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

• 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

OBJECTIVES

The Changing US Population

01020304050607080

1990 1996 2005 2030

White

African American

Hispanic

Asian/Pacific Islander

American Indian/ Alaskan Native

Source: Bureau of the Census

Perc

ent o

f pop

ulat

ion

Top Ten Countries of Birth

%N1. Mexico2. India3. China, People’s Republic 4. Philippines5. Vietnam6. El Salvador7. Cuba8. Haiti9. Bosnia-Herzegovina10. Canada

U.S. Immigration - 2001 Statistics

206,42670,290

56,42653,15435,53131,27227,70327,120

23,640

21,933

19.4 6.6 5.3 5.0 3.3 2.9 2.6 2.5 2.2 2.1

Top Ten States %N1. California2. New York3. Florida4. Texas5. New Jersey6. Illinois 7. Massachusetts8. Virginia9. Washington10. Maryland

U.S. Immigration - 2001 Statistics

282,957114,116104,715

86,31559,92048,29628,965 26,876

23,08522,060

26.610.7

9.88.15.64.52.72.52.22.1

Within - Group Diversity

is often greater than

Between - Group Diversity

• 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)

Institute of Medicine ReportsInstitute of Medicine Reports

U.S. Department of Health

and Human Services

“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

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

0 100 200 300 400 500 600

Hispanics

Whites

American Indians

Alaska Natives

Vietnamese

Koreans

Japanese

Hawaiians

Filipinos

Chinese

African Americans

MaleFemale

+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.

243319

346469

180196

273

348372

326

322

180266

241

321340

274

282213

224

326560

AGE-ADJUSTED MORTALITY RATES* FOR MAJOR CANCER FOR WHITE AND MINORITY GROUPS, BY UNDERLYING CAUSE

OF DEATH, UNITED STATES, 1990.

* 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.

Indicator

American Indian/ Alaska Native

White American

African- American

Asian/ Pacific Islander

Hispanic American

†

Lung Cancer 54.0 67.5 27.9 35.626.8

Colorectal cancer 20.6 26.6 18.210.1 12.6

Breast cancer 16.3 19.5 6.5 13.96.6

Cervical cancer 1.8 0.90.50.7

Prostate cancer 23.5 10.26.05.8

1.1

10.7

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

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.

• 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

TARGETING

VS

TAILORING

COMMUNITY HEALTH PROMOTION

• TARGETING

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.

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

COMMUNITY HEALTH PROMOTION

• TAILORING

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.

adaptation of the intervention and/or total redesign to best fit the needs and characteristics of a target audience

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

SectorAdapted 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

• Facts rather than feelings and personal relationships

• Impersonal communication (written, documented)

• Formal appointments and strict timelines

• Cost effective services

• Speedy delivery of services

• 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

• Taking whatever time is needed to accomplish healing

Professional System Place High Value on:

Families from Different Cultures Place High Value on:

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.

5L o c a l C o m m unity

3C lin ic a l

E nc o unte r2

C lin ic ian1

P atien t

4P ra ctic e

6H ea lth S ys te m

Ecology of Health Care

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

BECOMING A CULTURALLY COMPETENT HEALTH CARE

ORGANIZATION

National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care

DHHS Office of Minority Health

Final Report

Federal Register: December 22, 2000, Volume 65, Number 247, pages 80865-80879 www.omhrc.gov/CLAS

• Culturally Competent Care Standards 1-3

• Language Access Services Standards 4-7

• Organizational Supports Standards 8-14

CLAS STANDARDS THEMES

• Ageism

• Sexism

• Racism

• Classism

• Ableism

• Homophobia

• Xenophobia

• Other

Challenging “Isms” and “Fears”

Key Points

• Every encounter is a cross-cultural encounter.

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

• Avoid stereotyping and overgeneralization.

Guidelines for Health Practitioners: LEARN

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

E : Explain your perceptions of the problem.

A : Acknowledge and discuss the differences and similiarities.

R : Recommend treatment.

N : 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.

• 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.

A PLANNING FRAMEWORK

HEALTH PROMOTION AND DISEASE PREVENTION PROGRAMS IN

MULTICULTURAL POPULATIONS

The PEN - 3 Model

Educational Diagnosis of Health Behavior

Cultural Appropriateness of Health Behavior

Health Education

Perceptions Enablers

Nurturers

Person Extended Family

Neighborhood

Positive Existential Negative

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 DriveToledo, 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

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.

Clients havedeficiencies and needs

Citizens havecapacities and gifts

Neighborhood Needs Map

Unemployment Truancy

Illiteracy

Broken Families Slum Housing

Gangs Crime

Child Abuse

Grafitti

Mental disability

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 MapBusinesses Schools

Libraries

Churches Block Clubs

Parks

ElderlyYouth

Artists

Labelled People

Cultural Groups

Hospitals Community Colleges

DEFICITS VERSUS ASSETS MAPPING

Local Institutions

Income

Citizens Associations

Gifts of Individuals

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

and

Eleanor Roosevelt

“We need to comfort the afflicted,

afflict the comfortable.”

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

Rabbi Yakov R. Hilsenrath

Diversity in AmericaDiversity in America

Rainbow

What is your preferred image?Salad

Melting Pot Other?

Cauldron

MosaicKaleidoscope