Cultural Competency in Health Care Dr. Dorothy Dobbins Office of Cultural Affairs ETSU-Division of Health Sciences QI Resident Training Project April 8, 2009

Learning Objectives Define cultural competency By the close of this session, you will be able to: Define cultural competency Understand the impact of culture on health outcomes, i.e. health disparities in general and of the region Identify at least one model for enhancing cultural competency Discuss and relate cultural competency to the development of quality improvement activities in clinics.

Cultural Competency is: That set of knowledge, skills, behaviors, attitudes, and level of self awareness that allows an individual to work effectively in cross cultural settings. Cultural Competency Framework

Race Religion Nationality Region Culture Age the patterns of behavior and thinking that people living in social groups learn, create, and share. Ability Gender Sexual - Affectual

Changing Demographics Table F. Population Change of Regions by Race and Hispanic Origin: 1995 to 2025 (In thousands.) _________________________________________________________________ Year Total ----------Non-Hispanic--------- and White Black American Asian Hispanic region Indian origin U.S. 72,295 15,594 11,920 812 11,970 31,999 Northeast 5,927 -2,074 1,495 32 2,319 4,155 Midwest 7,306 1,825 1,857 194 1,132 2,298 South 29,558 10,407 7,642 199 1,792 9,518 West 29,504 5,436 926 387 6,727 16,028 Source: U.S. Bureau of the Census, Population Division, PPL-47, Preferred Series, PPL-47, table 3.

Health Disparities Specific population based differences in mortality and morbidity rates in diseases and treatment outcomes

Disparities in Health Care The Kaiser Family Foundation (2002) National Survey of Physicians: Doctors on Disparities in Health Care Institute of Medicine (2002) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care The Commonwealth Fund (2002) Minority Americans Lag Behind Whites on Nearly Every Measure of Health Care Quality During the past several years numerous major reports have been released highlighting disparities in health care based on race and ethnicity. “Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable.”-- Alan Nelson, retired physician, former president of the American Medical Association and chair of the committee that wrote the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Cancer screening and management Minority Populations are Disproportionately Affected Cardiac disease Diabetes Infant mortality HIV Infections/AIDS Cancer screening and management Immunizations                                                    Racial and ethnic groups experience serious disparities in health access and outcomes for many different diseases and conditions. Source: Centers for Disease Control and Prevention, http://www.cdc.gov/omh/AboutUs/disparities.htm Hispanics have higher rates of high blood pressure and obesity and are almost twice as likely to die from diabetes as are non-Hispanic whites. Despite recent national improvements in the infant death rate, rates among African Americans and Native Americans is still more than twice that of whites. Asians and Pacific Islanders living in the United States are developing hepatitis and tuberculosis at higher rates compared to whites.

Health Disparities http://www.ahrq.gov/qual/nhqr05/Index.html http://www.ahrq.gov/qual/nhqr05/safety/T2-38.htm The 2007 National Healthcare Quality Report (NHQR) is a comprehensive national overview of quality of health care in the United States.

Appalachian Experience

Where You Live Is Linked to Life Expectancy “The Eight Americas” “Eight Americas” Murray & et al. Harvard University 2006 article -Investigation of Morality Disparities across Races, Counties, and Race-Counties in the US (1982-2001) Used race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate in combination with the “traditional” variables (highlighted in the 2001 Health Disparities Study by IOM) to determine life expectancy, risk of mortality from specific diseases, health-care utilization. These “8 Americas” consisted of tens of millions Americans Concluded that the disparities observed in life expectancy couldn’t be explained by race, income, or basic health-care access and utilization alone. Suggested that Asian Americans (#1) as a group and Asian women in particular obtain the greatest longevity – even into the second and third generation –while blacks (males in particular) living in high-risk urban areas (#8) and Native American/American Indian (America 5) (males in particular) represent the America with the shortest longevity. What is of important to you as future physicians – many of whom will remain in the state (ranked 47th in health index)/South- is that America 4 consists of low-income white populations in Appalachia and the MS Valley; and America 7 is comprised mainly of rural blacks in the Deep South. Can anyone tell me the focus of the Quillen College of medicine mission? Where You Live Is Linked to Life Expectancy Source: Investigation of Morality Disparities across Races, Counties, and Race-Counties in the US (1982-2001), Murray et. Al., 2006

“Eight Americas” Murray & et al. Harvard University Northland L-I Rural Whites Asians High Risk Urban Blacks Middle America L-I Southern Rural Blacks L-I Whites Appalachia/ MS Valley Black Middle America Western Native Americans “Eight Americas” Murray & et al. Harvard University 2006 article -Investigation of Morality Disparities across Races, Counties, and Race-Counties in the US (1982-2001) Used race, location of the county of residence, population density, race-specific county-level per capita income, and cumulative homicide rate in combination with the “traditional” variables (highlighted in the 2001 Health Disparities Study by IOM) to determine life expectancy, risk of mortality from specific diseases, health-care utilization. These “8 Americas” consisted of tens of millions Americans Concluded that the disparities observed in life expectancy couldn’t be explained by race, income, or basic health-care access and utilization alone. Suggested that Asian Americans (#1) as a group and Asian women in particular obtain the greatest longevity – even into the second and third generation –while blacks (males in particular) living in high-risk urban areas (#8) and Native American/American Indian (America 5) (males in particular) represent the America with the shortest longevity. What is of important to you as future physicians – many of whom will remain in the state (ranked 47th in health index)/South- is that America 4 consists of low-income white populations in Appalachia and the MS Valley; and America 7 is comprised mainly of rural blacks in the Deep South. Can anyone tell me the focus of the Quillen College of medicine mission?

Gender, Race and Age Segments Specific Percent of Excess Mortality Rates in the Appalachian Region Compared to Total US Rates by Cause of Death, 1990-1997 Cause of Death Premature Mortality 35-64 Elderly Mortality age 65+ White Male Female Black Heart disease 27.4% 29.8 9.0 12.2 10.9 11.6 1.3 -5.7 Cancers 3.0 -2.1 5.0 -2.3 -4.9 Stroke 17.9 14.5 15.7 13.8 3.9 .8 .9 Lung Cancer 27.7 2.7 4.2 -3.7 -8.3 -3.4 -11.8 Accidental deaths -1.5 -2.0 2.4 16.9 10.2 10.3 12.5 COPD 6.6 9.2 14.9 11.9 -.7 6.0 -1.0 Diabetes 14.8 22.4 10.7 20.5 3.6 23.0 -3.5 1.2 Motor Vehicle Accidents 25.8 23.3 23.4 19.1 21.1 13.7 21.3 5.7 Halverson, J.A., Ma, L., and Harner, E.J. (2004). An analysis of disparities in health status and access to health care in the Appalachian region. Washington DC: Appalachian Regional Commission.

Kaiser National Survey of Physicians The Kaiser National Survey of Physicians was based on a nationally-representative sample of 2600 physicians whose primary responsibility is patient care. There responses were compared with those from a telephone interview of nearly 4000 U.S. adults. Both groups were asked how often they thought that our health care system treated people unfairly based on a number of factors, including health insurance status, whether they spoke English, educational level, racial or ethnic background, sexual orientation, disability, and gender. The bar graph shows how often physicians, in black, and the public, in gray, responded “very or somewhat often.” Their responses were quite different. As you can see, for every factor except health insurance status, doctors were much less likely to perceive unfairness in the health care system as compared to the general public. Only 29% of doctors, compared to 47% of the general public, thought that the health care system treated people unfairly based on race or ethnic background.

AETNA 2001 QUALITY CARE RESEARCH FUND Department of Family Medicine AETNA FOUNDATION AETNA 2001 QUALITY CARE RESEARCH FUND Project Title: "Assessing the Impact of Cultural Competency Training Using Participatory Quality Improvement Methods” Project Period: January 1, 2002 - December 31, 2003 Grantee: Center for Healthy Families and Cultural Diversity - Department of Family Medicine University of Medicine and Dentistry of New Jersey (UMDNJ) – Robert Wood Johnson Medical School Authors: Robert C. Like, MD, MS, Principal Investigator; Fulcomer, Kairys, Wathington, BA Jesse Crosson, PhD

Awareness Cultural Competency enacted within people and institutions requires adopting new paradigms (ways of thinking), which usually happens in stages Behaviors

Respect: A Cultural Competence Model Awareness (as a deliberate thought process) is an important first step in becoming culturally competent as an individual and an organization. Beyond gaining awareness, knowledge and skills, fundamentally cultural competency, whether at the individual or organizational level, must be about Above all, people, clients and organizations should be engaged in ways that provide: R – Rapport E – Empathy S – Support P – Partnerships E – Explanations C – Cultural T – Trust RESPECT! Source: Mutha, 2002

Beyond the Vital Signs What are some challenges you have faced with understanding the beliefs and/or practices of patients? What are some institutional policies that have limited your ability to treat your patient as an individual? What skills/behaviors did you note that appeared to be effective in handling cultural sensitive situations? Did the film suggest any cultural competency training for your residents that could improve the quality of patient care?