Cultural brokerage: Creating linkages between voices of lifeworld and medicine in cross-cultural clinical settings

Strategies and sacrifices of family caregiving in the Somali-American community: a qualitative study

BACKGROUND

Among the many pressing concerns of the Somali-American community, and other similar immigrant and refugee communities as they grow in the United States, is the provision of care for older adults and adults with disabilities. The implications of effective caregiving range from the facilitation of community building and place-making to the delivery and management of healthcare on a systemic level. However, little is currently known about Somali-American family caregivers, including their duties and responsibilities, primary concerns, and the impacts of surrounding influences on their ability to fulfill their role.

METHODS

Semi-structured interviews were conducted with 10 Somali-American family caregivers in Somali language. The resulting transcripts were translated into English by a professional interpreter and analyzed using an inductive thematic analysis approach. A key informant from the community was additionally consulted for insights regarding cultural nuances and interpretations of idiomatic expressions and concepts.

RESULTS

Thematic analysis of the reports revealed the principal themes of visitation, patient accompaniment, and self-sacrifice through acceptance and God-consciousness as pervasive and salient concerns across participants. Furthermore, the heightened stresses of the COVID-19 pandemic revealed just how severe the consequences can be when access to culturally habituated navigational tools and coping mechanisms are restricted.

CONCLUSIONS

In light of our findings, the growing concern for discrimination and sociocultural discord in the Somali-American community presents a particularly prescient threat to the well-being and sustainability of family caregivers. Their experiences must be understood and used to promote education and partnership between the healthcare system and the community in order to build trust and ensure a healthy future for this indispensable population.

Healthcare social network research and the ECHO model™: Exploring a community of practice to support cultural brokers and transfer cultural knowledge

BACKGROUND

Project ECHO® networks at Children's Health Queensland Hospital and Health Service (CHQHHS) are communities of practice designed to mitigate services and systems fragmentation by building collaborative partnerships addressing priority child and youth health needs. Aboriginal and Torres Strait Islander people experience the negative impacts of fragmentation in addition to historical challenges of absent or culturally inappropriate health services. Access to culturally safe and responsive services can be improved by engaging Aboriginal and Torres Strait Islander Health Workers and similar roles in an online community of practice, supporting the integration of cultural and clinical knowledge and self-determination of Aboriginal and Torres Strait Islander consumers in decisions affecting their health. Analysing professional support networks and knowledge sharing patterns helps identify enablers and barriers to partnerships. Using social network research, the multilevel network inclusive of ECHO network members and their colleagues was studied to identify interdisciplinary and cross-sector advice exchange patterns, explore the position of cultural brokers and identify common relational tendencies.

METHODS

Social network theories and methods informed the collection of network data and analysis of advice-seeking relationships among ECHO network members and their nominees. Registered members from two ECHO networks were invited to complete the Qualtrics survey. Networks analysed comprised 398 professionals from mainstream health, Aboriginal and Torres Strait Islander Community Controlled Health Organisation, education, disability and child safety service settings.

RESULTS

Brokers were well represented, both those who hold knowledge brokerage positions as well as cultural brokers who incorporate clinical and cultural knowledge enabling holistic care for Aboriginal and Torres Strait Islander patients (38 individuals, 17% of network). Professionals who occupy brokerage positions outside the ECHO network tend to be more connected with co-members within the network.

CONCLUSIONS

This study is the first application of contemporary social network theories and methods to investigate an ECHO network. The findings highlight the connectivity afforded by brokers, enabling the coordination and collaboration necessary for effective care integration. Inclusion of cultural brokers in an ECHO network provides sustained peer group support while also cultivating relationships that facilitate the integration of cultural and clinical knowledge.

"It Looks Like You're Making Very Healthy Choices": Attending to the Lifeworld and Medicine in Photo-Based Talk in Primary Care

Addressing patient-clinician communication barriers to improve multiple chronic disease care is a public health priority. While significant research exists about the patient-clinician encounter, less is known about how to support patient-clinician communication about lifestyle changes that includes the context of people's lives. Data come from a larger photo-based primary care study collected from 13 participants who were adults 60 or older with at least two chronic conditions, in English, Chinese (Cantonese or Mandarin), or Spanish. We use discourse analysis of three examples as anchor points demonstrating different interactional pathways for the photo-based communication. Patients and clinicians can move smoothly through a pathway in which photos are shared, clinicians acknowledge and align with the patient's explanation, and clinicians frame their medical evaluations of food choices, nutrition suggestions, and shared goal-setting by invoking the voice of lifeworld (VOL). On the other hand, when clinicians solely press the voice of medicine (VOM) in their evaluations of patients' pictures with little attention to patients' presentations, it can lead to patient resistance and difficulty moving to the next activity. Because photo-sharing is still relatively novel, it offers unique interactional spaces for both clinicians and patients. Photo-sharing offers a sanctioned moment for a primary care visit to operate in the VOL and promote goal-setting that both parties can agree upon, even if clinicians and patients framed the activity as one in which patients' lifeworld choices should be assessed as medically healthy or unhealthy based on the ultimate judgment of clinicians operating from the VOM.

Transcending Language Barriers in Obstetrics and Gynecology: A Critical Dimension for Health Equity

There is growing evidence that language discordance between patients and their health care teams negatively affects quality of care, experience of care, and health outcomes, yet there is limited guidance on best practices for advancing equitable care for patients who have language barriers within obstetrics and gynecology. In this commentary, we present two cases of language-discordant care and a framework for addressing language as a critical lens for health inequities in obstetrics and gynecology, which includes a variety of clinical settings such as labor and delivery, perioperative care, outpatient clinics, and inpatient services, as well as sensitivity around reproductive health topics. The proposed framework explores drivers of language-related inequities at the clinician, health system, and societal level. We end with actionable recommendations for enhancing equitable care for patients experiencing language barriers. Because language and communication barriers undergird other structural drivers of inequities in reproductive health outcomes, we urge obstetrician-gynecologists to prioritize improving care for patients experiencing language barriers.

Lived Experiences of Mental Health Recovery in Persons of Culturally and Linguistically Diverse (CALD) Backgrounds within the Australian Context

Lived experience research related to mental health recovery is advancing, but there remains a lack of narrative material from the perspectives of people from under-represented, non-dominant cultural backgrounds in this domain. This study aimed to explore the lived experiences of mental health recovery in people of culturally and linguistically diverse (CALD) backgrounds in the Australian context. The current study involved a secondary analysis of audio and visual data collected during the digital storytelling project Finding our way in Melbourne, Australia. Thematic analysis was used to understand the lived experience narratives of nine participants in relation to mental health recovery. Five themes were identified through an iterative process of analysis, including Newfound opportunities and care, Family as key motivators and facilitators, Coping and generativity, Cultivating self-understanding and resilience, and Empowerment through social engagement. First person lived experience narratives offer deep insight into understanding the ways in which individuals of marginalised communities conceptualise and embody recovery. These findings further the literature and understanding on how to better serve the needs of people with mental health challenges from CALD communities through informed knowledge of what may be helpful to, and meaningful in, individuals' recoveries.

Undocumented Latina GBV Survivors: Using Social Capital as a Form of Resistance

This research draws on the tradition of Latinx critical race theory (LatCrit) to explore how social capital is deployed by undocumented Latina GBV survivors as a form of personal and collective resistance. The study uses the social capital matrices of bonding, bridging, and linking capital as its primary narrative analysis grids. The research qualitatively analyzes a sample of undocumented survivors’ counter-stories regarding three factors: citizenship status, help-seeking behaviors, and service use patterns. Research findings illuminate the social logics of GBV disclosure locations, the use of informal support services, and how survivors strategically deploy new economic opportunity structures. The article highlights the intersectionality of GBV and undocumented status, demonstrating how survivors leverage various forms of social capital to resist both the carceral state and the violence of abusers.

Sociological contributions to race and health: Diversifying the ontological and methodological agenda

Sociologists have made fundamental contributions to the study of race and health in the United States. They have disrupted biological assumptions of race, uncovered individual and structural factors that drive racial health disparities and explored the effects of racism on health. In recent years, however, with broader shifts towards big data, the work to understand the dynamics between race and health has been increasingly pursued from a quantitative perspective. Often, such analyses isolate intermediary mechanisms to further explain race as a cause of disease. While important, these approaches potentially limit our investigations of underlying assumptions about race and the complexity of this critical social construct. We argue that the resulting dearth of qualitative research on race and health substantially limits the knowledge being produced. After providing an overview of the overwhelming shift towards quantitative methods in the study of race and health, we present three areas of study that would benefit from greater qualitative inquiry as follows: (1) Healthy Immigrant Effect, (2) Maternal Health and (3) End-of-Life Care. We conclude with a call to the discipline to embrace the critical role of qualitative research in exploring the dynamics of race and health in the United States.

The singular patient in patient-centred care: physiotherapists' accounts of treatment of patients with chronic muscle pain

A patient-centred approach has gained increasing interest in medicine and other health sciences. Whereas there are discussions about the meaning of a patient-centred approach and what the concept entails, little is known about how the patient as a person is understood in patient-centred care. This article investigates understandings of the patient as a self in patient-centred care through physiotherapy of patients with chronic muscle pain. The material consists of interviews with five Norwegian physiotherapists working in a rehabilitation clinic. Drawing on Kristeva's discussion of subjectivity in medical discourse, the study highlights two different treatment storylines that were closely entwined. One storyline focuses on open singular healing processes in which the treatment was based on openness to a search for meaning and sharing. In this storyline, the "person" at the centre of care was not essentialised in terms of biological mechanisms, but rather considered as a vulnerable, irrational and moving self. By contrast, the second storyline focused on goal-oriented interventions aimed at restoring the patient to health. Here, the person in the centre of the treatment was shaped according to model narratives about "the successful patient"; the empowered, rational, choosing and self-managing individual. As such, the findings revealed two conflicting concepts of the individual patient inherent in patient-centred care. On the one hand, the patient is seen as being a person in constant movement, and on the other, they are captured by more standardised terms designed to focus on a more stable notion of outcome of illness. Therefore, our study suggests that the therapists' will to recognise the individual in patient-centred care had a counterpart involving a marginalisation of the singular.

Barriers and facilitators of patient centered care for immigrant and refugee women: a scoping review

BACKGROUND

Migrants experience disparities in healthcare quality, in particular women migrants. Despite international calls to improve healthcare quality for migrants, little research has addressed this problem. Patient-centred care (PCC) is a proven approach for improving patient experiences and outcomes. This study reviewed published research on PCC for migrants.

METHODS

We conducted a scoping review by searching MEDLINE, CINAHL, SCOPUS, EMBASE and the Cochrane Library for English-language qualitative or quantitative studies published from 2010 to June 2019 for studies that assessed PCC for adult immigrants or refugees. We tabulated study characteristics and findings, and mapped findings to a 6-domain PCC framework.

RESULTS

We identified 581 unique studies, excluded 538 titles/abstracts, and included 16 of 43 full-text articles reviewed. Most (87.5%) studies were qualitative involving a median of 22 participants (range 10-60). Eight (50.0%) studies involved clinicians only, 6 (37.5%) patients only, and 2 (12.5%) both patients and clinicians. Studies pertained to migrants from 19 countries of origin. No studies evaluated strategies or interventions aimed at either migrants or clinicians to improve PCC. Eleven (68.8%) studies reported barriers of PCC at the patient (i.e. language), clinician (i.e. lack of training) and organization/system level (i.e. lack of interpreters). Ten (62.5%) studies reported facilitators, largely at the clinician level (i.e. establish rapport, take extra time to communicate). Five (31.3%) studies focused on women, thus we identified few barriers (i.e. clinicians dismissed their concerns) and facilitators (i.e. women clinicians) specific to PCC for migrant women. Mapping of facilitators to the PCC framework revealed that most pertained to 2 domains: fostering a healing relationship and exchanging information. Few facilitators mapped to the remaining 4 domains: address emotions/concerns, manage uncertainty, make decisions, and enable self-management.

CONCLUSIONS

While few studies were included, they revealed numerous barriers of PCC at the patient, clinician and organization/system level for immigrants and refugees from a wide range of countries of origin. The few facilitators identified pertained largely to 2 PCC domains, thereby identifying gaps in knowledge of how to achieve PCC in 4 domains, and an overall paucity of knowledge on how to achieve PCC for migrant women.

Transcending the Profession: Psychiatric Patients' Experiences of Trust in Clinicians

Classical medical sociological theory argues patients trust doctors in part because they are professionals. Yet in the past half-century, medicine has seen a crisis of trust as well as fundamental changes to the nature of professionalism. To probe the relationship between professionalism and trust today, we analyzed interviews with 50 psychiatric patients receiving care in diverse clinical settings. We found patients experience trust when they perceive clinicians transcending the formal bounds of professionalism. Patients find clinicians to be trustworthy when clinicians pursue connections to their patients beyond organizational strictures, cross boundaries of professional jurisdiction to provide holistic care, and embrace the limits of their professional knowledge. This dynamic of trust in professionals who transcend the profession highlights novel dimensions of contemporary professionalism, and it makes sense of a seeming contradiction in which patients have high trust in individual clinicians but low trust in institutions.

Parental Perceptions of Culturally Sensitive Care and Well-Child Visit Quality

OBJECTIVE

Incorporating culturally sensitive care into well-child visits may help address pediatric preventive care disparities faced by racial and ethnic minorities, families with limited English proficiency, and immigrants. We explored parents' perspectives about the extent to which their children's pediatric care is culturally sensitive and potential associations between culturally sensitive care and well-child visit quality.

METHODS

We conducted cross-sectional surveys with parents attending a well-child visit for a child ages 3 to 48 months. To measure culturally sensitive care, we created a composite score by averaging 8 subscales from an adapted version of the Clinicians' Cultural Sensitivity Survey. We assessed well-child visit quality through the Promoting Healthy Development Survey. Multivariate linear regression was used to understand associations between demographic characteristics and parent-reported culturally sensitive care. We used multivariate logistic regression to examine associations between culturally sensitive care and well-child visit quality.

RESULTS

Two hundred twelve parents (71% of those approached) completed the survey. Parents born abroad, compared with those born in the United States, reported significantly higher culturally sensitive care scores (+0.21; confidence interval [CI]: 0.004, 0.43). Haitian parents reported significantly lower culturally sensitive care scores compared with non-Hispanic white parents (-0.49; CI: -0.89, -0.09). Parent-reported culturally sensitive care was significantly associated with higher odds of well-child visit quality including receipt of anticipatory guidance (adjusted odds ratio: 2.68; CI: 1.62, 4.62) and overall well-child visit quality (adjusted odds ratio: 2.54; CI: 1.59, 4.22).

CONCLUSIONS

Consistent with prior research of adult patients, this study demonstrates an association between parent-reported culturally sensitive care and well-child visit quality. Future research should explore best practices to integrating culturally sensitive care in pediatric preventive health care settings.

Working with patients suffering from chronic diseases can be a balancing act for health care professionals - a meta-synthesis of qualitative studies

BACKGROUND

The number of patients with long-term chronic diseases is increasing. These patients place a strain on health care systems and health care professionals (HCPs). Presently, we aimed to systematically review the literature on HCPs' experiences working with patients with long-term chronic diseases such as type 2 diabetes, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD).

METHOD

A systematic search of papers published between 2002 and July 2019 was conducted in the Embase, AMED, PsycINFO, MEDLINE, CINAHL, and COCHRANE databases to identify studies reporting qualitative interviews addressing HCPs' experiences working with adults with COPD, CKD or type 2 diabetes. An interdisciplinary research group were involved in all phases of the study. With the help of NVivo, extracts of each paper were coded, and codes were compared across papers and refined using translational analysis. Further codes were clustered in categories that in turn formed overarching themes.

RESULTS

Our comprehensive search identified 4170 citations. Of these, 20 papers met our inclusion criteria. Regarding HCPs' experiences working with patients with COPD, CKD, or type 2 diabetes, we developed 10 sub-categories that formed three overarching main themes of work experiences: 1) individualizing one's professional approach within the clinical encounter; 2) managing one's emotions over time; 3) working to maintain professionalism. Overall these three themes suggest that HCPs' work is a complex balancing act depending on the interaction between patient and professional, reality and professional ideals, and contextual support and managing one's own emotions.

CONCLUSION

Few qualitative studies highlighted HCPs' general working experiences, as they mainly focused on the patients' experiences or HCPs' experiences of using particular clinical procedures. This study brings new insights about the complexity embedded in HCPs' work in terms of weighing different, often contrasting aspects, in order to deliver appropriate practice. Acknowledging, discussing and supporting this complexity can empower HCPs to avoid burning out. Leaders, health organizations, and educational institutions have a particular responsibility to provide HCPs with thorough professional knowledge and systematic support.

TRIAL REGISTRATION

PROSPERO number: CRD42019119052.

Chinese, Vietnamese, and Asian Indian Parents' Perspectives About Well-Child Visits: A Qualitative Analysis

OBJECTIVES

Well-child visits are a critical component of pediatric health care; however, disparities in attendance and quality of care exist for Asian children. Limited research has explored Asian immigrant parents' perspectives about their well-child visit experience.

METHODS

Qualitative interviews were conducted with Chinese, Vietnamese, and Asian Indian immigrant parents. Participants were recruited from community-based organizations in the Boston area. Interviews focused on parents' perceptions about well-child visits, including individual attitudes, social and cultural factors affecting their opinions, perceived behavioral control, and improving visits for Asian immigrant families. Data were coded and analyzed using thematic analysis.

RESULTS

Fifty-one parents participated. Although participants reported attending well-child visits, they thought language barriers and unfamiliarity with US preventive health care may limit attendance for other Asian immigrant families. Some reported high-quality visits, while others described them as "too simple," recollecting health care experiences from their countries of origin where more tests were completed. Participants described seeking advice about their children's preventive care from elder family members. Many expressed the importance of culturally concordant health care providers and culturally sensitive care, while others thought that culture was less relevant. Differences emerged among the 3 subgroups around culturally concordant care and traditional medicine.

CONCLUSIONS

Querying parents about their past health care experiences and providing information about well-child visits may be useful when caring for immigrant families. Social influences on children's health outside of the parent-provider-child triad may also be important. Further work should explore how to deliver culturally sensitive care that considers not only a family's language preferences but also their unique cultural identity.

A model for translating ethnography and theory into culturally constructed clinical practices

This article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

Unmasking quality: exploring meanings of health by doing art

Background

Quality in healthcare has many potential meanings and interpretations. The case has been made for conceptualisations of quality that place more emphasis on describing quality and less on measuring it through structured, vertically oriented metrics. Through discussion of an interdisciplinary community arts project we explore and challenge the dominant reductionist meanings of quality in healthcare.

Discussion

The model for structured participatory arts workshops such as ours is ‘art as conversation’. In creating textile art works, women involved in the sewing workshops engaged at a personal level, developing confidence through sharing ideas, experiences and humour. Group discussions built on the self-assurance gained from doing craft work together and talking in a relaxed way with a common purpose, exploring the health themes which were the focus of the art. For example, working on a textile about vitamin D created a framework which stimulated the emergence of a common discourse about different cultural practices around ‘going out in the sun’. These conversations have value as ‘bridging work’, between the culture of medicine, with its current emphasis on lifestyle change to prevent illness, and patients’ life worlds. Such bridges allow for innovation and flexibility to reflect local public health needs and community concerns. They also enable us to view care from a horizontally oriented perspective, so that the interface in which social worlds and the biomedical model meet and interpenetrate is made visible.

Summary

Through this interdisciplinary art project involving academics, health professionals and the local community we have become more sensitised to conceptualising one aspect of health care quality as ensuring a ‘space for the story’ in health care encounters. This space gives precedence to the patient narratives, but acknowledges the importance of enabling clinicians to have time to share stories about care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0233-x) contains supplementary material, which is available to authorized users.

Translating disability in a Muslim community: a case of modular translation

This study examines how Muslim religious leaders (imams) introduce the liberal notion of disability to their communities in Israel. The project described, initiated and supported by an American NGO, provides a case for exploring how the secular notion of disability rights is cast and recast in a Muslim world of meaning. It focuses on the mediation strategy that I call modular translation, employed by imams in sermons delivered for the purpose of altering or improving the status and conditions of people with disabilities. This strategy, as it emerged from the analysis, entails decoupling norms of conduct from their underlying justifications. It thus suggests that norms of conduct are open to change so long as the believers' cosmology remains intact. As such, this turn may offer new avenues of thinking and acting about globalizing human rights within the arena of health and disability.

The cultural brokerage work of occupational therapists in providing culturally sensitive care

Background.

The important place of culture within occupational therapy is widely recognized, and there is increasing emphasis on addressing the diversity of clients.

Purpose.

This study explores how occupational therapists perform cultural brokerage when providing culturally sensitive care to immigrant families.

Method.

A descriptive qualitative methodology was used for this study. A purposive sample of 17 occupational therapists from two Canadian paediatric rehabilitation centres were interviewed.

Findings.

Participants encountered several cultural and structural constraints in providing culturally sensitive care. To overcome these constraints, clinicians used four strategies: (a) translating between health systems for clients, (b) bridging different meanings of occupational therapy to make it relevant for clients, (c) establishing long-term relationships by building trust and rapport, and (d) working with clients’ relational networks to help them navigate the health system.

Implications.

Occupational therapists should advocate for both the individual needs of immigrant families and for institutional level resources to better meet the needs of diverse clients.

The ethical self-fashioning of physicians and health care systems in culturally appropriate health care

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is "culturally competent." We explore the diverse methods that cultural competence trainings use to foster a health care provider's ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.