Cultural Competency and Coalitions In Action

1
Cultural Competency and Coalitions In Action

• Cheza Garvin, PhD, MPH, MSW
• Program Director, Chronic Disease Prevention
  Healthy Aging
• Public Health - Seattle King County University
  of Washington School of Public Health and
  Community Medicine,
• Social and Behavioral Sciences Program
• (2006)

2
Acknowledgments

• Mike Smyser, MS, Epidemiologist
• James Krieger, MD, MPH, Chief Epidemiologist
• Epidemiology, Planning Evaluation
• Public Health Seattle King County
• Lois Watkins, REACH Program Manager
• Chronic Disease Prevention Healthy Aging
• Public Health Seattle King County

3
OBJECTIVES

• Learn what we mean by health disparities.
• Learn which groups report experiences of
  discrimination in health care settings.
• Learn recommendations for cultural competence,
  including the Culturally and Linguistically
  Appropriate Services (CLAS) Standards
• Learn about Seattle King County REACH community
  interventions.
• List one or more additional Public Health
  activities with a focus on health disparities

4
Definition of Health Disparities

• Inequalities in health status, access, care
  and/or outcomes.
• 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.
• SourceWashington State Board of Health

5
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

6
NATIONAL HEALTH DISPARITIES DATA

• Disease Prevalence, Compared to White Americans
• Cervical Cancer 5 times higher in Vietnamese
  Women, who are less likely to have had a pap test
  in last three years
• Stomach Cancer 2 to 3 times higher among Latinos
• Colorectal Cancer higher among African Americans
  and increasing among African American men

7
NATIONAL HEALTH DISPARITIES DATA

• Increasing rates of AIDS among African Americans,
  Hispanics and women
• Higher Prevalence among White Women
• Breast Cancer
• Higher Mortality from breast cancer among African
  American women

8
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

9
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
• Higher prevalence of end stage renal disease
  related to diabetes, among same groups

10
Understanding the Complexityof
HealthDisparities
Health Behaviors and Personal Risk Factors
Access to Health Services
Institutionalized biases (racism, sexism, etc.)
Mental Health and Social Support
Trust in Health System and Research
Economic Opportunity and Equity
Stress due to Social Factors
Education Background and Opportunity
Environmental Risk
Language and Other Cultural Factors
11
A King County, WA. Case StudyRacial and
EthnicDiscriminationin Health Care Settings
12
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

13
INDIVIDUAL EXPERIENCE of HEALTH CARE
DISCRIMINATION
14
Adults who experienced discrimination in the past
year, most frequently cited types of
discrimination by race and ethnicity, King
County, 1999
All other types (language or accent, religion,
disability, sexual orientation were cited by
less than 10 of respondents.
Source Communities Count 2000
15
What does discrimination in health care settings
look like?
16
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

17
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.

18
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.

19
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 Ill find
  someone else. Sometimes my leg hurts.

20
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)

21
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)

22
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)

23
Have you ever experienced, seen or heard
discrimination against people of color in medical
or non-medical settings?

• Someone being passed over in a store (or other
  service) line?
• Someone being stopped, or even arrested for
  driving while black, AKA Racial Profiling?
• 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.?

24
What emotions did you experience?

• Anger
• Disgust
• Disappointment
• Fear
• Loathing
• Curiosity

• Sympathy
• Protectiveness
• Empathy
• Embarrassment
• Confusion
• Apathy

25
ASSURING CULTURAL COMPETENCE

• Study Recommendations (Some of these are things
  you may be able to do where you work.)
• Health Care Staff Training
• physicians, nurses, PTs, dieticians, mental
  health, front desk, all staff
• Diverse Cultural Representation among Health Care
  Staff
• Self Awareness
• Change Institutional Policies
• Monitoring Progress
• Community Examples

26
Study 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.

27
Study 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.

28
Study 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.

29
Guidelines for Cross-Cultural Practice
Physician Toolkit To Implement Cross-Cultural
Practice Guidelines for Medicaid Practitioners
30
Culturally and Linguistically Appropriate
Services (CLAS) Standards

• Standard 1Health care organizations should
  ensure that patients/consumers receive from all
  staff member's effective, understandable, and
  respectful care that is provided in a manner
  compatible with their cultural health beliefs and
  practices and preferred language.
• Standard 2Health care organizations should
  implement strategies to recruit, retain, and
  promote at all levels of the organization a
  diverse staff and leadership that are
  representative of the demographic characteristics
  of the service area.
• Standard 3Health care organizations should
  ensure that staff at all levels and across all
  disciplines receive ongoing education and
  training in culturally and linguistically
  appropriate service delivery.

http//www.omhrc.gov/templates/content.aspx?ID87
lvl2lvlID13
31
CLAS Standards

• Standard 4Health care organizations must offer
  and provide language assistance services,
  including bilingual staff and interpreter
  services, at no cost to each patient/consumer
  with limited English proficiency at all points of
  contact, in a timely manner during all hours of
  operation.
• Standard 5Health care organizations must provide
  to patients/consumers in their preferred language
  both verbal offers and written notices informing
  them of their right to receive language
  assistance services.
• Standard 6Health care organizations must assure
  the competence of language assistance provided to
  limited English proficient patients/consumers by
  interpreters and bilingual staff. Family and
  friends should not be used to provide
  interpretation services (except on request by the
  patient/consumer).
• Standard 7 Health care organizations must make
  available easily understood patient-related
  materials and post signage in the languages of
  the commonly encountered groups and/or groups
  represented in the service area.

http//www.omhrc.gov/templates/content.aspx?ID87
lvl2lvlID13
32
CLAS Standards

• Standard 8 Health care organizations should
  develop, implement, and promote a written
  strategic plan that outlines clear goals,
  policies, operational plans, and management
  accountability/oversight mechanisms to provide
  culturally and linguistically appropriate
  services.
• Standard 9Health care organizations should
  conduct initial and ongoing organizational
  self-assessments of CLAS-related activities and
  are encouraged to integrate cultural and
  linguistic competence-related measures into their
  internal audits, performance improvement
  programs, patient satisfaction assessments, and
  outcomes-based evaluations.
• Standard 10Health care organizations should
  ensure that data on the individual
  patient's/consumer's race, ethnicity, and spoken
  and written language are collected in health
  records, integrated into the organization's
  management information systems, and periodically
  updated.
• Standard 11Health care organizations should
  maintain a current demographic, cultural, and
  epidemiological profile of the community as well
  as a needs assessment to accurately plan for and
  implement services that respond to the cultural
  and linguistic characteristics of the service
  area.

http//www.omhrc.gov/templates/content.aspx?ID87
lvl2lvlID13
33
CLAS Standards

• Standard 12Health care organizations should
  develop participatory, collaborative partnerships
  with communities and utilize a variety of formal
  and informal mechanisms to facilitate community
  and patient/consumer involvement in designing and
  implementing CLAS-related activities.
• Standard 13Health care organizations should
  ensure that conflict and grievance resolution
  processes are culturally and linguistically
  sensitive and capable o f identifying,
  preventing, and resolving cross-cultural
  conflicts or complaints by patients/consumers.
• Standard 14Health care organizations are
  encouraged to regularly make available to the
  public information about their progress and
  successful innovations in implementing the CLAS
  standards and to provide public notice in their
  communities about the availability of this
  information.

http//www.omhrc.gov/templates/content.aspx?ID87
lvl2lvlID13
34
Eliminating HealthDisparitiesWhat will it Take?
Freedom from Discrimination
Promotion of Healthy Behaviors
Access to Health Services
Trust in Health System and Research
Mental Health and Social Support
Reduced Stress due to Social Factors
Economic Opportunity and Equity
Lower Environmental Risks
Educational Opportunity
Respect for Language and Other Cultural Factors
35
What is the Government/County/Public Health Role
in Addressing Health Disparities?

• Prepared for Disparities Town Hall, February 27,
  2006

36
National Trends to Reduce Disparities

• Institute of Medicine, 2002 Publication Unequal
  Treatment brought attention to health disparities
• Department of Health and Human Services Office of
  Minority Health changing name to Office of
  Minority Health and Health Disparities
• Centers for Disease Control and Prevention (CDC)
  REACH Program
• National Minority Health and Health Disparities
  Institute for disparities research

37
(No Transcript)
38
Multiple Levels of Local Action at Public Health

• Environment
• Policy and Social Justice
• Medical Care
• Community Prevention Interventions
• Working in Partnership with others
• Collaboration and Coordination
• Awareness and Education
• Prevention and Management
• Research and Demonstration Programs

39
Environment

• Environmental Health Community Assessment Team
• Multi-disciplinary team approach to planning
• Focus on the built environment and accessibility
• Indoor air quality
• Outdoor air, noise, waste pollution

40
Policy and Social Justice

• Diversity and Social Justice Group
• Public Health Against Institutionalized Racism
  (PHAIR)
• Creating an environment free of discrimination
  and racism
• Assisting in, or supporting development of
  equitable legislation

41
Medical Care

• Public Health Centers
• Low cost medical care
• Locations accessible to diverse communities
• Interpreter availability
• Collaborations with community clinics and
  hospitals
• Supporting the integration of culturally relevant
  approaches to communication and care

42
Community Prevention

• Chronic Disease Prevention and Healthy Aging
• Nutrition for low income older adults
• Diabetes focus on reducing disparities
• Asthma focus on low income
• Overweight Prevention newly developing program
  with opportunity to focus on disparities
• Healthy Aging messaging through Healthy Aging
  Partnership, link to African American Elders
  Program

43
Community Prevention

• Steps to a Healthier US
• Asthma
• Diabetes
• Tobacco
• Overweight
• Nutrition and Physical Activity
• Community Health Workers
• Clinic-based Champions
• English, Spanish, Vietnamese

44
Community Prevention

• Washington Breast and Cervical Health Program
  (WBCHP) a population-based program to reduce
  mortality and morbidity from breast and cervical
  cancer
• In 2004, 5446 were screened, 12.8 of 42,388
  eligible women, 53 women of color
• early detection of cancer through regular
  mammogram and Pap tests, diagnostic services and
  prompt access to cancer treatment.
• WBCHP is dedicated to eliminating health
  disparities among under-served populations,
  including women of color, women living in rural
  communities, lesbians and women aged 50 and
  older.
• WBCHP serves women with low incomes and no health
  insurance who are age 40 to 64.
• Administered by Public Health Seattle King
  County in King, Kitsap, Jefferson and Clallam
  counties.

45
Community Prevention

• Colorectal Cancer Screening 3-year demonstration
  project funded by the Centers for Disease Control
  and Prevention (CDC).
• Piloting a comprehensive colorectal cancer (CRC)
  community recruitment, education and screening
  program
• Treatment access is linked to the WA State Breast
  and Cervical Health Program (WBCHP) and
  Comprehensive Cancer Control Plan (CCCP).
• Primary goal is to develop a replicable clinic
  and community-based system to increase CRC
  screening among priority populations,
• Support the CCCP efforts to increase CRC
  screening among the general population.
• Priority populations African American and
  American Indian

46
Community Prevention

• Reducing Racial Disparities In Birth Outcomes
• Infant Mortality Prevention Network (IMPN)
• Providing outreach, education and linkage
  services to high-risk women and young families
• General Public Health activities
• Public Health Nursing services
• First Steps/Maternity Support Services
• WIC
• Best Beginnings
• Support seek funding for community
  mobilization
• Native American Womens Dialog on Infant
  Mortality (NAWDIM)
• African American Womens Dialog on Infant
  Mortality (IntraAfrikan Konnection)

47
Community Prevention

• Access Outreach Team for Public Health (Seattle
  South County)
• Focusing on African American Latino communities
  
• Promoting health minimizing health disparities
  by increasing access to health care and other
  public benefit programs.
• Last year the Seattle team contacted 14,405
  individuals enrolled 841 individual into
  medical programs.
• South King County team contacted 8,128
  individuals enrolled 562 individuals into
  medical programs.

48
Community Prevention

• Eastside Refugee and Immigrant Coalition (ERIC)
• Resource guides for health and community services
• Cultural Broker program beginning soon to
  advocate for services for diverse populations
• Korean, Russian, Chinese, Vietnamese and Spanish

49
Community Prevention

• Cardiovascular Disease efforts specific to
  reducing health disparities include
• Support of community blood pressure screening in
  African American community
• Participation on American Heart Associations
  Cultural Health Initiatives program

50
Community Prevention

• Racial and Ethnic Approaches to Community Health
  (REACH) 2010
• 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
• Diverse Coalition addressing diabetes disparities
  through provision of culturally appropriate
  services and community/systems change work
• Interventions conducted by contracting community
  agencies

51
REACH 2010

• REACH Diabetes Program
• Focus on African American, Asian/Pacific Islander
  American, Latino/Hispanic communities
• Diabetes Education Classes
• Glucose testing, nutrition, physical activity,
• Self Management of Chronic Illness Classes
• Support Groups
• Case Coordination
• Diabetes Registry
• Referrals to Classes
• Systems Change
• Community Awareness
• English, Spanish, Cantonese, Mandarin, Korean,
  Vietnamese, Filipino (Tagalog), Khmer (Cambodian)

52
6 National REACH Priority Areas

• Cardiovascular Health
• HIV/AIDS
• Immunizations

• Infant Mortality
• Breast and Cervical Health
• Diabetes

42 REACH 2010 Communities Nationally
53
WASHINGTON STATE DIABETES DEATH RATES BY RACE AND
AGE
Rates are per 100,000 population Source
Washington Center for Health Statistics
54
Diabetes Death Rate in King County by
Race/Ethnicity, Three-Year Rolling Averages,
1994-2003
55
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.

56
REACH STAFFING

• REACH Coalition Members
• Principal Investigator (PI)
• Program Manager
• Health Educator
• Certified Diabetes Educator, Nutritionist
• Community Liaisons
• Peer Educators
• Evaluation Manager
• Evaluator Interviewers
• Researchers
• Case Coordinators
• Administrators and Administrative Support

57
Diabetes Education Classes

• Diabetes education
• Physical activity
• Nutrition
• Healthy eating
• Weight management
• Glucose testing
• Psychosocial issues
• Medications

Physical Activity
Nutrition Education in Spanish
58
Culturally appropriate Diabetes Food Guide
Pyramids in 9 Languages
Tagalog Chinese Korean Vietnamese Japanese Somali
Samoan Khmer Spanish
59
Support Groups

• Emotional support
• Common experiences
• Share resources
• Manage experiences of discrimination
• Tips for talking about diabetes with
• -Family
• -Providers
• -Friends each other

60
Chronic Illness Self- Management Classes

• Increase ability to personally manage chronic
  disease
• Increase self-efficacy
• Develop and follow personal action plan
• Improve communication between patient and
  provider
• Curriculum Developed at Stanford University by
  Kate Lorig, EdD.

61
ENHANCED DIABETES REGISTRY USE

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

62
CASE COORDINATION

• Complete diabetes registry
• Communicate with providers
• Communicate with patients about recommended
  procedures for them
• Inform patients of community activities and
  resources

63
COMMUNITY CAMPAIGNS

• Grocery Stores
• Restaurants
• Pharmacies
• Work Sites
• Media

64
RESEARCH DEMONSTRATION REQUIRES EVALUATION

• Coalition Member Interviews
• Participant Survey - pre/post
• Focus Groups
• Key Informant Interviews
• Systems Change Interviews
• Community Documentation

65
Participant Demographics
66
REACH Participant Results (n 655)

• Significant improvements in
• Diabetes knowledge
• HbA1c testing, 47.9 to 64.2, (p lt .05)
• proper foot care, (p lt .05 for L/H)
• Healthy behavior change
• Increased ability to control blood sugar and
  weight
• Better management of complex feelings related to
  living with diabetes
• Self-efficacy
• Improved confidence in maintaining a healthy diet
  and exercising 30 minutes a day

67
Health Behavior
68
Self Efficacy
69
REACH CULTURAL COMPETENCE

• Coalition Membership
• Staffing
• Listening to Participants
• Language Capacity
• Literature and Training
• Community Feedback

70
REACH LIMITATIONS

• Only King County
• Only Diabetes
• Native Americans Not Participating
• Limited Language Capacity
• Limited Geographic Scope

71
SUSTAINABILITY and SYSTEMS CHANGE

• Integrate activities into existing service system
  - Sea Mar example
• Registry
• Groups and Classes
• Train peer educators and encourage continued work
• Community network establishment
• Seek additional funding

72
SUSTAINABILITY HOPES AND PLANS

• Continue Diabetes Work
• Expand to Other Chronic Disease Prevention
• Expand to Primary Prevention
• Convince Funding Agencies and Legislators to
  Support Efforts
• Establish the REACH Alliance
• Reduce/Eliminate Health Disparities over Time

73
REACH Coalition Working At Sustainability
74
REACH Coalition Members

• Aging Disability Services
• Center for MultiCultural Health
• Harborview Medical Center
• International Community Health Services
• Sea Mar Community Health Centers
• University of Washington Schools of Nursing
  Public Health, Nutritional Sciences and HPRC
• Pacific Northwest Research Institute
• American Diabetes Association
• American Heart Association
• Qualis Health
• State Department of Health
• And Others

75
REACH COALITION DEVELOPMENT

• Multi-Cultural Focus
• Attention to membership
• Over 50 agencies and individuals
• Training
• Bi-Monthly Meetings
• Sub-Committees
• Coalition Structure

76
Coalition Challenges and Solutions

• 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

• Multiple Cultures and Languages
• Differences of Opinion - Managing Conflict
• Distribution of Funds
• Authority Hierarchy

77
Keys to Coalition Success

• Goal Setting - Implementation, Achievements
• Communication - Clear, Cultural, Guiding
  Principles, Methods that work
• Roles - Clearly Defined
• Infrastructure in Place
• Inclusiveness - Stakeholders, Outreach
• Cultural Competence - Race, Isms, Bias,
  Generalizations
• Conflict Management
• Change Takes Time (especially systems, smoking
  example)
• Celebrate Successes!

78
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

79
Reducing DisparitiesNeeded Environmental
Strategies

• Social environment
• Jobs
• Income
• Education
• Early childhood education
• Discrimination
• Increasing availability of healthy food
• Physical environment
• Environmental exposures
• Residential segregation
• Built environment
• Healthy and affordable housing

80
Reducing DisparitiesMedical Care System Changes

• Increase access to mental health and medical
  care
• Universal health insurance
• Remove organizational access barriers
• Locating facilities in areas of need
• Monitor disparities within organizations
• Enhance provider communication skills
• Increase cultural competence provider and
  institutional

81
Reducing DisparitiesMedical Care System Changes

• Offer culturally tailored health services (e.g.
  community health workers, classes, outreach)
• Employ more people of color as providers and
  managers
• Implement focused quality improvement programs
  and resources for providers serving disparity
  populations
• Link to and support culturally relevant
  community-based resources for education,
  management, support and advocacy

82
Reducing DisparitiesPublic Health System Needs

• Monitor disparities
• Increase access to medical and mental health care
• Support clinical quality improvement
• Screen for risk factors
• Educate community to promote healthy behaviors
• Provide self-management educations support
• Offer outreach and care coordination
• Generate social support
• Implement policy and environmental change

83
Resources
Institute of Medicine. Unequal Treatment
Confronting Racial and Ethnic Disparities in
Health Care. 2002. (http//www.iom.edu/?id4475re
direct0)
84
Resources

• Data
• http//www.kff.org/minorityhealth/index.cfm
• Community interventions
• http//www.preventioninstitute.org/healthdis.html
• Medical system interventions
• Evidence report/technology assessment number 90
• Strategies for improving minority healthcare
  quality http//www.ahrq.gov/clinic/epcsums/minqus
  um.htm
• IHI quality improvement tools
• http//healthdisparities.net
• CDC disparities website
• http//www.cdc.gov/omh/aboutus/disparities.htm