Health Disparities

1
Health Disparities

• Department of Family Practice
• Michigan State University
• College of Human Medicine

2
Why Do I Need to Know This?

• Healthy People 2010 (HP 2010) overarching goals
  are to
• Increase quality and years of healthy life and
• Eliminate Health Disparities
• Medical students need to learn to recognize
  situations and issues that prevent patients from
  receiving optimal care.

3
What are Health Disparities?

• Differences in rates of
• Mortality
• Morbidity
• Incidence
• Prevalence
• Burden of disease
• Other adverse health conditions
• among specific population groups
• Peters K, Elster A. Roadmaps for Clinical
  Practice Primer on Population-Based Medicine.
  2002 AMA Press.

4
Individual Factors Causing Disparity

• Demographic (age, ethnicity/race, gender)
• Socioeconomic status (including education)
• Disabilities
• Rural home
• Cultural norms and values
• Literacy level
• Family influence
• Environmental/occupational exposures
• Patient preference for care or treatment
• Ibid.

5
Societal Factors Causing Disparity

• Uneven distribution of medical resources
• Absence of social connections and resources to
  help avoid risk and consequences of disease
• Ibid.

6
Disparities Related to Health Care Delivery

• Insurance status and availability
• Transportation/geographic barriers
• Health beliefs of patient, attitudes, level of
  confidence relate to compliance with treatment
• Racial concordance of patient and physician
• Cultural preferences
• Provider bias, racism, and discrimination
• Ibid.

7
Examples of Disparities Mortality

• Infant mortality rates higher in black, American
  Indians, than in whites
• Homicideleading cause of death in black males
  age 15-25 17x the rate of homicide in
  non-Hispanic white males
• Strokerates for Asian-American males aged 45-54
  and 55-64 are 31-40 higher than for white males
  in those age groups
• Ibid.

8
Examples of Disparities Health Behaviors

• Rate of smoking in college grads11Rate of
  smoking in individuals without a HS
  diploma32Several studies demonstrate a
  prevalence of smoking of gt 40 in the Medicaid
  population
• Suicide Girls are 80 to 90 more likely to
  consider suicide than boys, and 50 more likely
  to make an attempt requiring medical
  attention.Homosexual or bisexual youth have a
  risk of suicide of up to 4x that of heterosexual
  youth.
• Ibid.

9
Examples of Disparities Preventive Health Care

• Women with incomes below the poverty level are
  27 less likely to have mammograms when compared
  with women with incomes above the poverty level.
• Ibid.

10
Examples of Disparities Access to Care

• 28 of children with family incomes 1-1.5 times
  the poverty level are without coverage compared
  to 5 of children with family incomes at least
  twice the poverty level.
• Nearly 33 of school-age children without health
  insurance coverage have no usual source of health
  care compared with 4 of those with insurance.
• Ibid.

11
Role of Cultural Competence

• Allows healthcare providers to acquire and use
  knowledge of
• health beliefs
• attitudes
• practices
• communication methods of patients
• to improve health care delivery.From Cross,
  et al 1989 Mackenzie 1996, Cultural Competence
  A Journey, Bureau of Primary Health Care. Health
  Resources and Services Administration, US
  Department of Health and Human Services, n.d.

12
Population-Specific Perspectives of Cultural
Competence

• Socioeconomic perspective (health-related beliefs
  and cultural values)
• Epidemiologic perspective (prevalence of disease
  in different populations)
• Outcome perspective (efficacy of treatment)Ibid.

13
Cultural Competence

• It is inappropriate to implement stereotypes for
  any population group.
• Physicians must be aware of and confront their
  own biases in order to practice in a culturally
  competent fashion.
• No matter how conscientious we are, we cannot
  entirely eliminate our own biases and prejudices.

14
Exploring Health Beliefs

• Discuss with patient what he or she believes is
  causing a particular condition, what would make
  it better
• Ask about family health beliefs and home
  remedies, role of traditional healers

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Considerations That May Be Determined By Cultural
Background

• Who makes health care decisionsthe patient,
  spouse, family?
• Who is the head of household, and how is that
  determined?
• Is the patient responsible for his/her own
  destiny, or is destiny predetermined?

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Encouraging Treatment Adherence

• Incorporate the patients health beliefs into
  your recommendation. Negotiate options that are
  mutually acceptable.
• Ask the patient what kind of treatment he/she
  expects from you.

17
One Great Reference for Cultural Competence and
Patient Care

• http//erc.msh.org/
• Click on Providers Guide to Quality and Culture

18
Language Barriers

• All recipients of federal funds (i.e. Medicare,
  Medicaid) must provide language access services
  at no charge to the patient.
• This is part of the Civil Rights Act (Title VI)
  and Executive Order 13166 (signed in 2000).

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Value of Interpreters

• Fewer hospital admissions
• Better patient satisfaction
• Fewer unnecessary tests ordered
• Less misdiagnosis and improper treatment
• Flores G, Rabke-Varani J, Pine W, Sabbarwal A.
  Pediatr Emerg Care. 200218271-284.
• Hampers LC, McNulty JE. Arch Pediatr Adoles Med.
  20021561106-1113.
• Meunch J, Verdieck A, Lopez-Vasquez A, Newell M.
  J Am Board Fam Pract. 20011446-50.

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Choosing an Interpreter The Ideal

• Use a professionally trained interpreter if
  possible and allowable by the patient (Evidence
  Level C). Use of a family member may lead to
  withholding of information by patient or
  interpreter based on cultural norms, or
  misunderstanding of medical information.

21
Choosing an Interpreter

• Avoid using bilingual personnel if they have not
  had professional training as an
  interpreter.(Evidence Grade C)
• Be sensitive to privacy rights

22
Using Interpreters

• Look at the patient and not at the interpreter
  during discussions. (Evidence Grade C)
• Ask questions in the second person, e.g. Where
  is your pain? (Evidence Grade C)
• Avoid medical jargon and technical terms
  (Evidence Grade C)
• Encourage the interpreter to use verbatim terms
  from you and the patient.
• Use reflective listening with the patient (have
  them repeat directions back in their own words).
• Watch patients nonverbal communication, e.g.
  body language, facial expression (Evidence Grade
  C)
• From Evidence-based protocol. Interpreter
  facilitation for persons with limited English
  proficiency.   University of Iowa Gerontological
  Nursing Interventions Research Center, Research
  Dissemination Core - Academic Institution.  2001
  Apr

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When There is No Interpreter

• Asking open-ended questions (e.g. Tell me about
  your knee pain. is MORE accurate than asking
  yes/no questions.
• Ask only one question at a time.
• Be aware that different cultures may use
  different non-verbal communication (e.g. Chinese
  may smile when unhappy, OK sign we use may be
  interpreted as vulgar or as meaningless in some
  cultures)
• Try not to use gestures, as different gestures
  mean different things in different cultures.