Examine the effectiveness of patient-centered care

The effectiveness of cultural competence programs in ethnic minority patient- centered health care—a systematic review of the literature A. M. N. RENZAHO1,2, P. ROMIOS3, C. CROCK4 AND A. L. SØNDERLUND5

1International Public Health Unit, Department of Epidemiology and Preventive Medicine, Monash University, Level 3, Burnet Building, 89 Commercial Rd, Melbourne, 3800 Victoria, Australia, 2Centre for Internal Health, Burnet Institute, Melbourne, 3004 Victoria, Australia, 3Health Issues Centre, Melbourne, 3086 Victoria, Australia, 4Australia Institute for Patient and Family-Centred Care, Melbourne, Victoria, USA, and 5Department of Psychology, University of Exeter, EX4 4QJ Devon, UK

Address reprint requests to: Andre M. N. Renzaho, International Public Health Unit, Department of Epidemiology and Preventive Medicine, Monash University, Level 3, Burnet Building, 89 Commercial Rd, Melbourne, 3800 Victoria, Australia. Tel: +61-3-92-51-77-72; Fax: +61-3-92-44-66-24; E-mail: andre.renzaho@monash.edu

Accepted for publication 2 December 2012

Abstract

Purpose. To examine the effectiveness of patient-centered care (PCC) models, which incorporate a cultural competence (CC) perspective, in improving health outcomes among culturally and linguistically diverse patients.

Data sources. The search included seven EBSCO-host databases: Academic Search Complete, Academic Search Premier, CINAHL with Full Text, Global Health, MEDLINE with Full Text, PsycINFO PsycARTICLES, PsycEXTRA, Psychology and Behavioural Sciences Collection and Pubmed, Web of Knowledge and Google Scholar.

Study selection. The review was undertaken following the preferred reporting items for systematic reviews and meta-analyses, and the critical appraisals skill program guidelines, covering the period from January 2000 to July 2011.

Data extraction. Data were extracted from the studies using a piloted form, including fields for study research design, popu- lation under study, setting, sample size, study results and limitations.

Results of data synthesis. The initial search identified 1450 potentially relevant studies. Only 13 met the inclusion criteria. Of these, 11 were quantitative studies and 2 were qualitative. The conclusions drawn from the retained studies indicated that CC PCC programs increased practitioners’ knowledge, awareness and cultural sensitivity. No significant findings were identified in terms of improved patient health outcomes.

Conclusion. PCC models that incorporate a CC component are increased practitioners’ knowledge about and awareness of dealing with culturally diverse patients. However, there is a considerable lack of research looking into whether this increase in practitioner knowledge translates into better practice, and in turn improved patient-related outcomes. More research examining this specific relationship is, thus, needed.

Keywords: patient-centered care, cultural competence, intercultural health care, health-care interventions

Introduction

Worldwide immigration has increased throughout the past century and considerably so in the past decade from 150 million migrants in 2000 to 214 million in 2010 [1]. Such change is reflected in various developed countries and specif- ically in public sectors such as health care, where the work- force and client base are becoming increasingly multifarious in terms of ethnicity and culture [2]. This demographic

transformation is not without its problems, however, as massive disparities in the health status of the population are evident, negatively affecting primarily ethnic and cultural mi- nority groups [3–6]. The successful delivery of health care in a multicultural

setting is often hampered by a host of factors, including chiefly language and non-verbal communication barriers between carer and patient [7, 8], lack of respect and/or aware- ness of cultural traditions and beliefs in the practitioner–client

International Journal for Quality in Health Care vol. 25 no. 3 © The Author 2013. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 261

International Journal for Quality in Health Care 2013; Volume 25, Number 3: pp. 261–269 10.1093/intqhc/mzt006 Advance Access Publication: 22 January 2013

relationship [9–11] and interpersonal as well as institutional stereotyping and prejudice [12–14]. Accordingly, several health-care models have been proposed to shift from a some- what paternalistic health-care model to an approach that engages the patient in decision making and self-care. Such models include cultural competence (CC) and patient-centered care (PCC) models [15, 16]. CC has been conceptualized as a ‘a set of congruent beha-

viors, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situa- tions’ [17–19]. It has been hypothesized that lack of awareness about cultural differences, together with culturally and linguis- tically diverse (CALD) patients’ lack of knowledge about the health system, can lead to two possible unwanted outcomes [16, 20]: (i) compromised patient–provider relationships, making it difficult for both providers and patients to achieve the most appropriate care and (ii) effects on patients’ health beliefs, practices and behaviors. As a result, the National Center for Cultural Competence in the USA has suggested a framework for CC [21] emphasizing the need of health-care systems to • have a defined set of values and principles, policies and structures that enable them to work effectively and cross-culturally;

• have the capacity to value diversity, conduct self- assessment, manage the difference and institutionaliza- tion of cultural knowledge and adapt to diversity and the cultural contexts of the communities they serve;

• incorporate the requirements above in all aspects of policy development, administration and practice/service delivery.

The health-care models

PCC relies on the recognition that each patient represents a distinctive case with unique requirements and treatment needs and, thus, focuses on holistic care provided through open carer–patient communication and collaboration [22]. Patient empowerment and support also feature prominently in this method. As such, PCC principally signifies a move away from a ‘one-size-fits-all’ approach in health care to a more tailored treatment plan [22, 23]. Several studies attest the relevance of PCC in a range of

health-care settings and the association between the form of patient care and health outcomes. For example, Stewart et al. [24] found significant positive correlations between patient- centered communication and patient perception of finding common ground (P = 0.01) and in turn linked such positive perceptions with better recovery (P = 0.0001), less concern (P = 0.02), better emotional health (P= 0.05) and fewer diag- nostic checks and referrals (up to 2 months later). These results were supported by Wanzer et al. [25] who linked patient satisfaction with communication and physician and nurse practice of PCC (r = 0.73, P = 0.001; r = 0.61, P = 0.001, respectively). Patient satisfaction with care received was also correlated with perceived physician PCC practice (r = 0.67, P= 0.001) and perceived nurse PCC practice (r = 0.68, P= 0.001) [25].

Similar findings highlight the value of PCC in other set- tings, including general preventive health care [26], diabetes management [27], cancer management [28–30], post-cancer follow-up treatment [31, 32], palliative care [33, 34], mental health [35] and HIV management and treatment [36]. Thus, there is considerable research providing relatively clear support for beneficial relationships between the practice of PCC and patient health, treatment and satisfaction.

PCC and CC

As PCC is designed to take into account the specific circum- stances relevant to each patient—including ethnic and cul- tural variables. The successful delivery of this type of collaborative care relies on the ‘CC’ of the health-care pro- vider. That is, for effective PCC, the practitioner must be able to communicate effectively verbally and non-verbally and respect the traditional practices and beliefs of the patient [37]. The significance of CC in health care is exemplified in several studies on issues such as physician language ability, cultural knowledge and patient satisfaction. Fernandez et al. [38], for example, found significant positive associations between physician self-rated language ability and successful elicitation of and responsiveness to patient concerns and pro- blems (OR 4.3; 95% CI, 1.75–10.56). Physician self-rated understanding of patients’ health-related cultural beliefs was also significantly linked with patient clarity (OR 3.98; 95% CI, 1.43–11.45), responsiveness (OR 4.56; 95% CI, 1.67– 12.46) and understanding of prognosis and condition (OR 4.5; 95% CI, 1.73–11.79). Similarly, Mazor et al. [8] found that a 10-week medical Spanish course for pediatric emer- gency department physicians was significantly associated with decreased use of interpreter services in patient care post- intervention (OR 0.34; 95% CI, 0.16–0.71) and increased patient satisfaction in terms of perceived physician concern (OR 2.1; 95% CI, 1.0–4.2), respectfulness (OR 3.0; 95%CI, 1.4–6.5) and listening/communication (OR 2.9; 95% CI, 1.4–5.9). In other examples, the CC of practitioners was positively correlated with minority patient satisfaction with received medical care (r2 = 0.193, P < 0.05) [39] (r = 0.32, P< 0.001) [40] and decreased blood pressure among hyper- tensive patients (r = –0.18; P < 0.05) [40]. These findings are further backed up in other research and appear to be rele- vant in a broad range of health-care settings [41–44]. As such, CC in health care can best be defined as practi-

tioner flexibility and adaptability in terms of working effective- ly within a variety of cultural and ethnic contexts. This includes linguistic abilities, as well as cultural knowledge, awareness, sensitivity and respect [32]. Considering the in- creasing ethnic and cultural diversity in health-care clientele, CC is, thus, an integral aspect of PCC.

The current review

PCC and CC have been found to be complementary in terms of improving health-care quality and outcomes [15]. Whereas patient-centeredness aims to improve health-care quality by

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emphasizing the inclusion of the patient’s perspective general- ly in caregiving, CC centers on circumventing cultural barriers between the health-care provider and client [45]. As such, both concepts focus on improved health care with an em- phasis on patient-centeredness that in turn begs for acknowl- edgement of patient diversity. On this backdrop, PCC and CC approaches aim for the development of effective communica- tion and clinical capabilities in health practitioners. For this reason, PCC and CC have been used interchangeably in the literature [45]. Nonetheless, there are relatively few PCC models that specifically incorporate a CC component and fewer still that have a cultural focus and have been empirically developed and evaluated [12, 46]. Thus, the aim of the follow- ing systematic review is to examine the effectiveness of PCC models that incorporate a CC perspective, in improving health outcomes among CALD patients.

Method

Protocol

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines that can be accessed at www.prisma-guidelines.org (Fig. 1).

Information sources

A search of the following databases was conducted during August 2011: Academic Search Complete, Academic Search Premier, CINAHL with Full Text, Global Health, MEDLINE with Full Text, PsycINFO, PsycARTICLES, PsycEXTRA, Psychology and Behavioural Sciences Collection, Pubmed, Web of Knowledge and Google Scholar.

Search strategy and study selection process

The search terms used were based on MeSH keywords for ‘PCC’ and ‘cultural competency’. Searches were conducted on the following terms simultaneously: (i) Cultural competency terms (MeSH terms):

Competency, Cultural; Cultural Competencies; Cultural Competence; Competence, Cultural.

(ii) PCC terms (MeSH terms): Care, Patient-Centered; Patient-Centered Care; Nursing, Patient-Centered; Nursing, Patient Centered; Patient-Centered Nursing; Patient-Centered Nursing; Patient-Focused Care; Care, Patient-Focused; Patient-Focused Care; Medical Home; Home, Medical; Homes, Medical; Medical Homes;

(iii) Other terms (text word): Prejudice, Health care; Racism, Health care; Attitude, Health care.

Reference lists for relevant papers were also manually searched for additional citations. Studies were included in the review based on the following criteria: (i) The study was published in a peer-reviewed scientific

journal. (ii) The full text was available in English. (iii) The population under study comprised health-care

professionals and/or students and/or ethnic minorities.

(iv) The study centered on the development and effective- ness of patient-centered health-care models with a CC focus.

(v) The date of the publication was no earlier than 1 January 2000.

Validity assessment

Search results were assessed in three rounds. First, articles were filtered based on their title. Second, articles were retained or excluded after reviewing their abstracts. Third, the full-text versions of the remaining articles were obtained and reviewed. The empirical quality of the studies was assessed according to critical appraisal skill program guidelines (see Table 1).

Data extraction process

Data were extracted from the studies using a piloted form, including fields for study research design, population under study, setting, sample size, study results and limitations.

Figure 1 Flow chart of study selection.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 1 Data extraction strategy

Inclusion criteria Yes No

Is the paper peer reviewed and is the full text available?

Proceed ↓

Exclude ↓

Does the study focus health-care delivery to ethnic minorities?

Proceed ↓

Exclude ↓

Does the study involve the development and assessment of (an) intercultural PCC model(s)?

Proceed ↓

Exclude ↓

Final decision Include Exclude

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Results

Study selection

A total of 1450 papers were identified in the initial search. The majority of these were rejected based on one or more of the following factors: the paper focused on general health- care delivery models without a CC component; the paper described culture-related training programs that were not part of PCC programs; the paper described CC health-care models, but with no empirical evaluation or evidence base; the paper was about work culture rather than ethnic culture; the paper did not cite empirical research (commentaries, book reviews, etc.); or a combination of the above. Overall, 13 studies met the inclusion criteria (see Table 1).

Study characteristics and samples

Seven of the studies reviewed were from the USA, four from Canada and two from the UK (See Table 1). The majority of the research was conducted in a professional (clinical/hos- pital) setting (n = 9) [47–55], but student settings were also used (n= 5) [49, 56–59]. All participants were adults over 18 years of age. The studies predominantly (n= 11) relied on quantitative research designs, including randomized control trials (RCT), longitudinal design, cross-sectional design and descriptive correlational design (see Table 1). Qualitative re- search designs were employed in the remaining studies (n= 2). Outcome measures comprised patient satisfaction with care, health outcome or practitioner behavior in four of the studies [50–52, 54], whereas the remaining nine studies gen- erally used practitioner knowledge and/or awareness of PCC and CC issues as evaluation measures [47–49, 53, 55–59] (Table 2).

Summary of findings

Two studies examined patient health outcomes as an evalu- ation measure. Majumdar et al. [51] investigated the effects of a CC course on 114 nurses and homecare workers. Effects of the program were also observed for 133 patients. Health-care workers who received the training demonstrated significantly higher understanding of multiculturalism than a control group (P< 0.0001). Similar findings were evident for cultural awareness (P= 0.0001), understanding of cultural dif- ferences (P = 0.001), cultural beliefs (P = 0.004), adopting health-care literature (P = 0.001), considering patient social circumstances (P = 0.011) and regarding culture as important in successful health-care treatment (P = 0.001). These results persisted over time. There were no significant findings in terms of patient health outcomes—however, this was pos- sibly due to attrition in the patient participant group [51]. Thom et al. [54] assessed the effectiveness of a CC training

curriculum administered to 53 physicians. The training program comprised cultural knowledge, intercultural commu- nication and cultural brokering (engaging the patient in the de- velopment of a treatment plan in a culturally sensitive fashion). The impact of the intervention was measured in

terms of the CC of the physician as rated by the patient. Secondary measures included patient satisfaction with received health care and outcomes. The study yielded no sig- nificant effects across all evaluation variables. Limitations were noted, however, and related to the brevity of the training cur- riculum (3–5 h), insufficient follow-up assessments and the fact that over 70% of participating physicians were of another ethnicity than Caucasian and, therefore, possibly already cul- turally capable [54]. The remaining eight studies relying on quantitative research

designs examined practitioner training and education pro- grams, with the exception of a single study that looked into African-American patient satisfaction and perception of phys- ician CC [52]. Here, the effectiveness of the ‘Ask Me 3’ inter- vention was evaluated. The program focused on increasing the quality of PCC and CC, by encouraging African-American patient involvement in the clinical process [52]. Results indi- cated no improvements in physician CC as rated by the patient. Significant progress was evident, however, in satisfac- tion for patients who saw their regular physician (P = 0.014). Thus, an interaction effect of physician familiarity and the intervention appeared to increase patient satisfaction with care received. Limitations mainly related to a small sample size (n = 64) [52]. Brathwaite and Majumdar [47, 48] assessed the effects of

a PCC educational program offered to 76 nurses at a Canadian hospital. The evaluation centered on pre- and post- intervention scores on the Cultural Knowledge Scale. Significant increases in CC over time were evident (P< 0.02) —specifically in relation to cultural knowledge, awareness, confidence and use of lessons learned [47, 48]. A study in the USA assessed the Cultural Competence

and Mutual Respect program that was delivered over 3 years to 1974 health-care students [57]. Evaluation was based on pre- to post-scores of the Inventory for Assessing the Process of Cultural Competence-Revised scale (ranging from 25 to 100 points), and significant improvements in student CC were evident with males increasing by 4.1 points (P < 0.001) and females by 3.8 points (P< 0.001) [57]. Comparable findings were established in four other studies.

[49, 53, 56, 59] One study [58] assessing the impact of a CC PCC educational program on university students found no significant improvements in CC post-intervention. This was, however, probably due to limitations of the measurement scales used and the brevity of the intervention period [58]. Finally, two qualitative studies were included in the review.

Kirmayer et al. [50] evaluated a program implemented as a cul- tural consultation service for mental health practitioners and primary care clinicians. Assessment of the service occurred through practitioner observation, reason for consultation, examining cultural formulations and recommendations as well as consultation outcome in terms of clinician satisfaction [50]. Patients comprised immigrants, refugees and asylum seekers (n = 102). The most common reasons for consultation with the service were difficulties with diagnosis (58%) and treat- ment planning (45%) as well as requests for assistance with specific ethnic groups or clients (25%) [50]. It was further evident that the main themes in terms of practitioner cultural

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Table 2 PCC models with a CC scope—from 2000 to present

Author (year) Location Experimental design

Sample (n) Integrated cultural care model

Outcome measures Results and limitations

Brathwaite[48] Canada Longitudinal pre- to post-intervention study

Registered nurses (76) Brief CC training course. Scores on the CKS. Results showed that the course was effective in increasing participants’ levels of CC (P< 0.000). Limitations relate to the small sample size and the lack of patient health outcome effects.

Brathwaite and Majumdar [47]

Canada Longitudinal pre- to post-intervention study

Registered nurses (76) Five-week CC training course.

Scores on the CKS. Nurses’ CKS scores increased significantly (Wilks’ Lambda P < 0.01). Limitations relate to small sample size, generalizability and lack of patient health outcome effects.

Crandall et al. [56] USA Longitudinal pre- to post-intervention study

Second-year medical students (12)

Adaptation and integration of cultural awareness, sensitivity and knowledge in medical practice.

Multi-national Assessment Questionnaire pre- to post-intervention scores.

A positive impact was apparent pre- to post-intervention. Further research to establish whether effect decays or persists. Lack of assessment of patient health outcome effects.

Ghallager-Thompson et al. [49]

USA Longitudinal pre- to post-intervention study

Health-care professionals and students (340)

The Alzheimer’s Hispanic Outreach, Resource and Access Project.

Participant knowledge of CC and related attitude and clinical behavior.

Significant improvements in the measured variables were evident post-intervention (P< 0.05–0.005).

Kirmayer et al. [50] Canada Qualitative study Minority mental health patients (100)

Cultural consultation service; integrating different perspectives of psychiatry and medicine.

Referring clinicians’ satisfaction with patient progress.

Clinicians reported increased insight into cases, improved treatment, therapeutic alliance, understanding and communication. Limitations relate to the small sample size.

Majumdar et al. [51] Canada RCT Health-care providers (114) and patients (133)

Cultural sensitivity training for health-care providers, cultural awareness, communication and understanding.

Health-care provider attitude and cultural competency and patient health outcomes.

The program improved knowledge and attitudes of health-care providers in the experimental group (P = 0.011–0.0001). There were significant improvement in patient health outcomes and satisfaction.

Michalopoulou et al. [52]

USA RCT African-American patients (64)

Culturally sensitive GP practice of Ask Me 3 intervention. Encouraging active patient articipation in clinical process. Communication and interaction.

Patient-Perceived Cultural Competency Measure score.

No significant differences were found between experimental and control groups. Individuals seeing their regular GP reported significantly higher levels of satisfaction with care, than patients seeing their regular GP. Limitations include small sample size and a single ethnicity under study.

(continued )

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Table 2 Continued

Author (year) Location Experimental design

Sample (n) Integrated cultural care model

Outcome measures Results and limitations

Musolino et al. [57] USA Longitudinal pre- to post-intervention study

IHSS, professionals in medicine [60], pharmacy, nursing and PT (1974)

Cultural Competency and Mutual Respect education program.

Pre- to post-intervention scores on Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competence-Revised.

Overall progress toward CC was observed pre- to post-intervention (P< 0.001). Cultural proficiency was not attained in IHSS, however. Further research needs to look into how the program can be delivered more effectively and its specific effect on health outcomes.

Reicherter et al. [58] USA Case control study/ pre-, post-test.

PT students (26) CC educational program. Yang Social Interaction survey [46] scores and Wilcoxon Rank Sum Test scores pre- to post-intervention.

There were no overall improvements in student knowledge and attitudes pre- to post-interventions. Limitations relate to small sample size and lack of examination of patient health outcomes effects.

Smith [53] USA Two group longitudinal pre- to post-intervention study

Registered nurses (94) CC curriculum. CSES scores and knowledge base scores.

Scores on the CSES and knowledge base were significantly better for intervention group (P= 0.015). Limitations relate to the sample size and the lack of assessment of patient health outcome effects.

Tang et al. [59] USA Cross-sectional pre- to post-intervention study

Medical students (167) Socio-cultural Medicine Program

Student attitudes to socio-cultural medicine.

Significant improvements were noted post-intervention in terms of general attitude, understanding of cultural issues in health care, importance of culture in doctor–patient relationship and patient health behavior (P < 0.01–0.001).

Thom et al. [54] USA RCT Primary care physicians (53) and patients (429)

CC curriculum for resident and practicing physicians.

Patient-Reported Physician Cultural Competence score; secondary outcomes were changes in patient health status and satisfaction.

There was no discernable impact of the intervention on patient health and attitude. Limitations relate to the brevity of the intervention.

Webb and Sergison [55]

UK Qualitative study Health-care professionals and students, social services professional and education professionals (140)

CC and antiracism training.

Self-reported cultural and racism awareness, knowledge and changed behavior.

CC and antiracism training were well received by professionals. It was a positive experience for trainees and perceived to be relevant to their practice. Appropriate and non-threatening training in CC change attitudes, behaviors and practice, including promoting good practice in communication across linguistic and cultural differences. Limitations relate to lack of measurement of patient satisfaction and health outcomes.

CKS, Cultural Knowledge Scale; IHSS, interdisciplinary health science students; PT, physical therapy; CSES, Cultural Self-Efficacy Scale.

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formulation and awareness were largely related to communica- tion issues and ignorance of traditions, different family struc- tures, identity conceptions and religious issues. [50]. Clinicians indicated favorable reviews of the consultation

service and reported overall greater CC [50]. In a similar study, Webb and Sergison [55] examined the effectiveness of the CC PCC training course, Equal Rights Equal Access. Of the respondents, 75% (n = 36) believed that the course had been effective in teaching CC and in particular communication and use of interpreter services [55]. Other notable themes were related to increased self-reported clinician awareness of the specific needs of ethnic minorities, embracing diversity in their clientele and alertness to own stereotypical views and generalizations [55].

Discussion

This review examined the effectiveness of PCC models that incorporate a CC perspective, in improving health outcomes among CALD patients. There were 13 studies that met the inclusion criteria for this review. Overall, we found evidence supporting the effectiveness of CC PCC training in increas- ing knowledge levels, self-reported practice and patient satis- faction. However, whereas increases in cultural knowledge and awareness were evident, no studies reported any signifi- cant findings in terms of patient health outcomes. In fact, only two studies used this variable as an outcome measure [51, 54], and both of these studies were hampered by partici- pant attrition or small sample sizes and short intervention periods. Importantly, the fact that most of the research on CC PCC programs measured effectiveness in terms of practi- tioner knowledge and not patient health represents a major shortcoming to the current research on this topic, as patient health outcome is one of, if not the most important indicator of effectiveness of any care model. Thus, the current results in this regard are limited, and more research is required to properly assess the impact of the reviewed interventions on patient health.

Limitations

As mentioned above, a major limitation to the research reviewed pertains to the lack of patient health outcome mea- sures in the majority of studies. Only two studies included such an evaluation variable, and both generated non- significant impacts—most likely due to low participant numbers and participant attrition. Future research should include evaluation of the practical effects of CC in PCC pro- grams in terms of patient health outcomes. Another limitation comprises the fact that the review did not include studies pub- lished in languages other than English, thus limiting an inter- national viewpoint. The current review was unable to include non-English language studies due to lack of funds to meet costs related to translation services. Finally, the difference in research design across studies—and the consequent difficulty in synthesizing and comparing the results of the research— also represents an important limitation.

Conclusion

The objective of this systematic review centered on the effect- iveness of PCC models that incorporate a CC perspective, in improving health outcomes among CALD patients. Of the initial 1450 studies identified in the first search round, 13 met the final inclusion criteria and were included in the review. The majority of the research demonstrated effectiveness of PCC models in terms of clinician/practitioner cultural knowl- edge, awareness and sensitivity. Only two articles examined effects of the intervention programs on patient health out- comes, with both studies reporting non-significant results on these variables. As such, although the programs may increase practitioner knowledge and awareness, there is no evidence that this translates to improved patient health. More research is, thus, required to properly examine the impact, if any, of CC PCC models on health outcomes.

Funding

This study was funded by the Australian Commission of Safety and Quality in Health Care.

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Literary Analysis of “Separate Ways”

Born Higuchi Natsu, Higuchi Ichiyo experienced an almost meteoric rise to stardom in Japan during the late 1800s due to the success of her novella Child’s Play (Puchner 971). Her final short story, “Separate Ways”, is an almost autobiographical look at life in Tokyo’s seedy red light district. The story is about Kichizo, a young umbrella oiler and his peculiar friendship with a beautiful young seamstress named Okyo. When Okyo makes the decision to leave her life of impoverished independence in exchange for one of sexual servitude as a mistress, Kichizo reacts harshly and vows never to see Okyo again. In Kichizo’s anger, he says, “How could I have thought of you as a sister? You, with all your lies and tricks, and your selfishness” (978). At first glance, it would appear as ego-centric or selfishness on the part of Kichizo for reacting in such a manner. However, as one looks more closely at Kichizo’s life, his reaction is perfectly understandable, if not completely expected. Throughout Kichizo’s entire life, he has experienced abandonment. The feeling of abandonment he suffers when Okyo informs him of her plan for the future is merely one more in a long line of people in which Kichizo has placed his trust, love, and vulnerability, only to be let down by their eventual departures. “Separate Ways” is an excellent example of how abandonment effects Kichizo and has a formative impact on his psychological development. Furthermore, there are several examples of Kichizo being abandoned by those close to him throughout his entire life, not just Okyo. Finally, Kichizo’s reaction is perfectly understandable from a psychological viewpoint when Okyo announces she is leaving.

In order to fully understand the feelings of Kichizo as they relate to his abandonment issues, the act of abandonment must be defined as it relates to psychological development. Early in a child’s development, a bond is formed between the child and the mother in utero. Nancy Verrier, an adoptive parent and author of the book, The Primal Wound, suggests that the child grows accustomed to the sounds of the mother, including the heartbeat and her voice, and can even recognize a photo of the birthmother before actually seeing her (20). The premature severing of that bond can have lasting effects on the child. Verrier states, “When this natural evolution is interrupted by a postnatal separation from the biological mother, the resultant experience of abandonment and loss is indelibly imprinted upon the unconscious minds of these children, causing that which I call the ‘primal wound’” (1). In “Separate Ways”, the fate of Kichizo’s parents is never explained. He has no idea as to the whereabouts of his mother and father, or if they are even still alive. Either way, he feels a deep emotional void resulting from that loss. Ichiyo describes this when she writes, “He didn’t even know the date of his parents’ death, he had no way to observe the yearly abstinences. It made him miserable, and he would throw himself down underneath the umbrellas drying in the yard and push his face against the ground to stifle his tears” (976). He experiences the loss, and from an early age, is left to fend for himself. This early self-dependency has been influential in his development and contributed to him becoming distrustful of others and having issues with anger. Ichiyo describes Kichizo as “- a fireball. He had a violence about him that frightened the entire neighborhood” (976). The act of abandonment is so destructive, it is considered a key component in both the Child Neglect and Psychological Abuse categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (718-719). Therefore, it is plain to see why Kichizo acts the way he does throughout the story, as well as when Okyo informs him of her decision to become a mistress.

Abandonment is not only a crucial element in Kichizo’s psychological development, it is experienced throughout his entire life. These continuous deaths and departures of people who love him or show him the slightest amount of kindness occur multiple times throughout the story. Early in the story, Ichiyo lets the reader know just how important Kichizo’s identity, or lack thereof, is to him. Kichizo says:

Boy, I’d sure be glad if someone like you would come and tell me she was my sister. I’d hug her so tight…After that, I wouldn’t care if I died. What was I, born from a piece of wood? I’ve never run into anyone who was a relative of mine. You don’t know how many times I’ve thought about it: if I’m never, ever going to meet anyone from my own family, I’d be better off dying right now. Wouldn’t I? (974)

This demonstrates how important family is to Kichizo and how devastated he is not to know who his family is or where he comes from. His parents are only the first to abandon Kichizo. While he is living as a street performer, he is basically adopted by Omatsu, the old woman who owned the umbrella factory. Omatsu takes him in, feeds him and gives him a place to live. She expresses belief in him by teaching him a trade and giving him a job in her umbrella factory. Kichizo develops a strong bond with Omatsu because she is caring for him the way his mother should have. Later, when Omatsu dies, Kichizo is once again abandoned by a mother figure. It is irrelevant to Kichizo whether or not Omatsu intended to leave him; there is not a difference in his eyes. He feels abandonment all over again, and it makes him that much more bitter because of it. Additionally, there is another woman to whom Kichizo has grown close to. Although she is only mentioned in one small part of the story, the reader is led to believe that the woman was very important to him. The woman’s name is Kinu and she works in the dyer’s shop. Ichiyo does not explain who she is to Kichizo, but she is important enough to him that she is mentioned along with Omatsu once he finds out Okyo is leaving him. Kichizo describes his pain when he exclaims:

What a life! People are friendly, and then they disappear. It’s always the ones I like. Granny at the umbrella shop, and Kinu, the one with short hair, at the dyer’s shop. First, Granny dies of palsy. Then Kinu goes and throws herself into the well behind the dyer’s – she didn’t want to marry. Now you’re going off. I’m always disappointed in the end. (978)

It is not that Kichizo is a narcissist, or that he believes the world revolves around him. He is expressing a pain that he does not understand. The pain in knowing that everyone he has ever felt safe with has let him down.

When Okyo finally announces to Kichizo that she is leaving, she becomes one more reinforcement to him that it is unsafe to get close to anyone. Kichizo and Okyo had become very close. Kichizo looked up to Okyo like he would an older sister. She was always available to him, to listen to him, to offer advice, or just someone he could vent to after a hard day of oiling umbrellas. When the other boys would tease him for being so small, he would counter with the fact that he was always welcome in her house. While all of the other men could only admire her from afar, he was the one she would invite into her home at any hour of the day or night. When they tease him, he would only say, “If you’re so manly, why don’t you ever visit Okyo? Which one of you can tell me each day what sweets she’s put in the cookie jar?…I’m the one who can go there any hour of the night, and when she hears it’s me, she’ll open the door in her nightgown” (976). Therefore, when Okyo informs him that she is leaving to be a rich man’s mistress, Kichizo is once again faced with the pain of being abandoned by someone close to him. Okyo had been most like a family member to him since the death of Omatsu. He had grown to finally trust and rely on her like he was not able to do with anyone else. He had allowed himself to be vulnerable, and in his eyes, the thanks he was receiving was yet another departure of someone that can be described as a caregiver. Not only is he faced with losing another loved one, but it is the conditions in which she is leaving that makes it doubly painful. Kichizo is a proud young man. He believes that working hard and being poor is better than receiving help to improve his station in life. That belief is also a by-product of his attachment issues. When one has been faced with a lifetime of abandonment, he begins to lose the ability to trust in anyone. People who suffer from attachment disorders have been responsible for taking care of themselves for so long (for Kichizo, since birth), that they can no longer rely on anyone. This is exemplified when Kichizo tells Okyo, “Even if someone came along and insisted on helping me, I’d still rather stay where I am. Oiling umbrellas suits me fine. I was born to wear a plain kimono with workman’s sleeves…” (974). As a result, when Okyo explains why she is leaving, he is faced with a feeling of revulsion. Kichizo is so distraught, he makes the claim that he will never associate with anyone again. He says, “This is the last you’ll ever see of me. Ever. Thanks for your kindness. Go on and do what you want. From now on, I won’t have anything to do with anyone. It’s not worth it” (978). It is not that Kichizo suddenly despises Okyo, but he is so devastated by losing another person he has seen as a caregiver, he does not know how to process it. Following another significant abandonment such as Okyo’s, he may be correct when he says he will never rely on anyone again.

The short story, “Separate Ways”, by Higuchi Ichiyo gives the reader an insider’s view of the impoverished working class in Tokyo in the late 1800s. Ichiyo is very adept at painting a exceptionally clear picture using dialogue almost entirely. The characters are fairly likeable, even the pugnacious anti-hero, Kichizo. At the end of the story, when Okyo informs Kichizo that she is going away, Kichizo is devastated and, instead of trying to support Okyo in a time when she is scared, confused, and apprehensive regarding what her future will bring, he berates her and takes it as a personal rejection of himself. The devastation that he feels is caused by the lifetime of abandonment and grief he has been subjected to. Throughout his entire life, every person who has assumed a role of caregiver, someone in which he could rely on, has suddenly and without warning deserted him. Whether it was the disappearance and presumed death of his parents, the death of Omatsu and Kinu, and finally the abandonment of Okyo, Kichizo has been forced to internalize that pain and find a way to move on. These traumatic occurrences have taken a harsh toll on the young boy, making him bitter and angry, but also strong willed and self-reliant. This repeated abandonment trauma has played a major part in Kichizo’s psychological development, molding him into the person he has become. Finally, the last two lines of the story sum up a lifetime of pain for the young Kichizo. Ichiyo writes, “He stared at her with tears in his eyes. ‘Take your hands off me, Okyo’” (979). For Kichizo, Okyo is only another person he made the mistake of being vulnerable with, and now he will have to pay for it.

Works Cited

Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association, 2013. Print.

Ichiyo, Higuchi. “Separate Ways.” The Norton Anthology of World Literature Volume II. Ed. Martin Puchner. third ed. New York: Norton, 2013. Print. 973-979.

Verrier, Nancy Newton. The Primal Wound: Understanding the Adopted Child. Baltimore: Gateway, 1993. Print.

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Poetry in the Light of Revolution

Poetry evolves through time for the reason that people and the world are evolving along with it. For one era in particular, the Romantic era, poetry by William Wordsworth and William Blake can be compared to see the similarities that are defined by the times. For this investigation, Wordsworth’s “I Wandered Lonely as a Cloud” and Blake’s “A Poison Tree” are closely explored to discover how poetic elements and historical context define them as poems from the Romantic era.

Romanticism identifies Western culture from 1785 to 1830. Historically, it falls in place with the American Revolution in 1776 and the French Revolution in 1789. This age has many changes in structure such as political, economic, and social traditions. These changes all occur along with the Industrial Revolution (1). The times are changing and power is shifting. Ideology is transforming into something new with the urbanization going on in society. Emotions are at full force in the Romantic era. Poets such as Wordsworth and Blake write with passion and base it on intuition. There is a disorder and spontaneity that exists within their work. The country and nature created by God are key topics in this time period (2). There is a list of characteristics that define Romanticism, and they are reflected in Wordsworth and Blake’s poetry as well. Poetry is a key tool that can show how society transforms in ideology with respect to revolution and urbanization within the Romantic era. Comment by Stephanie Dugger: since you are using more than one source for this paper, all citations need an author or title along with the page number. Comment by Stephanie Dugger: what sort of emotions?

Wordsworth’s “I Wandered Lonely as a Cloud” was written between 1804 and 1807 (3). Contextually, the French Revolution occurs during this time. It also is a period of urbanization where cities are growing rapidly. Wordsworth’s poem begins by saying “I wandered lonely as a cloud / That floats on high o’er vales and hills, / When all at once I saw a crowd, / A host, of golden daffodils;” (Wordsworth 1-4). These lines create a peaceful setting in a field that is void of the bustling city life. By looking at the historical context of this poem, it becomes apparent that the focus on nature and tranquility is deliberate. Daffodils are described as a crowd which alludes to the crowd of people in the city, yet there are no people out in this field. Nature and the universe are described with vivid imagery to show the beauty of the natural world, except the images become only a memory at the end of the poem. A turn in the poem occurs when Wordsworth writes “For oft, when on my couch I lie / In vacant or in pensive mood, / They flash upon that inward eye” (Wordsworth 19-21). The subject is thrown back into reality with his daily routine. Lying on the couch is typical for one to do when bottled up inside of a house. The vacant or pensive mood hints that the subject is trying to escape thoughts that are worrying or depressing him. Memories of daffodils are used by the subject as a way to relax and distract him from his current worries. He escapes the city through his memory of the fields, if only for a few minutes. Wordsworth is striving to write about the happiness and tranquility found in nature in a time where revolution is constantly a worry and urbanization is creating a depressing sheltered lifestyle.

Blake’s “A Poison Tree” was written in 1794 and alludes to the biblical story of Adam and Eve and the “tree of knowledge and evil” (4). The poem begins by describing a scenario of anger towards a friend and enemy with the lines, “I was angry with my friend; / I told my wrath, my wrath did end. / I was angry with my foe: / I told it not, my wrath did grow.” (Blake 1-4). The poem has two sides as it describes a friend and an enemy. There are also two sides in a war, so while the story of the poem comes off as biblical, it can also be compared to a war situation. This connection is valuable in the context of history with the French Revolution occurring. The poem raises questions about what is right and wrong when it comes to conflict. The last two lines of the poem end by saying, “In the morning glad I see / My foe outstretched beneath the tree.” (Blake 15-16). The subject of the poem is glad to see his enemy dead, but the way the poem drops off allows the reader to contemplate the actions of the subject since they were left unaddressed. By allowing the reader to reflect on morality, the author has created a way for the reader to relate their thoughts to current events. Blake writes about friends, enemies, and religion to create a scenario that makes readers draw connections and address issues in daily life.

The poetic themes that define a poem in the Romantic era are comparable due to the fact that war is a common underlying issue that influences a poet to write the way that they do. To compare Wordsworth and Blake’s poems, both have strong themes of nature, divinity and death. Wordsworth’s poem talks about how great and outreaching the nature and universe is that it eludes to a greater being out there. The subject says “I gazed—and gazed—but little thought / What wealth the show to me had brought” (Wordsworth 17-18). The nature and universe brings wealth that cannot be gained through money. But at the end of the poem, all this greatness is only a memory to reflect on in order to escape the current fears and sadness. Blake’s poem is a play on the biblical story of Adam and Eve, which is a direct correlation to a greater being. There are fears, as well as a false sense of happiness in the lines “And I waterd it in fears, / Night & morning with my tears: / And I sunned it with smiles, / And with soft deceitful wiles.” (Blake 5-8). Then the story ends in death. Poets push back against war and urbanization by focusing on themes of nature and divinity. The theme of death will always be present, whether explicitly or implicitly implied, when war is occurring. Themes in poetry from the Romantic era tend to be similar as they all pull from the same events of that time. Comment by Stephanie Dugger: awkwardly worded

The tones in Wordsworth and Blake’s poems are different, but at the same time they hold similarities. In “I Wandered Lonely as a Cloud,” there are somber tones mixed with joyful and aw-induced feelings. Somber tones are seen in the first stanza when the subject says, “I wandered lonely as a cloud” and again in the last stanza “For oft, when on my couch I lie / In vacant or in pensive mood” (Wordsworth 1, 19-20). Joyful tones are seen when the vivid nature is described, such as the lines “The waves beside them danced; but they / Out-did the sparkling waves in glee: / A poet could not but be gay, / In such a jocund company:” (Wordsworth 13-16). The joyful tones are only temporary and fleeting, as they are replaced at the end with somber tones again. For Blake’s “A Poison Tree,” the tone is full of anger, fear, anxiety, and a false sense of happiness and content. The multitude of tones and feelings can be seen alone in the second stanza that says, “And I watered it in fears, / Night and morning with my tears; / And I sunned it with smiles, / And with soft deceitful wiles.” (Blake 5-9). Both of the poems from Wordsworth and Blake have an underlying darkness and sadness covered with a thin layer of temporary happiness. The subjects in these poems are trying so hard to cover up the darkness, sadness, and death with a happy façade. In a time of war the fight for peace, light, and happiness is a difficult and almost a pointless effort, but there remains the slightest of hope that helps the people push forward for a brighter future.

Rhyme and meter are very apparent in Wordsworth and Blake’s poems. Wordsworth’s poem consists of four stanzas with an ababcc rhyme scheme. With the meter being in iambic tetrameter, the poem has a flow to it that pushes the reader along, but not too fast. The reader wanders along with Wordsworth appreciating the beauty of nature: “A host, of golden daffodils; / Beside the lake, beneath the trees, / Fluttering and dancing in the breeze.” (Wordsworth 4-6). But the rhyme and meter does not allow the poem to stop in the middle. It pushes the reader to the end of the poem where the daffodils are but only a memory.

Blake’s poem consists of four stanzas as well, but with an aabb rhyme scheme. There is iambic tetrameter in this poem, but there are also sporadic lines of trochee, which is the opposite of iambic tetrameter. For example, “I was angry with my friend” is a trochee, and “I told my wrath, my wrath did end.” is iambic pentameter (Blake 1-2). The changes in meter affects how some lines are read in terms of speed and emphasis. It helps create the changes in mood and tone. The flow of the poem is direct and carries the reader along through different emotions and days and nights until the reader is at the end of the poem and the enemy is killed. The reader is left to contemplate these results in his or her own thoughts. At the same time, the opposites in meter is another way to draw attention to the opposites of friends and enemies. For both poems, the flow of the poems push the reader forward but in a slow manner. Rhyme and meter determine the path of the journey in the thoughts and reflections of the reader. The poet creates this element of the poem on purpose. In relation to the context of the time, this can be an interpretation of the feelings people go through in a time of war. Time cannot stop for anyone and before you know it, happiness becomes a memory as darkness and death come to replace it.

The Romantic themes can be specifically defined in the poems of Wordsworth and Blake. Both poems have themes from the Romantic era as they talk about nature and death, which is a strong image of this time. They also contain poetic elements that seem to create a feeling of spontaneity when meter and tones start switching around. The disorder of these elements are characteristic of the Romantic era. The feelings in these poems are very strong and do not lack passion. Feelings are at full force and imagery intensifies this experience. All the elements involved in Wordsworth and Blake’s poems are characteristic of the Romantic era even though the subjects of the poems are different. The experiences of the subjects of the poems are similar as the feelings provoked are alike in many ways. When war and change is happening around the time of these poems being written, the authors will have emotional reactions and their experiences will be weaved into the poetry that they create. Common themes emerge from different eras when poets attempt to address issues through writing poetry.

Common themes of nature, divinity and death start to emerge as one reads multiple poems from the Romantic era. One will become immersed in the emotions and issues for this time in history. It will create a better understanding to see how people developed in cities and how they reacted to the revolutions. The similarities and differences can be compared of any poem to see how united the feelings and experiences were of this time. The lifestyle and experiences of any author should be taken into account when trying to fully understand a poem because the soul and very being of an author is formed by what they encounter in the world around them. Everyone is born into this world with original sin, but one only become aware of this when exposed to the sins of others. People are shaped by their surroundings and react in their own ways to different events, but there will always be similarities as everyone is connected by being a human. The connections in humanity during the Romantic era are defined through poetry the second a poet writes down his or her feelings into a very distinct documentation and interpretation of the world around them.

Sources:

(1) “Romanticism.” Romanticism. Web. 20 Apr. 2015.

(2) “Romantic Art Style (c.1770-1920).” Romanticism: Definition, Characteristics, History.

Web. 20 Apr. 2015.

(3) Wordsworth, William. “I Wandered Lonely as a Cloud.” Wikipedia. Wikimedia Foundation.

Web. 20 Apr. 2015.

(4) “Tree of the Knowledge of Good and Evil.” Wikipedia. Wikimedia Foundation. Web. 20 Apr.

2015.

(5) Blake, William. “A Poison Tree.” Wikipedia. Wikimedia Foundation. Web. 20 Apr. 2015. Comment by Stephanie Dugger: check MLA formatting for works cited entries

I Wandered Lonely as a Cloud

By: William Wordsworth

I wandered lonely as a cloud

That floats on high o’er vales and hills,

When all at once I saw a crowd,

A host, of golden daffodils;

Beside the lake, beneath the trees,

Fluttering and dancing in the breeze.

Continuous as the stars that shine

And twinkle on the milky way,

They stretched in never-ending line

Along the margin of a bay:

Ten thousand saw I at a glance,

Tossing their heads in sprightly dance.

The waves beside them danced; but they

Out-did the sparkling waves in glee:

A poet could not but be gay,

In such a jocund company:

I gazed—and gazed—but little thought

What wealth the show to me had brought:

For oft, when on my couch I lie

In vacant or in pensive mood,

They flash upon that inward eye

Which is the bliss of solitude;

And then my heart with pleasure fills,

And dances with the daffodils.

A Poison Tree

By: William Blake

I was angry with my friend;

I told my wrath, my wrath did end.

I was angry with my foe:

I told it not, my wrath did grow.

And I waterd it in fears,

Night & morning with my tears:

And I sunned it with smiles,

And with soft deceitful wiles.

And it grew both day and night.

Till it bore an apple bright.

And my foe beheld it shine,

And he knew that it was mine.

And into my garden stole,

When the night had veild the pole;

In the morning glad I see;

My foe outstretched beneath the tree.

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Preparing a report about alcohol regulations

Spring 2019

Assignment 5

Due Date: Thursday April 4th, 2019

Write up a brief report analyzing your design project from an environmental and human health perspective. For example, does your proposed process fall under any of the environmental regulations discussed in class (e.g., CAA, CWA, RCRA)? If CAA, are you a major or a minor source? What, if any, technology do you plan to implement to control your emissions/discharges? If RCRA, what is your generator status?

This report should include the following sections: introduction, process overview, environmental assessment, and conclusions/recommendations. See instructor with any questions

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