Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Programs Administered by WellPoint Partnership Plan, LLC, an independent company. © 2012 WellPoint Inc. All rights reserved.

Culturally Competent Medical Communications

V05-08-326

Cultural and Linguistic Webinar

Setting the Stage: Demographics in the U.S. Are Changing Rapidly

Between now and the year 2050, almost 90% of U.S. population growth will come from Asian Americans, African-Americans and Hispanic-Americans.

Today, people of color are already a majority in 48 of the nation’s 100 largest cities.

Today, four states have “minority majorities.” They include: California, Hawaii, New Mexico and Texas.

Five other states: Maryland, Mississippi, Georgia, New York and Arizona have non-white populations around 40%.

Source: “The Emerging Minority Marketplace: Minority Population Growth 1995-2050.” U.S. Census Bureau September 21, 1999.

White Of ColorSource: The Minority Business Development Agency.US Census 2000.

0

50

100

150

200

250

2000

Mill

ions

400

350

300

2050204520402035203020252020201520102005

U.S. Population by White/People of Color: 2000- 2050

2050: White = 52.8%; Hispanic =24.5% Black =14.6%; Asian = 8.1%

In the U.S., People of Color Are Becoming the “Emerging Majority”

Language Barriers Have Direct Implications for Quality, Cost, Safety in Medicine

Limited English Proficiency (LEP) and its related communication problems

Are the most frequent cause of serious adverse events

Lead to increased length of stay, preventable services and costs

LEP, combined with cultural differences and low health literacy, are leading causes of racial and ethnic health disparities

Source: Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press, 2003.

AI/AN = American Indian/Alaska Native.Note: Data are age adjusted.Source: National Center for Health Statistics. National Health Interview Survey. 2005.

Minority Groups (Except Asians) Are More Likely Than Whites to Report Their Health Status As Fair or Poor

62 65

51 5347

62

26 2429 30

3729

12 1120 18 16

8.7

0

20

40

60

80

100

Total White, non-Hispanic

Black, non-Hispanic

Hispanic AI/AN Asian

Excellent/Very good Good Fair/Poor

Percentage of adults age 18 and over, 2005

Economic Burden of Health Inequalitiesin the United States

Findings for Study Period of 2003-2006Combined costs of health inequalities and premature death in the U.S.

$ 1.24 trillion

Eliminating health disparities for minorities would have reduced direct medical expenditures

$ 229.4 billion

Excess costs in direct medical care expenditures due to health inequalities for African Americans, Asians, & Hispanics

30.6 %

Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death

$ 1trillion

*Joint Center for Political and Economic Studies (Researchers and authors: Laves, Gaskin, & Richard)

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Impact of Gender and Minority Status when Communicating with Health Care Providers

Base: Adults with health care visit in past two years.* Problems include understanding doctor, feeling doctor listened, had questions but did not ask.

Percent of adults with one or more communication problems*

What Are the Goals of CLAS Initiatives?

Culturally and Linguistically Appropriate Services (CLAS) : U.S. Department of Health and Human Services, Office of Minority Health

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15

14 CLAS Standards include 4 Federal Mandates required for recipients of federal funds

Goal is to bridge gaps in communication, service and access between:

health care providers & health care system

patients from diverse backgrounds

Federal Law Re: Language Access

1. Title VI of the Civil Rights Act of 1964 Executive Order 13166 “Improving Access to Services with LEP”

(Aug. 2000) DHHS Guidance Re: National Origin Discrimination Affecting

Limited English Proficient Persons (LEP) (August 30, 2003) OCR Case Summaries DHHS CLAS Standards

2. Section 504 of the Rehabilitation Act of 1973

3. The Americans With Disabilities Act

Interpreter Services and Translated Materials Are Not Enough…

Recent Research Show:

Even when interpreter services are available…

Even when the patient is insured…

Language barriers can lead to worse health outcomes

Doctor-Patient conversations are critical to improved health

Patient-empowered medical communication leads to…• Better quality of life• Improved health outcomes

Fernandez, A., Schilling, D., Wharton, E. M., Adler, N., Moffat, H. H., Schemer, Y.,...Carter, A. J (2011). Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: The Diabetes Study of Northern California (DISTANCE). Journal of General Internal Medicine, 26(2), 170-176.

Mali, R. C., Stein, J. A., Manawa, Y., Leaked, B., & Angling, M. D. (2008). Racial/ethnic differences in breast cancer outcomes among older patients: Effects of physician communication and patient empowerment. Health Psychology, 27(6), 728-736

Misunderstandings of Beliefs and Social ChallengesMay Hinder Optimal Medical Care

This Concept Is Obviously Not New, So Why Does the Problem Persist?

“Sociocultural differences between patient and physician influence communications and

clinical decision-making.”

(Eisenberg, 1979)

Factors Affecting the Physician Decision Making Process

Characteristics of the Patient

Age, Sex, Socio Economic Status, Race/Ethnicity, Religion, Insurance, Individual patient factors

Characteristics of the Physician

Specialty, Level of Training, Background

Features of the Practice Setting

Organization of Practice, Compensation, and expectations of productivity

Social Cognitive Theory: Stereotyping

Automatic aspects; group individual

“Cognitive Misers” cognitive shortcuts to save resources; principle of “least effort”

Primal race, gender, age

Activated most when:

Stressed

Under time constraints

Multitasking

Isn’t a Discussion of “Cultures” and “Cultural Norms” Stereotyping People?

Definitions:

Cultural Stereotypes: An oversimplified assumption or image treated as fact for all members of a group.

Cultural Generalizations: The accepted norm within a cultural group, allowing for individual variation.

In stress-free situations, we are fairly adaptable to different approaches to communication and clearing up misunderstandings.

In stress-free situations, we are fairly adaptable to different approaches to communication and clearing up misunderstandings.

In stressful situations, our adaptability is reduced.In stressful situations, our adaptability is reduced.

We revert to our core styles, using the strategies and frameworks that are consistent with our primary environment.

We revert to our core styles, using the strategies and frameworks that are consistent with our primary environment.

This can lead to an increased possibility of misunderstandings and conflict.This can lead to an increased possibility of misunderstandings and conflict.

Tight Time Constraint During the Medical Visit = Communication Barrier

Are There Strategies for Talking with Our Patients More Effectively?

Tip #1:

Understanding and Adapting to

Differences in Communication Styles of

Your Patients

Knowing Your Communication/Conflict Style Can Help You…

Intercultural Conflict Style Model (Hammer)

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DISCUSSIONDISCUSSION ENGAGEMENTENGAGEMENT

ACCOMODATIONACCOMODATION DYNAMICDYNAMIC

IND

IRE

CT

DIR

EC

T

RESTRAINED EXPRESSIVE

Direct and Indirect Communication Dynamics

Direct Style Patterns

• Focus on words: precise, explicit language use

• Logical, linear, factual, goal-oriented arguments

• Present and defend your opinion

• Problem solving approach to conflict resolution

• The speaker is responsible for the message

Indirect Style Patterns

• Analogies, metaphor and non-verbal language convey message

• Prefer use of a mediator

• Discretion in voicing goals

• Non-linear, relational examples, stories instead of facts

• Relationship repair focus

• The listener is responsible for the message

Direct and Indirect Communication Examples

"Say what you mean and mean what you say."

-American Proverb

“It is good to know the truth, but better to

speak of palm trees.”- Arab proverb

Emotionally Expressive and Restrained Communication DynamicsEmotional Expressiveness

• Overt display of emotions

• Maintain calm by letting out emotions

• Emotions are displayed through non-verbals

• Expansive vocalization

• Affective commitment must be demonstrated through actions not stated.

• Emotional display needed for credibility

Emotional Restraint

• Strong feelings are hidden

• Emotions are internalized so that a calm front can be presented.

• Minimal display of emotions through non-verbal behavior.

• Limited variation in vocalizations

• Emotional suppression for credibility

• Trust is built through steadiness of emotions

Emotionally Expressive and Restrained Communication Examples

“What is nearest the heart is nearest

the mouth.” -Irish Proverb

“The first to raise their voice loses the

argument.” - Chinese proverb

US Values (Cultural Tendencies)

Speaking Up

Capitalism

Control

Law & Order

Speed

Equality

Being Oneself

Self-Reliance

Self-Interest

Individual Rights

Directness

Competition

Freedom

Independence

Individual Achievement

Privacy

Hard Work

Fairness

Are There Strategies for Talking to Our Patients More Effectively?

Tip #2:

Understanding and Addressing

Important Cultural Values and Needs

That May Influence the Behaviors of

Your Patients

Culturally Relevant Messaging

What is “cultural competence?” (Betancourt et al., 2002)

Organizational culture

Respects and incorporates into health care delivery

• Cultural background

• Cultural beliefs

• Cultural valuesSource: Betancourt JR, Green AR, Carrillo JE. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.

Culturally Relevant Messaging

What makes something…“culturally relevant”?

• Language?

• Health literacy?

• Imagery?

• What else?

The Five F’s of Cultural Relevance

Food. Affinity to cultural foods and difficulties in changing dietary habits

Participants asked for specific information on how “traditional foods” (e.g. “Soul food” or “Mexican food”) can be made healthier

Resources should reflect real life – fast food dining, cooking healthfully on a budget

Family. Particularly “being there” for children and grandchildren

All participants were very motivated by “negative” family examples of those who had diabetes but did not take care of themselves well

Support and concern expressed by family members were critical in member health-activation

The Five F’s of Cultural Relevance

Faith and Spirituality. Respecting life as a gift Especially among African American women Faith-based organizations as a trusted source of health information Influence of cultural “spiritual/folk” beliefs

Fear. Disease complications, especially amputations, blindness, and kidney disease Especially among African American men Hispanic men worried about others finding out about diabetes Many struggled with depression

Finances. Affordability of health care and healthy lifestyles (food, gym membership) was also a concern

Effective Communication Is a Tool That Helps All of Us in Health Care Meet Our Mission

How do we link communication to outcomes?

Communication

Patient Satisfaction

Adherence

Improved Health Outcomes

Special Topics for Clinical Consideration

Use of Alternative or Herbal MedicationsPregnancy and BreastfeedingWeightInfant HealthSubstance AbusePhysical AbuseCommunicating with the ElderlyTalking About SexPain Management Across Cultures

Are There Strategies for Talking to Our Patients More Effectively?

Tip #3:

BCBSTX has reference tools for

physicians and their offices

Effective Communication

Based on CLAS goals and standards, the toolkit contents are designed to help physicians and other health care providers to

communicate with the increasingly diverse patient population

improve health care outcome.

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Caring for Diverse PopulationsKey Sections in Toolkit posted on the BCBSTX Provider Website

1. Resources to assist communication with a diverse patient population base

2. Resources to communicate across language barriers3. Resources to increase awareness of cultural

background and its impact on health care delivery4. Regulations and Standards for Cultural and

Linguistic Services5. Reference resources for Cultural and Linguistic

services

How to Access the Toolkit,Better Communications, Better Care

Other Resources on the Website

Employee Language Skills Self-Assessment ToolInterpreter Desktop Reference ToolInterpreter Attendance Verification

Questions?

BCBSTX Cultural Competency Contact:

Sara Daugherty-Pineda, RN

972-766-2493