Health Disparities/ Cultural Competence Curriculum

1. Health Disparities/Cultural Competence Curriculum Clinical Addiction Research and Education Unit Section of General Internal Medicine Boston University Schools of Medicine and Public Health Supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) R25 AA013822

2. Health Disparities/Cultural Competence Curriculum Objectives • To assure cross-cultural efficacy when screening for alcohol problems and assessing alcohol problem severity • To encourage providers to approach patients with an understanding of and respect for the patient’s needs and cultural values • To improve provider sensitivity to cultural characteristics including race, ethnicity, cultural identity and societal factors that may effect the patient-provider interaction • To increase the awareness of current health disparities regarding alcohol (prevalence, morbidity, treatment)

3. Cross Cultural Efficacy • Why is assuring cross cultural efficacy important?

4. Institute of Medicine Report • Assessed the extent of racial and ethnic disparities in healthcare • Reviewed >100 studies assessing quality of healthcare for various racial and ethnic minority groups • Even when insurance, income, and medical profiles are the same as whites, minorities often receive fewer tests and less sophisticated treatment for their ailments

5. Alcohol-Related Health Disparities Compared with whites: • Hispanic men have higher rates of alcohol-related problems, intimate partner violence, cirrhosis mortality • Black men have higher rates of intimate partner violence and cirrhosis mortality

6. Potential Sources for Disparities in Care • System-Level Factors: funding for mental health and substance abuse treatment, linguistic abilities of care providers • Patient-level factors: patient beliefs and preferences, trust and spirituality, stress and coping behaviors, explanatory model • Physician-level factors: the clinical encounter, default decision making, emphasis on prior expectations based on age, gender, race or ethnicity; bias, prejudice, stereotyping

7. Disparities:An integrated model • Social, Economic and Cultural Influences • Financial Incentives • Institutional Design • Legal Environment • Cultural Influences Medical History Patient Input Subject to ambiguity And misunderstanding Racially and Culturally Disparate Clinical Decisions INTERPRETATION INTERVENTION Data Physical Examination Diagnostic Test Results • Normative Values and Stereotyping • Conscious • Unconscious • Prejudice • Conscious • Unconscious

8. Cultural Competence Integrationvalues a variety of cultures, integrates aspects of other cultures in own Adaptation skilled in communicating across differences and can take on other’s view Acceptancerecognizes and values differences Minimizationtrivializes difference; similarities means “like me” Defensethreatened by perceived differences Where are you on this spectrum? Denialthere is no difference

9. Race • A social construct, varying by location, associated with certain physical attributes • Some shared ancestry and common gene pools but: genetic variation depends on geographic dispersal and varies MORE WITHIN most common racial groups THAN BETWEEN groups

10. Minorities View of the Healthcare System Health Quality Survey Commonwealth Fund 2002 • Minorities report belief that: • They are more likely to be treated with disrespect • They would receive better care if not black • Staying healthy is luck • Minorities report a greater difficulty communicating with physicians

11. Historical Relationship to the Healthcare System Tuskegee as an event and metaphor • 63% of AA and 38% of whites believed MDs often prescribe meds to experiment without consent • 25% of AA and 8% of Whites believe MD had given them experimental treatment without consent • 45% of AA and 35% of Whites believed MDs would expose them to unnecessary risk • 2 x as many AA as Whites felt they could not freely question their doctors

12. Bridging the Gap RESPECT- a framework that can assure effective cross cultural communication Respect Explanatory model Sociocultural context Power Empathy Concern and fears Trust

13. RESPECT • Respect - a demonstrable attitude • Explanatory Model - what is the patient’s point of view regarding his/her alcohol use • Sociocultural context - in what context does his/her drinking occur • Power - share the power in the patient-provider interaction

14. RESPECT • Empathy - make sure the patient feels understood • Concerns and fears - elicit patient’s fears regarding alcohol use • Trust - provider’s goal to deliver appropriate, effective healthcare most easily achieved when there is a therapeutic alliance and shared objectives between provider and patient