertility and the facts
  related to male factor
• Reassurance that there is no correlation with
  sexual performance
• Privacy

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VIETNAMESE

• A 5 year old girl brought in for fever and a cold
• Bruising noted on chest wall in reddish streaks
• Several cup marks seen on her back

• Beliefs Hot and cold theory of medicine and use
  of alternative medicines illness related to sins
  of past life
• Concerns Distinguish injury to child

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VIETNAMESE

• Assurance of language competency use of
  translator unless fluent in English
• History taking to include beliefs and practices
  in an open-ended way
• Negotiate plan to include parental belief to
  improve compliance
• Help family to deal with guilt at illness

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HAITIAN

• A 50 Year old man diagnosed with cancer of the
  stomach
• Has experience gradual illness and now is dying

• BeliefsIllness a continuum
• Kompa bon
• Moin malad
• moin malad anpil
• moin pap refe
• bon die vs loa

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HAITIAN

• Assurance of language competency
• Discuss beliefs about illness and death believer
  in spiritualism, or catholic or both
• Allow space for as much family as possible
• Final bath given by family member
• Prefer to die at home

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WEST INDIAN

• 35 Year old woman with new diagnosis of
  hypertension
• Sees herself as healthy, has no pain
• Told to avoid salt and fatty foods in diet

• Beliefs Diet with strong broths and organ meats
  will build up the body
• Fatigue and pain are symptoms of disease
• Hot and cold foods

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WEST INDIAN

• Nutritional interventions with cultural beliefs
  in mind hot and cold combinations and
  restrictions
• Discussions regarding asymptomatic nature of her
  diagnosis and the need for preventive
  interventions
• Regard for issues of respect, eye contact and
  touching

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MEXICAN

• A 15 year old girl brought in by her mother for
  amenorrhea
• History of recent arrival to city
• Concerns regarding pregnancy

• Beliefs Family loyalty, concerns regarding
  respect, family reputation
• Curanderos
• Maladies such as mal de ojo, susto. Empacho,
  caida de mollera, antojos

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MEXICAN

• Assurance of language competency
• Including mother in the interview
• Speaking to the teenager alone
• Exploring cultural beliefs and issues
• Providing interventions and bridging cultural gap

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UNIFYING PRINCIPLES

• Diversity vs. Similarity
• Language competency essential
• Respectful Inquisitiveness
• Negotiation to improve compliance
• Non-verbal communication is universal