Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
Programs Administered by WellPoint Partnership Plan, LLC, an independent company. © 2012 WellPoint Inc. All rights reserved.
Culturally Competent Medical Communications
V05-08-326
Cultural and Linguistic Webinar
Setting the Stage: Demographics in the U.S. Are Changing Rapidly
Between now and the year 2050, almost 90% of U.S. population growth will come from Asian Americans, African-Americans and Hispanic-Americans.
Today, people of color are already a majority in 48 of the nation’s 100 largest cities.
Today, four states have “minority majorities.” They include: California, Hawaii, New Mexico and Texas.
Five other states: Maryland, Mississippi, Georgia, New York and Arizona have non-white populations around 40%.
Source: “The Emerging Minority Marketplace: Minority Population Growth 1995-2050.” U.S. Census Bureau September 21, 1999.
White Of ColorSource: The Minority Business Development Agency.US Census 2000.
0
50
100
150
200
250
2000
Mill
ions
400
350
300
2050204520402035203020252020201520102005
U.S. Population by White/People of Color: 2000- 2050
2050: White = 52.8%; Hispanic =24.5% Black =14.6%; Asian = 8.1%
In the U.S., People of Color Are Becoming the “Emerging Majority”
Language Barriers Have Direct Implications for Quality, Cost, Safety in Medicine
Limited English Proficiency (LEP) and its related communication problems
Are the most frequent cause of serious adverse events
Lead to increased length of stay, preventable services and costs
LEP, combined with cultural differences and low health literacy, are leading causes of racial and ethnic health disparities
Source: Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press, 2003.
AI/AN = American Indian/Alaska Native.Note: Data are age adjusted.Source: National Center for Health Statistics. National Health Interview Survey. 2005.
Minority Groups (Except Asians) Are More Likely Than Whites to Report Their Health Status As Fair or Poor
62 65
51 5347
62
26 2429 30
3729
12 1120 18 16
8.7
0
20
40
60
80
100
Total White, non-Hispanic
Black, non-Hispanic
Hispanic AI/AN Asian
Excellent/Very good Good Fair/Poor
Percentage of adults age 18 and over, 2005
Economic Burden of Health Inequalitiesin the United States
Findings for Study Period of 2003-2006Combined costs of health inequalities and premature death in the U.S.
$ 1.24 trillion
Eliminating health disparities for minorities would have reduced direct medical expenditures
$ 229.4 billion
Excess costs in direct medical care expenditures due to health inequalities for African Americans, Asians, & Hispanics
30.6 %
Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death
$ 1trillion
*Joint Center for Political and Economic Studies (Researchers and authors: Laves, Gaskin, & Richard)
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Impact of Gender and Minority Status when Communicating with Health Care Providers
Base: Adults with health care visit in past two years.* Problems include understanding doctor, feeling doctor listened, had questions but did not ask.
Percent of adults with one or more communication problems*
What Are the Goals of CLAS Initiatives?
Culturally and Linguistically Appropriate Services (CLAS) : U.S. Department of Health and Human Services, Office of Minority Health
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15
14 CLAS Standards include 4 Federal Mandates required for recipients of federal funds
Goal is to bridge gaps in communication, service and access between:
health care providers & health care system
patients from diverse backgrounds
Federal Law Re: Language Access
1. Title VI of the Civil Rights Act of 1964 Executive Order 13166 “Improving Access to Services with LEP”
(Aug. 2000) DHHS Guidance Re: National Origin Discrimination Affecting
Limited English Proficient Persons (LEP) (August 30, 2003) OCR Case Summaries DHHS CLAS Standards
2. Section 504 of the Rehabilitation Act of 1973
3. The Americans With Disabilities Act
Interpreter Services and Translated Materials Are Not Enough…
Recent Research Show:
Even when interpreter services are available…
Even when the patient is insured…
Language barriers can lead to worse health outcomes
Doctor-Patient conversations are critical to improved health
Patient-empowered medical communication leads to…• Better quality of life• Improved health outcomes
Fernandez, A., Schilling, D., Wharton, E. M., Adler, N., Moffat, H. H., Schemer, Y.,...Carter, A. J (2011). Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: The Diabetes Study of Northern California (DISTANCE). Journal of General Internal Medicine, 26(2), 170-176.
Mali, R. C., Stein, J. A., Manawa, Y., Leaked, B., & Angling, M. D. (2008). Racial/ethnic differences in breast cancer outcomes among older patients: Effects of physician communication and patient empowerment. Health Psychology, 27(6), 728-736
Misunderstandings of Beliefs and Social ChallengesMay Hinder Optimal Medical Care
This Concept Is Obviously Not New, So Why Does the Problem Persist?
“Sociocultural differences between patient and physician influence communications and
clinical decision-making.”
(Eisenberg, 1979)
Factors Affecting the Physician Decision Making Process
Characteristics of the Patient
Age, Sex, Socio Economic Status, Race/Ethnicity, Religion, Insurance, Individual patient factors
Characteristics of the Physician
Specialty, Level of Training, Background
Features of the Practice Setting
Organization of Practice, Compensation, and expectations of productivity
Social Cognitive Theory: Stereotyping
Automatic aspects; group individual
“Cognitive Misers” cognitive shortcuts to save resources; principle of “least effort”
Primal race, gender, age
Activated most when:
Stressed
Under time constraints
Multitasking
Isn’t a Discussion of “Cultures” and “Cultural Norms” Stereotyping People?
Definitions:
Cultural Stereotypes: An oversimplified assumption or image treated as fact for all members of a group.
Cultural Generalizations: The accepted norm within a cultural group, allowing for individual variation.
In stress-free situations, we are fairly adaptable to different approaches to communication and clearing up misunderstandings.
In stress-free situations, we are fairly adaptable to different approaches to communication and clearing up misunderstandings.
In stressful situations, our adaptability is reduced.In stressful situations, our adaptability is reduced.
We revert to our core styles, using the strategies and frameworks that are consistent with our primary environment.
We revert to our core styles, using the strategies and frameworks that are consistent with our primary environment.
This can lead to an increased possibility of misunderstandings and conflict.This can lead to an increased possibility of misunderstandings and conflict.
Tight Time Constraint During the Medical Visit = Communication Barrier
Are There Strategies for Talking with Our Patients More Effectively?
Tip #1:
Understanding and Adapting to
Differences in Communication Styles of
Your Patients
Knowing Your Communication/Conflict Style Can Help You…
Intercultural Conflict Style Model (Hammer)
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DISCUSSIONDISCUSSION ENGAGEMENTENGAGEMENT
ACCOMODATIONACCOMODATION DYNAMICDYNAMIC
IND
IRE
CT
DIR
EC
T
RESTRAINED EXPRESSIVE
Direct and Indirect Communication Dynamics
Direct Style Patterns
• Focus on words: precise, explicit language use
• Logical, linear, factual, goal-oriented arguments
• Present and defend your opinion
• Problem solving approach to conflict resolution
• The speaker is responsible for the message
Indirect Style Patterns
• Analogies, metaphor and non-verbal language convey message
• Prefer use of a mediator
• Discretion in voicing goals
• Non-linear, relational examples, stories instead of facts
• Relationship repair focus
• The listener is responsible for the message
Direct and Indirect Communication Examples
"Say what you mean and mean what you say."
-American Proverb
“It is good to know the truth, but better to
speak of palm trees.”- Arab proverb
Emotionally Expressive and Restrained Communication DynamicsEmotional Expressiveness
• Overt display of emotions
• Maintain calm by letting out emotions
• Emotions are displayed through non-verbals
• Expansive vocalization
• Affective commitment must be demonstrated through actions not stated.
• Emotional display needed for credibility
Emotional Restraint
• Strong feelings are hidden
• Emotions are internalized so that a calm front can be presented.
• Minimal display of emotions through non-verbal behavior.
• Limited variation in vocalizations
• Emotional suppression for credibility
• Trust is built through steadiness of emotions
Emotionally Expressive and Restrained Communication Examples
“What is nearest the heart is nearest
the mouth.” -Irish Proverb
“The first to raise their voice loses the
argument.” - Chinese proverb
US Values (Cultural Tendencies)
Speaking Up
Capitalism
Control
Law & Order
Speed
Equality
Being Oneself
Self-Reliance
Self-Interest
Individual Rights
Directness
Competition
Freedom
Independence
Individual Achievement
Privacy
Hard Work
Fairness
Are There Strategies for Talking to Our Patients More Effectively?
Tip #2:
Understanding and Addressing
Important Cultural Values and Needs
That May Influence the Behaviors of
Your Patients
Culturally Relevant Messaging
What is “cultural competence?” (Betancourt et al., 2002)
Organizational culture
Respects and incorporates into health care delivery
• Cultural background
• Cultural beliefs
• Cultural valuesSource: Betancourt JR, Green AR, Carrillo JE. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.
Culturally Relevant Messaging
What makes something…“culturally relevant”?
• Language?
• Health literacy?
• Imagery?
• What else?
The Five F’s of Cultural Relevance
Food. Affinity to cultural foods and difficulties in changing dietary habits
Participants asked for specific information on how “traditional foods” (e.g. “Soul food” or “Mexican food”) can be made healthier
Resources should reflect real life – fast food dining, cooking healthfully on a budget
Family. Particularly “being there” for children and grandchildren
All participants were very motivated by “negative” family examples of those who had diabetes but did not take care of themselves well
Support and concern expressed by family members were critical in member health-activation
The Five F’s of Cultural Relevance
Faith and Spirituality. Respecting life as a gift Especially among African American women Faith-based organizations as a trusted source of health information Influence of cultural “spiritual/folk” beliefs
Fear. Disease complications, especially amputations, blindness, and kidney disease Especially among African American men Hispanic men worried about others finding out about diabetes Many struggled with depression
Finances. Affordability of health care and healthy lifestyles (food, gym membership) was also a concern
Effective Communication Is a Tool That Helps All of Us in Health Care Meet Our Mission
How do we link communication to outcomes?
Communication
Patient Satisfaction
Adherence
Improved Health Outcomes
Special Topics for Clinical Consideration
Use of Alternative or Herbal MedicationsPregnancy and BreastfeedingWeightInfant HealthSubstance AbusePhysical AbuseCommunicating with the ElderlyTalking About SexPain Management Across Cultures
Are There Strategies for Talking to Our Patients More Effectively?
Tip #3:
BCBSTX has reference tools for
physicians and their offices
Effective Communication
Based on CLAS goals and standards, the toolkit contents are designed to help physicians and other health care providers to
communicate with the increasingly diverse patient population
improve health care outcome.
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Caring for Diverse PopulationsKey Sections in Toolkit posted on the BCBSTX Provider Website
1. Resources to assist communication with a diverse patient population base
2. Resources to communicate across language barriers3. Resources to increase awareness of cultural
background and its impact on health care delivery4. Regulations and Standards for Cultural and
Linguistic Services5. Reference resources for Cultural and Linguistic
services
How to Access the Toolkit,Better Communications, Better Care
Other Resources on the Website
Employee Language Skills Self-Assessment ToolInterpreter Desktop Reference ToolInterpreter Attendance Verification
Questions?
BCBSTX Cultural Competency Contact:
Sara Daugherty-Pineda, RN
972-766-2493