- A Note from the Editor
Practicing health care among medically underserved populations entails numerous challenges. Many arise from the tangle of cause and effect encompassing poverty, ill health, structural discrimination, psychosocial stress, ineffective schools, and inadequate housing.
Here at JHCPU, we strive to help policymakers and practitioners cut through this tangle. The central lessons of the present issue concern primary care, the point of first contact between a patient and the health care system, and cultural variability.
Paul Hershberger and colleagues from the Dept. of Family Medicine at Wright State University's Boonshoft School of Medicine, in their Report from the Field, write about a training curriculum in which residents learn to engage with patients in a culturally proficient way. That is to say, residents reflect upon their own personal histories and cultural frameworks so that they become more sensitive to the fact that any individual patient understands his or her health in a unique way, a way that makes sense in terms of the patient's personal history and cultural framework. Hershberger et al. cite Tervalon's 1998 construct, cultural humility, in describing what they hope to instill in their residents.1 This month's ACU Column by Mitchell H. Rubin is an effective self-portrait of a practitioner who appears to have succeeded in cultivating cultural humility.
Understanding a culture is, fundamentally, an act of interpretation;2 Hershberger and colleagues abjure their students never to pre-interpret a patient's culture on the basis of race or ethnicity, but to enter into the caregiver-patient relationship with an open and curious mind, ready to learn from the individual patient how he or she understands health and healing.
Primary care practice is central to this very local, individualized approach to providing care effectively in an increasingly integrated yet plural world. In this issue, the bulk of the papers concern cultural variability and/or primary care as the site for effective interventions among the medically underserved.
Language is the cutting edge of culture, and linguistic barriers to care are the prototypical cultural barrier. Ramirez, Engel, and Tang's review of the literature on interpretation services in the emergency room is complemented by Flores et al.'s extensive paper on the availability of interpreter services in hospitals throughout the state of New Jersey. Both conclude that, despite definitive evidence of the beneficial effects on care of professional interpreter services, such services are under-used in hospitals.
A series of papers on specific populations illustrate how variably culture and history impinge on health. Beckham and colleagues from the Wai'anae Coast Comprehensive Health Center in Hawai'i report on the effectiveness of community health workers in promoting diabetes management (defined in terms of improved HbA1c) among a predominantly Native Hawaiian and Samoan population. Xu and Borders, using a national database, studied the relationship between immigration status and seeking health care, demonstrating that immigrants use both preventive and non-preventive [End Page vii] care less frequently than non-immigrants. Burgess et al. conducted focus groups with male and female Hmong smokers, in an effort to understand barriers to quitting that the Hmong encounter. Their interesting report illustrates that both gender and acculturation make a difference; for instance, Hmong women were concerned about having their smoking status revealed if they were to seek help, because of cultural prohibitions against female smokers, while less acculturated Hmong smokers considered U.S. cigarettes more addictive than the homegrown tobacco they smoked at home.
Social context can also influence health care utilization, and this is another site of cultural variability. Latino children use fewer professional dental services and experience more dental decay than non-Hispanic White and non-Hispanic Black children. Nahouraii et al. found a connection between social support for use of dental care and dental care utilization in Latino families: in families where the mother reported strong social support, the children were more likely to receive dental care.
Bosssarte et al. studied another sort of cultural (or counter-cultural) group, the Rainbow Family of Living Light (RFLL), and their use of health care services during an annual outdoor gathering that attracts tens of thousands of participants. Their assessments indicate that the RFLL...