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The Immunity Hypothesis

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					The Immunity Hypothesis: Using Cultural Competence to Eliminate Disparities in Mental Health Services
December 13, 2003

King Davis, PhD, Executive Director
Hogg Foundation for Mental Health Services, Research, Policy & Education Robert Lee Sutherland Chair in Mental Health & Social Policy School of Social Work

The University of Texas at Austin
Austin, Texas

The Immunity Hypothesis


“Slaves are immune from stress and from the subsequent risk of mental illness because they do not own property.”



John Galt, M.D.(1840)

Purpose of the Presentation
Conceptualize the term disparities  Place disparities in context  Link various types of disparities  Define key terms  Link disparities and cultural competence  Identify key causative variables  Relate to New Freedom Commission  Get out alive!
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Foci of the Presentation
Disparities have an extensive history  Disparities are related to a perverse conceptualization of people of color  This conceptualization pervaded clinical practice, research, education & policy  Disparities are imbedded in differences in income, access to information, and cultural traditions & social structures
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Four Critical Realities
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Universities, professional schools, and professional associations are responsible for the level of knowledge, skills, theory, and clinical practice that is applied to people of color. Cultural competency is not an acceptable approach in the majority of university based education programs. Most people of color seek help first from religious organizations. Collaboration/cooperation between religious organizations and behavioral health is minimal.

Conceptualizing Disparities
 Prevalence  Incidence  Services  Treatment  Prevention  Recovery

Rehabilitation Participation Outcomes Acceptable Norms Personal Choice Racial causation

King Davis, 2003

Service Disparities
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Racial, ethnic, and cultural differences in twenty characteristics designed to define and describe the nature of behavioral health service provision
Source: K. Davis (2003)

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Service Disparities 1760-2000
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>Frequency of Inaccurate Diagnosis

             

>Findings of Severe Mental Disorder >Inpatient Hospitalization/LOS >Involuntary Commitments >Recividism/Relapse >Involvement in Criminal Justice System >Mortality Rates (Primary Health Problems & Suicide) <Recovery >Uninsured/Underinsured <Access to Outpatient/Early Access <Access to Providers of Color <Utilization of Cultural Competency in Service Design <Participation in Behavioral Health Volunteer Organizations <Access to Information about Behavioral Disorder/Services <Family Support

Service Disparities
>Delays in help seeking  <Housing alternatives  <Access to trained interpreters  <Inclusion in research/clinical trials  >Executions while mentally disabled  <Integrated behavioral health services
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DISPARITIES IN MENTAL HEALTH CARE FOR RACIAL AND ETHNIC MINORITIES

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Minorities have less access to, and availability of, mental health services Minorities are less likely to receive needed mental health services Minorities in treatment often receive a poorer quality of mental health care Minorities are underrepresented in mental health research
Mental Health: Culture, Race, and Ethnicity, a Supplement to the Surgeon General’s Report on Mental Health

Expanded View of Disparities
Economic Dental Health

Political/ Legal
Mental Health Employment

Health Educational

King Davis, 2003

Substance

Uninsured

Literacy

Nutrition

Maternal/ Infant Deaths Low Birth Weight Babies

Crime Victims

Criminal Justice

Sentencing
Political Office

Sickle Diabetes Cell

Housing & Homelessness

Voting

HIV
Alcohol Abuse

Cardiovascular Periodontal Disease Disease

Asset Accumulation
Environmental Pollution

Cancer

Obesity
Mental Retardation

Low Graduation Income Rates Homicides

Cocaine Use/Sale

Domestic Violence

DepressionSchizophrenia
Personality Disorder
Dementia

Bipolar Capital Punishment

Unemployment
King Davis, 2003

Causes of Disparities
Societal policies: race, gender, income  Focus/content of professional education  Focus /content of research  Service design and implementation  Cultural traditions: beliefs/help seeking  Dissemination of information  Bundling health care to employment
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Removal of Disparities
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Recent efforts at the federal (Clinton 1994) presidential level are designed to eliminate disparities in health and mental health by 2010; President Bush (2003) has included this goal in the recent report on mental health Bush identifies cultural competence as the vehicle for eliminating disparities in mental health

A transformed system: Recovery
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To achieve the promise of community living for everyone, new service delivery patterns and incentives must ensure that every American has easy and continuous access to the most current treatments and best support services
Source: New Freedom Commission

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Six Critical Goals
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Americans understand that mental health is essential to overall health Mental health is consumer and family driven Disparities in mental health are eliminated Early intervention is common Excellent care is delivered and research is accelerated Technology is used to access mental health care and information
Source: New Freedom Commission

Disparities in Mental Health Services are Eliminated
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In a transformed mental health system, all Americans will share equally in the best available services and outcomes, regardless of race, gender, ethnicity, or geographic location.
Source: New Freedom Commission

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Recommendations:
Improve access to quality care that is culturally competent  Improve access to quality care in rural and geographically remote areas
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Source: New Freedom Commission

Primary Strategy:
How to develop & implement?  What are the key strategies?  What are the critical challenges?
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State Mental Health Plan
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The Challenge of Reform:

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Help seeking

Health Insurance Voluntary Participation
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System

Reform

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Disproportionate Poverty

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General Fund Pressure

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State Policy Reform

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Service Redesign: EBP

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Private
Sector State Government
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Human Resources
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Federal Government

The Immunity Hypothesis


“Slaves are immune from stress and from the subsequent risk of mental illness because they do not own property.”



John Galt, M.D.(1840)

Contextual Hypotheses
Immunity Hypothesis 1763-1865  Exaggerated Risk Hypothesis -18651980  No-difference Hypothesis 1981-1990s  _____________________  Immunity Hypothesis Recycled 2001  Exaggerated Risk Hypothesis Recycled 2001  No-difference Hypothesis Recycled 2001
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Historical Hypotheses

Historical Hypotheses - Continued

Multiple Costs
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Excess Preventable Deaths Untreated Illness & Lower Lifetime Achievement Excess Hospital Admissions & Readmissions Misdiagnosis & Inappropriate Care (LLOS) Community Suspicion and Mistrust Staff Division and Conflict Absence of Scientific Knowledge & Theory Ethical Conflict: Professional & Personal Increased Taxes & Agency Budgets: Waste

Differences by Culture
Access to Services/Treatment  Increased Risk Based on Low Income  Help Seeking/Family Participation  Source of Information/Accuracy  Involuntary Admissions/Readmissions  Involvement by Police  Medication Compliance  Severity of Diagnosis/Homelessness
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Admissions per 100,000 by Race, Ethnicity & Type of Facility

Involuntary Admissions by Race & State

Need for Behavioral Health Care
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African Americans:
– Overall rates of mental illness similar to nonHispanic whites – Differences in prevalence of specific illnesses – Suicide rates lower but on the rise – Environmental, economic and social factors
 Exposure to violence, homelessness, incarceration, social welfare involvement

– Less access to behavioral health services

Need for Behavioral Health Care
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American Indians and Alaska Natives
– Limited data on prevalence of MI
 One small study with 20 year follow-up found 70% lifetime prevalence of MI  Increase rise of depression among older adults  Suicide rate 1.5xs national average with young males accounting for 2/3 of suicides  2nd decade of life has highest mortality rate  Alcohol dependence, alcohol related deaths

– Little information on service utilization patterns

Need for Behavioral Health Care
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Latinos/Hispanic Americans:
– Overall rates of MI similar to non-Hispanic whites – Higher rates of some disorders
 Anxiety-related and delinquency behaviors, depression and drug use, more common among Latino youth
 Higher rates of depression among elderly Latinos

– Culture-bound syndromes:
 Susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios

– Access to behavioral health services is limited

Need for Behavioral Health Care
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Asian Americans/Pacific Islanders
– Limited data on prevalence of MI
    Existing data suggests overall rates similar to whites Higher rates of depression, PTSD Somatic complaints of depression Culture-bound syndromes

 Lower suicide rates - except elderly women who have the highest suicide rates in U.S.

– Refugees with PTSD – Language barrier limits access to services

Basic Assumption
 Culture

is an important variable in determining how people (consumers, staff & providers) see and interpret (know) the world around them and the basis of how they make decisions.

All Health Care is Cultural
Conceptualization Diagnosis Treatment Training Research Policy Help Seeking Compliance Participation  Health Beliefs  Expectations  Employment
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Defining Cultural Competence
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Market-Based Definition Cultural competence is the integration and transformation of knowledge, information, and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques, and marketing programs that match the individual’s culture and increase the quality and appropriateness of health care and outcomes (Davis, 1997).

Defining Cultural Competence
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Cultural competence is the conclusion reached and shared by members of a nation, community, group, organization, business, or a board that constitutes how the individual wants to be treated with respect by others based on their culture (T.Davis, 2002)

Status of Cultural Knowledge:


The Clinical Application of Cultural Competency is Relative
Non English Speaking Native Americans African Americans Mexican Americans Anglo Americans

Lowest Income

Asian/ Mexican Pacific Immigrants Islanders & Indian/Pakistani

Middle Income

Men

Lowest

Highest

Elements of Cultural Competence
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Attitudes of respect Agency Evaluation Beliefs Agency Plan Knowledge and Skills Inclusion in Vision Language and Communication Community Analysis Inclusion in Services Valuing Diversity Outcomes Cultural Self-Assessment Staffing

Potential Benefits of Cultural Competence

Applying Cultural Competence

Applying Cultural Competence
Governing Executive Senior Staff Board Director

Line Staff

Policies Consumers

Vision

Mission Budget Goals

Work Feedback Work Plans Plans Input Implementation Supervision Strategic Plan Budget Initiatives

Cultural Competence Plan

Figure 1. Conceptual Framework
C. Individual & Community Factors

Individual

Church Organizations

D. Formal Helping System

Degree of Impairment

Practitioner: Evidence Base

Professional : Evidence Based

Family Burde n Community Stigma

Theory and Model: Recovery

Delayed Help Seeking

Consumer Self help

Self
Help

DECISIONS TO UTILIZE SOME FORM OF HELP COMMUNITIES OF COLOR
PHASE 2 PHASE 3

Religious Based Help

PHASE 1
Family Choices/Actions
King Davis, Hogg Foundation 2003
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B. Number of Psychiatric Episodes

Differential Risk Analysis
Mental Illness Poverty Retardation Substance Use Unemployment Institutionalization Suicide Uninsured

Low Risk

Medium Risk

High Risk

Severe Mental Illness

Social Marketing
Consideration and integration of social variables in the design of plans and policies in health care services Help Seeking Study Culture:
Definitions of Health/Illness Use Information

Learning Style Leadership Family Systems Outlets Media

Why is Cultural Competence Important?
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Potential Cost Savings: people & dollars a. Excess use of inpatient d. >Diagnostic error b. High rates of recidivism e. >Insurance rates c. Under-use of outpatient f. LOS Ethical Base of Professions Quality of Care Demands it Potential Improvement in Diagnosis Potential Improvement in Treatment Potential for Prevention Potential for Increasing Participation in Policy Emphasis on Recovery Congruent with Evidence Based Approach Congruent with Disease Management

Useful Techniques:
Connect Cultural Competence to Public Image  Link Cultural Competence to Public Trust  Tie Cultural Competence to Profits  Include Cultural Competence into the Training Curriculum  Show how Cultural Competence is Useful to Save Money


Useful Techniques:
Decrease the Assumption that Cultural Competence is Affirmative Action  Decrease the Assumption that Cultural Competence is About Black People  Provide Training and Education in Cultural Competence for Key Managers in the Organization and Board Members  Develop Standards and Guidelines
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Useful Techniques:
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Non-Blaming Approach Focus on Cost Savings/Marketing Framework Focus on Service Improvements/Quality/Data Acknowledge Existing Competencies Understand Resistance/Nature/Origins Recognize Weaknesses in Cultural Competence Establish a Realistic Schedule for Change Develop a Plan of Action with Education, Licensure, and Accreditation Bind Cultural Competence to Vision/Goals

Who Uses Cultural Competence?
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Coca Cola/Pepsi Cola Budweiser General Motors IBM Time Warner HMOs Disney Europe Makers of Viagra

Defense Department NCQA JCAHO Managed Health Care California DMH Texas DMHRM Virginia DMHMR

Coca Cola in the Bush

DISNEY OF EUROPE

DISNEY’S CULTURAL ISSUES
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Marketing to Europeans Pricing: Too high in Europe Alcohol: Cannot ban drinks Language: Uses six different languages Differences in Attitudes Films: Must adhere to Euro standards History: Must reflect Europe Famous Figures: Limit American stars

Disney’s Outcomes
Tenth anniversary this Year  2000 New hotel rooms under construction  Visitors will exceed 17 million this year  Profits are up  Costs are down  Food does not meet European expectations
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Resistance to Cultural Competence
New & Unfamiliar Concept  Incongruence with Prior Education  Non-traditional Source  Degree of Change Required - Education  Lack of Evidence & Tools  Not Linked to Licensure/Accreditation  Conceptualization in Black & White Terms  Potential Cost of Implementation
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New Developments
National Alliance of all Four Groups has been Formed: Non-Profit Organization, Advocacy, Policy, Training, Research, Workforce Development, Interpretation Models  Ethnic/racial behavioral health care nonprofit advocacy associations: African, Asian, First Nation, and Hispanic
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Development of Standards

Broad Change Strategies
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Address the pipeline causes/issues Support alternative education models Focus on continuing education Provide training via technology Bundle licensure and cultural competence Bundle CC with accreditation Bundle federal research support to CC Provide federal incentives for retraining Support development of model curricula CC

Personal Development Strategies
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Plan your careers and geographic moves well Build and use strong cross ethnic networks Develop new concepts and theory Conduct research and test hypotheses Publish & present findings in key journals/books Teach in universities/key academic positions Hold influential positions in profession Advocate & participate in politics Provide financial support Mentor your replacement (s) Maintain your bilingual and tri-lingual skills

General Conclusions
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Too much new information (format) to access/digest or use Transformation cannot occur fully without addressing the complex issue of disparities: knowledge, evidence, research, participation, help seeking Transformation comes at a time of significant reductions in state budgets for human services; Evidence based approaches must be expanded to include the 4 populations of color; Cultural competence offers promise but requires national field testing, cost estimation, educational trials, linkages to licensure, accreditation, and further development; Cultural competence must demonstrate outcome and cost efficacy; Poverty and related socio-economic issues will affect the application of evidence based approaches; New epidemiological studies are needed on the four populations of color to increase knowledge of help seeking and utilization.


				
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