There’s an old saying that we see the world not as it is, but as we are conditioned to see it. This thought often comes to mind when I think of the latest national shift in the paradigm of health care. The current focus of discussion is “cultural competence” and the need to build a workforce that recognizes and appreciates the myriad factors that shape an individual’s definition of health and his or her experience in the health care system. While many organizations and institutions struggle to define exactly what cultural competence means, nowhere is the understanding of its importance more clear than in day-to-day clinical practice.
Case in point. Late one afternoon, in walks Shaye,* an 18-year-old male with diabetes. The youngest of four children, Shaye wears a low-hanging necklace with a beautiful gold pendant of a laughing Buddha. Shaye’s wide, bright smile is framed by a set of cheeks that look like two round apples. His shirt pokes out at the belly, which he rubs constantly in a way that conveys a touch of nervousness about our first visit.
Judging by the way his body has felt recently, Shaye knows the news of his latest lab results will not be good. He is right. His hemoglobin A1C is over 10. His LDL and triglycerides are double and triple what they should be. And, unfortunately, he has gained weight since his last visit nearly eight months ago. He has a short list of reasons for why things are wrong: He hasn’t been eating right, and, when he eats, he eats too much. He hasn’t been exercising, and what he does find time to do—a little soccer here and there—just isn’t enough. He didn’t pick up the new prescription the previous nurse practitioner gave him, despite the fact that he has prescription-insurance coverage. He even has a manufacturer’s savings card, which would have made it available at no charge.
 |
| dina2001/iStock/Thinkstock |
Contrary to instructions, he has stopped checking his blood sugars daily, because he ran out of lancets, and the prescription didn’t authorize a refill. Instead, every other week or so, he reuses the one he has if he feels bad and senses that his sugars are too high. It could be argued that Shaye is simply noncompliant and full of excuses.
A week later, Nick,* a 54-year-old accountant who hasn’t had time to come to the clinic in nearly nine months, shows up. First, it was the holidays, and he, his wife, and their four children were caught up in planning the family’s annual Christmas and New Year’s Eve parties, and he had simply forgotten. Then, it was spring break, tax season, and a slew of board meetings that he could not afford to miss. With all his responsibilities, he didn’t realize he had run out of one of his diabetic medications and, for some reason, hasn’t even thought to refill it.
As with Shaye, insurance coverage is not an issue for Nick. He came to the clinic partly to get “caught up” and partly because he senses that the news will not be good. Between the numbness and tingling in his feet and his increasingly blurry vision, he knows his condition is uncontrolled. Unlike Shaye, he hasn’t been checking his blood sugars at all, because there is simply no time in the mornings and definitely no time at night when he finishes work not completed earlier in the day.
At home, his elliptical exercise machine is, admittedly, covered with dust, and yes, he has gained a few pounds since his last visit. But, in his estimation, those few pounds don’t exactly qualify as being unhealthy, per se. He is proud of the fact that he has a wife at home who makes sure a balanced meal and a glass of after-dinner gin are ready for him to come home to every night. It could be argued that Nick, too, is full of excuses—some understandable, but excuses nonetheless. For some clinicians, it would be much simpler to cut losses, rewrite prescriptions, and send both of these patients on their way. Both Nick and Shaye illustrate why it’s so important to take the long view when it comes to population health and improving health outcomes—a view that must include foundational awareness and knowledge of the intersections of culture, ethnicity, and linguistics in the health experience of patients and health-care delivery by providers.
In its 2013 Enhanced Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS), the Office of Minority Health seeks to “advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health and health care organizations to implement culturally and linguistically appropriate services.” The enhanced standards offer a comprehensive approach to integrating culturally and linguistically appropriate practices into health-professions education, as well as clinical practice. Culture, in the standards, is broadly defined “in terms of racial, ethnic and linguistic groups, as well as geographical, religious and spiritual, biological and sociological characteristics.” In clinical practice and in teaching, I like to think of cultural competency as the discipline of and commitment to getting to know our patients’ stories.
Shaye’s story is a reflection of culture and socioeconomics. He and his family are recent immigrants from Thailand. His meals, cooked by his mother, are often hearty servings of rice and root vegetables, drenched in thick, spicy sauces unique to Thai culture. Shaye, who is still in high school after being put back a grade upon arriving in the United States, gets little exercise. After school, he works part time at a local Thai restaurant alongside his mother, whose English fluency is limited. Not only does Shaye help bring in additional income, he helps cover his mother’s embarrassment when interacting with customers at the store. Between school and his part-time job, there is little time for formal exercise or after-school participation in sports. This doesn’t bother him. In his culture, he explains, it is understood that families work together. He considers it honorable to help his parents maintain what is needed for their household.
Back home in Thailand, it never occurred to Shaye or his parents that he was obese or that obesity negatively affects a person’s health. Big babies are considered healthy babies. They never heard of the word “diabetes” until they arrived in the States. Most importantly, because the meals he grew up eating—vegetables, stews, and rice—were assumed to be loaded with vitamins and nutrients and were not the same as junk food, he finds it terribly confusing that those things make him feel worse. Shaye’s parents teach their children the value of conserving by reusing what can be reused. Anything less is considered wasteful. He sees no problem in reusing his lancets, because it saves the family money.
Nick’s story is strikingly similar. He grew up in a large Italian family, and a meal without pasta, bread, and wine is simply not a meal. He recalls how his mother and both sets of grandmothers would stand over the table waiting for nods of acceptance from his father, grandfather, and uncles, and how dinner wasn’t finished until every morsel was eaten—a sure sign of a good cook. Even today, Nick and his wife insist that their children finish meals in their entirety. Nick’s liking for wine and other alcoholic beverages, akin to a deep desire, is ingrained from childhood as such drinks were part of the meal as much as vegetables and dessert. As in Shaye’s family, a chubby baby was considered a healthy baby, and a few extra pounds around a man’s midsection at midlife are a sign he is well taken care of.
Critical to effective health care delivery is understanding that the concept of “culture” is far broader than skin color and ethnic origin. Each patient represents a collection of personal histories that includes a full range of biological and sociological influences. Understanding my patients’ personal narratives—their lifestyles, family histories, and health beliefs—helps me better understand their levels of health literacy and identify where there are gaps in their knowledge about their health in general and, more specifically, their diabetes.
In Nick’s case, talking about nutrition and the meaning of food at a level beyond calorie counting and carb elimination was time well spent, a chance to discuss work-life balance with him and help him set healthier boundaries that would allow time for exercise, glucose monitoring, and basic self-care. More importantly, it was an opportunity for me to see my work in diabetes prevention through a broader lens than just numbers.
* Names have been changed to protect identities.
For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.
No comments:
Post a Comment