4 strategic steps for clinicians: Providing culturally competent care for menopausal women

Vol. 9, No. 2 / May 2011

4 strategic steps for clinicians

Providing culturally competent care for menopausal women

Gloria Richard-Davis, MD, FACOG

Professor and Chair, Department of Obstetrics and Gynecology, Associate Director, Center for Women’s Health Research, Meharry Medical College, Nashville, Tennessee

The author reports that she has served as a consultant to Boehringer Ingelheim, Myriad Genetics, and Pfizer.

Physicians caring for menopausal women are challenged by the increasingly diverse racial, ethnic, and sociocultural backgrounds of their patients. Currently, more than 47 million women—including an estimated 3.5 million African Americans, 1 to 2 million Hispanics, and 1 million Asian Americans—are menopausal. Each day, another 5000 women enter menopause.

The US Census Bureau projects that by 2050, 47% of the US population will be non-white.¹ Much of our current knowledge about the prevalence of menopausal symptoms in the fifth and sixth decades of life, however, is based on data primarily from white women. Because social and cultural factors strongly contribute to the meaning of menopause among women from different sociocultural, racial, and ethnic backgrounds, clinicians caring for menopausal women need to be able to recognize how these factors may influence women’s attitudes toward menopause, menopause symptom expression, and even age at menopause onset. Providing effective medical care includes providing culturally competent care for patients of all backgrounds.

This article outlines 4 strategic steps that clinicians and staff can use to enhance cultural competence in their practice. Understanding key sociocultural terms and the meaning of cultural competency itself is an initial step toward becoming more culturally competent.

What is culture, and why is it important?

Culture is defined as the accumulated habits and attitudes that characterize the general behavior and way of life for a racial, ethnic, religious, or social group. It can also be defined as the characteristic features of everyday existence shared by people in a place or time (eg, popular culture, southern culture).

In contrast, race is defined as a group of individuals sharing common genetic attributes that determine that group’s physical appearance.

Ethnicity refers to groupings of individuals with certain common traditions, language, art forms, attitudes, and other means of expression. Ethnicity and culture are directly dependent on each other and indeed flow from one another in a symbiotic relationship.

Cultural and language differences between a health care provider and patient may result in misunderstanding, lack of compliance, or other consequences that may negatively influence clinical outcomes.

Defining cultural competence

There is no single definition of cultural competence. The National Center for Cultural Competence (NCCC) of the Georgetown University Center for Child and Human Development embraces a conceptual framework and model for achieving cultural competence. This framework has been adapted from the definitions developed by Cross and colleagues in their comprehensive monograph, “Towards a culturally competent system of care.”² Inherent within the NCCC philosophy is the concept that cultural competence is a developmental process that evolves over an extended period. Detailed information and resources on cultural competence can be found on the NCCC Web site at http://nccc.georgetown.edu.

Three crucial components of cultural competency, and measures that can facilitate progress toward cultural competency, include:

Open mind/attitude: Self-evaluation/cultural competency questionnaire
Cultural awareness and knowledge: Resources
Skills: Techniques to improve cultural competency,³ National Standards on Culturally and Linguistically Appropriate Services (CLAS), and national standards for health care organizations

STRATEGY 1: Understand how women from diverse cultures view and experience menopause

Understanding similarities and differences among women—especially in their expectations of menopause—is a basic yet essential step for providing culturally appropriate care and promoting lifestyles that decrease symptoms and enhance quality of life. In general, women who have more negative attitudes toward menopause report more symptoms during the menopausal transition.⁴

Key Point

Understanding similarities and differences among women—especially in their expectations of menopause—is a basic yet essential step for providing culturally appropriate care.

Analyses of the Study of Women Across the Nation (SWAN), a longitudinal community sample of more than 16,000 women representing 5 racial/ethnic groups within the United States (non-Hispanic white, African American, Hispanic, Japanese American, and Chinese American), report racial and cultural differences in risk factors, symptoms, physiology, and attitudes associated with menopause (see TABLE). For example, the SWAN multiracial/-ethnic quality-of-life (QOL) study of menopausal women found that marital status affected QOL for all racial/ethnic groups, but the nature of the association varied.⁵

TABLE

Symptom, lifestyle, and cultural factors in menopausal women from 5 racial/ethnic groups: Observations from the SWAN study*

	White	African American	Hispanic	Chinese	Japanese
Vasomotor symptoms, %	31	46	35	21	18
Attitude	+	+++	+	--	-
Complementary/alternative medicine use, %	60	40	20	46	60
Body mass index, kg/mg²	27.8	31.5	29.2	23.3	22.9
Genistein intake daily, μg	834	271	310	6398	11,165
Physical activity score	8.1	7.3	6.6	7.3	7.8
English only, %	99.3	99.8	3.5	37.7	53
Bilingual, %	0.7	0.1	25.7	44.5	16.4
Depressive symptoms, %	22.7	27.2	43.3	14	14.6
*Data from: Gold EB, et al. Am J Epidemiol. 2000;152(5):463-473 ; Sommer B, et al. Psychosom Med. 1999;61(6):868–875¹⁴; Gold EB, Colvin A, Avis N, et al. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: Study of Women’s Health Across the Nation. Am J Public Health. 2006;96(7):1226-1235; Bair YA, Gold EB, Zhang G, et al. Use of complementary and alternative medicine during the menopause transition: longitudinal results from the Study of Women’s Health Across the Nation. Menopause. 2008;15(1):32-43.

Age at menopause varies

Most estimates of age at natural menopause are based on samples of white women in Western societies. One international study of 18,997 women from 11 countries found that the median age at natural menopause is 50 years (range, 49 to 52 years).⁶ A few studies of nonwhite (African American, Hispanic) women have reported menopause onset at younger ages compared with age-of-onset for white women, while Japanese and Malaysian women report a median age at menopause similar to that of white women.⁷

Menopausal symptoms differ across groups

SWAN investigators reported that the prevalence of combined hot flushes and night sweats is lowest among women of Japanese (18%) and Chinese ethnicity (21%) and higher among Hispanic (35%) and African American women (46%); rates of these symptoms in white women fell in-between (31%).⁸

In another analysis of SWAN data, researchers found that language and acculturation may be related to cultural differences in the ways in which women report menopausal symptoms.⁹ This study used questionnaires that were translated into native languages for Spanish, Japanese, and Cantonese women. Symptom reporting was analyzed based on completion of the questionnaire in English or the women’s native language. Results showed that Chinese women who completed the questionnaire in Cantonese had more missing symptom items than those who responded in English, even when education level was controlled for. Whether differences in language or acculturation account for these results, however, is uncertain.¹⁰

To foster an understanding of the patient as well as to deliver patient-oriented, culturally sensitive care, questionnaires and forms should contain space for patients to note their individual beliefs or preferences about communication and attitude toward menopause. Privacy policies and logistics should be clearly explained in patients’ preferred language and method of communication (written, visual, etc).

Across ethnic groups in the SWAN study, women identified 2 consistent domains of menopausal symptoms: vasomotor and psychological/psychometric.¹¹ These were found to vary by ethnic group in the following respects:

White women reported significantly more symptoms overall, especially those categorized as psychosomatic, including tension, depression, irritability, forgetfulness, and headaches.¹²
African American women reported the most vasomotor symptoms and vaginal dryness¹³; however, they had a more positive attitude toward menopause than Hispanic and non-Hispanic white women.¹⁴
Chinese American and Japanese American women reported significantly fewer vasomotor symptoms than white, African American, or Hispanic women¹³ and had lower odds of experiencing mood symptoms, such as feeling blue, nervous, or irritable.¹⁵ However, they expressed the most negative attitudes of all groups, with the less acculturated (ie, those educated in their native countries) being the most negative.^14,16
Japanese American women experienced menopause at a significantly later age than did Hispanic, non-Hispanic white, African American, or Chinese American women.⁷
Compared with non-Hispanic white women, Chinese American and Japanese American women were less likely to say that sex was very important, whereas African American women were the most likely to say that sex was important and to report having sexual intercourse more than once a week.¹⁷

Cultural lifestyle differences and menopausal symptoms

Vasomotor and other symptoms were positively associated with greater body mass index (BMI), difficulty paying for basic needs, and smoking; physical activity was a negative association. Therefore, lifestyle, race/ethnicity, and socioeconomic status can affect symptom expression among menopausal women.⁸ In addition, study findings demonstrate that no single syndrome is definable based on symptomatology associated with waning estrogen levels and that variation in subjective reporting of symptoms by women of various ethnic groups does indeed exist.¹²

Two recent reviews of prevalence rates of vasomotor symptoms worldwide emphasize the importance of lifestyle differences— such as diet, physical activity, climate, and women’s roles—as factors in women’s experiences with menopause.^9,18 Some researchers speculate that the low rate of hot flushes among Japanese women may in part be due to the high intake of soy, a rich source of phytoestrogens, in the traditional Japanese diet. Soy continues to be investigated for a possible role in ameliorating hot flushes and other menopausal symptoms. A systematic literature review identified 23 randomized trials that investigated the use of isoflavone supplements to treat vasomotor symptoms in perimenopausal or postmenopausal women for at least 12 weeks.¹⁹ No conclusive evidence—but some indication—of a benefit of soy isoflavones in hot flush frequency or severity was found.

Diet and physical activity levels may also affect the menopausal experience indirectly by regulating body weight and lean body mass, 2 factors known to influence hormone levels.⁹

Key Point

Two recent reviews emphasize the importance of lifestyle differences—such as diet, physical activity, climate, and women’s roles—as factors in women’s experiences with menopause.

Use of complementary/alternative therapies for menopausal symptoms

In a Centers for Disease Control and Prevention study of 2602 women aged 45 years and older, 46% of women used complementary/ alternative therapy, either alone or in combination with conventional therapies.²⁰ Age-adjusted average symptom severity scores were significantly higher in women who had undergone a hysterectomy, either with removal of the ovaries (7.73; 95% confidence interval [CI], 7.33, 8.12) or without (7.60; 95% CI, 7.16, 8.05), compared with women who had experienced natural menopause (6.42; 95% CI, 6.14, 6.71). African American women are more likely to have undergone surgical menopause. Average symptom severity scores were significantly higher among women who used both conventional and complementary/alternative therapies for menopausal symptoms (8.61; 95%, CI 8.26, 8.96) than among women who used only conventional therapies (7.09; 95% CI, 6.67, 7.50). This association was statistically significant and persisted even when adjustments were made for age, education, income, race/ ethnicity, state of residence, and menopausal category.²⁰

STRATEGY 2: Develop self-awareness

The 2002 Institute of Medicine report, “Unequal treatment: Confronting racial and ethnic disparities in health care,” states that while some care inequities can be attributed to access and linguistic barriers, health care providers themselves may contribute to disparities in care for their minority patients (see Case: Vasomotor symptoms and vaginal dryness).

Provider awareness of personal factors that impact (consciously or unconsciously) patient care is an important component of cultural competency. The NCCC notes that, at a minimum, cultural competence requires individual health care providers to²:

Acknowledge cultural differences
Understand one’s own culture
Engage in self-assessment
Acquire cultural knowledge and skills
View behavior within a cultural context

In addition, to be culturally and linguistically competent, providers may need to modify their approaches to:

Assessment and diagnostic protocols
Treatment and interventions
Medication protocols
Consultations with traditional/indigenous practitioners and natural healers

Case: Vasomotor symptoms and vaginal dryness

S.F., a 54-year-old postmenopausal African American physician, visited her gynecologist. She noted that her last menstrual cycle was 5 years ago, and she is experiencing mild vasomotor symptoms and some vaginal dryness. She has not been treated with any hormone therapy since going through menopause.

The patient asked her physician about the need for a bone density scan. He appropriately questioned her about her family history, which was negative for osteoporosis. S.F. is physically active and runs 1 to 2 miles regularly. Her gynecologist reassured her that her risk for osteoporosis was low because she was African American and her family history was negative. A DEXA (dual energy X-ray absorptiometry) scan was not ordered.

Following her visit, S.F., who is a radiologist, out of curiosity had a bone scan done. To her surprise, not only did she have osteopenia, but osteoporosis as well.

DISCUSSION

Menopausal women are at increased risk of osteoporosis regardless of their race. In addition, African American women have lower levels of vitamin D, which may increase their risk of osteoporosis, cardiovascular disease, and malignancies such as breast cancer.

DEXA scans are ordered for white women 4 times more often than for African American women.¹ Further, of women diagnosed with osteoporosis, white women receive treatment more often than African American women (83% vs 62%).²

Health care providers need to be more aware of biases in ordering preventive screens. Studies show that bone density screens for osteoporosis are ordered more often for white women.

References

1. Hamrick I, Steinweg KK, Cummings DM, Whetstone LM. Health care disparities in postmenopausal women referred for DXA screening. Fam Med. 2006;38(4):265–269.

2. Hamrick I, Whetstone LM, Cummings DM. Racial disparity in treatment of osteoporosis after diagnosis. Osteoporos Int. 2006;17(11):1653–1658.

STRATEGY 3: Adapt cultural competency techniques

The Agency for Healthcare Research and Quality has identified 9 major cultural competency techniques that can help reduce racial and ethnic health disparities.³ These include:

Interpreter services. Institutions receiving federal funding must provide access to interpreters; nearly 14% of people living in the United States speak a language other than English at home (see Case: Headache, fatigue, hot flushes).

Recruitment and retention policies. Diversity in the workplace is critical; shared cultural beliefs and common language can create a more welcoming environment.

Training. Cultural competency training programs can help resolve problems that may arise from cultural differences and miscommunication.

Coordinating with traditional healers. Coordination of care is important, not only to ensure continuity of care, but to avoid complications from use of incompatible therapies.

Use of community health workers. Known and respected community members can serve as a liaison and guide to the health care system.

Culturally competent health promotion. Culturally specific attitudes and values should be incorporated into materials that encourage good health through healthy behaviors and risk reduction.

Including family and/or community members. Certain groups, such as Korean Americans and Mexican Americans, for example, are more likely to believe that family members should be involved in health care decisions.

Immersion into another culture. The goal of cultural immersion is to overcome ethnocentrism, increase cultural awareness, and integrate beliefs into health care practices.

Administrative and organization accommodations. Access and utilization of care should reflect the immediate community.

Know your community and collect information

Health care providers should elicit information from patients on whether they have particular communication needs stemming from their language, culture, education or literacy level, religion, or other factors. For example, some women have certain culturally based viewpoints regarding the nature and meaning of menopause, while others may have specific beliefs about advance directives. Some patients might not want to know the results of certain medical tests; other individuals might prefer that a family member serve as a primary communicator. Understanding and accommodating cultural preferences whenever possible helps in developing a culturally competent practice.

Case: Headache, fatigue, hot flushes

M.H., a 50-year-old Hispanic nonobese woman with last menstrual cycle 1 year ago, presented to her primary care physician with complaints of headaches, feeling tired, and hot flushes. She has limited English proficiency and is uninsured. The physician ordered a computed tomography (CT) scan and electrocardiogram (ECG) for evaluation, which M.H. paid for out-of-pocket. However, he did not address the patient’s menopausal symptoms, as he found communicating about hormone therapy to be challenging, even with patients who were proficient in English.

Over the next 6 months, M.H. continued to have debilitating headaches, hot flushes, and night sweats, which eventually caused her to lose her job. She then saw a gynecologist, who noted that her blood pressure and CT scan were normal. He further explored her menopausal symptoms and prescribed a low-dose transdermal estrogen patch. Within 2 weeks, the patient’s headaches and hot flushes were gone, and she successfully acquired another job.

DISCUSSION

Challenges with language discordance between provider and patient often result in miscommunication, ordering excessive diagnostic studies, and delays in treatment. Patients with language-discordant providers reported receiving less health education (beta=0.17, P<.05) compared with those who had language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care.¹ African American and Hispanic patients are more likely to prefer that physicians make decisions for them.²

References

1. Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22(suppl 2):324–330.

2. Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med. 2005;20(60):531–535.

STRATEGY 4: Access available resources for provider and staff lifelong learning

The NCCC has developed a self-assessment instrument known as the Cultural Competence Health Practitioner Assessment, which was designed to enhance care for culturally and linguistically diverse individuals. Available on the NCCC Web site (http://nccc.georgetown.edu/features/CCHPA.html), the assessment contains 6 subscales: values and belief systems, cultural aspects of epidemiology, clinical decision making, life-cycle events, cross-cultural communication, and empowerment/health management. Each subscale includes a questionnaire that, once completed, provides a profile that indicates areas in which clinicians may benefit by increasing awareness. Links to library, video, and online resources are also provided.

For additional online resources for improving cultural competency, see “Resources for improving cultural competency in the care of menopausal patients.”

Resources for improving cultural competency in the care of menopausal patients

TAKE THIS STRATEGIC STEP…	…TO THIS DESIRED OUTCOME	Reference
Understand how women from diverse cultures view and experience menopause	Better counseling and compliance in addressing menopausal health issues	SWAN: Study of Women’s Health Across the Nation http://www.swanstudy.org/
Develop self-awareness	Improve communications with diverse population	National Center for Cultural Competence, Georgetown University Center for Child and Human Development http://nccc.georgetown.edu National Center for Cultural Competence. Cultural Competence Health Practitioner Assessment (CCHPA) http://nccc.georgetown.edu/features/CCHPA.html
Adapt cultural competency techniques	Improve quality of patient care and outcomes	American Medical Association. Initiatives to eliminate health disparities http://www.ama-assn.org/ama/pub/physician-resources/ public-health/eliminating-health-disparities.shtml Association of Professional Chaplains. Learning module: Cultural and spiritual sensitivity www.professionalchaplains.org/uploadedFiles/pdf/learning-cultural-sensitivity.pdf Bureau of Primary Health Care. Culture, language and health literacy http://www.hrsa.gov/culturalcompetence/index.html Cross-cultural health care references http://www.ttuhsc.edu/cima/lectures_events/international/ Trejos_Cross_Cultural_Health_Care_References.pdf Diversity Rx. Resources for cross-cultural health care http://www.diversityrx.org Kaiser Family Foundation. Compendium of cultural competence initiatives in health care http://www.kff.org/uninsured/6067-index.cfm National Council on Interpreting in Health Care http://www.ncihc.org The Provider’s Guide to Quality and Culture http://erc.msh.org/qualityandculture
Access available resources for provider and staff lifelong learning	Improve clinical care environment with lifelong learning	All of the above plus: National Center for Cultural Competence. Cultural and Linguistic Competence Policy Assessment (CLCPA)http://www.clcpa.info/ Office of Minority Health http://minorityhealth.hhs.gov Public Health Foundation. Healthy People 2010 Toolkit: A field guide to health planning. Washington, DC: Public Health Foundation; 2002. http://www.healthypeople.gov/2010/state/toolkit/default.htm

Summing up

Experts in cultural competency believe that physicians can readily acquire the knowledge and skills necessary to provide effective patient-centered care for all their patients. The most critical element for providing culturally competent care is the clinician’s attitude and approach to patients. What attitudes, beliefs, biases, and behaviors exist that may influence how care is provided?

This understanding can help improve access to care and quality of care and, ultimately, improve health outcomes for patients. By utilizing the strategic steps and tools described in this review, every clinician and his or her office staff can effectively provide culturally competent care.

References

1. Day JC. Population Projections of the United States by Age Sex, Race, and Hispanic Origin: 1995 to 2050. US Bureau of the Census. Current Population Reports, P25-1130. Washington, DC: US Government Printing Office; 1996.

2. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Vol 1. Washington DC: Georgetown University Child Development Center; 1989.

3. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(suppl 1):181–217.

4. Ayers B, Forshaw M, Hunter MS. The impact of attitudes towards the menopause on women’s symptom experience: a systematic review. Maturitas. 2010;65(1):28–36.

5. Avis NE, Assmann SF, Kravitz HM, et al. Quality of life in diverse groups of midlife women: assessing the influence of menopause, health status and psychosocial and demographic factors. Qual Life Res. 2004;13(5):933–946.

6. Morabia A, Costanza MC. International variability in ages at menarche first livebirth, and menopause. World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives. Am J Epidemiol. 1998;148(12):1195–1205.

7. Gold EB, Bromberger J, Crawford S, et al. Factors associated with age at natural menopause in a multiethnic sample of midlife women. Am J Epidemiol. 2001;153(9):865–874.

8. Gold EB, Sternfeld B, Kelsey JL, et al. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Am J Epidemiol. 2000;152(5):463–473.

9. Crawford SL. The roles of biologic and nonbiologic factors in cultural differences in vasomotor symptoms measured by surveys. Menopause. 2007;14(4):725–733.

10. Avis NE, Crawford S. Cultural differences in symptoms and attitudes toward menopause. Menopause Manag. 2008;17(3):8–13.

11. Avis NE, Crawford SL. SWAN: what it is and what we hope to learn. Menopause Manag. 2001;10(3):8–15.

12. Avis NE, Stellato R, Crawford S, et al. Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups. Soc Sci Med. 2001;52(3):345–356.

13. Gold EB, Block G, Crawford S, et al. Lifestyle and demographic factors in relation to vasomotor symptoms: baseline results from the Study of Women’s Health Across the Nation. Am J Epidemiol. 2004;159(12):1189–1199.

14. Sommer B, Avis N, Meyer P, et al. Attitudes toward menopause and aging across ethnic/racial groups. Psychosom Med. 1999;61(6):868–875.

15. Bromberger JT, Meyer PM, Kravitz HM, et al. Psychologic distress and natural menopause: a multiethnic community study. Am J Public Health. 2001;91(9):1435–1442.

16. Kagawa-Singer M, Kim S, Wu K, et al. Comparison of the menopause and midlife transition between Japanese American and European American Women. Med Anthropol Q. 2002;16(1):64–91.

17. Cain VS, Johannes CB, Avis NE, et al. Sexual functioning and practices in a multi-ethnic study of midlife women: baseline results from SWAN. J Sex Res. 2003;40(3):266–276.

18. Freeman EW, Sherif K. Prevalence of hot flushes and night sweats around the world: a systematic review. Climacteric. 2007;10(3):197–214.

19. Jacobs A, Wegewitz U, Sommerfeld C, et al. A. Efficacy of isoflavones in relieving vasomotor menopausal symptoms: a systematic review. Mol Nutr Food Res. 2009;53(9):1084–1097.

20. Keenan NL, Mark S, Fugh-Berman A, et al. Severity of menopausal symptoms and use of both conventional and complementary/alternative therapies. Menopause. 2003;10(6): 507–515.

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