Issue: 18.03 April 2008

Leap of Faith

From Muslim athletes in headscarves to patients who don’t speak English, our clientele is growing more diverse by the day. Improving your cultural competence will ensure you are providing the best healthcare possible.

By Elicia Leal

Elicia Leal, MEd, LAT, ATC, is the Head Athletic Trainer at McKinney North High School in McKinney, Texas. She is the District 6 Representative to the NATA’s Ethnic Diversity Advisory Committee and serves as the Chair of the Southwest Athletic Trainers’ Association’s Ethnic Diversity Committee. A former member of the Advisory Board of Athletic Trainers for the State of Texas, she is also the Director of the Permian Basin Student Trainer Workshop. She can be reached at: eleal@mckinneyisd.net.

A football player on your high school team seems to have contracted bronchitis and you instruct him to see a physician immediately. When you check back with him two days later, he admits that he hasn’t seen a doctor, but says his grandmother gave him some medicinal herbs to help him get better.

Working in a hospital’s sports medicine clinic, you are assigned to provide rehab to a construction worker who is suffering from back pain. His case looks fairly straightforward and you plan an efficient half hour with him. But when you meet face to face, you learn he barely speaks any English.

Your track and field coach refers a female freshman athlete who seems to have shin splints to the athletic training room. She is bundled up from head to toe, apparently due to the cold. But she is reluctant to answer your questions, and when you ask her to roll up her sweatpants so you can examine her legs, she says she cannot—she is Muslim and not allowed to bare her legs in public.

As the American population grows more diverse and athletic trainers continue to broaden their role in healthcare delivery, understanding cultural, ethnic, and religious differences has become a must in our profession. Along with knowing physiology and the latest treatments, the need to develop our cultural competence is a top professional priority.

What is Cultural Competence?
As athletic trainers, we pride ourselves on treating every patient as an individual. We care about the fourth-string lineman as much as the starting quarterback. We understand that there are no one-size-fits-all protocols and different athletes respond to treatment in different ways, so we remain flexible and modify our plans accordingly.

We also pride ourselves on going out of our way to help an athlete, even if it is not our direct area of responsibility. We advocate for athletes who confide in us. We follow up after referring an athlete to an outside professional.

However, these efforts can sometimes fall flat if we don’t also understand how a patient’s cultural background affects our interactions with him or her. To be truly effective in our roles, we need to realize why an athlete might refuse to see a doctor who practices Western medicine, how to bridge a language barrier, and what it means to hold certain religious beliefs while participating in athletics.

Cultural competence is the ability to effectively serve culturally diverse populations. It is a realization that a patient’s beliefs can affect their response to treatment and shape the way they view us as healthcare providers. And it is a commitment to working through any differences.

Beliefs & Practices
The first step to becoming culturally competent is to understand that there are many beliefs about healthcare that do not fit what we learned in school. Every individual has their own frame of reference for what it means to be healthy, how to stay that way, how to label and categorize various symptoms, what type of treatment to seek for illness or injury, how to respond to medical advice, and so on. One’s cultural background usually plays a strong role in defining these beliefs. Therefore, it is important as healthcare professionals to be aware of the various attitudes and habits of ethnic groups in our community in order to better meet their needs.

For example, a traditional Native American belief about health is that it reflects living in total harmony with nature. For this group, medical care is concerned less with treating a disease and more with restoring an individual’s connectedness to the community and spirit of nature. Symbolic healing rituals are often used to prepare the body for cleansing and treatment can sometimes take weeks to complete.

Chinese medicine also teaches that health is a state of spiritual and physical harmony with nature. Traditional Chinese healthcare often combines the use of medicinal herbs, acupuncture, food therapy, massage, and therapeutic exercise. The terms yin and yang are used to describe various opposing physical conditions of the body.

Some African approaches to medicine believe spirits can cause illnesses and as treatment use herbs selected for both symbolic significance and medicinal effect. In the African-American community, some patients harbor feelings of distrust for the medical profession, especially when participating in medical research or clinical trials. Much of this distrust originates from incidents like the Tuskegee study, in which African-Americans were deliberately denied treatment for syphilis in order to study the progression of the disease.

In the Hispanic community, physical illness can sometimes be associated with a condition called susto, which means fright. Traditional healers are known as curanderos (folk healer), sobadoras (masseuse), and alborarios (herbalist).

Many Muslims adhere to strict religious rules that can interfere with how they receive treatment. These include fasting during the month of Ramadan and some other dietary restrictions. Rules requiring women to dress modestly in public—which some sects interpret as covering nearly the entire body—and a preference to be treated by a member of the same sex also have medical implications.

Some patients, regardless of background, follow alternative forms of medicine that borrow from several different cultures or come from religious groups that place limitations on medical treatment. For instance, Jehovah's Witnesses have restrictions against blood transfusions and many Buddhists will refuse narcotic pain killer medications that interfere with cognition.

When a patient receives Western-style treatment that conflicts with their cultural beliefs, it can create an inner struggle. The patient often feels compelled to make a choice: embrace Western medicine and neglect the beliefs they are comfortable with, or forego Western medicine and continue with their traditional practices.

A progressive athletic trainer, however, can help patients bridge the gap between the two. Often, it is possible to integrate some traditional or culture-specific treatments with Western medicine. At the very least, we can hear the patient’s concerns about why the treatment may conflict with their beliefs.

How do you do this? First, it’s important to ask the patient if he or she is comfortable with your treatment plan. Then, carefully listen and ask follow-up questions. Be open to whatever the patient tells you, even if you believe their ideas to be bad medical practices.

Next, try to integrate their cultural practices into the treatment you’d like to provide. If the patient is eager to see an herbalist, ask them to bring you the suggestions from the herbalist and see how that advice can work with your ideas. If the patient wants to get acupuncture, you may decide to help them do so. Even if you’re skeptical of any of their suggestions, remember that if a patient believes an herbal remedy or alternative therapy is key to their well-being, incorporating it with your treatment can help make them comfortable and lead to a better outcome.

Open to Differences
The second important element of cultural competence is being constantly aware that a patient’s experiences and beliefs can conflict with many aspects of Western healthcare, and thus you need to be ready to address these roadblocks. You also need to realize that an insensitive comment regarding ethnic and cultural beliefs may damage your relationship with the patient.

Barriers can be lack of knowledge about Western healthcare, embarrassment over a physical exam or being touched by strangers, belief that some illnesses are untreatable, and fear of medical equipment. It is important to show respect, sensitivity, awareness, and understanding of the different perspectives that may exist. You must also convey to the patient your desire to understand their viewpoint.

Some tactics for raising mutual awareness and building trust include the following:

• Ask the patient if they’ve ever met with an athletic trainer before. If they haven’t, take the time to explain your role in the medical community and ask them to tell you a bit about their past experience with Western healthcare.

• Ask them what other forms of healthcare they practice, and be accepting of whatever they tell you.

• Explain why you are doing everything you do. If you are probing or palpating an area, first describe why it is necessary for you to touch them. If they are uncomfortable with you touching them, ask if they’d like someone else (for instance a member of their own gender) to perform the exam.

• If English isn’t their first language, ask if they need an interpreter. If one is not available, you may need to use pictures and very simple descriptions. Ask them to stop you when they don’t understand what you’re saying, and remember to speak slowly.

• Encourage them to ask questions. This is a great way to find out what might be behind a hesitation they have.

• Never criticize a medical practice they describe. Ask them more about it and how it helps.

• See the illness or injury from the patient’s point of view. If the patient feels an injury is due to not living in harmony with nature, understand that restoring this balance will need to be a part of his or her healing.

• With high school and college athletes, understand that their life may be a constant challenge of assimilating while respecting their family’s traditional beliefs. Help them to talk and work through their decisions.

• Understand the challenges Muslim females face in playing sports if they choose to wear a headscarf and keep their bodies covered. This is becoming more prevalent, with leagues enacting rules to allow uniform modifications that comport with religious requirements.

An Exercise
In my efforts to increase my own cultural competence within the athletic training profession, I have devised an activity that can help a staff discuss and better understand this topic. All it requires is a few bags of M&M candies and a willingness to think outside one’s comfort zone.

I start by giving each participant a small bag of M&Ms and a piece of paper that has a six-pod diagram on each side. The pod diagram has one large circle with lines that lead to five smaller circles. One side of the paper is marked Side One, and the other Side Two.

On Side One, individuals are asked to randomly number the circles from one to six. Next, we open our M&M packages and in a blank area on Side Two, each person records the total number of M&Ms of each color (e.g., yellow = 6, brown = 5, and so on).

Now each individual creates an identity profile of a patient using six different categories. We start with ethnic/racial identification and I pass out the following chart:

Yellow =African American
Red=Asian American
Orange=Native American
Blue=Hispanic
Green=Caucasian
Brown=Other

Whatever color of M&M was most prevalent in the person’s bag is the patient’s ethnic/racial identification and it is written in the center circle on Side Two.

Then we define the job setting for our identify profile. The color of M&Ms that had the second highest number defines the job setting where the patient is seeking treatment and is written in one of the small pods/circles:

Yellow=High School
Red=Industrial
Orange=College/University
Blue=Professional
Green=Military
Brown=Clinical

The color of M&Ms that finished third determines the patient’s religion:

Yellow=Muslim
Red=Non-Catholic Christian
Orange=Other
Blue=No affiliation
Green=Catholic
Brown=Jewish

The fourth most common color establishes healthcare preference:

Yellow=Modern/Allopathic
Red=Natural
Orange=Holistic
Blue= Traditional Folk
Green=Complementary
Brown=Alternative

Next comes sexual and marital identity:

Yellow=Married, heterosexual
Red=Single, heterosexual
Orange=Single, gay/lesbian/transgender
Blue=Domestic partner, gay/lesbian/transgender
Green=Domestic partner, heterosexual
Brown=Widowed/Divorced

And finally, the color of M&M occurring least frequently in their bag denotes the patient’s healthcare concern:

Yellow=ACL tear
Red=Ankle sprain
Orange=Tendinitis
Blue=Back pain
Green=Low energy levels
Brown=Asthma

To add some fun, I usually have participants eat each color of M&M after they’re finished with that category. Then, as a group, we talk about the biases, stereotypes, and barriers that may be associated with each characteristic on their sheets. People should be encouraged to speak freely and offer their expertise, observations, and experiences related to each identity characteristic.

Participants are then instructed to turn their paper over to Side One and fill in the pods with their own personal information, using the numbers they already put down to determine which trait goes in which pod:

1=Ethnicity
2=Job setting
3=Religion
4=Healthcare preference
5=Sexual and marital status
6=leave blank

Once both sides are filled out, individuals compare and contrast their own personal profile with the identity profile of the patient, discussing the differences between them. For example, on Side One, the largest pod may have contained religion while on Side Two it will always be ethnicity/race. We might talk about the fact that most individuals assume they are being identified or categorized by their ethnicity, when in fact someone may identify them primarily by another category. Often, bringing our own assumptions and biases to a situation can greatly affect how we treat our patients or how we ourselves seek healthcare.

The next discussion centers on how the athletic trainer’s cultural competence can impact the way they work with patients. Using their own identity profile from Side One, they should imagine a patient with the profile defined on Side Two. They can then discuss how to approach this patient’s healthcare and how any biases, preconceptions, prejudices, or other obstacles may affect this patient’s overall treatment.

During this activity, encourage participants to come up with more questions for group discussion. For example, how might the policies and procedures at your particular job setting affect this patient, and what changes can or should be made to assure that they are receiving optimal treatment? How do you and your staff approach healthcare in your athletic training room or clinic and how culturally competent are you?

In today’s world, cultural competence is not optional for athletic trainers. The NATA has an explicit mission to enhance the quality of healthcare for athletes and those engaged in physical activity, and to advance the profession of athletic training through education and research in the prevention, evaluation, management and rehabilitation of injuries. By embracing cultural competence, athletic trainers can better fulfill their mission while improving the lives of people from all sorts of different backgrounds.

FEEDBACK:

My name is JD Sweet and I teach Social Studies and History at Central Kitsap High School in Silverdale, Washington. My wife, Elizabeth, who teaches English and Creative Writing here at CK and I have been training our staff in the areas of cultural awareness and culturally responsive teaching. This has been a two-year process so far, and one of the goals has been for us to encourage our staff to pass along interesting, informative and on-target information.

Our athletic trainer forwarded the article, "Leap Of Faith" by Elicia Leal to me and I found that it was very, very insightful. I was especially intrigued by the M&M exercise, and was wondering if I could adapt the idea into other scenarios other than health care and use in our trainings.

I don't know if I need to get permission, since we already do similar types of exercises. However, this is great and would really lend itself to many situations teachers, counselors and other educational support staff face on a daily basis. In any case, this is a great article. Well written and full of very useful examples.

- JD Sweet

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