Need for cultural competence increases as diversity becomes more commonplace

America has been called a “melting pot,” “a salad bowl,” a home to many cultures and ethnicities. Because of the large influx of immigrants into the United States, optometrists today are seeing a wide array of patients who do not share the same beliefs and customs – and who sometimes do not even speak the same language.

Hector C. Santiago

To prepare for that, experts are urging clinicians to become culturally competent or develop the skills to treat patients from cultures different than that of mainstream America.

“We have to prepare ourselves as optometrists to handle the new face of America,” Hector C. Santiago, OD, PhD, dean of the college of optometry at the Inter-American University of Puerto Rico, told Primary Care Optometry News in an interview. “The more we understand the people we serve, the better we can serve them and the better we understand their needs.”

“It’s no surprise to most that as a country we’re becoming more and more diverse,” Derrick Artis, OD, MBA, FAAO, Vistakon’s director of customer development, told PCON in an interview. “Hispanics make up 13.4% of America, African Americans make up 13% and Asian Americans represent more than 4%. The Asian American population is growing faster than any of them – more than 100% from 1990 to 2000. The entire U.S. population in that same time period grew only 6%.”

The Vision Care Institute, a Johnson & Johnson Company, provided educational grants to SECO the last 2 years that supported continuing education on cultural competency. The SECO CE program used professional actors to act out a scene in a fictitious optometry office that treated a diverse patient base.

Learn norms, behaviors of other cultures

To become culturally competent, practitioners must learn what norms and behaviors are common in the ethnic patients they treat, said Dr. Artis. For instance, Asian American patients may not look the doctor directly in the eye when speaking. “The doctor may interpret this as the patient not listening, when the patient is actually showing deference or respect,” he said.

“Cultural competency not only helps us understand our patients, but it forges a bond between us,” Charissa Lee, OD, a private practitioner from Irvine, Calif., told PCON. “That bond will tie them to our practice, create a loyal patient base and ultimately generate referrals. Communication is a key part of our role as optometrists, and cultural competency allows us to be better communicators.”

Levelle B. Jenkins, OD, retired assistant professor of clinical optometry at Ohio State University College of Optometry, said she became aware of the importance of cultural competency while practicing in a community health center in Cleveland.

“There were a multitude of different ethnic minorities in the area,” Dr. Jenkins said in an interview. “Although we learned about ethnic groups with a predilection for certain eye diseases, we never learned that different cultures will receive and respond to medical information in different ways based primarily on social customs, etiquette and primary language.”

Dr. Jenkins went on to OSU and introduced cultural competency courses into the school’s regular curriculum.

Being culturally competent is different than stereotyping a certain group, she said. “It doesn’t mean that everyone in the culture is going to act the same. There’s always going to be some individuality,” Dr. Jenkins explained. “The goal is for the practitioner to become familiar with and comfortable treating patients from different cultures, because this information can lead to patient compliance with the prescribed treatment plan for better outcomes.”

No matter the culture, it is important to address a patient by his or her title, Dr. Jenkins said.

“We have a tendency in medicine, and in American culture, to jump right in and call people by their first name,” she said. “To us, that should make the person feel at ease, but it doesn’t necessarily do that. Sometimes it actually insults them. Practitioners should wait until the patient invites them to use their first names or at the very least ask if it’s OK to call them by their first name.”

African Americans want interest, respect

Levelle B. Jenkins

“African American patients prefer direct eye contact, a positive posture and a respectful tone of voice when being addressed by medical personnel,” Dr. Jenkins said.

She noted that different cultures have different ways of seeking health care. Some African Americans, for instance, generally do not seek medical care until they feel it is absolutely necessary, and punctuality differs among them as well.

When they need corrective lenses, most African Americans prefer fashion over frugality. “African Americans, in general, take pride in their appearance and will spend money on a nice pair of glasses and all of the extras that go along with them,” Dr. Jenkins said.

Asian American culture is patriarchal

Other than a possible language barrier with recent immigrants, clinicians treating Asian American patients should be aware that the culture is patriarchal, with a gap between older patients with traditional values and younger ones with a desire to assimilate.

“Eye contact may not be deemed polite in the presence of an elder or superior,” Dr. Lee explained. “Shaking hands between sexes may also not be respectful. Asians may appear stoic and mask emotion, because showing emotion may be seen as a weakness.”

According to Dr. Lee, there are approximately 12 million Asians in America and they tend to live near the coasts. They also are the second fastest growing ethnicity with a stronger buying income because of their higher median incomes.

Still, Dr. Lee added that some Asian American patients might not understand the scope of an optometrist’s practice.

“They may not realize that we check the full health of their eyes and think that we only dispense contacts and glasses,” she said.

Asians, too, may look to homeopathic remedies for a “quick-fix” to their ailments, she said.

“Asians are also more likely to purchase both contacts and glasses,” Dr. Lee noted. “Sixty-one percent of Asians in the United States require vision correction, and they have the highest rate of myopia.”

Hispanic Americans fastest growing segment

Hispanic Americans are the largest growing immigrant population in the United States, so it is more and more likely that an optometrist will encounter such a patient in practice these days.

“It is expected that in the next 30 years one of every four Americans will be Hispanic,” Dr. Santiago said.

He said it is important to know that the family is the central core in Hispanic culture.

“It’s not unusual that when a Hispanic patient comes to your practice, he doesn’t come alone,” he said. “Family members want to become involved in the treatment and management of the patient. What looks like a nuisance, having to involve more people in the management of a patient, becomes an opportunity, because what you’ll find is once Hispanics become comfortable with you, you become the family doctor.”

In general, he said, Hispanic patients avoid eye contact and asking many questions as a sign of respect to the doctor. “The doctor has to be very careful about concluding that the patient understands the diagnosis and management of the disease just because he doesn’t ask a question,” Dr. Santiago said.

Herbs are widely used in Hispanic culture, and being overweight is sometimes seen as a sign of health, he added.

“Make sure to ask if the patient is taking herbs,” Dr. Santiago said. “These herbs may be very positive and effective but in some cases hinder your treatment. You have to educate the patient that being ‘gordito’ or chubby is not necessarily healthy. This is important, because the prevalence of diabetes is very high in Hispanics.”

Learn some of the language

With all three cultures, a little bit of research and learning on a practitioner’s part goes a long way. Dr. Santiago said learning a bit of Spanish can help forge a bond with Hispanic patients – and make them feel more comfortable.

“What it means to the patient is that you are a doctor who respects them and is making an effort to be understood and understand them,” he said. “That goes a long way to developing your practice. And you have to be sure that you have a staff that is sensitive to the needs of your patients.”

Dr. Artis agrees. “There’s also a huge economic opportunity for the doctor who embraces cultural competency,” he added. “What we do know is the purchasing power of these groups is estimated at more than $500 billion, and these patients tend to be very loyal to doctors who respect them and provide culturally competent care.”

Just the beginning

Learning about the three fastest growing cultures is just scratching the surface, Dr. Artis said.

“We recognize that this is a small subset of American culture, and we’re not covering all the ethnic groups in America. As we grow, we will try to expand,” he said. “This year we added the Islamic Americans to our program. In the future, we hope to address other cultures. We recognize that America is a rich and diverse country.”

For more information:

• Hector C. Santiago, OD, PhD, is dean of Inter American University of Puerto Rico School of Optometry. He can be reached at 500 John Will Harris Rd., Bayamon, PR 00957. He can be reached at (787) 765-1915, ext. 1000; fax: (787) 767-3920; e-mail: hsantiag@inter.edu.
• Derrick Artis, OD, MBA, FAAO, is Vistakon’s director of customer development in Jacksonville, Fla. He can be reached at (904) 443-1830; e-mail: dartis@visus.jnj.com.
• Charissa Lee, OD, is in private practice in Irvine, Calif. She also works as a consultant for Vistakon. Dr. Lee can be reached at 3971 Irvine Blvd. #110, Irvine, CA 92602; (800) 876-6622, ext. 9502; fax: (714) 505-2655; e-mail: clee23@visus.jnj.com.
• Levelle B. Jenkins, OD, is a retired assistant professor of clinical optometry at Ohio State University’s School of Optometry. She can be reached at lrbjenkins@aol.com.

Reference:

• Berlin, EA, Fowkes Jr. WC. A teaching framework for cross-cultural health care application in family practice. The Western Journal of Medicine. 1983;(139):934-938.

• For a free copy of the Americans’ Attitudes & Perceptions About Vision Care Executive Summary, write to VisionCareSurvey@visus.jnj.com.
• The consensus paper, Factors Impacting the Vision Care and Vision Wear of Culturally Diverse Groups: Focus on Hispanics, is available from Transitions Optical at us.transitions.com/professionals/partners/papers.htm. Transitions also offers Healthy Insights Informativo, an electronic newsletter for eye care professionals interested in learning how to reach the Hispanic market, an education course called Dispensing to Your Hispanic Patients (in English and Spanish), a Bilingual Pocket Card designed to help English-speaking ECPs communicate with Spanish-speaking patients, two Spanish language Web sites and various Spanish language point-of-sales tools.
• To learn more about cultural changes in your own community, check out the U.S. Census Bureau Web site at www.census.gov and click on the “American Community Survey.”
• A staff training DVD that illustrates some of the cultural challenges faced in an optometry practice has also been produced and is provided free to eye care providers from the Vision Care Institute. It can be acquired by going to www.thevisioncareinstitute.com.