Do You Speak the Other Guys Language: Culture, Diversity and the Bottom Line

1
Do You Speak the Other Guys Language Culture,
Diversity and the Bottom Line

• Dr. Paul Mendis,M.D., Chief Medical Officer
• Neighborhood Health Plan
• Boston, MA
• Shani A. Dowd, B.A., L.C.S.W.
• Dir., Clinical Cultural Competency Training
• Harvard Pilgrim Health Care
• Boston, MA

2
US Population by Race/Ethnicity2000
3
Racial and Ethnic Distribution of the Population
of the USProjected 2030
Bureau of the Census, Statistical Abstract of the
U.S. 1997.
4
Leading Causes of Death, by Race and Ethnic
Group, 1996
Rank
White, non- Hispanic
African American
Latino
Native American
Asian American
Cause of Death
1
Heart Disease
Heart Disease
Heart Disease
Heart Disease
Heart Disease
2
Cancer
Cancer
Cancer
Cancer
Cancer
CVD
3
CVD
AUI
AUI
CVD
Chronic lung Disease
4
HIV/AIDS
CVD
Diabetes
AUI
AUI
5
AUI
HIV/AIDS
CVD
Pneumonia and Influenza
AUI accidents and unintentional
injuries CVDcerebrovascular disease (stroke,
etc.)
Source DHHS, Health, United States,1998
5
Health Care Disparities Asthma

• 7 of all children in US have asthma
• African American children are
• twice as likely to have asthma
• Three times more likely to be hospitalized with
  asthma
• six times more likely to die from asthma

Source Kaiser Family Foundation www.kff.org
6
Health Care Disparities Asthma

• Among Latinos, asthma prevalence varies by
  ethnicity
• Puerto Ricans have the highest rates 11
• Mexican American children have the lowest rates
  among Latinos 3

Kaiser Family Foundation www.kff.org
7
Health Status

• While 16 of white Americans self-report
  indicated that they believed they were in only
  fair or poor health,
• of Asians reporting fair or poor health
• 40 of Vietnamese
• 29 Korean Americans
• 11 of Chinese

Kaiser Family Foundation www.kff.org
8
Chronic or Poor Health51 of all African
Americans have been diagnosed with at least one
of the following within the past 5 years

• High Blood Pressure
• Obesity
• Anxiety/depression

• Asthma
• Cancer
• Heart Disease
• Diabetes

Source Commonwealth Fund
9
Health Care DisparitiesHIV/AIDS Treatment

• African Americans are twice as likely as whites
  to NOT receive triple drug antiviral therapies.
• African Americans are 1.5 as likely to not get
  prophylaxis for PCP
• Latinos are 1.5 times as likely as whites to NOT
  get triple drug antiviral therapies

Kaiser Family Foundation www.kff.org
10
Racial/Ethnic Disparities in Health Diabetes
Outcomes
11
Health Care Disparities Treatment for Cardiac
Care

• Among Medicare Beneficiaries
• African Americans are 60 LESS likely than whites
  to received heart bypass surgery, even when
  controlled for income, insurance status and place
  of treatment

Kaiser Family Foundation www.kff.org
12
Racial/Ethnic Disparities in Health

• Cardiovascular Procedures
• Differential use based on race of
• Cardiac catherization and angioplasty (Harris et
  al, Ayanian et al.)
• Coronary artery bypass graft (Peterson et al.)
• Treatment of chest pain (Johnson et al.)
• Referral to cardiology specialist care (Schulman
  et al.)

13
Life Expectancy (in years) at birth and by race
and sex, United States, 1998
Source Health United States, 2000. Bureau of
Primary Health Care
14
10 Health Conditions with Greatest Disparities
Between Whites and Members of Ethnic Communities
COPD Cancer Cardiovascular Disease Infant
Mortality Rates Diabetes
HIV/AIDS Child and Adult Immunizations Pneumonia S
troke Tuberculosis
15
Percentage of Adults Reporting Problems with
Communication with MD

• 33 of all Latinos
• 27 of all Asians
• 23 of all African Americans
• 16 of all white, non-Latinos

Source Commonwealth Fund (www.cwf.org)
16
Communication Problems with MD

• Of those reporting problems, one or more of the
  following were reported
• MD did not listen to everything that pt. said
• Patient did not fully understand MD
• Had questions but did not feel comfortable asking

Source Commonwealth Fund www.cwf.org
17
Latinos Reporting Communication Problems

• 43 report Spanish as their primary language
• 26 report English as their primary language.

Source Commonwealth Fund \\www.cwf.org
18
Patient Satisfaction

• Patient satisfaction increases when clinician
  uses psychosocially-oriented interview
• Psychosocially oriented interview was LEAST
  frequently used
• Perception among physician that takes more time
• BUT Study found that psychosocial interview did
  not significantly increase time of the clinical
  encounter

Roter,DL, Stewart, M., Putnam, SM, Lipkin, M,
Stile, W. Inui, T (1997) Communication patterns
of primary care physicians. Journal of the Amer.
Med. Assoc., 277(4)350-56.
19
Malpractice and Physician-Patient Communication

• Specific communication problems were identified
  in a sample of malpractice claims. Physicians
  with no claims against them were more likely to
• orient patients to the process of the visit
• use facilitative statements more, e.g. Go on,
  tell me more
• ask patients opinions about their medical
  problems
• use humor, indicated warmth and friendliness

Levinson, WL, Roter, DL, Mullooly, JP, et al.
(1997) Physician -patient communication The
relationship with malpractice claims among
primary care physicians and surgeons. JAMA,
277553-559.
20
Malpractice and Physician-Patient Communication

• Four problematic themes emerged when plaintiffs
  depositions were reviewed
• Deserting the patient 32
• Devaluing the patient or family views 29
• Delivering information poorly 26
• Failing to understand the patient
• and/or family perspective 13

Beckman, HB, Markakis, KM, Suchman, AL and
Frankel, RM. (1994) The Doctor Patient
Relationship and malpractice Lessons from
Plaintiff Depositions. Arch. Internal Med., 154
1365-1370.
21
Malpractice and Physician-Patient Communication

• While 1 of hospitalized patients suffer a
  significant injury due to negligence, fewer than
  2 of these patients initiate a malpractice
  claim.
• Patient dissatisfaction is the key element in the
  decision to initiate a malpractice claim.

Levinson, WL, Roter, DL, Mullooly, JP, et al.
(1997) Physician -patient communication The
relationship with malpractice claims among
primary care physicians and surgeons. JAMA,
277553-559.
22
The New Millennium (Health Care Environment)
Health care entities are fewer in number, but
larger more complex in size, product offerings
geography E-Health will play an increasingly
important role in health care industry Loyalty
to skill/profession, work group, colleagues is
shifting for many providers Rapid change
(revolutionary)
23
Motivations for Addressing Cultural Issues in
Health Care in the United States

• Changing demographics
• Increasing globalization of US economy
• Rising advocacy of health care consumers
• Increasing regulatory requirements
• Continuing documentation of inequities in access
  to health care and health care information and in
  health outcomes

24
Meeting Regulatory and Accreditation Guidelines
NCQA JCAHO Office of Minority Health Department
of Medical Assistance Employer Request for
Proposals Licensure Requirements
25
Meeting Regulatory and Accreditation Guidelines

• Physicians and hospitals who wish to participate
  in federally funded medical programs, specific
  requirements are articulated in the language of
  the contract relating to cultural issues, such as
  linguistic access
• Balanced Budget Act of 1997
• Medicare
• Medicaid

26
Commercial Insurers

• Increasingly, large employer groups are finding
  that their workforces are increasingly diverse in
• languages spoken
• ethnic cultures
• racial groups
• religious groups
• gender
• disabilities

27
What is Cultural Competence?
It is the ability to deliver effective medical
care to people from different cultures. By
understanding, valuing and incorporating the
cultural differences of Americas diverse
population and examining ones own health-related
values and beliefs, health providers deliver more
effective and cost-efficient care.
28
What is Cultural Competence?

• the demonstrated awareness and integration
  of three population-specific issues
• health-related beliefs and cultural values,
• disease incidence and prevalence, and
• treatment efficacy.
• Risa Lavisso-Mourey, MD, MBA Elizabeth
  Mackenzie, PhD

29
Diversity and Its Stumbling Blocks

• Literacy and Language
• Class-related values
• Culture related values
• Communication
• Stereotypes
• Racism
• Ethnocentricity

Charles, L.T. Kennedy, D.B. (2000) Social and
Cultural Influences on Health. (www.pitt.edu/supe
r1/lecture)
30
Patient Cultural Factors

• These factors are shown to facilitate immigrants
  positive adjustment to medical care in the US
• A relatively high level of formal education
• Greater generational removal from immigrant
  status
• Low degree of encapsulation within an ethnic and
  family social network
• Experiences with medical services that
  incorporate patient education

31
Facilitating Cultural Factors (Contd)

• Previous experience with particular diseases in
  the immediate family
• Immigration to host culture at an early age.
• Urban, as opposed to rural origin.
• Limited migration back and forth to the home
  culture.

Harwood, A. (1981) Ethnicity and Medical Care.
Cambridge, MA Harvard Univ. Press.
32
Literacy

• 40 to 44 million adult Americans are functionally
  illiterate
• 50 million have only marginal literacy skills
• 72 million cannot read technical reports or news
  magazines

Charles, L.T. Kennedy, D.B. (2000) Social and
Cultural Influences on Health. (www.pitt.edu/supe
r1/lecture)
33
Literacy

• One-half of the adult population of the U.S. has
  basic literacy deficits
• 21-23 read no more than 4th grade level
• Unable to read newspaper, follow written
  instructions
• 25-28 of adult Americans read at about 8th grade
  level
• Greatest number of low-literate adults are native
  born whites.

Charles, L.T. Kennedy, D.B. (2000) Social and
Cultural Influences on Health. (www.pitt.edu/supe
r1/lecture)
34
Written Medical Material

• Literacy levels vary enormously across class,
  gender and age.
• Bilingual people often have widely different
  literacy levels in the languages they speak
• Literate readers may encounter difficulty
  translating diagrams which inevitably make use of
  culturally normal visual concepts

35
Literacy and Gender

• Among the Sudanese over 15 years of age
• 34.6 of all females are literate
• 57.7 of all males are literate
• Among the Congolese, over 15 years of age
• 67.2 of all females are literate
• 83.1 of all males

36
Written Medical Information

• Speakers of the same language may vary in
  idiomatic language use based on gender, age,
  nationality and class.
• How the information is dispersed may signal
  authenticity in a given culture.

37
Written Medical Material

• Literate readers may encounter difficulty
  translating diagrams which inevitably make use of
  culturally normal abbreviations.
• Readers may have cultural barriers to receiving
  certain kinds of information in writing, or in
  possessing certain kinds of written information.

38
Developing Written Materials in Languages other
than English

• Do not assume that highly educated bi-lingual
  staff, including physicians, are as literate in
  their firsat language as they are in English.
• Do research (focus groups) to determine which
  dialects should be used.
• Use simple language, and where possible, easy to
  communicate basic concepts.
• All literature must be back translated.

39
Back Translation

• Material is translated from English to target
  language and target dialect.
• Independent translator who speaks target language
  and target dialect translates document back to
  English.
• Independent translator re-translates document.
• Translation errors are corrected and errors in
  idiomatic expression are corrected.

40
Translation of Clinical Condition Rheumatoid
Arthritis
English Rheumatoid arthritis can be acute or
chronic. Acute rheumatoid arthritis is more
common during adolescence. The cause is believed
to be due to an over-sensitive reaction of the
joints to the Beta Hemolytic Streptococcus. The
most common sites of infection are the throat and
tonsil.
English to Chinese to English Wet Wind Style
Joint inflammation has fast and slow type. The
fast type sees more at small year time. The
reason for its up believes to be the joints
over-sensitive reaction to the blood-dissolving
chain-ball bacteria. And the affecting path is
most frequently the swallow tube and the
flat-peach gland.
41
Linguistic Heterogeneity Chinese

• Majority of elderly speak Toisenese most of them
  also understand Cantonese.
• Mandarin speakers are likely to be students or
  professionals who probably also speak English
  (except for the elderly). They tend not to speak
  Cantonese.
• Cantonese-speaking Chinese also speak Mandarin if
  they are educated.

42
Written Medical Material

• Materials providing medical instructions need to
  be carefully written to avoid dangerous
  misunderstandings
• For Example
• three times a day
• insert suppository
• take with food

43
Case Example

• A fifty-nine year old bilingual Vietnamese
  immigrant who had been a farmer in Vietnam and
  was poorly educated prior to immigration,
  interpreted the direction, Take with meals, to
  mean he should carry the medication in his lunch
  pail. He did not actually take the medication at
  the time he ate, as he did not want anyone to
  know he was ill.

44
The lower the patient satisfaction with the
interaction, the greater the likelihood of
non-adherence
Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
45
Perceptions of Time

• How does the patient perceive or organize time?
• Patients who are not regularly employed outside
  the home are usually less clock-bound in their
  perceptions of and organization of time.
• Some patients organize time by tasks, rather than
  by clock time.
• In many communities of color, time is organized
  in a more fluid and phenomenological manner.

46
Perceptions of Time

• Medications requiring rigid dosing by clock
  time must be carefully discussed and reviewed.
• The provider should attempt to determine how the
  patient understands time.

47
Perceptions of Time

• In some cases it may be necessary to tie dosing
  to an activity or to an event rather than to
  clock time
• e.g. Take the medication about the time your
  children would come home from school.

48
Employ Positive Non-Verbal Behaviors

• Lean forward
• Silence - LISTEN
• Appropriate eye contact
• Warm expression

Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
49
The Popularity ofAlternative Medicine

• More than 4 out of 10 people in the United States
  visited alternative medicine practitioners in
  1997.
• Sharp increase in the number of Americans using
  it, from 61 million in 1990 to 83 million in
  1997, even though many alternative therapies
  arent covered by insurance.
• Patients spending on alternative therapies
  nearly doubled from 9.4 billion dollars in 1990
  to 17 billion dollars in 1997.
• (1998)Trends in Alternative Medicine Use in the
  United States, 1990-1997, JAMA , 280 1569-1575.

50
Demographic Profile of People Using Alternative
Medicine

• In addition to patients from many ethnic groups
• People who are ages 35 49
• Very well-educated
• Incomes of about 50,000 a year
• People who are sick
• In fact, 7 out of 10 cancer patients turn to an
  alternative therapy as a means of maximizing
  their hopes of seeing a cure.

51
Use of Herbal treatments

• Most patients tend to think of herbal treatments
  as natural and safe
• However a small scale study examining the effects
  of St. Johns Wort (n5) reported
• That patients taking St. Johns Wort Camptosar
  (a chemotherapy agent) showed a 40 reduction
  in blood levels of Camtosar
• Suppressant effect may last for at least 3 weeks
  after discontinuing St. Johns Wort

Source Boston Globe, April 9, 2002
52
Lack of Trust

• In many ethnic communities, there is a distinct
  lack of trust of medical institutions
• African Americans recall the infamous Tuskeegee
  study which affected hundreds of African american
  families.
• Forced sterilization of ethnic minority women was
  a fairly common event well into the 1960s
• In many American medical institutions, ethnic
  minorities and poor whites were used as
  experimental subjects without their consent.

53
Lack of Trust

• Many ethnic minority patients find it easy to
  believe that a provider is experimenting on them
• Many believe that medications used to treat
  whites are too strong for the system of ethnic
  people.
• Patients who are being treated for diseases with
  no apparent symptoms, find it hard to be
  compliant with treatment regimens, especially in
  the context of abuses in the medical care system.

54
Provide Information

• Be persuasive as opposed to commanding
• Describe use
• Inform about side effects
• Research shows This does NOT increase
• side effects
• Tell when and how medication will help
• Avoid being too complicated or detailed
• Use plain English, avoid technical terms
• Avoid anxious mannerisms (e.g. touching self,
  shuffling papers, looking at watch). These may be
  interpreted as a lack of truthfulness or honesty.

Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
55
Determine the Patients View of the Medication
Regimen

• Ask the person Do you think there will be any
  problems with the medication?
• Have you taken a medication similar to this in
  the past?
• Provide Information
• Provide Strategies

Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
56
Causes of Non-Adherence

• Health Beliefs
• Persons perceptions of
• Seriousness of the illness
• Outcomes of non-treatment
• Perceived ineffectiveness of treatment
• Lack of social support
• Social discouragement
• Adverse effects
• Lengthy or complicated treatment regimens

Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
57
Causes of Non-Adherence

• Poor Communication
• Minimal medical supervision
• Insufficient instruction
• Poor Feedback
• Interactions with health professional
• perceived as unfriendly
• perceived as unconcerned
• little interaction
• unilateral interaction

Source Cohn, E. R. (2000) Communication to
Promote Therapeutic Adherence. (www.pitt.edu)
58
Patient Satisfaction

• Patient satisfaction increases when clinician
  uses psychosocially-oriented interview
• Psychosocially oriented interview was LEAST
  frequently used
• Perception among physician that takes more time
• BUT Study found that psychosocial interview did
  not significantly increase time of the clinical
  encounter

Roter,DL, Stewart, M., Putnam, SM, Lipkin, M,
Stile, W. Inui, T (1997) Communication patterns
of primary care physicians. Journal of the Amer.
Med. Assoc., 277(4)350-56.
59
Linguistic Access Eliciting Clinical Information

• Many languages lack terms equivalent to our
  medical terminology
• When interviewed in English, patients sometimes
  responded positively to questions, even when they
  were confused by the terminology used in the
  interview.
• When interviewed in their language of origin,
  lack of understanding was more readily identified.

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
60
Linguistic Access Eliciting Clinical Information

• Questions that created problems for respondents
  included those in which
• The concept or wording was unclear
• The translation was difficult
• The concept or wording was culturally
  inappropriate
• The request for sensitive information led to
  untruthful responses

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
61
Linguistic Access Eliciting Clinical Information

• Questions which worked better were those which
• used clearly defined concepts
• used clear and simple language
• asked for factual information

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
62
Linguistic Access Eliciting Clinical Information

• Survey questions which were identified as most
  problematic were those which attempted to elicit
• socio-demographic information
• preventive behaviors
• attitudes and beliefs

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
63
Linguistic Access Eliciting Clinical Information

• Consider the question When did you have your
  last check-up?
• Focus groups were conducted in Spanish, English,
  Cantonese and Vietnamese.

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
64
Linguistic Access Eliciting Clinical Information

• When did you have your last check-up?
• Focus group feedback revealed
• Latinas felt that most Latina respondents would
  lie, because they knew they were supposed to
  get check-ups, whether they did or not.

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
65
Linguistic Access Eliciting Clinical Information

• Focus Group feedback Last Checkup?
• Chinese women wondered why one would go to a
  doctor if one was healthy. They felt that Chinese
  respondents might associate regular check-ups
  with a presumption of illness, may not answer
  truthfully, even if they did indeed have a
  check-up.
• Vietnamese women had trouble understanding the
  concepts of routine and check-up though most
  answered the question in the affirmative when
  interviewed in English.

Pasick, RJ.,Stewart, SL, Bird, JA DOnofrio, CN
(2001) Quality of Data in Multiethnic Health
Surveys, Public Health Reports, Supplement 1,
Vol. 116223-243
66
Communication Soliciting the Patients Concerns

• Communication is at the heart of the clinician
  patient encounter
• Physicians actively solicited patient concerns in
  75.4 of interviews
• Patients initial statement of concerns was
  completed in only 28 of interviews.
• In 24.6 of visits, the physician did not ask the
  patient about his/her concerns.

Marvel, MK, Epstein, RM, Flowers, K Beckman, HB
(1999) Soliciting the patients agenda have we
improved? JAMA, 281(3)283-287
67
Communication

• The average visit length was 15 minutes.
• The average patient who came with one or more
  concerns used only 32 seconds to complete their
  review of concerns.
• No patient used more than 129 seconds.

Marvel, MK, Epstein, RM, Flowers, K Beckman, HB
(1999) Soliciting the patients agenda have we
improved? JAMA, 281(3)283-287
68
Communication

• When patients were allowed to complete their
  initial statement of concerns, there were fewer
  spontaneous statements of concerns which occurred
  after the history taking portion of the interview
  (14.9 vs. 34.9)

Marvel, MK, Epstein, RM, Flowers, K Beckman, HB
(1999) Soliciting the patients agenda have we
improved? JAMA, 281(3)283-287