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Transcript of Cultural Competencies Delphina Sánchez, MA March … · Cultural Competencies Delphina Sánchez,...
3/15/2017
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Nurse Case ManagementSan Antonio, TexasMarch 7‐9, 2017
CulturalCompetenciesDelphinaSánchez,MA
March7,2017
• Recognize foreign‐born populations as a high risk group for TB.
• Discuss the barriers and special considerations in caring for these groups.
Objectives
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Foreign‐bornPopulationsasaHighRiskGroup
Persons at Risk for Developing TB Disease
Persons at high risk for developing TB disease fall into 2 categories
• Those who have been recently infected
• Those with clinical conditions that increase their risk of progressing from TB infection to TB disease
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Recent Infection as a Risk FactorPersons more likely to have been recently infected include
• Close contacts to a person who has TB disease
• People from a country where TB disease is common (most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia)
• Children 5 years with a positive
TST
• Skin test converters (within past 2 years)
• Residents and employees of high‐risk congregate settings (correctional facilities, homeless shelters, health care facilities)
Increased Risk for Progression to TB DiseasePersons more likely to progress from TB infection to TB diseaseinclude
• People with HIV infection
• People who became infected with TB bacteria in the last 2 years
• Babies and young children
• People who inject illegal drugs
• People who are sick with other diseases that weaken the immune system
• Elderly people
• People who were not treated correctly for TB in the past
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Countries with High Prevalence of TB
AFRICA LATIN AMERICAASIA
20%
13%
8%
9%
7%
3%
Haiti
2%
Table 35. Tuberculosis Cases and Percentages Among Foreign‐Born Persons1 by Top Seven Countries of Birth: Reporting Areas, 2015
Reporting areaTotal Cases
Country of Origin
Mexico Philippines Vietnam India China Haiti Guatemala All others2Unknown / missing
No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)
United States 6,350 1,254 (19.7) 820 (12.9) 579 (9.1) 519 (8.2) 426 (6.7) 189 (3.0) 166 (2.6) 2,387 (37.6) 10 (0.2)
Arizona 141 70 (49.6) 14 (9.9) 9 (6.4) 3 (2.1) 6 (4.3) 4 (2.8) 0 0 35 (24.8) 0 0
Arkansas 18 3 (16.7) 1 (5.6) 0 0 3 (16.7) 1 (5.6) 4 (22.2) 0 0 6 (33.3) 0 0
Kansas 26 3 (11.5) 0 0 3 (11.5) 2 (7.7) 0 0 1 (3.8) 0 0 17 (65.4) 0 0
Louisiana 39 4 (10.3) 3 (7.7) 2 (5.1) 12 (30.8) 1 (2.6) 3 (7.7) 0 0 14 (35.9) 0 0
Missouri 55 4 (7.3) 4 (7.3) 14 (25.5) 7 (12.7) 1 (1.8) 3 (5.5) 1 (1.8) 21 (38.2) 0 0
Nebraska 25 3 (12.0) 0 0 0 0 3 (12.0) 1 (4.0) 2 (8.0) 0 0 16 (64.0) 0 0
New Mexico 24 20 (83.3) 1 (4.2) 0 0 1 (4.2) 0 0 0 0 0 0 2 (8.3) 0 0
Oklahoma 25 8 (32.0) 1 (4.0) 3 (12.0) 5 (20.0) 0 0 0 0 0 0 8 (32.0) 0 0
Texas 764 324 (42.4) 25 (3.3) 40 (5.2) 71 (9.3) 18 (2.4) 30 (3.9) 1 (0.1) 255 (33.4) 0 0 1Includes persons born outside of the United States (including the U.S. insular areas) and the sovereign freely associated states (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau).
2Includes 136 countries.
CDC. Reported Tuberculosis in the United States, 2015
TB Prevalence in the Heartland Region
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• Immigrants
• Refugees
• Migrant workers
• Students
Foreign‐born Persons at Risk for TB
• Visa pre‐departure exam
– College students
– Workers
– Refugees
• Primary care
– Community clinics
• The goal of TB screening should be to complete therapy
Opportunities for TB Screening
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CDC Supports New USPSTF Latent TB Infection Recommendation
The U.S. Preventive Services Task Force (USPSTF) issued a recommendation that supports CDC guidance to test for latent tuberculosis infection in populations that are at increased risk.
Full recommendation statement
• Drug resistance– Percentage increase of primary MDR TB reported among foreign‐born (31% in 1993 to 88% in 2014)
– Drug resistance higher in foreign‐born vs U.S. born
– During 2015 seven countries accounted for >60% of all cases among foreign‐born persons
Characteristics (1)
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• Bacille Calmette‐Guérin (BCG)
– A live, attenuated (weakened) vaccine derived from a strain of Mycobacterium bovis.
– Many highly TB‐prevalent countries vaccinate infants with BCG as part of TB control effort.
– Recent BCG vaccination may cause a subsequent false positive reaction to the TST.
• IGRA
– Test of choice for TB infection diagnosis.
Characteristics (2)
BarriersandSpecialConsiderations
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• Language ‐ limited English proficiency
• Low health literacy
• Fear of job loss
• Immigration status ‐ fear of deportation
• Anti‐immigrant sentiments
• Lack of awareness of entitlement to health services
Social Barriers
• TB treatment requires time and resources
• Patient and provider education specific to TB is important
– Providers need to know who & how to screen & why
– Patient needs to know what TBI and TBD are
• Cultural competence
Special Considerations
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Resources• Providers and patients
• Local Public Health,
families, community leaders
and others
• Qualified interpreters
• Transportation
• Stable housing and good
nutrition
• Time ‐ treatment is long
• DOT is standard of care for
TB
• Monthly monitoring for TB
infection
TB Education is critical to managing and preventing TB
• TB is complex
• Treatment is time and resource intensive
• Preparation / acceptance to treatment regimen
• Positive attitude toward treatment
• Language and cultural challenges
Education
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• Health care workers need to be aware of, and sensitive to, cultural diversity, life situations, and other factors that shape a person’s identity
• The first step is an open, non‐judgmental attitude and demeanor
The Importance of Cultural Competency
Culture has been defined in a number of ways, but most simply, as the learned and shared behaviors of a community of interacting human beings.
What is Culture?
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• Religious beliefs
• Understanding of TB (or illness in general)
– May not recognize common signs and symptoms of TB
– Misperception of the origins or causes of the disease
• Suspicion of modern medicine
• Use of alternative medicine / healers
• Stigma
– Affects the patient’s attitudes and adherence to treatment
Cultural Barriers
• Description and communication of symptoms– Inability to communicate in language of provider
• Perceived causes of illness, understanding of infection, transmission, and contacts
• Understanding of disease process, treatment expectations, and decisions
Impact of Cultural Barriers (1)
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• Interaction with health care system and health care professionals
• Attitudes towards helpers, authorities, revealing contacts
• How a person identifies and describes their contacts
Impact of Cultural Barriers (2)
• Awareness & Understanding
• Collaboration & Cooperation
• Stepping outside our comfort zone
Overcome Social and Cultural Barriers
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Mexico: TB TransmissionA young man from Mexico entered the U.S. last year and has been living with 10 other friends while working at a local chicken processing plant.
He has been coughing and losing weight for the past 6 months.
He has heard that TB is transmitted by sharing eating utensils and household goods with TB patients.
Use the Quick Reference Guide: MEXICO to answer the following question:
He might experience anxiety, distress, fear, or mistrust related to his diagnosis because…..
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He might experience anxiety, distress, fear, or mistrust related to his diagnosis because…..
1. Consequences of TB ‐ condemned for spreading TB
2. Losing job, housing or being deported
3. Denied application for legal permanent resident status
4. Social isolation ‐ rejected by family and friends
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Philippines: TB TransmissionYou receive a call from the infection control nurse at the hospital informing you that a child, originally from the Philippines, has been diagnosed with active TB disease.
As you head out the door to interview the patient’s parents, a colleague informs you that some Filipinos believe that children cannot have TB, it is an illness that only affects adults.
Use the Quick Reference Guide: PHILIPPINES to answer the following question:
The parents of this child may experience anxiety, distress, fear, or mistrust because…..
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The parents of this child may experience anxiety, distress, fear, or mistrust because…..
1. Someone with TB touched the child
2. Isolation ‐ being shunned or avoided by family members
3. Job loss
4. Another illness or not eating nutritional food caused TB
Resources
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http://globaltb.njms.rutgers.edu/downloads/products/Newsletter‐7.pdf https://sntc.medicine.ufl.edu/Products.aspx
http://www.cdc.gov/tb/publications/guidestoolkits/ethnographicguides/default.htm
http://sntc.medicine.ufl.edu/products.aspx
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https://findtbresources.cdc.gov/
• CDC. CDC. Reported Tuberculosis in the United States, 2015. Atlanta, GA: U.S. Department of Health and Human Services, CDC, November 2016. Available at http://www.cdc.gov/tb/statistics/reports/2015
• Center for Immigration Studies http://cis.org
• National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas http://www.cdc.gov/nchhstp/atlas/
• Online Tuberculosis Information System (OTIS) http://wonder.cdc.gov/tb.html
More Resources
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• CDC. CDC. Reported Tuberculosis in the United States, 2015. Atlanta, GA: U.S. Department of Health and Human Services, CDC, November 2016. Available at http://www.cdc.gov/tb/statistics/reports/2015
• Delivering Culturally Competent Patient Education and Care to Tuberculosis Program Clients, October 2015, Austin , Texas, Joan M Mangan, PhD MST, Centers for Disease Control and Prevention, Division of Tuberculosis Elimination.
• Taylor, Z., C. M. Nolan, et al. (2005). "Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America.[erratum appears in MMWR Morb Mortal Wkly Rep. 2005 Nov 18;54(45):1161]." Morbidity & Mortality Weekly Report Recommendations & Reports. 54(RR‐12): 1‐81
References
Thank You!