Bridging the Gap

Providing the optimal level of health care for the general public is the goal all health care professionals strive to achieve. To attain this goal, dental and medical professionals must share their knowledge and experience and assess the delivery of health care to eliminate disparities and improve outcomes.

Increasingly, attention has focused on cultural issues and their influences on delivering quality health care. By 2035, minorities will compose 40% of the United States population.¹ Numerous studies demonstrate that the quality of health care in the United States varies according to a patient’s race and ethnicity.²

Changing demographics challenge the demand for oral health care professionals with cross-cultural competence to communicate, educate, and treat all patients successfully.² The number of preventive visits is below recommended levels, and access to dental care remains problematic for minorities, the elderly, children on Medicaid, and other low-income children.

For example:

• More than one-third (38.6%) of poor children age 2 to 9 have one or more untreated decayed primary teeth, compared to 17.3% of nonpoor children.
• Uninsured children are half as likely as insured children to receive dental care.
• Untreated dental decay afflicts one-fourth of children entering kindergarten in the United States.
• Low-income and minority children have more dental caries than other children
• Poor Mexican-American children age 2 to 9 have the highest proportion of untreated decayed teeth (70.5%), followed by poor non-Hispanic Black children (67.4%).
• Poor Mexican-American and non-Hispanic Black children see the dentist less often than other children.
• Less than one out of every five poor children enrolled in Medicaid receives preventive dental services in a given year, even though Medicaid provides dental coverage for enrolled children.³

In addition to the considerable access problems faced by poor and Medicaid-eligible children, poor elderly people and minorities also have problems with access to care.³

In the 50-69 age group, non-Hispanic Blacks (31.2%) are more likely than Mexican Americans (28.2%) or non-Hispanic Whites (16.9%) to have at least one tooth site with periodontitis. In those 70 years and older, the percentages rise to 47.1%, 32%, and 24.1% for the three groups.

A survey conducted by Dr. Saha et al² explored whether racial differences in patient-physician relationships contribute to disparities in the quality of health care. The data were analyzed to determine whether racial differences in patient satisfaction with health care and use of basic health services were explained by differences in patient-physician interactions, physician’s cultural sensitivity, or patient-physician racial concordance. The results of both satisfaction and use of health services were lower for Hispanic and Asians than for Blacks and Whites. Racial differences in the quality of patient-physician interactions helped explain the observed disparities in satisfaction, but not in the use in health services. Barriers in the patient-physician relationship contributed to racial disparities in the experience of health care.² (See Tables 1 and 2).

THE INFLUENCE OF CULTURE

Patients’ feelings about health, sickness, and treatment, which are often culturally related, impact the outcomes of health care.² Recognizing the influence of culture on the decisions patients make in response to dental treatment and preventive measures is vital. In addition, fostering collaboration between patients and health care providers may result in enhanced treatment outcomes.

Today, one of the major challenges in both medicine and dentistry is how to effectively address the health disparities that exist among various ethnic and racial groups in the American population. To meet the national health goals established by the Healthy People 2010 initiative, we need to understand the cause of racial and ethnic disparities and design interventions to improve therapeutic outcomes. Cultural and linguistic competence in health care is integral to achieving the overarching goals of Healthy People 2010—increasing the quality and years of healthy life and eliminating health disparities.

Access to health care is a leading health indicator. Barriers to access include cultural differences, language barriers, and discrimination. Culturally competent health services improve all focus areas of Healthy People 2010 by reducing barriers to clinical preventive care, primary care, emergency services, and long-term and rehabilitative care.⁴

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TABLE 3. GOALS OF CULTURALLY COMPETENT CARE

1. Cultural Knowledge
   Familiarization with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group.⁵
2. Cultural Awareness
   Developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others. Cultural awareness must be supplemented with cultural knowledge.⁵ 
3. Cultural Sensitivity
   Knowing that cultural differences, as well as similarities exist, without assigning values, ie, better or worse, right or wrong, to those cultural differences.⁵

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WHAT IS CULTURAL COMPETENCY?

To understand cultural competency, the term must be defined. Culture refers to “integrated patterns of human behavior that include the language, opinions, beliefs, communication, actions, customs, attitude, values, and group of racial, ethnic, religious or social union.”⁵ Competency means “having the ability to function successfully as an individual and a group within the environment of the cultural beliefs, behaviors, and needs presented by consumers and their communities.”⁵

Cultural competency is therefore defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.”⁶ Usually, cultural competency begins with the health care provider’s desire to be open, accepting, and sensitive of differences. We need to value diversity by incorporating cultural competency in our profession. Valuing diversity means accepting and respecting differences.⁶ People come from very different backgrounds and their customs, thoughts, ways of communicating, values, traditions and institutions vary.⁶ The idea of more effective cross-cultural capabilities is captured in many terms similar to cultural competence. Cultural knowledge, cultural awareness, and cultural sensitivity all convey the idea of improving cross-cultural capacity (see Table 3).

The United States is one of the most diverse nations in the world. Cross-cultural dental hygiene is the effective incorporation of the patient’s sociocultural background into the dental hygiene process of care.⁵

BARRIERS

Health care professionals must recognize the barriers that prevent minorities from receiving access to community services and systems. Eliminating health care disparities requires that we go beyond financial barriers and pay attention to social and cultural determinants of health.⁷ For example, when patient-provider ideas hold opposing views concerning disease, compliance will not be achieved. In the case of “invisible diseases,” such as hypertension, high cholesterol, and HIV infection, the consequences may not be recognized because there are no symptoms. Accordingly, the patient may take a smaller dose of medication than prescribed because of a belief that Western medicine is too strong.⁸ Dental hygienists should not try to change patients’ beliefs, but educate them on the importance of conventional medicine as complementary to their belief system.

If patient and clinician ideas differ about the structure and function of the body, for example, causes of disease being bacteria, virus, or the environment versus the “evil eye”or “loss of souls,” it will be difficult to get patients to comply with treatment.⁸ Dental hygienists must have the capacity to determine their own inherent culture biases. This is usually one of the first steps in attaining true cultural competence.

Past injustices may cause minority patients to distrust their providers. For example, immigrants who are not in the United States legally may be hesitant to fill out forms because of deportation fears. Taking time to establish a rapport with your patient and explain why the forms are needed and who sees the forms may alleviate their fears.⁶

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TABLE 4. OVERCOMING LANGUAGE BARRIERS

• Identify language barriers.
• Select an interpreter: friends and family of the patient, bilingual office staff, or trained interpreters.
• Brief the interpreter prior to the procedure.
• View situational video vignettes of role playing between provider and patient where cultural beliefs become an issue in the provision of dental hygiene care.¹¹

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Distrust of the health care system among certain minority groups also causes barriers. African American patients’ distrust of the health care system may be due to historical experiences and the deception and mistreatment of study subjects; most noteworthy is the discrimination of the Tuskegee syphilis study, with African Americans used as involuntary research subjects.⁹

Monolingual clinicians who encounter patients who do not speak their language, cite this as a barrier to health care. In the United States, 12% of the population speaks a language other than English. Dental hygienists will inevitably treat patients with limited or no English proficiency.⁸ Both law and good dental hygiene care require that the oral health care provider make the best attempt at communicating with these patients. Ideally, a professional medical/health care interpreter is the best choice.⁸ (See Table 4.)

IMPROVING OUTCOMES

Entry level dental hygiene programs need to address the cultural differences that are present in a multicultural society. Dental hygiene students must become providers who understand how culture affects patients’ health status, beliefs, and behaviors.⁹ Integrating cross-cultural information and experience into the curriculum can help students develop cross-cultural competency.

The American Dental Hygienists’ Association’s (ADHA’s) Code of Ethics for Dental Hygienists includes some beliefs, fundamental principles, and core values requisite to the provision of cross-cultural dental hygiene care in multicultural society.² According to the code, ethical dental hygienists believe that all individuals have “intrinsic worth, are responsible for their own health, and are entitled to make choices regarding their health.” Ethical dental hygienists value respect and are expected to treat patients accordingly; they have a responsibility to “serve all patients without discrimination, and avoid behavior toward any individual or group that may be interpreted as discrimination.”⁵

CROSS-CULTURAL EDUCATION

Compliance and education are the windows to cross-cultural competency.¹⁰ Universities and school administrators of medical and dental schools throughout the United States have progressively recognized the need to incorporate cross-cultural education into the curriculum to improve health care delivery and outcomes.

Berlin and Fowkes¹⁰ created a learning model that helps educate health care professionals to become cross-culturally competent.

The L-E-A-R-N Model is as follows:

• Listen with sympathy and understanding to the patient’s perception of the problem.
• Explain your perception of the problem and the strategy for treatment.
• Acknowledge and discuss the differences and similarities between these perceptions.
• Recommend treatment while remembering the patient’s cultural parameters.
• Negotiate an agreement. It is important to understand the patient’s explanatory model so that medical treatment fits in his/her cultural framework.¹⁰

INTEGRATING CULTURAL CARE

Effective verbal and nonverbal communications are critical aspects of all phases of the dental hygiene process of care.

1. Assessment. The first phase of the dental hygiene process of care is assessment, which is the foundation of patient-centered care. During the assessment phase, the dental hygienist obtains the patient’s personal, medical, and dental histories; takes vital signs; performs extra/intraoral, periodontal, and restorative examinations; and then formulates a dental hygiene diagnosis. In addition, the culturally competent dental hygienist explores and assesses the patient’s cultural values, beliefs, and cultural-specific health practices.

Dental hygienists should become skilled in nonoffensive ways to communicate with their patients to incorporate traditional beliefs into patient assessment.⁵ For example, a patient with Indian, New Guinean, or South East Asian heritage may chew betel nut quid. This practice is addictive and injurious to both the hard and soft tissue of the oral cavity; it can result in attrition and staining of the teeth, while damaging the oral mucosa. However, these patients may believe that the habit actually strengthens the teeth and that stain is a sign of maturity and aging. When dental hygienists are confronted with oral hygiene belief systems and practices that are incongruent with their own, dental hygienists need to explain why the practice is not endorsed. Clinicians should offer support and encouragement and avoid self-righteously imposing their own belief systems on the patient.⁵

Assessment also provides the opportunity for clinicians to develop rapport with patients. At this phase, the culturally competent dental hygienist would research and assess the patient’s cultural ethics, attitude, and beliefs of health practices. The personal data collected during this phase help formulate an ethnic/ racial identification, which should help the hygienist understand what may influence the patient’s health behaviors and future outcomes. Patients are usually very vulnerable at this stage, and criticism should be avoided because it will block future interactions and compromise healthcare outcomes.⁵

2. Planning. When planning treatment, dental hygienists must avoid imposition of their own beliefs and values. Clinicians should explain their expectations and ask about the patient’s expectations as well. When planning, dental hygienists should not include any practices, products, or substance that the patient’s culture forbids. For example, the Muslim culture forbids the consumption of alcohol, therefore, the clinician should not have the patients control gingivitis or fluoride treatments with alcohol-based mouthrinses.⁵

3. Implementation. In this phase of the dental hygiene process of care, the treatment takes action. Patient education is the most important intervention dental hygienists can provide. At this time, it may be necessary to spend more time than usual when providing services for patients with different cultural backgrounds. During this time the use of visual aids is vital, the “tell-show-do” instruction is the best method to facilitate understanding and reinforcement to change patient behavior.⁵ By involving the patient in demonstrating a technique, the patient’s behavior is more likely to change. Sensitivity toward the patient’s needs during this phase enhances the probability of a successful treatment outcome.

4. Evaluation. This is the final ongoing phase in the dental hygiene process of care. Measuring the patient’s oral health care status and comparing it to the baseline data collected are crucial. Dental hygienists must avoid labeling patients from ethnic minority groups as difficult or noncompliant if they do not understand or accept the treatment or maintenance recommendation.

Although the disparities and outcomes in the delivery of dental hygiene care are influenced by many factors, the impact of the patient’s culture and vulnerability, relative to the disparities of knowledge and power should not be trivialized. With population demographics increasing to a multicultural society, dental hygienists must be prepared to practice in a culturally sensitive and appropriate manner if they expect to deliver optimal oral hygiene care to all patients.⁵

REFERENCES

1. Formicola AJ, Stavisky J, Lewy R. Cultural competency: dentistry and medicine learning from one another. J Dent Educ. 2003;67:869-875.
2. Saha S, Arbelaez JJ, Cooper LA. Patientphysician relationships and racial disparities in the quality of health care. Am J Public Health. 2003; 93: 1713-1719.
3. Stanton MW. Dental Care, Improving Access and Quality. Available at http://www.ahrq.gov/research/dentalcare/dentria.htm. Accessed November 20, 2008.
4. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J, Task Force on Community Preventive Services. Culturally competent healthcare systems. A systematic review. Am J Prev Med. 2003;24(3 Suppl):68-79.
5. Fitch P. Cultural competence and dental hygiene care delivery: integrating cultural care into the dental hygiene process of care. J Dent Hyg. 2004;78:11-21.
6. Issacs M, Benjamin M. Toward a Culturally Competent System of Care. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center; 1991.
7. Mouradian WE, Berg JH, Somerman MJ. Addressing disparities through dental-medical collaborations, part 1. The role of cultural competency in health disparities: training of primary care medical practitioers in children’s oral health. J Dent Educ. 2003;67:860-868.
8. American Medical Student Association. Cultural Competency in Medicine. Available at www.amsa.org/programs/gpit/cultural.cfm. Accessed December 4, 2008.
9. Johnson J, Smith N. Health and social issues associated with racial, ethnic, and cultural disparities. Generations. 2002;25-32.
10. Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 1983;139:934-938

From Dimensions of Dental Hygiene. December 2008; 6(12): 20-23.