I
The Basics
More than just getting along
As
health care providers we should appreciate
the key role culture plays in our ability
to influence behavior in a patient population
or other group we seek to influence. We
cannot afford to let cultural barriers
limit our ability to meet the needs of
our patients, or reduce their opportunity
to benefit from the services we can provide.
I.
The Basics Chapter One: Culture –
What it is, How it Works
| Perhaps
nowhere are cultural differences
more sharply drawn than in our approaches
and definitions of health and healthy
living. Culture is what we live
every day and what we bring with
us to our workplace, which is why
Dr. Arthur Keinman, Harvard psychiatrist
and anthropologist, believes every
encounter between a health care
provider and a patient is a cross-cultural
experience.1
By deepening our understanding of
culture we can begin to strengthen
the promise of high-quality primary
health care that is accessible,
effective, and cost efficient for
all of our patient populations.
|
|
Culture
is what we live every day and what
we bring with us to our workplace.
|
| Unlike
certain animals, human beings are
not hardwired with a complex set
of behavior patterns and instincts
that allow us to function successfully
from birth, and so we have to learn
how to survive our varied environments
and pass these acquired lessons
down through the generations by
means of language, both verbal and
symbolic. In the sociological sense
this learned language is the culture,
the way of life, of human society.
|
|
...
human beings... pass these acquired
lessons down through the generations
by means of language, both verbal
and symbolic. |
| Material
culture includes the artifacts we
create from stone tools to Mayan
pyramids, from cave paintings to
telecommunications satellites and
the internet. Non-material culture
is the common behaviors, thoughts,
actions, customs, and beliefs that
bind a racial, ethnic, religious
or social group within society.
In Mexican culture, for example,
the celebration of the Feast of
the Virgin of Guadalupe is rooted
not only in Catholic religious tradition
but in Pre-Columbian customs that
transcend geographic borders in
the American Southwest.
|
|
Non-material
culture is the common behaviors,
thoughts, actions, customs, and
beliefs that bind a racial, ethnic,
religious or social group within
society. |
| Every
society recognizes its healers or
health care providers as central to
the functioning of human civilization,
... |
|
Beyond
unique examples like this one, anthropologist
George Murdock has listed a number
of cultural universals. These include:
athletic sports, bodily adornment,
cooking, cooperative labor, courtship,
dancing, dream interpretation, family
feasting, folklore, food taboos, funeral
ceremonies, games, gift-giving, incest
taboos, laws, music, myths, sexual
restrictions, toilet-training, tool-making,
religion, and of course medicine.2
Every society recognizes its healers
or health care providers as central
to the functioning of human civilization,
but few previous societies have been
as culturally diverse as ours, offering
both a challenge and opportunity to
those who would, as their chosen vocation,
cure and comfort the afflicted. |
|
...as certain as the existence of
cultural universals, is the opposing
tendency of every human society
to develop ethnocentrism —
to judge other cultures by the standards
of one's own...
|
|
One challenge to understanding culture
is the simple recognition that,
as certain as the existence of cultural
universals, is the opposing tendency
of every human society to develop
ethnocentrism – to judge other
cultures by the standards of one's
own, and beyond that to see one's
own standards as the true universal
and the other culture in a negative
way. The tendency towards ethnocentrism
also may lead us to deny the reality
that most cultures are in truth
highly adaptive and likely to borrow
from one another. This is certainly
notable within the western hemisphere,
where one can see the extent to
which mainstream U.S. and Hispanic
cultures have long benefited and
been enriched by an ongoing exchange
and intermingling of cultural standards,
icons, symbols, and habits both
within and outside of the United
States' border.
|
| While
some aspects of culture remain steadfast,
other parts evolve. |
|
Another
challenge to understanding culture
is its permeability to critical
events. While some aspects of culture
remain steadfast, other parts evolve.
They are influenced by social events
such as technology, war, economic
fluctuation, birth control, HIV/AIDS,
etc. These events may or may not
change values, practices, and beliefs.
These influences complicate knowing
which aspects of a culture are consistent
and which are fluid. It is also
the reason why many Hispanic subgroups
differ in culture even though they
all speak Spanish. Each country
and often each region will experience
various critical events. This is
also the reason why each individual
within a cultural group may not
be a sole reflection of cultural
norms. Each person’s experiences
and susceptibility to social norming
drives what aspects of culture change
and what stays the same. This complicates
the application of cultural competence.
|
| "Mainstream"
U.S. culture itself is going through
a continuous renewal generated by
Hispanic and other cultures that
contribute to the mosaic of daily
life in the United States. A typical
American diet today consist of an
array of foods from hamburgers to
tacos, sushi to pupusas, middle
eastern kabobs to paella, and curry
to black beans and rice. |
|
"Mainstream"
U.S. culture itself is going through
a continuous renewal generated by
Hispanic and other cultures that
contribute to the mosaic of daily
life in the United States.
|
Of
course if we were a more homogeneous
society, medicine and social service
work might be easier in that we
could use a single all-inclusive
model for health care delivery.
Then again, in a simpler society
our work wouldn't be as exciting
or as challenging. |
|
|
As a society based on laws and principles
rather than religion, "blood,”
race, or ethnicity, the United States
is rich in diversity and has one of
the most fluid, complex, and democratic
cultures in the world. It is, quite
simply, a culture and society that
recreates itself with each new wave
of migration and immigration, technological
change, and social progress. On the
other hand, it is also a political
culture that periodically generates
fear of the "other," of
the so-called stranger among us. Historically
we've seen bias and backlash emerge
with each new wave of ethnic immigration
that has been added to the weave of
our cultural tapestry. Today, 9% of
the U.S. population was born in another
country.3
|
|
...the United States is rich in
diversity and has one of the most
fluid, complex, and democratic cultures
in the world.
|
Of course each new wave of immigration
brings with it its own unique culture,
questions, and problems. With the
latest Hispanic immigrants comes the
question of self-definition and issues
of class structure, especially in
light of a larger, more stable Hispanic
population already living in the United
States. |
|
Of course each new wave of immigration
brings with it its own unique culture,
questions, and problems.
|
Today, the term Hispanic has emerged
as a cloaking term that refers to
all Spanish speaking ethnic groups.
|
|
The term "Hispanic"
did not come into wide usage until
the 1970s and '80s. In the 50’s
and 60’s, Hispanics tended to
organize around their own national
identities as Mexicans, Mexican Americans,
Puerto Ricans, Cuban Americans, Central
Americans, and South Americans. By
the early 1970’s, new organizations
formed that brought together the numerous
Hispanic subgroups to coalesce into
a more unified voice around numerous
social, civil, and political causes.
Today, the term Hispanic has emerged
as a cloaking term that refers to
all Spanish speaking ethnic subgroups.
Hispanics in the United States can
be of any racial background —
white, black, Asian, American Indian,
etc. |
| |
|
"We
wanted all Spanish-speaking people
involved. That was it. We weren't
going to be isolated anymore,"
recalls one group's founder.4
Today, most national Hispanic organizations,
even those formed representing the
interests of one Hispanic subgroup,work
to strengthen the role of all Hispanics.
|
| To
understand Hispanic culture one first
has to come to a more basic understanding
of what constitutes a culture. |
|
To
understand Hispanic culture, one first
has to come to a more basic understanding
of what constitutes a culture. What
are the often ephemeral constructs
of language, values, experiences and
conditions that make for unique "peoples"
and cultures, and how can an understanding
of these assist health care providers
to better meet the needs of Hispanic
patients or clients, as well as, those
of other emerging ethnic groups? |
I.
The Basics Chapter Two: The Continuum
of Working Across Cultures
As
health care providers we should appreciate
the key role culture plays in our ability
to influence behavior in a patient population
or other group we seek to influence. We
cannot afford to let cultural barriers
limit our ability to meet the needs of
our patients, or reduce their opportunity
to benefit from the services we can provide.
'So
what exactly is "cultural competence?"'
you might ask.
Cultural
competence is, the set of behaviors, attitudes
and policies that come together in an
institution, agency, or among a group
of individuals, that allows them to work
effectively in cross-cultural situations.*
Key Concept
The
need for cultural competence in health
care at the individual patient-provider
level can be justified by a number of
specific factors that include:
- the
perception of illness and disease and
their causes varies by culture;
- the
diverse belief systems that exist related
to health, healing, and wellness;
- cultural
influences that help seeking behaviors
and attitudes toward health care providers;
- individual
preferences and culture that affect
traditional and non-traditional approaches
to health care;
- patients
having personal experiences of biases
within health care systems;
- environmental
conditions influencing cultural practices,
beliefs, and perceptions; and,
- health
care providers from culturally and linguistically
diverse groups being under-represented
in the current service delivery system.5
*
See endnote 6 for citation of source.
We
cannot afford to let cultural barriers
limit our ability to meet the needs of
our patients, or reduce their opportunity
to benefit from the services we can provide.
...
"culture," ... implies patterns of
human behavior...that can bind a racial,
ethnic, religious or social group
within a society.
Key Concept |
The
word "culture," as stated earlier,
implies patterns of human behavior
including thoughts, actions, customs,
values, and beliefs that can bind
a racial, ethnic, religious or social
group within a society. Cultural
behaviors are initiated at the moment
of birth, learned in early infancy,
and reinforced throughout a lifetime.
This early learning and reinforcement
become ingrained primary schemas/beliefs.
They form our world view and perceptions
about how the world should function.
|
Often,
it is difficult to alter the hold these
beliefs have on attitudes, values, and
behaviors. For instance, a Christian who
believes in the concept of God may find
it difficult to pray to Buddha, even when
living in Japan and everyone else may
be doing it. Unfortunately, while "culture"
changes and is adaptive, it is challenging
for individuals to recognize and change
their own cultural practices.
The
word "competence" implies
having the capacity to function
effectively. Cultural competence
reinforces the need for understanding
the core of one's beliefs. The client/patient
may not be able to follow a recommended
practice of care if it is contrary
to their core cultural or individual
beliefs. Since the provider is responsible
for the quality of care, comprehending
the patient’s cultural beliefs
and crafting them into the treatment
or prevention plan becomes critical.
|
|
...”competence”
implies having the capacity to function
effectively. |
However, having superficial knowledge
of another's culture is often not
enough. This knowledge must be integrated
into the providers world view and
must penetrate his/her ethnocentrism
and professional training. The depth
of the penetration into the provider's
world view and the ability to see
the world through another's world
view is a precursory factor which
influences one's ability to be culturally
competent. |
|
...having
superficial knowledge of another's
culture is often not enough. |
A
culturally competent system of care acknowledges
and incorporates the importance of culture,
the assessment of cross-cultural relations,
vigilance towards dynamics that can result
from cultural differences and ethnocentric
approaches, the expansion of cultural
knowledge, and the adaptation of services
that meet culturally-unique needs.6*
Key Concept
*
The following 6 pages are derived from
Towards a Culturally Competent System
of Care (see endnote 6)."
There
is within our various institutions, including
the health care system, a continuum of
cultural competency that ranges from cultural
destructiveness to cultural proficiency.
This six-part continuum, as defined by
researchers at Georgetown University's
Child Development Center, is a progression
from cultural destructiveness, to cultural
incapacity, to blindness, to pre-competence,
to competence, and finally, to cultural
proficiency. Understanding this continuum
may help the individual provider assess
and improve their own workplace or institutional
setting.
| ...
cultural destructiveness,... attitudes,
policies and practices that are destructive
to cultures and the individuals within
these cultures. |
|
The
most negative end of the continuum,
cultural destructiveness,
is represented by attitudes, policies
and practices that are destructive
to cultures and the individuals
within these cultures. A system
which adheres to a destructive extreme
assumes that one race or culture
is superior and should eradicate
"lesser" cultures because
of their perceived subhuman condition.
Bigotry coupled with vast power
allows the dominant group to disenfranchise,
control, exploit, or systematically
destroy the less powerful population.
|
The
most extreme examples of cultural destructiveness
involve programs, agencies, and institutions
that actively participate in purposeful
attacks on another culture, and dehumanize
their clients from different racial and
ethnic groups.
Historically,
some health and social service agencies
have been involved in services that have
denied patients access to care. Among
the most infamous example is the Tuskegee
experiments in which poor black men with
syphilis were observed but not treated
for a number of years by white medical
personnel interested in studying the progression
of the disease.
The
consequences of this experiment left a
legacy of distrust of government research
programs among African Americans. The
term cultural destructiveness can also
be applied to instances in which a peoples’
trust has been betrayed by neglecting
to fully inform them of medical risks
and benefits, an approach that can also
have grave legal consequences. One such
example occurred in a 1989–1991
study conducted by the Centers for Disease
Control and Prevention, Kaiser Permanente,
and the Los Angeles County Department
of Health Services during a measles outbreak.
In this instance, Kaiser-members, mainly
Hispanic and Non-Hispanic Black parents,
were asked if they would allow their infants
to take part in a study designed to compare
the effectiveness of different measles
vaccines. The parents, however, were never
informed that one of the vaccines used
was an experimental vaccine and not licensed
for sale in the United States. Therefore,
these parents made the decision to be
included in the study without being fully
aware of the risks involved.
Cultural
Incapacity occurs when
agencies do not intentionally seek
to be culturally destructive but
rather have no capacity to help
clients from other cultures. The
system remains extremely biased,
believes in the superiority of the
dominant group, and assumes a paternal
posture towards "lesser"
groups. A private hospital in which
it may not have been unusual for
a sick or injured Hispanic person
to be turned away from an emergency
room and directed to the nearest
public hospital is an example of
cultural incapacity. |
|
Cultural
Incapacity occurs when agencies do
not intentionally seek to be culturally
destructive but rather have no capacity
to help clients from other cultures.
|
These
agencies may apply resources disproportionately,
discriminate against individuals, and
believe in the supremacy of the dominant
culture. Such agencies may act in a negative
manner by enforcing policies which deny
services to people and maintain stereotypes.
Such agencies are often characterized
by ignorance and an unrealistic fear of
people who are different.
One
example of cultural incapacity was described
in a study published in the Journal of
the American Medical Association.7
This study found that Hispanics who were
treated for certain bone fractures at
the UCLA Emergency Medicine Center were
twice as likely as non-Hispanic whites
to receive no pain medication. The precise
reason for this was not specified, but
the investigators identified failure on
the part of hospital staff to recognize
pain in Hispanic patients as a possible
reason for the discrepancy.
| Culturally-blind
agencies are characterized by...a
well-intended philosophy: however,
the consequences of such a belief
can often camouflage the reality
of ethnocentrism, ... |
|
Cultural
Blindness, the predominant
system in place today, involves agencies
and organizations providing services
with the express philosophy of being
unbiased. They function with the belief
that color or culture makes no difference
and that all people are the same.
Culturally-blind agencies are characterized
by the belief that all helping approaches
traditionally used are universally
applicable. If the system works as
it should, all people — regardless
of race or culture — will be
served with equal effectiveness. This
view reflects a well-intentioned philosophy.
The consequences of such a belief,
however, can often camouflage the
reality of ethnocentrism, making services
so ethnocentric as to render them
useless to all but the most assimilated
people from other cultures. |
A
simple example of cultural blindness was
the light tan bandage that for years was
sold as "flesh colored." It
was, but only if you were a fair-skinned
white person.
Culturally-blind
agencies suffer from a deficit of information
and often lack the avenues through which
they can obtain needed information. While
these agencies often view themselves as
unbiased and responsive to the needs of
minority people, their ability to effectively
serve these patient populations may in
fact be severely limited.
| As
agencies move toward the positive
end of the scale they reach a position
called Cultural Pre-Competence.
This term implies movement towards
reaching out to other cultures. The
pre-competent agency realizes its
weaknesses in serving some communities
and attempts to improve some aspect
of its services to a specific population.
|
|
Cultural
Pre- Competence... implies movement
towards reaching out to other cultures.
|
| Such
agencies experiment with hiring staff
who reflect a different culture, exploring
how to reach underserved populations
in their service areas, initiate training
for their workers on cultural sensitivity,
enter into needs assessments concerning
minority communities, and recruit
minority individuals for their boards
of directors or advisory committees.
Efforts at minority hiring and recruitment
at the nation's medical schools in
the 1970s are an example of this initial
stage of cultural understanding. Pre-competent
agencies are characterized by the
desire to deliver high-quality, cost-effective
services, and have a commitment to
civil rights. They respond to the
needs of racial/ethnic communities
for improved services by asking, "What
can we do?" |
|
Pre-competent
agencies are characterized by the
desire to deliver high-quality, cost-effective
services, and have a commitment to
civil rights. |
| One
danger at this level, however, is
a false sense of either accomplishment
or of failure that prevents the agency
from moving forward along the continuum.
An agency may believe that the accomplishment
of one goal or activity fulfills its
obligation, or conversely, it may
undertake an activity that fails and
become demoralized and reluctant to
make another attempt at improving
its health care delivery to the targeted
community. |
|
|
| Culturally
Competent agencies are characterized
by acceptance of and respect for difference,
continuing self- assessment regarding
culture, careful attention to the
dynamics of differences, continuous
expansion of cultural knowledge and
resources, and adaptations of service
models in order to better meet the
needs of different racial and/or ethnic
groups. Such agencies recognize and
value groups as distinctly different
from one another and as having numerous
subgroups, each with important cultural
characteristics. |
|
Culturally
competent agencies are characterized
by acceptance of and respect for difference.. |
Culturally
competent agencies work to hire unbiased
employees and seek advice and consultation
from their clients. These agencies seek
staff who represent the racial and ethnic
communities being served and whose self-analysis
of their role has left them committed
to their community and capable of negotiating
a diverse and multicultural world. These
agencies also provide support for staff
to become comfortable working in cross-cultural
situations. Further, culturally competent
agencies understand the interplay between
policy and practice, and are committed
to policies that enhance services to a
diverse clientele.
| ...Cultural
Proficiency... is characterized by
holding culture in high esteem. |
|
The
most positive end of the scale is
Cultural Proficiency.
This culmination point on the continuum
is characterized by holding culture
in high esteem. Culturally proficient
agencies seek to add to the knowledge
base of culturally-competent practices
by conducting original research, developing
new therapeutic approaches based on
culture, and publishing and disseminating
the results of their research and
demonstration projects. |
Culturally
proficient agencies hire staff who are
specialists in culturally competent practice.
Such agencies are expansive, advocating
for cultural competence throughout the
health care system and for improved relations
between cultures.
I.
The Basics Chapter Three: On Language
¡Si
puedes leer esto, ya vas por buen camino!
(“If
you can read this you’re headed
in the right direction!”)
According
to an article in the Journal of
the American Medical Association
(JAMA), "The physician-patient
relationship is built through communication
and the effective use of language.
Along with clinical reasoning, observations,
and nonverbal cues, skillful use
of language endows the [physicianpatient]
history with its clinical power
and establishes the medical interview
as the clinician's most powerful
tool."8
|
|
"The
physician-patient relationship is
built through communication and
the effective use of language."
|
Growing
numbers of Americans are proficient in
two or more languages or at least have
chosen to study a language other than
English. In addition, there are some 32
million Americans who speak a language
other than English at home. Spanish is
the main "other language" spoken
in the United States. A majority of Hispanics
in the United States are bilingual and
likely to retain their Spanish language
skills as their communities are replenished
with new Spanish speaking immigrants.
Although only 24% of Hispanics were born
outside the United States and the Commonwealth
of Puerto Rico, 77% report Spanish as
their primary language and the language
they speak at home.
Interfacing
with Hispanics, appreciation of the Spanish
language, and the different accents, idioms,
and meanings within different Spanish-speaking
sub-groups, are crucial to becoming culturally
competent.
Language
is a communication tool by which cultural
meaning is transferred and its complexity
understood. When understanding language
from this perspective, it is important
to differentiate its layers. In it's simplest
form, each word has a meaning. The combination
of words within a particular context takes
on a specific cultural meaning.
| The
initial stage of language development....may
not be effective in communicating
health beliefs, core values, or
a description of symptoms. |
|
The
initial stage of language development
is direct translation of words with
their literal meaning. However, this
level of language may not be effective
in communicating health beliefs, core
values, or a description of symptoms.
As a result, language differences
and the width of the gap pose a challenge
to both the patient and provider in
health care communication. This is
not to say that some form of quality
care cannot be achieved even with
the most extreme language differences.
|
|
Beliefs, values, and behaviors are
influential in determining the patient’s
assessment of satisfaction with
care and compliance to treatment.
|
|
Quality care has various
components. Two important components
that may be influenced by language
are medical care and psychosocial
care. In medical care, many health
problems today are diagnosed with
specialized tests such as blood analysis,
Magnetic Resonance Imaging (MRI),
CAT Scans, etc. Standardized treatments
typically are associated with the
diagnosis. Thus, language differences
beyond the description of symptoms
are less likely to present problems
from the purely medical model. However,
quality health care should involve
psychosocial care as well. Beliefs,
values, and behaviors are influential
in determining the patient’s
assessment of satisfaction with care
and compliance to treatment. |
|
One can learn to speak a language
without learning how to use the
language to reflect culture.
|
|
To fully understand the complexities
of language and culture one has to
examine the layer of language development.
Primary language development, the
first learned language, provides relational
meaning to words and phrases that
reflect culture. Secondary language
development, or learning a second
language may not provide the speaker
with the idiomatic expressions or
cultural meanings specific to location
and ethnicity. One can learn to speak
a language without learning how to
use the language to reflect culture.
|
Cultural
competence is not necessarily indicated
by one's ability to speak the language.
A provider or a patient may be able
to literally speak the same language
but the effectiveness of that communication
is influenced by the cultural exposure
that fosters command of the meaning
of the words and phrases. A patient/provider
that do not share any language knowledge
will have more challenges to quality
care than those who have learned
the other's language (secondary
language development). However,
that relationship will be more facile
in a patient/provider who share
the same primary language development.
|
|
A
patient/provider that do not share
any language knowledge will have
more challenges to quality care
than those who have learned the
other's language. |
Language
differences can also interfere with aspects
of the medical model. Subjective diagnosis
or assessing which modality to test for
a medical diagnosis is influenced by the
patient’s description of the symptoms.
What the patient says and how they say
it, facilitates the appropriate diagnosis.
Without the element of communication,
quality care can be obtained, but it is
challenged. The patient can become frustrated,
does not return or is unable to comply
with treatment. The physician/provider
can misdiagnose and incorrectly treat
the patient as well as expend additional
costs to appropriately determine the problem.
There
is a growing number of health care
professionals who care for America’s
multi-ethnic, multi-racial, and
increasingly multilingual society.
According to the Census Bureau,
at least 14% of the nation's population
now speaks a language other than
English in their home. In major
cities including New York, Los Angeles,
Miami, Honolulu, Newark, and El
Paso, Texas, the figure is over
40%. Some 7 million persons in the
United States do not speak English
well, or at all. Spanish, as stated
earlier, is the second most common
language in the United States, and
the language of over half of the
nation's non-English speakers.9
|
|
...at
least 14% of the nation's population
now speaks a language other than
English in their home.
Spanish,
... is the language of over half
of the nation's non-English speakers.
|
| |
|
In
addition, direct translations of English
into other languages without a cultural
awareness of the meaning, idioms,
slang usage, and various contexts
in which those languages are used,
can lead to confusion and miscommunication.
A humorous example involved an insecticide
ad that ran in the 1980s. Recognizing
the value of the growing Hispanic
market, the company promoted its product
in Spanish-language ads as guaranteed
to kill "bichos." What they didn't
realize is that while bichos means
bugs or insects in Mexico, in Puerto
Rico it's understood to refer to the
penis. Needless to say, they didn't
have a lot of sales in San Juan. Similarly
GM's Spanish language ads for the
Chevy Nova were received with great
hilarity by their target audience.
The company hadn't considered that
in Spanish "No va" means "It doesn't
go." |
...having a language-concordant physician
resulted in better outcomes for well-being
and functioning. |
|
But in a health setting language differences
can have some very deleterious effects.
In one study "The Effects of Ethnicity
and Language on Medical Outcomes of
Patients with Hypertension or Diabetes,"
Dr. Perez-Stable et. al. found that
for Spanish-speaking patients, having
a language-concordant physician resulted
in better outcomes for well-being
and functioning. Monolingual Spanish-speaking
patients were more likely to ask more
questions and had a better understanding
with physicians who also spoke Spanish.10
|
The communications difficulties associated
with language differences have also
made for some tricky legal arguments.
|
|
The communications difficulties associated
with language differences have also
made for some tricky legal arguments.
Legal advocates for Hispanic and other
limited English proficient (LEP) people
seeking full and competent access
to health care, education, and other
resources have traditionally worked
to advance their cause using Title
VI of the Civil Rights Act of 1964.
This act states, "No person in the
United States shall, on ground of
race, color, or national origin, be
excluded from participation in, be
denied the benefits of, or be subjected
to discrimination under any program
or activity receiving Federal financial
assistance." (such as Medicare, Medicaid,
and Hill-Burton funds).11
|
The
Civil Rights Act can be helpful on issues
relating to protecting the rights of limited
or non-English speakers. Title VI, according
to the Department of Health and Human
Services Office of Civil Rights, assures
that language be taken into account in
the provision of health and hyman services.
This is particularly important with issues
of informed consent.
The
Joint Commission on Accreditation
of Hospitals explains the doctrine
of informed consent this way: "The
patient has the right to reasonable
informed participation in decisions
involving his health care. To the
degree possible, this should be
based on a clear, concise explanation
of his condition and of all proposed
technical procedures, including
the possibilities of any risk of
mortality or serious side effects,
problems related to recuperation,
and probability of success. The
patient should not be subjected
to any procedure without his voluntary,
competent, and understanding consent
or the consent of his legally authorized
representative."12
|
|
Informed
consent must be obtained. |
| Unfortunately
it is not possible to get a thorough
patient history or give information
to the patient required for informed
consent when the patient and his or
her health care provider do not speak
the same language. But solutions can
be found. Providers should also appreciate
that in addition to being a medical
necessity, serious efforts to accommodate
Limited English Proficient (LEP) patients
also makes good business sense as
the following care study will illustrate.
|
|
Providers
should also appreciate that in addition
to being a medical necessity, serious
efforts to accommodate Limited English
Proficient (LEP) patients also makes
good business sense. |
A
Kaiser Permanente Journal report found
that, "communication failures between
patient and physician are a significant
factor in a patient's decision to sue..."13
and a more recent review of Harvard University-affiliated
health care institutions, employees, and
physicians found that, "12% of their
total claims involved communication failure
as the key risk management issue."14
...concept
of linguistic accommodation in clinical
and human service settings, even
without the impetus of law, is easy
to support as a common sense approach,
smart business, and ethically responsible.
|
|
Of
course, the concept of linguistic
accommodation in clinical and human
service settings, even without the
impetus of law, is easy to support
as a common sense approach, smart
business, and ethically responsible.
It's the development of practical
means for realizing this accommodation
that poses a great challenge to health
care professionals. |
In
interviews conducted with experts in the
field of addressing language barriers
in health care settings, six approaches
were identified to bridge the gap of cultural
and linguistic barriers for effective
health service delivery.15
Having
identified these approaches, an in-depth
assessment of health care facilities was
conducted to determine to what extent
they were using these existing approaches
to address language barriers, and to gather
advice from them on ways to improve their
communication with non-English speaking
clients.16
The
assessment focused on 80 health care facilities
serving 15 communities with significant
Hispanic populations. Of the 80 health
care facilities surveyed, 78 percent have
a stated policy of hiring bilingual/bicultural
professional staff; 43 percent use a language
bank; 26 percent encourage language training;
23 percent hire trained interpreters;
16 percent use phone-based interpretation;
and 13 percent use written translators.
Six
Approaches for Bridging Language Barriers
Each
method and key aspects are listed below
in order from most effective to least
effective.
| 1.
Bilingual/Bicultural Professional
Staff
- Recruit
and retain bilingual/bicultural
staff at all levels of the organization.
- Provide
significant additional compensation
for bilingual ability.
2.
Interpreters
- Establish
minimum standards for interpreter
training, competency, and other
continuing education efforts.
- Make
a concerted effort to increase
and foster medical interpreter
training through national conferences,
information clearinghouses, technical
assistance, and start-up grants.
- Provide
courses designed to train providers
to work with interpreters.
- Use
only trained medical interpreters.
- Reimburse
for interpreter services.
3.
Language Skills Training for Existing
Staff
- Support
the development of bilingual skills
for all staff members.
- Establish
clear goals and realistic expectations
for Spanish language courses,
including idioms.
- Offer
classes in medical Spanish to
all staff.
- Utilize
training programs that have a
demonstrated track record in increasing
the bilingual level or the interpretation
quality of services provided.
4.
Internal Language Banks (Only as
a back-up measure)
- Hire
supervisors to assess the language
and interpretation capabilities
of language bank members, to provide
minimal interpreter training,
and to regularly assess the quality
of the language bank program.
• List interpretation as
a secondary responsibility of
language bank members so that
supervisors of these staff members
understand why they may spend
time away from their regular duties.
- Compensate
language bank members who do a
significant amount of interpretation.
5.
Phone-Based Interpreter Services
(Emergency back-up measure for brief
follow-up questions only.)
- Inform
health care providers that phone-based
interpreters may not be proficient
in medical terminology. •
Use simple or common terms when
using phone interpreters.
6.
Written Translators (Emergency stop-gap
measures, never as the sole means
of communication)
- Develop
mechanisms to promote the sharing
of bilingual written materials,
such as consent forms and patient
education pamphlets.
|
|
Six
Approaches
1)
Bilingual/Bicultural Professional
Staff
2)
Interpreters
3)
Language Skills Training for Existing
Staff
4)
Internal Language Banks
5)
Phone-Based Interpreter Services
6)
Written Translators |
| Do
not use patient’s relatives,
especially those younger.
Do not use support or janitorial
staff who’s primary job is
not translation!
|
|
Two
common approaches to resolving language
differences are so detrimental that
they warrant "Don't Statements."
Do
not use patient's relatives, especially
those younger.
Do
not use support or janitorial staff
who's primary job is not translation!
|
| Antonia
M. Villarruel Ph.D., an assistant
professor at the University of Pennsylvania
School of Nursing recommends a seventh
approach to overcoming language
barriers through the use of "cultural
mediators." "Cultural
mediators form part of the health
care team, working closely with
medical and nursing staff,"
she writes. "In addition to
medical interpreting, the cultural
mediator interprets the cultural
and social circumstances that may
affect care. This enables providers
to gain a more comprehensive understanding
of patients needs, and to negotiate
culturally appropriate plans of
care."17
|
|
Use
of "cultural mediators"
is also recommended. |
|
Cultural mediators often can bridge
the gap created by language differences.
They can also assist in getting
to know the culture and to foster
trust.
Providers
who follow the programmatic approach
outlined above can qualitatively
improve their ability to interact
effectively with patients/clients
whose dominant language is one other
than English. But language, of course,
is only a first step to understanding
culture and the positive role it
can play in the delivery of effective
health care. |
|
..language of course, is only a first
step to understanding culture and
the positive role it can play in the
delivery of effective health care.
|
In working with Hispanic patients
language can be such an obvious barrier,
challenge, and point of identity that
it can sometimes obscure other more
subtle aspects of cross-cultural understanding.
These essential cultural aspects can
involve interactions as simple as
conversational gambits and spatial
(physical space) relationships, along
with larger institutional issues such
as family visiting hours, patient
education, and measuring individual
responses to pain. Being aware and
understanding the cultural context
for these interactions can be a tremendous
asset to you as a health care professional,
and in your ability to deliver effective
care, regardless of language. |
|
... language can be such an obvious
barrier, challenge, and point of identity
that it can sometimes obscure other
more subtle aspects of cross-cultural
understanding. |
|
