Six Steps Toward Cultural Competence

[Pages:24]6Six Steps Toward Cultural Competence

How to Meet the Health Care Needs of Immigrants and Refugees

Compliments of

Six Steps Toward Cultural Competence

How to Meet the Health Care Needs of Immigrants and Refugees

Recommendations from the Minnesota Public Health Association's

Immigrant Health Task Force

Task Force Chair: Carol Berg, R.N., M.P.H. Report Editor: Patricia Ohmans, M.P.H.

Design: Patricia Ohmans, Michelle Sorenson Design services donated by Boynton Health Service, University of Minnesota

Printing donated by 3M Community Affairs Foundation Copies of this report are available from Refugee Health Program Minnesota Department of Health 717 Delaware Street S.E. Minneapolis, MN 55440

Nonprofit uses of this report are encouraged. Feel free to reproduce its contents for educational purposes, but please credit the Minnesota Public Health Association's Immigrant Health Task Force.

For even more information, a packet of supplementary materials for this report is available. To order, see the last page of this report.

Executive Summary

This is a report for anyone interested in the relationship between health and culture in Minnesota. It tackles one important question:

How can health care be more accessible to immigrants and refugees who come to our state?

The report proceeds from three premises: that access to health care should be universal for Minnesotans, whether they are "new" or "old"; that such access is, in fact, more difficult for Minnesotans who are immigrants or refugees, and that we can, and should, take steps to correct this inequity.

By taking the steps outlined in this report, we will become more culturally competent as health care providers, consumers, administrators, scholars, policy-makers, and citizens. The report is the work of a yearlong task force created by the Minnesota Public Health Association. Members of the Task Force are listed in appendix c.

What Is Cultural Competence?

Every human being is a member of many cultures. Culture influences an individual's health beliefs, practices, behaviors, and even the outcome of medical treatments. Because of this, health care providers must learn about culture. We must try to become culturally competent.

Cultural competence in health care is defined in this report as the ability of individuals and systems to respond respectfully and effectively to people of all cultures, in a manner that affirms the worth and preserves the dignity of individuals, families and communities. Cultural competence is important in every aspect of our public lives, but it is a critical skill for health care providers, who deal daily with diverse people in life-and-death situations. To be culturally competent, a provider should acknowledge culture's profound effect on health outcomes and should be willing to learn more about this powerful interaction.

Moving Toward Competence: Six Steps

Complete cultural competence is not so much a goal, as a continuous process. This report identifies six critical steps in the journey toward cultural competence in health care for immigrants. We will know we are moving toward cultural competence when we:

? involve immigrants in their own health care ? learn more about culture, starting with our own ? speak the language, or use a trained interpreter ? ask the right questions and look for answers ? pay attention to financial issues, and ? find resources and form partnerships

The report is intentionally short. We want it to be used, not filed for later reading. The appendices include just a sampling of the many useful resources available.

Six Steps ? Executive Summary

Why Cultural Competence?

Doctor: Why does your child have these red marks on her arm? Did someone abuse her? Mother: No, my child had a fever, so I rubbed a coin over her skin.

Admitting Clerk: How old are you? When were you born? Elderly patient: I am older than anyone in my community. I was born in the year of the flood.

Doctor: How long have you been feeling this way? What do you think has caused your symptoms? Patient: I come to the doctor to get answers and treatment, not to be asked so many questions!

Do these scenes sound or look familiar? If they do, it's because scenes like these are increasingly common in Minnesota hospitals, clinics and doctors' offices. If you're a Minnesotan involved in health care, chances are, you've dealt with an increasing number of immigrant patients every day.

Changes in Minnesota's Health Care

Of course, except for Native Americans, all Americans are immigrants. Our country was built on immigrant energy and enterprise, and people from all over the world still emigrate to America. Nearly a million new arrivals enter the country each year. Some come for political reasons, others are joining relatives, and some come for work. Of these, thousands settle in Minnesota each year. Others come as "secondary immigrants" after first settling elsewhere. Minnesota receives its share of undocumented immigrants, as well. Each "new Minnesotan" brings with him or her a new challenge to our health care system.

What happens when these new Minnesotans, many of whom are unfamiliar with the biomedicine practiced in the U.S., end up in the hospital? What happens when a Westerntrained provider serves a patient whose expectations about life-and-death matters are vastly different from her own?

Health care providers throughout the state are considering these questions, and working hard to provide sensitive, informed, culturally competent care when their patients' languages and cultures differ from their own.

What is This Report and Who Is Responsible for It?

This report is a guide for both providers and consumers of health care as well as administrators, policy makers, academics, and members of the general public who are interested in improving health care for immigrants to Minnesota. The report is the result of a yearlong series of discussions by the members of the Minnesota Public Health Association's Immigrant Health Task Force. (For a complete list of Task Force members, see appendix c.)

Six Steps ? 1

Task Force members, themselves providers, advocates and consumers of health, education and social services, were directed to produce a report that would:

? promote access to quality care for refugees and immigrants ? collect resource information about relevant programs and services, and ? encourage cooperation among health care agencies.

What Were Our Guiding Assumptions?

As task force members, we began with individual assumptions about health care and immigrants. As meetings progressed, we acknowledged those assumptions collectively. As a group, we agreed that everyone deserves access to quality health care, and that we all have an obligation to eliminate barriers to such access. These basic assumptions inform the recommendations in this report.

What Is Cultural Competence?

Every human being is a member of many cultures. Culture influences an individual's health beliefs, practices, behaviors, and even the outcome of medical treatments. Because of this, health care providers must learn about culture. We must try to become culturally competent.

Cultural competence in health care is defined in this report as the ability of individuals and systems to respond respectfully and effectively to people of all cultures, in a manner that affirms the worth and preserves the dignity of individuals, families and communities. Cultural competence is important in every aspect of our public lives, but it is a critical skill for health care providers, who deal daily with diverse people in life-and-death situations.

The culturally competent provider: ? has the knowledge to make an accurate health assessment, one which takes into consideration a patient's background and culture; ? has the ability to convey that assessment to the patient, to recognize culture-based beliefs about health and to devise treatment plans which respect those beliefs; and ? is willing to incorporate models of health and health care delivery from a variety of cultures into the biomedical framework.

To be culturally competent, a provider should acknowledge culture's profound effect on health outcomes and should be willing to learn more about this powerful interaction. We hope our report's recommendations will help you in your journey toward cultural competence.

Why Does Cultural Competence Matter?

Why do these recommendations matter? Is cultural competence a luxury for health care providers? We don't think so. Much has been written about the hazards of ignoring cultural factors in diagnosis and treatment of immigrant patients. Other research documents the fact that culturally competent care improves diagnostic accuracy, increases adherence to recommended treatment, and reduces inappropriate emergency room use. (See the bibliography in appendix b and the supplementary resource packet for a few of these key articles).

Based on the evidence and on our collective experience, we believe that culturally competent care is not just an ethical nicety. It is a clinical imperative and a financial necessity.

Six Steps ? 2

Six Steps Toward Cultural Competence

Our meetings over the past year reaffirmed the obvious: Cultural competence is a journey, not an endpoint. Because cultures are constantly evolving, no health care practitioner can hope to be completely familiar with health beliefs of all of his or her immigrant patients, nor can patients realistically expect such encyclopedic awareness from their providers. Further, there is no cookbook for competence, no secret formula for sensitivity. Those who seek to standardize a culture's beliefs and practices are dealing in stereotypes. Nevertheless, there are steps we can all take to improve the level of cultural competence in Minnesota's health care facilities, whether we are providers, patients, administrators, scholars, orpolicy makers.

Here are the steps we recommend:

Involve immigrants in their own health care Learn more about culture, starting with your own Speak the language, or use a trained interpreter Ask the right questions and look for answers Pay attention to financial issues Find resources and form partnerships The rest of this report elaborates on these steps, with specific suggestions for health care providers, teachers, patients, administrators, policymakers and members of the interested public. Whatever your role is, these suggestions are action steps to take. As you go through this report, you may see ideas that seem particularly relevant or useful. Jot them down on the next page, and take action!

Six Steps ? 3

Six steps I can take toward cultural competence

Here's how I will...

1. Involve immigrants in their own health care. 2. Learn more about culture, starting with my own. 3. Speak the language, or use a trained interpreter.

4. Ask the right questions and look for answers.

5. Pay attention to financial issues.

6. Find resources and form partnerships.

Feel free to copy this worksheet.

1. Involve Immigrants in Their Own Care

Administrator: Why haven't our immigrant patients been using the new special clinic we set up for them? It's been two months and we haven't seen many new patients.

Interpreter: Maybe you should try asking them. Or we could put an ad in the community's newspaper.

How do we know if immigrant patients are satisfied with their care at our hands? Consumer advisory committees, patient satisfaction surveys, community focus groups and marketing surveys are all useful strategies--if they involve immigrant patients in a meaningful way. Here are some other suggestions:

If you are a health care administrator or provider:

? Ask immigrant patients if they're satisfied. Check with them in waiting rooms, while their experiences are fresh in their minds. Encourage them to write comments in a log, in their own languages.

? Recognize that in many cultures, family members are deeply involved in individual members' health decisions. Involve extended family members whenever possible in planning care.

? Train bilingual and bicultural staff or volunteers to orient patients to the health care system, and to document complaints as floorwalkers and observers.

? Include patient and bilingual staff input in designing Continuous Quality Improvement indicators.

? Make complaint mechanisms clear and safe. Make sure patients know who to talk to. Don't just rely on formal incident reports; develop a short, informal complaint form.

? Look for patterns of complaints to identify a trouble spot. Some patients may not want to speak up or "complain." Tell them you are looking for ways to improve the system.

? Use bilingual staff in member services of health plans. Be sure to diversify staff at all levels in any facility.

? Remember that social workers and other staff can also serve as patient advocates.

? Assemble a community board to help oversee delivery of services. Contact immigrant mutual assistance associations for feedback. See the supplementary resource packet for ideas.

Six Steps ? 5

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