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Disparity in Care: A Problem with a Solution. Presented by Marcy Donley Healthcare Communications Consultant. Data on Existence of Disparities. In 2002, the IOM released Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care .

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Disparity in Care: A Problem with a Solution

Presented by Marcy Donley

Healthcare Communications Consultant


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Data on Existence of Disparities

  • In 2002, the IOM released Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

  • It reported evidence of healthcare inequality  irrespective of income, insurance status, or education.


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Reasons for Inequalities

  • Subtle differences in the way individuals respond to treatment.

  • Variations in individual help-seeking behavior.

  • Barriers in language proficiency, literacy level and cultural beliefs.


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Reasons for Inequalities (cont.)

  • A healthcare professional’s beliefs may influence patient interaction.

  • The healthcare professional may be limited in the amount of time available to gather information.

  • An unconscious prejudice or bias may exist.


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Why Is It Important?

  • The US Census Bureau estimates that by 2050, one in every two Americans will be an African/American, Hispanic/Latino, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander.


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“Health care providers should be made aware of racial and ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

“Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare”

Institute of Medicine, March 2002


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Title VI -- Civil Rights Act of 1964 ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

“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.”


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CLAS Standards ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care Final Report, OMH, 2001

    • The Standards

      • http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlid=15

    • Executive Summary

      • http://www.omhrc.gov/assets/pdf/checked/executive.pdf


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Healthcare Disparities Report ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • The Agency for Healthcare Research and Quality’s National Healthcare Disparities Report was one of the first efforts (2003) to measure differences in health care by various populations.

  • An annual report is released along with the National Healthcare Quality Report.

  • http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf


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Purpose of NHDR ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Identify the differences or gaps where some populations receive poor or worse care than others and to track how these gaps are changing over time.

  • Emphasis is on disparities related to race, ethnicity, and socioeconomic status.

  • Also includes “priority populations” (women, children, older adults, rural, disabilities/special needs).


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2008 Report Key Findings ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Disparities persist in health care quality and access.

  • Magnitude and pattern of disparities are different within subpopulations.

  • Some disparities exist across multiple priority populations.


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National Focus on Cultural and Linguistic Competency ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Since it has been found that cultural expectations, assumptions, and language affect the quality of care patients receive…

  • Efforts have focused on improving the skills of health care professionals to deliver culturally and linguistically competent care for diverse populations.


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Goals for Today ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Make you aware that cultural expectations, assumptions, and language affect the quality of care patients receive.

  • Bring you the best of available research, tools and resources to improve cultural and linguistic competency.

  • Encourage self and organizational assessment and improvement that facilitates bridging the gap in healthcare disparities.


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Health Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”


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Health Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Poor health literacy is "a stronger predictor of a person's health than age, income, employment status, education level, and race.“ (Source: AMA)

  • 90 million people in the United States (nearly half the population) have difficulty understanding and using health information. (Source: IOM’s Health Literacy: A Prescription to End Confusion)


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What is Health Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Health literacy is the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

    Adopted by the IOM and Healthy People 2010


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More Than Reading or Writing ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Health literacy is the ability to:

    • Comprehend complex vocabulary and concepts including medical terms or probability and risk.

    • Share personal information with providers about health history and symptoms.

    • Make decisions about basic behaviors like healthy eating and exercise.


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Health Literacy Definition (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Engage in self-care and chronic-disease management.

  • Navigate a complex healthcare system  from walking hospital corridors to filling out insurance forms.

    Source: HHS Office of Disease Prevention and Health Promotion


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Low Literacy/ ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”Limited English Proficiency


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Myths About Low Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Myth: People who have limited literacy skills are dumb and learn slowly, if at all.

  • Fact: Most people with low literacy skills have average IQs and function quite well.


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Myths About Low Literacy (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Myth: People will tell you if they can’t read.

  • Fact: Since there is a strong social stigma attached to limited reading and writing skills, nearly all nonreaders or poor readers will seek to conceal this fact. They will use ruses such as “I forgot my glasses” or “I’ll have to take this home for my husband (or wife) to see it first.”


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Myths About Low Literacy (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Myth: Years of schooling is a good measure of literacy level.

  • Fact: Years of schooling tell what people have been exposed to, not what reading skill they acquired. Surveys show that, on average, adults currently read three to five grade levels lower than the years of schooling completed.


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Writing for Low Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Organize information so the most important behavioral or action points come first

  • Break complex information into smaller, understandable chunks

  • Use simple language or define technical terms


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Writing for Low Literacy (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Use short sentences and active voice.

  • Design for impact; use ample white space, bullets for lists/numbers for steps.

  • Check reading level (MS Word can check RL and grammar)

  • Test materials with audience.

  • Consider using translated or easy-to-read patient materials.


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Reading Level ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

Contact your insurance carrier at least 24 hours before your planned admission time to obtain needed referrals or authorizations. Because many insurance companies have strict guidelines about covered services, where they can be done and which physicians can provide them, your insurance company must be involved in your admission to the hospital. Even though the hospital's admissions office will contact your insurance company, there may be information only you can provide.


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Speaking for Low Literacy ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Avoid jargon and use everyday examples to explain technical or medical terms.

  • “Read” written instructions out loud.

  • Speak slowly (don’t shout).

  • Draw pictures; use posters or models; use video or audio.


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$50,000 Words ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • A television news anchor asked a physician on air about a celebrity’s cancer. The doctor stated: “Well, the cancer has metastasized.”

  • The TV anchor immediately realized that most viewers may not understand what the word “metastasized” means. He asked the doctor to explain.

  • The doctor was quick to say that metastasize means the cancer has “spread” or “traveled” to other parts of the body.


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Teach Back Method ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Ask the patient to restate the conversation in their own words. Example: Ask them to repeat back instructions on taking a prescribed medication.

  • When their understanding is not accurate or complete, repeat the information until is it restated correctly.

  • You can also ask the patient to show you how they will conduct a process, such as checking and recording blood sugar.


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Limited English Proficiency ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Assess percentage of foreign language use in your population, consider translating commonly used materials

  • Consider using professional interpreters; assess staff capabilities

  • Consider offering language translation telephone service


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Cultural Competency ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”


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What is Culture? ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Culture refers to integrated patterns of human behavior of racial, ethnic, religious, or social groups that include:

    • Language/Communications

    • Actions/Customs

    • Beliefs/Values/Institutions


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Cultural Considerations ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Style of Speech  People vary greatly in length of time between comment and response, the speed of their speech, and their willingness to interrupt.

    • Tolerate gaps; impatience may be seen as rude

    • Modify your speech to match that of the other person

    • Don’t interrupt or be offended by interruption

      Source: Industry Collaboration Effort


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Cultural Considerations (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Eye Contact  The way people interpret various types of eye contact is tied to cultural background and life experience.

    • Euro-Americans may interpret an indirect gaze as a sign of disrespect. Other cultures may see direct eye contact as rude.

    • If someone seems uncomfortable with direct gaze, try sitting next to the person instead of across from them.


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Cultural Considerations (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Body Language  Sociologists say that 80% of communication is non-verbal. Body language varies greatly by culture, class, gender, and age.

    • Follow the patient’s lead on physical distance and touching.

    • Be very conservative in your own use of gestures and body language.

    • The way that pain or fear is expressed is closely tied to a person’s cultural and personal background.


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Cultural Considerations (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Communication Style  English predisposes us to a direct communication style, however other languages and cultures differ.

    • Formal or informal?If the patient’s preference is not clear, ask how they would like to be addressed.

    • Patients from other backgrounds may not ask questions or answer with narrative.

    • Avoid yes/no questions. Ask open-ended questions.


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Culture by Ethnicity - Latino ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Illness may be seen as an imbalance between internal and external. (hot vs. cold, natural vs. unnatural, etc.)

  • Many patients seek care from folk healers.

  • The mother decides when to seek medical care, the father gives permission.

  • La Familia is an important source of emotional support.

  • Relationships are extremely important.

    Source: “Culture Clues” University of Washington Medical Center


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Culture by Ethnicity - Asian ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Health may be viewed as finding harmony between complementary energies.

  • May use foods to restore yin/yang balance.

  • May try traditional approaches first; may consider Western medicine too strong.

  • Emphasis on loyalty to family/traditions; not on individual feelings.

  • Family may not tell patient bad news.

    Source: “Culture Clues” University of Washington Medical Center


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Culture by Ethnicity - AI/AN ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • A holistic view in which people, community, nature, and spirituality are interconnected and interrelated.

  • Practices may include different rituals and ceremonies as well as herbal remedies (sweat lodge, talismans)

  • Family and community (tribe) may be involved and source of support.

  • May resist expressions of pain.

    Source: “Culture Clues” University of Washington Medical Center


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Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”


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Assessment Tools ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Organizational

  • Policy

  • Health Practitioner

  • http://www.hrsa.gov/culturalcompetence/


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Cultural Competency Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • EthnoMed – University of Washington Medical Center

  • Information about cultural beliefs, medical issues and other related issues pertinent to the health care of recent immigrants.

  • http://ethnomed.org


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Cultural Competency Resources (cont.) ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • National Center for Cultural Competence

  • http://www11.georgetown.edu/research/gucchd/nccc/


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Health Literacy Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • NIH “Clear Communication” Health Literacy Initiative

  • http://www.nih.gov/clearcommunication/index.htm


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Low Literacy Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • MedlinePlus Easy to Read Brochures by Health Condition

    • http://www.nlm.nih.gov/medlineplus/easytoread/easytoread_a.html


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LEP Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Guide to Implementing Language Access Services

  • Assists healthcare organizations in planning, implementing, and evaluating language access services.

  • https://www.thinkculturalhealth.org/LanguageAccessServices.asp


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In-Language Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • National Network of Libraries of Medicine Health Brochures in Other Languages

    • http://nnlm.gov/outreach/consumer/multi.html#A2#A2

  • Healthy Roads Media (Health resources in many languages and multiple formats.

    • http://www.healthyroadsmedia.org/index.htm


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Quality Improvement Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Multicultural Healthcare: A Quality Improvement Guide (Based on CLAS Standards)

  • New resource from the National Committee for Quality Assurance, developed in collaboration with Lilly USA

  • QI initiatives to improve culturally and linguistically appropriate services (CLAS) and to reduce disparities in health care

  • http://www.clashealth.org/


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Continuing Education Resources ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • Think Cultural Health -- free online courses with continuing education credits for physicians and nurses.

  • Sponsored by the Office of Minority Health (OMH)

  • https://www.thinkculturalhealth.org/


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Conclusion ethnic disparities in health care, and of the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future health care providers can benefit from cross-cultural education programs.”

  • The 2008 National Healthcare Disparities Report concluded that some Americans receive even worse care than other Americans, due in part to differences in access to care, provider biases, poor provider-patient communication, poor health literacy, and other factors.


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Thank you for being part of the growing nationwide effort to help bridge the gap in health disparities.


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