culturally responsive obstetrical and gynecological care

1. culturally responsiveobstetrical and gynecological care Jean Gilbert, PhD Geri-Ann Galanti, PhD Los Angeles County Department of Health Services Office of Diversity Programs

2. Who Thinks Cultural Competency is a Clinical Skill? • The Accreditation Council for Graduate Education (Residency Programs) • The Association of American Medical Colleges (Medical Schools) • The American College of Obstetrics and Gynecology • The Los Angeles County Department of Health Services: Cultural and Linguistic Competency Standards

3. Why This Recent Emphasis on Culture and Health Care? • Major changes in the composition of the U.S. population: 25% of the California population is foreign born. • Many immigrants are from non-Western nations with non-Western health concepts. • Increasing emphasis on patient-centered care within medicine. • Of the 1.7 million DHS patient visits over the last 6 months, about 779,000 were limited English proficient, preferring services in 88 languages.

4. If You And Your Patient Hold Very Different Health Beliefs... • This may impact on their trust in you and their evaluation of your abilities. • It might impede understanding of your assessment and treatment plan. • It may make obtaining consent for procedures very difficult. • It might reduce willingness to comply with treatment and follow-up.

5. Culture is a Major Force in Shaping an Individual’s: • Expectations of a physician • Perceptions of good and bad health • Understanding of disease etiology • Methods of preventive care • Interpretation of symptoms • Appropriate treatment • Health care self-efficacy

6. In Understanding Cultures, a Little Knowledge is Dangerous • Don’t let cultural generalizations become stereotypes. • Generalizations are testable probabilities; we couldn’t do science without them. • Stereotypes attribute the central tendencies of groups to individuals… ignoring the bell curve! • Your patient is an individual, not a culture.

7. The Importance of Women’s Roles Which one of these women is the model for your patient?

8. Acculturation is a Critical Factor in: • Family dynamics and gender roles • Knowledge of and access to public and private helping agencies. • Ability to speak and read English. • Experience with the U.S. health care system.

9. Video: Lupe’s Dilemma Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

10. Cultural Resistance to Breast Cancer, PAP and STD Screenings • Lack of orientation to preventive care • Fatalistic perspective • Fear and embarrassment about pelvic examinations • Social shame, invasion of bodily privacy • Doctors “push” testing too early, endanger hymen

11. Video: A Big Baby is Coming Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

12. Gestational Diabetes • Gestational diabetes is the most common complication of pregnancy among Mexican Americans. • Lack of early prenatal care often prevents appropriate treatment. • Language issues often make appropriate education and treatment difficult.

13. Labor Pains • Asian women tend to be stoic. • African American women may • be either.

14. Labor Pains • Iranian women tend to be • expressive. • Mexican women also tend to be • expressive.

15. Preferred Labor Attendants Anglo American: Husband or Domestic Partner Hispanic: Mother or Female Relative Asian: Mother or Mother-in-Law

16. Video: Hmong Birthing Practices Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

17. Hmong Prenatal and Birthing Practices • Hmong women may resist napping and invasive prenatal testing; • Consent for prenatal and birthing procedures may have to be gotten from parents, husband, and in-laws; • At childbirth, both mother and baby are considered especially vulnerable to malevolent spirits.

18. Video: Female Circumcision Video is part of the Multicultural Health Series, a community service project of Kaiser Permanente and The California Endowment.

19. . Female Circumcision (aka Female Genital Mutilation) Normal Female Anatomy Modified Sunna Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

20. . Female Circumcision (aka Female Genital Mutilation) Infibulation Infibulation Illustrations from Prisoners of Ritual, (1989) by Hanny Lightfoot-Klein

21. Breastfeeding Colostrum

22. Postpartum Lying-in • Traditionally 30 - 42 days • Rest, stay warm, avoid bathing & exercise • Eat foods designed to restore warmth • Failure to follow custom is thought to result in aches & pains in later years

23. Bonding Bonding and Baby Naming SERENA: serene Kabira: powerful Taci: washtub Radman: joy CALEB: devotion to God Duranjaya: a heroic son CHAN JUAN: the moon; graceful; ladylike

24. Menopause in Cultural Perspective • Although menopause is universal, the “symptoms” attributed to it are not. • Research suggests that the variety of ways menopause is experienced can be termed “local biologies.” • Cessation of the menses is looked upon very positively by women in many cultures.

25. Issues of Language Access in Health Care • DHHS guidance for language access under the Title VI, Civil Rights Act of 1964 • MediCal contract regulations • DHS Cultural & Linguistic Standards • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes standards for cultural competence training and language services.

26. JCAHO Ruling • JCAHO views the provision of linguistically appropriate care as an important quality and safety issue. • JCAHO requires the inclusion of language and communication needs in the medical record. • Interpretation and translation must be provided for patients who need it.

27. DHHS says: • Assess patients’ language needs. • Try not to use family or friends or whoever you can grab. • Don’t use minors to interpret. • Try to use trained medical interpreters whenever possible. • Use telephonic interpreters for rare languages.

28. What Can You Do? • Honestly assess your own bilingual skills • Understand the pitfalls in using untrained interpreters • Use interpreters effectively • Use telephonic interpreters skillfully

29. Are your bilingual skills really adequate? Can you: • formulate questions easily? • ask a question in more than one way? • understand nuance and connotation in the patient’s response to questions? • understand regional variations? • know terms for anatomy and healthcare concepts? • convert biomedical terms into lay terms in the target language?

30. Pitfalls in Using Untrained Interpreters • Studies show that an average of 70% of the interpreted exchanges by ad hoc interpreters contain clinically important errors. • Family members, especially, are prone to edit both the clinician’s and patient’s utterances. • Children are frightened or intimidated if asked to interpret. There are ethical problems involved. • Confidentiality concerns must also be considered.

31. The Effective Use of Face-to Face Interpreters • Brief the interpreter first, if possible. • Introduce the interpreter to the patient. • Position the interpreter behind the patient or behind you. • Speak and look directly at the patient. • Use first person and expect the interpreter to do the same. • Avoid interrupting the interpretation.

32. Using Telephonic Interpreters • Use a speaker phone; do not pass a handset back and forth. • Remember that the interpreter is blind to visual cues. • Let the interpreter know who you are, who else is in the room, and what sort of patient encounter it is. • Let the interpreter introduce her/himself.

33. What You Need to Know to Connect • The language needed • Dial 0 for hospital operator • Tell operator to connect you with the Language Line. • Remember that the telephonic interpreter is bound by confidentiality regulations, just as any other health care personnel.

34. What Can You Do To Be More Culturally Competent? • Practice ways to build rapport • Ask tactful, nonjudgmental questions about their preferences and practices • Understand family roles in health care • Know something about the cultural beliefs of your patients, but don’t stereotype • Use interpreters and use them effectively, don’t “wing it.”

35. Consider: • Think back on your “difficult” patients. • May any of the challenges they presented be linked to their cultural beliefs or practices? • Would cultural competence skills have made a difference?