CULTURALLY COMPETENT HEALTH PROMOTION AND DISEASE PREVENTION

Robert C. Like, MD, MS Associate Professor and Director Center for Healthy Families and Cultural Diversity Department of Family Medicine UMDNJ-Robert Wood Johnson Medical School

OBJECTIVES

• • • Review demographic and epidemiologic statistics relating to cultural diversity and health disparities in the United States, with a focus on cancer Discuss the difference between targeting and tailoring of interventions in community health promotion efforts Describe the health seeking process, different healing systems, and sources of care

OBJECTIVES

• • • Define the concept and rationale for culturally competent health care Identify strategies and resources that can facilitate the delivery of culturally and linguistically appropriate services Describe why community partnerships are needed in developing successful health promotion and disease prevention programs in multicultural communities

The Changing US Population

80 70 60 50 40 30 20 10 0 1990 1996 2005

Source: Bureau of the Census

2030 White African American Hispanic Asian/Pacific Islander American Indian/ Alaskan Native

U.S. Immigration 2001 Statistics

Top Ten Countries of Birth 1. Mexico 2. India 4. Philippines 5. Vietnam 6. El Salvador 7. Cuba 8. Haiti 9. Bosnia-Herzegovina 10. Canada N 206,426 70,290 53,154 35,531 31,272 27,703 27,120 23,640 21,933 % 19.4

6.6

5.3

5.0

3.3

2.9

2.6

2.5

2.2

2.1

U.S. Immigration 2001 Statistics

Top Ten 2. New York 3. Florida 4. Texas 5. New Jersey 6. Illinois 7. Massachusetts 8. Virginia 9. Washington 10. Maryland N 282,957 114,116 104,715 86,315 59,920 48,296 28,965 26,876 23,085 22,060 % 26.6

10.7

9.8

8.1

5.6

4.5

2.7

2.5

2.2

2.1

Within - Group Diversity

is often greater than

Between - Group Diversity

Institute of Medicine Reports

• • •

To Err is Human: Building a Safer Health System

(1999)

Crossing the Quality Chasm: A New Health System for the 21st Century

(2001)

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

(2002)

U.S. Department of Health and Human Services

HEALTHY PEOPLE 2010 INITIATIVE

“Eliminate health disparities experienced by racial and ethnic minorities by year 2010, while continuing the progress in improving the overall health of the American people.”

HEALTHY PEOPLE 2010 INITIATIVE

• • • • • • Infant Mortality Cancer Screening and Management Cardiovascular Disease Diabetes HIV/AIDS Infection Child and Adult Immunization

CANCER EPIDEMIOLOGY

Cancer Facts & Figures - 1997 Cancer Incidence Rates+ for all Sites Combines by Race, Ethnicity, and Sex, US, 1988-1992 Race or Ethnicity 560

African Americans Chinese Filipinos Hawaiians Japanese Koreans Vietnamese Alaska Natives American Indians Whites Hispanics

326 180 282 213 274 224 241 266 340 321 322 326 273 348 372 196 180 319 346

200

243

300 400 0 100

+Incidence rates are per 100,000 and are age-adjusted to the 1970 US standard population. *Persons of Hispanic origin may be of any race. Data Source: NCI Surveillance, Epidemiology, and End Results Program, 1996. © 1977, American Cancer Society, Inc.

469

500 Male Female 600

AGE-ADJUSTED MORTALITY RATES* FOR MAJOR CANCER FOR WHITE AND MINORITY GROUPS, BY UNDERLYING CAUSE OF DEATH, UNITED STATES, 1990.

Indicator American American Indian/ American Native Lung Cancer 54.0

67.5

27.9

26.8

35.6

Colorectal cancer Breast cancer Cervical cancer Prostate cancer 20.6

16.3

1.1

10.7

26.6

19.5

1.8

23.5

10.1

6.6 0.7

5.8

12.6

6.5

0.5

6.0

18.2

13.9

0.9

10.2

* Age-adjusted to the 1980 U.S. standard population; rate per 100,000 persons .

Source

: CDC, NCHS, National Vital Statistics Systems, 1990.

Source

: CDC, NCHS, National Vital Statistics Systems, 1990 .

CANCER PREVENTION

FIRST GENERATION HEALTH PROMOTION

• reducing health risks through interventions to broad population segments, with little or no differentiation in terms of target populations Pasick RJ, D’Onofrio CN, Otero-Sabogal R. “Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research,“ Health Education Quarterly 1996; 23 (Supplement) S142-S161.

SECOND GENERATION HEALTH PROMOTION

• • targeting racial and ethnic groups, yielding early efforts at identification of group-specific characteristics and needs interventions may be insensitive to within-group differences in language, culture, health, and life circumstances (eg, education, socioeconomic status) Pasick RJ, D’Onofrio CN, Otero-Sabogal R. “Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research,“ Health Education Quarterly 1996; 23 (Supplement) S142-S161.

THIRD GENERATION HEALTH PROMOTION

• • understanding determinants of pertinent behaviors that are universal (etic) and those that are culture specific (emic), as well as common and unique elements of intervention communities may be segmented not by ethnicity or race, but by differential health risks and stage of change ... interventions are tailored to those at highest risks Pasick RJ, D’Onofrio CN, Otero-Sabogal R. “Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research,“ Health Education Quarterly 1996; 23 (Supplement) S142-S161.

TARGETING VS TAILORING

COMMUNITY HEALTH PROMOTION

•

TARGETING

the process of identifying a population subgroup (defined by parameters relevant to health promotion goals and objectives) for the purpose of insuring exposure to the intervention by that group Pasick RJ, D’Onofrio CN, Otero-Sabogal R. “Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research,”“ Health Education Quarterly 1996; 23 (Supplement) S142-S161.

COMMUNITY HEALTH PROMOTION

•

TAILORING

adaptation of the intervention and/or total redesign to best fit the needs and characteristics of a target audience Pasick RJ, D’Onofrio CN, Otero-Sabogal R. “Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research, “ Health Education Quarterly 1996; 23 (Supplement) S142-S161.

PATHWAYS TO EARLY DETECTION

• • Medical Care System Pathway Community Socio-Cultural System Pathway Hiatt RA, Pasick RJ et al. “Pathways to Early Cancer Detection in the Multiethnic Population of the San Francisco Bay Area,” Health Education Quarterly 23(Supplement) S10-S27, December, 1996.

THE HEALTH CARE SYSTEM

Popular Sector Individual-based Family-based Social nexus-based Community-based Professional Sector Folk Sector Adapted from Kleinman A: Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine, and Psychiatry, Berkeley, University of California Press, 1980

CONFLICTING VALUES • •

Professional System Place High Value on :

• and personal relationships • • Impersonal communication (written, documented) Formal appointments and strict timelines • Cost effective services

Families from Different Cultures Place High Value on:

Building personal, trusting relationships with providers as people, not systems • Sharing information through conversation, not documents Family involvement in and support from the culture for health care choices Speedy delivery of services • Taking whatever time is needed to accomplish healing Nelkin VS, Malach RS: Achieving Healthy Outcomes for Children and Families of Diverse Cultural Backgrounds: A Monograph for Health and Human Services Providers. Bernalillo, NM: Southwest Communication Resources, 1996, page 20.

Community Voices: Exploring Cross-Cultural Care Through Cancer

Harvard Center for Cancer Prevention, 2001 Fanlight Productions (www.fanlight.com)

What is Cultural Competence?

• A system of care that acknowledges and incorporates —at all levels—the importance of culture, and the adaptation of services to meet culturally unique needs; an awareness of the integration and interaction of health beliefs and behaviors, disease prevalence and incidence, and treatment outcomes for different patient populations (Lavizzo-Mourey)

• • • • • •

Rationale for Culturally Competent Health Care

Responding to demographic changes Eliminating disparities in the health status of people of diverse racial, ethnic, & cultural backgrounds Improving the quality of services & outcomes Meeting legislative, regulatory, & accreditation mandates Gaining a competitive edge in the marketplace Decreasing the likelihood of liability/malpractice claims

Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999.

Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model.

Brach C, Frazer I. Medical Care Research and Review 57, Supplement 1:181-217, 2000.

Ecology of Health Care

6 H e a lth S y s te m 5 L o c a l C o m m u n ity 1 P a tie n t 4 P ra c tic e 3 C lin ic a l E n c o u n te r 2 C lin ic ia n

Crabtree BF et al. “Understanding practice from the ground up,” The Journal of Family Practice 2001; 50(10):883.

BECOMING A CULTURALLY COMPETENT HEALTH CARE ORGANIZATION

National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care Final Report DHHS Office of Minority Health Federal Register: December 22, 2000, Volume 65, Number 247, pages 80865-80879 www.omhrc.gov/CLAS

CLAS STANDARDS THEMES

• • •

Culturally Competent Care Standards 1-3 Language Access Services Standards 4-7 Organizational Supports Standards 8-14

Challenging “Isms” and “Fears”

• • • • Ageism Sexism Racism Classism • • • • Ableism Homophobia Xenophobia Other

Key Points

• Every encounter is a cross-cultural encounter.

• There is no “cookbook approach” to treating patients.

• Avoid stereotyping and overgeneralization.

L

Guidelines for Health Practitioners: LEARN

:

Listen with sympathy and understanding to the patient’s perception of the problem.

E A : :

Explain your perceptions of the problem.

Acknowledge and discuss the differences and similiarities.

R N :

Recommend treatment.

:

Negotiate agreement.

From: Berlin EA, Fowkes WCJr: “A Teaching Framework for Cross-Cultural Health Care,” Western Journal of Medicine 1983, 139:934-938.

“Promoting Health in Multicultural Populations: A Handbook for Practitioners”

Editors: RM Huff, MV Kline Thousand Oaks, CA: SAGE, 1999.

A PLANNING FRAMEWORK

HEALTH PROMOTION AND DISEASE PREVENTION PROGRAMS IN MULTICULTURAL POPULATIONS

• • • Task 1: Planning the Program Task 2: Implementing the Program Task 3: Evaluating the Program Adapted from Line MV: “Planning Health Promotion and Disease Prevention Programs in Multicultural Populations,” in Promoting Health in Multicultural Populations: A Handbook for Practitioners, eds. RM Huff, MV Kline, Thousand Oaks, CA: SAGE, 1999, pp. 73-102.

The PEN - 3 Model

Health Education Person Extended Family Neighborhood Cultural Appropriateness of Health Behavior Positive Existential Negative Perceptions Enablers Nurturers Educational Diagnosis of Health Behavior Adapted from: Airhihenbuwa CO 1990. A conceptual model for cultural appropriate health education programs in developing countries.

International Quarterly of Community Health Education

11:53-62.

“Where’s Shirley?” A Video Production About Breast Cancer The Women’s Cancer Screening Project 3 Cooper Plaza, Suite 220 Camden, New Jersey 08103 (609) 968-7324 (609) 338-0628 - Fax

CD-ROM: Cultural Competence in Breast Cancer Care

Medical College of Ohio Ohio Department of Health/CDC VERTIGO PRODUCTIONS LTD.

3634 Denise Drive Toledo, Ohio 43614 Phone: 877-385-6211 FAX: 1- 419-385-7170

Communicating Across Boundaries: A Cultural Competency Training on Breast and Cervical Cancers in Asian American Women

National Asian Women’s Health Organization (NAWHO) http://www.nawho.wego.net/index.v3page?p=18357

INTERNET WEBSITES

•

The Provider’s Guide to Quality and Culture

http://erc.msh.org/quality&culture •

Resources for Cross-Cultural Health Care

http://www.diversityrx.org

THE NEED FOR COMMUNITY PARTNERSHIPS

Clients have deficiencies and needs Citizens have capacities and gifts

Kretzmann, JP, McKnight, JL. (1993). Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Evanston, IL: Center for Urban Affairs and Policy Research.

Parks, CP, Straker HO. (1996). Community assets mapping: Community health assessment with a different twist. Journal of Health Education, 27(5), 321-323.

DEFICITS

VERSUS ASSETS MAPPING Neighborhood Needs Map

Unemployment Truancy Broken Families Slum Housing Gangs Child Abuse Crime Grafitti Mental disability Illiteracy Welfare recipients Lead poisoning Dropouts Kretzmann, JP, McKnight, JL. (1993). Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Evanston, IL: Center for Urban Affairs and Policy Research.

Parks, CP, Straker HO. (1996). Community assets mapping: Community health assessment with a different twist. Journal of Health Education, 27(5), 321-323.

DEFICITS VERSUS

ASSETS

MAPPING Community Assets Map Local Institutions

Businesses Schools Parks

Citizens Associations

Churches Block Clubs Income Youth

Gifts of Individuals

Elderly Artists Libraries Labelled People Cultural Groups Hospitals Community Colleges Kretzmann, JP, McKnight, JL. (1993). Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Evanston, IL: Center for Urban Affairs and Policy Research.

Parks, CP, Straker HO. (1996). Community assets mapping: Community health assessment with a different twist. Journal of Health Education, 27(5), 321-323.

The Business Case for Cultural Competence

• • • •

Hispanic/Latino population in the U.S. is growing five times as fast as the general population and represent $170 billion in purchasing power annually.

African-American purchasing power is approaching $300 billion per year.

Asian-Americans are the fastest-growing ethnic group in the U.S. increasing at rates eight times as fast as the general population. Such buying power is approaching $100 billion per year.

In 1990, the total purchasing power of African, Hispanic, Asian, and Native-Americans and Pacific Islanders was nearly $600 billion.

Source: Work Force 2000 - Hudson Institute; Opportunity 2000, U.D. D.O.L.

Cultural Humility

• • • A lifelong commitment to self-evaluation and self-critique Redressing the power imbalances in the patient-physician dynamic Developing mutually beneficial partnerships with communities on behalf of individuals and defined populations Tervalon M, Murray Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.

“The notion of cultural competence ... needs to build on a two-sided partnership with the expectation that individuals need to work together and ... that each needs to be aware of the other’s cultural values, beliefs, and norms.”

Michael V. Kline and Robert M. Huff

“We need to comfort the afflicted, and afflict the comfortable.”

Eleanor Roosevelt

“Sometimes it is easier to change the world than to change oneself.”

Rabbi Yakov R. Hilsenrath

Diversity in America

Kaleidoscope Rainbow What is your preferred image?

Salad Melting Pot Other?

Mosaic Cauldron