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Define Health Disparities and Health Equity
Define Cultural and Linguistic Competency and the rationale for practicing as a culturally and linguistically competent healthcare professional.
Implement/practice strategies for reducing practitioners’ own biases and misconceptions when encountering patients of a differing cultural background
Identify when a language barrier is present and an interpreter is needed
Recognize the advantages and disadvantages of trained vs. untrained interpreters
Identify resources to assess individual and organizational cultural and linguistic competency
Discuss the link between health reform, cultural and linguistic competency.
Agency for Healthcare Research and Quality
US DHHS Office of Minority Health MedScape Internal Medicine: Cultural
Competency in Healthcare: A Clinic Review and Video Vignettes From the National Medical Association
Georgetown Center for Cultural Competence
Google or Bing it: “Cultural and Linguistic Competence”
o KY has seen unprecedented growth in the diversity of their demographics.
o The rate of population increase is higher for communities of color.
o According to the Census from 1990 to 2000 there was a 172.6% growth of the Hispanic/Latino population.
o There was a 49.3% growth of American Indian/Alaska Native; 75.1% growth of Asians; and a 76.1% growth of Native Hawaiian and Other Pacific Islanders.
o The African American population grew by 12.6% while the White, non-Hispanic population grew by 6.8%.
o In 2000, More than 29,000 Kentuckians had limited English proficiency, and the number is expected to increase.
o Gonzalez indicated that U.S. residents will speak an estimated 329 languages, and 32 million will speak a language other than English at home within the next decade.
Established in Fall 2008 Funded by the U.S. DHHS, Office of
Minority Health and the KY Dept. for Public Health
Overarching Goals: To eliminate health disparities among
racial and ethnic minorities, rural and low income populations in the state of KY.
To promote health equity in the state of KY.
Obtained an Administrative Order from Secretary Miller to officially establish the Branch.
Obtained $420,000 over the course of 3 years from the US DHHS Office of Minority Health to focus on: Cultural and Linguistic Competency Hispanic Health Programming Research and Evaluation
Cultural and Linguistic Competency Assessment of Local Public Health Depts. in KY.
Promoting Health Equity Mini-GrantsHealthy People 2020 Infant Mortality Health DisparitiesDiabetes/Obesity CollaborativeEnvironmental Health DisparitiesLex-Fayette Health Equity Network
Health Disparities or Health Inequalities: Empirically evident differences that exist in the quality of health and health care across racial, ethnic, sexual orientation, and socioeconomic groups. US DHHS sees health disparities as “population-specific differences in the presence of disease, health outcomes, or access to health care. across different social groups in a society (Peter, 2000).
Health Inequities: are a subset of health inequalities or disparities involving circumstances that may be controlled by a policy, system, or institution so that the disparity is avoidable. These kinds of health disparities may include health and healthcare disparities.
SOURCE: Center for Health Equity, Louisville Metro Public Health & Wellness, Overview & Key Ideas, Retrieved Januray,12, 2009 online at: www.louisville.gov/Health/equity/
Low socioeconomic status (SES) has been specifically linked to racial/ethnic disparities in access to quality health care.
Agency for Healthcare Research and Quality (AHRQ) 2006 National Health Disparities Report stated that 73% of Afr-Am and 77% of Hispanic received worse quality healthcare than their counterparts or reference groups, partially attributed to provider or health system biases.
SOURCE :U.S. DHHS (2005). 2005 National Healthcare Disparities Report. Agency for Healthcare Research and Quality. Rockville, MD. Retrieved online June 25,2009 at http://www.ahrq.gov/qual/Nhdr05/nhdr05.pdf
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White African American
Heart Disease 321.5 Heart Disease 382.8
Cancer (all sites) 213.82 Cancer (all sites) 244.13
Stroke 50.0 Stroke 69.0
Diabetes 26.1 Diabetes 51.8
SOURCE:
Multifactoral Sociocultural Genetics Economic Healthcare delivery systems
Systems of CarePatient and CommunitiesHealthcare providers
SOURCE:
Health Equity: When everyone has the opportunity to “attain their full health potential” and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance.
SOURCE: Whitehead M, Dahlgren G. Leveling Up (Part 1): A Discussion Paper on Concepts and
Principles for Tackling Social Inequities in Health. World Health Organization. Available at http://www.euro.who.int/document/ e89383.pdf.
Awareness: Increase significance of health disparities, their impact on the nation, and actions necessary to improve health outcomes.
Leadership: Strengthen and broaden leadership for addressing health disparities at all levels.
Health and Health System Experience: Improve health and healthcare outcomes for racial and ethnic minorities and for underserved communities.
Cultural and Linguistic Competency: Improve competency.
Research and Evaluation: Improve coordination and utilization of research and evaluation outcomes.
Data Collection Directs new Assist. Sec of Health Information to ▪ Set standards for data collection▪ Coordinate analysis of data on health disparities with HHS
Language Access and Cultural Competence Qualified health plans have appropriate communication and
services Test models and curricula that train health professionals Require a study on how Medicare can reimburse health
professionals providing language services and create a 3 yr grant program to test
Extend matching rates for states that provide language services to for Medicaid beneficiaries not just children.
Workforce Diversity Permanent advisory committee Increase funding and scholarships for disadvantaged students,
with special consideration to institutions with a track record of training individuals from minority communities.
Workforce Training: Develop and support broad availability of cultural and linguistic training
Diversity: Increase diversity and competency of the healthcare and administrative workforces through recruitment and retention of racially, ethnically, and culturally diverse individuals through leadership by healthcare organizations and systems
Standards: Require Interpreters and bilingual staff providing services in languages other than English to adhere to National Council on Interpreting in Health Care (NCIHC) Code of Ethics and Standards of Practice
Interpretation Services: Improve financing and reimbursement for medical interpretation services
Cultural Competence: A set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework.
Linguistic Competence: Providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/cultural staff, trained medical interpreters, and qualified translators.
SOURCE: Cross et al. 1998. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.
Cultural and Linguistic Competency: The ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter. SOURCE:2 U.S. Department of Health and Human Services, Office of Minority Health.
2000. Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda. http://www.omhrc.gov/clas/finalpo.htm Accessed January 17, 2003.
o In 1994, Congress recognized the need to address the impact of cultural and linguistic competency on health disparities and mandated the Office of Minority Health, USDHHS to develop to capacity of health professionals to eliminate barriers to health care delivery and access to health care for limited English-proficient people.
o As a result of the 1994 legislation, the Center for Cultural and Linguistic Competence in Health care was created.
o The National Standards on Culturally and Linguistically Appropriate Services (CLAS) were developed to help guide health care delivery organizations towards a competent workforce.
Joseph Betancourt defines a culturally competent health care system as one that
“acknowledges and incorporates-at all levels-the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaption of services to meet culturally unique needs. “
Awareness of one’s own cultural worldview’
Attitude toward cultural differencesKnowledge of different cultural
practices and worldviews; and Cross-cultural skills
Dilworth-Anderson discovered that a provider’s awareness about their own biases has influence on providing culturally appropriate care.
Many studies indicated that physicians tend to display less emotion and communication when dealing with ethnic minority patients, which translated to shorter consultation time and empathy.
Gao, Burke, and Sumkin, et.al discovered in their study of culture in physician patient communication during colorectal screening, that interpersonal relationships were common themes that determined whether or not a patient was referred for screening.
Clinical (Provider-patient encounter): Interventions that include equipping individual clinicians with the skills to effectively provide care to diverse patient populations.
Organizational (Leadership/Workforce): Recruiting a diverse workforce and leadership that represents the diversity of the community that it serves.
Structural (Processes of care) Developing processes of care that facilitate access for underrepresented communities and cultures.
Diverse workforce reflecting patient population.
Convenient facilities Language assistance for patients with LEP Ongoing staff training regarding delivery
of CLAS. Quality of care tracked across racial,
ethnic, and cultural subgroups. Community included in setting priorities
and planning, delivery, and coordination of care.
Explores and respects patients beliefs, values, meaning of illness, preferences, and needs.
Builds rapport and trust Establishes common ground Is aware of own biases or assumptions Maintains and is able to convey
unconditional positive regard Is knowledgeable about different cultures Is aware of health disparities and
discrimination affecting minority groups Effectively uses interpreter services when
needed.
Healthcare providers may: Lack recognitions of nonverbal cues
when dealing with patients of different cultural backgrounds;
Biases; Stereotypes http://cme.medscape.com/viewarticle/57
3591_2?src=emailthis
Awareness training of bias and stereotypes and their effect on clinical decision-making
Self-reflection practices Individuation vs. categorizationPerspective-taking and affective
empathyPartnership building
Minority patients report lower satisfactions with medical encounters, less partnership with healthcare providers, and less involvement in medical decision making.
Minority patients also tend to perceive a lack of respect for their preferences compared with similar white patients.
Minority patients may also be distrustful of the healthcare system due to personal experiences or the experiences of people they know.
Minority patients may feel better with “Setting Talk”: Discussions centers on topics of immediate context, such as the surrounding environment, the clothes one is wearing or daily activities.
Healthcare providers may feel more comfortable with “Categorical Talk”: Openly inquiring about another person’s age, occupations, place of residence-things which may be considered private or personal.
Differences in Expectations of Treatment and Outcomes
Differences in Expectation With regard to respective roles Appropriateness of asking questions and
receiving info Level of family involvement
Differences in Explanatory Models Understanding the connection between
symptoms and the underlying disease process or causes of illness
May lead to poor patient compliance
Selected Behaviors/Perspectives of Various Groups That May Impact Treatment-Seeking Behaviors
Culture Behaviors/Perspectives
Mexicans •Health is a gift from God and a reward for good behavior
•Health results from maintaining balance in the universe between “hot” and “cold” forces, illness in an individual body is considered a punishment meted out for wrong doing.
Haitians •Health is a state of harmony with nature. Illness is a state of disharmony and is also caused by movement of blood, problems with gas, imbalance between “hot” and “cold” forces, and voodoo or a spell placed on a person. To maintain health, the spirit and body must be linked together by the soul.
•May not feel comfortable discussing their spirit and soul with a medical practitioner for fear that their explanation may be misunderstood
Native Americans •Health is a state of total harmony with nature; human beings have an intimate relationship with nature.
•Illness is considered a price paid for something that happened in the past or that will happen in the future. Illness may also be due to evil spirits.
Southern Blacks •May feel that their illness is due to sin or evil.
•May feel that illness such as a cold is due to weather rather than a microbiologic factor (e.g. going out in the cold weather will cause one to a catch a cold.)
SOURCE: Data from Giger, J.N., & Davidhizar, R.E. (1991). Transcultural nursing, assessment and intervention. St. Louis, MO: Mosby Year Book.
Explore the respective expectations of an encounter
Open discuss interpretation of nonverbal cues
Use models of cross-cultural communication
Use shared decision-makinghttp://cme.medscape.com/viewarticl
e/573591_2?src=emailthis
Tool Question or Approach
Kleinman’s questions
What do you think has cause your problem?
What do you think your sickness does to you?
How severe is your sickness? Will it have a short or long course?
What kind of treatment to you think you should receive?
What are the most important results you hope to receive from this treatment?
What are the chief problems your sickness has caused for you?
What do you fear most about your sickness?
LEARN
Listen with sympathy and understanding to the patient’s perception of the problem
Explain your perceptions of the problem
Acknowledge and discuss the differences and similarities in perceptions Recommend treatment
Negotiate treatment
Limited English Proficiency Patients are more likely to: Receive Preventive Care Have consistent source of primary care Receive timely eye, dental, and physical
examinations Receive error-free medical care Visit their clinician Return for follow-up visits after being an
ER patient
Gold Standard: Bilingual-Bicultural Provider who is fluent in the patient’s language and culture and who expects patients to communicate their needs in English only if they have adequate English language skills. Provider should also have the necessary communication proficiency and an understanding of the patient’s language to be able to explain medical concepts in lay terminology.
Title VI of the 1964 Civil Rights Act says that “requiring, suggesting, or encouraging” a patient to bring his or her friends, minor children, or family members to serve as an interpreter infringers on the patients civil rights. It is also considered illegal if the institution receives federal funds.
Professionally Trained Interpreters at no cost to patient: Staff Interpreters Agency Interpreters Volunteer Interpreters Telephone Interpreters
Bilingual staff is Ok, but not preferred
IF patient insists on family member or friend: please honor the request after full disclosure of
options Have patient sign waiver, releasing institution of
liability.
Interpreters should be able to do the following: Be faithful in communicating the
patient’s own words to the provider Maintain confidentiality Be trained in memory, note-taking,
language transposition Skills that go beyond proficiency in
speaking language
Compromise of confidentiality Family member or friend may filter info Level of comfort may be lost Comprehension Children may lack the vocab. Or be
embarrassed to discuss sensitive topics.
http://cme.medscape.com/viewarticle/573591_2?src=emailthis
Triadic Interview: Provider briefs Interpreter before patient
encounter, concerns, expected duration Interpreter may indicate when he/she does not
know how to translate or may feel uncomfortable
Provider should ask direct questions to patient and observe patient, not the Interpreter
Provider should use lay terminology Open to feedback Debrief Be aware of potential problems b/w the patient
and Interpreter
Torrie T. Harris, Dr.P.H. Director, Office of Health Equity KY Dept. for Public Health [email protected] 502-564-3527 ext 4027
Maria Gomez, MPH, Doctoral Candidate
