Cultural Diversity  in Healthcare

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Objectives. Provide background information on need for cultural competency training to care for diverse communitiesGive demographics of the disparitiesIllustrate programs attempting to inculcate cultural sensitivity into education and practiceExplore potential activities to move forward. Cultural Competency.

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Cultural Diversity in Healthcare

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1. Cultural Diversity in Healthcare Nereida Correa M.D. February 26, 2004 Women’s Healthcare Network-Iona College

2. Objectives Provide background information on need for cultural competency training to care for diverse communities Give demographics of the disparities Illustrate programs attempting to inculcate cultural sensitivity into education and practice Explore potential activities to move forward

3. Cultural Competency Defined as a set of congruent practice skills, behaviors, attitudes and policies that come together in a system, agency or among providers and professionals that enables that system, agency, or professionals to work effectively in cross-cultural situations.

4. Title VI-Civil Rights Act “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

5. CLAS Standards Office of Minority Health of the US Department of Health and Human Services developed and recommends national standards for culturally and linguistically appropriate services in health care Current requirement for all recipients of Federal funds

6. CLAS Standards Standard 8 states that health care organizations should have a strategic plan that outlines goals, policies, operational plans and oversight mechanisms to provide culturally and linguistically appropriate services

7. Institute of Medicine: Among 13,000 heart patients for every 100 whites who had a procedure to clear the heart arteries, only 74 blacks did Of 15,578 urban ER patients blacks were 1.5 times more likely to be denied authorization by managed care providers Differences exist even when insurance, income, age, and the severity of the disease are the same for both groups

8. National Leadership Summit-Minority Health Eliminating Racial and Ethnic Disparities in Health by: broadening scientific research and data increasing awareness of the issues establishing partnerships to mobilize communities and stakeholders developing and enforcing policies and laws ensuring access to health care

9. Institute of Medicine: Recommendations include: Changing health insurance programs to reduce disparities Recruiting more minorities into health care Expanding patient education Enforcement of discrimination laws Programs to increase awareness among providers

10. Diverse Communities, Common Concerns Despite being younger African-Americans and Hispanics are less likely to consider themselves in good or excellent health Communication between patient and physician more problematic; feel their doctor did not listen, did not fully understand, had questions but did not ask


12. Births and Deaths US by Race/Ethnicity: CDC Data Deaths ’99 Births ‘00 Non-Hispanic White 1,953,197 2,362,968 Black 281,979 604,346 Hispanic Puerto Rican 13,909 58,124 Mexican 57,425 581,914 Cuban 11,209 13,429 Other Hispanic 21,377 162,400

13. Hispanic Women Median age: 26 Education: 45% < high school Life expectancy: 77 yrs vs. 79 for White and 74 for Non Hispanic Black Birth rate: Highest in US Comprise 56% if Hispanic labor force Lowest paid: 46% , 10,000/yr; 30% head of household Most likely to be uninsured

14. Access to Health Care for Women Health insurance often pregnancy related and reverts to uninsured status following delivery Less than 35% of women return for post partum care Health problems identified in prenatal care are lost to follow-up Less than 5% physicians of color with 3.1% of entrants to medical school of Hispanic origin








23. Low Birth Weight Rate Low birth weight 5.3% White US Born 15% Black US Born 11% Black Immigrant 8.6% PR US Born 8.0% PR Immigrant 5.9% Mexican US Born 4.8% Mexican Immigrant Rate Prematurity 15% Black, 12 % PR

26. Low Birth Weight and Access to Health Care Vasquez Calsada compared availability of prenatal care with birth outcomes in Puerto Rico and found that low birth weight and infant mortality were related to lack of access to prenatal care Sheriden reported positive birth outcomes with access to prenatal care



29. HEALTH DISPARITIES Accidents and Homicide HIV infection Morbidity: Injury from gun violence High Risk Behaviors : Smoking Alcohol and Illicit Drug Use Domestic Violence Heart Disease and Diabetes Cancer

30. Health Issues: Cardiovascular Cardiovascular- death rate from heart attack 30% higher in African Americans Heart attacks declined by 29% in whites vs 21 % for African Americans Death rates from stroke were 40% higher in African American adults

31. Health Issues: Diabetes Diabetes is 2 times higher in African Americans and 1.9 times higher in Hispanics Overweight and obesity are higher in all ethnic minorities Native Americans have 2.6 times the rate of Diabetes and Pima Natives of Arizona have the highest known prevalence in the world

32. Violence Rape: 41% women of color report being raped In most cases the perpetrator is an acquaintance Women are 7 times more likely to be victims of a crime or homicide committed by an intimate partner

33. HIV Infection CDC reported 10,459 AIDS cases among women age 13 and older Major exposure categories: heterosexual contact and injected drugs African-American women largest group, Hispanic women second December 2000: majority AIDS cases 25-44 age group

34. HIV/AIDS HIV/AIDS- 28% of US population in 2001, African Americans and Hispanics are 66% of adult AIDS cases and nearly 82% of pediatric AIDS cases 75% and 81% respectively in 2000 Death from HIV declined 32% in whites, and increased by 13-22% in other groups

35. Disparities: Syphilis/Hepatitis Cases of primary and secondary syphilis in 1999 with 30 times greater rate in African Americans Asian Americans represent 50% of those infected with Hepatitis B Minority teens with higher incidence of Hepatitis B and C

36. DISPARITIES: Tuberculosis Of all tuberculosis cases reported in 1991-2001 80% were in racial and ethnic minorities Tuberculosis increased by 51% for Asian Americans and 30% for Hispanics Asian Americans and Pacific Islanders, 4% of the US population had 22% of the cases

37. Immunizations 48% African American and 56% Hispanic receive influenza vaccine compared to 67% Whites 31% of African American and 30% of Hispanics receive pneumococcal vaccine compared to 57% Whites In 2001 African Americans and Hispanic aged 65 and older were less likely to report having received vaccination

38. Disparities: Mental Health Native Americans disproportionate rate of depression and substance abuse Minorities have less access to mental health services and receive poorer quality services Under-represented in mental health research

39. Cancer Screening and Management African American women are twice as likely to die of cervical cancer, a preventable disease with routine screening Breast Cancer increased 3.9% for African Americans and they are more likely to die of breast cancer than any other racial or ethnic group

40. Cervical Cancer Ethnic specific age-adjusted rate for invasive cervical cancer is 18.5 Hispanic vs. 7.6 Non Hispanic Whites in California (19.4 in NY) Spanish language isolation associated with higher risk of diagnosis at invasive stage Lower acculturation a risk of less frequent PAP screening Less education and lower socioeconomic status, living in “disadvantaged” areas

41. Cervical Cancer Women’s Health Loteria as a cervical cancer education tool targeted at decreasing cervical cancer mortality by increased screening of Hispanics in Texas in a culturally sensitive approach Culturally specific game format used with bilingual counselors to evaluate if women understood the risk factors

42. Cancer Screening Suarez studied cancer screening vis a vis social integration in four US Hispanic groups in Texas, California, Florida, and New York Aim was to improve behavior related to cancer screening, cigarette smoking and nutrition Found that social support was a factor to all except Puerto Rican women

43. Cancer Screening Por La Vida screening program using natural helpers in the community increased the rate in the study group in regard to mammography services Used existing social networks in a culturally sensitive and community oriented method

44. HEALTHY PEOPLE 2010 Plan to eliminate disparities in health care provision and in health outcomes by 2010 Addresses highly preventable conditions Requires participation by health care providers to be successful Includes issues of cultural and linguistic competence in access to care

45. Minority Health Initiatives Closing the Gap-Nov 2001 Health Education and Information campaign for communities of color Racial and Ethnic Adult Disparities in Immunization Initiative (READII)-July 2002-to promote adult immunizations especially pneumoccocal and influenza vaccines in elderly of color

46. CULTURAL COMPETENCE Culturally appropriate, community-driven programs are critical Promote cultural awareness Encourage cultural competence inclusion in medical school and health careers curriculum Advocate for the needs of the patients by providing translators, culturally competent information and instructions in simple language

47. Changes in Curriculum: Lincoln Experience Office of Graduate Medical Education developed a curriculum designed to foster inclusion of cultural competency education in all residency program in the institution Experts gave a series of lectures and case-based modules designed to train faculty in all the disciplines

48. Cross-Cultural Aspects Diversity in medical staff and nursing personnel recognized and addressed Diversity in patient population integrated in curriculum System within the culture of medicine and the institution recognized and addressed

49. Methods and Results Two conference held to provide a base of information to all residents and attendings in all disciplines with residency programs Two consecutive train-the-trainer sessions with 2-3 representative from each department Three sessions given in each department by June 2003 with support from trainers On-going integration in the curricula at all levels

50. Albert Einstein Experience Inclusion of introductory lectures in the first year curriculum including access to Spanish course and graded experiences in the community Second year lectures and workshops; case-based discussions in physical diagnosis and interviewing; Spanish with a community physician and as part of international health rotations

51. Albert Einstein Experience Inclusion in didactic lectures in third year clerkships in family medicine, OB/GYN, and pediatrics Opportunities for community based research and student run clinic within the community Cultural “brokering” as a concept

52. CULTURAL COMPETENCE Encourage recruitment, admission and retention of persons of color into the health professions Foster mentorships for young people to help them remain in school and work towards a goal Support other physicians and health workers of color in attaining their goals

53. Cultural Humility Training outcomes that incorporate a lifelong commitment to to self-evaluation and critique Redress of power imbalances in the physician-patient relationship Partnerships with communities on behalf of individuals and defined populations

54. Challenges Increase the number of culturally competent providers Linguistic competency Mentor young people into health careers: recruitment and promotion Inclusion of minorities in research Improve the health of our communities Healthcare partnerships and collaboration

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