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!