Social Determinants of Adolescent Health: Culturally Respectful Care: Growing Beyond Competency

Coordinating Care around the Social Determinants of Health is a blog series from the School-Based Health Alliance. We feature stories from clinicians that demonstrate the impact of safety-net health centers that use a social determinants lens when providing coordination of care for adolescents. Read more posts in the series here.

“Once, my doctor made an offhand comment about it being difficult to work with a Muslim patient she had, because of a ‘cultural clash.’ I didn’t feel comfortable sharing as much with my doctor after that.”

Cultural respect: what is it?

“Culture” seems like one of those words that everyone says even though it means something different to each person. It’s often described as a mosaic of pieces—a body of knowledge, beliefs, experiences, or behaviors.

You’ve probably heard of “cultural awareness” or “cultural competency,” but just knowing someone’s culture isn’t enough. Culturally respectful care takes the foundation of cultural competency and puts it into practice. It means that you understand that people’s experiences, expectations, and values can be different than your own—and you realize when those differences may impact your practice.

Is this any different than how we usually respect patients?

It may not be! However, respecting a patient’s culture means putting in extra effort to learn about their community—and putting that into practice can require more intentionality than usual.

Maine Migrant Health Program (MMHP) offers a variety of services that bring coordinated care into the lives of migrant agricultural families. “There’s a real gap between health care and health,” explains Lisa Tapert, MPH, executive director at MMHP. Liz Charles coordinates MMHP’s outreach, which includes providing training to interested health centers. “To us, it’s about cultural humility. You don’t — and can’t, really — become a master of someone else’s culture. It’s a lifelong learning process to provide effective care in the presence of differences.”

In the summer of 2016, Sonia* wasn’t spending her days at the beach like most 10-year-old girls. Instead, she was at Blueberry Harvest School, an educational program for migrant students whose families work the blueberry barrens in Maine. While at school, MMHP and the Harrington Family Health Center hosted a dental screening clinic, and they found that Sonia had many untreated cavities that needed the attention of a dentist. A community health worker from MMHP put her on a list of priority students for dental visits, helped her find transportation to the dentist’s office, and assisted with translation during Sonia’s visit.

At her first visit, Sonia was too scared to get an x-ray. Rather than writing her off, the community health worker understood Sonia’s unfamiliarity and nervousness. He reached out to coordinate a second visit; one that Sonia’s father could accompany her to (and get his teeth cleaned while he was there!). During that second appointment, the dentist told Sonia she needed several extractions that would need to be done by a special dentist whose office was more than an hour away. Here’s the problem with that: the first available appointment was for late September and Sonia’s family would have already migrated to another farm outside the area.

Again, working with the family, the community health worker conveyed Sonia’s limited time frame to see the dentist. They were able to shift their schedule to allow her an appointment within the week, and Sonia was able to get the care she needed before her family had to move.

Elizabeth Charles, director of outreach for MMHP explains, “This reflects how the community health worker acknowledged the family’s needs instead of insisting that they fit into the more traditionally defined box.”

*Name has been changed to respect privacy.

Why is cultural respect important?

Better Outcomes

By building a deeper level of respect and trust with your patient and being more patient-centered, your patient will feel comfortable sharing the social and physical problems affecting their health. Gaining an understanding of their culture and background can also help you build a better plan for overcoming those barriers to improved health.

Reducing Disparities

Minority communities often have trouble accessing comprehensive care. However, you can make sure that these communities have access to the best care possible by having a culturally respectful medical practice.

But who are we talking about?

Everyone. Everyone has differences that ought to be respected. A lot of times there’s no way to know for certain what communities a patient identifies with just by looking at them. That’s why it’s critical that cultural respect is a priority in your practice, no matter who walks in the door.

“I told my therapist I was bisexual, but not really dating right now. The therapist said ‘Oh, well that’s good. We wouldn’t want you going around being with lots of different people now, would we?’ Her stereotyping me like that really hurt.”

What do I do?

Providers and other health center staff can reach out to community groups and take steps to understand how those communities might interact with your practice. Maybe they have different perspectives on what health is or a different view of medicine—or maybe they just have a different diet.

We must also realize that global, national, and local events impact diverse communities differently — financially, physically, and emotionally.

We shouldn’t generalize. While certain issues may resonant more with some communities, or some members of those communities, everyone still needs the same quality of comprehensive medical care. You can be culturally respectful without trying to memorize new recipes or guess about every patient’s experience. Here are some tips:

  • Avoid assumptions
    • Don’t make assumptions about a patient’s sexuality, ability, gender, education, income, or anything else. Ask open-ended questions that don’t presume a certain answer.
    • Even if you know a person’s identity, don’t assume you know right away how they interact with that identity — everyone is different!
  • Don’t judge
    • If someone feels comfortable enough to share their experiences with you, make sure you don’t jeopardize that by inadvertently making them feel bad about their identity.
    • Be careful with your comments about other identities, even if you know your patient doesn’t identify that way. If you make a comment that doesn’t embrace one identity, the patient may not feel confident that you will embrace theirs — and that trust is key for any doctor-patient relationship.
  • Use inclusive language
    • Use language that is inclusive of a wide spectrum of identities, abilities, and sexualities.
    • Use and reinforce the language the person uses to talk about themselves.
    • Remember that any aspect of a person’s identity is only that: one aspect of a broader identity.
  • Try the “teach-back” method
    • Start by having your patients explain to you what they expect or understand of their condition. You’ll be better equipped to meet them where they are, respecting that space and building on it. Even outside of the cultural respect context, the Department of Health and Human Services says the teach-back method can improve patient compliance and satisfaction and decrease callbacks and cancelled appointments.

“My doctor always made an effort to include my mother in my health decisions. She is Puerto Rican and had never had comprehensive health care before. It meant a lot to me that my doctor always worked to make sure my mom understood what was said in the appointment and that I had the support I needed.”

How can I learn more?

About cultural respect:

NIH: https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect

DHHS: https://www.thinkculturalhealth.hhs.gov/

http://canatx.org/CAN-Initiatives/ccdi/index.php

National Association of School Nurses: https://www.nasn.org/ToolsResources/CulturalCompetency

About putting it into practice:

A useful checklist for your residential program: http://nccc.georgetown.edu/documents/NCCC_ChecklistResidentialProgram.pdf

A checklist for your practice: http://nccc.georgetown.edu/documents/checklist_PHC.html

A variety of assessments for different populations: http://www.canatx.org/CAN-Initiatives/ccdi/assessments.php

About the teach-back method:

A quick video: http://nchealthliteracy.org/teachingaids.html

Teach-back Toolkit: http://www.teachbacktraining.org/

About inclusive language:

http://www.emerson.edu/creative-services/editorial-style-guide/guidelines-inclusive-language

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