Jessica Gregg

Losing culture on the way to competence: the use and misuse of culture in medical education.

Most cultural competence programs are based on traditional models of cross-cultural education that were motivated primarily by the desire to alleviate barriers to effective health care for immigrants, refugees, and others on the sociocultural margin. The main driver of renewed interest in cultural competence in the health professions has been the call to eliminate racial and ethnic disparities in the quality of health care. This mismatch between the motivation behind the design of cross-cultural education programs and the motivation behind their current application creates significant problems. First, in trying to define cultural boundaries or norms, programs may inadvertently reinforce racial and ethnic biases and stereotypes while doing little to clarify the actual complex sociocultural contexts in which patients live. Second, in attempting to address racial and ethnic disparities through cultural competence training, educators too often conflate these distinct concepts. To make this argument, the authors first discuss the relevance of culture to health and health care generally, and to disparities in particular. They then examine the concept of culture, paying particular attention to how it has been used (and misused) in cultural competence training. Finally, they discuss the implications of these ideas for health professions education.

A time for change: an exploration of attitudes toward part-time work in academia among women internists and their division chiefs.

Background Increasing numbers of clinicians desire part-time work, and many will opt out of academic medicine if the barriers to part-time work are too great. Method Purposeful sampling was used to investigate the experiences of part-time academic physicians and their division leaders to understand (1) how each identified the negative and positive consequences of part-time work, and (2) how each conceptualize part-time work. In 2004, the authors interviewed the Society of General Medicine Horn Scholars Program applicants and their division chiefs from the 2001 and 2004 award cycles and performed a qualitative analysis of the one- to two-hour audiotaped interviews. Results Seven out of nine eligible applicants and six of seven division chiefs participated. All applicants were female junior faculty clinician educators in academic internal medicine from seven institutions. All division chiefs were male full-time faculty members. Both applicants and division chiefs identified multiple specific negative and positive consequences of part-time work. Analysis of interviews suggested that both groups tended to frame part-time work as a decision to “work less” or to “work differently.” Self-reflection and articulation of values helped some faculty determine where they derive the greatest happiness and fulfillment personally and professionally. Conclusions As more academics seek work–life balance and consider part-time work as a tool to achieve that balance, academic medicine will be challenged to develop creative models for integrating successful part-time physicians, or it will lose that segment of the workforce. This study’s findings suggest that one such model may require that physicians and their leaders reconceptualize work altogether.

Communicative Competence: A Framework for Understanding Language Barriers in Health Care

When clinicians and their patients speak different languages, patient care and clinical outcomes suffer. Specifically, when patients have limited English proficiency (LEP) they have worse access to care, receive poorer quality care, are less likely to understand and adhere to care plans, and are less satisfied with their physicians and the care they do receive.1

“You Always End up Feeling Like You’re Some Hypochondriac”: Intimate Partner Violence Survivors’ Experiences Addressing Depression and Pain

Little is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression. Focus group study. Adult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV. Thematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm. Twenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a “full picture” of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were “all in their head” or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust. Understanding a patient’s IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients’ intelligence, experience, and complexity; and to share control.ObjectiveLittle is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression.DesignFocus group study.Patients/ParticipantsAdult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV.InterventionsThematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm.Measurements and Main ResultsTwenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a “full picture” of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were “all in their head” or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust.ConclusionsUnderstanding a patient’s IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients’ intelligence, experience, and complexity; and to share control.

Prioritizing Prevention: Culture, Context, and Cervical Cancer Screening among Vietnamese American Women

Few studies have investigated what Vietnamese American women believe about the Pap smear or how those beliefs might influence behavior. Thirty-one Vietnamese American women recruited through snowball sampling were interviewed about their beliefs regarding the Pap smear. Interviews were qualitatively analyzed using a theoretically informed, inductive approach. The women interviewed emphasized the importance of primary prevention of disease through culturally-informed personal health regimens. They were also largely unfamiliar with the Pap smear, but believed that gynecological exams in general were effective and necessary for disease detection. Finally, when access to gynecological care was difficult, women’s faith in their own preventive behaviors helped alleviate their concerns over lack of care. While culturally associated beliefs do not simply “cause” Vietnamese American women to seek or avoid Pap smears, they do influence screening behaviors to a greater or lesser degree, depending on other contextual variables.

Beliefs About the Pap Smear Among Mexican Immigrants

Few studies have examined Latinos’ beliefs about the Pap smear or what uses they attribute to the procedure. We conducted qualitative interviews with 28 Mexican immigrant women and 23 Mexican immigrant men recruited through snowball sampling. We found that individuals learned about the Pap smear from a wide variety of sources and often understood the exam to be a screening test for sexually transmitted infections in general. They also related the need for Pap smears and the development of cervical cancer to high risk sexual behaviors. Finally, participants considered men to have a significant role as vectors for disease and as barriers to screening. Our results suggest that interventions to improve cervical cancer prevention among Mexican immigrants may be most effective if they include both men and women and if they recognize and address concerns about STI spread and prevention. Furthermore, interventions must recognize that even when women know how to prevent disease, they may feel disempowered with regard to making behavioral changes that will decrease their risk for STIs or cancer.

Mixed blessings: cervical cancer screening in Recife, Brazil.

This study examines the effects of a large‐scale cervical cancer prevention campaign in Recife, Brazil between 1994 and 1995. It suggests that while this program effectively motivated women to get pap smears, it reinforced local understandings of the pap smear that ultimately had unintended negative consequences for womens health. It argues that because the campaign connected female sexual activity directly with cervical cancer, the programs message was interpreted by many women to mean that cervical cancer was a sexually transmitted disease and that it would behave like one. Women who were no longer sexually active believed that they did not need to be screened. In addition, women who were sexually active believed that they could use pap smears to diagnose and cure sexually transmitted diseases.

Interpretations of Interpretations: Combining Community-Based Participatory Research and Interpretive Inquiry to Improve Health

Background: Latina immigrants from Mexico suffer significantly increased morbidity and mortality from cervical cancer when compared with non-Hispanic White women, largely owing to lack of screening and appropriate treatment. Objectives: To demonstrate that by combining the tools of community-based participatory research (CBPR) with the tools of interpretive inquiry, it is possible to address explicit community concerns surrounding a particular problem such as cervical cancer while also examining what other, perhaps less immediately visible, matters consume the time and attention of community members. Methods: We first briefly discuss and compare CBPR as an approach to research and interpretive inquiry as a qualitative research method. We then provide a case study from our own research using a CBPR approach to examine beliefs and attitudes about cervical cancer prevention among Oregon Latinos. Methods in that study included extensive discussions with our community advisory board (CAB) and promotores (community health workers) regarding barriers to cervical cancer screening for Latinas and community health concerns in general, and in-depth interviews with more than 50 Latino immigrants. Conclusion: Combining the tools of CBPR with the tools of interpretive qualitative inquiry may allow researchers to address explicit community concerns while also examining what other, less immediately visible, issues consume the time and attention of community members. In our specific case, combining the insights of our community partners with the results of our interpretive analysis helped us shift the focus from cervical cancer alone to a focus on gender relations and family health as we design future interventions.

Increasing the Relevance of Research to Underserved Communities: Lessons Learned from a Retreat to Engage Community Health Workers with Researchers

This article presents information on a community retreat developed to seek input from community health workers (CHWs) to increase the relevance of our research to underserved communities in Oregon. Retreats facilitating dialogue between researchers and CHWs could yield important insight to enhance the significance of research for communities.

Understanding how low-income families prioritize elements of health care access for their children via the optimal care model

BackgroundInsurance coverage alone does not guarantee access to needed health care. Few studies have explored what “access” means to low-income families, nor have they examined how elements of access are prioritized when availability, affordability, and acceptability are not all achievable. Therefore, we explored low-income parents’ perspectives on accessing health care.MethodsIn-depth interviews with a purposeful sample of 29 Oregon parents who responded to a previously administered statewide survey about health insurance. Transcribed interviews were analyzed by a multidisciplinary team using a standard iterative process.ResultsParents highlighted affordability and limited availability as barriers to care; a continuous relationship with a health care provider helped them overcome these barriers. Parents also described the difficult decisions they made between affordability and acceptability in order to get the best care they could for their children. We present a new conceptual model to explain these experiences accessing care with health insurance: the Optimal Care Model. The model shows a transition from optimal care to a breaking point where affordability becomes the driving factor, but the care is perceived as unacceptable because it is with an unknown provider.ConclusionsEven when covered by health insurance, low-income parents face barriers to accessing health care for their children. As the Affordable Care Act and other policies increase coverage options across the United States, many Americans may experience similar barriers and facilitators to health care access. The Optimal Care Model provides a useful construct for better understanding experiences that may be encountered when the newly insured attempt to access available, acceptable, and affordable health care services.