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Cultural Diversity in Healthcare

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					Cultural Diversity in
Healthcare




    Nereida Correa M.D.
    February 26, 2004
    Women’s Healthcare
    Network-Iona College
Objectives

Provide background information on need
 for cultural competency training to care
 for diverse communities
Give demographics of the disparities
Illustrate programs attempting to
 inculcate cultural sensitivity into education
 and practice
Explore potential activities to move
 forward
Cultural Competency

Defined as a set of congruent practice
 skills, behaviors, attitudes and policies
 that come together in a system, agency or
 among providers and professionals that
 enables that system, agency, or
 professionals to work effectively in cross-
 cultural situations.
Cross TL, Bazron BJ, et al. Towards a Culturally Competent System of Care. CASSP Technical Assistance Center,
Georgetown University Child Development Center, March 1989
Title VI-Civil Rights Act

“No person in the United States shall, on
 the ground of race, color, or national
 origin, be excluded from participation in,
 be denied the benefits of, or be subjected
 to discrimination under any program or
 activity receiving Federal financial
 assistance.”
CLAS Standards

Office of Minority Health of the US
 Department of Health and Human
 Services developed and recommends
 national standards for culturally and
 linguistically appropriate services in health
 care
Current requirement for all recipients of
 Federal funds
CLAS Standards

Standard 8 states that health care
 organizations should have a strategic plan
 that outlines goals, policies, operational
 plans and oversight mechanisms to
 provide culturally and linguistically
 appropriate services
 Institute of Medicine:
Among 13,000 heart patients for every 100
 whites who had a procedure to clear the heart
 arteries, only 74 blacks did
Of 15,578 urban ER patients blacks were 1.5
 times more likely to be denied authorization by
 managed care providers
Differences exist even when insurance, income,
 age, and the severity of the disease are the
 same for both groups
  National Leadership
  Summit-Minority Health

Eliminating Racial and Ethnic Disparities in
 Health by:
  broadening scientific research and data
  increasing awareness of the issues
  establishing partnerships to mobilize
   communities and stakeholders
  developing and enforcing policies and laws
  ensuring access to health care
 Institute of Medicine:
Recommendations include:
  Changing health insurance programs to reduce
   disparities
  Recruiting more minorities into health care
  Expanding patient education
  Enforcement of discrimination laws
  Programs to increase awareness among providers
Diverse Communities,
Common Concerns

Despite being younger African-Americans
 and Hispanics are less likely to consider
 themselves in good or excellent health
Communication between patient and
 physician more problematic; feel their
 doctor did not listen, did not fully
 understand, had questions but did not ask

 Collins KS, Hughes DL, etal. Commonwealth Fund, 2001 Health Care Survey
US POPULATION

1998              PROJECTED 2030
WHITE 72%         WHITE 60%
BLACK 12%         BLACK 13%
HISPANIC 11%      HISPANIC 19%
ASIAN 4%          ASIAN 7%
NATIVE AMERICAN   NATIVE AMERICAN
 1%                 1%
 Births and Deaths US by
 Race/Ethnicity: CDC Data
                Deaths ‟99         Births „00
Non-Hispanic
  White        1,953,197          2,362,968
  Black          281,979            604,346
Hispanic
  Puerto Rican     13,909            58,124
  Mexican          57,425           581,914
  Cuban            11,209            13,429
  Other Hispanic         21,377            162,400
Hispanic Women

Median age: 26
Education: 45% < high school
Life expectancy: 77 yrs vs. 79 for White
 and 74 for Non Hispanic Black
Birth rate: Highest in US
Comprise 56% if Hispanic labor force
Lowest paid: 46% , 10,000/yr; 30% head
 of household
Most likely to be uninsured
Access to Health Care for
Women

Health insurance often pregnancy related and
 reverts to uninsured status following delivery
Less than 35% of women return for post partum
 care
Health problems identified in prenatal care are
 lost to follow-up
Less than 5% physicians of color with 3.1% of
 entrants to medical school of Hispanic origin
DISPARITIES:POVERTY


 35

 30
 25
                           WHITE
 20                        BLACK
 15                        HISPANIC
                           ASIAN
 10                        ALL
 5
 0
      1990   1995   1997
DISPARITIES:INCOME

 50
 45
 40
 35
                     WHITE
 30
                     BLACK
 25
                     HISPANIC
 20
                     ASIAN
 15
                     ALL
 10
  5
  0
      1997
                                                                              DRAFT
Uninsured Children and Women                                                  1-07-02
United States, 2000 and 2001

          Percent
     20          18.3                  18.7


     15
                                                          12.3         12.1

     10


      5


      0
                2000        2001                          2000         2001
                Women Ages 15-44                         Children < Age 19

Source: Bureau of the Census
Prepared by March of Dimes Perinatal Data Center, 2003
DISPARITIES:EDUCATION
  45
  40
  35
  30
  25
  20                                        WHITE
  15                                        BLACK
  10                                        HISPANIC
   5                                        ALL
   0
              HS GRAD



                        COLLEGE


                                  COLLEGE
       < HS




                                   GRAD
DISPARITIES:LIFE
EXPECTANCY

MEN
74 WHITE VS 66 BLACK

WOMEN:
80 WHITE VS 74 BLACK

6-8 year DECREASE
MMC:
PER 1000 LIVE
BIRTH




       TEEN PREGNANCY RATES
       120

       100
                              TOTAL
       80
                              WHITE
       60                     BLACK
                              HISPANIC
       40                     ASIAN
                              NATIVE AMERICAN
       20

        0
                1990   1997
INFANT MORTALITY

 20
 18                 WHITE
 16
 14                 BLACK
 12
 10                 HISPANIC
  8
  6                 ASIAN
  4
                    NATIVE
  2
                    AMENRICAN
  0
      1983   1996
LOW BIRTH WEIGHT

14

12

10                 ALL
                   WHITE
 8                 BLACK
 6                 HISPANIC
                   ASIAN
 4                 NATIVE AMERICAN
 2

 0
Low Birth Weight

Rate Low birth weight
  5.3% White US Born
  15% Black US Born
  11% Black Immigrant
  8.6% PR US Born
  8.0% PR Immigrant
  5.9% Mexican US Born
  4.8% Mexican Immigrant
Rate Prematurity
  15% Black, 12 % PR

Cervantes, A, et.al, MCHJ, Vol 3, No 2, 1999
                                                                                              DRAFT
Preterm Births by Race/Ethnicity                                                              1-07-02
United States, 2001

          Percent
    20
               17.5

    15                         13.2
                                                12.1                 11
                                                                            10.3
    10
                                                                                        7.6

     5


     0
             Black          Native  Hispanic                   White       Asian/      2010
                           American                                        Pacific   Objective
                                                                          Islander



Preterm is less than 37 completed weeks gestation
People of Hispanic origin may be of any race,
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2003
                                                                                 DRAFT
Preterm Births                                                                   1-07-02
United States, 1981-2001

          Percent
    14
                                                                 11.9
    12                                    10.8
                   9.4
    10
                                                                           7.6
     8

     6

     4

     2

     0
                 1981                    1991                   2001      2010
                                                                        Objective
                             27 Percent Increase

Preterm is less than 37 completed weeks gestation
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2003
Low Birth Weight and
Access to Health Care

Vasquez Calsada compared availability of
 prenatal care with birth outcomes in
 Puerto Rico and found that low birth
 weight and infant mortality were related
 to lack of access to prenatal care
Sheriden reported positive birth outcomes
 with access to prenatal care

Vasquez Calsada, et.al., Prenatal Care, Vol 8, No 3, 1989
Sheriden, MS, Barrera RE, Journal of Med Systems, 20:5, 1996
CAUSE OF DEATH:WOMEN
        White       Black     Hispanic


1-4     Accident/ Accident/ Accident/
        congenital homicide congenital
15-24   Accidents/ Accidents/ Accidents/
        suicide    homicide homicide
25-44   Cancer/     HIV/      Cancer/
        accidents   cancer    HIV
CAUSE OF DEATH:MEN

ALL     WHITE        BLACK       HISPANI
1-4     Accident/    Accident/   Accident/
        congenital   homicide    congenital
5-14    Accident/    Accident/   Accident/
        cancer       homicide    cancer
15-24   Accidents/   Homicide/   Accidents/
        suicide      accidents   homicide
25-44   Accidents/   HIV/        Accidents/
        suicide      homicide    HIV
HEALTH DISPARITIES

Accidents and Homicide
HIV infection
Morbidity: Injury from gun violence
High Risk Behaviors : Smoking Alcohol
 and Illicit Drug Use
Domestic Violence
Heart Disease and Diabetes
Cancer
Health Issues:
Cardiovascular


Cardiovascular- death rate from heart
 attack 30% higher in African Americans
Heart attacks declined by 29% in whites
 vs 21 % for African Americans
Death rates from stroke were 40% higher
 in African American adults

HHS Disparities Initiative, 9/24/2002
Health Issues: Diabetes
Diabetes is 2 times higher in African
 Americans and 1.9 times higher in
 Hispanics
Overweight and obesity are higher in all
 ethnic minorities
Native Americans have 2.6 times the rate
 of Diabetes and Pima Natives of Arizona
 have the highest known prevalence in the
 world
 National Center for Health Statistics, 2002
Violence

Rape: 41% women of color report being
 raped
In most cases the perpetrator is an
 acquaintance
Women are 7 times more likely to be
 victims of a crime or homicide committed
 by an intimate partner

 National Institute of Justice Data, 2000
HIV Infection

CDC reported 10,459 AIDS cases among
 women age 13 and older
Major exposure categories: heterosexual
 contact and injected drugs
African-American women largest group,
 Hispanic women second
December 2000: majority AIDS cases 25-
 44 age group
HIV/AIDS

HIV/AIDS- 28% of US population in 2001,
 African Americans and Hispanics are 66%
 of adult AIDS cases and nearly 82% of
 pediatric AIDS cases
75% and 81% respectively in 2000
Death from HIV declined 32% in whites,
 and increased by 13-22% in other groups
Disparities:
Syphilis/Hepatitis

Cases of primary and secondary syphilis in
 1999 with 30 times greater rate in African
 Americans
Asian Americans represent 50% of those
 infected with Hepatitis B
Minority teens with higher incidence of
 Hepatitis B and C
AAP, Committee on Infectious Disease, 2000
National Center for HIV, STD, and TB Prevention
DISPARITIES: Tuberculosis

Of all tuberculosis cases reported in 1991-
 2001 80% were in racial and ethnic
 minorities
Tuberculosis increased by 51% for Asian
 Americans and 30% for Hispanics
Asian Americans and Pacific Islanders, 4%
 of the US population had 22% of the
 cases
NCHSTP Division of TB Elimination
Immunizations
48% African American and 56% Hispanic
 receive influenza vaccine compared to
 67% Whites
31% of African American and 30% of
 Hispanics receive pneumococcal vaccine
 compared to 57% Whites
In 2001 African Americans and Hispanic
 aged 65 and older were less likely to
 report having received vaccination
Morbidity and Mortality Weekly, 2002
Disparities: Mental Health

Native Americans disproportionate rate of
 depression and substance abuse
Minorities have less access to mental
 health services and receive poorer quality
 services
Under-represented in mental health
 research

 National Center for Health Statistics, 2002
Cancer Screening and
Management

African American women are twice as
 likely to die of cervical cancer, a
 preventable disease with routine
 screening
Breast Cancer increased 3.9% for African
 Americans and they are more likely to die
 of breast cancer than any other racial or
 ethnic group
National Center for Health Statistics (NCHS), Health US, 2002
Cervical Cancer

Ethnic specific age-adjusted rate for invasive
 cervical cancer is 18.5 Hispanic vs. 7.6 Non
 Hispanic Whites in California (19.4 in NY)
Spanish language isolation associated with
 higher risk of diagnosis at invasive stage
Lower acculturation a risk of less frequent PAP
 screening
Less education and lower socioeconomic status,
 living in “disadvantaged” areas

Howe, et.al., Stages at diagnosis of cervical cancer among
Cervical Cancer

Women‟s Health Loteria as a cervical
 cancer education tool targeted at
 decreasing cervical cancer mortality by
 increased screening of Hispanics in Texas
 in a culturally sensitive approach
Culturally specific game format used with
 bilingual counselors to evaluate if women
 understood the risk factors
Sheridan-Leos S, Onc Nursing Forum, 22:4, 1995
Cancer Screening

Suarez studied cancer screening vis a vis social
 integration in four US Hispanic groups in Texas,
 California, Florida, and New York
Aim was to improve behavior related to cancer
 screening, cigarette smoking and nutrition
Found that social support was a factor to all
 except Puerto Rican women



 Suarez I, Am J of Prev Med, 19, 2000
Cancer Screening

Por La Vida screening program using
 natural helpers in the community
 increased the rate in the study group in
 regard to mammography services
Used existing social networks in a
 culturally sensitive and community
 oriented method

Navarro AM, Am J Prev Med, 15. 1998
HEALTHY PEOPLE 2010

Plan to eliminate disparities in health care
 provision and in health outcomes by 2010
Addresses highly preventable conditions
Requires participation by health care
 providers to be successful
Includes issues of cultural and linguistic
 competence in access to care
Minority Health Initiatives

Closing the Gap-Nov 2001 Health
 Education and Information campaign for
 communities of color
Racial and Ethnic Adult Disparities in
 Immunization Initiative (READII)-July
 2002-to promote adult immunizations
 especially pneumoccocal and influenza
 vaccines in elderly of color
   CULTURAL COMPETENCE
Culturally appropriate, community-driven
 programs are critical
Promote cultural awareness
Encourage cultural competence inclusion in
 medical school and health careers curriculum
Advocate for the needs of the patients by
 providing translators, culturally competent
 information and instructions in simple language
Changes in Curriculum:
Lincoln Experience

Office of Graduate Medical Education
 developed a curriculum designed to foster
 inclusion of cultural competency education
 in all residency program in the institution
Experts gave a series of lectures and
 case-based modules designed to train
 faculty in all the disciplines
Cross-Cultural Aspects

Diversity in medical staff and nursing
 personnel recognized and addressed
Diversity in patient population integrated
 in curriculum
System within the culture of medicine and
 the institution recognized and addressed
Methods and Results

Two conference held to provide a base of
 information to all residents and attendings in all
 disciplines with residency programs
Two consecutive train-the-trainer sessions with
 2-3 representative from each department
Three sessions given in each department by
 June 2003 with support from trainers
On-going integration in the curricula at all levels
 Albert Einstein Experience
Inclusion of introductory lectures in the first
 year curriculum including access to Spanish
 course and graded experiences in the
 community
Second year lectures and workshops; case-
 based discussions in physical diagnosis and
 interviewing; Spanish with a community
 physician and as part of international health
 rotations
 Albert Einstein Experience
Inclusion in didactic lectures in third year
 clerkships in family medicine, OB/GYN,
 and pediatrics
Opportunities for community based
 research and student run clinic within the
 community
Cultural “brokering” as a concept
 CULTURAL COMPETENCE
Encourage recruitment, admission and retention
 of persons of color into the health professions
Foster mentorships for young people to help
 them remain in school and work towards a goal
Support other physicians and health workers of
 color in attaining their goals
Cultural Humility

Training outcomes that incorporate a
 lifelong commitment to to self-evaluation
 and critique
Redress of power imbalances in the
 physician-patient relationship
Partnerships with communities on behalf
 of individuals and defined populations

 Tervalon M, Murray-Garcia J. Cultural Humility Versus Cultural Competence, Journal of Health Care
 for the Poor an Underserved, Vol 9, No 2, 1998
Challenges

Increase the number of culturally
 competent providers
Linguistic competency
Mentor young people into health careers:
 recruitment and promotion
Inclusion of minorities in research
Improve the health of our communities
Healthcare partnerships and collaboration

				
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