Susan C. Scrimshaw, Ph.D. Dean

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Cultural Competency and Health Literacy
Educational Imperatives
Susan C. Scrimshaw, Ph.D.Dean School of Public
HealthUniversity of Illinois at Chicago
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Health Disparities
Differences in rates (likelihood) of disease,
severity of disease or disease outcomes between
populations or groups.
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Health Disparities must be seen in terms of
Outcomes (rates) Causes Interventions to
prevent and treat Opportunities to promote health
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This Talk Will Cover

• Definition of health disparities
• Underlying factors influencing health disparities
• Measurement and definition of ethnicity, culture
  and cultural competence
• The importance of health literacy
• The roles of communities

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Evidence for Health Disparities

• Summarized in several IOM/NAS Reports e.g.
• The Unequal Burden of Cancer 1999
• Speaking of Health 2002

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IOM/NAS Reports, continued

• Safety is Seguridad 2003
• Unequal Treatment 2003

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Evidence for Health Disparities HHS

• National Healthcare Quality Report
• 2003
• National Healthcare Disparities Report 2003

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What Underlies Health Disparities?

• Disparate access to prevention and treatment
  services broadly defined
• Differences in patterns of utilization of
  services
• Differences in behaviors in response to illness
• Different environmental and occupational risks

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Green et al New England Journal of Medicine Vol.
344 June 28, 2001 16.
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What Underlies Health Disparities?

• Differences in health promotion and disease
  prevention behaviors
• Differences in community factors such as stress,
  societal support, community cohesion
• Genetic factors come into play for individuals,
  but seldom for groups

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Guide to Community Preventive Services
Sociocultural Environment Logic Framework
Health Outcome
Intermediate Outcomes
Determinants
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2
HEALTHIERCOMMUNITIES
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4
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SOCIETAL RESOURCES concerns the presence of
essential resources while EQUITY and SOCIAL
JUSTICE concerns the distribution of those
resources within the population.
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HEALTHYPOPULATION
A pathway that will not be examined.
Links 1-6 indicate strategic points for
intervention.
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CDC Guide

• http//www.thecommunityguide.org/
• Anderson, L.M., S.C. Scrimshaw, M.T. Fullilove,
  J.E. Fielding, and Task Force on Community
  Preventive Services. The Community Guides Model
  for Linking the Social Environment to Health.
  American Journal of Preventive Medicine.
  24(3S)12-20, April, 2003.

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Six Risk Behaviors Are Related to the Largest
Burden of Disease

• Tobacco Use
• Alcohol Abuse and Misuse
• Other Substance Abuse
• Nutrition
• Physical Activity
• Sexual Behavior

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What About Culture/Ethnicity?
IOM Report Speaking of Health NAS Press 2002
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Culture
Shared ideas, meanings, values Socially
learned, not genetically transmitted Patterns
of behavior guided by shared ideas, meanings,
values Constantly being modified through lived
experiences Often exists at an unconscious
level
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Ethnicity
Ethnicity implies some sharing of lived
experience and learned traditions, including
meanings and values.
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Diversity
Diversity in the U.S. is culturally and socially
constructed.
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1977 OMB Directive
This directive provides standard classification
for record keeping, collection, and preservation
of data on race and ethnicity in Federal program
administrative reporting and statistical
activities. These classifications should not be
interpreted as being scientific or
anthropological in nature, nor should they be
viewed as determinants of eligibility for
participation in any Federal program.
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Paleontologist Stephen Jay Gould states
races arent definable, and even if definable,
not very well defined. Racial variation is the
original geographic variation of the species that
spread, presumably from an African center, all
over the world....when you measure the actual
genetic differences among people, theyre
astonishingly small.
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Anthropologist Alan Goodman adds
Because race and racism are sociopolitical
realities, they affect individual biologies.
Understanding this presents a new and radical
biocultural agenda. The continuance of race and
ethnic differences in health calls for an
explication of the biology of inequality and
racism. Goodman (200131)
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Thus, the fact that race is not a valid concept
for scientific measurement does not negate the
fact that racism exists, and shapes how people
are seen, defined and treated.
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Cultural Processes Lived Experiences
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Culture and Meaning
The definitions and meanings of health and
illness are shaped by our cultural experiences
(e.g. male/female differences in illness
definition in different cultures, including
Western biomedicine)
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Cultural Competency

• understanding, appreciation, and respect for
  cultural differences and similarities within,
  among and between groups
• behaviors, attitudes, and policies which ensure
  that a system, agency, program, or individual can
  function effectively and appropriately in diverse
  cultural interactions and settings
• 
  (adapted from DHHS, HRSA)

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Why Look at Behavior?

• Health behaviors are continually changing
• Health behaviors are a key factor in many health
  outcomes
• Roughly half of the underlying causes of death in
  the U.S. are behavioral in origin
• McGinnis, J.M. and Foege, W.H. Actual Causes of
  Death in the United States. Journal of the
  American Medical Association 270 (1993) 2207-2212

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Culture and Behavior
Health behavior is in the fabric of our cultures,
but varies by ethnicity, cultural processes and
lived experiences
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Cultural Competency must recognize health behavior

• Therefore, cultural competency must include
  understanding and appreciation of health beliefs
  and behaviors in their cultural contexts, and
  respectful strategies to negotiate optimum health
  in the context of these beliefs and behaviors.

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Health Literacy
The degree to which individuals have the
capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions. (Ratzan and
Parker, 2000, Healthy People 2010, HHS)
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Institute of Medicine Committee on Health
Literacy

• David Kindig, M.D.
• Committee Chair
• Lynn Nielsen-Bohlman, Ph.D.
• Study Director
• Institute of Medicine
• Washington, DC

www.iom.edu/healthliteracy
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90 million American adults may lack the needed
literacy skills to effectively use the U.S.
health system. (literacy skills below the High
School level) Estimated from 1992 National Adult
Literacy Survey
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Anyone can misunderstand health communications

• Health literacy is about more than literacy
  levels for individuals-it is about how health
  care providers communicate and about peoples
  understanding of health concepts, regardless of
  literacy or educational levels.

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Meaning

• Medical vs. lay terminology
• Concepts E.G. Weight, moderate
• Meanings Risk-riesgo, peligro etc.
• Language the meaning of trauma

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Communication Affects

• Understanding of patient concerns, complaints
• Patient understanding of treatment, diagnosis,
  follow up to care needs
• Overall quality of care
• Patient and provider satisfaction

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Miscommunication Risks Exist for

• Ethnicity/culture (not just language)
• Language
• Gender
• Age (younger, elderly)
• Economic Status
• Social class
• Blind
• Deaf, hard of hearing

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• The fundamental key to improved health literacy
  is
• Clear communication

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How Do We Find Out What People Are Thinking?
Individual interviews and conversations Focus
groups Observation/participant observation
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Community Involvement

• Cultural competence in improving health must
  include community participation in planning,
  education of health professionals, and in the
  carrying out of programs.
• CDPHs Chicago Center for Community Partnerships
  provides a model
• To do this well means sharing power

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Meaning Centered Approach to Clinical Practice
(Good and Good 1981)
Primary Principles

• Groups vary in the specificity of their medical
  complaints.
• Groups vary in their style of medical
  complaining.
• Groups vary in the nature of their anxiety about
  the meaning of symptoms.
• Groups vary in their focus on organ systems.
• Groups vary in their response to therapeutic
  strategies.
• Human illness is fundamentally semantic or
  meaningful.
• (It may have a biological base, but is a human
  experience).

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Meaning Centered Approach to Clinical Practice
Corollary - Clinical practice is inherently
interpretive.
Actions

• Practitioners must
• Elicit patients requests, etc.
• Elicit and decode patients semantic networks
• Distinguish disease and illness and develop plans
  for managing problems.
• Elicit explanatory modes of patients and
  families, analyze conflict with biomedical model
  and negotiate alternatives.

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Actions
Understand the difference between language and
culture and address both Work with individuals
and families to define problems and develop
solutions
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Actions
Work with community and advocacy groups to define
problems, develop solutions (e.g.
www.savethepatient.org)
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Summary Causes

• Need to measure effects of the social, cultural
  and physical environment
• Need to measure factors such as access to care,
  utilization, occupational risks, health behaviors

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Summary Interventions

• Interventions must take complexity and multiple
  causes into account
• Interventions must take culture and behavior into
  account
• Interventions must include community
  participation at all phases

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The Educational Imperative

• All health professionals must learn cultural
  competency, including understanding health
  behavior, clear communication and community
  involvement
• This requires radical changes to initial health
  professions education as well as to continuing
  education and in-service training.

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Guide to Community Preventive Services
Sociocultural Environment Logic Framework
Health Outcome
Intermediate Outcomes
Determinants
1
2
HEALTHIERCOMMUNITIES
3
4
5
SOCIETAL RESOURCES concerns the presence of
essential resources while EQUITY and SOCIAL
JUSTICE concerns the distribution of those
resources within the population.
6
HEALTHYPOPULATION
A pathway that will not be examined.
Links 1-6 indicate strategic points for
intervention.
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Susan C. Scrimshaw, PhDDean
School of Public Health (MC 923)1603 West Taylor
StreetChicago, Illinois 60612-4394(312)
413-6620(312) 996-1374 faxE-mail
Scrimsha_at_uic.edu
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Cultural Competence

• Cultural competence in health care describes
  the ability of systems to provide care to
  patients with diverse values, beliefs and
  behaviors, including tailoring delivery to meet
  patients social, cultural, and linguistic needs
  (Betancourt et al., 2002).

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Explanations of Disease Causation
Insider view Outsider view
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Disease vs. Illness
Disease Undesirable deviation from a measurable
norm Illness Not feeling well