Moving beyond cultural stereotypes in end-of-life decision making.
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Attitude to Death↗
Biomedical subjects
Linda M Hunt
Publications and source records attributed to Linda M Hunt.
The routine and the traumatic in prenatal genetic diagnosis: does clinical information inform patient decision-making?
With the increasing technical sophistication of medicine, clinicians' task of assuring patient informed consent is increasingly elusive. Taking the example of prenatal genetic testing, we examine efforts to communicate the complexities of genetic knowledge and risk calculation to patients. In this qualitative, descriptive study, we interviewed 50 clinicians and 40 patients, and observed 101 genetic counseling sessions. We found the clinicians and patients have different goals, purposes, and values regarding testing, which affect their clinical interactions. The information the clinicians provide patients reflects their clinical interest in identifying and controlling pathophysiology, while patients, in contrast, are most concerned with protecting and nurturing their pregnancy. We argue informed patient decision-making about prenatal testing options requires information that is responsive to patient interests. We recommend developing a shared decision-making approach, to facilitate the full participation of both clinicians and patients in the decision-making process.
Adult↗
Clinical myths of the cultural "other": implications for Latino patient care.
PURPOSE: Cultural competency is now a requirement in the curriculum of many health professions. However, clinicians' understandings of cultural difference, the accuracy of those understandings, and their impact on patient care have not yet been carefully explored. The authors conducted an ethnographic study designed to describe clinicians' views of Latino culture in the context of amniocentesis decision making, compared those to patients' discussions of their decision making, and explored how clinicians' views about culture are manifested in consultations with Latinas. METHOD: Between 2000 and 2002, semistructured, open-ended interviews were conducted in southern Texas with convenience samples of 50 clinicians who discuss prenatal testing with patients, and 40 self-identified Latina patients who had been offered amniocentesis. Observations were also made of 101 genetic counseling sessions. Content analysis focused on the cultural characteristics clinicians identified as affecting Latinas' decision making, patients' self-reported decision-making processes, and clinician and patient comments and actions observed during genetics counseling sessions. RESULTS: Most clinicians said Latinas are likely to decline amniocentesis because they are religious, fatalistic, male-dominated, family-centered, and superstitious. However, patients' discussions of their decision making were not consistent with these characterizations. Furthermore, clinicians reported providing less complete information to Latina patients in their efforts to be culturally sensitive. CONCLUSIONS: Comparing patient and clinician interviews bring into question clinicians' notion of Latino culture's role in amniocentesis decision making. Efforts to be "culturally competent," in the absence of a patient-centered approach, may unintentionally encourage stereotyping, thereby negatively affecting the quality and content of clinical care.
Adolescent↗
Genetic research and health disparities.
Alleviating health disparities in the United States is a goal with broad support. Medical research undertaken to achieve this goal typically adopts the well-established perspective that racial discrimination and poverty are the major contributors to unequal health status. However, the suggestion is increasingly made that genetic research also has a significant role to play in alleviating this problem, which likely overstates the importance of genetics as a factor in health disparities. Overemphasis on genetics as a major explanatory factor in health disparities could lead researchers to miss factors that contribute to disparities more substantially and may also reinforce racial stereotyping, which may contribute to disparities in the first place. Arguments that promote genetics research as a way to help alleviate health disparities are augmented by several factors, including research funding initiatives and the distinct demographic patterns of health disparities in the United States.
Genetic Research↗
Should "acculturation" be a variable in health research? A critical review of research on US Hispanics.
Acculturation has become a popular variable in research on health disparities among certain ethnic minorities, in the absence of serious reflection about its central concepts and assumptions. Key constructs such as what constitutes a culture, which traits pertain to the ethnic versus "mainstream" culture, and what cultural adaptation entails have not been carefully defined. Using examples from a systematic review of recent articles, this paper critically reviews the development and application of the concept of acculturation in US health research on Hispanics. Multiple misconceptions and errors in the central assumptions underlying the concept of acculturation are examined, and it is concluded that acculturation as a variable in health research may be based more on ethnic stereotyping than on objective representations of cultural difference.
Acculturation↗
Childbirth care-seeking behavior in Chiapas.
This study was designed to better understand how women in a developing region choose between the multiple options available to them for birthing. We conducted focused, open-ended ethnographic interviews with 38 nonindigenous, economically marginal women in Chiapas, Mexico. We found that although medical services for birthing were readily available to them, these women most often chose traditional birth attendants (TBAs) for assistance with their births. They expressed a clear preference for TBAs in the case of a normal birth, but viewed medical services as useful for diagnosing and managing problem deliveries and for tubal ligations. They favored TBAs because they valued being able to choose birthing locations and birthing positions and to have relatives present during the birth, all features they must give up for medically attended births in this region.
Adult↗
Health research: what's culture got to do with it?
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Acculturation↗
Exploring loss to follow-up: abnormal Pap screening in Hispanic patients.
PURPOSE: The loss of patients to follow-up for abnormal findings from Pap screenings is an important public health concern, particularly among poor and minority women. This study explores factors affecting incomplete follow-up among a group of Hispanic women with low incomes. DESCRIPTION OF STUDY: A qualitative descriptive study was conducted of 11 Hispanic patients with incomplete Pap smear follow-up at a public clinic in a major city in south Texas. Patients were interviewed using a semistructured, open-ended schedule of questions, and their medical records were abstracted. The clinic's five staff members also were interviewed. Comparative chronologies were constructed for each case, contrasting patient and staff accounts of the same set of events. All data were coded by at least two investigators. RESULTS: All study patients had mildly abnormal Pap smear results and had not met the follow-up criteria, but all understood and were committed to Pap screening. Although viewed by staff as noncompliant, none of the patients viewed her behavior this way. This staff-patient discrepancy was attributable to poor communication, mixed messages, clinic errors, and, perhaps most importantly, to a conflict between program policies and the specific circumstances of individual cases. Two case examples are presented to illustrate key points. CLINICAL IMPLICATIONS: Strategies that may help to reduce loss to follow-up among similar patients include the following: allowing clinic staff more flexibility in follow-up procedures for women who have consistently normal follow-up tests, including Spanish translations of written messages; enlisting patients' agreement in setting appointments; and updating patient records to reflect follow-up care that had been received in other clinics.
Adult↗
Do notions of risk inform patient choice? Lessons from a study of prenatal genetic counseling.
Risk modeling is an increasingly important part of clinical medicine; however, "risk status" is a complex notion, understood differently by patients and clinicians. Patients' ability to make informed choices about clinical procedures often requires that they interpret risk statistics, which may be difficult to understand and apply. In this article, which is based on a study of prenatal care in South Texas, we consider how notions of risk affect patient decisions about prenatal genetic testing. The term "risk" carries multiple meanings for clinicians and patients. These meanings may conflate concepts of danger and probability as well as muddle population risk and individual risk. We propose that failure to articulate the varied and contrasting meanings of risk held by clinicians and patients can undermine clinical communication and, thereby, hamper patients' ability to make autonomous, informed choices. Attending to these differences may prove useful in empowering patients to make truly informed decisions.
Adult↗
BiDil: assessing a race-based pharmaceutical.
Isosorbide and hydralazine in a fixed-dose combination (BiDil) has provoked controversy as the first drug approved by the Food and Drug Administration marketed for a single racial-ethnic group, African Americans, in the treatment of congestive heart failure. Family physicians will be better prepared to counsel their patients about this new drug if they understand a number of background issues. The scientific research leading to BiDil's approval tested the drug only in African American populations, apparently for commercial reasons, so the drug's efficacy in other populations is unknown. Race as a biological-medical construct is increasingly controversial; BiDil offers a good example of how sociocultural factors in disease causation may be overlooked as a result of an overly simplistic assumption of a racial and hence presumed genetic difference. Past discrimination and present disparities in health care involving African American patients are serious concerns, and we must welcome a treatment that promises to benefit a previously underserved group; yet the negative aspects of BiDil and the process that led to its discovery and marketing set an unfortunate precedent. Primary care physicians should be aware of possible generic equivalents that will affect the availability of this drug for low-income or uninsured patients.
Black or African American↗