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Culture, Quality of Care and Health

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Title: 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

9
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)

13
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)

14
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

19
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

24
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

27
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

28
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

29
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

30
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.

40
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

45
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

46
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
  • (202) 476-5857
  • dcorabra_at_cnmc.org
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