Addressing Oral Health Care Disparities: The Role of Patient Communication

Virginia J. Dodd, PhD, MPHDepartment of Community Dentistry and Behavioral Science

ObjectivesFollowing today’s presentation participants

will be able to:1. Discuss the relationship between health

literacy and health disparities.2. Describe the role of attitudes, values, and

beliefs in oral health-care seeking behaviors.

3. List common access barriers faced by individuals when accessing oral health care.

4. Define culturally appropriate patient communication strategies.

Health LiteracyThe degree to which individuals have the

capacity to understand basic health information and services needed to make appropriate health decisions.◦ Includes the ability to

identify what information is needed understand and interpret the information in order to

access health care.

Males with low oral health literacy were more likely to not show for dental treatments1

◦ Dental treatment was a low priority Not serious Can wait

Health LiteracyLow health literacy is more

prevalent among individuals who are ◦Sicker◦Older◦Poorer◦Minority population member

Health LiteracyNearly 50% of all American

adults have limited functional health literacy.◦Translates into

Difficulty understanding medical terms Following treatment instructions Engaging in a dialogue about

medical/dental condition Difficulty with patient

information/education handouts

Health LiteracyLimits the patient’s ability to ask

questions◦Difficult to ask meaningful questions

about something you do not understand.

◦Don’t want to be judged as “that kind of patient” … ignorant, not smart.

Health LiteracyIndividuals with low oral health

literacy have difficulty understanding the risks and benefits of health decisions◦This affects one’s beliefs and

attitudes toward oral health.

Assessing Health Literacy2

Cannot tell by looking.ASK in a non-threatening manner

◦How often do you need to have someone help you when you read instructions, pamphlets, or other written health information such as from your doctor or pharmacist?

◦How confident are you when filling out medical or dental forms by yourself?

Oral Health Care Seeking: Patient Attitudes, Values, and BeliefsTime orientation

◦Past, Present, FutureLow SES associated with PRESENT

orientation◦Future plans unlikely

Effects of today’s behavior on future health not fully considered Long term effects of edentulism

“I have no money today. I won’t have it tomorrow. I won’t have it next year.”

“I don’t bother booking appointments 5 to 6 months in advance because I won’t even be able to remember the appointment, let alone keep it.” 13

Oral Health Care Seeking: Patient Attitudes, Values, and Beliefs

Quality of life issues rarely discussed with dental patients.

Common belief that loss of teeth is a natural part of aging.

Value of dental esthetics varies.◦Spending a lot of money of your

teeth takes away from your family.◦No pain- no urgency◦Can’t afford- can get me into a bad

situation

Oral Health Care Access BarriersDifficulty cancelling the appointment

◦No phone◦“Trouble getting through”

Long time periods between appointments◦“They drag it out to get more money.”

Conflicting time commitmentsDisrupted school/work scheduleLack of trust in health care systemHealth issuesDifficulty leaving work

◦ Individual or family member – lost wages

Oral Health Care Access BarriersTransportation cost/reliabilityChildcare cost/reliabilityTravel time/distanceDental fear

◦ Being judged (“I have bad teeth so I am embarrassed to go.”)

◦ Unintentional/unexpected debt◦ Not understanding/ not knowing what to ask◦ Fear of the procedure

Satisfaction with previous treatment (dental and personal)

Finances/payment system

Oral Health Care Access BarriersLong wait times

◦“I can’t be late, BUT THEY CAN.”Multiple appointments magnify the

difficulties and introduce greater probability for difficulties in attending.

Stigma of Medicaid◦Perception is reality.◦Know our personal biases.◦Providers and staff should be cognizant of

this barrier.

Oral Health Care Seeking: Patient Attitudes, Values, and Beliefs

Most patients, regardless of race/ethnicity, believe that healthcare personnel do not respect them.

Patient CommunicationIndividuals and cultural groups

that have experienced oppression, consistent disrespect, or minority status may place a much higher priority on being treated with respect first, earning trust second, and then, possibly, a personal relationship.

Cross-Cultural CommunicationThe most important factor in

cross-cultural communication cited by African American, Asian, and Latino patients:◦The health care providers display of

concern, courtesy and respect.6

Cross-Cultural Communication Approach7

Goal is to understand the patient’s needs, values and preferences.

Regarding treatment, routinely ask what matters most to them.

Relies on identifying and negotiating ◦different styles of communication◦decision-making preferences◦roles of family, sexual, gender issues◦issues of mistrust, prejudice, and

racism.

Patient-Centered Communication5

Characterized by communication that:◦elicits and understands the patient’s

perspective and social context◦Reaches a shared understanding of

the problem and its treatment◦Involves patients in choices to the

extent they desire.

Patient CommunicationRecognize preconceived perceptions

about different groups.2

Improve your awareness and sensitivity to “others”. 2

◦No one is immune from unconscious bias and “othering.“ 3

Ask yourself:◦How do I differ from my patients? 2

Risk stereotyping by assuming that all members of a group hold the same beliefs. 2

Patient CommunicationPatients stereotype practitioners

through previous experiences with health care inequities or past unfavorable interactions with doctors/staff. 2

Ask yourself, “How would a patient stereotype me?”

Culturally Competent and Effective Communication

Acquire knowledge about specific cultural groups (religious customs, explanatory models of disease, etc.)

Skills and attitudes that are not specific to any particular group (delivering individualized care and developing appropriate rapport.)

Patient CommunicationSome providers believe “other”

patients are not interested in shared decision-making or being fully informed about treatment.◦AHRQ Survey: Black and Hispanic

patients were less likely to be asked their preferences in treatment decisions.

◦Dodd, Logan, Catalanotto interviews and 2014 DEN 5221 Interviews (N=225): Less than 1% report ever being asked how

they would like their smile to look

Patient CommunicationOften patients do not realize that

there are decisions to be made– or that they are allowed to ask questions.◦Some cultures believe questioning

someone in authority is disrespectful. “Other” individuals believe it is fruitless. Minority patients are less likely to ask

questions.

◦Encourage patients to ask questions.◦Tell them YOU expect them to ask

questions and to let you know if you have answered them appropriately.*

Patient CommunicationShared decision-making for

patients with low health literacy require◦Patience◦Audiovisual decision aids

Available data suggest that minority groups may benefit most from shared decision-making.4

Patient CommunicationKey Issue

◦Address the patient’s fear and anxieties Explore the patient’s concept of their

problem. This can provide the information needed to

bridge the gap between their understanding of the problem and the biomedical explanation.

Explore the patient’s concept of their problemThe patient wants all of their

pulled for dentures.◦Explore the patient’s concept of their

problem: The patient thinks restorative care will

only postpone the inevitable loss of teeth and sees dentures as proactive behavior.

Based on the belief that edentulism is inevitable the patient sees the restorative treatment plan as a way for the dentist to make more money. Restorative treatment plan: “I pay twice.”

Explore the patient’s concept of their problemWhat is your understanding

about having your teeth removed and wearing dentures for the rest of your life?◦“I think we need to talk about your

quality of life.”

Patient Communication TipsIf the patient can read give them

instructions in writing.Use the “Teach Back Technique” to

confirm understanding:◦ I want to make sure I have explained things

correctly. Can you tell me how you plan to take care of your extraction site over the next seven days?”

◦ I want to make sure I have done a good job explaining things to you. When you go home tonight and tell your spouse about today’s visit what will you say?”

Cross Cultural Communication TipsUS main stream culture tends to be

more direct and open than other cultures.8

Among Latinos silence may indicate disagreement or lack of understanding.9

◦Not appropriate to question health care providers.

Asian societies are low touch- explain examinations prior to performing them.10

◦Orthodox Jews, some Islamic sects opposite sex touching may be prohibited.

Cross Cultural Communication TipsAsian and Latino individuals may

prefer less personal space than Anglo individuals.10

In some cultures avoiding eye contact may be a sign of respect related to sex or social status.10

Having a basic understanding of English is not sufficient for a patient to understand health care information. Use interpreters when needed. 11

Cross Cultural Communication TipsElicit the patient’s explanatory

model◦Assure understanding of treatment

plans- especially for patients with low health literacy or language barriers.

Six Steps to Improve Patient Communication12

1. Slow down.2. Use plain, non-medical language.3. Show or draw pictures.4. Limit the amount of information

provided.5. Use the teach-back technique to

confirm understanding.6. Create a shame-free environment;

encourage questions.

Culturally Competent Communication Techniques

Taking sufficient time◦ Be attentive to the patient◦ Be present in the encounter

Apologizing for being busyAnswering questionsProviding explanationsActing interested in the patient

◦ Connect with the patient Active listening Curious without making quick assumptions Eliciting patient perspectives Empowering the patient to make decisions

Patient Communication: Non-verbal CuesWhat does the clothing and body

language communicate?Strong emotions such as fear,

sadness, pain, and anxiety are usually apparent in the patient’s facial expression and/or body language.

Consider: How does your behavior affect the patient and the patient encounter?◦Are they mirroring you?

Patient CommunicationMaster techniques to effectively

explain treatment plans to patients with low health literacy.2

Mutually acceptable treatment plans must encompass acknowledgment of patient health beliefs (often based on cultural norms).

Patient Communication7

The key to cultural competence is patient centeredness which is built on◦Respect◦Sensitivity◦Composure◦Partnership◦Honesty◦Astuteness◦Curiosity◦Tolerance

All people really care about is being cared about…

especially when feeling cared about is rare.

Questions?

1. Holtzman JS, Atchison KA, Gironda MW, Radbod R, et al. The association

between oral health literacy and failed appointments in adults attending a university-based general dental clinic. Community Dent Oral Epidemiol 2013.

2. Misra-Hebert AD, Isaacson JH. Overcoming health care disparities via better cross-cultural communication and health literacy. Cleveland Clinic Journal of Medicine 2012; 79 (2): 127-133.

3. Dharamsi S. Moving beyond the limits of cultural competency training. Medical Education 2011; 45: 764-766.

4. Rothman, Clark 20115. Teal CR, Street RL. Critical elements of culturally competent

communication in the medical encounter: A review and model. Social Science & Medicine 2009; 68: 533-543.

6. Murray-Garcia 20007. Epner DE, Baile WF. Patient-centered care: the key to cultural

competence. Annals of Oncology 2012; 23(S3): iii33-iii42.8. Kohls LR. The values Americans live by.

http://www.uri.edu/mind/VALUES2.pdf Accessed May 7, 2014.9. Givaudan M, Pick S, de Venguer MT, et al. Bridging the

communication gap: Provider to patient written communication across language and cultural barriers. Hablamos Juntos. October 2002.

10.Juckett G. Cross-cultural medicine. Am Fam Physician. 2005; 72: 2267-2274.

11.Tripp-Reimer T, Choi E, Kelley LS, et al. Cultural barriers to care: Inverting the problem. Diabetes Spectrum. 2001; 14:13-22.

12.Weiss BD. Health literacy and patient safety: Help patients understand. 2nded. American medical Association Foundation and American Medical Association. http://med.fsu.edu/userFiles/file/ahec_health_clinicians_manual.pdfAccessed May 1, 2014.

13. Askelson NM, Chi DL, Hanson JD, Ortiz C, et al. Preventive dental care utilization for preschool–aged children in Medicaid: Parents’ perceptions and experiences with Medicaid dentists. Journal of Theory and Practice of Dental Public Health. 2013; 1 (3): 26-31.