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Culturally Competent Pediatric Care

Maria Herran MD, Ana Velez MPA Oscar Hispanic Clinic MetroHealth Medical Center Cleveland

Objectives •

Define culture / cultural competency

Discuss the concepts of cultural competency

Create awareness to cross-cultural issues that may be barriers to effective pediatric care

Give insight into models for effective crosscultural communication

Definitions •

Culture originated from the latin word cultura meaning to 'cultivate'

Edward Burnett Taylor , UK social anthropologist (1871) defined culture “Culture ... is that complex whole which includes knowledge, belief, art, morals, law, customs and any other capabilities and habits acquired by man as a member of society”

Characteristics of culture • • • • • •

Everyone has culture Culture as an adaptive mechanism Culture is non-instinctive and is learned Cultures change over time Permissible actions / behaviours Ethnocenterism

21st Century vs. the Past ďƒ˜ Acculturation,


 Look

beyond your American glasses

ďƒ˜ Understand

that other people’s belief, tastes, way of life are different and as good as yours.

Models of effective cross-cultural communication and negotiation •

ETHNIC : Explanation, Treatment, Healers, Negotiate, Intervention, Collaboration


LEARN : Listen, Explain, Acknowledge, Recommend, Negotiate

Patient explanatory model • •

way in which patient explains their own illnesses culturally determined but also influenced by other factors ( socioeconomic factors, education )

Theory of causality among different cultures : 1. Invasion – eg. germs, cancer, food, 2. Degeneration - being run down or accumulating toxins. 3. Mechanical - blockage of GI tract or blood vessels. 4. Balance - proper diet, vitamins, sleep, as well maintenance of harmony in the patient's life and relationships. Chrisman NJ (1977)Cul Med Psychiatry

Health and Culture •

Disease : abnormalities of function and structure within the body organs / systems

Illness : experience of disvalued changes in states of being and function ;

Where there is no shared medical background, disparities between concepts of disease and illness can have significant effects

Culture may be affected by: • educational level • income level • geographic residence • identification with community groups (e.g., religious, professional,community service, political) • individual experiences • length of residency in the US • age Source: AMA, Culturally Competent Health Care for Adolescents, 1994

Cultural competency “Delivery of care within the context of appropriate physician knowledge, understanding and appreciation of all cultural distinction leading to optimal health outcomes” AAP Policy Statement 2004 “ Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy ”

Cultural competency •

Involves acquisition of knowledge development of skills demonstration of behavior, attitudes that are appropriate to care for patient with wide variety of cultural attributes


Involves fundamental changes

Cultural competency •

According to Carillo et al, to be culturally competent, one has to possess the following : empathy curiosity respect Carillo JE et al Ann Intern Med1999

The statement is based on the conviction that culturally effective health care is vital and a critical social value and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through focused curricula throughout the spectrum of lifelong learning, from premedical education and medical school through residency and continuing medical education.

Why is cross cultural communication important ? •

Shift in demographics : Ethnic minority currently constitute 25% of population 1 in every 5 children is from a minority group * US Census bureau projects that by 2020, 44.5 % of children < 19 yrs will belong to a ethnic minority group •

Health and illness are culturally defined To be able to be effective , physicians have to be able to understand the role of pt’s culture in providing medical care • Ethnic minority populations : American Indian and Alaska Native, Asian, Black or African American, Hispanic or Latino, and Native Hawaiian and Other Pacific Islander.

Why is cross cultural communication important ? â&#x20AC;˘

Disparity of health ( health access, patterns of health usage ) amongst cultural groups is a challenge to health professionals - infant mortality rate amongst minority groups are twice as high as rates among whites - maternal mortality is 4x higher than whites - rates of diabetes of native americans 3-5 times higher - cervical cancer amongst vietnamese women 5 x compared to whites

Cultural competency is no longer a luxury

Barriers to access of care due to lack of cultural competency  Lack

of diversity in health care’s leadership and workforce  Systems of care poorly designed to meet the needs of diverse population  Poor communication between providers and patients of different racial, ethnic, and/or cultural backgrounds

Balancing Fact-Centered and Attitude/Skill-Centered approaches to Cultural Competence ď&#x192;&#x2DC;

Fact-centered approach enhances cultural competence by teaching cultural information about specific ethnic groups. Risks racial stereotypes


Attitude/skill-centered approach represents an universal approach to cultural competence that enhances communication skills and emphasizes the particular sociocultural context of individuals.

ď&#x192;&#x2DC; Acquisition


of cultural competence is a developmental

Patient-Centered Care  Defined

by the Institute of Medicine as “health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs and preferences and that patients have the education and support they need to make decisions and participate in their own care.”

Frameworks for Culturally Competent Care 

Organizational Cultural Competence 

Systemic Cultural Competence 

Importance of racial and ethnic diversity in health care leadership and workforce. Importance of recruitment, include community Health systems have limited capacity to deliver quality of care to diverse population if they do not survey service satisfaction

Clinical Cultural Competence 

Importance of sociocultural factors in clinical encounters. Importance of training in cultural competence including communication skills, mechanism for addressing racism and bias.

Potential barriers for physicians 

Lack of knowledge


Fear of the unknown or the new

Feeling of pressure due to time constraints

Issues with providing culturally effective care for children • •

• •

Involves child-parent relationship Calls into play child rearing attitudes Parents / guardians act as health brokers for their children Healthcare providers are less likely to accept refusal / modification of treatment

â&#x20AC;&#x153; It is more important to know what sort of patient has a disease, than what sort of disease a patient has â&#x20AC;?

Sir William Osler


Developing cultural competence •

Six elements :

1. Changing one’s world view – examining one’s own values and acknowledging other values

2. Familiarity with core cultural issues – universal concepts but are also specific ( time+space ; styles of communication; nature of self-identity; relationship with others : gender, age, social class; social organization ) Dunn AM J Pediatr Health Care (2002)

Elements of developing cultural competence 3. Developing knowledge about cultural groups within our community 4. Familiar with core cultural issues relating to health / illness 5. Relationship of trust 6. Negotiate for mutually acceptable + understandable interventions of care

Models of effective cross-cultural communication and negotiation â&#x20AC;˘

BATHE : Background (What is going on in your life ?) Affect (How do you feel about what is going on ?) Trouble (What troubles you most ?) Handling (How are you handling that ?) Empathy (This must be very difficult for you)

Center for Linguistic and Cultural Competency in Health Care ď&#x192;&#x2DC;

The office of Minority Health (OMH and part of established the Center for Linguistic and Cultural Competency in Health Care (CLCCHC) to address the health needs of populations who speak limited English.


OMH was mandated by US Congress in 1990 to develop the capacity of health care professionals to address the cultural and linguistic barriers to health care delivery and to increase access to health care for limited English-proficient patients

CLAS Standards 

Principal Standard: 1.

Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs

Governance, Leadership, and Workforce

Communication and Language Assistance

Engagement, Continuous Improvement, and Accountability

MetroHealth Medical Center  Director 

of Inclusion and Diversity

Lourdes Negron-McDaniel

 Language

Access and Communication Services: Open M to F, 9 AM to 5 PM. Brings system’s resources for diverse population under one umbrella 

Mari Galindo-Dasilva

ď&#x201A;§Golden Rule: Respect other cultures as though they were your own.

References • •

• • •

• •

Carillo JE et al. “ Cross-cultural Primary Care : A Patient Based Approach” Ann Intern Med 130:829 Kagawa-Singer M, Kassim-Lakha S. “A Strategy to Reduce CrossCultural Miscommunication and Increase the Likelihood of Improving Health Outcomes ” Academic Medicine 78:577 Korbin JE, Johnston M. “Steps toward Resolving Cultural Conflict in a Pediatric Hospital ” Clinical Pediatrics 21 : 259 Shields MK, Behrman RE “ Children of immigrant families: analysis and recommendations” Mccubbins HI et al. “ Culture, Ethnicity and the Family: Critical Factors in Childhood Chronic Illnesses and Disabilities” Pediatrics 91:1063 Dunn AM. “Culture Competency and the Primary Care Provide ” J Pediatr Health Care 16:105 Committee on Pediatric Workforce. “Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy ” Pediatrics 114 :1677

Culturally competent pediatric care  
Culturally competent pediatric care