PRINCIPLES OF ORAL HEALTH MANAGEMENT FOR THE HIV/AIDS

PATIENT

CULTURAL COMPETENCY

Elias J. Llerandi, DMDClinical Instructor, NY Medical College

Consultant, NYS Dept. of HealthStaff Dentist, Dept. of V.A.Private Practice, Queens

Former Chief of Service, Spellman Dental Clinic, SVMH

OBJECTIVES

• Define and Recognize fundamental characteristics of Culture

• Identify components of the process of Cultural Competence

• Discuss the importance of understanding cultural variation in the dental clinical setting and how it influences our Tx plan and its implementation

CULTURE

• What is it?

…acting, feeling, judging, perceiving, and organizing (Shade, Kelly and Oberg, 1997)

• Why is it important?

-facilitates tx plans that can be followed by pts and supported by their families

-enhances communication and clinical interaction

-helps Bottom line: Leads to retention of pts in a competitive environment ($$$)

CHARACTERISTICS OF CULTURE

• Learned Behavior

• Shared

• Ever-changing

• No culture is better of worst than another, they are just different

CULTURAL COMPETENCY

• A SET OF CONGRUENT BEHAVIORS, ATTITUDES AND POLICIES THAT COME TOGETHER IN A SYSTEM, AGENCY OR AMONG PROFFESIONALS AND ENABLE THAT GROUP TO WORK EFFECTIVELY IN CROSS-CULTURAL SITUATIONS

SPECIAL POPULATIONS IN HIV

• Racial & Ethnic Minorities

• Women

• Substance Abusers

• Gay/Lesbian/Bi-sexual/Transgender

• MSM

Disproportionate Incidence of New Cases of HIV/AIDS in People of Color in 2002

Total US PopulationTotal US Population(n=288,369,000)(n=288,369,000)

White*69%

Black*Black* HispanicHispanic

OtherOther

12%12%13%

5%

15

30

45

60

Black* White* Hispanic Black* White* Hispanic

54%54%

26%26%19%19%

New HIV CasesNew HIV Cases(n=40,000)(n=40,000)

Cas

es (

%)

Cas

es (

%)

15

30

45

60

Black* White* Hispanic Black* White* Hispanic

50.4%50.4%

28.4%28.4%

19.6%19.6%

New AIDS CasesNew AIDS Cases(n=42,024)(n=42,024)

Cas

es (

%)

Cas

es (

%)

*Not Hispanic.CDC: HIV/AIDS Surveillance Report. 12/2003.

CULTURAL VARIATIONS

Communication: Verbal, non-verbal, silence, eye contact

Space: Degree of comfort, perception of space

Social Organization: church, family

Time: latinos/substance abusers

Environmental controls: ‘I am undetectable’

CULTURAL VARIATIONS

Communication: Verbal, non-verbal, silence, eye contact

Space: Degree of comfort, perception of space

Social Organization: church, family

Time: latinos/substance abusers

Environmental controls: ‘I am undetectable’

Incorporating Culture into Health

• Individual Pt-Provider & System Level

• Culture influences help seeking behavior and attitudes toward HCP

• Communication must be clear

• Pt has personal experiences of biases within the healthcare system

• HCP from culturally and linguistically diverse groups are under represented

Recipe for Disaster

• Alcohol• Ether (starting fluid)• Benzene• Paint thinner• Freon• Acetone• Camp stove fuel• Ammonia• Red Phosphorous

• Toluene (brake cleaner)• Red Devil Lye• Drain cleaner• Battery Acid• Lithium from batteries• Ephedrine• Cold tablets• Diet aids• Energy boosters

Health Literacy

POTENTIAL FAILURES!!!

• HCP are reluctant to offer Tx plan option to pts they believe will be non-compliant

• MDs are more likely to Rx HAART to those perceived to be likely to be adherent

• MDs were more likely to tx African Americans as non-adherent

( Bogart et al.,2001)

Do not limit tx plan choices based on assumptions about a cultural group…

PT-HCP COMMUNICATION CHALLENGES

• 40-80% OF MEDICAL INFORMATION IS

IMMEDIATELY FORGOTTEN

• HALF IS REMEMBERED INCORRECTLY

• THE MORE GIVEN, THE MORE FORGOTTEN

• SPEAKING INFO-17%

• SPEAK AND SHOW-84%

PROCESS OF CULTURAL COMPETENCE

• Cultural Awareness: Front desk

appreciates/respects values and problem solving

strategies

• Cultural Knowledge: Seeking/obtaining factual info

on different cultures…’TWO MASK JOB’…

• Cultural Skill: Collect relevant data about health

hx/problems latinos HIV is taboo/’DL’ in aa

FROM DESTRUCTIVENESS TO PROFICINECY

• Cultural Destructiveness: misinforming pt of

medical risks and benefits e.g.: LA Co. DHS

measles study, sargenti

• Cultural Blindness: color or culture makes no

difference , all people are the same OR making

services so ethno centric as to render them useless to

other cultures

FROM DESTRUCTIVENESS TO PROFICINECY

• Cultural Pre-Competence:

hire staff that reflects different cultures

Training

Needs assessments

Recruit diverse individuals to advisory committees

FROM DESTRUCTIVENESS TO PROFICINECY

• Cultural Competence:

Respect for difference

Continue self-assessment

Continue expansion

Adapt

FROM DESTRUCTIVENESS TO PROFICINECY

• Cultural Proficiency:

Hold culture in high esteem

Close cultural gaps and improve service delivery

Positive tx outcome

Minimize oral disease with systemic consequences

Improve quality of life

MINORITIES AND HIV

• 63.8% of new AIDS cases in men (3/5)

• 81.9% of new AIDS cases in women (4/5)

• 85.6% of new AIDS cases in children (4/5)

• Latinos receive an AIDS diagnosis at early

ages(<30yrs old)

LATINOS AND HIV

• Latinos have different perception of time, more

flexible understanding of punctuality

• Saving time less important than a warm

relationship.

• May see as rudeness a hurried pace or focus on

saving time

TRANSGENDER (LGBT)

• Bigender, MTF, FTM

• Identities change

• Hormones and Surgery

• Transgender=Gay

TRANSGENDER (LGBT)

• The Office:

‘Scan’

Train staff

Forms

Unisex bathroom

Non discrimination policy poster visibly

HOW CAN WE BE EFFECTIVE

• Become familiar w/ pts culture

• Respect pt’s desires

• Modify teaching as necessary

• Involve family/significant other

• DO NOT BE JUDGEMENTAL