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Mili

Patia

…..…delivering culturally-appropriate nutrition interventions to Pacific People

Kokua Kalihi Valley Health CenterKalihi, Hawai’i

Sheryl R Yoshimura, MPH, RD

COMMUNICATING WITH IMPACT

• Identify at least 2 aspects of an individual’s culture that may affect their view of overall health.

• Identify at least 2 culture based education strategies used in health and chronic disease management to help improve outcomes.

• State at least 2 components of a culturally-appropriate nutrition intervention.

OBJECTIVES

I AM NOT A CULTURAL EXPERT

DISCLAIMER

TERMS & DEFINITIONS

Office of Minority Health, 2001

• Culture: thoughts, communications, language, practices, beliefs, values, customs, courtesies, rituals, manners in interacting, roles and relationships, and expected behaviors of a racial, ethnic, religious, or social group.

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TERMS & DEFINITIONS

Cultural Knowledge(Level 1)

Familiarization with cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group

Cultural Awareness(Level 2)

Development of sensitivity and understanding of another ethnic group. It must be supplemented with cultural knowledge

Cultural Sensitivity(Level 3)

Knowing that cultural differences as well as similarities exist, without assigning values, i.e., better or worse, right or wrong, to those cultural differences. It means having an understanding of the needs and emotions of your own culture and the culture of others. Avoiding the Blind Spot Syndrome.

Office of Minority Health, 2001

• Identification of cultural group: Pacific People

• Description of cultural practices of Pacific People

• Interventions strategies that works with Pacific People

• Community Resources

OUTLINE

WHO ARE THE PACIFIC PEOPLE? WHO ARE THE PACIFIC PEOPLE?

WORKING WITH SAMOAN PATIENTS

• Physical illness may, at times, be attributed to past misdeeds or conduct

• The concept of health is attuned not only to obvious physical ailments, but also to relationships with others, the environment and the spiritual world.

• Prayer is an important element of the healing process.

HEALTH BELIEFS & PRACTICES

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• Certain conditions are believed to be "Samoan illnesses" ( ma'i samoa ) that are explained and treated by indigenous practitioners

• Others conditions to be "European illnesses" ( ma'i papalagi ), which are best understood and treated by those trained in the Western biomedical tradition

• Preventive health is not a well -established concept in Samoa.

HEALTH BELIEFS & PRACTICES

• Samoans stress politeness and deference to those in perceived positions of authority

• Physical space is important (especially the area in front of a person)

• Touching is seen as a sign of sincerity or intimacy• First name greetings are preferred. A handshake

is the customary greeting.• Language:

– Samoan– English

LANGUAGE & COMMUNICATION STYLE

• Large, extended families are common• The family is the basis of the community. • There is a strong commitment to mutual aid and

support within the family and church. • It is important to be hardworking, self-sufficient

and loyal to the family. • Modesty, politeness and humility are valued. • Women have an active role in decision-making.

FAMILY STRUCTURE Pay attention their immigration/migration history and regional orientation

• American Samoa– US nationals (qualify for the benefits of their US citizen

counterparts including welfare benefits but cannot vote)• Western Samoa

– Welfare reform, 1996• Requires 5 residency for Medicaid benefits• Uninsured (if living in US less than 5 yrs and/or

working <20 hrs/wk)• Most come to US on a visitor visa (can only stay 6

months at a time).• Use faith healers or plants

HEALTH CARE ACCESS

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• Sharing of food is a central element of ceremonies and feasts– sunday feasting (eating all day) –weddings– funerals – conferring of chiefly titles–annual feasts such as White Sunday

FOOD/DIETARY PRACTICES FOOD/DIETARY PRACTICES

FOOD/DIETARY PRACTICES

WORKING WITH MICRONESIAN PATIENTS

• The Compact of Free Association(COFA) defines the relationship that three sovereign states—the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI) and the Republic of Palau—have entered into as associated states with the United States.

UNDERSTANDING COFA

• Guam

• Kiribati

• Nauru

• Marshall Islands

• Northern Mariana Islands

• Palau

• Federated States of Micronesia

WHO ARE MICRONESIANS?

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Working with Micronesian patients(Chuukese)

• Health-seeking behaviors (don’t go to the doctor until they are very sick)

• Prefer hospital over clinic

• Traditional healing

• Prayer is an important element of the healing process.

HEALTH BELIEFS & PRACTICES

• Long term medication use not usual– 4-6 weeks then stop (healers usually take 4-6 weeks to

cure disease)– Side effects (“medicines making me sick”)– Why should I take medicine when I don’t feel sick?

• Certain conditions are believed to be “Micronesian illnesses“ that are explained and treated by traditional healers

• Others conditions to be “Western illnesses“ which are best understood and treated by those trained in the Western biomedical tradition

HEALTH BELIEFS & PRACTICES

• Often feel uncomfortable with the opposite sex

• Males often have higher status and females are restricted more than males

• Examples: – Women and men occupy separate social spaces during

church of community gatherings.– When they enter a room containing men, women have

to lower themselves as they enter the door.– Women show respect for their husbands

by walkin behind them in public or serving them first during meals.

LANGUAGE & COMMUNICATION STYLE

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• Physical contact is inappropriate• Direct, prolonged eye contact is seen as invasive

or challenging• Conflict is often avoided by saying “yes” even

when one means “maybe” or “no”• When community members meet, there is often a

hierarchy to who sits where and who may speak• Concept of time is relative• Language:

– Chuukese • Limited English

LANGUAGE & COMMUNICATION STYLE

• Family plays a large role in an individual’s decision making.– Children are highly valued

• Family units at least include grandparents, parents, and children

• Head of household is generally the eldest male. Influence is stratified by age and sex

FAMILY STRUCTURE

• Values:– Interdependence - strong family support – social

security system

– Communal approach to working together and the strength of the social support networks of their churches

– Reciprocity & respect

– Friendly

FAMILY STRUCTURE

• Use traditional healers or plants

• CoFA– Free medical service/insurance

– Not qualified for welfare (food stamp or financial assistance

– Only American-born can receive food stamp or financial assistance

– Can receive WIC

– Homeless ( hidden homelessness)

HEALTH CARE ACCESS

• Food is an integral part of celebrations, meetings, and other important events.– Expression of solidarity that validates kinship ties.

FOOD/DIETARY PRACTICES

Traditional food Seafood, fish, chicken, pork,fruits, and starches such as sweet potatoes, cassava, breadfruit, yams and taro) Fruits (banana, papaya, mango, citrus fruits) are casually eaten throughout the dayCoconut are incorporated into recipes.

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• Prefer traditional foods– Men (fishing, work at fish market)

• Rely on other people for food or food bank– Canned meats, rice, pastries, bread

• Very little access to fruits and vegetables

• Have a lot of soup (chicken and onions).

– Traditionally, vegetables not part of the diet (vegetables were grown to feed the pigs)

FOOD/DIETARY PRACTICES

WORKING WITH FILIPINOPATIENTS

• Good health = balance + harmony

• Religion is closely tied with health

• Faith takes precedence over a person’s openness to Western medicine, but does not reject it.

• Prayer contribute to healing and wellness.

• Being overweight is not a concern

• Exercise is not a regular part of daily living

HEALTH BELIEFS & PRACTICES• Over 170 languages (includes English, Spanish,

Hokkien (Chinese), Cantonese, Mandarin, Chavacano.

• 13 indigenous languages including Tagalog, Ilocano, and Cebuano/Visayan.

• 2 or more of these is spoken natively by more than 90% of the population.

• Tagalog is the national language.• English is the 2nd official language.

LANGUAGE & COMMUNICATION STYLE

• Sensitive to tone and manner of the speaker• Typically shy and affectionate • Feel awkward in unfamiliar surroundings

– They will look for a Filipino worker • Handshakes are not commonly practiced,

(address them as Mr or Mrs tata or nana)• Little direct eye contact, especially with superiors

and authority figures• authority figures are respected • little tendency to disagree.

LANGUAGE & COMMUNICATION STYLE Pay attention their immigration history and regional orientation

Tagalog

Visayan

Ilocano

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• Family-oriented, multigenerational household.• Women will serve as the primary bedside care

providers• Grandmothers are the babysitters• Filipino values:

• Pakikisama (group loyalty)• Bayanihan (people convening, and pooling resources

together to help others who are in need)• Hospitable• Amor propio (pride, self-love, self-respect)• Utang na loob (indebtedness) • Hiya (shame)• Bahala na (resignation)

FAMILY STRUCTURE

• Use faith healers or plants• Prefer Filipino-speaking providers

– Will look for a Filipino worker• Less likely to get all recommended care than US

born counterparts• Welfare reform in 1996

– Requires 5 residency for Medicaid benefits– Uninsured (if living in US less than 5 yrs

and/or working <20 hrs/wk)

HEALTH CARE ACCESS

• Eat three meals a day at regular meal times

• Rice (Jasmin) is served with every meal – It’s not a meal if it doesn’t include rice.

– Sandwich is considered a snack.

• Fish, meat, vegetables and fried food

• They prefer soft and warm food when ill and do not like ice in their drinks

• Celebrations• festivals

• birthdays

• visitors

• funerals• weddings• welcome parties• holidays

FOOD/DIETARY PRACTICES INTERVENTION STRATEGIES

PACIFIC PEOPLE RELATIONSHIP TO LAND

• Enduring part of Pacific People identity, history, and spiritual beliefs

• Familial relationship between plants & humans

• Filial relationship between humans & land

• Land provides substance for body & spirit

CULTURE-BASED EDUCATION THEORETICAL MODEL

Culture-Based Education

Language, Cultural content, Cultural

context, ‘Ohana & community, Assessment

Socio-Emotional Development

Self-worth, Cultural identity, Family &

community relations

(Health) Outcomes

Engagement, Achievement, Behavior

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CULTURE –BASED EDUCATION IN ACTION

CBE Aspects Program/Intervention Adaptation Language In-language material, Hawaiian and Pacific

language/words, stories, graphics, metaphors

Family & Community Family and support persons as participants, neighborhood resources, community or backyard food garden

Context Aloha (love), Ha‘aha‘a (humility), Hō‘ihi (respect), ‘Olu‘olu , Pule (prayer), Ho‘ike, introductions, “talk story”, informal, family-style eating

Content Sharing/testimonial, food security, cooking lessons, shopping tours, tastings, reciprocity, sharing, return to the land

Data & Accountability Attendance, Retention, HbA1c, Blood pressure, Cholesterol, Weight

Class Rules (Expectations)

• Come to every session

• Be respectful of others and their ideas

• Maintain confidentiality

• Give any new activity at least a two-week trial

• Make & do action plan

• Turn off cell phones

• No selling or promoting of products

Parts of an Action Plan• Something that

YOU want to do• Achievable• Action specific

• Answer the Questions:– What?– How much– When?– How often?– How confident are

you that you will be able to do your action plan?

(confidence interval: 1-10 you want 7)

Tool Kit

• Raffle tickets• Door prizes• Music• Food demo• Report card – any improvement in

clinical value (Announce it in class!)

E.T.H.N.I.C ModelCommunication with Patients

A Framework for Practicing Culturally Competent Care

College of Medicine. University of South Carolina

E.T.H.N.I.C ModelExplanation

• What do you think may be the reason you have this health problem (DM, HTN, etc)?

• What do friends, family, and others say about this problem?

• Do you know anyone else who has had or who has this kind of problem?

(If the patient cannot offer an explanation, ask what most concerns them about their problems).

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E.T.H.N.I.C ModelTREATMENT

• What kinds of medicines, home remedies or other treatments have you tried for this illness?

• Is there anything you eat, drink or do (or avoid) on a regular basis to stay healthy? Tell me about it.

• What can I do to help you?

E.T.H.N.I.C ModelHEALERS

• Have you sought any advice from alternative/folk healers, friends or other people (non-doctors) for help with your problems?

• Tell me about it.– If first time, they won’t tell you. But it’s

important to talk about it early on

Evaluating Treatments1.Where did you learn about this (scientific journal, supermarket

tabloid, Ad on newspaper or TV, neighbor)2.Were the people who got better like you? (age, gender, lifestyle,

same health problem)3.Could anything else have caused these positive changes (seasonal

change, other medication, emotional changes, change in stress level)

4.Does the treatment suggest stopping other medications or treatments? (does it require you stop other basic medication because of dangerous interactions?)

5.Does treatment suggest not eating a well-balanced diet? (does it eliminate any important nutrients or stress only a few nutrients)

6.Can you think of any possible dangers/harm?7.Can you afford it (financially, emotionally, physically)8.Are you willing to go to the trouble/expense?

E.T.H.N.I.C ModelNEGOTIATE

• Negotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs.

E.T.H.N.I.C ModelINTERVENTION

• Determine an intervention with your patient. –May include incorporation of alternative

treatments, spirituality, and healers as well as other cultural practices (e.g. food eaten or avoided in general and when sick).

E.T.H.N.I.C ModelCOLLABORATE

• Collaborate with the patient, family members, other health care team members, healers and community resources

• Know your community! – Re-define if necessary.

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Community Resources• People’s Open Market (locations & times)• Food Pantries (call 211)• Community Health Centers• Native Hawaiian Healthcare Systems on all

islands• Univesity of Hawaii, Dept of Hative

Hawaiian Health (JABSOM)

Partners in Care Diabetes Self-Management Intervention

A program of the PILI ‘OHANA Partnerhip

Partnership in Improving Lifestyle Intervention (PILI) Ohana

Open Invitation

Cultural Immersion

100-acre State Park in Kalihi Valley

SUMMARY

• Culture-based interventions contribute to significant– Improvements in Clinical outcomes– Significant decreases in A1c & weight

• Group activities form natural support groups– Decrease anxiety to make lifestyle changes

• “Nutrition Moments” activities

• Malama ‘Aina, Aloha ‘Aina– Connect them to the land– Exercise with a purpose

SUMMARY

• Behavioral Changes –Information to Action– Changes in eating

patterns• more vegetables ,

water, diet drinks, “brown rice at potlucks”

– Changes in shopping patterns• Reading labels,

Shopping at farmer’s markets

– Changes in physical activity

• Improved quality of life – Empowered– Renewed sense of

cultural identity– Sense of belonging – Sense of usefulness – Promotes access for

physical activity; – Improving food

security & diet quality;

– Maintaining cultural identity

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Mahalo• Partners:

– UH - Department of Native Hawaiian Health, JABSOM

– National Institutes for Health, National Center of Minority Health and Health Disparities