Cultural Competency

Cultural Competency - 5TH Annual Primary Care &...

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Unformatted text preview: 5TH Annual Primary Care & Prevention Conference MULTICULTURAL MEDICINE MEDICINE AND ENSURING GOOD HEALTH FOR ALL FOR Rubens J. Pamies, M.D., FACP UNMC, Vice Chancellor for Academic Affairs/Dean for Graduate Studies Professor of Internal Medicine September 21-23, 2005 September Wyndham Atlanta Hotel, Atlanta GA Wyndham IOM REPORT: UNEQUAL TREATMENT UNEQUAL “Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factor as such as patient’ insurance status and income are controlled. The sources of these disparities are complex, are rooted in historic and contemporary inequities, an involve many participants at many levels . . .” IOM REPORT: IOM UNEQUAL TREATMENT UNEQUAL “The [IOM] study committee focused part of its analysis on the clinical encounter itself and found evidence that stereotyping, biases, and uncertainty on the part of healthcare providers can all contribute to unequal treatment.” Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002), Institute of Medicine. http://www.nap.edu/books/030908265X/html/ IOM REPORT: IOM UNEQUAL TREATMENT UNEQUAL “The Physician-Patient interaction is a contributing factor causing health disparities.” Recommendations: Training programs should incorporate curriculum that will help health care providers gain the skills needed to navigate the cross-cultural interaction. CURRENTLY CURRENTLY Only 9% of U.S. Medical schools offers a separate course in the curriculum that addresses cultural competency Less than half offer course work in health disparities ISSUES THAT NEEDS TO BE INCLUDED IN CROSS-CULTURAL CURRICULUM CROSS-CULTURAL Stereotyping and bias Perception of health and illnesses Communication and language Knowledge of health disparities Understanding the role of culture in health care Cultural competency training DEMOGRAPHICS DEMOGRAPHICS AND AND IMMIGRATION DOCUMENTED IMMIGRATION DOCUMENTED By Area of Origin 120% 100% 97% 94% 89% 87% 83% 79% 80% 63% 60% 47% 40% 34% 34% 34% 23% 21% 20% 14% 1%2%0% 0% 00 19 19 18 3% 4% 0% 10 19 10 19 7% 20 19 11 19 4% 0% 3% 0% 30 19 12 19 13% 10% 40 19 13 19 Europe 3% 0% 50 19 14 19 Latin America 8% 8% 4% 4% 60 19 15 19 Asia 41% 36% 12% 7% 70 19 16 19 Other Areas 80 19 17 19 14% 9% 90 19 18 19 9% UNITED STATES CENSUS 2002 Asian 4% Asian 5% African American 3% African American 12% Hispanic 13% White 69% Hispanic 14% White 67% Other/Native American 2% 2000 Asian 8% African American 14% Other/Native American 1% 2010 White 53% Hispanic 25% Other/Native American 1% 2050 AVERAGE ANNUAL RATE OF NATURAL INCREASES AND NET IMMIGRATION INCREASES Rate per 1,000 Population Race Ethnicity White Hispanic African American Natural Net Increase Immigration 5.1 0.5 21.2 17.1 14.8 *Lewit, E.M. and Baker, L.G., Race and Ethnicity-Changes for Children The Future of Children, Vol. 4, No. 3 Winter 1994 DEMOGRAPHICS DEMOGRAPHICS By the year 2050: – 80 million people in the U.S. will be from immigrant groups who came here after 1994 – They will make up 25% of the total U.S. population DEMOGRAPHICS DEMOGRAPHICS 1 out of every 5 children under age 18 is the child of an immigrant. 75% of these children are from regions of the world where English is not spoken. The most common language spoken in these groups is Spanish. These children are disproportionately minorities, poor, and uninsured. Table 18-4 Table TOP 10 COUNTRIES WITH HIGHEST PROPORTION OF MEDICAL GRADUATES IN THE UNITED STATES THE Country Percentage of the U.S. IMG Population India 19.5% Pakistan 11.9% Philippines 8.8% Ex-USSR 3.1% Egypt 2.6% Dominican Republic 2.5% Syria 2.5% United Kingdom 2.4% Germany 2.3% Australia 2.1% SOURCE: The Educational Commission for Foreign Medical Graduates, 1992. GROWTH IN MIDWEST’S POPULATION BY RACIAL AND ETHNIC GROUP U.S. CENSUS 1990 AND 2000 1990 2000 CENSUS PERCENT CHANGE State Total Pop White % Black % Latino % Asian % Native % Other Kansas 2,688,418 86.1 -4.0 5.7 -0.1 7.0 3.2 1.7 0.5 0.9 0.0 3.4 Nebraska 1,711,263 89.6 -4.2 4.0 0.4 5.5 3.2 1.3 0.5 0.9 0.1 2.8 Oklahoma 3,450,654 76.2 -5.9 7.6 0.2 5.2 2.5 1.4 0.4 7.9 -0.4 2.4 Iowa 2,926,324 93.9 -2.7 2.1 0.4 2.8 1.6 1.3 0.4 0.3 0.0 1.3 Missouri 5,595,211 84.9 -2.8 11.2 0.5 2.1 0.9 1.1 0.3 0.4 0.0 0.8 % FACTORS LEADING FACTORS TO DISPARITIES TO HEALTH BEFORE CARE CARE Poverty Socioeconomic Status Environmental Conditions Health Before Care Lifestyle Choices Education Level Employment HEALTH CARE DELIVERY Effectiveness DELIVERY Insurance Cultural Competency of Care Appropriateness of care Pt-Provider Communication Health Care Delivery Ethnic/ Racial Predilection Of Diseases Pt. adherence to tx plan Pt. Preference Provide Bias HEALTH HEALTH CARE ACCESS ACCESS Finance Availability of Providers Distrust Proximity of Providers Health Literacy Health Care Access Legal Barriers Transportation Medical Home Diversity of Workforce Pts Cultural Preference Language Barriers Insurance Health Care Access Socioeconomic Status Proximity of Providers Health Literacy Availability of Providers Health Before Care PatientProvider Communication Medical Home Poverty Distrust What Difference Can I Make? Make? Cultural Competency Appropriateness of care Pt. adherence to tx plan Ethnic/Racial Predilection Of Diseases Finance Effectiveness of Care Pts Cultural Preference Legal Barriers Lifestyle Choices Diversity of Workforce Health Care Delivery Pt. Preference Employment Provide Bias Environmental Conditions Education Level Transportation Language Barriers HEALTHY PEOPLE 2010 GOALS GOALS Increase quality and years of healthy life Eliminate health disparities AGE ADJUSTED MORTALITY RATES, UNITED STATES 2000 RATES, Deaths per 10,000 1200 1000 800 600 400 200 0 White Race/Etnicity AA/B HIV/AIDS DEATH RATE HIV/AIDS AGE> 13, RATES PER 100,000 POPULATION 115.3 120 100 80 55.8 60 40 20 0 16.2 WHITE 14.1 BLACK HISPANIC AI/AN 7.5 ASIAN/PI ADULT IMMUNIZATIONS ADULT AGE >65, PERCENT OF POPULATION 60 60 49.9 50 49 50.8 39.7 38.6 40 31 27.4 30 20 15 10 0 FLU White PNEUMO Black Hispanic AI/AN ASIAN/PI 14 CANCER DEATH RATE CANCER DEATHS PER 100,000 POPULATION 180 167.8 160 140 125.2 120 100 77.8 84.9 80 76.3 60 40 20 0 WHITE BLACK HISPANIC AI/AN ASIAN/PI W H CARDIOVASCULAR DISEASE DEATH RATE CARDIOVASCULAR DEATHS PER 100,000 POPULATION DIABETES-RELATED DEATH RATE DIABETES-RELATED DEATHS PER 100,000 POPULATION INFANT MORTALITY INFANT DEATHS PER 100,000 POPULATION ASIAN/PI 5.3 AI/AN 9 7.6 HISPANIC 14.7 BLACK 6.3 WHITE 0 2 4 6 8 10 12 14 16 RACIAL & ETHNIC DISPARITIES RACIAL INFANT MORTALITY 1 4 13.5 D e a t h s P e r 1 ,0 0 0 L i ve B i r t h s 1 2 1 0 Year 2010 Goal 8 5 .7 6 4 2 0 African Amrican e W ite h NCHS 2003 RACIAL & ETHNIC DISPARITIES RACIAL LOW BIRTH WEIGHT < 2500g 1 4 1 2 P e r ce n t of L i ve B i r t h s 1 3 .4 % 1 0 Year 2 0 1 0 Goal 8 6 .9 % 6 4 2 0 African Am rican e W ite h NCHS 2003 RACIAL & ETHNIC DISPARITIES RACIAL VERY LOW BIRTH WEIGHT <1500g 3 2.5 3.2% Percent of Live Births 2 1.5 Year 2010 Goal 1 1.2% 0.5 0 African American White NCHS 2003 RACIAL DISPARITY RACIAL PRETERM BIRTHS <37 WEEKS 18 16 Percent of Live Births 17.7% 14 12 10 Year 2010 Goal 11% 8 6 4 2 0 African American White NCHS 2003 RACIAL DISPARITY VERY PRETERM BIRTHS < 32 WEEKS PRETERM 4 3.5 Percent of Live Singleton Births 4% 3 2.5 2 Year 2010 Goal 1.5 1.6% 1 0.5 0 NCHS 2003 African American White INFANT MORTALITY FOR AFRICAN AMERICANS & WHITES, U.S. 1980-2000 AFRICAN NCHS RACIAL & ETHNIC DISPARITIES RACIAL INFANT MORTALITY - Per 1,000 Live Births INFANT 14 12 0 NCHS 2002 Chinese Japanese Cuban Mexican White Filipino 2 Hawaiian 4 Year 2010 Goal Puerto Rican 6 Native American 8 African American 10 RACIAL & ETHNIC DISPARITIES RACIAL INFANT MORTALITY, HISPANIC 9 P e r 1 ,0 0 0 L i ve B i r t h s 8 8.3 7 7.2 6 5 5.5 4.7 4 4.7 3 2 1 0 NCHS 2002 Mexican Puerto Rican Cuban Central/SA Mexican Puerto Rican Cuban Central/SA Other Other RACIAL & ETHNIC DISPARITIES RACIAL CAUSES OF INFANT DEATHS - Per 1,000 Live Births CAUSES 3 Birth Defects Preterm/LBW SIDS 2.5 2 1.5 1 0.5 0 African American Native American Hispanic Asian/PI White NCHS 2001 RACIAL AND ETHNIC DISPARITIES RACIAL BIRTH OUTCOMES BIRTH Why? Why? RACIAL AND ETHNIC DISPARITIES RACIAL BIRTH OUTCOMES BIRTH Race? Race? RACIAL AND ETHNIC DISPARITIES RACIAL BIRTH OUTCOMES BIRTH Race has no clear biologic or Race genetic basis genetic Genetic diversity appears to be a continuum, with no clear breaks delineating racial groups. racial Science 1998 Science RACIAL AND ETHNIC DISPARITIES RACIAL BIRTH OUTCOMES BIRTH Many birth outcomes have no clear Many genetic basis genetic RACIAL AND ETHNIC DISPARITIES RACIAL LOW BIRTH WEIGHT & NATIVITY 6 Scribner 1989 5.5% Percent LBW 5 4 3 3.9% 2 1 0 Mexico Born United States Born Mexican Americans RACIAL AND ETHNIC DISPARITIES RACIAL LOW BIRTH WEIGHT & NATIVITY 8 Per 1,000 Live Births 7 7.3 6 5 5.3 4 3 2 1 0 Foreign Born All Races United States Born NCHS 2002 RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY 16 Per 1 ,0 0 0 L i v e B i r t h s 14 14.2 12 10 8 9.2 6 4 2 0 Foreign Born United States Born African Americans NCHS 2002 RACIAL AND ETHNIC DISPARITIES RACIAL BIRTH OUTCOMES BIRTH Behavior? Behavior? RACIAL & ETHNIC DISPARITIES RACIAL INFANT MORTALITY & CIGARETTE SMOKING 16 14 12 10 8 14.3 13.7 African American 9.7 White 6 6 4 African American White 2 0 Infant Mortality Cigarette Smoking NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & CIGARETTE SMOKING 14 12.8 Per 1,000 Live Births 12 9.4 10 8 6 4 2 0 African American Non-Smokers White American Smokers NCHS 2002 RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES DISPARITIES Prenatal Care? Care? RACIAL & ETHNIC DISPARITIES RACIAL FIRST TRIMESTER PRENATAL CARE Per cen t of L i ve B ir t h s 100 84% 90 80 74% 70% 74% 85% 70 60 50 40 30 20 10 0 NCHS 2002 African Am Native Am Hispanic Asian/PI White RACIAL & ETHNIC DISPARITIES RACIAL INFANT MORTALITY & PRENATAL CARE African American 14.1 African American Hispanic 74% 74% 74% Hispanic 5.7 NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & PRENATAL CARE 14 12 12.7 Per 1,000 Live Births 10 8 5.2 6 4 2 0 African Americans First Trimester Prenatal Care White Americans First Trimester Prenatal Care NCHS 1999 RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES SES? SES? RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION 14 12 African American 14.1 African American 10 74% 74% 8 6 4 2 0 N CH S 2 0 0 2 Hispanic Hispanic 5.7 51% RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION 12 10.2 Per 1,000 Live Births 10 8 6.8 6 4 2 0 NCHS 2002 African Americans 16+ years of schooling White Americans <9 years of schooling RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES Stress? Stress? RACIAL & ETHNIC DISPARITIES RACIAL STRESS AND CRH IN PREGNANCY Levels of Corticotrophin Releasing Hormone (CRH) 1000 900 800 P < 0 .0 0 1 Preterm Control 700 600 500 400 300 200 100 0 18-20 wks H ob el 1 9 9 8 28-30 wks 35-36 wks STRESS AND PRETERM BIRTH Money Preterm Birth Work Relations Health Abuse Safety Racism Stress Intrauterine Growth Retardation Low Birth Weight Infant Mortality STRESS AND PRETERM BIRTH Money Preterm Birth Work Relations Health Abuse Safety Racism Stress Intrauterine Growth Retardation Low Birth Weight Infant Mortality RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & RACISM 20 Percent Women Reporting Discrimination 18 16 Collins 2000 20% P < 0.01 14 12 12% 10 8 6 4 2 0 <1,500 g > 2,500 g Birthweight RACIAL AND ETHNIC DISPARITIES RACIAL CULTURE AND RACISM While it is true that other US racial and ethnic minorities have suffered economic and social discrimination, few, if any, have faced these exposures for as long as have African Americans, nor have they faced them standing on an economic and cultural base that was systematically undermined by the larger society. undermined James (1993) LIFE COURSE PERSPECTIVE Poor Nutrition, Stress Abuse, Tobacco, Alcohol, Drugs, Poverty Lack of Access to Health Care Exposure to Toxins White African American P oor B i r t h O u t com e Age 0 5 Puberty Pregnancy ALLOSTASIS ALLOSTASIS M cE w en 1 9 9 8 STRESS AND ALLOSTASTIC LOAD STRESS M cE w en 1 9 9 8 ALLOSTASIS ALLOSTASIS Ch ik an za 2 0 0 0 LBW & VLBW INCREASE WITH INCREASING AGE IN BLACKS BUT NOT IN WHITES AGE B lack 30 Perce t L W &V B nB LW 25 20 15 10 5 0 15 -19 20-24 25-29 M rnal Age ate Ger on im u s 1 9 9 6 30-34 W ite h AMONG AFRICAN AMERICANS, LBW INCREASES WITH INCREASING AGE IN LOW SES BUT NOT HIGH SES SES 15 20 25 30 Odds of Low Birth Weight 3.5 3 2.5 2 1.5 1 0.5 0 Low SES Average SES African Americans r on im u s 1 9 9 6 High SES 34 AS AFRICAN AMERICAN WOMEN GET OLDER, THEY ARE MORE LIKELY TO SMOKE CIGARETTES THEY Black White Percent of women smoke cigarettes during pregnancy 35 30 25 20 15 10 5 0 15 20 25 Age r on im u s 1 9 9 6 30 LIFE COURSE PERSPECTIVE White African American Primary Care for Children Early Intervention Prenatal Care Primary Care for Women Prenatal Internatal Care Care Poor Birth Outcome Age 0 Lu 2003 5 Puberty Pregnancy ORAL HEALTH ORAL DISPARITIES DISPARITIES ORAL HEALTH FACTS ORAL Over one third of the U.S. population (100 million people) has no access to community water fluoridation. is Over 108 million children and adults lack dental insurance, which over 2.5 times the number who lack medical insurance. Professional care is necessary for maintaining oral health, yet 25 percent of poor children have not seen a dentist before entering kindergarten. Americans make up 2.2 % of dentists, Hispanic Americans accounting for 2.8% and Native American representing .2% SUPPLY OF DENTIST 56 Schools of Dentistry in US. 4,618 First Year dental students (2003 7,987 applicants (2003) 5.4% of dental students are AfricanAmerican (vs. 12% of US population) 5.9% of dental students are Hispanic/Latino (vs. 12% of population) R. Strauss, U of North Carolina/L. Tedesco, U. of Michigan HEALTHCARE HEALTHCARE MANPOWER MANPOWER DISTRIBUTION OF SELECTED HEALTH PROFESSIONS BY RACE AND ETHNICITY PROFESSIONS Non-Hispanic Non-Hispanic White Black Am Indian Asian/ Pacific Islander Clinical laboratory technologists & technicians 18% 1% / 7% Dentists 86% 3% 0% / 9% Dental Hygienist 96% 2% 0% / 0% Dietitians 71% 19% 0% / 5% Health records technologists & technicians 73% 18% 0% / 7% Occupational therapists 88% 3% 0% / 1% Radiology technicians 80% 11% 0% / 1% Registered nurses 87% 5% 0% / 4% Respiratory therapists 80% 12% 0% / 3% Social workers 66% 23% 1% / 2% Speech therapists 94% 4% 0% / 0% Pharmacists 79% 3% 0% / 14% TOTAL RESIDENT U.S. POPULATION Table 18-2 67% 71% 12% 1% / 4% Table 18-1 Table HEALTH PROFESSIONS WITH THE GREATEST PROJECTED JOB OPENINGS, 2000-2010 PROJECTED Occupation Employment (in thousands) Increase Projected % 2000 2010 Registered nurses 2,194 2,755 25.6 Nurse aides, orderlies, and attendants 1,373 1,697 23.5 Home health aides 615 907 47.3 Personal and home care aides 414 672 62.5 Licensed practical and licensed vocational nurses 700 842 20.3 Medical assistants 329 516 57.0 Physicians and surgeons 598 705 17.9 Dental assistants 247 339 37.2 Medical and health services managers 250 330 32.3 Pharmacy technicians 190 259 36.4 Source: Bureau of Labor Statistics (2001b). Employment by Occupation, 2000and Projected 2010available at http://www.bls.gov/emp/emptab21.htm. HEALTH DISPARITY IN THE IMMIGRANT POPULATION POPULATION 10 MOST COMMON PROBLEMS SEEN IN THE AFRO-CARIBBEAN COMMUNITY SEEN Reported domestic violence is #1 among Afro-Caribbean in Boston Lack of insurance/unemployment Language barriers Fear of immigration Led Poisoning, HIV/AIDS TB/(reactivation) Breast & Cervical Cancer - diagnosed very late Untreated D.M./CVD Immunization HEATH ISSUES HEATH Increase risk for childhood vaccine – Increase preventable illnesses, ex: chronic Hep.B, Rubella Rubella Other conditions, includes: – Intestinal parasite – Malaria – Typhoid Fever – Malnutrition, (Iron Folate and B-12 deficiency) Malnutrition, (Iron HEATH ISSUES HEATH Asthma – very common in all immigrant Asthma groups, most common in non-Hispanic Blacks Blacks Dental disease – 77% of immigrants needed Dental emergency dental care (study in San Francisco immigrant population) Francisco Mental Health: – PTSD – Depression (many goes undiscovered because of cultural differences) BARRIERS IN THE HEATH CARE SYSTEM IN Prevents optimum care for immigrants, Prevents ex: ex: – Clinic vs. private physician’s office. – Delay in providing medical emergency Delay care. care. – PRWORA (Personal Responsibility and PRWORA Work Opportunity Reconciliation Act of 1996) 1996) – Availability of translators CULTURAL CULTURAL COMPETENCE COMPETENCE CULTURAL COMPETENCE, CULTURAL OUTCOMES, AND QUALITY OF CARE OUTCOMES, Cultural differences between providers Cultural and patients affect the provider-patient relationship. relationship. How patients feel about the quality of that How relationship is directly linked to patient satisfaction, adherence, and subsequent health outcomes. health Stewart M, et al, Cancer Prev Control. 1999 CULTURAL COMPETENCE CULTURAL Focus Instruction Communication methods Identify the patient’s preferred method of communication. Make necessary arrangements if translators are needed. Language barriers Identify potential language barriers (verbal and nonverbal). List possible compensations. Cultural identification Identify the patient’s culture. Contact your organization’s culturally specific support team (CSST) for assistance. Comprehension Double-check: Does the patient and/or family comprehend the situation at hand? Beliefs Identify religious/spiritual beliefs. Make appropriate support contacts. CULTURAL COMPETENCE CULTURAL Focus Instruction Trust Double-check: Does the patient and/or family appear to trust the caregiver? Remember to watch for both verbal and non-verbal cues. If not, seek advice from the CSST. Recovery Double-check: Does the patient and/or family have misconceptions or realistic views about the caregivers, treatment, or recovery process? Make necessary adjustments. Diet Address culture-specific dietary considerations Assessments Conduct assessments with cultural sensitivity in mind. Watch for inaccuracies. Healthcare providers bias Always remember, we all have biases and prejudices. Examine and recognize yours. CULTURAL COMPETENCY LEARN Model LEARN Listening to the patient’s perspective Explaining and sharing one’s own perspective Acknowledging differences & similarities between these two perspectives Recommending a treatment plan Negotiating a mutually agreed-on treatment plan Berlin EA, Fowkes, WC Jr. West J Med 1983; 139(6):934-8 Do you speak another language? Do you work with staff who speak another language? Do you offer health materials and/or appointment materials in other languages? Do you have a list of community resources that serve a variety of ethnic groups? Do you ask you patients about heir use of alternative health practices? Do you ask about the use of home remedies, medicines, or treatments? Have you attended a cultural diversity seminar workshop in the past year? Does your screening procedure include cultural lifestyle issues such as dietary practices, health beliefs, home remedies, medicines, or other treatments? Do you have an interpreter system for non-English-speaking patients? Do you know key words and phrases in the languages of your patients? Good morning!/How are you?/Thank you! CULTURAL DIFFERENCES AND EXPECTATION OF IMMIGRANT POPULATION POPULATION Need to have a prescription after every Need visit. visit. Injected medicine are preferable. Decision maker – father or grandmother. Use of alternative/home remedies Gender preference of health professional How they express pain or discomfort RESOURCES RESOURCES Bureau of Primary Health Care of the US Dept of Health and Human Services (DHHS) Cultural Linguistically Appropriate Health Care Service (CIAS) Cultural Brokers: Individuals who are bicultural and bilingual that can assist in the delivery of culturally appropriate care Other resources: mental health for immigrant program (MHIP); National Center for Cultural Competency (NCCC). WHAT IS NEEDED? WHAT National guidelines and standards. Funding to assist hospital, physician’s office, clinics and community health centers to assist in providing culturally appropriate and comprehensive care Research “In the end, In it’s not what we don’t know that will destroy us… will but rather the failure to respond appropriately to what we do know” know” ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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