Cultural Competency and Coalitions In Action

Cheza Garvin, PhD, MPH, MSWProgram Director, Chronic Disease Prevention

and Healthy AgingPublic Health - Seattle & King County University

of Washington School of Public Health and Community Medicine,

Social and Behavioral Sciences Program(2003-2005)

Acknowledgment

Mike Smyser, MS, EpidemiologistEpidemiology, Planning & EvaluationPublic Health – Seattle & King County

OBJECTIVES

Learn which groups report experiences of discrimination in health care settings.

Learn recommendations for cultural competence.

Learn the six health priority areas targeted by REACH 2010.

Learn about Seattle & King County REACH community interventions.

IMPORTANCE: The Bad News

Health Disparities Data (some of the major killer diseases)

Social Indicators, including Individual Experience in Health Care Settings - Discrimination Factor

Definition of Health Disparities

Health Disparities describe the disproportionate burden of disease, disability and death among a particular population or group when compared to the proportion of the entire population.

Source:Washington State Board of Health

NATIONAL HEALTH DISPARITIES DATA

Disease Prevalence, Compared to White Americans:– Infant mortality: 2½ times higher in

African Americans, 1½ times higher in Native Americans

– Prostate Cancer: 2 times higher among African Americans

Infant mortality rates by race and Hispanic origin of mother, United States

Infant Mortality by Race/Ethnicity, King County, 1981-1998

0

5

10

15

20

25

81-8

3

82-8

4

83-8

5

84-8

6

85-8

7

86-8

8

87-8

9

88-9

0

89-9

1

90-9

2

91-9

3

92-9

4

93-9

5

94-9

6

95-9

7

96-9

8

Rat

e p

er 1

,000

Liv

e B

irth

s African American

Native American

White

Hispanic

Asian

Source: Birth Certificate Data: Washington State Department of Health, Center for Health Statistics.

NATIONAL HEALTH DISPARITIES DATA

Disease Prevalence, Compared to White Americans:– Cervical Cancer: 5 times higher in

Vietnamese Women– Stomach Cancer: 2 to 3 times higher

among Latinos– Colorectal Cancer: higher among

African Americans and increasing among African American men

Pap test in last three years among women 18 years of age and older (age adjusted to the year

2000 standard population), United States

NATIONAL HEALTH DISPARITIES DATA

Higher Common Disease Prevalence among White Americans :– Breast Cancer (although mortality is

higher among African American women)

NATIONAL HEALTH DISPARITIES DATA

Disease Prevalence, Compared to White Americans:– Heart Disease: ~ 2 times higher

among African American men– Hypertension: higher among African

Americans – Stroke: higher among African

Americans

NATIONAL HEALTH DISPARITIES DATA

Disease Prevalence, Compared to White Americans or to Average Rate:– Diabetes: Nearly 3 times higher

among Native Americans than the average rate; 70% higher among African Americans

Persons with diabetes and end-stage renal disease, United States

Year 2010 target 78 per 1 million persons

Lower extremity amputations in persons with diabetes (age adjusted to the year

2000 standard population), United States

AIDS* case rates among persons 13 years of age and older, United States

Total Death Rate by Race/Ethnicity,King County, 1980-1998

White

African American

Native American/Alaska Native

Asian/Pacific Islander

Latino/Hispanic

0

100

200

300

400

500

600

700

800

900

80-8

2

81-8

3

82-8

4

83-8

5

84-8

6

85-8

7

86-8

8

87-8

9

88-9

0

89-9

1

90-9

2

91-9

3

92-9

4

93-9

5

94-9

6

95-9

7

96-9

8

Ag

e-A

dju

sted

Rat

e p

er 1

00,0

00 P

erso

ns

Source: Death Certificate Data: Washington State Department of Health, Center for Health Statistics.

HealthBehaviors and

PersonalRisk Factors

Access to Health

Services

EconomicOpportunityand Equity

Stress due to SocialFactors

Mental Healthand Social

SupportTrust in HealthSystem andResearch

EducationBackground

andOpportunity

Language andOther Cultural

Factors

EnvironmentalRisk

Institutionalizedbiases (racism, sexism,

etc.)

Understanding the

Complexityof Health

Disparities

Median household income by race and Hispanic origin United States, 1980-96

Asian orPacific

Islander

White,non-Hispanic

HispanicBlack

All races

10

15

20

25

30

35

40

45

50

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

Me

dia

n h

ou

se

ho

ld in

co

me

(in

th

ou

sa

nd

s o

f 1

99

6 d

olla

rs)

Source: Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United States, 1998. Hyattsville, Maryland: National Center for Health Statistics, 1998. Pp 35 and 144.

Educational attainment among persons 25 years and over by race and Hispanic

origin: United States, 1996

0% 10% 20% 30% 40% 50%

All races

Asian or Pacific Islander

White, non-Hispanic

Black, non-Hispanic

Latino or Hispanic

Less then 12 years12 years13-15 years16 years or more

Source: US Census Bureau. Current Population Survey, March 1996.

A King County, WA. Case Study:

Racial and EthnicDiscrimination

in Health Care Settings

Sources of information

Random surveys of King County residents Ethnicity and Health Survey

Included 2,400 adults, 1995-1996 Communities Count 2000 Survey

Included 1,500 adults, late 1999

Personal Interviews Interview Project

Included 51 African Americans, Jul-Sep 1999 Intended to describe range of experiences

INDIVIDUAL EXPERIENCE of HEALTH CARE DISCRIMINATION

32%

21%

11%

19%

8%

17%

7%

13% 13%

0%

5%

10%

15%

20%

25%

30%

35%

Africa

n Am

eric

an, n

=205

Latio

n/His

panic

, n=2

24

Chines

e, n

=273

Filipin

o, n=3

09

Japan

ese,

n=3

16

Korean

, n=3

03

Vietn

ames

e, n

=332

White

, n=4

63

King C

ounty, n

=242

5

Adults who experienced discrimination in the past year, most frequently cited* types of discrimination

by race and ethnicity, King County, 1999

Source: Communities Count 2000

33%

16%19%

41%

23%

17%

13%10%

37%

3%

17%

21%

12%

19%

6%

0%

10%

20%

30%

40%

50%

60%

Race or color? Gender (being male or female)?

Ethnic background or country of origin?

Age? Socioeconomic position orsocial class?

Do you believe that the act of discrimination was based on your….

All Persons of Color (n=114) White (n=446) King County Total (n=568)

*All other types (language or accent, religion, disability, sexual orientation were cited by less than 10% of respondents.

What does discrimination in health care settings look

like?

Example: Interview Project Findings Experiences Reported by 51 African Americans

Experiences ranged from incidents of differential treatment to rude behavior and racial slurs.

Most respondents were surprised by the incidents; they did not expect this type of treatment and considered the personal impact to be very severe.

Many respondents had more than one story. Most of the events reported are recent. All events were perceived to be racially motivated. The events reported occurred in 30 facilities, both

public and private, located all over King County

Examples of reported experiences:

“He treated the Caucasian woman better and differently.” “The radiologist made a couple of crude remarks, like I was dumb.” “I was in the emergency room at the hospital and I feel that I was

ignored due to my race.” “I know you shoot dope,” a nurse was reported to have accused one

of the respondents. “You people accepted pain as part of slavery because you tolerate

pain so well,” said a nurse to a respondent who, before having a breast biopsy, requested a sedative due to a low tolerance for pain.

What was the response to the reported event?

About half made a complaint. Most were verbal; few were written or formal.

Many respondents mentioned actively avoiding offending personnel and/or facilities where the incident took place.

Some respondents reported delaying treatment due to the negative experience.

Others reported avoiding the health care system.

Comments from respondents:

“I vowed never to take my child to ____ Hospital.”

“It was the last time my son would see Dr. _____.”

“I was so ticked off when I went home that I cut up my ____ card.”

“I have not sought surgery for my other leg. I would like surgery but I guess that I’ll find someone else. Sometimes my leg hurts.”

Differential Treatment and Access to Medical Care by Race and Ethnicity

A review of many studies conducted in different parts of King County indicated significant differences in medical care received by persons of different racial and ethnic backgrounds.

Differential treatment and access to care in most studies could not be “explained by such factors as socioeconomic status, insurance coverage, stage or severity of disease, co-morbidities, type and availability of health care services, and patient preferences.“

(Mayberry et al., Med Care Res Rev 2000)

Examples of Differential Treatment and Access

Heart Disease With respect to by-pass operations, in

five studies African Americans were 32% to 80% less likely to receive these operations compared to whites with similar disease severity.

(Mayberry et al., Med Care Res Rev 2000)

Examples of Differential Treatment and Access

Cancer Several studies have documented differences with

respect to certain types of cancer (e.g., lung and colon). African Americans were often less likely to receive major therapeutic procedures.

One study of nursing homes found African Americans with cancer to be 63% less likely to receive any pain medication.

(Mayberry et al., Med Care Res Rev 2000)

Have you ever experienced, seen or heard discrimination against people of

color? (not limited to medical settings)

Someone being passed over in a store (or other service) line?

Someone being stopped, or even arrested for “driving while black”?

A race-based joke?Assumptions of addictions, criminal

behavior, subservience, low (or unusually high) intelligence?

A racial slur or name calling?Exclusion from housing, clubs, etc.?

What emotions did you experience?

AngerDisgustDisappointmentFearLoathingCuriosity

SympathyProtectivenessEmpathyEmbarrassmentConfusionApathy

ASSURING CULTURAL COMPETENCE

Study Recommendations (Some of these are things you may be able to do where you work….)

Health Care Staff TrainingHealth Care Staff Cultural

RepresentationSelf Awareness (checklist)

Change Institutional PoliciesMonitoring ProgressCommunity Examples

Recommendations

Train all health care providers and support staff in cultural competency– Incorporate cultural competency measures in

individual performance evaluations. – Periodically evaluate training to improve

effectiveness.– Providers should be able to respectfully obtain

cultural and ethnic heritage information of clients when this information is a necessary component of quality service.

Recommendations

Change institutional policies in order to: – Maintain a non-discriminatory workplace– Assure a diverse workforce at all levels– Promote awareness among consumers

regarding rights and grievance processes

– Require subcontractors to report on racial and ethnic background.

Recommendations

Continue studies that will contribute to eliminating discrimination by: – Collecting information routinely

regarding race and ethnic background– Monitoring and reporting differential

treatment– Examining and reporting experiences of

other racial and ethnic groups.

Eliminating Health

DisparitiesWhat will it Take?

Access to Health

Services

EconomicOpportunityand Equity

ReducedStress due to SocialFactors

Mental Healthand Social

Support

Trust in HealthSystem andResearch

EducationalOpportunity

Respect forLanguage andOther Cultural

Factors

LowerEnvironmental

Risks

Freedom fromDiscrimination

Promotion of Healthy

Behaviors

NATIONAL TREND: The Good News

Department of Health and Human Services

Centers for Disease Control and Prevention

National Institutes of Health

REACH 2010

Racial and Ethnic Approaches to Community Health

– National Goal: By the year 2010, eliminate disparities in health status experienced by racial and ethnic minority populations

– Funding through the Centers for Disease Control and Prevention

6 REACH PRIORITY AREAS

Cardiovascular Health

HIV/AIDS Immunizations

Infant MortalityBreast and

Cervical HealthDiabetes

34 REACH 2010 Communities Nationally

WASHINGTON STATE DIABETES DEATH RATES BY RACE AND AGE

0

200

400

600

800

1000

1200

1400

1600

1800

0-44 45-64 65-74 75+ All Ages

White, non-Hispanic

African descent, non-hispanic

AmericanIndian/Alaska Native

Asian American /Pacific IslanderAmerican

Hispanic, any race

Rates are per 100,000 populationSource: Washington Center for Health Statistics

KING COUNTY DIABETES DEATH RATES BY RACE AND GENDER

White - M

African Am - M

Asian - M

Hispanic - M

White - F

African Am - F

Asian - F

Hispanic - F

0

5

10

15

20

25

30

35

40

458

0-8

4

81

-85

82

-86

83

-87

84

-88

85

-89

86

-90

87

-91

88

-92

89

-93

90

-94

91

-95

92

-96

Ag

e-A

dju

ste

d R

ate

pe

r 1

00

,00

0

REACH 2010 SEATTLE & KING COUNTY

MISSION– “The mission of the REACH Coalition is to

reduce diabetes health disparities experienced by communities of color. Through strong partnerships, we will support the empowerment of individuals, families, and communities, and create sustainable long-term approaches to prevention and control of diabetes utilizing all appropriate community resources in King County.”

MULTIPLE CULTURES WORKING TOGETHER TO REACH FOR HEALTH

REACH COALITIONAfrican AmericanAsian American/Pacific Islander AmericanLatino/HispanicEuropean American

LOCAL REACH HISTORY

PHASE I ACTIVITIES– Coalition Development– Community Assessment– Community Action Plan

REACH PHASE II

Continued Coalition DevelopmentImplementation of Community

Action Plan (CAP)Evaluation, Feedback, Revisions

and ReportingSustainability

REACH COALITION DEVELOPMENT

Multi-Cultural FocusAttention to membership

– Over 50 agencies and individuals

TrainingBi-Monthly MeetingsSub-CommitteesCoalition Structure

Coalition Challenges and Solutions

Multiple Cultures and Languages

Differences of Opinion - Managing Conflict

Distribution of Funds Authority Hierarchy

7 Languages, Hire Bilingual/Bicultural Staff, Listen and Learn

Consensus Decision Making; Bring Concerns back to the Coalition - (Ops)

Coalition Selection Committee

Process Discussion; Take Backseat

REACH STAFFING

REACH Coalition Members Principal Investigator (PI) Co-PI Program Manager Community Liaisons Peer Educators Evaluation Manager Evaluator Interviewers Researchers Case Coordinators Administrators and Administrative Support

COMMUNITY ACTION PLAN ELEMENTS

Interventions conducted by contracting community agencies

Support GroupsEducation ClassesSelf Management ClassesEnhanced Diabetes Registry useCase CoordinationCommunity CampaignsEvaluation

SUPPORT GROUPS

Emotional SupportShared ExperiencesShared ResourcesDealing with discriminationTips for talking about diabetes

– family– providers– friends– each other

EDUCATION CLASSES

Physical ActivityNutritionMarketingWeight ManagementGlucose testingOther topics

SELF MANAGEMENT CLASSES

Self care focusIncreasing self-efficacyIncreasing provider-

patient communication by patient initiative

ENHANCED DIABETES REGISTRY USE

Tracking of– HbA1c– blood pressure– eye exams– foot exams– urine tests– referrals

CASE COORDINATION

Complete diabetes registryCommunicate with providersCommunicate with patients about

recommended procedures for them

Inform patients of community activities and resources

COMMUNITY CAMPAIGNS

Grocery StoresRestaurantsPharmaciesWork SitesMedia

EVALUATION

Coalition Member InterviewsParticipant Survey - pre/postFocus GroupsKey Informant InterviewsCommunity Documentation

REACH CULTURAL COMPETENCE

Coalition MembershipStaffingListening to ParticipantsLanguage CapacityLiterature and TrainingCommunity Feedback

REACH LIMITATIONS

Only King CountyOnly DiabetesNative Americans Not ParticipatingLimited Language CapacityLimited Geographic Scope

SUSTAINABILITY

Integrate activities into existing service system - Sea Mar example– Registry– Groups and Classes

Train peer educators and encourage continued work

Community network establishmentSeek additional funding

HOPES AND PLANS

Continue Diabetes WorkExpand to Other Chronic Disease

PreventionExpand to Primary PreventionConvince Funding Agencies and

Legislators to Support EffortsReduce/Eliminate Health

Disparities over Time

WHAT MIGHT YOU DO TO INCREASE YOUR CULTURAL COMPETENCE AND HELP TO ELIMINATE

HEALTH DISPARITIES?

Open your empathetic heart to humans of other hues

Recognize power differences and how they affect you

Learn what your own biases are and channel them in a positive direction

Discuss racism with friends/family, & how to prevent discrimination

Speak out against discrimination when you see it

Make your health/wellness practice one that welcomes all and/or targets the disenfranchised

Join a local coalition or community group with relevant goals

Be willing to learn

REACH Coalition At Work

AVOID COMPLICATIONS

Neuropathy / Amputations

Kidney Disease / Renal Failure

Heart Disease

Blindness

ELIMINATE RACIAL/ETHNIC DIABETES HEALTH DISPARITIES

INCREASE HEALTH AND WELL BEING