CE Sponsored by Philips—Clinical Strategies for Ethical, Culturally Competent Care

INTRODUCTION

It is our responsibility as dental professionals to treat every patient with ethical, culturally competent care. Philips is a health technology company that cares about people and delivers meaningful innovation. We believe there’s always a way to make life better, and to achieve this positive impact we have teamed up with Decisions in Dentistry by providing an unrestricted educational grant supporting this excellent continuing education article by Pamela Zarkowski, BSDH, MPH, JD. An awareness and understanding of patients’ values and beliefs, along with cultural differences, helps practicing dental professionals best accommodate patients’ needs and concerns. We believe you will find this article helpful as you serve your diverse patient population and make their lives better.

—Cindy Sensabaugh, RDH, MS
Senior Manager, Professional Education and Academic Relations
Philips Oral Healthcare

Treating Diverse Patients With Cultural Respect

Every dental patient seeks and deserves a quality, evidence-based and respectful experience. Each patient brings to the appointment a unique set of oral health needs and expectations. At the same time, each arrives with an individual understanding of his or her oral condition, health beliefs and practices. Using the ethical principles of autonomy, nonmaleficence, beneficence and justice as a framework for patient interactions will help guide all facets of professional care.

The American Dental Association’s Principles of Ethics and Code of Professional Conduct states in its preamble that the association calls upon dentists to follow high ethical standards that have the benefit of the patient as their primary goal.¹ Dentists are expected to understand a patient’s cultural background in order to best address the patient’s needs and concerns, while recognizing and respecting that individual’s values and beliefs.²

Today’s patient population is diverse, and each individual brings to the provider/patient experience not only specific oral health needs, but also an expectation that diversity will be respected and understood. Dental teams must work to develop awareness so as to recognize each individual’s cultural diversity and health literacy. Culture influences a patient’s communication style, beliefs, understanding of health and disease, and attitude toward health care.³ Cultural competency is a set of skills, knowledge and attitudes that enhance a clinician’s understanding of — and respect for — a patient’s values, beliefs and expectations.³ Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic information concerning health and services that is necessary to make appropriate health decisions.⁴

Providers should take into consideration a patient’s culture, his or her ability to comprehend and synthesize information, and recognize the need to treat that individual in a professionally competent manner. Embracing the concepts of cultural competence, health literacy and culture lays the foundation for cultural respect. The latter is defined as a combination of a body of knowledge, a body of belief, and a body of behavior.⁵ It involves a number of elements, including personal identification, language, thoughts, communication, actions, customs, beliefs, values and institutions that are often specific to ethnic, racial, religious, geographic or social groups.⁵ The provider of health information or health care must recognize that these influence beliefs and belief systems surrounding health, healing, wellness, illness and disease. Integrating cultural respect into daily practice has a positive effect on patient care by enabling providers to deliver services that are respectful of — and responsive to — the health beliefs, practices, cultural and linguistic needs of diverse patients.⁵ Recognizing and embracing the importance of cultural respect contributes to improved care.

Ethically Based Care

Patient care involves treating a broad spectrum of individuals who can be described in many ways, including diverse patient family, demographically diverse, or representative of the culture or cultures living in a community. Diversity can be broadly defined to include all aspects of human differences; for example, physical dimensions, including race, ethnicity and cultural background. Diversity can also be described using other influencing factors, such as socioeconomic status, religion, place of birth or educational achievement. Additional characteristics that contribute to diversity include age, mobility, disability, gender, gender expression, height, weight or marital status. Each of these factors influences a patient’s understanding and management of oral health.

In many situations, cultural backgrounds and experiences have a unique way of influencing oral and general health practices and beliefs. For example, many cultural groups are not prevention oriented, and only seek care when there is a serious problem. In this scenario, an individual will only seek care from an oral health professional after experiencing significant pain, with the expectation that the tooth will be extracted so the pain will stop. In the United States and other Western cultures, suggesting a root canal and a restoration would be expected. However, the person experiencing the pain may view such treatment available only to the wealthy and not consider it as a viable option.⁶

A commitment to treating diverse patients and integrating their cultural beliefs and practices in assessment, treatment planning and therapy is based on ethical principles. In turn, recognizing the emphasis on cultural respect in patient care heightens the need to practice in an ethical manner. The principles of autonomy, beneficence, justice and veracity provide a foundation for managing patient interactions and care, and integrating cultural respect into all clinical care situations.

The principle of autonomy supports the patient’s role in independent decision-making. A patient must be able to make an informed decision about the care he or she is to receive in order to allow the individual to self-determine a course of action. Communication plays a critical role. Appropriate communication and information collection enhance patient rapport and compliance. Obtaining informed consent for treatment is a legal obligation that is based on the ethical principle of autonomy. To be informed, the patient must understand the reasons for a recommended treatment, as well as the risks and benefits. The provider also has an obligation to inform the individual in a manner that recognizes the patient has his or her own belief system. The patient makes decisions based on the information that was provided under the context of the individual’s beliefs and practices.

By way of example, an oral health professional may observe the clinical signs of periodontal disease, and collect and record clinical findings that support a diagnosis of advanced periodontitis. Following data collection and analysis, the provider offers a treatment recommendation and plan for therapy. As a result of the patient’s beliefs, however, that individual may view the same condition differently. For instance, some cultures believe that periodontal conditions are related to a hot and cold syndrome, and that mixing the wrong combination of hot and cold foods will lead to poor oral health.⁶ A patient may attribute a particular condition to an imbalance in the individual’s life, or a consequence of a particular action. Other cultures value the esthetic appearance of teeth, but do not value having both healthy teeth and gingiva;⁶ in other words, red and bleeding gingiva are not perceived as a problem if the visible teeth look good.

As these examples demonstrate, beliefs impact a number of clinical issues, including when a patient seeks care, management of the condition, the treatment choices the individual elects, and, in some instances, how he or she follows or responds to specific recommendations or therapies. All of these considerations help shape the patient’s assessment of the options presented and, ultimately, influence informed consent.

The principle of beneficence motivates the provider to take steps to benefit the patient’s well being and oral health. A clinical example of beneficence is assessing a patient’s dietary habits to determine what may be contributing to an increase in caries. In this case, understanding that diet is influenced by culture is important. Food plays a significant role in many cultures, whether as a form of sustenance, custom or celebration. A dental team member recommending a reduction in sugar intake may not recognize that sweets are an important part of a culture’s regular diet, and that, due to cultural practices, reducing or eliminating that food product is not an option.

The principle of justice means treating patients fairly. Although a clinician might not consciously want to treat someone in an unfair manner, if the provider does not consider the cultural, religious or ethnic background of the patient when planning care, or assumes that every patient follows the same health philosophy as the provider, there is a possibility the patient will be treated unfairly. Practitioners cannot assume that each patient has adopted the same health beliefs and practices, as culture, socioeconomic factors, generational practices and religious requirements all contribute to different perspectives. Patients may be unfamiliar with oral health practices for preventing caries or periodontal disease. Some cultures rely on folk remedies or family traditions to address oral health conditions, such as soaking a cotton ball in clove oil and dabbing it on the tooth. Other cultures believe that a painful tooth is a result of the body harboring excess heat, or from inhibiting the flow of energy. Acupuncture may be the treatment of choice to address the pain. Providers must not make assumptions about patients, whether positive or negative, based on their values, practices or beliefs.

The principle of veracity demands truthfulness. Oral health professionals cannot hesitate to be honest with a patient and explain that an action they are taking to address an oral condition may be harmful. For example, if used to treat tooth pain, a culturally based practice, such as coin rubbing therapy, may appear as a bruise or abrasion on the face or neck. Coin rubbing is a global alternative medicine practice that employs special oil or ointment and rubbing the coin in a linear pattern until a skin ­abrasion occurs on the affected area. Ignoring a discolored or bruised portion of the face that may be near an area of the oral cavity in which there is caries or an infection is not being truthful with the patient.

Alternately, if the clinician does not ask about the source of the bruising, he or she may incorrectly assume the bruise is the result of an abusive situation. Ignoring or not seeking additional information about home remedies or alternative treatments the patient may have used prevents providers from demonstrating sincerity and trustworthiness, thus violating the ethical principle of veracity. Clinicians must also be truthful in educating patients that home remedies or alternative therapies might negatively impact the professional treatment being rendered.

Cultural Perceptions

The ethical principles of autonomy, beneficence, justice and veracity must be translated into action by the oral health professional. During interactions with a patient, when taking a health history, and when suggesting treatment or evaluating outcomes, the provider must be sensitive to the patient’s health care beliefs. Patients may define and categorize health and illness in a variety of ways. The illness may be attributed to an evil force that is retaliating for moral or spiritual failings, and/or violations of social norms or religious taboos. Or it may be attributed simply to bad luck or karma.

Some cultures view health in relation to maintaining balance by regulating one’s diet according to the seasons. For example, a patient may believe that a specific illness is the result of an imbalance in one’s life, or that the condition may be the result of other factors, such as a test of character. Patients may not value Western medicine’s solutions to a particular condition, but, rather, seek alternative therapies based on their cultural beliefs and practices. Providers can gather insight into a patient’s beliefs by asking questions and making sure their assessment protocol includes questions about the specific condition, treatments used by the patient, and any healers that have been consulted.

Treatment Strategies

For practitioners, the challenge is to balance ethical principles and the need to meet the standard of care within the context of a patient’s cultural beliefs. Any clinician practicing within a community that has a large population from a specific culture is advised to learn about that ­culture’s health beliefs and practices. The provider must assign priority to each patient’s autonomy and ability to determine care. Designating autonomy as a priority translates to valuing informed consent and taking steps to partner with the patient in the treatment planning process by recognizing the patient’s beliefs, practices and values. This requires meaningful communication, shared decision-making, and participation by both the provider and patient in the treatment planning and informed consent process. The emphasis should be on educating patients about their choices.⁷

To enhance shared decision-making, providers must identify areas where cultural differences may be an issue, cultivate awareness of one’s own values, biases and understanding, and develop an unbiased, nonjudgmental stance.⁸ Clinicians must recognize that diverse patients have different communication needs — including the pace of speech, volume, and sensitivity to body language and eye contact. Another strategy to enhance communication is using a series of questions that will provide the clinician with information about the patient’s culturally based health care beliefs and practices. The D-I-V-E-R-S-E Mnemonic for Patient Encounters (Table 1) provides a framework for seeking information that will assist in patient assessment while supporting culturally respectful care and the ethical principles that guide care delivery.⁹

Health literacy is also an important factor in patient communications. Practitioners should not assume that all culturally diverse patients have low health literacy; however, they should monitor behaviors that may indicate low health literacy, such as an inability to answer questions or complete health forms, noncompliance with specific recommendations, postponing decision-making, or making excuses for delaying treatment. Oral health professionals can incorporate a number of strategies to assist patients with low health literacy. Speaking slowly, showing pictures and utilizing the tell-show-do technique (to confirm that patients understand what they have been told) are all useful techniques.

A simple approach to evaluating health ­literacy is to ask the patient, “When you go home, tell me what you will tell your partner about the directions I gave you concerning your premedication.” Using plain language is also helpful, as this makes written and oral information easier to understand. An important tool for improving health literacy, plain language is communication that patients can understand the first time they read or hear it. Sometimes referred to as “living room” language, it is a technique that clinicians use to explain oral conditions in simple, understandable language. This approach is useful for patients from a wide variety of backgrounds. In terms of written materials, a plain language document is one in which individuals can find what they need, understand what they find, and act appropriately on that understanding.¹⁰ Plain language documents can be developed to explain oral health conditions and their treatment, postoperative directions, or habits that are harmful to oral health.

Conclusion

While a clinician may work in a practice, clinic or community center with a patient population that represents a wide range of diversity, one cannot possibly understand all the cultural beliefs or practices due to sheer variety of patients. However, the provider can utilize models that serve as a framework for interacting with patients. For example, Ask Me 3 is an effective tool that suggests three simple, but essential, questions that patients should ask their providers.

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

Ask Me 3 is intended to help patients become more engaged with their oral health and medical providers. These questions improve communications between patients, families and health care professionals. Resources are available for dental offices and include brochures, posters and a health literacy website.¹¹

In order to provide ethical, culturally competent care, clinicians must recognize the diversity of patients seeking treatment. Respecting cultural diversity means communicating with patients to determine their health beliefs, and understanding their perception of health and disease, as influenced through their cultural lens. Beyond the strategies explored in this article, further resources and tools exist to assist oral health professionals in providing culturally respectful care to all patients.

REFERENCES

1. American Dental Association. Principles of Ethics and Code of Professional Conduct. Available at: ada.org/~/media/ADA/Member%20Center/FIles/2016_ADA_Code_Of_Ethics.pdf?la=en. Accessed October 3, 2017.
2. Jacquot J. Trust in the Dentist-Patient Relationship: A Review. Available at: jyi.org/issue/trust-in-the-dentist-patient-relationship-a-review/. Accessed October 3, 2017.
3. Spector RE. Cultural Diversity in Health and Illness. 9th ed. New York, NY: Pearson; 2017.
4. Health Resources and Services Administration. Culture, Language and Health Literacy. Available at: hrsa.gov/culturalcompetence/index.html. Accessed October 3, 2017.
5. National Institutes of Health. Clear Communication: Cultural Respect. Available at: nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Accessed October 3, 2017.
6. Carteret M. How Culture Affects Oral Health Beliefs and Behaviors. Available at: dimensionsofculture.com/2013/01/how-culture-affects-oral-health-beliefs-and-behaviors/. Accessed October 3, 2017.
7. Donate-Bartfield E, Lobb WK, Roucka TM. Teaching culturally sensitive care to dental students: a multidisciplinary approach. J Dent Educ. 2014;78: 454–464.
8. Betancourt JR. Cultural competence and medical education: many names, many perspectives, one goal. Acad Med. 2006;81:499–501.
9. Anthem Blue Cross. Caring for Diverse Populations — Better Communication, Better Care: A Toolkit for Physicians and Health Care Professionals. Available at: anthem.com/ca/provider/f3/s1/t0/pw_b 144192.pdf?refer=agent. Accessed October 3, 2017.
10. U.S. Centers for Disease Control and Prevention. Plain Language Materials and Resources. Available at: cdc.gov/healthliteracy/developmaterials/plainlanguage.html. Accessed ­October 3, 2017.
11. Institute for Health Care Improvement and National Patient Safety Foundation. Ask Me 3: Good Questions for Good Health. Available at: npsf.org/?page=askme3. Accessed October 3, 2017.

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From Decisions in Dentistry. November 2017;3(11):39–44.