Culture, Quality of Care and Health

1
Culture, Quality of Care and Health

• Denice Cora-Bramble, MD, MBA
• Professor of Pediatrics, George Washington
  University
• Executive Director
• Goldberg Center for Community Pediatric Health
• Childrens National Medical Center

2
Overview

• Making the case
• Scientific, legal and regulatory landmarks
• Definitions
• State of the art
• Knowledge gaps
• Providers role
• Culture and research
• Continuing education
• Final thoughts

3
Making the Case for Culturally Competent Care

• Demographic changes
• Business of medicine
• Quality of care
• Health disparities
• Federal and state laws

4
Making the CaseDemographic Changes
5
Demographic Trends in the US
Los Angeles Times Latino baby boom changing
demographics in California July 29, 2007By Mike
Swift Preschool teacher Sara Porras leans down to
speak, first in English, then in Spanish, to one
of the toddlers she cares for at the Parkway
Child Development Center. "Which one do you
want?" Porras says to 2 1/2-year-old Alicia
Molina Correa, holding up a game and a puzzle
with children on it. "Cuál quieres, el juego o
los niños?"
Chicago Tribune Census measures ethnic shifts By
Darnell Little Chicago Tribune staff reporter
August 9, 2007 The Latino population in the
Chicago area and throughout Illinois continues to
soar, while growing numbers of whites are leaving
Cook County for outer suburban counties such as
Will, McHenry and Kendall Counties, according to
new population estimates released by the Census
Bureau today.
6
Making the CaseBusiness of Medicine

• Business Imperative - Enhancing quality of care,
  expanding markets, maximizing retention rates,
  customizing care and containing costs
• (Kaiser Permanente)

7
Making the CaseQuality of Care

• Importance of equity no variations in the
  quality of care according to patients personal
  characteristics, including race and ethnicity
• Institute of Medicine. Crossing the Quality
  Chasm a New Health System for the 21st Century.
  Washington, DC National Academies Press, 2001.

8
Making the CaseHealth Disparities

• Evidence of racial and ethnic disparities in
  healthcare is, with few exceptions, remarkably
  consistent across a range of illnesses and
  healthcare services.
• IOM Report Unequal Treatment Confronting Racial
  and Ethnic Disparities in Healthcare, 2003

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Healthcare Disparities

• Access
• Outcomes
• Quality

10
Racial/Ethnic Disparities in Cardiac Care
(1984-2001)
2 studies find the racial/ethnic minority group
more likely than whites to receive appropriate
care (2)
11 studies find no racial/ethnic differences in
care (14)
84 (68 studies) find racial/ethnic differences
in care
Total 81 studies Racial/Ethnic
Differences in Cardiac Care The Weight of the
Evidence. Kaiser Family Foundation, 2002
11
Making the CaseFederal and State Laws

• Title VI of the Civil Rights Act of 1964
• Requires that all entities receiving Federal
  financial assistance, including health care
  organizations, take steps to ensure that LEP
  persons have meaningful access to the health care
  services they provide
• New Jersey first state to mandate cultural
  competence training as part of medical licensure
  requirement

12
Important Scientific, Legal and Regulatory
Landmarks

• Importance of culture in health care, Kleinman
  (1978)
• Accepted definition of cultural competence, Cross
  et al. (1989)
• Cultural humility, Tervalon et al. (1999)
• As a matter of social justice, Kennedy et al.
  (1999)

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Important Scientific, Legal and Regulatory
Landmarks

• Within context of reduction of health
  disparities, Brach et al. (2000)
• Liaison Committee on Medical Education, required
  curricular content in medical schools (2000)

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Important Scientific, Legal and Regulatory
Landmarks

• Culturally and Linguistically Appropriate
  Standards/CLAS (2000)
• Institute of Medicine Report Unequal Treatment
  Confronting Racial Ethnic Disparities (2003)
• Link between interpretive services and medical
  errors, Flores et al. (2003)

15
Cultural Alphabet Soup

• Cultural Competence
• Cultural Sensitivity
• Cultural Awareness
• Cultural Humility
• Cultural Ethics
• Human Diversity

16
Cultural CompetencePractical Definitions

• The ability of health care providers and health
  care organizations to understand and respond
  effectively to the cultural and linguistic needs
  brought by patients to the health care encounter.
• US DHHS, Office of Minority Health. National
  Standards for Culturally and Linguistically
  Appropriate Services in Health Care Final Report,
  2001.

17
Cultural CompetencePractical Definitions

• The ability of individuals to establish effective
  interpersonal and working relationships that
  supersede cultural differences.
• Cooper LA, Roter DL Patient-Provider
  Communication. The Effect of Race and Ethnicity
  on Process and Outcomes of Health Care. In
  Smedley DB, et al, eds. Unequal Treatment
  Confronting Racial and Ethnic Disparities in
  Health Care. Washington, DC National Academy
  Press 2003552-93

18
Beyond Cultural Awareness Sensitivity

• Knowledge
• Skills
• Attitude

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Measuring Cultural Competence

• Critical Domains
• Values and attitudes
• Cultural sensitivity
• Communication
• Policies and procedures
• Training and staff development
• Lewin Group Measuring Cultural Competence in
  Health Care Delivery Setting A Review of the
  Literature 2001

20
Measuring Cultural Competence

• Domains - continued
• Facilities characteristics, capacity and
  infrastructure
• Intervention and treatment model features
• Family and community participation
• Monitoring, evaluation and research

21
Research Literature

• What do we know?
• Delineation of theory, evidence and gaps in
  scientific knowledge

22
What Do We Know?

• Excellent or good evidence to suggest that
  cultural competence training can
• Increase knowledge of providers
• Improve attitudes and skills
• Favorably affect patient satisfaction
• Beach et at. Strategies for Improving Minority
  Healthcare Quality. Evidence Report. JHU2004

23
What Do We Know?

• Poor evidence to suggest that cultural competence
  training can affect patient adherence
• No studies that have evaluated patient outcomes
• Beach et at. Strategies for Improving Minority
  Healthcare Quality. Evidence Report. JHU2004

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Cultural Competence and Health Outcomes

• Culturally incompetent care linked to adverse
  health outcomes
• Wrong or partial diagnosis due to unfamiliarity
  with disease incidence and prevalence
• Missed screening opportunities
• Unexpected drug interactions due to failure to
  include traditional practices in medical history
• Poor compliance

25
Cultural Competence and Health Care Quality

• Emerging data, with one 2004 study providing some
  of the strongest available evidence policies
  that promote cultural competence are associated
  with higher quality of care
• Lieu T et al. Cultural Competence Policies and
  Other Predictors of Asthma Care Quality for
  Medicaid-Insured Children. Pediatrics 114(1) 2004

26
Study Highlights

• Focused on practice-site policies that enhance
  quality of care for asthmatic children (2-16
  y.o.) on Medicaid
• Five large nonprofit health plans in Mass., CA
  and Washington state
• Lieu T et al. Cultural Competence Policies and
  Other Predictors of Asthma Care Quality for
  Medicaid-Insured Children. Pediatrics 114(1)
  2004

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Study Highlights

• Cultural competence policies
• Recruitment of ethnically diverse nurses
  providers (71)
• Recruitment of bilingual nurses providers (58)
• Printed material that minimizes cultural barriers
  (48.6)
• Cross cultural or diversity training (23.5)
• Evaluates level of cultural competence among
  providers (14.5)
• N83

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Study Highlights

• Underuse of preventive asthma medications was
  lower among patients of practice sites with
  higher scores for cultural competence and in
  sites that had policies to promote access and
  continuity
• Lieu T et al. Cultural Competence Policies and
  Other Predictors of Asthma Care Quality for
  Medicaid-Insured Children. Pediatrics 114(1) 2004

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Within Context ofHealth Disparities

• African American and Latino children enrolled in
  Medicaid managed care had worse asthma status and
  were less likely to be using preventive asthma
  medications than White children
• This disparity persisted after adjusting for
  socioeconomic status
• Lieu T et al. Ethnic Variation in Asthma Status
  and Management Practices Among Children in
  Managed Medicaid Pediatrics 109(5) 857-865
  2002

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Providers Contribution

• How does preconceptions of the patients race,
  ethnicity and culture impact (positively or
  negatively) providers clinical decision making?

31
Providers Contribution

• Subconscious strategy to simplify decision making
  and lessen the level of effort by using
  categories or stereotypes
• We apply expectations and beliefs about
  individuals in these groups (race, gender, age)
• Strategy used most when multitasking or stressed
• Betancourt J Eliminating Racial and Ethnic
  Disparities in Health Care What is the Role of
  Academic Medicine? Acad Med 2006 81(9)788-792.

32
Probing Questions

• Do clinicians provide the same quality of care to
  all patients?
• Do assumptions, biases and stereotypes impact the
  delivery of health care services?
• Is speaking the patients language or sharing
  their race sufficient to ensure culturally
  competent care?

33
Self-Reflection

• If patient was a different race, gender, age or
  ethnicity, would I do things differently?

34
A Physicians Reflection

• I have often contemplated whether, as a
  physician, I can rise above the attitudes of the
  society in which I was born and live and the city
  in which I practice. Can I learn to see through
  the faces of the people I treat and deliver to
  every one of them the highest quality care I have
  been trained to provide?
• Calman NOut of the Shadow Health
  Affairs,19(1)2000

35
Impact of Culture on Research

• Cultures
• Race/ethnicity
• Study participants
• Researchers
• Interdisciplinary collaborations
• Communities

36
Impact of Culture on Research Participation of
Minorities

• Are there differences in rates of participation
  of minorities in research studies?

37
Differential Participation

• Distrust
• Negative experiences
• Fewer studies conducted in minority-serving
  institutions
• Ineffective communication of research staff
• Complex study medicine regimens
• Complicated record-keeping requirements
• Lack of feedback
• Ineffective informed consent procedures
• El-Khorazaty M, Johnson A, Kiely M et al.
  Recruitment and Retention of Low-Income Minority
  Women in a Behavioral Intervention to Reduce
  Smoking, Depression, and Intimate Partner
  Violence During Pregnancy. BMC Pub Health
  2007.7233

38
Differential Participation

• Fear of being used as guinea pigs
• Lack of awareness of clinical trials
• Influences of family and friends
• Work schedules
• Transportation and child care barriers
• Literacy and language barriers
• Priorities
• Financial incentives
• El-Khorazaty M, Johnson A, Kiely M et al.
  Recruitment and Retention of Low-Income Minority
  Women in a Behavioral Intervention to Reduce
  Smoking, Depression, and Intimate Partner
  Violence During Pregnancy. BMC Pub Health
  2007.7233

39
Counterargument?

• A 2006 study by Wendler et al. suggests that
  differences in participation of minorities in
  research is small
• Where differences did occur, minorities were more
  willing than non-minorities to participate in
  research
• Lack of participation may be due to failure to
  invite minorities and to overcome barriers
  (transportation, childcare, study location)
• Wendler D, Kington R, Madans J et al. Are Racial
  and Ethnic Minorities Less Willing to
  Participate in Health Research? PLoS Med
  2006,30001-0010.

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Interdisciplinary Cultures

• Cultural differences exist between and within
  disciplines
• Each interdisciplinary team member must
• value diversity
• develop the capacity for self-assessment
• work towards understanding the disciplinary
  cultures
• be sensitive to interactive dynamics
• Reich SM, Reich JA Cultural Competence in
  Interdisciplinary Collaborations A Method for
  Respecting Diversity in Research Partnership. Am
  J Community Psychol2006. Sepr38(1-2)51-62

41
Culture of the Community

• Human subjects, study participants or partners?
• Asset-based community model
• Community-based participatory research

42
Professional Development

• Cultural competence training is not an endpoint
  but part of a continuum

43
Professional Development The Journey

• Providers Guide to Quality and Culture
• http//erc.msh.org/qualityandculture
• Office of Minority Healths free,web-based
  course A Family Physicians Practical Guide to
  Culturally Competent Care
• http//cccm.thinkculturalhealth.org
• AAFPs Quality Care for Diverse Populations video
  and CD-ROM
• httpwww.aafp.org/x13887.xml

44
Recommended National Standards

• For culturally and linguistically appropriate
  services in health care
• httpwww.omhrc.gov/CLAS

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Final Thoughts

• But culture in all its richness, does not simply
  explain health behaviors, nor does sensitivity to
  culture solve health disparities. Rather,
  culture works dynamically, in conjunction with
  economic and social factors, to affect health
  behaviors and to alleviate or exacerbate health
  disparities.
• Gregg J, et al Loosing Culture on the Way to
  Competence The Use and Misuse of Culture in
  Medical Education. Academic Medicine200681(6)54
  2-547

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Contact Information

• Denice Cora-Bramble, MD, MBA
• Professor of Pediatrics, George Washington U.
• Executive Director
• Goldberg Center for Community Pediatric Health
• Childrens National Medical Center
• 111 Michigan Ave., N.W.
• Washington, D.C. 20010
• [phone]
• dcorabra_at_cnmc.org