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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
0
10
20
30
40
50
60
70
80
1990 1996 2005 2030
White
African American
Hispanic
Asian/Pacific Islander
American Indian/ Alaskan Native
Source: Bureau of the Census
Per
cent
of
popu
latio
n
Top Ten Countries of Birth
%N1. Mexico
2. India
3. China, People’s Republic
4. Philippines
5. Vietnam
6. El Salvador
7. Cuba
8. Haiti
9. Bosnia-Herzegovina
10. Canada
U.S. Immigration - 2001 Statistics
206,426
70,290
56,426
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
Top Ten States %N1. California
2. New York
3. Florida
4. Texas
5. New Jersey
6. Illinois
7. Massachusetts
8. Virginia
9. Washington
10. Maryland
U.S. Immigration - 2001 Statistics
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
• 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
Male
Female
+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 ca l C o m m unity
3C lin ica l
E nco unter
2C lin ic ian
1P atien t
4P rac tice
6H ea lth S ys tem
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 ProgramAdapted 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 Map
Businesses 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
Mosaic
Kaleidoscope