Bridging Cultural Health Care Gaps...Best Companies for Blacks in Technology Black Data Processing Associates (BDPA), 2007-2010 Best Diversity Company Diversity/Careers in Engineering

Bridging Cultural Health Care Gaps: Helping “People Like Me” — Reducing Health Disparities with Culturally Relevant Strategies

Terri AmanoHealth Equities & Cultural and Linguistic Programs OfficePrograms in Clinical ExcellenceWellPoint, Inc.

Seventh National Conference on Quality Health Care for Culturally Diverse Populations Renaissance Harborplace Hotel, Baltimore MDOctober 20, 2010

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About WellPoint

1 out of 9 Americans are covered by WellPoint’s affiliated health plans

Nation’s Largest Health Benefits Company*

• Approximately 33 million members in affiliated health plans

Corporate Responsibility• More than $112 million in

grants awarded by WellPoint Foundation to community partners

• Strong commitment to diversity and addressing disparities

* In terms of membership

3Content Property of WellPoint, Inc. | Do Not Copy or Use Without Permission3

Recognition for Corporate Commitment to Diversity

Top 50 Companies for DiversityDiversityInc, 2008-2010 100 Best Companies for Working MothersWorking Mother Magazine, 2009-2010 Diversity Leader AwardProfiles in Diversity Journal, 2008-2010 Top 10 Companies for Innovations in DiversityProfiles in Diversity Journal, 2007-2009 Latina Style Top 50 CompaniesLatina Style Magazine, 2008, 2009 Corporate Equality IndexHuman Rights Campaign, 2007-2009 50 Out Front Companies for Diversity LeadershipDiversity MBA Magazine, 2008-2009Top 100 Military Friendly EmployersG.I Jobs Magazine, 2010 Top 50 EmployerCareers and the disABLED Magazine 2008-2010Top 100 Employers of the Class of 2009The Black Collegian

Best Companies for Blacks in Technology Black Data Processing Associates (BDPA), 2007-2010 Best Diversity CompanyDiversity/Careers in Engineering & Information Technology Magazine, 2009, 2010 GoldSea “100 Great Employers for Asian Americans”GoldSea.com, 2010 Top Companies for Executive WomenNAFE-National Association for Female Executives, 2009-2010 25th Anniversary Visionary Leadership in Diversity AwardThe American Institute for Managing Diversity, 2009

Top Diversity Employers for African-AmericansTop Supplier Diversity Programs for African-AmericansTop Hospitals & Healthcare for African-AmericansBlack EOE Journal, 2009

Best of the Best Diversity Employers for HispanicsTop Supplier Diversity Programs for Hispanics Top Hospitals & Healthcare for HispanicsHispanic Network Magazine, 2009Top Diversity Employers for WomenTop Supplier Diversity Programs for Women Top Hospitals & Healthcare for WomenProfessional WOMAN's Magazine, 2009 Congress of Diversity Executives Leadership in Diversity AwardCareer Communications Group, 2009WellPoint recognized as “An Adoption Friendly Employer”Dave Thomas Foundation for Adoption, 2009

WellPoint CEO Angela Braly recognized with CEO Diversity Leadership AwardDiversity Best Practices, 2009


Health Equities & Cultural and Linguistics Program OfficeDedicated enterprise-wide focus on addressing disparities

Joint projects with external stakeholders

Cultural competency training for clinical staff

Community-based medical consumerism curriculum (open to general public)

Online resource portal (open to general public – members and providers)

Indirect methodology for estimating member race/ethnicity

• Identify disparities• Focus resources

Pilot studies to test new strategies

Addressing Disparities


Why Is Any of This Important? In the Words of Members…

“I didn’t ask any questions because I was so scared and didn’t know what to do.”

~ African American Focus Group Participant

“The doctor did not give me any information… Sometimes, I pick up pamphlets, or there’s an article in the newspaper. I cut them out and I save them to have some type of reference… I have to translate them with my dictionary.”

~ Hispanic Focus Group Participant

Source: WellPoint diabetes focus groups of African Americans and Hispanics, Q4 2007

“I went to ask the doctor, “So I have diabetes?” and the doctor very rudely said, “Yes, you do.” They didn’t tell me anything, how I could treat it or how I could get informed about it.”

~ Hispanic Focus Group Participant


1. How did we identify “culturally relevant” themes to be included in “culturally relevant” health education materials?

2. What are the themes?

3. What potential risks were involved with direct member outreach?


Objective: Pilot Study

Goal: Develop and test culturally relevant strategies for

African American and Hispanic adults with diabetes

Two Key Elements:1. Culturally relevant themes

• Gleaned from research, focus group interviews, and consultation with subject matter experts

2. Direct outreach to members in target populations• Based on estimated race/ethnicity


Identifying the Themes

3-phased approach

I: Study “positive deviants”• Find drivers of adherence and strategies for overcoming

lifestyle and care barriers

II: Test prototype concepts• Evaluate responses to concepts by “non-adherents”• Beta test with WellPoint internal associate Hispanic resource

group

III: Evaluate field responses to pilot materials• Determine abrasion level, if any


Identifying the Themes

Methodology: In-depth interviews and focus groups

African American (n=44), Hispanic (n=37), and white (n=10)

• Commercially insured adults living with diabetes, by gender

Conducted by an independent market research firm

• R/E/L concordance between Interviewers and Participants

Themes and prototypes reviewed and endorsed by external expert physicians, including from:

• UCLA• Cleveland Clinic • Columbia University• Harvard• University of Colorado


Culturally Relevant Themes

Thematic Findings: The 4 (or 5) Fs

Despite inter- and intra-cultural heterogeneity, four (five) key engagement drivers emerged

These key drivers considered as integral components of culturally relevant communication strategies

Food. Family. Faith. Fear. (Finances.)


“I followed the diet at first because I was very scared, but Mexican Food is delicious and it is

hard to give up. ”~ Focus Group Participant



Food. Affinity to cultural foods and difficulties in changing dietary habits

Participants wanted specific information

• How to make “traditional foods” (e.g. “Soul food” or “Mexican food”) healthier

Resources need to reflect real life

• Fast food dining

• Cooking healthfully on a budget



“People of color tend to accept diabetes as a rite of passage. Our families expect us to get diabetes.”

~ Focus Group Participant



Family. Particularly “being there” for children and grandchildren

Participants very motivated by “negative” family examples

• e.g., those with diabetes but did not take care of themselves well

Support and concern of family members critical in member health-activation



“The ideas about why we don’t take care of ourselves. ‘God sent me this’ – my abuela (grandmother) says that.”





Faith and Spirituality. Respecting life as a gift

Especially among African American women

Faith-based organizations as trusted sources of health information

Influence of cultural spiritual or folk values/beliefs


“My mother and sister and niece all passed with kidney disease and now my young nephew needs a transplant.”




Fear. Disease complications, especially amputations, blindness, and kidney disease

Especially among African American men

Hispanic men worried that others would find out about diabetes

Many struggled with depression

Finances related to health care and healthy lifestyles (food, gym membership) was also a concern



“I want to be around for the grandchildren. And, if I’m not around I don’t know who’s going to take care of my wife.”

“When you have diabetes, they amputate your feet.

That’s an important thing I worry about, is that they

see me without feet.”

“I ask Jesus, I ask God, if you’re going to take me, don’t make me suffer so much.”

“It’s hard like at the 4th of July barbeques. It’s hard

not to eat what you want.”



Incorporating the 4 Fs

Food: Ingredient substitution for “traditional” family recipes guide; Fast food guide; DVD; website

Family: Family reunion guide; Fotonovela; DVD; website

Faith: Bringing health education to houses of worship; DVD; website

Fear: Depression booklet; Fotonovela; DVD; website



Culturally Relevant Themes Sample Pilot Materials


Identifying & Mitigating Risks

Challenge: Helping or Offending?

On the one hand…

• Segmenting populations based on estimated race/ethnicity

– Highly accurate (> 90%) but still not 100%

• Culturally relevant messaging

… and on the other hand

• Risking perceptions of “racial profiling” or stereotyping

Image from http://www.flickr.com/photos/91515119@N00/1795141144

Walking a fine line…

>> HOW do we push out culturally relevant materials to individuals estimated to be in our target populations in a sensitive and non-offensive manner? <<


Identifying & Mitigating Risks

Our solution

Up front honesty

• Disparities issue for all in the U.S.• Condition-related facts

A message of wanting to help

• We care• We want all our members to have tools to avoid

disparities

What to expect

Option to decline


“They did all right. Tell them not to worry about that.”“It’s not offensive. They’re educational. How could anyone get offended?”

Findings

Both African American and Hispanic participants were generally very receptive to the culturally relevant materials

Helpful, useful, easy to understand

Participants were very emphatic that they did not find anything offensive in the materials


Overall“Informative, easy to understand, lay terms. And the visuals help. Short and concise.”

“Great medium to attract the Hispanic population, because any store we go into, there’s lots of little novelas.”

“This will make me take the disease more seriously.”

“I like that it’s geared to the African American community. I always look (at material) to make sure that there are chocolate people like me.”

Why Is Any of This Important? In the Words of Our Members…


Food“Understanding that not everything is out of my repertoire of what I can eat was very important. It made it seem a little more bearable and helped me get over my depression.”

“We all eat so much fast food. This gives you alternatives. And it mentions places that we go in real life.”

Faith“In the Black community, the church is the center, so it’s an ideal place to start.”

Family“The family part is important, because you can’t do it on your own.”

“You’re not only helping yourself, you’re helping them [family members/next generation].”

Fear“And a lot of people don’t want to talk about sexual dysfunction, but that’s real.”

"So maybe it is machismo. And this gives you permission to be depressed.”

Why Is Any of This Important? In the Words of Our Members…


Contact:

[email protected]

Documents

Bridging Cultural Health Care Gaps...Best Companies for Blacks in Technology Black Data Processing Associates (BDPA), 2007-2010 Best Diversity Company Diversity/Careers in Engineering