Cultural Competency Training Program

Practicing Kina’ole for Hawai’i

Copyright September 2008 Revised: March 2014

Objectives: • Provide an overview of the Hawaiian Islands

• Discover the rich ethnic diversity of the people of Hawaii

• Review existing health disparities in Hawaii

• Understand the concept of cultural competency and its relevance on healthcare delivery

• Offer tips on interacting and caring for the people of Hawai‘i in a culturally competent manner

UnitedHealthcare Community Plan strives to impart upon our employees and business partners the meaning of Kina’ole as well as supporting and

reinforcing the importance of the practice of Kina’ole as we interact and engage with our health plan

members.

“Doing the right thing,

in the right way,

at the right time,

in the right place,

to the right person,

for the right reason,

with the right feeling,

the first time.”

The astounding beauty of Hawai‘i is matched only by the beauty of its people, each contributing to the aloha spirit that makes Hawai‘i a place unmatched around the world. Polynesians sailed from other Pacific islands between A.D. 300 and 600 settling throughout the Hawaiian islands, one of the most remote island chains in the world. Hawai‘i was visited in 1778 by British captain James Cook with subsequent visits and an increasing presence from the outside. External contact since the late 1700s has had a profound and often devastating impact on the social, cultural, political and health status of Native Hawaiians. As Hawai‘i has become home to many different ethnic groups in the last 200 years, each ethnic group has added elements of its own culture to local life. Today, contemporary culture in Hawai‘i is a mix of the different cultures and ethnic groups that make up its unique population. Hawai‘i is an embodiment of diversity, a veritable melting pot of cultures from the Pacific Basin and beyond.

Hawaii’s culture is influenced by contributions from many ethnicities. Hawai‘i is one of the most racially diverse places in the world as there is no single majority. You will find a “mixed plate” of ethnic groups in Hawai‘i, including Hawaiian, Portuguese, Chinese, Japanese, Korean, Caucasian, Filipino, Vietnamese, Samoan, and other Pacific Island ethnic groups. According to the U.S. 2012 Census Bureau:

• Asians (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) account for 38.6% of Hawaii’s total population.

• Native Hawaiians and other Pacific Islanders (Native Hawaiian, Guamanian, Chamorro, Samoan) make up 10% of the state’s population.

• Caucasians account for 24.7% of the total population.

• Two or more races account for 23.6% of the total population. • Hawaii’s population consists of 50.1% males and 49.9% females.

Source: U.S. Census Bureau, 2010 Census Summary File 2 Hawaii.

Rural Hawaii What most visitors do not realize is that much of Hawai‘i is rural. Nearly 90% of the state’s land mass, with 20% of the state’s population, is federally designated as rural. The majority of the state’s population resides on the island of O‘ahu, where the state’s only major urban area, Honolulu, is located. Hawaii’s neighbor islands (Kaua‘i, Ni‘ihau, Maui, Lana‘i, Moloka‘i and Hawai‘i) face challenges common to all rural communities with the additional complexities of allocating resources to distinct island populations. One of the challenges the neighbor islands (and rural areas on O‘ahu) face is the difficulty of accessing specialists, longer travel times for care, and often a shortage of primary care services.

Population Neighbor Island populations are growing at a faster pace than that of Honolulu. Hawai‘i’s total resident population has grown at varying rates since statehood and is now estimated at 1.36 million. Projections from the Department of Business, Economic Development and Tourism (DBEDT) suggest that Hawai‘i's population will grow by about 140,000 every ten years between 2000 and 2030, with over 40 percent of that growth taking place on the Neighbor Islands. Tourism and the military have a significant impact on Hawaii. There are over 6 million visitors per year and the military adds around 100,000 to the population. Source: http://www.healthtrends.org/demo_overview.aspx

Overview

Today, life in Hawai‘i is influenced by the traditional culture of the Native Hawaiians. Hawai‘i's history in story and legend is ancient and proud, dating back at least a thousand years before the American colonies became a nation in 1776. It is unlikely that the exact date when Polynesian people first set foot on these previously uninhabited islands will ever be known, nor are we likely to know much detail about events occurring between that date and the first contact with Europeans. The language of Hawai‘i and archaeological discoveries indicate that Hawai‘i was impacted by two distinct waves of Polynesian migration. Lacking instruments of navigation or charts or any kind, the Polynesians sailed into the vast expanse of the Pacific. They staked their success on their knowledge of the sky and its stars, the sea and its currents, the flight of birds and many other natural signs. They were superior navigators and seafarers of their time.

People from various cultures immigrated to Hawaii from the mid-1800s through the first quarter of the 20th century as a source of contract labor for the sugar plantations. • Chinese were the first Asians to immigrate as workers for the plantations, coming to Hawaii’s shores in the mid- 1800s.

• Active recruitment and immigration of Portuguese workers in the late 1870s brought the largest grouping of Portuguese to Hawai’i.

• Japanese started immigrating in large numbers in the 1880s to work on the plantations.

• In the early 1880s, Norwegians and Germans were also recruited by the plantations.

• In the early 1900s, Hawai’i experienced an influx of multiple cultures as plantation owners began actively recruiting Filipino, Korean, Puerto Rican, Okinawan and Spanish laborers.

Source: Hawaii School Reports, Culture, Immigration

After the approval of the 1924 immigration act, diverse groups emigrated to Hawai’i for several reasons, including economic opportunities, political persecution and education. Vietnamese immigrants began arriving after the fall of Saigon in 1975. The majority of Cambodians who emigrated to the United States were affected by the genocide under Pol Pot and the Khmer Rouge. As a result of a 1985 pact between the United States and the newly independent Micronesia and the Marshall Islands, citizens of those territories may freely migrate to the United States. Since then, Hawaii has seen an influx of individuals from island nations such as Chuuk, Yap, Pohnpei and Truk. Source: US Immigration Support, Hawai’i

There are marked differences in the ethnic composition of Hawaii’s counties although the proportion that is mixed is consistent across all counties, at 16 to 20 percent in 2005. • The island of Hawai‘i has the largest proportion of Hawaiians/part-Hawaiians at 33.8%.

• Honolulu County has the largest proportion of Japanese at 15.7%.

• Kaua‘i and Maui have the largest proportion of Filipinos at 18%.

• Maui and Hawai'i have the largest proportion of Caucasians at 34 %.

Source: U.S. Census Bureau, 2010 Hawaii Census Demographic Profile

Health Status and Disparities Hawai'i's population is aging, with decreasing birth rates and increasing death rates. Hawai‘i’s mortality rates for the major categories of disease have been closer to or better than the national “Healthy People 2010” objectives. Of concern are marked differences among ethnic groups in age at death. In particular, Hawaiians / part-Hawaiians, are dying at much younger ages than members of other ethnic groups. In 2008, 64% of deaths among Japanese in Hawai'i occurred at age 80 years or older, compared to only 23% of the Hawaiians/part-Hawaiians. 14% of deaths among Hawaiians/part-Hawaiians in 2008 occurred before age 45, at least 2.5 times higher than any other group. Source: www.healthtrends.org

Life Expectancy Hawai’i’s overall death rate increased between 1980 and 2006, from 580 to 727 deaths per 100,000 population. This increase is largely a reflection of the increasing proportion of the elderly in Hawai’i’s population. Hawai'i's death rate has been consistently below that of the mainland as a whole; however, Hawai'i's rates are moving closer to national rates. Source: http://www.healthtrends.org/status_life_expect.aspx

Birth Rates Birth rates in Hawai‘i differ significantly by ethnicity even though birth rates across all ethnicities have decreased since 1980. Excluding "all others" as a group, since the late 1980s Hawaiians/part-Hawaiians and Filipinos have had the highest birth rates. Chinese and Japanese ethnic groups have consistently had the lowest rates. Source: www.healthtrends.org

Health Data Limitations Specific health status information for all the various ethnicities in Hawaii is limited, in part because of: • inconsistencies in coding race and ethnicity in research projects.

• use of aggregate data linked to a specific ethnic group regardless of geographic location within the U.S.

• lack of differentiation between the various ethnicities within the Asian or Native Hawaiian / Pacific Islanders kaleidoscope. Source: Asian and Pacific Islander American Health Forum, Health Brief

Native Hawaiians age 36-65 in Hawai‘i are almost 1 1/2 times more likely to experience heart disease than other racial groups in the state and have a higher rate of death and disability due to heart disease, stroke, cerebrovascular conditions and hypertension than other ethnic groups. In 2007, Native Hawaiians and Pacific Islanders may have had the highest age-adjusted percentage of people with diabetes among all the racial groups in the United States. A study of two rural communities in Hawai'i found type 2 diabetes prevalence was four times as high as the average diabetes percentage of the U.S. Traditional Hawaiian diet programs with intensive instruction on traditional diet, cooking methods and serving sizes have been successful in lowering and controlling blood sugar rates among diabetic Native Hawaiians. Native Hawaiians in Hawai‘i have an asthma rate that is much greater than that for all other ethnic groups in the state. Source: Asian and Pacific Islander American Health Forum, Health Brief: Native Hawaiians in the United States (Revised August 2010) http://www.cdc.gov/omhd/Brochures/PDFs/NHOPI.pdf

Native Hawaiians

Native Hawaiian women and Filipino women have the highest breast cancer mortality rate in Hawai‘i. Nationally, the five-year survival rate for Native Hawaiian women is 9% shorter than for Caucasians and all races combined, which is attributed, in part to late-stage detection of cancer in Native Hawaiians. Native Hawaiian women have the highest incidence of cervical cancer of Hawaii’s 5 major ethnic groups. Lung and bronchus cancer is the most commonly diagnosed cancer among Hawaiian men. At 21%, they have the highest incidence rates for lung and bronchus cancer. Nearly 90% of all lung cancer deaths can be linked to tobacco use, and about 1 in 5 Hawaiians smoke tobacco everyday, the highest percentage among the five major ethnic groups in Hawai'i. Source: Asian and Pacific Islander American Health Forum, Health Brief: Native Hawaiian in the United States (Revised August 2010) `Imi Hale, Native Hawaiian Cancer Network, A Program of Papa Ola Lōkahi, www.imihale.org

Of Samoans living in Hawaii as well as those referred here for diagnosis and treatment, the more commonly encountered cancers for men include cancer of the lung, prostate, stomach and liver, as well as leukemia. Samoan males are more likely to be diagnosed with cancer after metastasis had occurred. Breast cancer is the most frequent form of cancer in Samoan women. A 2001 study that measured estimates of breast cancer utilization rates among Samoan women in Hawaii, Los Angeles, and American Samoa revealed that only 55.6% of women 30 years of older had ever had a clinical breast exam and 32.9% of women 40 years or older had ever had a mammogram. Only 46% reported having Pap smears within the previous 3 years. The study concluded that cultural attitudes about cancer had a greater influence over screening and treatment patterns than knowledge and attitudes about cervical cancer.

Sources:

Asian and Pacific Islander American Health Forum, Health Brief: Samoans in the United States (Revised August 2010) Dianne N. Ishida, Ph.D.,Tusitala F. Toomata-Mayer, B.S. Nafanua S. Braginsky, B.S., Beliefs and Attitudes of Samoan Women toward Early Detection of Breast Cancer and Mammography Utilization (2000)

Samoans

High rates of obesity among American Samoans led to several comparative studies with Western Samoans and Samoans in Hawaii. The findings revealed differences between dietary habits of residents of Western Samoa and Samoans in the U.S., with those in the U.S. consuming more carbohydrates and proteins, as well as a higher intake of cholesterol and sodium. Prevalence of diabetes among Pacific Islander groups is also very high and culturally appropriate interventions have been shown to be effective in the control of diabetes given the relationship between diabetes, lifestyle and diet. The Pacific Diabetes Education Program, funded by the CDC, is a good resource for educational materials for this population. While Pacific Islanders come to Hawai‘i from many places in Micronesia, one of the largest group is the Marshallese, whose recent history is complicated by exposure to ionizing radiation from US nuclear weapons testing, conducted from the mid-1940s to the mid-1950s. Source: Asian and Pacific Islander American Health Forum, Health Brief: Samoans in the United States (Revised August 2006) http://www.pdep.org/

Samoans and other

Pacific Islanders

Studies that compare Filipino adults with other API ethnic categories or white adults have found disparities in areas such as cancer, cardiovascular health, and mental health. Heart Disease is the leading cause of death for Filipinos in the U.S., followed by cancer and then stroke. Relatively high rates of hypertension have been reported for both Filipino men and women. In Hawaii, Filipino children have one of the highest rates of dental caries (defined as decayed and filled teeth) at nearly three times the national average. In one study conducted in San Diego, Filipino women had a higher prevalence of diabetes and metabolic syndrome when compared to white women, despite the fact that the majority of Filipino women were not defined as obese, suggesting that diabetes in Filipinos may be missed by health care providers because they are not obese by Western standards.

Source: http://www.cdc.gov/pcd/issues/2007/apr/06_0069.htm Asian and Pacific Islander American Health Forum, Health Brief: Filipinos in the United States (Revised August 2006)

Filipinos

The incidence of liver cancer in Filipino populations is higher than rates among Caucasians. Filipinos have the second poorest 5-year survival rates for colon and rectal cancers of all U.S. ethnic groups. The prevalence of some types of cancer in Filipinos varies according to their place of birth. For example, rates of primary liver cancer as well as thyroid cancer are higher for foreign-born Filipino men than American-born Filipino men and both were higher than Caucasians. The Philippines is the country of origin with the highest number of TB cases among the foreign-born residents in Hawai‘i. Source: Asian and Pacific Islander American Health Forum, Health Brief: Filipinos in the United States (Revised August 2006)

The incidence of stomach cancer among Koreans in the U.S. is much higher than among other ethnicities in the U.S. Colorectal cancer is the second most common type of cancer among Korean women and third among Korean men in the U.S. Screening practices such as digital rectal exam and fecal occult blood tests are underutilized in this population. Depression is more common among Koreans in the U.S. than among Filipino, Chinese or Japanese populations. Rates of depression decrease among those Koreans who are more adapted to their new culture but can be offset by an immigration experience which resulted in a loss of connection to their traditional culture and society. Source: Asian and Pacific Islander American Health Forum, Health Brief: Koreans in the United States (Revised August 2006)

Korean

A comparative study of health behaviors and diet in U.S.-born and Korea-born Korean women showed that adaptation to western culture affected dietary intake in ways that alter chronic disease risk. US-born women reported more whole grains, red meat and nuts, and less soy products, than did Korea-born women. US-born women consumed fewer vegetables and fruit than those born in Korea. Intake of discretionary fat was higher in US-born than in Korea-born women. One characteristic of a traditional Korean diet is a high intake of sodium, which is derived mainly from kimchi, soup and dried or salted fish, all of which are very popular in the Korean diet. While US-born women reported less sodium intake that Korean-born, overall sodium consumption was still higher than the upper limit recommended. Calcium intake was also very low for Koreans in the U.S., primarily as a result of low intake of dietary products. Source: Song-Yi Park*, Suzanne P Murphy, Sangita Sharma and Laurence N Kolonel; Dietary intakes and health-related behaviours of Korean American women born in the USA and Korea: The Multiethnic Cohort Study Cancer Etiology Program, Cancer Research Center of Hawaii, University of Hawaii, Public Health Nutrition: 8(7), 904–911

U.S. born Japanese men has a 60% higher rate of colorectal cancer than U.S. born Caucasian men and rates of liver cancer are also substantially higher than the Caucasian population.

Some duties suggest that, with increasing adaptation to the Western diet (greater proportions of meat, less roughage), there appears to be an increase in coronary artery disease and colon cancer among Japanese residing in the U.S.

Studies from the Honolulu Heart Program and the Honolulu-Asia Aging Study suggest that vascular dementia among Japanese men in Hawaii may be higher than it is among white men. Japanese women in Hawaii experience a higher breast cancer survival rate than other ethnicities. Source: Asian and Pacific Islander American Health Forum, Health Brief: Japanese in the United States (Revised August 2006)

Japanese

Depression among Chinese elders in the U.S. is underdiagnosed and undertreated. Chinese women aged 65+ have three times the suicide rate of white women in the U.S. Among women aged 75+, the rate is seven times that of white women. Chinese have the highest rates of nasopharyngeal cancer in the U.S., and Chinese men have a higher incidence of liver cancer. Vascular dementia is prevalent among U.S. Chinese elders, possibly more prevalent than Alzheimer's disease in this group (Lum, 1995). There is a higher prevalence of Hepatitis B among Chinese-in the U.S., and hence, a higher prevalence of Hepatitis B-associated liver cancer. Hepatitis B infection is present in 80% of liver cancer cases (Chen, 1994). Source: http://www.stanford.edu/group/ethnoger/chinese.html

Chinese

Hepatitis B viral (HBV) infection is of concern among Vietnamese Americans, principally because the country of Vietnam is a high incidence area for HBV. HBV carriers are over 200 times livelier to develop liver cancer than non-carriers and Vietnamese men experience the highest rate of liver cancer incidence of any ethnic group in the nation. Tobacco use varies by ethnic group among Asian Americans and Pacific Islanders, with Vietnamese Americans males having some of the highest rates. Vietnamese women have the highest rates of cervical cancer of any ethnic group in the U.S. A study of cancer screening rates in Hawaii, conducted from 1996-2000 revealed high under-utilization of cancer screening tests by both male and female Vietnamese Americans. Sources: Asian and Pacific Islander American Health Forum, Health Brief: Vietnamese in the United States (Revised August 2006) Ly T Nguyen Kelley Withy, The health status of Vietnamese Immigrants in Hawaii from chart records Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Manoa Asian Am Pac Isl J Health. ;10 (2):114-9 15509152

Vietnamese

UnitedHealthcare and direct providers of care have the potential to directly affect the health status of the people of Hawai’i. The Institute of Medicine's report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare" focused on clinical encounters and found evidence that stereotyping, biases, and uncertainty on the part of health care providers can contribute to unequal treatment. There is increasing evidence of how important it is for us, as a healthcare community, to recognize the value of and respond appropriately to cultural differences. Cultural differences all too often result not only in deficiencies of care but also of health outcomes. (Smedley et al. 2003). Source: http://erc.msh.org/aapi/cc1.html

Culture shapes healthcare beliefs, behaviors, and expectations for treatment. The primary language spoken, religious beliefs, culturally-shaped attitudes about health and wellbeing, and family structure all impact the member-provider relationship. We also need to recognize that within and among cultures, there is great variation in disease patterns, communication styles, beliefs, and health practices. Each patient, each member is a unique individual. There is no one correct way to treat any racial and ethnic group. Given the great socio-cultural diversity even within an ethnic or cultural group, care must be individualized and applied in a patient-centric and family-centered fashion. Source: http://www.hrsa.gov/culturalcompetence

Culturally Competent Healthcare

Providing culturally competent health care that is member and family-centric should result in: More effective health education which is personalized to the needs and background of the member in a language readily understood by that member.

An increase in preliminary care and follow-up as greater trust and understanding develops between the provider and member.

More appropriate testing and screening, because providers will have more knowledge about the health status, risk exposure, and common health-related behavior of various cultural groups.

Source: http://www.hrsa.gov/culturalcompetence

Providing culturally competent health care that is member and family-centric should result in (cont.):

More comprehensive and accurate medical histories as providers are enabled to elicit information about alternative therapies and treatment being utilized.

A decrease in the potential for drug complications, by becoming aware of traditional remedies and alternative therapies used by members.

Greater adherence to medical advice, because providers can establish a treatment plan that is most consistent with the member's cultural beliefs and lifestyle, and members can better understand how to follow the treatment plan. Sources: http://erc.msh.org/aapi/mt2.html http://www.hrsa.gov/culturalcompetence

The ability to speak English has a tremendous impact on access to health information, public services (i.e. Medicaid, Medicare), effective communication with providers and emergency personnel, and the ability to understand and utilize medications properly. Hawai'i is the only state in the United States that has designated a native language, Hawaiian, as one of its two official state languages. According to the U.S. Census Bureau, over one-fourth of the people in Hawai‘i speak a language other than English in their home. Asian and Pacific Islander American Health Forum, Health Brief: Native Hawaiians in the United States (Revised August 2010), http://quickfacts.census.gov/qfd/states/15000.html

Language and Healthcare

Source: U.S. Census Bureau, 2010

When working with someone who does not have English as a primary language, the provider will want to:

Ask what language the member prefers to speak when talking about their healthcare and in what language they wish to receive written materials about their health condition.

Use qualified interpreters wherever and whenever possible. Contact our local Member Services department to have free access to the Language Line for interpretation.

If use of a family member as interpreter cannot be avoided, ask the family to translate your words and the member’s words exactly. Tell the family that they can give you their opinion separately. Be aware of the potential for discomfort of family and the member when discussing personal matters.

Be aware of the tone and volume of your voice when speaking with individuals with limited English proficiency. Keep statements simple and pace discussion to allow for adequate time for interpretation.

Use the “teach-back” method of education, e.g. asking the individual to demonstrate how to give or take medication.

Sources: http://erc.msh.org/aapi/index.html Exceeding Patients’ Expectations for Culturally Competent Care, The Permanente Journal

Non-verbal Communication Non-verbal communication is heavily influenced by culture. Observe the non-verbal communication of your member/patient while being aware of your own cultural context. A smile may not always indicate happiness or agreement. In some cultures, a smile might also indicate respect, embarrassment or even be used when discussing something that is sad or uncomfortable. Depending upon one’s cultural upbringing, direct eye-contact may convey honesty, or it could be interpreted as being rude or disrespectful. Source: http://www.hrsa.gov/culturalcompetence

Non-verbal Communication (cont.) The sense of personal space varies between cultures. Some Asian and Pacific Islanders may require more personal space than, for example, someone from a Latino culture.

For some Asian cultures, touching certain parts of the body, such as the head, may be offensive.

While it is now common to embrace as part of greeting another person in Hawaii, for some new Asian and Pacific immigrants to the state, casual touching or hugging may be very uncomfortable. Source: http://erc.msh.org/aapi/mt2.html

Every culture has explanatory models of illness that includes ideas about the cause and onset of symptom, pathology of the disease, the natural history of the illness, and even appropriate treatments. Source: http://erc.msh.org/aapi/mt2.html

Concepts of illness and health

The traditional Hawaiian concept of wellness incorporates pono. In order for a person to have proper wellness, the physical, environmental, spiritual, emotional, social, and interpersonal aspects of life must be in balance.

Many Pacific Island cultures share the belief that all aspects must be in balance and that illness or other misfortune occurs as a result of an imbalance is one of more aspects of life. Restoring health may include a search into the cause of imbalance, open expressions of feelings or apologies by all concerned and the asking of forgiveness as needed. The principle of balance is central to Filipino concepts of health and balance is sought in all social relationships. There is also a range of beliefs pertaining to the influence of warmth and cold on the body and health. Sources:

Asian and Pacific Islander American Health Forum, Health Brief: Filipinos in the United States (Revised August 2006)

http://erc.msh.org/aapi/mt2.html

The health beliefs of some traditional Chinese, Japanese, Koreans, Vietnamese and many Asian ethnic groups are influenced by Taoist principles based upon the idea of balancing natural processes and forces, such as yin and yang. The underlying principle of Ayurveda (based upon Hindu philosophy) is the relationship between the universe and the body. Some followers of Ayurvedic medicine believe illness is a result of karma, even though they may understand that illness has a biological cause. Ayurvedic medicine includes recommendations for a balanced diet of “hot” and “cold” foods. Buddhism promotes a spiritual understanding of disease causation and illness, and a person is considered healthy when their mind is not troubled. Sources: http://erc.msh.org/aapi/mt2.html

http://www.hrsa.gov/culturalcompetence

Spiritual and Religious Influence

on Health and Illness

Naturalistic belief utilizes the integration of physical and social factors to diagnose illness. Many Asian populations believe that disease can be caused by shifts in environmental forces, i.e., wind may affect the upper part of the body and respiratory system. Catholicism and other Christianity based-religions emphasize the importance of prayer and spiritual guidance. Prayer and religious healing can be a common form of complementary or alternative medicine. Sources: http://erc.msh.org/aapi/mt2.html http://www.hrsa.gov/culturalcompetence/

When talking with members about their condition or illness, the provider will want to: Determine what the member believes may have caused their health condition Ask the member to explain the effect that illness has on all aspects of their life

Ask the member what results they hope to achieve with treatment Incorporate dietary beliefs and practices into any dietary changes proposed

Demonstrate respect and sensitivity to cultural health beliefs

Ask if there is anything that would make it difficult for the member to follow your recommended treatment plan or if there is anything they believe should be changed

Sources: http://erc.msh.org/aapi/index.html Exceeding Patients’ Expectations for Culturally Competent Care, The Permanente Journal

Many Asian American and Pacific Islanders practice alternate or traditional cultural healing methods in concert with Western medicine or resort to the other when one fails. Native Hawaiian healing practices include Lomilomi, a form of Hawaiian massage; Ho‘oponopono, a spiritual counseling process used for mending a broken relationship; and La‘au Lapa‘au which are medicinal herbs that treat common ailments and chronic conditions. Most Pacific Island cultures have similar practices. Many Asian cultures engage in traditional cultural health practices such as holistic medicine, acupuncture, herbalism and meditation, therapeutic massage, Qigong and other martial arts. Source: http://www.wcchc.com/NativeHawaiianHealing.aspx

Complementary and/or Alternative

Therapies

When developing a treatment plan for members, the provider will want to:

Ask the member if they take any treatments, medicines or herbs to help them stay healthy or as treatment for their condition

Inquire whether the member has sought advice or treatment from friends, alternative healers or other practitioners

Acknowledge the member’s choice for consultation of a spiritual or traditional cultural practitioners in addition to prescribing more western forms of treatment

Sources: http://erc.msh.org/aapi/mt2.html http://www.hrsa.gov/culturalcompetence/

In many Asian and Pacific cultures, health concerns of an individual are thought to be concerns of the family and it may be considered disrespectful to exclude family members from provider interactions with the member. In the Hawaiian culture, the concept of family is not limited to those “born into blood relationship, but can also include individuals that are informally adopted by conscious choice and are “hanai” family”. It can also include ancestral family members

Family

In some Asian cultures, the family provides most of the care for elders and there is a sense of obligation to individual family members, especially one’s parents. In some Pacific Islander cultures, the greater sense of the community may impact how the family deals with a member’s illness. The involvement of family may be vital to the member's ability to adhere to the recommended treatment. Families may decide what the member will eat, when he/she takes medication, whether he/she exercises, and when he/she seeks medical attention. Source: http://erc.msh.org/aapi/index.html

When determining treatment options, providers will want to:

Be sensitive to the diversity within Asian American and Pacific Island ethnic groups and determine whether it is appropriate to involve family members.

Discuss the patterns of decision-making in the family to understand the oftentimes complex interactions that may exist within the family structure.

Sources: http://erc.msh.org/aapi/index.html Exceeding Patients’ Expectations for Culturally Competent Care, The Permanente Journal

Do: Be respectful of the member’s cultural beliefs and practices.

Be aware of personal attitudes, biases and behaviors that may affect the nature of interactions with members from different ethnic, cultural or social backgrounds.

Call Customer Services when utilization of an interpreter is needed.

Recognize that religion and other beliefs may influence how members and families respond to illnesses, disease, and death. Respect and allow for inclusion of complementary and/or alternative healing practices. Keep abreast of health issues and concerns of the various ethnic groups in Hawaii Accept that family is defined differently by different cultures and involve family in a culturally appropriate way

Provider Dos and Don’ts

Don’t: Hesitate to contact your Provider Services Coordinator or any health plan representative for a complete copy of the United Healthcare Cultural Competency Plan.

• Health Trends in Hawai‘i: A Profile of the Health Care System, 7th Edition., www.healthtrends.org

• www.nativehawaiianhealth.net • Asian Pacific Islander Health Forum, Health Briefs

www.apiahf.org • U.S. Department of Health & Human Services, Office of Minority

Health, www.omhrc.gov • U.S. Department of Health & Human Services, Health Resources

and Services Administration, Cultural Competence Resources for Healthcare Providers, www.hrsa.gov/culturalcompetence

• Reducing Health Disparities in Asian American and Pacific

Islander Populations, The Provider’s Guide to Quality and Culture, Management Sciences for Health http://erc.msh.org/aapi/index.html

• CDC’s Office of Minority Health and Health Disparities www.cdc.gov/omhd

• National Center on Minority Health and Health Disparities

http://ncmhd.nih.gov

• Exceeding Patients’ Expectations for Culturally Competent Care, The Permanente Journal http://xnet.kp.org/permanentejournal/sum02/compcare.html

References and Resources