Chapter 2 Cultural Competency

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5TH Annual Primary Care Prevention Conference
MULTICULTURAL MEDICINE AND ENSURING GOOD
HEALTH FOR ALL Rubens J. Pamies, M.D.,
FACP UNMC, Vice Chancellor for Academic
Affairs/Dean for Graduate Studies Professor of
Internal Medicine September 21-23, 2005
Wyndham Atlanta Hotel, Atlanta GA
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IOM REPORT UNEQUAL TREATMENT

• Racial and ethnic minorities tend to receive a
  lower quality of healthcare than non-minorities,
  even when access-related factor as such as
  patient insurance status and income are
  controlled. The sources of these disparities are
  complex, are rooted in historic and contemporary
  inequities, an involve many participants at many
  levels . . .

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IOM REPORT UNEQUAL TREATMENT

• The IOM study committee focused part of its
  analysis on the clinical encounter itself and
  found evidence that stereotyping, biases, and
  uncertainty on the part of healthcare providers
  can all contribute to unequal treatment.

Unequal Treatment Confronting Racial and Ethnic
Disparities in Health Care (2002), Institute of
Medicine. http//www.nap.edu/books/030908265X/html
/
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IOM REPORT UNEQUAL TREATMENT

• The Physician-Patient interaction is a
  contributing factor causing health disparities.

Recommendations Training programs should
incorporate curriculum that will help health care
providers gain the skills needed to navigate the
cross-cultural interaction.
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CURRENTLY

• Only 9 of U.S. Medical schools offers a separate
  course in the curriculum that addresses cultural
  competency
• Less than half offer course work in health
  disparities

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ISSUES THAT NEEDS TO BE INCLUDED IN
CROSS-CULTURAL CURRICULUM

• Stereotyping and bias
• Perception of health and illnesses
• Communication and language
• Knowledge of health disparities
• Understanding the role of culture in health care
• Cultural competency training

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DEMOGRAPHICS ANDIMMIGRATION
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DOCUMENTED IMMIGRATIONBy Area of Origin
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UNITED STATES CENSUS 2002
Asian 4
Asian 5
Asian 8
African American 3
African American 12
African American 14
Hispanic 13
Hispanic 14
White 69
White 53
White 67
Hispanic 25
2000
2050
2010
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AVERAGE ANNUAL RATE OF NATURAL INCREASES AND NET
IMMIGRATIONRate per 1,000 Population

• Race Natural Net
• Ethnicity Increase Immigration
• White 5.1 0.5
• Hispanic 21.2 17.1
• African American 14.8 1.6
• Asian/Pacific Islander 20.2 46.2
• American Indian 22.9

Lewit, E.M. and Baker, L.G., Race and
Ethnicity-Changes for Children The Future of
Children, Vol. 4, No. 3 Winter 1994
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DEMOGRAPHICS

• By the year 2050
• 80 million people in the U.S. will be from
  immigrant groups who came here after 1994
• They will make up 25 of the total U.S. population

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DEMOGRAPHICS

• 1 out of every 5 children under age 18 is the
  child of an immigrant.
• 75 of these children are from regions of the
  world where English is not spoken.
• The most common language spoken in these groups
  is Spanish.
• These children are disproportionately minorities,
  poor, and uninsured.

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Table 18-4 TOP 10 COUNTRIES WITH HIGHEST
PROPORTION OF MEDICAL GRADUATES IN THE UNITED
STATES
SOURCE The Educational Commission for Foreign
Medical Graduates, 1992.
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GROWTH IN MIDWESTS POPULATION BY RACIAL AND
ETHNIC GROUP U.S. CENSUS 1990 AND 2000
16

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18
FACTORS LEADING TO DISPARITIES
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HEALTH BEFORE CARE
20
HEALTH CARE DELIVERY
21
HEALTH CARE ACCESS

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Health Before Care
Patient- Provider Communication
Health Care Access
Medical Home
Insurance
Poverty
Availability of Providers
Socio- economic Status
Cultural Competency
Distrust
Proximity of Providers
What Difference Can I Make?
Appropriateness of care
Pt. adherence to tx plan
Ethnic/Racial Predilection Of Diseases
Health Literacy
Finance
Effectiveness of Care
Environmental Conditions
Lifestyle Choices
Pts Cultural Preference
Health Care Delivery
Employment
Education Level
Transportation
Provide Bias
Pt. Preference
Diversity of Workforce
Legal Barriers
Language Barriers
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HEALTHY PEOPLE 2010 GOALS

• Increase quality and years of healthy life
• Eliminate health disparities

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AGE ADJUSTED MORTALITY RATES, UNITED STATES 2000
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HIV/AIDS DEATH RATEAGEgt 13, RATES PER 100,000
POPULATION
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ADULT IMMUNIZATIONSAGE gt65, PERCENT OF POPULATION
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CANCER DEATH RATEDEATHS PER 100,000 POPULATION
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CARDIOVASCULAR DISEASE DEATH RATEDEATHS PER
100,000 POPULATION
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DIABETES-RELATED DEATH RATEDEATHS PER 100,000
POPULATION
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INFANT MORTALITYDEATHS PER 100,000 POPULATION
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
13.5
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RACIAL ETHNIC DISPARITIESLOW BIRTH WEIGHT lt
2500g
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RACIAL ETHNIC DISPARITIESVERY LOW BIRTH WEIGHT
lt1500g
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RACIAL DISPARITYPRETERM BIRTHS lt37 WEEKS
NCHS 2003
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RACIAL DISPARITY VERY PRETERM BIRTHS lt 32 WEEKS
Percent of Live Singleton Births
Year 2010 Goal
NCHS 2003
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INFANT MORTALITY FOR AFRICAN AMERICANS WHITES,
U.S. 1980-2000
NCHS
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY -
Per 1,000 Live Births
NCHS 2002
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY,
HISPANIC
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RACIAL ETHNIC DISPARITIESCAUSES OF INFANT
DEATHS - Per 1,000 Live Births
NCHS 2001
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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Why?

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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Race?

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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Race has no clear biologic or genetic basis
• Genetic diversity appears to be a continuum, with
  no clear breaks delineating racial groups.
• 
  Science 1998

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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Many birth outcomes have no clear genetic basis

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RACIAL AND ETHNIC DISPARITIESLOW BIRTH WEIGHT
NATIVITY
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RACIAL AND ETHNIC DISPARITIESLOW BIRTH WEIGHT
NATIVITY
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RACIAL AND ETHNIC DISPARITIESLOW BIRTH WEIGHT
NATIVITY
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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Behavior?

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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
CIGARETTE SMOKING
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
CIGARETTE SMOKING
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RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES

• Prenatal Care?

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RACIAL ETHNIC DISPARITIESFIRST TRIMESTER
PRENATAL CARE
NCHS 2002
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
PRENATAL CARE
NCHS 2002
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
PRENATAL CARE
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RACIAL AND ETHNIC DISPARITIESBIRTH OUTCOMES

• SES?

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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
EDUCATION
NCHS 2002
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RACIAL ETHNIC DISPARITIESINFANT MORTALITY
EDUCATION
NCHS 2002
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RACIAL AND ETHNICDISPARITIES BIRTH OUTCOMES

• Stress?

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RACIAL ETHNIC DISPARITIESSTRESS AND CRH IN
PREGNANCY
Hobel 1998
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STRESS AND PRETERM BIRTH
Money
Preterm Birth
Work
Stress
Low Birth Weight
Relations
Intrauterine Growth Retardation
Health
Infant Mortality
Abuse
Safety
Racism
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STRESS AND PRETERM BIRTH
Money
Preterm Birth
Work
Stress
Low Birth Weight
Relations
Intrauterine Growth Retardation
Health
Infant Mortality
Abuse
Safety
Racism
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RACIAL AND ETHNIC DISPARITIESLOW BIRTH WEIGHT
RACISM
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RACIAL AND ETHNIC DISPARITIESCULTURE AND RACISM

• While it is true that other US racial and ethnic
  minorities have suffered economic and social
  discrimination, few, if any, have faced these
  exposures for as long as have African Americans,
  nor have they faced them standing on an economic
  and cultural base that was systematically
  undermined by the larger society.

James (1993)
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LIFE COURSE PERSPECTIVE
White
Poor Nutrition, Stress Abuse, Tobacco, Alcohol,
Drugs, Poverty Lack of Access to Health
Care Exposure to Toxins
African American
Poor Birth Outcome
Puberty
Pregnancy
0
5
Age
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ALLOSTASIS
McEwen 1998
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STRESS AND ALLOSTASTIC LOAD
McEwen 1998
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ALLOSTASIS
Chikanza 2000
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LBW VLBW INCREASE WITH INCREASING AGE IN BLACKS
BUT NOT IN WHITES
Geronimus 1996
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AMONG AFRICAN AMERICANS, LBW INCREASES WITH
INCREASING AGE IN LOW SES BUT NOT HIGH SES
Geronimus 1996
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AS AFRICAN AMERICAN WOMEN GET OLDER, THEY ARE
MORE LIKELY TO SMOKE CIGARETTES
Geronimus 1996
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LIFE COURSE PERSPECTIVE
Lu 2003
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• ORAL HEALTH DISPARITIES

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ORAL HEALTH FACTS
Over one third of the U.S. population (100
million people) has no access to community water
fluoridation. is Over 108 million children and
adults lack dental insurance, which over 2.5
times the number who lack medical insurance.
Professional care is necessary for maintaining
oral health, yet 25 percent of poor children have
not seen a dentist before entering kindergarten.
Americans make up 2.2 of dentists, Hispanic
Americans accounting for 2.8 and Native American
representing .2
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SUPPLY OF DENTIST

• 56 Schools of Dentistry in US.
• 4,618 First Year dental students (2003
• 7,987 applicants (2003)
• 5.4 of dental students are African-American (vs.
  12 of US population)
• 5.9 of dental students are Hispanic/Latino (vs.
  12 of population)

R. Strauss, U of North Carolina/L. Tedesco, U. of
Michigan
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• HEALTHCARE
• MANPOWER

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DISTRIBUTION OF SELECTED HEALTH PROFESSIONS BY
RACE AND ETHNICITY
Table 18-2
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Table 18-1 HEALTH PROFESSIONS WITH THE GREATEST
PROJECTED JOB OPENINGS, 2000-2010
Source Bureau of Labor Statistics (2001b).
Employment by Occupation, 2000and Projected
2010available at http//www.bls.gov/emp/emptab21.h
tm.
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HEALTH DISPARITY IN THE IMMIGRANT POPULATION
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10 MOST COMMON PROBLEMS SEEN IN THE
AFRO-CARIBBEAN COMMUNITY

• Reported domestic violence is 1 among
  Afro-Caribbean in Boston
• Lack of insurance/unemployment
• Language barriers
• Fear of immigration
• Led Poisoning, HIV/AIDS
• TB/(reactivation)
• Breast Cervical Cancer - diagnosed very late
• Untreated D.M./CVD
• Immunization

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HEATH ISSUES

• Increase risk for childhood vaccine preventable
  illnesses, ex chronic Hep.B, Rubella
• Other conditions, includes
• Intestinal parasite
• Malaria
• Typhoid Fever
• Malnutrition, (Iron Folate and B-12 deficiency)

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HEATH ISSUES

• Asthma very common in all immigrant groups,
  most common in non-Hispanic Blacks
• Dental disease 77 of immigrants needed
  emergency dental care (study in San Francisco
  immigrant population)
• Mental Health
• PTSD
• Depression (many goes undiscovered because of
  cultural differences)

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BARRIERS IN THE HEATH CARE SYSTEM

• Prevents optimum care for immigrants, ex
• Clinic vs. private physicians office.
• Delay in providing medical emergency care.
• PRWORA (Personal Responsibility and Work
  Opportunity Reconciliation Act of 1996)
• Availability of translators

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• CULTURAL COMPETENCE

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CULTURAL COMPETENCE, OUTCOMES, AND QUALITY OF CARE

• Cultural differences between providers and
  patients affect the provider-patient
  relationship.
• How patients feel about the quality of that
  relationship is directly linked to patient
  satisfaction, adherence, and subsequent health
  outcomes.

Stewart M, et al, Cancer Prev Control. 1999
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CULTURAL COMPETENCE
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CULTURAL COMPETENCE
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CULTURAL COMPETENCY LEARN Model

• Listening to the patients perspective
• Explaining and sharing ones own perspective
• Acknowledging differences similarities between
  these two perspectives
• Recommending a treatment plan
• Negotiating a mutually agreed-on treatment plan

Berlin EA, Fowkes, WC Jr. West J Med 1983
139(6)934-8
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• Do you speak another language?
• Do you work with staff who speak another
  language?
• Do you offer health materials and/or appointment
  materials in other languages?
• Do you have a list of community resources that
  serve a variety of ethnic groups?
• Do you ask you patients about heir use of
  alternative health practices?
• Do you ask about the use of home remedies,
  medicines, or treatments?
• Have you attended a cultural diversity seminar
  workshop in the past year?
• Does your screening procedure include cultural
  lifestyle issues such as dietary practices,
  health beliefs, home remedies, medicines, or
  other treatments?
• Do you have an interpreter system for
  non-English-speaking patients?
• Do you know key words and phrases in the
  languages of your patients? Good morning!/How are
  you?/Thank you!

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CULTURAL DIFFERENCES AND EXPECTATION OF IMMIGRANT
POPULATION

• Need to have a prescription after every visit.
• Injected medicine are preferable.
• Decision maker father or grandmother.
• Use of alternative/home remedies
• Gender preference of health professional
• How they express pain or discomfort

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RESOURCES

• Bureau of Primary Health Care of the US Dept of
  Health and Human Services (DHHS) Cultural
  Linguistically Appropriate Health Care Service
  (CIAS)
• Cultural Brokers Individuals who are bicultural
  and bilingual that can assist in the delivery of
  culturally appropriate care
• Other resources mental health for immigrant
  program (MHIP) National Center for Cultural
  Competency (NCCC).

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WHAT IS NEEDED?

• National guidelines and standards.
• Funding to assist hospital, physicians office,
  clinics and community health centers to assist in
  providing culturally appropriate and
  comprehensive care
• Research

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• In the end,
• its not what we dont know that will destroy us
• but
• rather the failure to respond appropriately to
  what we do know