Are you interested in learning more about cultural diversity in health care?
If so, I suggest you read my book. I focus on case studies of actual cultural conflicts with explanations of why they occurred and what could be done to achieve cultural competency. Click on the links near the top of the page to go directly to a specific section.
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A handy reference guide!
CULTURAL SENSITIVITY:
A Guidebook for Health Care Professionals
(Click on link, then type "Cultural Sensitivity" in the Product Search box.)
UPDATED!
Written by Geri-Ann Galanti
A handy pocket reference guide to the important principles underlying culturally competent health care. Provides easy access to potential patient behaviors and beliefs that impact your success in providing care.
This guidebook has been updated and expanded. It is now being published by Joint Commission Resources.
**********************************************E-Learning Course
on
Culture and Healthcare
9 units of CME
Offered through PerforMax3
Developed by Geri-Ann GalantiDesigned for any professional who cares for patients- physicians, nurses, assistants, pharmacists, physical therapists, etc.
Written by Geri-Ann Galanti
A user-friendly training manual which provides everything you need to help foreign-born nurses make a successful transition to an American health care environment. It
covers four major areas:
• The Role of the Registered Nurse
• Improving Cultural Communication
• Working with Patients
• Working with Multicultural Staff
Each section integrates information with an array of exercises and activities, such as case studies and role-plays to help with application.
Also included is a set of 119 PowerPoint slides to accompany your presentation.
To see more, download this pdf sample.
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65 Tips for Foreign-Born Nurses Working in American Hospitals
Written by Geri-Ann Galanti
This short booklet was designed to enable nurses to get useful information easily and quickly in order to successfully adapt to their environment. It is divided into seven categories: Physician/Nurse Relationships, Nurse/Nurse Relationships, Nurse and Patient, Role of the Nurse, American Culture and Values, Understanding (Anglo) American Families, American Communication Patterns and Pain Management. There is also a list of resources in the back of the booklet to support a nurse’s ongoing education.
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The 4 C's of Culture: A Mnemonic for Healthcare ProfessionalsA simple way for healthcare professionals to remember the questions to ask to get at the patient's perspective. They are a key to providing culturally responsive, patient-centered care.
1. What do you call your problem? (Remember to ask “What do you think is wrong?” It’s getting at the patient’s perception of the problem. You should not literally ask, What do you call your problem)
The same symptoms may have very different meanings in different cultures and may result in barriers to compliance. For example, among the Hmong, epilepsy is referred to as “the spirit catches you, and you fall down.” Seeing epilepsy as spirit possession (which has some positive connotations for the possessed) is very different from seeing it as a disruption of the electrical signals in the brain. This should lead to a very different doctor-patient conversation and might help explain why such a patient may be less anxious than the physician to stop the seizures. For an excellent example of what can happen when caring, competent physicians do not understand the patient's perspective, see Anne Fadiman's 1997 book, The Spirit Catches You and You Fall Down. Understanding the patient's point of view can help the healthcare provider deal with potential barriers to compliance.
2. What do you think caused your problem? (This gets at the patient’s beliefs regarding the source of the problem.)
Not everyone believes that disease is caused by germs. In some cultures, it is thought to be caused by upset in body balance, breach of taboo (similar to what is seen in the US as diseases due to “sin” and punished by God), or spirit possession. Treatment must be appropriate to the cause, or people will not perceive themselves as cured. Doctors thus need to find out what the patient believes caused the problem, and treat that as well. For example, it may sometimes be appropriate to bring in clergy to pray with them if they believe God is punishing them for some transgression.
3. How do you cope with your condition? (This is to remind the practitioner to ask, “What have you done to try to make it better? Who else have you been to for treatment?”)
This will provide the healthcare provider with important information on the use of alternative healers and treatments. Most people will try home remedies before coming in to the physician; however, few will share such information due to fear of ridicule or chastisement. It’s important that healthcare providers learn to ask – in a non-judgmental way, since the occasional traditional remedy may be dangerous, or could lead to a drug interaction with prescribed medications. This question can also help you discover if they’ve been unable to cope with whatever it is that’s going on.
4. What are your concerns regarding the condition and/or recommended treatment? (This should address questions such as “How serious do you think this is”? “What potential complications do you fear”? “How does it interfere with your life, or your ability to function?” "Do you know anyone else who has tried the treatment I've recommended? What was their experience with it?")
You want to understand their perception of the course of the illness and the fears they may have about it so you can address their concerns and correct any misconceptions. You also want to know what aspects of the condition pose a problem for the patient; this may help you uncover something very different from what you might have expected. It is also important to know their concerns about any treatment you may prescribe. This can help avoid problems of non-adherence, since some patients may have misplaced concerns based upon past experience. For example, some patients may not be taking insulin because they believe insulin causes blindness. They’ve seen friends and family members go blind after going on insulin, and they incorrectly perceive that as the cause; it’s a logical assumption based on observed cause and effect. Unless a healthcare provider asks, however, s/he may not elicit such beliefs from the patient, who will simply not take their insulin. By asking, the healthcare provider can correct any misconceptions that can interfere with treatment.
Developed by Stuart Slavin, MD, Geri-Ann Galanti, PhD, and Alice Kuo, MD.
4 C's of Culture: Spanish Version
Un modelo para la entrevista clínica culturalmente competente:
“ The 4 C´s of Culture / PCCP”
Es sin duda útil tener información sobre la cultura de origen de nuestros pacientes. De todas formas, no podemos tener información sobre todas las culturas de todos nuestros pacientes, y tampoco sabremos hasta qué punto nuestro paciente va a ser el “prototipo” de su cultura. Por ello, aparte de estar sensibilizado sobre posibles diferencias culturales, es importante para el médico saber formular las preguntas adecuadas para averiguar la información necesaria. Para este propósito, Geri-Ann Galanti ha desarrollado junto a los médicos Stuart Slavin y Alice Kuo un modelo mnemotécnico llamado “The 4 C´s of Culture”:
1) What do you call your problem?
2) What do you think caused your problem?
3) How have you coped with the problem?
4) What are your concerns, regarding the condition and regarding the treatment?
En castellano, se pueden utilizar como modelo mnemotécnico las siglas PCCP:
• P: ¿Cuál cree que es su problema?
• C: ¿Qué piensa que lo causó?
• C: ¿Qué ha hecho para confrontarlo?
• P: ¿Qué le preocupa, en relación a su problema y al tratamiento prescrito?
P) ¿Cuál cree que es su problema?
¿ Qué piensa que le está pasando? Esta pregunta nos sirve para averiguar la percepción del paciente sobre su problema. Los mismos síntomas pueden tener significados diferentes según la cultura. Comprender la perspectiva del paciente puede ayudar al médico a actuar de tal forma que la probablididad de lograr el cumplimiento del tratamiento prescrito aumente de forma significativa.
C) ¿Qué piensa que lo causó?
Con esta pregunta puede averiguar las creencias del paciente acerca del origen del problema. No todo el mundo cree que las enfermedades son causadas por los gérmenes. Posibles causas percibidas podrían ser, entre otras, un desequilibrio físico o psicológico o bien alguna creencia religiosa o espiritual (p.ej. la enfermedad como castigo de un comportamiento no apropiado). El médico tiene que averiguar cuál es la creencia del paciente acerca de la causa del problema y, aparte de prescribir un tratamiento, intentar encontrar una solución a la causa percibida por el paciente. Si no se toma en cuenta la perspectiva del paciente, es menos probable que éste perciba que se le está ayudando en su proceso de curación.
C) ¿Qué ha hecho para confrontarlo?
¿ Qué ha hecho para mejorar su estado? Esta pregunta puede revelar información importante sobre si el paciente ha ido a ver a algún naturópata, curandero etc. y si ha tomado ya algunos medicamentos alternativos o remedios naturales.
Muchos pacientes habrán probado curarse a sí mismos antes de consultar con un médico. Es importante que el médico esté informado acerca de ello para evitar una interacción medicamentosa con el tratamiento prescrito. (Nota: en el módulo 4 de este curso encontrará información sobre remedios naturales comunmente utilizados así como sobre sus posibles efectos beneficiosos y dañinos)
En referencia a remedios caseros y alternativos, es probable que muchos pacientes no los mencionen por iniciativa propia: por un lado, porque no lo consideran como un medicamento, y por el otro lado, porque posiblemente sientan vergüenza y teman quedar en ridículo. Es por ello que se recomienda a los médicos el preguntar por estos remedios, de una manera neutra (no valorativa), para animar al paciente a explicarlo. Para ello, usted debería expresar básicamente tres aspectos:
• Que usted asume que muchos pacientes prueban tratamientos alternativos
• Que está bien tomarlos
• Que es importante que compartan esta información con usted.
Podría decir algo como “Muchos de mis pacientes toman remedios caseros antes de venir a la consulta. Muchas veces son efectivos y hacen que haya mejoras significativas. De todas formas, es importante para mí saber lo que ha tomado, ya que esto puede afectar a lo que le voy a prescribir.”
P) ¿Qué le preocupa, por lo que refiere a su problema y al tratamiento prescrito?
¿ Qué le preocupa por lo que refiere a su problema? – Aquí podría preguntarle al paciente si considera su problema grave, de qué manera interfiere con su vida, o si teme cualquier complicación. Haciendo estas preguntas averiguará qué aspectos de la enfermedad suponen un problema para el paciente y puede llegar a descubrir algo muy diferente a lo que usted esperaba.
¿ Qué le preocupa por lo que refiere al tratamiento prescrito?
Esta pregunta puede ayudar a evitar problemas de no cumplimiento del tratamiento prescrito. Por ejemplo, si algún paciente cree que la toma de insulina puede dejar ciego, posiblemente como consecuencia a este miedo, no tomará la insulina tal y como le ha sido prescrita.
Muchas veces, el paciente no va a compartir sus temores y el médico no se enterará de ellos hasta que pregunte sobre las preocupaciones referentes al tratamiento. Al averiguar las preocupaciones, puede corregir posibles ideas equivocadas relacionadas con el tratamiento.
Translated by Anne Rupp
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Other Recommended Readings
General
Andrews, M.M. and J.S. Boyle, eds. (1999) Transcultural Concepts in Nursing Care, 3rd edition. New York: Lippincott.
Gardenswartz, L. and A. Rowe (1998) Managing Diversity in Health Care. San Francisco: Jossey-Bass Publishers.
Giger, J.N. and R.E. Davidhizar, eds. (1999) Transcultural Nursing: Assessment and Intervention. St. Louis: Mosby.
Gropper, R.C. (1996) Culture and the Clinical Encounter. Yarmouth, ME: Intercultural Press, Inc.
Lipson, J.G. and
S.L. Dibble, eds. (2005) Culture
and Clinical Care. San Francisco: UCSF Nursing Press.
Salimbene,
S. (2005) What Language
Does Your Patient Hurt In? A Practical Guide to Culturally Competent
Patient Care. Amherst, MA: Diversity Resources,
Inc.
Spector, R. (2000) Cultural Diversity in Health and Illness, 5th edition. Upper Saddle River, NJ: Prentice Hall.
The Western Journal of Medicine (December, 1983) Volume 139, No. 6. Special Issue: Cross-Cultural Medicine.
The Western Journal of Medicine (September, 1992) Volume 157, No. 3. Special Issue: Cross-Cultural Medicine--A Decade Later.
Specific Ethnic Groups
Fadiman, A. (1997) The Spirit Catches You and You Fall Down. New York: Farrar, Straus and Giroux. (Hmong)
Hammerschlag, C.A. (1988) The Dancing Healers: A Doctor's Journey of Healing with Native Americans. San Francisco: Harper & Row.
Ohnuki-Tierney, E. (1984) Illness and Culture in Contemporary Japan. Cambridge: Cambridge University Press.
Payer, L. (1996) Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York: Henry Holt & Co.
Sheikh, A. and A.R. Gatrad, eds. (2000) Caring for Muslim Patients. Oxford: Radcliffe Medical Press. [See review I wrote for BMJ]
Snow, L.F. (1993) Walkin' Over Medicine. Boulder, CO: Westview Press. (African Americans)
Kaiser Handbooks
Provider's Handbook Series on Culturally Competent Care provides an
overview of cultural
and epidemiological characteristics of the following groups: Latino;
African American; Asian and Pacific
Islander; and Lesbian, Gay, Bisexual and
Transgendered. They also have handbooks on Individuals with Disabilities
and Women's Health. They focus on general aspects of each group that
affect health care utilization, presenting background information and
health care statistics that can help providers become even more sensitive,
responsive and knowledgeable about diverse population. To obtain free (other
than shipping & handling) copies, use the online
form.
Other
Excellent Books
These books do not have a cultural focus, but are related to competent
and compassionate health care delivery. They are books I would recommend
that all health care professionals read.
Callanan, M. and P.Kelley
(1992) Final
Gifts: Understanding the Special Awareness, Needs,
and Communications of the Dying. New York: Bantam.
Woods, Michael S. (2004) Healing
Words: The Power of Apology in Medicine.
Oak Park, IL: Doctors in Touch.
Recommended
Films
Patient
Diversity: Beyond the Vital Signs
This comprehensive training program from CRM Learning features a 20-minute
video and a Leader's Guide with exercises and role-plays for 2-4 hours
worth of training on the topic of cultural diversity in healthcare. The
patients include:
A Mexican man whose
loud post-operative suffering is not taken seriously by the nurse,
who stereotypes him as a typical "expressive" Mexican. His pain, however,
is real, and due to internal hemorrhaging. It serves as a reminder not to stereotype patients.
A Cambodian boy is brought in covered with welts;
a traditional
healing remedy (coining) is mistakenly thought to be child
abuse.
An Hispanic woman brings in
her infant because she believes one of the nurses gave her baby the “evil
eye.”
An African American woman refuses treatment because she believes God is
punishing her for a past transgression. A culturally compentent nurse
succeeds in changing her mind by communicating though the patient's belief
system.
An elderly Chinese patient's wife rejects the hospital food because it is the wrong balance of yin and yang.
For more information, go to www.crmlearning.com. Or call 1-800-421-0833.
Note:
I served as a consultant on the film and wrote the Leader's Guide.
Kaiser Films
Kaiser Permanente's award winning cultural issues videos were produced by Kaiser Permanente's MultiMedia Communications and the Educational Theatre Program's CareActors, M. Jean Gilbert, Project Director, Jo Ann Lesser, Producer. The project was jointly funded by Kaiser Permanente and The California Endowment. Now available in both video and DVD format.
Cultural
Issues in the Clinical Setting-Series A and B
The brief but dramatic vignettes are each
accompanied by support materials for facilitators and participants which
will be sent electronically and are included in the nominal price. The
vignettes raise numerous issues around differing health beliefs and practices,
conflicting values, stereotyping, overt and covert prejudices, and language
barriers. The video is 70 minutes long and contains 10 vignettes.
Series
A:
Diabetic Compliance: Latino. Two versions of an interview with a
non-English-speaking, non-compliant diabetic Hispanic woman. The
first uses a family member
as the interpreter and is an example of how not to handle an encounter.
The second uses a professional interpreter and goes much better. It’s
a good example of why professional interpreters are important.
Sickle-Cell Case in the E.R. An African American adolescent is in crisis
and needs pain medication; the E.R. staff is not so sure. A good example
of stereotyping.
Pediatric Asthma: A Middle-Eastern doctor and an aggressive mother tangle
over the care of a young girl...a values clash. The second part of the
segment is a good example of how foreign physicians’ presentation
of self may be misinterpreted by Americans.
A Somatic Complaint: Long buried painful memories of an Asian woman manifest
in diffuse symptoms that are not well understood by this physician. A
good example of how Asians may somaticize psychological problems into
physical complaints.
A Gay Adolescent: An adolescent football player comes out to his family
doctor. The doctor deals with the situation both knowledgeably and sensitively.
Series B: Birthing Issues
Goes through a day in the life of a young OB/Gyn physician coping with
a diverse group of patients. Good advice from another, more experienced
physician is at first spurned then sought as the doctor is confronted
by special needs and circumstances.
Lesbian Parents: The physician is caught off-guard when she learns that
the two women before her are both the prospective parents and have some
special concerns.
The Hmong Way: The physician is startled when young woman's mother wishes to
incorporate unusual birthing practices in the birthing care of her pregnant daughter,
including keeping the placenta.
A Middle Eastern Dilemma: A conversation between the more experienced physician
and one of her Middle Eastern patients reveals conflicts and familial concerns
around acculturation in an immigrant family.
A Big Baby is Coming: A non-English speaking woman from Mexico is delivering
a very large baby with macrosomia. She is diabetic and has lost several babies
at birth. Her husband is very uncomfortable in the labor room and a nurse reveals
her tendency to stereotype through prejudicial remarks.
A Circumcised Somali Mother in Labor: A by now tired and concerned
physician discovers that the woman presenting for childbirth, having had no prenatal
care,
must have her vaginal opening enlarged in the presence of thick scar tissue or
have
a C-section.
Download video
order form
Download
DVD order form NEW!
Or
contact:
Clari Arbona
Production Coordinator
825 Colorado Boulevard, Suite 300
Los Angeles, California 90041
Phone: 323.259.4341/ tie line: 8.365.4341
E-mail: Multimedia.duplication@kp.org
Multicultural
Health Series 2
Four vignettes, 8-1/2 to 10 minutes each
Walking in Beauty:
Navaho beliefs about illness & curing.
The case focuses on a Navaho man with cancer. It emphasizes both aspects of communication
and of world view. His understanding of the cause of his disease and how it should
be treated are very different from those of biomedicine.
Day of Rest: The Jewish Sabbath
An orthodox Jewish man brings his wife into the hospital to deliver a baby on
the Sabbath. The segment focuses on the conflicts he has with the nurses due
to his religious beliefs.
Changes:
Foreign Physicians
An older, Anglo American man comes into the clinic for a check-up. He’s
not happy to find that a young, female, East Indian physician with a rather
heavy accent has replaced his regular doctor of 20 years. It is a good example
for foreign-born physicians of how to deal with prejudice on the part of patients.
Voice Inside the Phone: Using the Interpreter Line
Vignette illustrates the use of the language line service for interpreting
in a medical setting. The physician is skeptical at first, but finds it very
easy and helpful in treating the young son of an Armenian woman.
Download
video order form
Download
DVD order form (contains Series 2 & 3) NEW!
Or contact:
Clari Arbona
Production Coordinator
825 Colorado Boulevard, Suite 300
Los Angeles, California 90041
Phone: 323.259.4341/ tie line: 8.365.4341
E-mail: Multimedia.duplication@kp.org
Multicultural
Health Series 3
Six vignettes, 6-11 minutes each.
Rebirth:
End of Life.
Dr. Jerry Mitchell empathically assists an ethnic Chinese
family as
they come to terms with the unexpected
death of their 22 year-old daughter. He benefits from a “cultural consult” with
a Buddhist colleague.
Pocketful of Miracles: Alternative Medicine/Literacy Issues.
Dr. Funaki is surprised to learn that his patient from Colombia is using
alternative
medicines
along with her prescribed medication and also finds out that she can’t
read her prescription labels even though they are in Spanish.
Proof: Domestic Violence.
Nurse Singh brings suspicions
of domestic violence in a South Asian family to the attention of Physician
Assistant, Eliza Polanco.
Suspicions are confirmed when the patient finally whispers a request for
help.
Lupe's Dilemma: Sexually Transmitted Disease. Lupe Pena
is pregnant and infected for the second time with chlamydia. Physician Assistant
Ernie Walker
helps her come up with a safe, family-supported way to get her partner to
come in for treatment.
Lost Opportunities: Mistrust and Denial.
Roy Turner, an
African American patient who came to the emergency room with a heart attack,
is finally coming in
for a follow-up visit in cardiology. Dr. Ryan provides appropriate clinical
information
and education, but cultural and economic barriers are ignored; trust and
rapport are never achieved.
Between Two Worlds: Refugees Confronting the American Medical
System.
A care team comes to understand the unique concerns and sacrifices
made by the Rhamatis
in fleeing their native Afghanistan. The couple leaves this visit reassured
that they will receive ongoing care in a safe, confidential, and welcoming
environment.
Download video order
form
Download
DVD order form (contains Series 2 & 3) NEW!
Or contact:
Clari Arbona
Production Coordinator
825 Colorado Boulevard, Suite 300
Los Angeles, California 90041
Phone: 323.259.4341/ tie line: 8.365.4341
E-mail: Multimedia.duplication@kp.org
Worlds
Apart
A
Four-Part Series on Cross-Cultural Healthcare by Maren Grainger-Monsen,
MD, and Julia Haslett, Stanford University, Center for Biomedical
Ethics.
Contains 4 video documentaries, each highlighting a different ethnic
group, disease, and cultural issue. Comes with an excellent facilitator’s
guide. Videos range from 10-14 minutes each. Topics covered are:
• Mohammad: An Afghani Muslim man who refuses chemotherapy for
stomach cancer due to religious reasons. Addresses issues of language
barriers.
• Justine: A young Laotian girl with Atrial Septal
Defect whose grandmother fears that a scar left by surgery to close the
hole will
mark her in
successive
lifetimes. Addresses the issue of various explanatory models.
• Robert: An African American man with End Stage Renal Disease
who is awaiting a kidney transplant.
Addresses issues of racial/ethnic disparities
in medical care.
• Alicia: A Puerto Rican woman with diabetes, hypertension, and
asthma. Adresses issues of non-adherence to medical regimes and use of
traditional
remedies.
Available from Fanlight Productions.
PowerPoint Presentations
Below are PowerPoint presentations by M. Jean Gilbert and/or Geri-Ann Galanti, created for physicians as part of a pilot project entitled "Implementing CLAS Standards: Designing, Implementing & Evaluating 3-Tiered Cultural Competency Training." Project is funded by The California Endowment and headed by Miya Iwataki, Director, Office of Diversity Programs, LA County Department of Health Services.
OB-Gyn
There are QuickTime
videos embedded in this PowerPoint. The videos are from Kaiser Permanente's
Multicultural Health Series. They will not play when you download this
file. However, you can purchase them at minimal cost from Kaiser
(Cultural Issues in the Clinical Setting, Series B).
Slides for presentation on Racial and Cultural Disparities in Healthcare (PDF file only)
Other Resources
CHISPA
(Caring for HISpanic PAtients interactively)
A
technology based approach for the acquisition of cultural and linguistic
competencies for the multicultural workplace. It is designed to teach
Allied Health professionals how to approach Hispanic patients in a culturally
appropriate manner. CHISPA consists of three components: Interactive CD,
Website, Train the Trainer and Activities Manual. For further information,
go to http://itdc.lbcc.edu/chispa/about.html
Also see the Embanet
Success Letter and Nurse
Village for more information about the program.
Note:
I served as a consultant on the project and wrote the Trainer's Manual.
DIVERSOPHYTM
Interactive training game is designed for use in the continuing education of physicians, nurses, non-medical front-line support staff and administrators in healthcare organizations and for integration into the Nursing and Medical school curriculums. For more information and additional resources, contact:
Inter-Face International
tel. (815)282-2433
CLAStalk
An e-mail discussion group
sponsored by Resources for Cross Cultural Health Care and the DiversityRx
website (www.diversityRx.org). Participants
can raise issues, ask questions, share information and resources and
network with each other around topics related to the design, delivery
and evaluation of culturally and linguistically appropriate services
(CLAS) in health care.
