Cultural Competency in Cultural Competency in Health Care ProfessionalsHealth Care Professionals

Waugh E, PhD; Triscott J, MD, CCFP; Waugh E, PhD; Triscott J, MD, CCFP; Szafran O, MHSASzafran O, MHSA

Division for Care of the ElderlyDivision for Care of the Elderly

Centre for Cross-Cultural Study of Health Centre for Cross-Cultural Study of Health and Healingand Healing

Department of Family Medicine, University of Department of Family Medicine, University of AlbertaAlberta

Learning ObjectivesLearning Objectives

• To be aware of the importance of cultural competency in healthcare providers

• To be aware of pre-assessment tool for assessing cultural competency in healthcare professionals

• To learn about the research of the pre-assessment cultural tool given to healthcare professionals in Northern Alberta

Dementia Dementia

• Prevalence of dementia is doubling every 5 years of increase in patients’ age and this rate will increase by 50% during the next 25 years (Hofman 1991,Ernst 1994)

• Investigators believe that age-specific prevalence of dementia is similar throughout the world (White,1992)

• Prevalence of dementia and depression among elders from several different ethnic minority groups in the UK is similar or higher than among indigenous elders (Khatnagar and

Frank,1997,Lindesay et 1997a,McCracken at al 1997, Livingston et al , 2001).

Utilization of Services for Dementia Utilization of Services for Dementia

• Ethnic minorities from major studies are underrepresented in both inpatient and outpatient settings and in the use of mental health services. (Matsuoka, 1990, Sue, 1994)

• Caregivers in ethnic minority communities use fewer services than white caregivers (US Congress, Office of Technology Assessment, 1990; Yeo, Gallagher_Thompson,& Lieberman. 1996)

• Certain groups have shown shame or stigma attached to mental illness e.g. depression , dementia (Browne, Fong & Mokuau,1994;Sue, 1994;Takamura,1991)

Diagnosis of DementiaDiagnosis of Dementia

• Ethnic minorities elderly are more likely to receive the diagnosis of Dementia at later stages of the disease , following a long and debilitating course ( Gallagher-Thompson et al, 1997,Guo et

al,2000, Hinton et al 2000)

Therefore, less likely to access early interventions and benefit from available treatments.

Cultural Competency Education for Cultural Competency Education for of Health Professionalsof Health Professionals

Health Care professionals are often not aware of disparity in services provided to ethnic minorities and may have different levels of cultural competency.

Survey of Family Medicine Residency programs revealed that only 28% had formal diversity curriculum in place: the remaining 72% had either an informal curriculum or none at all (Culhane-Perak, 2000)

Importance of Cultural Competency Importance of Cultural Competency for Health Care Professionalsfor Health Care Professionals

• Canadian Consensus Conference on Dementia (Paterson et al,1999)

• Conclusion 34: Family Physician need to be aware of the cultural impact on families; recognition and acceptance of issues of dementia in a family members, and that more in-depth discussion about symptoms and the meaning of aging may be required (Grade B, Level 3,

Consensus (Pollitt,1996).

Cultural Sensitive Services Cultural Sensitive Services

• With better cultural awareness, one can design and implement appropriate sensitive and affective Dementia education and treatment programs for patients in our communities (Jones 2006)

Toward Culturally Responsive Toward Culturally Responsive Care in the Community: Care in the Community:

Self Assessment of Cultural Self Assessment of Cultural Competency for HealthCompetency for Health Care Care

ProfessionalsProfessionalsWaugh EWaugh E, PhD;, PhD; Triscott J Triscott J, , MD, CCFP;MD, CCFP;

Szafran OSzafran O, MHSA, MHSADivision for Care of the ElderlyDivision for Care of the Elderly

Centre for the Cross-Cultural Study of Health and Centre for the Cross-Cultural Study of Health and Healing Healing

Department of Family Medicine, University of Alberta Department of Family Medicine, University of Alberta

BackgroundBackground• Canada’s rapidly developing diversity - circa

250,000 immigrants annually• Health Canada report (2001) identified cultural

competence as being essential for quality of health care delivery .

• UBC –Introduced “Cultural Competence Module” in Division of Health Care Education – 2003.

• Phase 1 of our study identified cultural competence of health care professionals as key issue in health care delivery in 3 of 4 communities surveyed.

PurposePurpose

• To describe the self-assessment of

cultural competency of health care

professionals working in five northern

Alberta ethnic communities.

MethodsMethodsDesign

• Self–administered questionnaire survey

• Health care professionals invited to culturally responsive care Workshop

Participants

• Health care professionals (physicians, nurses, social workers, dentist) working in five communities in northern Alberta

• Identified by facilitators in the respective communities

• n = approx. 60

Communities First Nations (Cree) → Wabasca Mandarin-speaking Chinese → Edmonton Cantonese-speaking Chinese → Edmonton Francophone → McLennan

Muslim → Lac La Biche

Questionnaire: • “Clinical Cultural Competence Questionnaire” (adapted from

Self-Assessment models in US National Center for Cultural Competence, (modified for Alberta content)) assessed:

1. socio-cultural knowledge 2. skill in dealing with socio-cultural issues3. comfort with cross-cultural patient encounters4. attitude (awareness, importance)5. training in cultural diversity

• Utilized five-point rating scale: 1=Not at all, 2= A little, 3=Somewhat, 4=Quite a bit, 5 =Very Much

• All practitioners completed questionnaires before workshops.

Results Results – – 41 returned questionnaires41 returned questionnaires

Knowledge Level n=41 (%)

Health Professionals’ KNOWLEDGE about … Not At All/A Little

Somewhat Quite a Bit/Very

1. Demographics of diverse racial/ethnic groups 22.0 43.9 34.1

2. Sociocultural characteristics of diverse racial/ethnic groups

19.5 48.8` 31.7

3. Health risks experienced by diverse racial/ethnic groups (n=40)

17.5 42.5 40.0

4. Health disparities experienced by diverse racial/ethnic groups

24.4 34.1 41.5

5. Sociocultural issues in: Geriatrics Psychiatry (n=37) Women’s Health (n=37)

9.8 32.4 18.9

34.1 35.1 40.5

56.1 32.4 40.5

6. Ethnopharmacology 53.7 31.7 14.6

7. Different healing traditions (n=40) 30.0 40.0 30.0

8. Historical and contemporary impact of racism, bias, prejudice & discrimination in health care experienced by various population groups in Canada

19.5 48.8 31.7

Knowledge Level n=41 (%)

Health Professionals’ KNOWLEDGE about … Not At All/ A Little

Somewhat Quite a Bit/Very

8. Providing culturally sensitive clinical preventative services (n=39)

25.6 28.2 46.2

9. Providing culturally sensitive end-of-life care (n=39) 23.1 25.6 51.3

10. Assessing health literacy (n=39) 20.5 43.6 35.9

11. Working with medical Interpreters (n=39) 20.5 41.0 38.5

12.Dealing with cross-cultural conflicts relating to diagnosis/treatment

29.3 39.0 31.7

13.Dealing with cross-cultural adherence/ compliance problems (n=40)

22.5 47.5 30.0

14.Dealing with cross-cultural ethical conflicts (n=39) 30.8 43.6 25.6

15.Apologizing for cross-cultural misunderstanding or errors (n=38)

28.9 36.8 34.2

Knowledge Level n=41 (%)

Health Professionals’ SKILL in dealing with …. Not At All/A Little

Somewhat Quite a Bit/Very

1. Greeting patients in a culturally sensitive manner 7.3 36.6 56.1

2. Eliciting the patients perspective about health and illness

17.1 34.1 48.8

3. Eliciting information about the use of folk remedies and/or alternative healing modalities (n=40)

37.5 25.0 37.5

4. Eliciting information about the use of folk healers and/or alternative practitioners (n=40)

40.0 30.0 30.0

5. Performing a culturally sensitive physical examination (n=39)

25.6 38.5 35.9

6. Prescribing/negotiating a culturally sensitive treatment plan (n=40)

30.0 35.0 35.0

7. Providing culturally sensitive patient education/ counseling (n=39)

23.1 33.3 43.8

Comfort LevelPercent

Health Professionals’ COMFORT with … Not At All/A Little

Somewhat Quite a Bit/ Very

1. Caring for patients from culturally diverse backgrounds

12.2 9.8 78.0

2. Caring for patients with limited English proficiency

7.3 22.0 70.7

3. Caring for a patient who insists on using/seeking folk healers or alternative therapies (n=40)

12.5 35.0 52.5

4. Identifying beliefs that are not expressed by a patient or caregiver, but might interfere with the treatment regimen (n=39)

17.9 41.0 41.0

5. Being attentive to nonverbal cues or the use of culturally specific gestures that might have different meanings in different cultures (n=40)

27.5 30.0 42.5

6. Interpreting different cultural expressions of pain, distress, and suffering

22.0 31.7 46.3

Comfort LevelPercent

Health Professionals’ COMFORT with … Not At All / A Little

Somewhat Quite a Bit / Very

7. Advising a patient to change behaviours or practices related to cultural beliefs that impair one’s health (n=39)

30.8 35.9 33.3

8. Speaking in an indirect, rather than a direct way, to a patient about his/her illness, if this is more culturally appropriate (n=39)

28.2 41.0 30.8

9. Breaking “bad news” to a patient’s family first, rather than to a patient, if this is more culturally appropriate (n=36)

27.8 36.1 36.1

10.Working with health professionals from culturally diverse backgrounds (n=40)

10.0 17.5 72.5

11.Working with a colleague who makes derogatory remarks about patients from a particular ethnic group (n=39)

48.7 28.2 23.1

12.Treating a patient who makes derogatory comments about your racial/ethnic background

43.6 25.6 30.8

Level of ImportancePercent

Importance of sociocultural issues in interaction with…

Not At All/ A Little

Somewhat Quite a Bit/ Very

Patients

4.9 14.6 80.5

Health professional colleagues

7.3 29.3 63.4

Residents/medical students (n=39)

10.3 28.2 61.5

Staff 4.9 29.3 65.9

Level of Importance

Percent

Awareness of your own… Not At All/ A Little

Somewhat Quite a Bit/ Very

Racial/ethnic/cultural identity (n=39) 2.6 7.7 89.7

Racial/ethnic/cultural stereotypes (n=39)

2.6 10.3 87.2

Biases & prejudices 7.7 15.4 76.9

Level of ImportancePercent

Not At All / A Little

Somewhat Quite a Bit / Very

Importance for health professionals to receive training in cultural diversity or multicultural health care

0.0 14.6 85.4

Amount of training in cultural diversity health professionals previously received in…

College/post secondary education (n=35) 45.7 34.3 20.0

University (n=29) 55.2 31.0 13.8

Medical school 9n=14) 57.1 28.6 14.3

Residency training (n=16) 56.3 25.0 18.8

Continuing professional education (n=36) 30.6 30.6 38.9

LimitationsLimitations• Small sample size

• Mixed group of health professionals

• Generalizability of findings beyond selected communities is unknown (only one specific community within each cultural group)

• Self-reported perceptions

• Subject bias (sensitized to cultural issues)

ConclusionsConclusionsHealth care professionals:

Are aware of issues surrounding cultural competence related to patient care.

Recognize the importance that socio-cultural issues play in interactions with patients, colleagues and students.

Are aware of their own cultural identity, stereotypes, biases and prejudices.

Have received little or no training in cultural competence and indicate a need for formal culturally-sensitive training.

AcknowledgementsAcknowledgements

• This study was funded by the Pallium Project (Phase II) under the aegis of the Primary Health Care Transition Fund, Health Canada.

• Special thanks to Ms. Bunny Bourgeois for administrative assistance on this project.