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THIS COURSE FULFILLS YOUR DIVERSITY OR CULTURAL COMPETENCY REQUIREMENT Chapter 1: Cultural Competency for Massage Therapists (Mandatory)
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[1 CE hour] The need for cultural competency training as an ethical precept has been articulated at many levels: through federal and state legislatures, public health administrations, the medical profession, and other professional health education organizations. This course will discuss how race and culture impact health, identify patterns of disparities, and emphasize the importance of diversity factors that influence effective cross-cultural communication in clinical encounters.
THIS COURSE FULFILLS YOUR PROFESSIONAL ETHICS REQUIREMENT Chapter 2: Ethics in Massage Therapy (Mandatory)
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[3 CE hours] Ethical code and professional standards of conduct have important values and concepts in professional massage, also within the boundaries that define therapeutic relationships. THIS COURSE FULFILLS YOUR HIV/AIDS (COMMUNICABLE DISEASE) REQUIREMENT Chapter 3: HIV/AIDS Update: Prevention, Transmission, and Treatment, 2nd Edition (Mandatory) [3 CE hours] The purpose of this course is to enhance healthcare providers’ knowledge of HIV/AIDS infection, including prevention, transmission, and treatment. An estimated 1.2 million people are living with HIV/AIDS infection in the U.S. CDC. HIV/AIDS infection is a persistent public health problem in the U.S. and worldwide. In 2018, an estimated 36,400 new HIV infections were diagnosed. HIV is disproportionately present in certain racial and ethnic minorities and in gay and bisexual men (HIV.gov, 2020b). It is imperative that all healthcare professionals work to prevent HIV transmission and facilitate treatment among those infected. This course provides nurses with information about HIV/AIDS incidence, prevalence, transmission, prevention, and treatments.
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Final Examination Answer Sheet
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©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. i MASSAGE THERAPY CONTINUING EDUCATION Book Code: MMD0724
What are the requirements for license renewal? Licenses Expire CE Hours Required Frequently Asked Questions
Mandatory Subjects
1 hour cultural competency 3 hours professional ethics or jurisprudence 3 hours in HIV/AIDS (communicable disease education)
24 (All hours are allowed through home study)
Licenses renewals are due October 31, of the even- numbered year.
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How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you an Maryland board-approved provider? Colibri Healthcare, LLC is approved by the National Certification Board for Therapeutic Massage and Bodywork (Provider #450215-06). Most states accept courses approved by this board. Are my hours reported to the Maryland board? No, the Maryland Board of Massage Therapy Examiners performs random audits at which time proof of continuing education is required. At the time of renewal, you may be audited for CEU compliance. It is the responsibility of each massage therapist and practitioner to keep accurate records of attendance of approved continuing education programs. Completion certificates must be maintained for at least four years and must be presented to the Board on demand. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Massage-Therapy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-866-344-0973, Monday - Friday 9:00 am - 6:00 pm Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. EST. and Saturday 10:00 am - 4:00 pm EST. Important information for licensees:
Licensing board contact information: Maryland Department of Health | Board of Massage Therapy Examiners 201 W. Preston Street | Baltimore, Maryland 21201-2399 I Phone: (410) 767-6500 I Fax: (866) 888-1308 Website: https://health.maryland.gov/massage/
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Book Code: MMD0724
MASSAGE THERAPY CONTINUING EDUCATION
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iii
MASSAGE THERAPY CONTINUING EDUCATION
Book code: MMD0724
Chapter 1: Cultural Competency for Massage Therapists (Mandatory) 1 CE Hour
By: John Vinacci Learning objectives Define the terms cultural competence, race, ethnicity and culture as they apply to health and wellness professions. Describe five ways that race and culture impact health. Identify patterns of health disparities and strategies to address them. Discuss the importance of diversity factors that influence effective cross-cultural communication in clinical encounters. List assessment tools to help therapists identify personal attitudes toward culture and cultural differences, and improve communication clients, patients and massage therapists. Give three examples of stereotyping and its effect on health. professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact Acronyms used throughout this course ● AAMC - Association of American Medical Colleges. ● ACGME - Accreditation Council for Graduate Medical Education. ● AMTA - American Massage Therapy Association. ● AHRQ - Agency for Healthcare Research and Quality. ● CDC - Centers for Disease Control and Prevention. ● CLAS - The U.S. Department of Health and Human Service’s (HHS) Standards for Culturally and Linguistically Appropriate Services. ● EPoCH - The American Medical Association’s (AMA) Educating Physicians on Controversies in Health. Implicit bias in healthcare Implicit bias significantly affects how healthcare
List strategies to uncover and eliminate stereotyping. Describe three models of effective communication for providing culturally competent care. Explain the impact of limited English language (LEP) proficiency on health outcomes. Identify legislative actions to promote equity in language access for LEP patients. Select and discuss four reasons for the under-utilization of interpreters for LEP patients in health care settings. Describe four practical strategies to improve interpretation services to support culturally competent care. List and explain four components of self-evaluation and reflection to enhance culturally competent care. health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. ● HHS - U.S. Department of Health and Human Services. ● IOM - Institute of Medicine. ● LCME - Liaison Committee on Medical Education. ● LEP - Limited English proficiency. ● NCHD - National Commission for Human Development. ● NCHS - Centers for Disease Control and Prevention’s National Center for Health Statistics. ● TACCT - Association of American Medial Colleges’ Tool for Assessing Cultural Competence Training.
OVERVIEW: BACKGROUND
“Acknowledge the inherent worth and individuality of each person by not discriminating or behaving in any prejudicial manner with clients and/or colleagues.” The Liaison Committee on Medical Education (LCME) - the accreditation entity for U.S. and Canadian medical schools - revised the standards in 2016 for the upcoming 2017- 2018 academic year. It included the following guidelines for building cultural competence among health practitioners.
The need for cultural competency training as an ethical precept has been articulated at many levels: through federal and state legislatures, public health administrations, the medical profession, and other professional health education organizations. The American Massage Therapy Association’s (AMTA) Code of Conduct - last revised in 2010 - helps massage therapists to interpret the Code of Ethics. The second principle states that a massage therapist shall: Standard 3: Academic and learning environments A medical school ensures that its medical education program occurs in professional, respectful, and intellectually stimulating academic and clinical environments, recognizes
the benefits of diversity, and promotes students’ attainment of competencies required of future physicians.
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Benefits of diversity Having medical students and faculty members from a variety of socioeconomic backgrounds, racial and ethnic groups, and other life experiences can: 1) enhance the quality and content of interactions and discussions for all students throughout the preclinical and clinical curricula; and 2) result in the preparation of a physician workforce that is more culturally aware, competent and better prepared to improve access to healthcare, and to address current and future health care disparities (Standard 3). language, and religion influence health, health care delivery and health behaviors (AAMC, 2016). This project’s activities included: ● Commissioning three papers to establish the basis for deliberation regarding the domains of cultural competence. ● Convening an expert panel to identify the major domains of cultural competence training, and to develop the “Tool for Assessing Cultural Competence Training” (TAACT) in the undergraduate medical school curriculum, as well as in all health professions. This continuing education activity is designed to introduce cultural competency to massage therapists. The majority of the material in this course is derived from the primary study group of physicians - similar findings are expected to occur in all health professions. In case discussions, the massage therapist will relate to similar situations that apply to that field. The Tool for Assessing Cultural Competence Training (TACCT) – revised in 2015 - outlines the six domains and specific components for cultural competency training in medical schools. The six domains include: ● Domain I: Cultural Competence Rationale, Context, and Definition ● Domain II: Key Aspects of Cultural Competence ● Domain III: Impact of Stereotyping and Medical Decision-Making ● Domain IV: Health Disparities and Factors Influencing Health ● Domain V: Cross-Cultural Clinical Skills ● Domain VI: Self-Reflection, Culture of Medicine Each domain covers the knowledge, skills, and attitudes related to the component. TACCT provides a framework for this course, which is divided into four sections:
Mission-appropriate diversity The inclusion in a medical education program’s student body and staff based on the program’s mission, goals, and policies to recruit persons from diverse racial, ethnic, economic, and/or social backgrounds, and life experiences to enhance the educational environment for all medical students (Element 3.3). Standard 7: Curricular content The faculty of a medical school ensures that the medical curriculum provides content that is of sufficient breadth and depth to prepare medical students for entry into any residency program, and for the subsequent contemporary practice of medicine. Cultural competence and health care disparities The faculty of a medical school ensures that the medical curriculum provides opportunities for medical students to learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the health care delivery process. The medical curriculum includes instruction regarding the following: ● The manner in which people of diverse cultures and belief systems perceive health and illness, and then respond to various symptoms, diseases, and treatments. ● The basic principles of culturally competent health care. ● The recognition and development of solutions for health care disparities. ● The importance of meeting the health care needs of medically underserved populations. ● The development of core professional attributes (e.g., altruism, accountability) needed to provide effective care within a multidimensional and diverse society. (Element 7.6) Health care disparities are defined as differences between groups of people based on a variety of factors: race, ethnicity, residential location, sex, age, socioeconomic, educational, and disability status, that may affect access to health care, the quality of the health care received, and the outcomes of their medical conditions (Element 7.6). The Association of American Medical Colleges (AAMC) began the “Medical Education and Cultural Competence: A Strategy to Eliminate Racial and Ethnic Disparities in Health Care” project in 2016 to support and develop these standards. This project was designed to address the increasing diversity within the United States and discuss strong evidence of disparities in health care that still exist today (AAMC, 2016). The AAMC stressed that it is critically important that health care professionals are specifically
educated about how their own (and their patients’) demographic, gender, income, race, ethnicity, culture, 1. Cultural competence rationale, context, and definition. 2. Impact of stereotyping on clinical decision-making. 3. Cross-cultural clinical skills. 4. Working effectively with interpreters. SECTION 1: CULTURAL COMPETENCE RATIONALE, CONTEXT AND DEFINITION Health professionals are aware of the need to provide
and training programs. Using the framework of TACCT, this section will review the domain covering the rationale, context, and definitions of key terms used for cultural competency training in the health profession.
health care services that are respectful and responsive to the cultural and linguistic diversity of their clients and patients. Educational institutions for health professionals include cultural competency education at all levels of their curriculum Defining cultural and linguistic competence As the linguistic and cultural diversity of the United States grows, health care professionals must adapt their skills, knowledge, and attitudes to build linguistic and cultural competency. Due to shifting demographic trends in the
United States, managed care plans must evolve in order to address the needs of their multi-ethnic members. Centers for Medicare & Medicaid Services (CMS, 2016) provide the following definitions (HHS, 2016):
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● Linguistic competence: Providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through bilingual/bicultural staff, trained medical interpreters, and qualified translators. ● Cultural competence: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals which enable effective interactions in a cross-cultural framework. ● Cultural and linguistic competence: The ability of health care providers and health care organizations to understand and respond effectively to the cultural and Cultural competency and health care education Cultural competence is recognized by governmental and accreditation agencies as essential for improving client or patient health status and access to health care, as well as eliminating disparities in treatment delivery. Health care system interventions to increase cultural competence can include programs to recruit and retain a staff that reflects the cultural diversity of a community, retain the use of interpreter services or bilingual providers, offer cultural competency training for health care providers, provide the use of linguistically and culturally appropriate health education materials, and offer culturally specific health care settings. Health may be improved through these approaches because clients gain trust and confidence in accessing health care; health care providers increase their ability to understand and treat a culturally diverse clientele. The effectiveness of these interventions can be assessed through intermediate outcomes - as well as through health outcomes. Need for linguistic competency A wide range of approaches has been used to provide interpretive services for patients with limited English proficiency (LEP), ranging from using family members or friends, community language banks, telephone, video or computer interpreters, contracted interpreters, bilingual staff, and on-staff salaried interpreters. Although family members or friends are commonly used, confidentiality is breached. The quality of interpretation is frequently inadequate and may lead to misunderstandings. Given the fact that more than one hundred languages are spoken in the United States, all health care professionals should be adequately trained in how to work with interpreters. As the client completes the initial medical and informed consent intake process, it is important to address the language barriers. It is a fundamentally ethical and legal obligation to mention the foundation of an effective relationship between a caregiver and client or patient. The risk of medical malpractice associated with language discordance between providers and patients is reduced when competent medical interpretation is provided. Define race, ethnicity, and culture Changes in the racial and ethnic composition of the United States have important consequences for the nation’s health care: measures of disease and disability often differ significantly by race and ethnicity. One of the main goals of U.S. public health policy is the elimination of racial and ethnic disparities. Diversity has long been a characteristic of the U.S., but the racial and ethnic composition of the nation has changed over time. According to data from the U.S. Census Bureau in 2016, about 40 percent of adults (and over 24 percent of children) were racial or ethnic minorities. The percentage of the population identifying as Hispanic or Asian has more than doubled in recent decades. Individuals
linguistic needs brought by the patient to the health care encounter. (HHS, 2016) Cultural competence requires organizations and their personnel to incorporate the following concepts in practice: ● Value diversity. ● Acquire and institutionalize cultural knowledge. ● Adapt to diversity and the cultural contexts of the individuals and the communities served. (LCME, 2016) ● Conduct ongoing self-assessments. ● Manage the dynamics of difference. The Accreditation Council for Graduate Medical Education (ACGME), as revised in 2016, identified six core competencies for physicians: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, as well as systems-based practice. Each competency pertains to knowledge, skills, and attitudes related to treating clients from diverse populations. The third competency specifically requires interpersonal and communication skills, and will result in an effective information exchange and collaboration with patients, families, and other health professionals by “communicating effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.” Professionalism, the fourth competency, states that, “sensitivity and responsiveness to a diverse patient population, including but not limited to, diversity in gender, age, culture, race, religion, disabilities, and sexual orientation” (ACGME, 2016). The federal government has recognized barriers that can be created by language discordance between providers and clients. It has articulated the responsibilities of service providers toward LEP clients. These responsibilities have a legal basis in Title VI of the Civil Rights Act of 1964, which states that, “no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance” (Civil Rights Act of 1964, Section 601, 78 Stat. 252 [42 USC 2000d]). The Department of Health and Human Services (HHS) regulations require that all recipients of federal financial assistance from HHS provide meaningful access to LEP persons - at no cost to the client [45 CFR § 80.3(b)(2)]. Guidelines have been published in accordance to this that elaborates what constitutes “meaningful access” for LEP patients (Office for Civil Rights, 2003). reporting they were foreign born were 13.1 percent, and 20.9 percent of the respondents reported that a language other than English was spoken at home. Noncitizen, foreign-born persons are disproportionately low-income and uninsured (Kaiser Commission on Medicaid and the Uninsured, 2015). They are also more likely than naturalized citizens to face other barriers to accessing health care - including ineligibility for many government-sponsored programs as well as difficulty in finding providers who speak their language and provide culturally sensitive care.
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racial and national origin, or sociocultural groups. People may choose to report more than one race to indicate their race, such as “American Indian” and “White.” People who identify as Hispanic, Latino, or Spanish may be of any race. OMB requires five minimum categories: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander. “Race” and “ethnicity” are variable and fluid terms; there is no consensus as to what either means. Patterns of human genetic variation are not well described by concepts of “race” or “ethnicity” because these notions include socio- cultural and political factors. To be consistent with the latest research on the causes of health disparities (as well as the findings from the Human Genome Project) it is recommended that a more socio- cultural definition of race be used: Any of several extensive human populations associated with broadly defined regions of the world and distinguished from one another on the basis of inheritable physical characteristics, traditionally conceived as including such traits as pigmentation, hair texture, and facial features. Because the number of genes responsible for such physical variations is tiny in comparison to the size of the human genome and because genetic variation among members of a traditionally recognized racial group is generally as great as between two such groups, most scientists now consider race to be primarily a social rather than a scientific concept” (The American Heritage Science Dictionary, 2012). Differences in life expectancy, mortality, incidence of disease, and causes of death are well documented among racial groups. Social and economic factors as well as barriers to treatment - language, public health policy, illiteracy, health, beliefs, and coping behaviors - contribute to unequal health outcomes. the body produces abnormal red blood cells that are sickle shaped. People of African descent are not the only ones affected by this disease; it is also present in Portuguese, Spanish, French Corsicans, Sardinians, Sicilians, mainland Italians, Greeks, Turks and Cypriots, South Asians, Middle Easterners, and Caucasians from southern Europe. Today, 1 to 3 million Americans is affected by sickle cell disease (SCD). Self-reported or observed race cannot be used to predict accurately who has the sickle cell trait or disease; universal screening is now being recommended and practiced throughout the United States. The U.S. Census Bureau (2016) estimates that: ● SCD occurs among about 1 out of every 365 Black or African-American births. ● SCD occurs among about 1 out of every 16,300 Hispanic-American births. ● About 1 in 13 Black or African-American babies is born with sickle cell trait (SCT). Economic, social, and cultural factors can influence health disparities in prevention, early detection, diagnosis, treatment, post-treatment quality of life, survival, and mortality. For example, racial disparities in asthma emergency department use, hospitalization, and death are documented. Possible explanations include a more acute asthma among racial and ethnic minorities, greater environmental obstacles in high poverty areas, a lag in
The Kaiser Commission noted the following data about health care disparities: ● Most uninsured people are in low-income working families. In 2014, 5 of 10 families had income below 200% of the poverty level, although 8 of 10 families had at least one employed member. ● Adults are more likely to be uninsured than are children, due to provisions in the Affordable Care Act (ACA). ● People of color are at a higher risk of being uninsured than non-Hispanic whites. ● In 2014, 48 percent of uninsured adults said that the main reason they were uninsured was because the cost of insurance was too high. Many people do not have access to health coverage through a job. Some individuals - particularly poor adults in states that did not expand Medicaid - remain ineligible for public coverage. ● Undocumented immigrants are ineligible for Medicaid or Marketplace coverage. ● As of 2014, the ACA expanded health coverage to millions of previously uninsured people through the expansion of Medicaid eligibility and the establishment of Health Insurance Marketplaces. The ACA also included reforms to help people maintain coverage and to make private insurance affordable and accessible. Through 2014 and the beginning of 2015, evidence has shown substantial gains in public and private insurance coverage, as well as historic decreases in uninsured rates during the first full year of ACA coverage. Racial data was derived from questions that were asked by The United States Census Bureau. The U.S. Census Bureau collects racial data based on self-identification in accordance with guidelines provided by the U.S. Office of Management and Budget (OMB). The racial categories included in the census questionnaire reflect the social definition of race recognized in this country, and is not an attempt to define race biologically, anthropologically, or genetically. In addition, it is recognized that the categories of race include Case study Adriana was a 4-year-old girl who had been experiencing pain in her joints that kept her awake at night. Upon an initial screening, she was referred to a pediatric physical therapist for treatment. She did not respond to therapy and her therapist suggested that a pediatric specialist reevaluate her. Adriana was an only child; her parents had emigrated from Greece two years before. Her parents had taken her to multiple doctors to find out what was wrong, and had become frantic. One of her physicians performed a complete blood count (CBC), hemoglobin electrophoresis, and a sickle cell test. She was found to be positive for sickle cell disease. Adriana finally received the treatment that was needed. Discussion The disease was not initially diagnosed because the child was not African American; therefore, it was thought that she would not have this disease. This demonstrated a lack of knowledge concerning race, genetics, and the disease itself: Sickle cell disease is an inherited form of anemia in which The impact of race and culture on health A person’s culture and self-identify are influenced by their race and ethnicity, religion, gender, sexual orientation, age, disability, socio-economic status, and linguistic ability. Linguistic factors - including people with limited English proficiency (LEP), low literacy skills, the hearing impaired, speech or physical or cognitive impairment - affect language and are integrally related.
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medical advances to control asthma symptoms among health care providers who treat minority children, and the lack of asthma education, as well as difficulties in the Identify patterns of national data on disparities The United States Office of Disease Prevention and Health Promotion (ODPHP) Healthy People 2020 provides a scientifically-based, 10-year national objective for improving the health of all Americans. For three decades, the Healthy People program has established benchmarks and monitored progress over time in order to: ● Encourage collaborations across communities and sectors. ● Empower individuals toward making informed health decisions. ● Measure the impact of prevention activities. With the launch of Healthy People 2020, the elimination of health disparities was firmly placed on the national disease prevention and health promotion agenda. The rejection of health disparities currently remains on the national disease prevention and health promotion agenda. The following goals have been proposed for Healthy People 2020: ● Achieve health equity, eliminate disparities and improve health of all groups. ● Eliminate preventable disease, disability, injury and premature death. ● Create social and physical environments that promote good health for all. ● Attain high-quality, longer lives, free of preventable disease, disability, injury, and premature death. ● Promote quality of life, healthy development and healthy behaviors across every stage of life (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020). Healthy People 2020 defines health disparity as: A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. The scope of the Healthy People program goes beyond the prevention and treatment of disease and illness and addresses health care services. It analyzes the multi-faceted relationships between health, biology, genetics, behavior, socioeconomic factors, environment, discrimination, racism, discrimination, education, and legislation that are identified as determinants of health. The mission of The Commonwealth Fund (CF) was designed to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency - particularly for society’s most vulnerable: low- income individuals, the uninsured, minority Americans, young children, and elderly adults (CF, 2015). Race and culture in the medical interview Subsequent to the socio-cultural definition of race and the earlier discussion about genetics, statements about the race of a client or patient should be documented in the social history or subjective information section - race cannot be considered part of the medical history. Keep in mind that clients or patients are using self-identity when describing
implementation of certain asthma control methods within minority families (Akinbami, 2014).
Based on the findings of the Commonwealth Fund’s 2014 Biennial Health Insurance Survey of working-age adults, higher proportions of people in Florida and Texas had difficulty obtaining needed health care than in California and New York, because of the cost. More than four in ten people in Florida (43%) and in Texas (43%) said they did not see a doctor when sick. It was also reported that they did not fill a prescription, skipped a test, did not schedule a treatment or a follow-up visit, and did not seek needed specialist care in the past twelve months for cost reasons - compared to three of ten in California (31%) and New York (30%). The differences in the ability to put money toward medical bills, debt, or cost-related access problems remained - even when taking demographic variations across the states into account. Studies conducted by the Commonwealth Fund’s Princeton Survey Research Associates (2015) noted that uninsured rates within the working-age population are drastically higher for Blacks and Hispanics than for Whites. In 2013 - the year before the ACA’s major coverage expansions took effect - more than one of five Blacks ages 18 to 64 (22%) and two of five Hispanics (43%) did not have health insurance, compared with one of seven Whites (14%). Before the Affordable Care Act (ACA) coverage expansions, uninsured rates were also highest among adults with low incomes. Black and Hispanic adults also were disproportionately more likely than Whites to have low incomes. Among adults ages 18 to 64, nearly half of Hispanics and half of Blacks had incomes below 200 percent of poverty in 2013 - compared with less than one-quarter of Whites. Blacks and Hispanics are more likely to lack resources for care, and often go without care because of cost. One or more individuals had an established source of care that was identified as a personal doctor or health care provider; this has been shown to be an important link to primary and preventive care services and better health outcomes. Yet in 2012 and 2013, more than one-quarter of Black adults ages 18 to 64 (27%) and more than two-fifths of Hispanics (43%) reported not having an established source for care, compared with just over one-fifth of Whites (21%). Black and Hispanic working-age adults also reported an instance within the past year when they could not see a health care provider when needed because of cost - a rate 1.5 to 2 times more frequent than White adults. Minorities have obtained health insurance at higher rates than White Americans since the creation of the ACA Marketplaces in October 2013. Health and Human Services officials report that 20 million people have gained insurance since 2010 (HHS, 2016). African-American and Latino adults still remain less likely to have health coverage than Whites; although the disparities are declining. Hispanic adults are less likely to have employer-sponsored insurance, and immigrants who are in the country illegally are not eligible to buy insurance through Marketplace plans created by the ACA. their race or races; only they can make that determination. Race should not be associated with social class, genetic variation or other elements of the social history. Therapists must be mindful of the potential influence of racism in the health and wellness environment, including the potential for personal bias.
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Book Code: MMD0724
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Time investment ● Allow the interviewee to direct the pace of the interview. ● Allow extra time for interviews conducted in English with people who speak English as a second language – these take longer because the interviewee needs additional time to formulate responses. ● Plan ahead to be able to give more time to the interview, and schedule more than one interview. Tone of voice and demeanor ● Use voice and demeanor to convey two things: respect and support. ● Recognize that the demeanor being conveyed by the therapist may not be the demeanor that is actually perceived by the interviewee. ● Consider the way to best ask questions, take notes, fill out forms and examine injuries. ● Solicit feedback from a colleague, or view a videotape of an interview to recognize how the techniques may be viewed by others. ● Convey patience and avoid verbal or nonverbal signs of criticism or impatience. ● Use a gentle, direct, non-threatening tone. ● Avoid being too loud or too quiet. ● When speaking English to a non-native English speaker, avoid mumbling or talking while chewing gum. ● Vary your tone of voice for adults and children. ● Avoid using a loud voice or making direct commands. ● Manage your responses to the tone of voice and speaking style of the interviewee, as many speakers of English as a second language use the tone and volume typical of their first language, and may not be the same as native English speakers. Understanding the family’s communication style Ask yourself: ● Does the family communicate with each other in a direct or indirect style? ● Does the family tend to interact in a quiet manner or a loud manner? ● Does the family ask the therapist direct questions? Working with interpreters First consider: ● With which culture is the interpreter primarily affiliated? ● Is the interpreter familiar with the colloquialisms of the family members’ country or region of origin? ● Is the family member comfortable with the interpreter? Would the family member feel more comfortable with an interpreter of the same sex? ● If written materials are used, are they in the family’s native language? Tips: ● Arrange for an interpreter if not proficient in the language of the interviewee, or if the interviewee is not proficient in the therapist’s language. ● Whenever possible, interview people in their native language. ● Use a professional interpreter; do not ask children to interpret for their parents. ● Focus on the interviewee, not the interpreter. Maintain eye contact and non-verbal communication with the interviewee. Additional considerations: ● Avoid placing a physical barrier, such as a desk, between the interviewer and interviewee. ● Avoid non-verbal displays of power such as sitting back with hands behind the head, putting hands on hips, sitting with legs apart, or showing the bottom of the foot or shoe which are taken as disrespect in some cultures.
A client or patient’s culture can shape their views of causation, symptoms, and treatment of illnesses. It is important to recognize that providers and patients may differ in their perceptions and their use of time, personal space, gestures, eye contact, body language, privacy, acceptability and preferences for treatment and care. Several communication models exist to help elicit patients’ perceptions of their conditions, as well as what treatments they have tried. These communication models can be helpful in facilitating a mutually acceptable plan of treatment. Two examples of cross-cultural communication models include Kleinman’s (1978) and LEARN (Berlin 1983). Kleinman’s tool to elicit health beliefs in clinical encounters includes the following questions: ● What do you call your problem? What name does it have? ● What does your condition do to you? How does it work? ● How severe is it? Will it have a short or long course? ● What do you fear most about your disorder? ● What are the chief problems that your condition has caused for you? ● What do you think caused your problem? ● Why do you think it started when it did? ● What kind of treatment do you think you should receive? ● What are the most important results you hope to receive from the treatment? The LEARN communication model is shorter and includes the following: ● L isten with sympathy and understanding to the patient’s perception of the problem. ● E xplain your perceptions of the problem. ● A cknowledge and discuss the differences and similarities. These two models are still widely referenced and implemented, despite their publication dates. Lisa Aronson Fontes expanded these models in 2009, and wrote I nterviewing Clients Across Cultures: A Practitioners Guide . Her article Tips for Cross Cultural Interviewing is summarized as follows: Interview content ● Take time at the beginning of the interview to provide thorough information about the scope of the interview and the role of the interviewer. ● Continue to check in with the interviewee throughout the interview, providing explanation when needed and ensuring the interviewee understands the process as it evolves. ● Leave time in the interview for the interviewee to ask questions and, allow for a period of silence to give the interviewee time to formulate questions. ● If needed, suggest typical questions to help the interviewee begin to ask questions. ● Reassure interviewees that they are free to share any and all information, and that the therapist will not be shocked or upset by what they say. Emotional content ● Use active listening: maintain eye contact, lean forward, repeat responses from the client if needed for clarification. ● Show evidence of caring on a personal level by asking ● R ecommend treatment. ● N egotiate agreement. personal questions about the interviewee’s likes and dislikes or hobbies, and by finding a personal connection with these.
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Book Code: MMD0724
Page 6
● Do they utilize a combination of these approaches? ● Who is the primary medical provider or conveyer of medical information, family members, elders, friends, folk healers, family doctors, or medical specialists? ● Do all family members of the family agree on approaches to medical needs? ● It is important to remember to remain nonjudgmental about differences in beliefs about the medical issue, cause, or treatment. ● Correcting a client or patient’s different beliefs about their condition may lead the person to withhold future thoughts, and may interfere with building a trusting relationship. ● Treating patients with respect and allowing them to openly discuss differences in health beliefs permits them to reveal their medical history and symptoms, so that the therapist can make an accurate plan of treatment and the client will be willing and able to adhere to the therapist’s advice. biases, and beliefs can be used to ensure that they do not negatively affect the care that is provided to patients. One example of a self-assessment tool to assess conscious preferences, beliefs, and related practices is the set of cultural competency assessment questions provided by the American Academy of Family Physicians (2016): Questions to assist with informally assessing one’s level of cultural competence ○ Am I knowledgeable about the worldviews of different cultural and ethnic groups? ○ Am I aware of my biases and prejudices towards other cultural groups, as well as racism in health care? ○ Do I seek out face-to-face and other types of encounters with individuals who are different from me? ○ How do I react when a person I encounter does not speak English? ○ What are my beliefs toward folk remedies? 2.6% Racial and ethnic minority patients tend to be more receptive to care from practitioners of their own race or ethnicity, particularly in primary care and mental health settings. Non-English speaking patients experience better relationships of trust, greater medical comprehension, and greater likelihood of keeping follow-up appointments when they see a language-concordant practitioner, particularly in mental health care. ● Native Hawaiian/Pacific-Islander ● Multiple Other Race/ Non-Hispanic 0.2 % These findings suggest that greater diversity in health professions will likely lead to improved public health by increasing access to care for underserved populations, and by increasing opportunities for minority patients to see practitioners with whom they share a common race, ethnicity, or language. Although there is no consensus about how to define cultural and linguistic competence, what is common to their definitions is the need to be respectful and responsive to cultural and linguistic needs. The National Human Genome Project has found that any two humans are approximately 99.9 percent genetically identical. The most important genetic material for human functioning is in the shared set (NIH, 2016). It is for this reason that a sociocultural definition of race is recommended.
● Personal space and conversational distance vary across cultures. Look to the family for nonverbal cues about acceptable distance. ● Nonverbal signals for yes and no vary across cultures. In some cultures, nodding signals disagreement (Greece, Turkey, Iran). ● When taking notes, explain the contents and why they are being written. ● Be sure to ask the interviewee what he or she prefers to be called. ● Do not use a medical title as a tool to enforce a power differential. ● Eye contact patterns vary by culture and should not be used to assess truthfulness. Sample questions Regarding medical care: ● What is the family’s approach to medical needs? ● Do they rely solely on Western medical services? ● Do they rely solely on holistic approaches? Health provider’s self-assessment and reflection Most health professionals harbor some assumptions about patients, based on characteristics such as race, ethnicity, culture, age, social and language skills, education or socioeconomic status, gender, sexual orientation or disability. Often unconscious, these assumptions are so deeply rooted that even when a client or patient behaves contrary to assumptions, the therapist may view this as an exception to the rule. A conscientious therapist, aware of these underlying assumptions, will work diligently to ensure that these prejudices do not interfere with designing an appropriate treatment plan. Two different types of self-assessment tools are available for massage therapists to assess conscious and unconscious preferences: beliefs and related practices. Completion of self-assessment tools should be accompanied by reflection of how this new information on personal experiences, Value importance of diversity in health care According to the Health Resources and Services Administration, racial and ethnic minorities, particularly African-Americans, Mexican-Americans, Native- Americans, mainland Puerto Ricans, and people from a socioeconomically disadvantaged background are significantly underrepresented among health professionals. The following data was provided in the January 2015 report from the U.S. Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce National Center for Health Workforce Analysis: Minority representation among massage therapists ● White/Non-Hispanics 83.6 % ● Black/African American /Non-Hispanic 5.2 % ● Asian/Non-Hispanic 7.9% ● American-Indian/Alaskan Native 0.5% Section summary The United States lags behind other developed countries in key health indicators. Significant differences in health and health care persist by race, ethnicity, and socioeconomic status. As the linguistic and cultural diversity of the United States population grows, health care professionals are becoming increasingly aware of the need to be both linguistically and culturally competent.
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Book Code: MMD0724
EliteLearning.com/Massage-Therapy
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