MULTICULTURAL INFLUENCES ON PRIMARY CARE

Beverly C. Wilson, APRN, FNP-BCGrand Strand Advanced Practice Nurses AssociationLecture at the Beach - 2015

OBJECTIVES1. Identify the major cultural & ethnic groups in

the Horry/Georgetown communities. 2. Cultural Competency

A. Model Definition

B. Application of Model to Horry/Georgetown Counties

3. Enumerate the potential barriers to effective communication in primary care.

OBJECTIVES – INHIBITIONS TO COMMUNICATION

A. Barriers for African-Americans

a. Lack of health care in the past b. Mistrust of health care providers c. Intra-cultural variation.

B. Barriers for Latino clients

a. Language – variety of Spanish dialects b. Mistrust of health care providers c. Fear of deportation d. Intra-cultural variation

Source: Caminha-Bacote, J. (2009)

CULTURAL AWARENESS

Cultural Awareness

Conscious exploration of one’s personal biases, prejudices and stereotypical attitudes that we hold about those unlike ourselves.

What attitudes and judgements do I, the nurse practitioner have about my client re:

Education, language, religion, affluence, first impressions sexual orientation,

CULTURAL SKILL

Cultural Skill

Creation of a physical assessment which is culturally sensitive using open-ended questions.

What problem brought you here today? What do you call your illness? What do you think caused your illness? When & why do you think it started? What do you think your illness does to you and why? How bad do you think is your illness?

CULTURAL SKILL – CONT’D

How severe is your illness? What is frightening about your illness? What kind of problems have your illness caused for you? What do you want your treatment to do for you? What results do you want to see?

CULTURAL ENCOUNTERS

Cultural Encounters

Deliberate seeking of clients of that particular culture using conscious intercultural communications.

Avoiding stereotyping to provide respectful care.

Is your client literate about their health?

Does your client have the ability to obtain, process and comprehend health information or to make decisions regarding his/her health.

CULTURAL KNOWLEDGE Obtaining a sound knowledge base about African-American or Hispanic culture

Caveats

Suspicion of health care providers – Tuskegee Study of Untreated Syphilis in the Negro Male in 1932 conducted by the Public Health Service. Decision made in 1936 to withhold treatment and follow the 600 subjects to death. The ethics were questioned in 1968 ending the study in 1972.

Influence of Spirituality in coping with illness.

Intracultural variation based on age, education, economic condition

CULTURAL DESIRE

Cultural Desire

Pivotal to developing cultural competence

Process of discovering how clients think and feel differently from the nurse practitioner. This does not mean that the practitioner needs to accept the client’s belief system but the client must be treated respectfully. Cultural desire expression of respect, human dignity, equity and social justice.

Poor health outcomes have been associated with inequities of health care.

MULTICULTURAL INFLUENCES

Issues impacting cultural competence

Issues in the local & national news

Historical

Political

Societal

HISTORICAL FACTORS FOR AFRICAN AMERICANS IN HORRY/GEORGETOWN COUNTIES

I. Slavery to 1865

II. Civil War - 4/1861 to 4/1865.

III. Emancipation Proclamation – 9/22/1862 the initial proclamation that slaves in rebel areas would be free in 100 days. Final proclamation made on 1/1/1863.

HORRY/GEORGETOWN (CONT’D)

IV. Plessy vs Ferguson Supreme Court Ruling – 4/13/1896 upheld the constitutionality of equal but separate schools for whites and blacks

V. Jim Crow Laws – the racial caste system that existed in the United States primary in the south for almost 100 years from the 1870s to 1960s. It was a way of life proscribing how blacks should behave & interact with whites enforcing segregation legally.

VI. Brown vs Board of Education - Supreme Court Ruling in 5/1954. The court determined unanimously that segregation of public schools was unconstitutional.

HORRY/GEORGETOWN (CONT’D)

VII. Civil Rights Movement under Dr. Martin Luther King – 12/1955 to 4/1968. Attempts made to desegregate the United States after the Brown vs Board of Ed. Decision. This segment ended with his assassination on 4/4/1968.

VII. Election of Barack H. Obama in 2008

DEMOGRAPHICS FOR AFRICAN AMERICANS AND HISPANICS IN HORRY/GEORGETOWN COUNTIES

I. Race & ethnicity breakdown for Horry county (Census Reporter, 2013) A. Whites: 77%B. Blacks: 13%C. Hispanics: 6%

II. Race & ethnicity breakdown for Georgetown county (Census Reporter, 2013)

A. Whites: 62%B. Blacks: 34%C. Hispanics: 3%

POLITICAL FACTORS INFLUENCING AFRICAN AMERICANS AND HISPANIC CLIENTS

I. Obama Administration – 2008 to presentA. Economy – 2008 Recession B. Percentage living in poverty in Horry/Georgetown Counties

1. Percentage living in poverty a. Horry County – 19.3% as of 2013b. Georgetown County – 20.6%

C. Unemployment rate: 1. Nationally - 5.8%2. South Carolina – 6.4%

a. Horry county: 6.4% b. Georgetown county: 7.6%

POLITICAL INFLUENCES (CONT’D)

B. Health care1. Affordable Care Act (Obamacare)

a. Subsidies – decrease as one’s income increases. How long will subsidies last – unknown.b. Mandated coverage – pay for contraceptive coverage when the individual does not want or

need that coverage.2. Emer gency Med ical Treat ment and Active Labor Act (EMTALA) for undocumented

immigrantsa. Pays for emergency hospital care until stableb. Federally Qualified Health Centers (FQHCs)

i. Horry County – Health Care Partners & Little River Medical Centerii. Georgetown County – St. James-Santee Family Health Center

c. Migrant Health Centers3. Medicaid and Medicare4. Employment Based Health Insurance

RECENT IMAGES OF AFRICAN AMERICANS

IMAGES (CONT’D)

YOUR CLIENT – 38 YEAR OLD MALE MOVING TO AREA, NEEDS A PCP FOR HIS WELLNESS PROGRAM

IMAGES OF HISPANICS

UNACCOMPANIED CHILDREN FROM MEXICO

Source: Breitbart, (2014)

YOUR CLIENTS – 4 YEAR OLD GIRL & 2 YEAR OLD GIRL NEEDING WELL CHILD CHECKS AND IMMUNIZATIONS

FAMILY - BECKY, REESE, TIFFANY & DARRELL

CARE OF OTHER CULTURAL GROUPS – GENDER HEALTH

Gender Health

A. Definitions1. SEX

a. Division of male, female or intersex (atypical combinations of distinguishing sexual characteristics) by presence of reproductive organs

b. The sum of the structural, functional, and behavioral characteristics of organisms that are involved in reproduction. (DSM-5 definition.)

GENDER HEALTH

2. GENDERa. Cultural behaviors associated with a person’s

biological sex.b. Culturally acceptable behaviors conforming to

societal expectations.

OTHER CULTURAL GROUPS (CONT’D)

3. Gender Assignment – usually at birth, gender assigned to a person based on external genitalia. (American Psychiatric Association, 2013).

4. Gender Dysphoria – a person’s discontent or incongruence with expressed gender versus their assigned gender.a. In children – ICD 9 code 302.6 or ICD 10 code F64.2b. In adolescents and adults – ICD 9 code 302.85 or ICD 10 code

F64.1c. Prevalence

i. Natal males – 0.005% to 0.014%ii. Natal females – 0.002% to 0.003%iii. Probably underestimated

YOUR CLIENT – 65 YEAR OLD NATAL MALE NOW FEMALE, SEEKING PCP

Vanity Fair, (2015)

WHAT DO YOU EXAMINE FOR YOU TRANSGENDERED CLIENT

I. AHQR are based on the individual’s sex not genderA. Dependent upon where the individual is in sexual

reassignment1. Male → Female

Level A recommendations Aspirin daily Colorectal cancer screening Testing for HIV Lipid screenings

GENDER HEALTH

Level B recommendations Breast exam & mammogram (?) Depression & Fall Prevention Alcohol Misuse No Prostate screening since 2012

REFERENCES

American Psychiatric Association. (2013). Gender Dysphoria. In Diagnostic and statistical manual of mental disorders (5th ed.). 451-461

Bansal, S. (Photographer) (2015, June 5). Caitlyn Jenner Vanity Fair Cover: Snoop Dogg, Timbaland, Connor Cruise and others'

Negative Reactions and Apologies. Retrieved from http://www.ibtimes.co.in/catilyn-jenner-vanity-fair-

cover-snoop-dogg- timbaland-connor-cruise-others-negative-reactions-634839

Census Reporter, (2013). Georgetown, SC. Retrieved from http://censusreporter.org/profiles/05000US45043-georgetown-county-sc/

Census Reporter, (2013). Horry, SC. Retrieved from http://censusreporter.org/profiles/05000US45051-horry-county-sc/

REFERENCES

Caminha-Bacote, J. (2009). A Culturally Competent Model Of Care for African Americans, Urologic Nursing and Associates, 29(1), 49-54.Jones, D. P. (Winter 2015). Knowledge, Beliefs and Feelings about Breast Cancer: The Perspective of African American Women, Association of Black Nursing Faculty Journal, Turner Publication, Inc. 5-10.Long, J. M., Sowell, R., Bairan, A., Holtz, C., Curtis, A. B., & Fogarty, K. J., (2012). Exploration of Commonalities and Variations in Health Related Beliefs Across Four Latino Subgroups Using Focus Group Methodology: Implications in Care for Latinos With Type 2 Diabetes, Journal of Cultural Diversity, 19(4), 133-142.

REFERENCES

Rkaina, S. (Photographer) and Simpson, I. (Photographer). (2015 April 28). Baltimore riots: City on fire as violent protests continue after black man died in police custody. Retrieved from http://www.mirror.co.uk/news/world-news/baltimore-riots-city- fire-violent-559478

Tate, K. (Photographer). (2014 July 17). Illegals aren’t all medically cleared prior to being housed. Retrieved from

http://www.breitbart.com/texas/2014/07/17/source-illegals- arent-all-medically-screened-before-traveling-to-housing-facilities

WOW, HAVE A GREAT CONFERENCE!!