Transcript Immigrants, refugees and migrants

Patient-Centered Care
Becoming Culturally Humble When
Working with Refugees, Migrants
and Immigrant Youth
Maxine Proskurowski
Eugene, OR School District
Immigrants, Refugees and Migrants
• Demographic changes
• Strengths and challenges for the new Americans,
and their health care needs
• Culturally competent care
our own beliefs and assumptions
skills to provide culturally humble care
film and discussion around different cultural
beliefs
CULTURAL COMPETENCY
Describes a set of skills, knowledge and attitudes that
enhances a clinician’s ability to:
• Understand and respect the patient’s values,
beliefs and expectations;
• Be aware of one’s own assumptions and value
systems, and those of the American medical
system;
• Adapt care to be acceptable to the patient’s
expectations and preferences
Rationales for cultural competence
training
• Rapidly changing demographics calls for
new skills, attitudes and knowledge to allow
clinicians to work effectively with diverse
racial, ethnic and social groups;
• By reflecting on our own assumptions and
biases, we can develop a greater
understanding and acceptance of beliefs that
differ from our own
Demographic changes in the last 100
years
• More than 281 million people counted by
the latest federal census in 2000
• four times the number in 1900
• double the population in 1950
• In the decade 1990-2000 the population
grew by the biggest ten year numerical leap
in the US history
The ticking clock
• Every 8 seconds a new American is born
• Every 12 seconds one dies
• As each 25 seconds ticks by there is a net
gain of one immigrant from abroad
• Every 12 seconds the nation’s population
clock records a net increase of one more
American overall
Immigrant profile
• 56 million Americans or 1 in 5 are foreign
born or children of foreign born parents
• Foreigners keep coming to this country, as
they have for hundreds of years:
• refugees: to escape discrimination, death
• job availability
• and most importantly, people seek the best
opportunity to improve their own lives and those of
their children
Alteration of America’s racial and
ethnic dynamic
• For the first time African Americans are no longer
the nation’s biggest minority group
• Jose is
• #1 name for baby boy in Texas
• #2 in Arizona
• #3 in California
• Smith remains the most common surname
• Top 50 names include Garcia, Martinez,
Rodriguez, Hernandez, Lopez, Gonzalez, Perez
www.futureofchildren.org
Children of
Immigrants by
region of origin,
1910-2000
Dispersion of Immigrant families
between 1990 and 2000
www.futureofchildren.org
Distinguishing factors for the latest
waves of immigrants
• Besides 6 major gateway states (California,
New York, Texas, Florida, Illinois, New Jersey)
22 other states experienced immigration
growth three times faster than the nation as a
whole
• Limited English proficient population grew by
52% from 14 million to 21.3 million.
Source: Pew Hispanic Center
Distinguishing factors for the latest
waves of immigrants (cont)
Rise in undocumented immigration
• between 1990 and 2002 the undocumented
population tripled from 3 to 9.3 million, by March
2003 increased another million and by March
2007 estimated 12 million
• Of the 17.9 million foreign born workers in the
US
– 5.2 million or 29% are undocumented
• 57% from Mexico,
• 24% other Latin American countries,
• 9% Asians.
Source: Pew Hispanic Center
Strengths of immigrant families
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Healthy, intact families
Strong work ethics and aspirations
Community cohesion
Children have high educational aspirations
Children are less likely to engage in risky
behaviors
• Children spend more time doing homework
• Do well in school during the early school years
Challenges faced by immigrant
families
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Less educated parents
Low wage work with no benefits
Language barriers
Discrimination and racism—racial profiling
Poverty and multiple risk factors
Lack of social supports
High poverty rate for immigrant
children
• High poverty rate for immigrant children is
a recent phenomenon.
• 2002 overview of immigrant children :
– 29% live in families with incomes below
poverty level
– 18% lack health insurance
– 40% live in a family worried about affording
food
Restrictions on benefits for legal
immigrants
Most legal immigrants are ineligible for
benefits during their first five years in the
United States:
– TANF (Temporary Assistance for Needy
Families)
– Food stamps
– Supplemental social security income
– Health benefits-SCHIP and Medicaid
Health profile of immigrants
First generation children do well at early ages
• healthy babies
• high immunization rates
Adolescent health
• Adolescent well being declines the longer
the families have lived in the United States.
• Foreign born youth report better health as
compared to American born adolescents of
the same ethnicity.
Educational challenges
While the majority of teens in immigrant families
attend school, they are more likely to be behind
grade level and not to graduate.
This is especially evident in those families with
origins in Mexico, Central America, the Dominican
Republic, Haiti and Indonesia, who together account
for the majority of immigrant children.
Richard Rothstein’s
recommendations for all children
Richard Rothstein, a researcher at the Economic
Policy Institute, author of “Class and Schools: Using
Social, Economic and Educational Reform to Close
the Black-White Achievement Gap” calls for three
programs:
1. Early education programs
2. After school programs
3. Fully staffed health clinics in schools
serving low income children.
Health Disparities
• Defined as racial or ethnic differences in the
quality of health care.
• Differences result in worse clinical outcomes.
• The differences persist after adjusting for known
factors, including
economic and social class
access to care
Health disparities=unequal quality of care
2006 Center for the Health Professions, University of California, San Francisco
Healthy People 2010 Findings
• Women of Vietnamese origin in the U.S. have cervical
cancer at nearly 5 times the rate of White women.
• 55% of reported AIDS cases are among African American
and Hispanic populations.
• Infant mortality rates among American Indians and
Alaskan Natives is almost double that of Whites.
• Pima Indians of Arizona have one of the highest rates of
diabetes in the world.
• Evidence suggests that lesbians have higher rate of
smoking and obesity than heterosexual women.
US. Department of Health and Human Services, 2001
Role of clinicians in health
disparities
Clinical decision making study with standardized patients who were
identical in all aspects except for race and gender:
• Videos shown to 720 physicians
• African Americans 40% less likely to be referred for cardiac
catheterization
• African Americans were rated as having lower income, despite the
same occupation.
• Race and sex of patient affected decision to refer patient
• Lowest referral rates were for African American women
• Findings “may suggest bias on part of the physician…could be the
result of subconscious perceptions rather than deliberate actions or
thoughts.”
Schulman, 1999.
Biases and Assumptions
• An inherent human trait—we all have biases and
make assumptions. This is how our minds
efficiently receive, file, store and retrieve
information. Society also shapes our beliefs.
• We are more likely to make assumptions when
time and information are limited.
• We may subconsciously discriminate on basis of
race, gender, age.
Schulman K. NEIM 1999;340-618:26
Stereotypes
• A type of “mental shortcut” for taking in,
processing and retrieving information.
• We use this to assign an individual to a category
based on what we believe, consciously or
unconsciously, about a general group to which the
person belongs.
• Based on limited personal knowledge and/or
experience
• More likely when time pressure, need for quick
judgments, multi-tasking, and anxiety.
2006 Center for Health Professions, University of California, San Francisco
Generalizations
• Another type of “mental shortcut” for
taking in, processing and receiving
information.
• Based on a summary of common trends in
beliefs or behaviors about groups
• Are a starting point; add knowledge, skills
and practice to this base
First Memory of Difference
• Who were the messengers of difference?
• What people, or institutions were involved
in your memory?
• What feelings did your memory evoke?
Linking health disparities and
cultural competence
• Culture matters in health care—affects all aspects of life, including
how we think about disease, health and healing
• Cultural causes of disparities can include:
communication gaps between clinician and families
health beliefs of patients
biases and stereotypes among health professionals
patients’ use of complementary or alternative healing traditions
language barriers
Culturally competent care is care that is tailored to the linguistic and
cultural needs of the patients
2006 Center for Health Professions, University of California, San Francisco
Eliciting Health and Healing Beliefs
• Communication is culture-bound
• Explanatory frameworks can be used to
help bridge cross-cultural communication
• Examples of frameworks:
LEARN
Kleinman’s questions
Framework for Eliciting Health
Beliefs
• LEARN
Listen with sympathy and understanding to
the patient’s perception of the problem
Explain your perceptions of the problem
Acknowledge and discuss the differences
and similarities
Recommend treatment
Negotiate agreement Berlin, West J.Med 1983
Kleinman’s Questions
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What do you call this problem?
What do you think has caused the problem?
Why do you think it started when it did?
What do you think the sickness does? How
does it work?
• How severe is the sickness? Will it have a
long or short course?
Kleinman A. Ann.Intern.Med. 1978
Applying Models to Elicit Patients’
Experience of Illness
“ The best way to learn about something is to
play about it.”
Mr. Rogers
Role of Culture in Health, Illness
and Healing
Culture is society’s style, its way of living and dying.
It embraces the erotic and the culinary arts;
dancing and burial; courtesy and curses; work and
leisure; rituals and festivals; punishments and
rewards; dealing with the dead and with the ghosts
who people our dreams; attitudes toward women,
children, old people and strangers; enemies and
allies; eternity and the present; the here and now
and the beyond.
Octavio Paz
World’s apart: a Laotian child
Film about Laotian child raises issues around:
1. Understanding the family’s health and
illness beliefs
2. Family decision-making and authority
figures;
3. Traditional/alternative medical practices
4. Cross-cultural negotiations
5. Barriers to effective communication
Do Cultural Differences Exist?
In working with a patient/family
• What would prompt you to consider that
there may be differences in the health
beliefs or healing beliefs between you and
the patient/family?
• What questions would you ask?
Working with Differences
Without some agreement about the nature of what is
wrong, it is difficult for a clinician and a patient to
agree on a plan of management acceptable to both
of them. It is not essential for the clinician to
actually believe that the nature of the problem is as
the patient sees it, but the clinician’s explanation
and recommended treatment must be at least
consistent with the patient’s point of view.
Moira Stewart, 1995 Patient Centered Medicine
Evolution of Health Care
2000 BC Here, eat this root.
1000 BC The root is heathen. Say this prayer.
1850 AD That prayer is superstition. Here,
drink this potion.
1940That potion is snake oil. Here, take this
antibiotic.
2000 That antibiotic does not work. Here, eat this
root.
Source: unknown
Culturally Humble Care
Understanding a patient’s culture and beliefs not only helps us
resolve purely medical complaints. Cultural competence
brings solace and sustenance for the provider as well as the
patient.
By leaving behind preconceived notions and opening our
minds to other sets of values and beliefs, we embark on a
voyage of spiritual discovery of our fellow human beings.
It is a voyage that can mature us and strengthen us for the rest
of our lives.
Miguel Angel Corzo