What’s race/ethnicity got to do with it? The Essential Role that College Health Can Play

2. What’s race/ethnicity got to do with it? The Essential Role that College Health Can Play Claire Brindis, Dr. P. H. Professor of Pediatrics and Health Policy National Adolescent Health Information Center University of California, San Francisco

3. Today’s Presentation Demographic Profile Risk-Taking Profile Opportunities for College Health as an agent of change Tips for Implementing Culturally-Appropriate Interventions

4. “Framing and Reframing” “It’s summer in Washington DC. A hazy, hot and humid, “triple H” day with predictions of numbers hovering in the mid 90’s. Imagine a 21 year-old young man of color. What do you think he would be doing that day? What do you think his prospects for the future would be? On the floor of the Senate in Congress, what words would be chosen to describe him and people like him?” Source: Hein, 1997

5. Defining DiversityWide Casting - Narrow Casting • Age • Cultural • Race/ethnicity • LGBT • Gender • Disabilities • Geographic Variability • Generational (including 1.5 generation) • Income • Genetic

6. GENETIC/BIOLOGIC • DIVERSITY • Gender • Age • SOCIOPOLITICAL CONTEXT • Legal system • Income • Family Policy • ORGANIZATIONAL • FACTORS • Access • Reimbursement • HEALTH BEHAVIORS • Adherence • Health promotion • Risk Taking/Resilience • SOCIALCONTEXT • Group history • Identity • Acculturation • PROVIDER FACTORS • Training • Cultural competence • PSYCHOLOGICAL FACTORS • Mood, affect • Self-efficacy • NEIGHBORHOOD • Social support • Income inequality • Environmental Exposures HEALTH DISPARITIES PERSONAL FACTORS CONTEXTUAL FACTORS HEALTH CARE SYSTEM Courtesy of Jill Joseph

8. Adolescents & Young Adults – Who are they? • Between 1990 and 2020, the number of adolescents ages 10-19 is projected to increase from 35 to 42 million (A 20% increase); representing 13% of the total population. Young adults ages 20-24 are expected to increase from 19 to 21 million between 2000 and 2020, an 11% increase; they represent approximately 7% of the total population. # in thousands US Population, Ages 10-19, 1980-2050 Sources: U.S. Census Bureau, 2000; U.S. Census Bureau, 2002

9. Young Adult Population (Ages 20-24) by Race/Ethnicity, 2000 vs. 2020 2000 2020 Sources: U.S. Census Bureau, 2000; U.S. Census Bureau, 2002

10. National Initiative to Improve Adolescent and Young Adult HealthGrounded in Healthy People 2010 • A comprehensive set of national disease prevention and health promotion objectives that measure the nation’s progress over time. • Two overarching goals of Healthy People 2010: • Increase quality and years of life; • Eliminate health disparities. www.healthypeople.gov

11. Adolescent- and Young Adult-Specific Health Objectives • 21 Critical Health Objectives for Adolescent & Young Adult Health: • Include individual health outcomes (injury, disease & death), as well as related behaviors (e.g., substance abuse, physical activity, safety belt use). • 21 Objectives fall into six general areas: • Mortality; • Unintentional Injury; • Violence; • Mental Health and Substance Abuse; • Reproductive Health; • Chronic Disease Prevention.

12. Trends in Mortality by Age Group, Ages 10-24, 1980-2005 Deaths per 100,000 Source: CDC Wonder, Compressed Mortality Database, 2009

13. Prevalence of Leading Health Indicators in US Young Adult Females: Health Care Source: Harris, K., et al, 2006

14. Prevalence of Leading Health Indicators in US Young Adult Females: Risk Factors Source: Harris, K., et al, 2006

15. Prevalence of Leading Health Indicators in US Young Adult Females: Mental Health Source: Harris, K., et al, 2006

16. Prevalence of Leading Health Indicators in US Young Adult Males: Health Care Source: Harris, K., et al, 2006

17. Prevalence of Leading Health Indicators in US Young Adult Males: Risk Factors Source: Harris, K., et al, 2006

18. Prevalence of Leading Health Indicators in US Young Adult Males: Mental Health Source: Harris, K., et al, 2006

19. How does the changing “face” of America and the Profile of Young Adult Health impact your health care delivery?

20. Lessons from Malcolm Gladwell’sBlink:“Listening with Your Eyes”

21. Potential Impacts of Growing Student Diversity on Health Care Access • Trust Issues • Fears of being judged and of poor quality care • Lack of experience in utilizing health care resources • Underlying levels of stress beyond “typical” college student – mental health (acculturative stress, discrimination, etc.) and other concerns

22. “Physicians had more verbally dominant and less patient-centered communication with African American patients compared with Whites.” “African American adults reported that perceived racism and mistrust of Whites had a significant negative impact on trust in their clinician and satisfaction in their health care.” Sources: Johnson, et al, 2004; Benkert, et al, 2006

23. What do diverse students from their providers? Respect and support Avoidance of negative stereotypes Quality Care Tailoring messages Concrete tools and guidance Shared patient-provider decision making

24. Examples of Cultural Factors in Young Adult Health Latino Students “Research has suggested that the utility of supporting the value of machismo, or manliness, which could encourage health-seeking behavior as a way of fulfilling cultural and familial obligations to be good fathers, husbands, and community members.” Asian American Students “Youth wanted clinicians to be knowledgeable about Asian cultural values and traditional medicine and wanted clinicians to help them communicate with their parents about difficult issues.” Native American Students “Research… has reported culturally specific variables associated with suicidal ideation, including perceived discrimination and lower identification with traditional ethnic culture.” Sources: Sobralske, 2006; Vo et al, 2007, Yoder et al., 2006

25. Importance of College Health Programs • Focus on prevention and primary care • Identifiable health care provider and care structure • Increased access to care with fewer traditional barriers in place. • Avoiding high out-of-pocket expenses in most cases. • Transition to young adulthood: a critical time to be establishing ties with primary care clinicians. • Prevent higher use of acute care with access to primary care, with the exception of trauma. Source: Collins et al., Commonwealth, 2006

26. Culturally Competent Interventions and Resultant Outcomes Source: Anderson, LM, et al. “Culturally Competent Healthcare Systems: A Systematic Review.” Am J Prev Med 24.3S (2003): 68-79.

27. Cultural Competence Broadening Tips 1. Use the University student profile and clinic data to conduct a Needs and Assets Assessment 2. Incorporate critical moments for outreach: freshman & transfer students 3. Adopt ecological approaches: link health center to special interest groups of students, race/ethnic-identified groups, tutoring, community service, etc. Example – • Cancer program manager at Howard University Cancer Center noted that the center was seeing an increase in the number of African American women in their 20s and 30s with breast cancer lumps. • The Center partnered with 5 schools to create a long-term initiative; in an open class period, “cultural broker” Kimberly shared her story with 11th and 12th grade girls, while a health educator taught breast self-examinations. Source: “Bridging the Cultural Divide in Health Care Settings,” 2004

28. Tips, contd. 4. Engage students in participatory research Example – • Date rape and violent dating relationships are significant problems on the Yankton Sioux reservation in South Dakota. • Focus groups for female teens were held at the Resource Center, in addition to regular independent meetings of youth that resulted in constant feedback on a developing curriculum. This resulted in a guide for teachers and a workbook for young women, which has been requested more than 300 times by schools, tribal youth programs, and shelters. 5. Use National Standards on Culturally and Linguistically Appropriate Services (CLAS) to guide your efforts. Example – “Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups represented in the service area.” Sources: “Bridging the Cultural Divide in Health Care Settings,” 2004

29. Tips, contd. 6. Use multi-media alternative health education, including e-mail reminders. 7. Identify programs developed with different ethnic/racial groups, incorporating a cultural lens, in a variety of areas—from tobacco to obesity prevention. Example – • AMA workbook on culturally effective care for adolescents: * cultural aspects of health care, such as distrust of government and medical systems, * language barriers, * cultural influences on worldviews, health beliefs, and health practices, and * identity formation and acculturation among immigrant youth. 8. Celebrate diversity and strengths resulting from having a diverse campus. 9. Document your findings for different racial/ethnic groups and share information. Source: Fleming & Towey, 2001

30. Resources • University of California, Los Angeles (UCLA)’s Center for Mental Health in Schools has coalesced a comprehensive clearinghouse for publications, reports, program descriptions, and more, all pertaining to “Cultural Competence and Related Issues”: http://smhp.psych.ucla.edu/qf/culturecomp.htm • The Asian and Pacific Islander Health Information Network (APIAHF) publishes census data, fact sheets, health briefs and research guides about the specific health needs of Asian Americans and Pacific Islander (AAPI) health information, resources and policy issues; and provides links to other AAPI youth focused groups http://www.apiahf.org/. • The Center for Women in Government and Civil Society’s Immigrant Women and State Policy department developed reports on immigrant youth and their specialized needs, including Creating Successful Programs for Immigrant Youthhttp://www.cwig.albany.edu/

31. Resources, contd. Healthy Teen Network has resources addressing cultural competency and various population groups: including resource kits on Young Men and LGBTQ Youth; provides information on cultural competency; research and resources on issues affecting various racial and ethnic groups, and links to relevant organizations: www.healthyteennetwork.org. The American College Health Association’s National College Health Assessment (NCHA) provides recent reports, including both summaries and detailed information, on the results of their broad survey of college students’ health and behavior: http://www.acha-ncha.org/

33. References “Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs.” National Center for Cultural Competence (Spring/Summer 2004): 1-29. “National Standards on Culturally and Linguistically Appropriate Services (CLAS).” The Office of Minority Health 12 April 2007. Web. 26 May 2009. <http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15> Benkert, R., et al. “Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care.” Journal of the National Medical Association 98 (2006): 1532-1540. Fleming, M. & Towey, K. “Delivering culturally effective health care to adolescents.” American Medical Association (2001) Harris, Kathleen M., et al. “Longitudinal Trends in Race/Ethnic Disparities in Leading Health Indicators from Adolescence to Young Adulthood.” Archives of Pediatrics & Adolescent Medicine 160 (2006): 74-81. Hein, Karen. “Framing and Reframing.” Journal of Adolescent Health 21 (1997): 215-217. Johnson, R.L., et al. “Patient race/ethnicity and quality of patient-physician communication during medical visits.” American Journal of Public Health 94 (2004): 2084-2090. Sobralske, M. “Machismo sustains health and illness beliefs of Mexican American men.” Journal of the American Academy of Nurse Practitioners 18 (2006): 348-350. Vo, D.X., et al. “Voices of Asian American youth: Important characteristics of clinicians and clinical sites.” Pediatrics 120 (2007): e1481-1493. Yoder, K.A., et al. “Suicidal ideation among American Indian youths.” Archives of Suicide Research 10 (2006): 177-190.

34. National Adolescent Health Information Center & Public Policy Analysis & Education Center for Middle Childhood, Adolescent & Young Adult Health WEB SITES http://nahic.ucsf.edu http://policy.ucsf.edu BY EMAIL nahic@ucsf.edu policycenter@ucsf.edu BY PHONE 415.502.4856 Public Policy Analysis & Education Center for Middle Childhood, Adolescent & Young Adult Health