Post on 20-May-2018
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Does culture play a role in Does culture play a role in quality of medical care?quality of medical care?
Jorge A. Girotti, PhDJorge A. Girotti, PhDUIC College of MedicineUIC College of Medicine
Dept. of Medical EducationDept. of Medical EducationApril 18, 2012April 18, 2012
Learning objectivesLearning objectives
Identify factors that impact quality of care Identify factors that impact quality of care and their relationship to cultureand their relationship to culture
Describe the connection between culture Describe the connection between culture and health care disparitiesand health care disparities
Discuss one model of incorporating the Discuss one model of incorporating the patientpatient’’s culture into standard practices culture into standard practice
Culture DefinedCulture Defined
An integrated pattern of learned beliefs An integrated pattern of learned beliefs and behaviorsand behaviors
Includes thoughts, communication styles, Includes thoughts, communication styles, ways of interacting, views of roles and ways of interacting, views of roles and relationships, values, practices, and relationships, values, practices, and customscustoms
Shapes how we explain and value the Shapes how we explain and value the worldworld
Betancourt 2003
It is dynamic!
It is dynamic!
What is quality What is quality medical care?medical care?
Quality of Care DefinedQuality of Care Defined
The degree to which health services for The degree to which health services for
individuals and populations increase the individuals and populations increase the
likelihood of likelihood of desired health outcomesdesired health outcomes and and
are are consistent with current professional consistent with current professional
knowledgeknowledge
Institute of Medicine 2001
What Factors May Affect Quality?What Factors May Affect Quality?
Communication gaps between physician Communication gaps between physician and patient/familyand patient/family
Health beliefs of patients/familiesHealth beliefs of patients/families
Biases and stereotypes of health Biases and stereotypes of health professionalsprofessionals
PatientsPatients’’ use of alternative/complementary use of alternative/complementary healing traditions or healershealing traditions or healers
Language barriersLanguage barriers
CommunicationCommunication
Improved communication leads to Improved communication leads to improved adherenceimproved adherence
Appropriate use of prescribed medicationsAppropriate use of prescribed medications
Better selfBetter self--management of chronic diseasemanagement of chronic disease
More acceptance of preventive measuresMore acceptance of preventive measures
Link between Communication Link between Communication and Health Outcomesand Health Outcomes
Effective Communication
Patient Satisfaction
Adherence
Improved Health Outcomes
Health Literacy & CommunicationHealth Literacy & Communication
Health Literacy means:Health Literacy means:
The ability to The ability to readread, , comprehendcomprehend and and actact on written and on written and numerical information numerical information received in health care received in health care settingssettings
Institute of Medicine 2004
Health Literacy FactsHealth Literacy Facts
Health care systems place Health care systems place high literacy and language high literacy and language demands on patients/ demands on patients/ familiesfamilies
Average reading level of Average reading level of Medicaid recipients: 5Medicaid recipients: 5thth gradegrade
Over half of EnglishOver half of English-- and and SpanishSpanish--speaking public speaking public have limited HLhave limited HL
Growing evidence linking HL Growing evidence linking HL to clinical outcomesto clinical outcomes
Schillinger D et al 2002
Health BeliefsHealth Beliefs
Culture influences health beliefsCulture influences health beliefs
These beliefs shape the patientThese beliefs shape the patient’’s/familys/family’’ss
Control and empowerment over health issues Control and empowerment over health issues (wellness, illness and healing)(wellness, illness and healing)
Interpretations of healing, disability and Interpretations of healing, disability and quality of lifequality of life
Attitudes about survival and deathAttitudes about survival and death
Biases and AssumptionsBiases and Assumptions
An inherent human trait An inherent human trait –– we all make we all make assumptions and have biasesassumptions and have biases
ItIt’’s an efficient way to manage informations an efficient way to manage information
ItIt’’s also shaped by societys also shaped by society
More likely to make assumptions when More likely to make assumptions when time and information are limitedtime and information are limited
We may have subconscious biasesWe may have subconscious biases
StereotypesStereotypes
A type of mental shortcut for receiving, A type of mental shortcut for receiving, processing and retrieving informationprocessing and retrieving information
Used to assign an individual to a category Used to assign an individual to a category based on what we believe about a general based on what we believe about a general group or groups to which they belonggroup or groups to which they belong
ItIt’’s based on limited personal knowledge s based on limited personal knowledge and/or experienceand/or experience
More likely to happen with time pressure, More likely to happen with time pressure, need for quick judgments, anxiety or need for quick judgments, anxiety or multimulti--taskingtasking
Complementary and Complementary and Alternative MedicineAlternative Medicine
National Center for Complementary and Alternative Medicine 2008
Health DisparitiesHealth Disparities
Ethnic differences in the quality of health Ethnic differences in the quality of health carecare
Difference results in worse clinical Difference results in worse clinical outcomesoutcomes
Difference persists even after controlling Difference persists even after controlling for known factors, such as social for known factors, such as social determinants, access to care, insurancedeterminants, access to care, insurance
Populations with Equal Access to
Health Care
Quali
ty of
Healt
h Car
eCategories of Unequal Health Care Categories of Unequal Health Care
Quality and OutcomesQuality and Outcomes
Difference
Disparity
Need for careClinical AppropriatenessPatient Preferences/Choices
The Operation of Health Care Systems and the Legal and Regulatory Climate
Discrimination: Biases, Prejudices, Stereotyping; Uncertainly; Pt. Trust
Minority
Non-Minority
Source: Gomes and McGuire (2001) Model of Difference, Disparities and Discrimination
Unequal TreatmentUnequal Treatment
Health Disparities= Health Disparities= Unequal Quality of Unequal Quality of CareCare
Disparities in Asthma CareDisparities in Asthma Care
Asthma lends itself to monitoring quality Asthma lends itself to monitoring quality of careof care
There are established, clear guidelines for There are established, clear guidelines for appropriate careappropriate care
Lieu and colleagues set out to study Lieu and colleagues set out to study outcomes of children with asthma enrolled outcomes of children with asthma enrolled in managed Medicaid programs in CA, MA, in managed Medicaid programs in CA, MA, and WAand WA
Asthma DisparitiesAsthma Disparities
They found that Black and Latino children They found that Black and Latino children in the study of 1,658 subjects had worse in the study of 1,658 subjects had worse asthma status and were less likely to use asthma status and were less likely to use preventive medications than White preventive medications than White childrenchildren
These disparities persisted even after These disparities persisted even after adjusting for socioeconomic status and adjusting for socioeconomic status and family structurefamily structure
Why?Why? Lieu TA et al Pediatrics 2002
Asthma Disparities (contAsthma Disparities (cont’’d)d)
Authors attribute difference to:Authors attribute difference to:
Ethnic/racial differences in health beliefs and Ethnic/racial differences in health beliefs and concepts of diseaseconcepts of disease
Different beliefs about value of preventionDifferent beliefs about value of prevention
Fears about steroidsFears about steroids
Lack of regularity in life of familyLack of regularity in life of family
Possible communication barriers between Possible communication barriers between doctors and patients/familiesdoctors and patients/families
Not obtaining refills even when covered by Not obtaining refills even when covered by MedicaidMedicaid
Lieu TA et al Pediatrics 2002
Cultural Competence in Cultural Competence in Health CareHealth Care
A set of congruent behaviors, attitudes, and policies that enables effective work in cross- cultural situations
‘Competence’ implies having the capacity to function effectively within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities
Office of Minority Health, US HHS (2000) Culturally and Linguistically Appropriate Services (CLAS) Standards
Cultural Competence (contCultural Competence (cont’’d)d)
Is a continuumIs a continuum
May be situationalMay be situational
Culture is dynamic and complexCulture is dynamic and complex
Context is critical since we cannot separate culture Context is critical since we cannot separate culture from social and economic factorsfrom social and economic factors
Cultural competence is not an inherent skillCultural competence is not an inherent skill
The foundation is built on awarenessThe foundation is built on awareness
We then add knowledge, and skills to the baseWe then add knowledge, and skills to the base
Happens at the individual and organizational Happens at the individual and organizational levellevel
Patient Interview: One ModelPatient Interview: One Model
LL Listen to the patientListen to the patient’’s perception s perception of the problemof the problem
EE Explain your perceptions of the Explain your perceptions of the problemproblem
AA Acknowledge and discuss differences and similarities
RR Recommend treatment
NN Negotiate an agreement
Berlin & Fowkes 1987
Working with DifferenceWorking with DifferenceWithout some agreement about the nature of what is wrong, it is difficult for a doctor and a patient to agree on a plan of management acceptable to both of them.
It is not essential for the physician to It is not essential for the physician to actually believe that the nature of the actually believe that the nature of the problem is as the patient sees it, but the problem is as the patient sees it, but the doctordoctor’’s explanation and recommended s explanation and recommended treatment must be at least consistent with treatment must be at least consistent with the patientthe patient’’s point of view.s point of view.
Moira Stewart, Patient-Centered Medicine
Thank you for your Thank you for your kind attention!kind attention!