Radio Inspire

How To Learn Sign Language

Culturally-competent Health Provider Communication

Hi everyone. On behalf of the National
Diabetes Education Program and especially our Asian
American, Native Hawaiian and Pacific Islander
stakeholder group, welcome. As the population in the United
States becomes more diverse we’re going to have a
greater need for culturally competent communication. So we’re very excited to be
able to offer this webinar. Today we have two speakers, Dr.
William Hsu and Dr. Nia Aitaoto who have extensive experience in culturally-competent communication. We’re very lucky that they’ve
agreed to share lessons that they’ve learned from their work. So we’ll be starting with Dr.
William Hsu, who is the medical director of the Asian
Clinic and a senior physician at the Joslin Clinic and
associate investigator at the Joslin Diabetes Center
and co-director of Joslin’s Asian American
Diabetes Initiative and also an assistant professor of medicine at the Harvard Medical School. His research interests include
understanding the barriers to diabetes care in Asian Americans
and developing novel mobile health technologies for treatment of diabetes. He works on key research,
clinical and community projects that address diabetes health
disparities in Asian Americans. He graduated from Cornell
University, received his medical degree from Mt.
Sinai School of Medicine in New York City and completed
his residency at Yale and his fellowship training in endocrinology and metabolism at Harvard Medical School. So please welcome Will Hsu. Well good day to
friends and colleagues. It’s really just wonderful to be
able to share some of the things that we’ve been doing here at
Joslin as well as just to share with you some of the
things that we’ve learned. By having you coming on this
webinar you probably have heard about the terrible
burden of diabetes in the Asian American community. What I plan to do for the next
20 minutes is to take you through a little bit of sort of
introduction on the physiology, some of the unique features of
diabetes in the population and then march on to talk
about communications and cultural competency. I hope to give you sort of a
well-rounded picture of the challenges that we see in the
Asian American community. So if you look at data such as
the one that I’m showing you on the slide, this is the burden
of diabetes in New York City. The red represents the burden of
disease and you’ll see on the far right Asian Americans now have about 16 percent of its population with the diagnosis of diabetes and that is one out of six adults of Asian
backgrounds living in your city having diabetes. Now, that is an epidemic. If you combine that with the
yellow bar which represents a state of diabetes that’s called
pre-diabetes — it’s not quite diabetes yet, but they are at very high risk for developing diabetes — combined with
the red bar you see the Asian American population up to
about 50 percent of them of those adults living in your city
has diabetes or pre-diabetes, a truly astounding figure. Now you may say, “But Will,
this is New York City. Other parts of the country
may have a different burden of disease,” and
you’re absolutely right, that’s possible and that’s why
we’re truly looking forward to September when the CDC will be
sharing for the first time national data based on NHANES. This is the first time the U.S. government has ever sampled the Asian American population and
we will be hearing about the burden of diabetes on a
national level, so that will be truly a wonderful thing to have. Now what is quite different
about diabetes in the Asian American is the fact that Asian Americans develop diabetes more than Caucasians at
every weight category. So here you will see that
the far right bar off the three triplets represent
Japanese American and you will see that regardless
whether they are with BMI less than 22, 22 to 25, 25 to 30
or 30 plus Asian Americans they have more diabetes compared
to their counterparts in other populations. Looking at it in another way
is the amount of weight gain. Asian Americans are especially
susceptible to the risk of weight gain and in every weight
gain magnitude Asian Americans in this case the results done in Japanese Americans show that they have higher hazard or
risk of developing diabetes. So with that background I would
like to just ask us a question here and if you will all
participate if you’re on the web, what’s the average BMI for
Asian Americans with diabetes? Venture to guess? And all of you click on it and
let me see if I may show the results here and most of you
are, actually it’s changing. Most of you are right. Actually the BMI less than 25 is
the right answer so I’ll share with you a study that was done
through telephone survey. This is the behavior risk factor
surveillance system here. This is a national study
using telephone survey. Now there is some deficiency
obviously in telephone survey where people who do not know
that they have diabetes probably weren’t included and for
sure they weren’t included in this database. Here I think again you’ll not
be surprised if you know a friend of Asian background with
diabetes is that many of them don’t look overweight and you can see under the column Asian the BMI indication here is only
about 24 compared to almost 27 in white population and about 28, 29 among Pacific Islanders, Hispanic and black populations. So that’s one very different
characteristic of diabetes in the Asian American population. The implication is that, as a
provider, if we see somebody of Asian background and we say “Oh
you know, you don’t look very overweight, I don’t think
you’re at risk for diabetes and therefore we’re not going
to screen you for diabetes. We’re not going to address
risk factors of diabetes,” then we completely
miss the picture here. To this point,
organizations such as American Diabetes Association have been paying attention to if we should redefine
obesity and overweight in the Asian American population. Now because of this inherent
deficiency in using BMI as a risk stratifier when it comes to
diabetes some organizations have proposed to use other
parameters, for example, the abdominal circumference. The International Diabetes
Federation has proposed that measuring central obesity using
a tape measure, just simply measuring the girth, the circumference of the abdomen, may be an alternative way
of identifying risk and defining overweight and obesity. Now in this scenario while
Caucasians would be using a cut off points of 102
centimeters or 85 centimeters in women this is equal to about
40 inches and 35 inches. Asians would be using a lower
cut off point of 35.5 inches in men and 31.5 inches in women. Now these aren’t the
only differences. I just wanted to show a few
other biologic differences that just would open up our minds to see that while we’re more alike than different there are still some subtleties which are very, very important especially
when it comes to caring for patients of different
background. Here’s yet another example, in a
large women’s health study looking at inflammation and diabetes this is one study that looks a specific marker. It doesn’t matter what the
marker is, but I would just say the name of CRP which is an
inflammatory marker and just as a background inflammatory marker has been linked to the occurrence of heart
disease and diabetes. So the higher the level
inflammatory marker the higher the risk for developing these
metabolic complications and you will see that there seems to be
an ethnic difference in the level of CRPs across the different ethnic groups with that Asian group having
the lowest level of CRP. So this is just to point out
that there could be differences, biologic differences that the
underlying principle of what a CRP does is still true and the same across different groups, but just like BMI and abdominal
circumferences the cut off defining what’s normal
or abnormal may be very ethnically dependent. Now I will give you
another very important and shocking example here. Now you know there are two
different types of diabetes, there is type 1 and type 2. Type 1 often is described
as an autoimmune disease. It’s a condition where the
body’s immune system recognizes the pancreas is something
foreign and therefore launches a destructive process to basically stop the production of insulin. One of the hallmarks of that
autoimmunity or that defensive mechanism is the presence of
something called antibody. These are tests that physicians
can order to confirm the presence of these
self-directed attacks on bone, tissues and cells. So without going into the
details, this is one of the tools that physicians commonly
use to make sure that somebody has type 1 diabetes. If you were to measure the three
markers and you will see in the chart on the left hand side
there are GADab antibody, IA-2ab antibody and insulin
antibodies and so on and so forth these kinds of antibodies if they’re present it’s highly, highly correlated to
an autoimmune process. Now, so why did I just go over
a very complicated situation? Well this is to illustrate that
among the Caucasian population if you look at the antibodies
together, if you draw a panel about 90 percent 85 to 90
percent of all the Caucasians with true type 1
diabetes would have a positive antibody panel, but if
you look at the numbers here under type 1 under Chinese,
type 1 under Indian, type 1 under Malay the
numbers are very low, in fact less than 50 percent. Now this is not really common
knowledge in medicine. A lot of people believe that
antibody is very predictive and very few people, actually
practicing physicians are aware that there are ethnic
differences to the reliability of these tests. So that’s just really to give
you an angle to why appreciating these ethnic differences in
biology is very important to making us a competent physician
or healthcare providers. So let’s move on to the next
section really talking a little bit about the cultural aspects. So the question is which of the
following statements are true? Race and ethnicity are the same. A person can only
belong to one race. Race equals social, ethnicity
equals biological or that ethnicity is
independent of race. So please cast your vote. All right, counting down,
three more seconds. Okay, let’s skip to results and
let’s look at the results and most people have the right
answer that ethnicity is independent of race. So let’s talk a little
bit about this. So a lot of people when they
talk about diabetes they think about race, because after all
earlier I’ve been talking about Hispanics, Asians and Caucasians and so on and so forth, but when it comes to diabetes
care ethnicity may be even more important. What is ethnicity? Here we said that ethnicity
refers to self-identifying groups based on
beliefs concerning shared culture and history. It’s often rooted more
in the idea of social grouping rather than on biology. Culture shapes lifestyle. That’s why it’s so important
for diabetes care and that as health care providers we should not see culture as a barrier, because whenever we talk
about culture we always say, “oh, there are culture
barriers.” In contrast as health care
providers we should leverage culture in helping our patients. Now a few years ago we did
a study looking at a very important part of culture which
is language and how that plays out in diabetes
knowledge and care. So we did the study in different
community hall centers where providers actually spoke the
same language as the patient. We took a survey looking at the
knowledge base of those who prefer to speak English compared
to the group of individuals in terms of their diabetes
knowledge and this group belonged to those who
prefer to speak Chinese. You will see that by preferring
to speak English it gives superiority just in terms of their diabetes knowledge. So this study sheds the light
that by living in linguistic isolation or even sort of as a
degree of culturation that those who are not in the mainstream culture, speaking mainstream language here in the U.S. are probably at a disadvantage when it comes to diabetes knowledge. We also have the data that says
they tend to be, they tend to have a worse or higher
A1C level as well. That just goes to show you a lot
of times and in fact most times health disparities may have a
strong social determinant as a root for the cause rather
than simply biological roots. So to explore this idea of
culture a little bit more here on the right I’ve listed a
number of characteristics that’s part of our culture. Everybody’s got a culture and so
as a health care provider it’s so important for us to
understand not only the behavior which we always emphasize,
eat less, exercise more, monitor blood glucose more, take
more insulin, but unless we address the cultural aspect and their deep thinking their deep philosophy about life we
will not be affected. So let me explain. This is a picture of
sort of what really drives behavior in our patients. So on the tip of the
iceberg is behavior, right? This is where we see they’re not
exercising, they’re not doing what we want them to do, but underneath that, is a set value system that truly drives the behaviors and it’s a world view on how they view disease that impacts their value system and therefore impacts
their behavior. So I’m going to tell you
using one example to show you about this frame of thinking. So I remember maybe about five
or six years ago I had a patient who came into the office
and she was 18 years old. It’s a woman who
was just recently diagnosed with type 1 diabetes. As you might know the type 1 is
actually relatively rare in the Asian American population. Type 2 is rampant; type 1
is actually very low, so she felt entirely alone
dealing with this diagnosis. None of her friends have this
and so when I told her that she needed to take insulin to
survive, this is her survival medicine she met
with that invitation with such strong opposition. As a physician trying to comfort
her I asked her to bring her family along so we could all
talk about this together. I remember the next visit the
mother came by and she would hold my hand and the mother
actually cried in the room and said “Dr. Hsu
please, please don’t start my daughter on insulin.” I said, “But she needs this to
survive,” but the mother said doctor you don’t understand. If you start her on insulin
she will never get married. Now you can imagine this lady,
not only was was diagnosed with an incurable condition but
now she’s just been told that no one would ever love her, would ever take her to be a wife. So if you go back to our earlier
slide you’ll see if she believes, her world view of
disease like diabetes that is a shameful disease, if her view
on complications of diabetes, on diagnosis one that comes from
let’s say a result from something that she didn’t do right in the past, maybe is a declaration of her sin, of
course she’s going to feel very embarrassed and shameful
about having this diagnosis. That value system is going
to drive her behavior, what the behavior’s going to be. She is not going to take
her insulin in public. She’s not going to tell her
friends, her teachers, her co-workers that
she has diabetes. She is not going to monitor
her blood glucose in public. This is why simply
addressing the issue of why are you not doing this? Why are you not
taking your medicine? Why are you not monitoring your
blood glucose can be futile without truly understanding the
values behind the behavior and perhaps even deeper. What is the world
view about disease? What’s the explanatory
model that she’s using to understand her diabetes? So let’s move on. If you see patient behavior in
this light then there is truly no such thing as non-compliance. People do not take their
medicine for a reason. They may think that western
medicine is too strong. They may thing that this
injectable is not good for them. They might think
that giving blood, doctors are always
checking blood. Blood is so important. If you draw it out of me
I’m going to get weak. You know people’s values
dictate their behavior. Most patients are entirely
consistent, their values and their behaviors so they key is
to understand how they understand diabetes
and try to address your treatment accordingly. So let me give you
maybe in the interest of time maybe just two examples. You know a lot has been said
about patients, Asian patients, always quiet,
non-confrontational and it could be true, especially when you’re
providing care for a patient that does not speak
your language or you don’t speak their language. A lot of times our Asian
patients appear to be agreeable to treatment plan and so that’s
in the first box right here. In fact some of
the communication may be lost in translation. That’s why they’re
just being agreeable. That’s part of in their
culture not to challenge, not to confront but
that information may be lost in translation. So what is potentially a
culturally-competent way for a physician to do is to ask the
patient always to repeat back what his or her treatment plan
is, even through an interpreter. This will assure that he or she
truly was able to understand and retain the information
that was discussed. Let me go through another
example, our last example here. Let’s say here’s another example
where a patient might report a lot of trouble with sleep and
eating difficulties, loss of energy and you may think well that sounds like depression but they may not use that term. A lot of the patients might
believe it’s just part of the difficulties in life. Yes I do feel sad, but yes I’m
not sleeping well but you know to refer me to see a
psychological counselor, a social worker or
psychiatrist you probably will meet a lot of resistance. So the inside is that the
patient will not generally agree to be seeking psychological help
because of the shame and stigma of being diagnosed
with a psychiatric or a psychological disorder. As a provider’s primary care
doctor a lot of times there’s no way for you to convince
them to take medicines or to see a mental health worker. You might need to refrain
this psychological service part of the medical treatment. There are many different
examples, many different ways a health care provider can
adapt to the situation, to the needs of the patient. So my last slide, so if you
think about all these approaches what is truly
cultural competency? You might ask is it knowledge? Is it to know that people, a lot
of Asian Americans develop diabetes when BMI is less than
24, is that really the key? Is knowing really the key? Well some will argue yes you
might know, but if your attitude is not right, if you don’t have
an attitude to openness and attitude of respect, an attitude
willing to listen to the patient, you might have all the knowledge in the world and you still would not cross that
gap, make that connection. Is it all knowledge,
is it all attitude but perhaps it’s a skill. For example we say if the
patient appears agreeable the skill of your patient of your
professionalism my call to you to say you know what,
I’m not so sure. So why don’t I just politely ask
the patient to repeat back the instructions or the agreement
of the treatment plan? So that’s an adaptation of the
knowledge you already know and you’re applying to a
certain situation. I would just conclude by saying
you know with these years of caring for many Asian patients
I feel that there is a universal language of
care and that’s really the language of compassion. As providers if we can arm
ourselves with great knowledge, with open attitude and adapting
our skills and also always speak the language of love and compassion it may not matter so much if we don’t know
the specifics of a culture and so on and so forth. So with that I would like to
close and I’m sure that later on we’ll have other opportunities
at the end of the program for some questions and
answers, so thank you. Okay, thank you very much Will. Now I would like to introduce
our next speaker Nia Aitaoto. She is a fellow and just
completed her Ph.D. at the University of Iowa
College of Public Health. She has over 15 year of
experience in the health and education field focusing on
cancer awareness, diabetes awareness and prevention, cultural-competency training and tobacco related initiatives. She also is an advisor to two
regional coalitions in the Pacific, the Pacific
Chronic Disease Coalition and the Pacific Partnership
for Tobacco Free Island. She specializes in providing
technical assistance, data assessment, and support
to community groups in Hawaii, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States
of Micronesia, Guam, the Republic of Palau
and the Republic of the Marshall Islands. So please welcome Nia Aitaoto. Thank you Jude. Aloha to everyone. Here are my education objectives
and on my presentation outline I’m going to start out very
broadly and then I’m going to go into communication tips. First of all we talked about
race and ethnicity and under the umbrella of Pacific Islanders we
have three racial groups and underneath each racial group there are multiple ethnicities. We’re very familiar here in the
U.S. with Polynesians like Hawaiians and Samoans and with recent migration of Micronesians here, especially in
my state of Iowa. We have a large population of
Micronesian and Samoans and Marshallese and Polonaise here,
but then we also have other Pacific Islanders
from Melanesia. Within our context
this is our home land. As you can see the Polynesian
triangle, that’s the largest group of islands and then up north is Micronesia and then underneath that in the
south is Melanesia. It’s a large area just for
the USATI area Pacific Islands is the size of three continental
U.S. and for the whole we’re part of this huge ocean so it’s very hard geographically to reach all these
different islands. Even our affiliations I think in
the past couple of weeks you know you hear a lot
of talk about the Affordable Care Act and
also Immigration Reform. If you really look at it some of
our affiliations, some of our islands have close
affiliations with the U.S. For example, for Native
Hawaiians our home land is the state of Hawaii. The U.S. also has two territories, the territory of Guam and then American Samoa. Under the United Nations they
consider these two territories as colonies of the U.S. We also have a common
wealth and then free, freely associated space. So my question is what is
the prevalence of diabetes among Native Hawaiians Pacific
Islanders in the U.S.? Wow, look at the
results, still going. Most of you got it right. The prevalence rate is
about 20.6 percent and for Native Hawaiians Pacific
Islanders living in the U.S., they’re six times more
likely to die from diabetes complications than whites. For my region in the Pacific
the burden is actually larger. It ranges from 11
percent in Guam to 47 percent in American Samoa. That is extremely
high compared to 8 percent in the United States. If you look at some of the risk
factors which is obesity, eight of the top ten most of
these countries in the world are in the region of the Pacific. The only other two that are
not there are Kuwait and the U.S. but if you count the U.S. territories like Guam and American Samoa then all of the
top ten, most of these countries or jurisdictions in
the world will be in that region in the Pacific. Today’s talk will focus mostly
on cultural literacy and this is a very important topic for
especially Pacific Islanders because of our cultural
identity and beliefs. Although there are not a
lot of information about Native Hawaiian Pacific
Islanders and cultural beliefs in diabetes there’s enough
evidence to show that if we consider culture, our language, our beliefs and our systems, our cultural systems like our families and our churches there is a strong evidence to show that culture actually plays a huge role in improving diabetes
outcome for Pacific Islanders. A lot of those studies actually
come out of New Zealand and Australia, so here in the U.S.
we’re kind lacking but in the last two years we’ve
conducted studies here so this is a new area. I know the folks at University
of Hawaii started many studies for Native Hawaiians but for us
Pacific Islanders we have not started all of these studies
on compliance, especially western medicine compliance. So two years ago we started a
study, we actually started looking at this patient
centered model. You know what I mean? With the whole Affordable Care
Act you know people talk about this patient-to-home or
patient centered but what does that mean for the patient? We actually conducted focus
groups and interviews with 150 Native Hawaiian Pacific
Island patients who tell us what does that mean to them. Where do they seek health for
treatment or anything that ails them and the finding
was very revealing. The narratives were around four
different types of healing, so we all know the first type which
is the western healing type and the healer or advisor is a
doctor, they usually say a doctor or a nurse
and the treatment is pills, insulin and dialysis. This is specifically
for diabetes. They focus they say that
for western medicine we focus mostly on the body. We have a large group of
people that actually follow a traditional type of healing that
is our traditional healing. The healer type is traditional
type is traditional healers and the treatment are plant based
and based on traditional knowledge, but the focus there is the spirit, primary focus and secondary focus is
mind and the body. Now compare that to the third
type of healing that we seek we call that local healers. So it’s kind of like
it’s the same thing as traditional healers, but for
traditional healing we focus on the spirit because there’s a lot
of spiritual beliefs that are tied into traditional healing, but with Christianity in the Pacific, many Pacific
Islanders do not consider the “real traditional healing”
as appropriate, because the spiritual is outside of
the Christian beliefs. Pacific Islanders in most of our
research say that they still believe the plants, at
least they work and they also like the emotional support. So they kind differentiate
between traditional healing and local healing on the spiritual
side, so they still seek after the new type of traditional
healer and now they call them local healers. They use the same kind of plant
based product and then on top of that they also use new type
of plant based products. For example, a lot our Pacific
Islanders now, especially in the Chuuk area, the Marshalls and Pushi they use Ampalaya. That is actually a plant
from the Philippines. You know they use that
as cure for diabetes. So that is what we call local
healing, because that was not a plant based knowledge that we
had from the beginning and the primary focus of local healing
is now back to the body. However they do believe that
they do have a secondary focus which is the mind
and the spirit. Mind is usually information and
also emotional support and then we also have this
new type of healing. Interesting enough this is
the healer or the advisors are your family and friends. They used plant based from other
cultures like Ampalaya, but they also use non-plant based. So in Pacific we find all these
waters, these oxidized water, the other new type of healing. We also call that fad
medicine because it comes and goes for the past 20 years. We saw things come
in and go out. For example the oil, the
oxidized water, there’s now a bracelet that you
wear, all of those. That’s another type of healing
that they’re seeking, and of course they say that focus is on the body and then they also are getting mind and spiritual support so a lot of emotional support from these healers. If you really look at this, if
you look at the western model it just focuses mainly on the body,
but the other three they really like the idea of
emotional support and also spiritual support. I just want to say that in
the survey 98 percent of Pacific Islanders actually are
Christians and they also have strong spiritual beliefs and
they believe that spirituality is closely linked to our health. That is the reason why we
decided to do another study and looking at this pathway to
compliance and non-compliance. So in this study we really
look at compliance to western medicine we look
at the other group to see that their compliance is
for a different type of healing, but we want to find out what
makes them comply to western medicine and not just medicine
for diabetes but also comply to nutrition recommendations
and also physical activity recommendations. So there were five different
narratives that came out of that study and the first narrative is
actually the most popular one. They do believe that diabetes is
part of their lifestyle you know by the type of food that
they eat and lack of physical activity, but in the context now it’s important for us to look at beliefs
but also in the context where that belief is at. So in the context they
said there’s no support. They do not have a lot of support
for medication adherence, physical activity and
nutrition, so as a result they talk a lot about emotion. I mean that was the most
shocking thing to me during the study is that they take a lot of
time to describe what their emotional reaction to diabetes
and diabetes treatment. So from that first group they
talk about shame, that they cannot control their diabetes
and a lot of denial so a lot of them deal with it were saying
that well some say shameful but others are well it’s
not going to happen to me or I’m not going to get sick. Then a lot of [inaudible]
additional hope, and then it’s not going to happen, deny so all
those three, attitude, emotion came up over and over again
in that group and at the end they’re not compliant to any
of the recommendations. The third group, the
second to the fourth group always talk about God’s will. Again, like the first set of
subjects this group actually talks about spirituality,
because this group believes they believe diabetes is part of God’s will and then this is God’s global will saying that God actually gave me this disease and I need
to live with it. Of course they do not receive
any support for diabetes, but at the same time the locus of
control is actually outside of themselves so their reaction
to it is very passive. There’s nothing they can
do about it, denial and there’s a lot of sadness. People talk about it is sad to
have diabetes, but there’s nothing they can do about
it, of course no compliance. Third group they say it is God’s
will but it’s also genetics, but the same kind of emotional
reaction, passive, denial and then sadness and
then no compliance. The fourth group talks about
God’s will, but they said God has a global will for our lives;
however it’s also our lifestyle. God also gave us a will to
choose, you know what I mean, gave us a freedom to choose
how to live our lives. So this group talks a lot more
about repentance and they believe that it is actually
going against God’s will to live an unhealthy lifestyle and all
that kind of stuff and we need to actually move into repentance and they really need to repent. Then from that repentance
you will actually be lead to hope and this is actually
the only group that actually reported that they are actually complying to physical activity, nutrition and medication compliance, but if you really look at it it’s just a
minority of the group. This is very few of the 150 that
actually follow this pathway. The last pathway is that you
know a lot of time we don’t talk about this in the Pacific, but
it’s still a group of people that still believe in spirits
other than God’s will. There are other evil
spirits out there that is causing things for them. For example, I hear people say
something like well my mother has diabetes and I did not go
home and take care of her and then she passed away so
she gave me this disease so it’s that kind of spirit. Then of course the context
is no resources, but instead of change now in the hope and
passiveness their emotional reaction is fear and
the compliance is low. I think the most important thing
that came out of these studies is that we really need
especially now we talk a lot about motivational interviewing and motivation actually emotion. So if you really need to look at
motivational interview we really need to look at these emotions. It’s very different for you to
actually motivate somebody who has fear, somebody who is
at sadness and denial and all that kind of stuff. So this study actually will help
us understand more of the emotional part of Pacific
Islanders, but also our disease ideology because we really need to especially such a large group of people
believing not only God’s global will for your life, but
also God’s specific will for them to have diabetes. Then we actually went out
and actually interviewed faith leaders, because from the
focus groups participants say that the people that can
actually influence their thinking when it comes to spiritual matters are not physicians and not nurses. That is actually the
responsibility of faith leaders, so we really need to engage
faith leaders to actually look at this disease ideology
and believe in that context so it was very, very interesting
that they actually identify faith leaders as
a very important part of your care team. A lot of the health care
providers and community health centers and hospitals we
have all these care teams to address diabetes and none of
them have faith leaders or even consider having faith
as part of their team. So then we move on to some of
the key Pacific culture concepts, doing those
research and then going off the big picture now. You know family structure
is important to the Pacific especially if you’re
working with your patient. Make sure that you involve
the entire family. A lot of the Pacific Islanders
follow a major familial line. For example, women are very
influential not only in decision making but they’re also
caregivers, respect for the elders and then the most
important part there is a collectivistic culture. Many times people cannot
control their diabetes because it’s part of a group. In one of the focus groups that
they we did the food that they eat is actually influenced by
what other people are eating, because we eat a lot of meals
together and it’s important for us to cultivate relationships. After a talk like this or
culture competency training allows the health care providers
come up to me like wow now knowing all this spiritual stuff, “Where can I start?” I think a good place to start is
to cultivate that relationship with your patient with good
communication and I’ll go over some of my communication tips. Also, keep in mind you have to
do all this in the context of spirit, mind and the body. So for communications tips
during all these focus groups and 15 years of trying
to hone into some of our communication skills, we came
up with a long tips’ list and these are some of it. The first thing is that say the
encouraging first and last so if you’re giving instructions stay
what is written first just in case we tune out but repeat it at the end, because in our narrative in our [inaudible] in
the Pacific those are the two times that we kind of like
wake up and listen in. Repetition is okay. In a lot of cultures when you
repeat things they’re like am I stupid, why are you repeating
yourself, but in our culture repetition is very,
very important. For example, for Native
Hawaiians all of our songs last verse is whatever [inaudible],
let’s tell the story again. Repetition, that’s how important
repetition is in our culture. Third is do not yell. A lot of times we do not
understand English; that doesn’t mean we’re deaf so yelling was
thing where focus group members saying tell our doctors
not to yell at us and write things down. A lot of times if it’s in
English you write it down and give it to them, because
there’s somebody at home that can translate it and help. I think Dr. Hsu talked
about this learner verification of repeating. Another point is to not use
jargon, slang or idioms. A lot of times you have a hard
time with all these idioms or sayings in the U.S. that
we depend on all the time. Speak clearly and emphasize
the last couple of letters. English as a second language and
if you’re learning English you kind of see and pay attention to
words and especially the last couple of letters, because
that’s how you differentiate the two different words so it’s part
of a tip that’s very important. Then most importantly we
need to mind the gaps. So mind the gaps by culture
you know a lot of the western culture in a
conversation we kind of like finish each other sentence
and it’s a ping pong and goes back and forth very quickly, but there are some cultures that there has to be a gap between
a question and an answer. I find that for westerners
they’re very uncomfortable with that gap, especially
when that patient is not answer you quickly. Then you actually continue
on or answer your own question without waiting. For our culture
many of the Pacific culture we need that gap. We are going to eventually
answer your question, but you need to give us enough time for
us, because there is a gap in our culture that needs
to be respected. Also remember that there are
non-verbal communications. You know for example be cautious
about touching and in eye contact and also pay attention
to your patient or client’s facial expression, body
language and tone. Tone is very important. A lot of times [inaudible] tone
it’s just your tone of voice, we all have different tones. In the Pacific there is. We pay attention to
a lot about tone. Patients talk about that person
was harsh and then when we review the transcript there
was no harsh words in there, but the tone was kind of harsh,
so pay attention to that. For interpreters, you know
a lot of times we all use most of our [inaudible]
interpreters in our practice. For our Pacific culture
older is better. If you’re a younger interpreter
there are a lot of things you cannot say to your elder. For gender same is better. There’s a lot of
stuff women cannot say to men and vice versa. Also keep in mind
confidentiality and privacy. We’re from a very small
community and it’s very hard to find interpreters that actually
do not know each other so you have to make sure you tell your
interpreter that confidentiality is very, very important. Another thing you
have to consider is technology and science literacy. Within a definition of health
literacy there’s actually a part there that talks about
technology and science literacy. So for that many times us
who grew up in the U.S. we’re used to taking health classes. All this technology was around
us, you know what our clinic looked like and all that kind of
stuff, but what if you did not grow up in that environment, you’re not familiar with all these scientific terms and equipment and things like that? So the tip here is take time to
provide health education and define health or
scientific terms. Many times we take it for
granted that we understand all terminology so for your Pacific
Islander patients ask them if they understand and just go ahead and just define them so you all can be on
the same level. Recognize or apologize for using
sensitive words and most times you don’t know what’s sensitive
and not sensitive, so many times in the beginning I always ask our health care providers just say something, I’m going
to say some stuff that might be sensitive so I’m sorry. I’m just saying that to explain
things better and remove uncertainty by explaining
procedures step by step. A lot of times there’s
a lot fear and it’s a fear of uncertainty. So if you explain the procedure
and what you’re going to do step by step that will
remove some of that. Then finally tell patients what
to expect and that is also removing uncertainty, because
sometimes if you know what to expect then that will remove
some of the fear and it relaxes the patient a lot more. Thank you so much and we’re going to move this one to Jude. Okay, wow, thank you,
thank you to both of you. I just want to give you
a very quick summary. I looked at some of the
literature on cultural competency in health
communications for health care providers and essentially you
can see that there are number of issues that both Dr. Hsu
and Dr. Aitaoto brought up. So to answer the questions that
Dr. Hsu answered at the end the answers are yes, you need
awareness of the disease in that group and he gave you
many examples of that. You need to have knowledge of
core cultural issues, but also of the social context and how
the person sees themselves in that social context,
the value systems that most Nia and Will talked about. You do need skills. There are communication skills,
cultural competencies in building the relationship, in gathering information, in gathering history
and assessing what the problem is, and particularly if you’re working with someone who doesn’t speak the language well. Then also the ability to in the
situation perceive different queues and adapt to them, so if
you can see that someone is looking uncomfortable being able to deal with that and identify is it that they don’t
understand, is it that they don’t agree, are you making
some big cultural mistakes? I just want to let you know
before we go to the questions that the Asian American, Native
Hawaiian and Pacific Islander stakeholder group at NDEP did compile all the resources that we have for these populations, in-language, tailored and those that they identified as
relevant to these populations. You can get in touch with
me or go on the website to access these, because it pulls
them all together in one place. We also sent out with the
meeting notice, but also can send out later on handouts of
some other resources related to cultural competence diabetes in AINHPI populations and other diabetes education resources
for AINHPI populations. So now let’s move to your
questions and comments, I can start with
some of the questions that have come over on the web. I think maybe either of
you could take this. We defined ethnicity
but not race, so how would you define race? This is Will. You know race is a very
interesting concept. It’s based mostly on outward
appearance, the color of our skin, the color of our hair,
the way our facial features shape and so on and so forth, but you know part of the reason why it’s so hard to define
is in biology is actually race is a very imprecise term. Think about it. Two people in China may have
vastly different genetic make-up compared to a Chinese
and Caucasian. There could be more similarities
between the two people from different racial groups
compared to two people within the same racial group. So if that’s the case then
how do you define race? That’s why while race is often
self-identified and it’s characterized by specific
biologic traits in the science community it’s very hard to
come up with a definition. Nia, I wonder whether
you have maybe a different angle looking at this. No, actually I love your answer
and for us the way that we describe it is that many times,
especially with the three racial groups under Pacific Islanders it’s the same kind of thing where the racial group we don’t have the same language, but we’re very similar like if you
look at Samoans, Tongans and Native Hawaiians you now physically you look at them it’s kind of the same, racial part but then ethnicity we do have Pacific language and
different cultural practices. So many times like you we
focus a lot more on ethnicity especially when it comes
to culture so culture is a lot more on ethnicity. Of course we have like what,
80 percent stuff that we have in common, but at
the same time that 20 percent is very important. There was a question also and
this is for you Nia about the relationship between
lifestyle and repentance. Oh, that’s from Ann. Hi Ann Leak. Yes, I saw that one. So the thing is if you have
hope then when lifestyle alone doesn’t work in bringing
down A1C then how can you get people to take insulin? Yes, in a narrative we
talk a lot about hope, but what you have your hope in. So when it comes to medication
adherence, because there was a huge part of the study on
western medication adherence and the groups that talk about this
they say well if they have hope their hope is that
God will heal them. They repent, but if the
lifestyle alone is not going to do it, but God does have a will
for your life to be healthy and He did produce medication and
that kind of stuff so if you frame your education around hope and those kind of things then I think that group we are going to do an intervention to actually look at that to see the way that
we frame our messages around hope and medication, especially insulin because it’s very hard. They reported they don’t want to
take the medicine or needle issues and that kind of stuff so
our study we focus a lot more on the narrative on hope and then
also the — that’s why we needed faith leaders to actually
promote medication or say something like it is part
of healing to take this medicine and then move forward. So that, I mean that is a future
study so I’m very excited about doing that study, but there is a
group that really believes that medication is actually part of hope and part of God’s will and that’s actually the
group that actually have a good level of A1C. Actually that was the only group
that has control, their diabetes under control is that group
that talks about hope and the role of medication around hope. Hopefully I helped. Okay, well now please stay
on the line for a minute. We have run out of time. Number one I’d like to thank Dr.
William Hsu and Dr. Nia Aitaoto very much for your
presentations. We will be able to answer the
questions that weren’t answered, we’ll be able to answer them
individually so you will get an answer but please stay on to
fill out a very short survey. One issue that has been brought up is yes this presentation will be available in the future. So we’ve been putting the
contact information up, but if you have any questions please
feel free to get in touch with me and thank you Nia, thank
you Will and thank you for all of you for attending.

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