IMPORTANCE OF USING CULTURALLY SENSITIVE TOOLS FOR ACQUIRING PERCEPTIONS

OF HEALTH

The Art of Communication

Our Best Tool

The patient’s voice on the perception of their

health

BackgroundAs early as the 1920’s, it was suggested that

individual perceptions of health could be indicators to the onset of disease

Established standards and empirical results have underscored the importance of incorporating measurement of health perceptions in studies that assess an individual’s health, illness, or disease impact.

Perceptions of health are internal and subjective within individuals

At the individual level, they may channel actions

At the societal level, they may channel policy for change

Often individuals’ perceptions of health are categorized as:

EXCELLENTGOODFAIR

POORVERY POOR

Used by the Behavioral Risk Factor Surveillance System and the National Health Interview Survey

Although this is a validated method for obtaining individuals’ perceptions of health;

the cultural meaning of health can be lost

How is health defined within the culture? What values are placed on health? What is the contextual placement of good, fair, or poor? What senses and experiences are dominating that culture to

form the perception?

These are important questions to ask the individual

Need to go back to foundational experiences of people, and the medical anthropological understanding of disease and illness where culture is embedded and sustained over a period of lifetimes; followed by providing the individual the measurement tool which will help to categorize perceptions of health

Qualitative SurveysQualitative Surveys World Health Organization Quality of Life Survey (WHOQOL) Believed that the “missing element of health” was the humanistic

element Health Perceptions Questionnaire Form II (1976) Nottingham Health Profile (1985) EQ-5D (EuroQol Group) 1990 SF-36 Health Survey Questionnaire (1992) Medical Outcome

Survey

Lost its most meaningful context

SF 36MOS 20MOS 12

Qualitative Research Methods Reveal underlying meanings and patterns of relationships

within a culture Provides contextual description of how people experience

health Identify intangible factors such as : • social and cultural norm • beliefs, rituals and values • socioeconomic status • gender roles • ethnicity • religion THEY BRING THE PATIENTS VOICE TO THE FOREFRONT

Methods of Obtaining Qualitative Information

Focus GroupsOne-to-One Interviews

Participant ObservationsField Work Observations

New Tools

1. Better Communication, Better Care:Provider Tools to Care for Diverse Populations

AHRQ Healthcare Innovations Exchange website:http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10 .pdf

2. AHRQ Health Literacy ToolkitAHRQ Pub. No. 10-0046-EF

Citation:

DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010. H

In addition:

Knowledge of: › the cultures’ history › ethnic composition › past religious, political, and social forces

This rich experiential data can help to retain and sustain culture within the health perceptions measurement tool

Preliminary information regarding: demographics, social and economic variables, vital statistics, and chronic disease factors can be obtained through:

Country websites: United States www.factfinder.census.gov

WHO website: http://www.who.int/whosis/en/index.html

United Nations website:http://unstats.un.org/unsd/default.htm

The use of information must be carefully considered because often the information is from an aggregate population, not the subgroup. They may yields very different profiles

CAUTION!!!!!!

EXAMPLES OF CULTURAL

VARIATIONS IN PERCEPTIONS OF

HEALTH

SRI LANKASRI LANKA

History of Medicine

4 ancient periods

1. Medicine under Sri Lankan kings2. The Portuguese period3. The Dutch period4. British period

Health Care Systems in Sri Lanka1. Alophatic: dominates Sri Lanka; (basically western

medicine) yet people retain some components of the other two systems in their belief when they define health

2. Ayurveda: originated in India; individuals would maintain that illness and suffering are due to change in Wa (air), Pith (bile), and Sem (mucus)

3. Indigenous: developed within the context that the king and others should do their best to reduce suffering due to illnesses. This teaching helps people tolerate suffering such as pain

The majority of Sri Lankans are Buddhists. The Buddhist philosophy defines health as wealth; yet it also says that people get sick because of their “Karma”. Elimination of suffering can only be achieved through the person by elimination of any attachment it may have to the subconscious body

Other considerations

95% of people can read and write this will affect your tool design when

considering time and budgeting

MEXICOMEXICO

In most homes, health is seen as a luxury Little value is placed on prevention of disease Class separation is very visible/the poor are

left uninsured and without care

Mexicans value Familismo(the family unit)

High value placed on religion, with illness placed in the hands of God

Curanderos (spiritual healers) are very important in Mexico with their holistic approach to healing

The Mexican government plays a role; due to corruption, pharmacies are able to sell medicine with little regulation

Mexicans are taught not to complain; most will answer “good” when asked the question…..How are you feeling?

Mexican use many different dialects and different words in various parts of the country

Cambodia

Misconception

Often Asians in the aggregate present a picture of good health, higher levels of income, and higher family income

(Koch-Weser S, Liang SL, Grigg-Saito DC)

In Cambodia

March 2008: United Nations reports population at 13,388,910

Life expectancy at birth: 59 yrs. old for men 63 yrs. old for womenLiteracy rate in 2004: 73% Infant mortality rate in 2006: 66 per 1,000 births

Cambodians have struggled with poverty,

corruption and the aftermath of the Khmer Rouge war

Many people struggle on a daily basis to have a small meal whether they find it, grow it, or buy it with the small income they receive

Hunger may be a variable of perceptions of health

Most hospitals and clinics are located in Phnom Penh. Many have no means of transportation; the village healer is utilized

There is no form of health insurance in Cambodia

When speaking to a Cambodian, they will say “ This is the life we live, what options do we

have?”This is the unfortunate reality of the lifestyle

in Cambodia

Conclusion

Various cultures provide for important variations in:

• The definition of health• Values placed on health• The contextual and experiential placement of

good, fair, or poor• What senses dominate the perceptions==========================================

ALL WHICH AFFECT PERCEPTIONS OF HEALTH

Importance of• Conceptual clarity: provides common definitions within

the culture that guides the tool • Operating from an understanding of the cultures

contextual conditions to assure that all questions are locally, culturally, and developmentally appropriate

Unites the caregiver with the voice of the individual

= Improved service satisfaction

Importance of Culturally Sensitive Measurement Tools

• Key component to formulation qualitative data into quantitative data which my initiate change

• Healthcare reform is now at the forefront of Congressional committees in the U.S.

• Ranked as high priority is the improvement of health of underserved population

“The Measurement of Health is an Essential Requirement for the Evaluation of Health

Policy, Assessment of Intervention Effectiveness, and Measurement of the

Efficiency of Health Systems”(McDowell, Ian)

The Patient’s Voice is Our Greatest Ally

Thank you

Bohoma Sthu-thee-yi

Gracias

Ar kun