Harborview Women s Clinic July 22, Jennie Mao, MD, Kimela Vigil, MSW, and Leondra Weiss, MN, RN

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1 Harborview Women s Clinic July 22, 2016 Jennie Mao, MD, Kimela Vigil, MSW, and Leondra Weiss, MN, RN Identify barriers Identify motivators Identify methods that improve adherence and compliance with recommendations Provide culturally sensitive education on why care is important Review examples of cultural issues and cultural sensitivity 1

2 What populations do you work with? Type your responses into the Chat box. New immigrants generally arrive as healthy or healthier than their American peers Over time, their health is similar or worse then their US peers, due to less access to healthcare, discrimination and mental health issues, obesity and increasing rates of diabetes, hypertension, and heart disease Yang, P, 2016 Among foreign-born women residing in the US less than 10 years, only 61 percent received a Pap smear in the last three years, compared to 83 percent of US-born women. Foreign-born women who have been in the US more than 10 years fared significantly better, but still less well than US-born women (79%). Nationwide, 84 percent of naturalized Latinas received Pap smears in the last two years, while only 70 percent of Latina noncitizens did A study of Los Angeles immigrants found that Laotians, Cambodians, Vietnamese, Asian Indian, and Chinese immigrants had low screening rates within the last two years (52 to 56 percent) compared to Korean, Filipino, and Japanese women (65 to 75 percent) Schleicher, E,

3 Lack of familiarity with the concept of preventative care only go to doctor with symptoms if I am not sick, why would I go to a doctor Never had screening tests Lack of understanding of disease risk Lack of understanding about western Medicine in general Language barriers increase challenges Providers lack of understanding of patients cultural background Confusion about insurance, payment, co-payment Health literacy Difficulty navigating system to make appointment Difficulty getting transportation Competing life demands Unable to afford co payments Lack of insurance If you don t have money for treatment, you don t want to know if you re sick. Lack of affordable childcare Education in primary language Dialogue between provider and patient Culturally sensitive and accurate interpretation Culturally specific videos that address common concerns Utilize resources like Ethnomed Incorporate partners, extended family, and/or community to understand importance Learn about specific cultural practices and respect traditions--ask questions and listen Shared decision making 3

4 Build trust between patients, families and providers Having on-site navigators or cultural ambassadors Team work: MD, RN, Social Work, House Calls/cultural mediators, BHIP Network with local partners who are culturally sensitive (e.g. Columbia, SeaMar) Attend Community Health Fairs Word of mouth Education through creative means: i-pad, Walk and Wok class Incorporating multi-level tacticstechnology, written materials, diagrams/visuals, teach-back Call back reminders Field trips to map out barriers Help with transportation and parking fees Care coordination through Cultural Mediators in Community House Calls or train a champion Students Fertility Men? Trust & Respect Religion Interventions seem unnecessary 4

5 In many cultures you don t go to the doctor unless you are ill Inshallah, if God wills Understanding that illness is linked to karma My mother is 90, my 8 sisters are all healthy without these tests Many Asians believe that their lifestyles and cultural norms keep them healthy, that diseases are for unclean women or that certain interventions will create an imbalance Distrust of the medical system Fear of pain/diagnosis Past trauma Discrimination/healthcare inequity Fear of stigmatization Concern about legal status Preference for female providerssometimes prefer same ethnicity 35 year old Amharic-speaking Ethiopian female who was originally referred to HMC Women s Clinic for history abdominal pain and fertility work-up. This patient s fertility is detrimental to the viability of her relationship with her husband. Her husband remains in Africa, but may consider leaving this patient if she cannot bear children. 5

6 35 year old Spanish-speaking female, originally from Mexico with on-going abdominal pain. This patient is a single-mother who has two young daughters. She reports having abdominal pain off and on since her last daughter was born. After a thorough work-up, there are no clear physical causes for her abdominal pain. This patient continues to have difficulty with pain. Case Examples 33 year old female and single mother of 2 children in the US and 5 children in Africa (Kenyan refugee camp). The father of the 5 children in Africa died before the patient was able to immigrate to the US. The patient was able to bring with her 2 children from a second relationship, this father stayed in Africa or was unable to emigrate. 48 yr old Spanish-speaking female with hot flashes and sleep problems, originally from Honduras. Pt works full-time as an in-home caregiver while managing the care of her adult disabled daughter and teenage son. 6

7 Prenatally: Vast majority of women are practicing Muslims Women and community value large families Female circumcision is a consideration for fertility and delivery May decline vaccination, concern it may not be halal or concern for autism Often won t take meds due to concerns for halal, no pork, no gelatin in prescriptions May restrict calories to ensure small baby Almost all decline genetic testing Intrapartum Perception that c/s are done too commonly, could harm ability to have more babies Some but not all will prefer to have female providers May decline recommended treatment inshallah, even c/s for delivery for fetal distress. Belief that death and disease are fated Post partum Rarely desire contraception May be at high risk for depression-new culture, language barrier, possible history of circumcision, sexual trauma, or somatization Always try to use a qualified translator and in person certified interpreter for important diagnosis. Must have added patience and flexibility. These patients have a harder time navigating all the systems, and thus even getting to the clinic on time may be difficult (also the concept of time is different) Building rapport definitely helps. Seeing the same provider and building trust will help guide patients through this complicated medical system. It might take 3 or 5 visits until the patient will agree to a pelvic exam or why you need to do it Respect patient s integrity of cultural belief. Their idea of illness may not agree with yours and they may not accept your ideas for treatment. Listen to your patients and have them teach you what is important to them. 7

8 Many patients have somatic complaints. It can make it difficult to discern real disease, depression, PTSD Screening for domestic violence or human trafficking is important Talk to patients about annual female exams including mammograms as patients may have never heard of mammograms as their physicians often don t recommend it Johnson, E., Reed, S., Hitti, J., Batra, M. (2005). Increased risk of adverse pregnancy outcome among Somali immigrants in Washington State. American Journal of Obstetrics and Gynecology, 193, Mitchell, C., Mohamed, A., Moussa, S., Reed, S., Optimizing the Somali Birth Experience at UWMC, powerpoint. Schleicher, E. Immigrant Women and Cervical Cancer Prevention in the United States. Baltimore, MD. Women s and Children s Health Policy Center. Johns Hopkins Bloomberg School of Public Health, 2007 Yang, P., Hwang, S., Explaining Immigrant Health Service Utilization, A Theoretical Framework, SAGE Open May 2016, 6 (2)

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