Culturally Effective Pediatric Care in a
Community-based Health Program
April 7, 2011
-Denice Cora-Bramble MD, MBA, FAAP
-Dodi Meyer MD, FAAP
Webinar Objectives:
1. Understand the American Academy of Pediatrics’
definition of culturally effective care.
2. Learn about the Culturally Effective Care Toolkit
and how to apply concepts from the toolkit to a
community-based health program.
3. Learn how a current Healthy Tomorrows grantee
is addressing low health literacy levels through
their Healthy Tomorrows project.
American Academy of Pediatrics’
Culturally Effective Care Toolkit
Denice Cora-Bramble, MD, MBA
Lead Author, AAP Culturally Effective Care Toolkit
Senior Vice President, Children’s National Medical Center
Goldberg Center for Community Pediatric Health
Professor of Pediatrics, George Washington University
Overview




Culturally Effective Care
AAP toolkit development
Website architecture
Case studies & application of toolkit
resources
 Q&A
Case Study to Frame the
Discussion
Your last case of the day is a 6 y.o. Hispanic male
referred by the school nurse because of a fever
of 400C. His mother accompanies the patient but
does not speak English. The patient speaks and
understands both English & Spanish. Your only
on-site trained interpreter left for the day and
you only know a few words in Spanish.
What are your next steps?
Culturally Effective Care
Culturally Effective Care
“The delivery of care within the context of appropriate
physician knowledge, understanding, and appreciation of
cultural distinctions. Such understanding should take
into account the beliefs, values, actions, customs and
unique health care needs of distinct population groups.
Providers will thus enhance interpersonal and
communication skills, thereby strengthening the
physician-patient relationship and maximizing the health
status of patients”.
AAP Committee on Pediatric Workforce:
Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy
Pediatrics 2004;114;1677-1685
Quality of Care
Safety
Effectiveness
EQUITY
Patient
centeredness
No variations in the quality of
care according to patients’
personal characteristics,
including race and ethnicity
Timeliness
Efficiency
Equity
Institute of Medicine. Crossing the Quality Chasm: a New
Health System for the 21st Century. Washington, DC:
National Academies Press, 2001
Diversifying U.S. Population
Estimates of US Population 2000 to 2050
(U.S. Census Bureau)
100%
90%
Percent of Population
80%
70%
69.4
65.1
57.5
61.3
53.7
50.1
60%
.White alone, not Hispanic
50%
.All other races
.Hispanic (of any race)
.Asian Alone
40%
30%
12.6
20%
10%
15.5
20.1
17.8
22.3
24.4
4.1
6.2
4.7
7.1
5.3
2.5
3.8
3.0
4.6
3.5
5.4
12.7
13.1
13.5
13.9
14.3
14.6
2000
2010
2020
2030
2040
2050
8.0
0%
Year
.Black alone
How do these changes impact
the clinical setting?
 In California, Latino children comprise the
largest group of children
US Census Bureau, 2000
 By the year 2020, an estimated 1 in 5
children in the US will be Latino
Changing America: Indicators of Social and Economic Well-Being by Race and Hispanic
Origin; Council of Economic Advisors for the President’s Initiative on Race, 1998
AAP Toolkit Development
Toolkit Development Team
 Lead Author: Denice Cora-Bramble, MD, MBA, FAAP
 Lead Staff: Regina M. Shaefer, MPH
 Review Group
– Julio Bracero, MD, Section on Medical Students, Residents, and
Fellowship Trainees
– Colleen Kraft, MD, FAAP, Council on Community Pediatrics
– Alice Kuo, MD, PhD, MEd, FAAP, Council on Community
Pediatrics
– Dennis Vickers, MD, MPH, FAAP, Medical Home Initiatives
– William Zurhellen, MD, FAAP, Section on Administration and
Practice Management, Practice
– Management Online Editorial Board
– Mary Brown, MD, FAAP, American Academy of Pediatrics Board
of Directors
Culturally Effective Care Toolkit Needs
Assessment Results
September 2009
Do questions regarding the delivery of culturally effective care
(such as language/interpretive services, traditional practices,
cross-cultural communication) arise as you are caring for patients?
No, 4.7%
n=278
Yes, 95.3%
Culturally Effective Care Toolkit Needs
Assessment Results
September 2009
Which specific delivery mechanisms for culturally effective care resources
would be most useful for you? (check top 3 delivery mechanisms)
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
74.1%
74.1%
55.1%
26.6%
32.3%
25.1%
10.3%
Web-based
Resources
Patient
Materials in
Other
Languages
Topicspecific
CME
Best 10
Articles
Annotated
Bibliography
11.0%
DVD/Video
Loan
Library
Interpretive
Services
Information
Culturally
Effective
Care
Manual
n=263
Culturally Effective Care Toolkit Needs
Assessment Results
September 2009
Which specific topics would be most helpful for a culturally
effective care toolkit to include? (check top 3 tools)
70.0%
60.0%
58.9%
58.2%
47.5%
50.0%
41.8%
40.0%
35.7%
30.8%
30.0%
22.8%
20.0%
14.8%
10.0%
0.0%
Conducting
cultural
interview
Using
interpreter
services
Presentation Conducting
Conducting
f or
organization
individual
of f ice/clinical cultural comp cultural comp
staf f
assessment assessment
Literacy
Cost analysis
assessment of interpretive
services
Accessing
community
resources
n=263
Website Architecture
Case studies & application of
toolkit resources
Case Study #1
Your last case of the day is a 6 y.o. Hispanic male
referred by the school nurse because of a fever
of 400C. His mother accompanies the patient but
does not speak English. The patient speaks and
understands both English & Spanish. The only
on-site trained interpreter left for the day and
you only know a few words in Spanish.
What are your next steps?
Linguistic Barriers
Studies have documented the multiplicity of
adverse effects that language barriers
have in health care including:
– Impaired health status, nonadherence to
medication regiments, higher resource use for
diagnostic testing and others
Flores G: Dolor Aqui? Fiebre?: Arch Pediatr Adolesc Med; Vol156, 638-640; 2002
Linguistic Barriers
One study identified language problems as
the single greatest barrier to health care
access for Latino children.
Flores G and Abreau M: Access Barriers to Health Care for Latino Children; Arch Pediatr Adolesc
Med, Vol 152(11), 1119-1125; 1998
Interpretive Services
 Medical interpreter as an essential
component of effective communication
between the limited English proficient
(LEP) patient and health care provider
 Professional in-house, ad hoc, untrained
family member, non-clinical hospital
employee, stranger
 Untrained commit many errors
Flores G et at.: Errors in Medical Interpretation and Their Potential Clinical Consequences. Pediatrics;
Vol 111(1); 6-14; 2003
Clinically Significant Medical Errors
 Omissions
– Drug allergies
– Past medical history
– Chief complaint
 Substitutions
– Abx for 2 days instead of 10
– HC to entire body instead of lesion
Flores G et at.: Errors in Medical Interpretation and Their Potential Clinical Consequences.
Pediatrics; Vol 111(1); 6-14; 2003
Toolkit Resource: Interpretive
Services Section
I.
II.
III.
IV.
Options for providing interpretive services
Pros & cons associated with different options
Cost & payer payment
Integrating interpretive services into office
systems & practice
V. What to look for in hiring/contracting for
interpretive services
VI. Pitfalls to avoid
VII. Tips for working effectively with interpreters
VIII. Assessing the need for interpretive services
Case #2
You have been treating a 7 year old with
severe and poorly controlled asthma. The
parents refuse to use the inhaled steroids
as prescribed and continue to rely on
traditional medicine.
What are the next steps in managing this
patient?
Asthma Disparities:
More than Access Barriers
 African American and Latino children
enrolled in Medicaid managed care had
worse asthma status and were less likely
to be using preventive asthma medications
than White children.
 This disparity persisted after adjusting for
socioeconomic status.
Lieu T et al.: Ethnic Variation in Asthma Status and Management Practices Among Children in
Managed Medicaid; Pediatrics 109(5);
857-865; 2002
Sociocultural Determinants
of Health
 Parental and child health beliefs
 Knowledge of asthma and asthma
management
 Competition with other basic life needs
 Environmental factors
– Can parents afford to control the
environmental triggers?
Mansour M et al.: Barriers to Asthma Care in Urban Children: Parent Perspectives. Pediatrics
106(3);512-519
Sociocultural Determinants
of Health
 Racial and ethnic differences in health
beliefs and concepts of disease
 Differences in beliefs about the value of
prevention
 Fears about steroids
 Lack of regularity in the life of the family
Lieu T et al.: Ethnic Variation in Asthma Status and Management Practices Among Children in
Managed Medicaid; Pediatrics 109(5);
857-865; 2002
Understanding Pediatric
Asthma Disparities
While the control and treatment for asthma
is primarily based on medications, some
parents have strong personal and cultural
beliefs against the use of medications.
Belief Systems and Asthma
 60% of Dominican mothers believed that
their child did not have asthma in absence
of symptoms
 88% thought that medicines are overused
in the US
 72% did not use prescribed medicines but
substituted traditional practices instead
Bearison DJ et al.: Medical Management of Asthma and Folk Medicine in a Hispanic Community.
J Pediatr Psychol; 24(4);385-392;2002
Traditional Practices Used in
the Treatment of Asthma
Ethnomedical therapies
– Prayer
– Vicks VapoRub or “alcanfor”
– “Siete jarabes”
– “Agua maravilla”
– “Te de manzanilla”
Pachter L et al.: Ethnomedical (Folk) Remedies for Childhood Asthma in a Mainland Puerto
Rican Community. Arch Pediatr Adolesc Med, Vol149(9);982-988;1995
Culturally Effective Toolkit: Health
Beliefs and Practices
I.
II.
III.
Clinic and Emergency Department Use
Pain and Analgesia
Traditional Practices, Alternative Medicine
and Indigenous Healers
IV. Bed Sharing and SIDS
V. Birth and Early Infancy
VI. Death and Dying
VII. Role of Women
VIII. Role of Family
Culturally Effective Care Toolkit: What Is
Culturally Effective Pediatric Care?
Final Thoughts
“But culture in all its richness, does not
simply explain health behaviors, nor does
sensitivity to culture solve health
disparities. Rather, culture works
dynamically, in conjunction with economic
and social factors, to affect health
behaviors and to alleviate or exacerbate
health disparities.”
Gregg J, et al: Loosing Culture on the Way to Competence: The Use and Misuse of Culture in Medical
Education. Academic Medicine;2006;81(6);542-547
Contact Information
Please submit your questions via the question pane.
Denice Cora-Bramble, MD, MBA
Professor of Pediatrics, George Washington Univ.
Senior Vice President
Children’s National Medical Center
Goldberg Center for Community Pediatric Health
111 Michigan Ave., N.W.
Washington, D.C. 20010
(202) 476-5857
dcorabra@cnmc.org
HEALTH EDUCATION & ADULT LITERACY
PROGRAM
Bridging the Communication Gap
Between Medical Providers and Patients
Dodi Meyer, MD, Emelin Martinez, Marina Catallozzi, MD,
Rosa Morel
Community Pediatrics
Ambulatory Care Network- New York Presbyterian,
Columbia University Medical Center
Alianza Dominicana
Practice Setting
• Community based, hospital affiliated
primary care practice in Northern
Manhattan
• Faculty run, resident integrated
practice
• 11,000 visits per year representing
approx 5000 patients
Patient Population
• Mostly Latino: Dominican, Mexican
• Low SES: 73.3% born into poor families
• Limited English Proficiency : 40% children
have LEP
• Health Literacy Level: 83.8% ranging from
limited to possibly limited HL using NVS
•
U.S. Census 2000. Manhattan, New York Community District 12. Retrieved from http://www.infoshare.org.
Citizen Committee for Children, NYC 2005
Personal communication: Larson, Nevarra 2011.
Impact of Low Health Literacy
•
•
•
•
Health outcomes
Healthcare costs
Quality of care
Medication administration practices
Health Literacy Interventions and Outcomes: An Updated Systematic Review, Structured Abstract. Agency for
Healthcare Research and Quality, March 28, 2011
Yin, et al. Parents medication administration errors: Role of dosing instruments and health literacy. Arch Pediatric
Adolesc Med 2010; 164 (2): 181-186.
Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.) (2004). Health literacy: A prescription to end confusion.
Washington, DC: National Academies Press.
Healthy People 2010: Health communication. 2000: 11-20. Office of Disease Prevention and Health Promotion
HEAL: Health Education Adult Health Literacy
Modeled after the Health Education and Literacy for Parents Project at Bellevue Hospital, NYC
Goal:
Improve health literacy of the population
served with a focus on medication
administration
HEAL
• Educational interventions can improve health
knowledge, behaviors and use of healthcare
resources among patients with low health
literacy (HL).
• Interventions must integrate HL with cultural
and linguistic competency
• Interventions must address service needs of
patients and training needs of providers
Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled
trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among
caregivers of young children. Arch Pediatr Adolesc Med, 162(9), 814-822.
Paasche-Orlow, M. K., Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. Am J Health
Behav, 31, S19–S26.
HEAL: Principles Used
• Partnership model
• Participatory, collaborative process
• Link to existing coalitions,
organizations
Target Population
• All patients in community basedhospital affiliated practices
• Clients served by a Home Visiting
Program ( Best Beginnings/ Alianza
Dominicana)
HEAL Program Objectives
• Objective 1: To develop culturally responsive health
education material regarding medication
administration using the basic tenets of health literacy
• Objective 2: To train pediatric providers, family support
workers, and volunteers to appropriately address low
health literacy in different health care settings
• Objective 3: Implement the HEAL curriculum in health
care organizations and community based
organizations serving the Northern Manhattan
population
Curriculum Development
Purpose of Curriculum:
Increase patient’s involvement in planning care
Enhance patient’s understanding of medication use
Improve patient’s adherence to medical instructions
Teaching Methodology:
Training driven by patient interest and prior
knowledge
Information conveyed in a non didactical method
Curriculum Development: Focus Groups
• Three focus groups in community setting (two
in Spanish/one in English)
• 22 participants
• Domains:
communication, medications, expectations,
physician qualities, clinic qualities and home
remedies.
48
FOCUS GROUPS FINDINGS
Communicating with Doctors
• Explain specific ailments verbally, not with handouts.
• Outline a treatment plan for the family and ask for the family’s input. Give the
family several options
Medications
• General distrust of medications. Fear of overdose and side effects. When they
don’t want to give medicine and use something else instead, they don’t tell the
doctor.
• Want accurate instructions that include a visual and tsp/ml conversion for oral
syringes.
• When they pick out OTCs they ask friends or use previously used OTCs
• When they go to the doctor for a sick visit they expect medication
Home Remedies
• For some, a secondary healing source after western medicine does not work.
Others use when children too small for OTCs
• Some don’t tell doctor about home remedies because it would insult the
doctor/patient relationship. Others don’t tell the doctor because they fear a
negative response
49
Components of the HEAL Curriculum
• PREPARING FOR A VISIT TO THE DOCTOR
– Preparations Prior to a Medical Visit
– My Child’s Medical History
– Medical Words That You May Hear or See
• PRESCRIBED MEDICATION
– Understanding Prescribed Medication Labels
• OVER-THE-COUNTER MEDICINE
– Understanding OTC Medication Label
– Selecting OTC Medications for Children Over 6
• MEDICATION MANAGEMENT
– How to Give Medicine
– Medication Logs
• HOME REMEDIES
– Common Home Remedies Used in the Community
– Disclosing Use of Home Remedies to Medical Providers
HOW DO I CHOOSE AN OVER THE COUNTER
COLD MEDICINE?
Over the Counter Cold Medicines should NOT be given to children under the age of 2.
For children between the ages of 2-6, talk to your doctor first! Children over the age of 6
can use Over the Counter Cold Medicines.
Newborn to 2 months old:
A baby under 2 months with cold symptoms should be seen by a doctor. NO MEDICATIONS
ARE SAFE!
Ages 2 months to 2 years:
Ages 2 to 6 years:
DO use as directed:
Tylenol
Motrin (> 6 months old)
DO use as directed:
Tylenol
Motrin
DO NOT use:
Vicks Vapor Rub
Pediacare products
Robitussin products
Triaminic products
Dimetapp products
Other medications in a the store
Use ONLY after talking to a doctor:
Pediacare products
Robitussin products
Triaminic products
Dimetapp products
Vicks Vapor Rub and Vicks products
The following label is the most recent U.S, Food & Drug Administration
approved over-the-counter drug label format.
Active Ingredient: The main
medicine. If I want to take more than
one medication with the same active
ingredient I should talk to my doctor
first.
Purpose: The type
of medicine.
Uses: Tells you what it treats. Do you have
these symptoms?
Warnings: Reasons not to use or stop
using the medicine.
Directions: How to take, how often
and how much medicine to give for a
specific age.
Other information: How to store
medicine.
Inactive ingredients: These
ingredients are not the ones that fix
you.
TOOLS TO MEASURE WITH:
Dropper
Oral
Syringe
Tablespoon
Teaspoon
Dosage Cup
Converting Units of Measurement
•
•
•
•
•
•
•
CC stands for cubic centimeters
ML stands for milliliters
One cc = one ml
One teaspoon (tsp) = 5 cc = 5 ml
One Tablespoon (Tbl) = 15 cc = 15 ml
One Tablespoon = 3 teaspoons
One ounce = 30 cc = 30 ml = 2
Tablespoons = 6 teaspoons
Measuring Liquid Medicines
5 cc = 5 ml = 1 teaspoon (tsp)
=
5 ml = 1
Teaspoon
5 ml = 1
Teaspoon
+
+
15 ml =
Tablespoon
=
5 ml = 1
Teaspoon
Physician Training: Parent/Patient Exit Interviews
•
•
•
Clinical observation at two randomly selected clinics
20 physicians observed using a checklist
Communication issues identified:
•
•
•
•
•
•
•
Allowing the patient’s parent to describe the problem
uninterrupted
Asking if the patient’s parent has questions before the end of the
visit
Using visual methods
Identifying additional resources
Knowing and using the teach-back method, particularly
regarding medication instructions
Asking about the patient parent’s ability to follow treatment plans
Using the translator phone when needed
Content of Training for Physicians and FSWs
• Principles of health literacy
• Communication skills: effectively
communicate with families who may have
low health literacy levels.
• Teach back method: identify
misunderstandings and allow clients/patients
to enhance personal knowledge.
Williams, M. V., Davis, T., Parker, R. M., Weiss, B. D. (2002). The role of health literacy in patient-physician
communication. Fam Med, 34(5), 383-9.
Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse
populations. American Journal of Health Behavior, 31(Suppl 1), S122-133.
Turner, T., Cull, W. L., Bayldon, B., Klass, P., Sanders, L. M., Frintner, M. P., et al. (2009). Pediatricians and health
literacy: Descriptive results from a national survey. Pediatrics, 124, S299-S305.
TRAINING
• Physicians
– Pediatric residents
– General Pediatric Faculty
• Medical students
• Volunteers (from surrounding colleges)
• Family Support Workers
60
CURRICULUM IMPLEMENTATION
•
•
Waiting Rooms at community basedhospital affiliated practices
Clients’ homes enrolled in home
visiting program
Evaluation
• Process
• Outcome
Caregivers Encountered in
Waiting Rooms with HEAL Curriculum
700
609
600
502
500
400
300
200
100
0
Total Caregivers Approached
Total Caregivers Interested in
Curriculum
Rate of HEAL Topics Discussed
Topics Discussed in Waiting Room Patient Encounters
10%
3%
24%
Preparing For A Visit
OTC
16%
Prescription Medications
Medication Management
Home Remedies
12%
18%
The Cold & Flu
Use of Antibiotics
17%
People trained
•
•
•
•
•
16 pediatric faculty
64 pediatric residents
9 first year medical students
46 Family Support Workers
30 volunteers
Outcome Evaluation
1) Pre-post knowledge test:
– FSW: significant difference (W=-3.493,
p=0.0005)
– Faculty: No statistical significance
2) Feedback logs: collected in waiting
rooms
Feedback Logs
Lessons Learned From Encounters
Understanding Prescribed
Medication Labels.
Understanding OTC
Medication Labels.
Caregivers Who
Demonstrated
Discomfort
Reading Label
34%
Caregivers Who
Demonstrated
Comfort Reading
Label
66%
Caregivers w ho w ere
comfortable reading
label and using OTC
38%
62%
Use of Home Remedies.
300
Incidences of
Home Remedies
Topic Discussed
250
200
Patient uses home
remedies
150
100
Discloses the Use
of Home Remedies
to Doctor
50
0
1
Caregivers w ho had
difficulties reading
label and using OTC
How program evolved
• Research need to demonstrate
effectiveness of the program
• H1N1 epidemic:
– Need to teach patients about emergent virus
– Treatment of the flu and the common cold
Revised HEAL Curriculum
•
•
•
•
•
•
•
PREPARING FOR A VISIT TO THE DOCTOR
– Preparations Prior to a Medical Visit
– My Child’s Medical History
– Medical Words That You May Hear or See
TREATING THE COMMON COLD & FLU
– What Is a Cold and How to Treat It?
– Distinguishing Between the Common Cold & Flu
– How to Treat & Prevent the Flu
USING ANTIBIOTICS
– What Does it Treat?
– Safe Way to Use Antibiotics
– Results of Misusing Antibiotics
PRESCRIBED MEDICATION
– Understanding Prescribed Medication Labels
OVER-THE-COUNTER MEDICINE
– Understanding OTC Medication Label
– Selecting OTC Medications for Children Over 6
MEDICATION MANAGEMENT
– How to Give Medicine
– Medication Logs
HOME REMEDIES
– Common Home Remedies Used in the Community
– Disclosing the Use of Home Remedies to Medical Providers
Implementing HEAL in Research
Melissa Stockwell MD MPH, Elaine Larson RN PhD, Dodi Meyer, MD,
Marina Catallozzi MD, Anu Subramony MD MBA
•
Appropriate Care of Upper Respiratory Infections (ACURI)
Collaborative and Multidisciplinary Pilot Research Study (CaMPR,
2009) funded by CUMC CTSA
– Goal: determine impact of 3 health literacy modules with regard to
treatment of the common cold in a Latino Head start population
•
Appropriate Care of Upper Respiratory Infections (ACURI) funded by
NIH/ NIMHD :
Randomized control study to evaluate a health literacy intervention
among Latino Early Head Start/Head Start parents.
– Goals: Increase health literacy levels regarding upper respiratory
infections (URI) , decrease pediatric emergency department visits
for viral URI, determine the cost effectiveness of this intervention
Implementing HEAL in research
Anu Subramony MD MBA, Melissa Stockwell MD MPH, Elaine
Larson RN PhD, Dodi Meyer, MD
•
Decreasing Medication Administration Errors: A Health Literacy
Intervention
Collaborative and Multidisciplinary Pilot Research Study (CaMPR,
2010) funded by CUMC CTSA
– Goals: decrease medication errors in our community by
developing an web based educational module to be implemented
at discharge form our emergency room
HEALth Literacy Initiative:
Delivery Model
Direct service: ACN Clinics & CBOs
Training
HEAL
Pediatricians,
residents, CHWs
Service
Individual patient encounters
with pediatricians and
residents in waiting room and
individual client encounters
with CHWs
Curriculum
Focus groups to inform
development and
implementation
Community-engaged research
Head Start/Early
Head Start /ER
/CBO home visit
Outcomes
Health practices
ER use
Challenges
• Recruiting volunteers for teaching in
the waiting room
• Assessing long term impact of waiting
room education program
Conclusions
• Patients and clients are receptive to the
curriculum
• Physicians and FSW recognize need for
training in this area
Developing and Implementing a Culturally-Responsive Health Literacy Program in a Pediatric Immigrant
Community (unpublished data)
Conclusions
• Need to establish a process for HL
curriculum development and
implementation that is applicable to
any community regardless of
demographic served, health topic
addressed, language used or health
belief embraced
FUNDING PROVIDED BY:
Healthy Tomorrows
Maternal Child Health Bureau
in partnership with the
American Academy of Pediatrics
Questions
Please type your question
into the question pane.
Thank you!