The Immunity Hypothesis: Using Cultural Competence to Eliminate Disparities in Mental Health Service

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The Immunity Hypothesis Using Cultural
Competence to Eliminate Disparities in Mental
Health Services

• December 13, 2003
• King Davis, PhD, Executive Director
• Hogg Foundation for Mental Health Services,
  Research, Policy Education
• Robert Lee Sutherland Chair in Mental Health
  Social Policy
• School of Social Work
• The University of Texas at Austin
• Austin, Texas

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The Immunity Hypothesis

• Slaves are immune from stress and from the
  subsequent risk of mental illness because they do
  not own property.

• John Galt, M.D.(1840)

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Purpose of the Presentation

• Conceptualize the term disparities
• Place disparities in context
• Link various types of disparities
• Define key terms
• Link disparities and cultural competence
• Identify key causative variables
• Relate to New Freedom Commission
• Get out alive!

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Foci of the Presentation

• Disparities have an extensive history
• Disparities are related to a perverse
  conceptualization of people of color
• This conceptualization pervaded clinical
  practice, research, education policy
• Disparities are imbedded in differences in
  income, access to information, and cultural
  traditions social structures

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Four Critical Realities

• Universities, professional schools, and
  professional associations are responsible for the
  level of knowledge, skills, theory, and clinical
  practice that is applied to people of color.
• Cultural competency is not an acceptable approach
  in the majority of university based education
  programs.
• Most people of color seek help first from
  religious organizations.
• Collaboration/cooperation between religious
  organizations and behavioral health is minimal.

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Conceptualizing Disparities

• Prevalence Rehabilitation
• Incidence Participation
• Services Outcomes
• Treatment Acceptable Norms
• Prevention Personal Choice
• Recovery Racial causation

King Davis, 2003
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Service Disparities

• Racial, ethnic, and cultural differences in
  twenty characteristics designed to define and
  describe the nature of behavioral health service
  provision
• Source K. Davis (2003)

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Service Disparities 1760-2000

• gtFrequency of Inaccurate Diagnosis
• gtFindings of Severe Mental Disorder
• gtInpatient Hospitalization/LOS
• gtInvoluntary Commitments
• gtRecividism/Relapse
• gtInvolvement in Criminal Justice System
• gtMortality Rates (Primary Health Problems
  Suicide)
• ltRecovery
• gtUninsured/Underinsured
• ltAccess to Outpatient/Early Access
• ltAccess to Providers of Color
• ltUtilization of Cultural Competency in Service
  Design
• ltParticipation in Behavioral Health Volunteer
  Organizations
• ltAccess to Information about Behavioral
  Disorder/Services
• ltFamily Support

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Service Disparities

• gtDelays in help seeking
• ltHousing alternatives
• ltAccess to trained interpreters
• ltInclusion in research/clinical trials
• gtExecutions while mentally disabled
• ltIntegrated behavioral health services

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DISPARITIES IN MENTAL HEALTH CARE FOR RACIAL AND
ETHNIC MINORITIES

• Minorities have less access to, and availability
  of, mental health services
• Minorities are less likely to receive needed
  mental health services
• Minorities in treatment often receive a poorer
  quality of mental health care
• Minorities are underrepresented in mental health
  research
• Mental Health Culture, Race, and
  Ethnicity, a Supplement to the Surgeon Generals
  Report on Mental Health

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Expanded View of Disparities
Economic
Dental Health
Political/ Legal
Mental Health
Employment
Health
Educational
Substance
King Davis, 2003
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An Expanded View of Disparities
Maternal/ Infant Deaths
Uninsured
Literacy
Nutrition
Crime Victims
Sickle Cell
Low Birth Weight Babies
Criminal Justice
Sentencing
Diabetes
Housing Homelessness
Cardiovascular Disease
Periodontal Disease
Political Office
Voting
HIV
Asset Accumulation
Alcohol Abuse
Environmental Pollution
Cancer
Obesity
Low Income
Graduation Rates
Cocaine Use/Sale
Mental Retardation
Schizophrenia
Depression
Bipolar
Domestic Violence
Homicides
Personality Disorder
Dementia
Capital Punishment
Unemployment
King Davis, 2003
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Causes of Disparities

• Societal policies race, gender, income
• Focus/content of professional education
• Focus /content of research
• Service design and implementation
• Cultural traditions beliefs/help seeking
• Dissemination of information
• Bundling health care to employment

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Removal of Disparities

• Recent efforts at the federal (Clinton 1994)
  presidential level are designed to eliminate
  disparities in health and mental health by 2010
• President Bush (2003) has included this goal in
  the recent report on mental health
• Bush identifies cultural competence as the
  vehicle for eliminating disparities in mental
  health

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A transformed system Recovery

• To achieve the promise of community living for
  everyone, new service delivery patterns and
  incentives must ensure that every American has
  easy and continuous access to the most current
  treatments and best support services
• Source New Freedom Commission

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Six Critical Goals

• Americans understand that mental health is
  essential to overall health
• Mental health is consumer and family driven
• Disparities in mental health are eliminated
• Early intervention is common
• Excellent care is delivered and research is
  accelerated
• Technology is used to access mental health care
  and information
• Source New Freedom Commission

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Disparities in Mental Health Services are
Eliminated

• In a transformed mental health system, all
  Americans will share equally in the best
  available services and outcomes, regardless of
  race, gender, ethnicity, or geographic location.
• Source New Freedom Commission

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Recommendations

• Improve access to quality care that is culturally
  competent
• Improve access to quality care in rural and
  geographically remote areas
• Source New Freedom Commission

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Primary Strategy

• How to develop implement?
• What are the key strategies?
• What are the critical challenges?

• State Mental Health Plan

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The Challenge of Reform

• Help seeking

• Health Insurance

• Voluntary Participation

System Reform

• Disproportionate Poverty

• General Fund Pressure

• State Policy Reform

• Service Redesign EBP

• Human Resources

• Private
• Sector

• Federal Government

• State Government

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The Immunity Hypothesis

• Slaves are immune from stress and from the
  subsequent risk of mental illness because they do
  not own property.

• John Galt, M.D.(1840)

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Contextual Hypotheses

• Immunity Hypothesis 1763-1865
• Exaggerated Risk Hypothesis -1865-1980
• No-difference Hypothesis 1981-1990s
• _____________________
• Immunity Hypothesis Recycled 2001
• Exaggerated Risk Hypothesis Recycled 2001
• No-difference Hypothesis Recycled 2001

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Historical Hypotheses
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Historical Hypotheses - Continued
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Multiple Costs

• Excess Preventable Deaths
• Untreated Illness Lower Lifetime Achievement
• Excess Hospital Admissions Readmissions
• Misdiagnosis Inappropriate Care (LLOS)
• Community Suspicion and Mistrust
• Staff Division and Conflict
• Absence of Scientific Knowledge Theory
• Ethical Conflict Professional Personal
• Increased Taxes Agency Budgets Waste

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Differences by Culture

• Access to Services/Treatment
• Increased Risk Based on Low Income
• Help Seeking/Family Participation
• Source of Information/Accuracy
• Involuntary Admissions/Readmissions
• Involvement by Police
• Medication Compliance
• Severity of Diagnosis/Homelessness

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Admissions per 100,000 by Race, Ethnicity Type
of Facility
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Involuntary Admissions by Race State
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Need for Behavioral Health Care

• African Americans
• Overall rates of mental illness similar to
  non-Hispanic whites
• Differences in prevalence of specific illnesses
• Suicide rates lower but on the rise
• Environmental, economic and social factors
• Exposure to violence, homelessness,
  incarceration, social welfare involvement
• Less access to behavioral health services

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Need for Behavioral Health Care

• American Indians and Alaska Natives
• Limited data on prevalence of MI
• One small study with 20 year follow-up found 70
  lifetime prevalence of MI
• Increase rise of depression among older adults
• Suicide rate 1.5xs national average with young
  males accounting for 2/3 of suicides
• 2nd decade of life has highest mortality rate
• Alcohol dependence, alcohol related deaths
• Little information on service utilization
  patterns

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Need for Behavioral Health Care

• Latinos/Hispanic Americans
• Overall rates of MI similar to non-Hispanic
  whites
• Higher rates of some disorders
• Anxiety-related and delinquency behaviors,
  depression and drug use, more common among Latino
  youth
• Higher rates of depression among elderly Latinos
• Culture-bound syndromes
• Susto (fright), nervios (nerves), mal de ojo
  (evil eye), and ataque de nervios
• Access to behavioral health services is limited

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Need for Behavioral Health Care

• Asian Americans/Pacific Islanders
• Limited data on prevalence of MI
• Existing data suggests overall rates similar to
  whites
• Higher rates of depression, PTSD
• Somatic complaints of depression
• Culture-bound syndromes
• Lower suicide rates - except elderly women who
  have the highest suicide rates in U.S.
• Refugees with PTSD
• Language barrier limits access to services

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Basic Assumption

• Culture is an important variable in determining
  how people (consumers, staff providers) see and
  interpret (know) the world around them and the
  basis of how they make decisions.

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All Health Care is Cultural

• Conceptualization
• Diagnosis
• Treatment
• Training
• Research
• Policy
• Help Seeking
• Compliance
• Participation
• Health Beliefs
• Expectations
• Employment

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Defining Cultural Competence

• Market-Based Definition
• Cultural competence is the integration and
  transformation of knowledge, information, and
  data about individuals and groups of people into
  specific clinical standards, skills, service
  approaches, techniques, and marketing programs
  that match the individuals culture and increase
  the quality and appropriateness of health care
  and outcomes (Davis, 1997).

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Defining Cultural Competence

• Cultural competence is the conclusion reached and
  shared by members of a nation, community, group,
  organization, business, or a board that
  constitutes how the individual wants to be
  treated with respect by others based on their
  culture (T.Davis, 2002)

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Status of Cultural Knowledge

• The Clinical Application of Cultural Competency
  is Relative

Non English Speaking
Native Americans
African Americans
Mexican Americans
Anglo Americans
Mexican Immigrants
Lowest Income
Asian/ Pacific Islanders Indian/Pakistani
Middle Income
Men
Lowest
Highest
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Elements of Cultural Competence

• Attitudes of respect Agency Evaluation
• Beliefs Agency Plan
• Knowledge and Skills Inclusion in Vision
• Language and Communication
• Community Analysis Inclusion in Services
• Valuing Diversity Outcomes
• Cultural Self-Assessment Staffing

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Potential Benefits of Cultural Competence
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Applying Cultural Competence
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Applying Cultural Competence
Line Staff
Senior Staff
Policies
Governing Board
Executive Director
Consumers
Work Plans Supervision
Feedback Input
Work Plans Implementation
Vision
Mission Budget Goals
Strategic Plan Budget Initiatives
Cultural Competence Plan
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Figure 1.Conceptual Framework
D. Formal Helping System
Individual
Church Organizations
C. Individual Community Factors
Degree of Impairment
Practitioner Evidence Base
Family Burden
Theory and Model Recovery
Professional Evidence Based
Faith
Community Stigma
Consumer Self help
Absorption
Delayed Help Seeking
Information
DECISIONS TO UTILIZE SOME FORM OF HELP
COMMUNITIES OF COLOR
A. Organizing Concepts
Boundary Expansion
Self Help
Collective Caring
PHASE 2
PHASE 3
Religious Based Help
PHASE 1
Family Choices/Actions

• King Davis, Hogg Foundation 2003

B. Number of Psychiatric Episodes
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Differential Risk Analysis
Poverty Retardation Substance Use Unemployment In
stitutionalization Suicide Uninsured
Mental Illness
Low Risk
High Risk
Medium Risk
Severe Mental Illness
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Social Marketing

• Consideration and integration of social variables
  in the design of plans and policies in health
  care services

• Study Culture Help Seeking
• Definitions of Health/Illness
  Information Use
• Learning Style Leadership
• Family Systems Media
  Outlets
• Languages Spoken
  Schools
• Religious Ideas
  Neighborhoods

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Why is Cultural Competence Important?

• Potential Cost Savings people dollars
• a. Excess use of inpatient d. gtDiagnostic
  error
• b. High rates of recidivism e. gtInsurance
  rates
• c. Under-use of outpatient f. LOS
• Ethical Base of Professions
• Quality of Care Demands it
• Potential Improvement in Diagnosis
• Potential Improvement in Treatment
• Potential for Prevention
• Potential for Increasing Participation in Policy
• Emphasis on Recovery
• Congruent with Evidence Based Approach
• Congruent with Disease Management

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Useful Techniques

• Connect Cultural Competence to Public Image
• Link Cultural Competence to Public Trust
• Tie Cultural Competence to Profits
• Include Cultural Competence into the Training
  Curriculum
• Show how Cultural Competence is Useful to Save
  Money

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Useful Techniques

• Decrease the Assumption that Cultural Competence
  is Affirmative Action
• Decrease the Assumption that Cultural Competence
  is About Black People
• Provide Training and Education in Cultural
  Competence for Key Managers in the Organization
  and Board Members
• Develop Standards and Guidelines

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Useful Techniques

• Non-Blaming Approach
• Focus on Cost Savings/Marketing Framework
• Focus on Service Improvements/Quality/Data
• Acknowledge Existing Competencies
• Understand Resistance/Nature/Origins
• Recognize Weaknesses in Cultural Competence
• Establish a Realistic Schedule for Change
• Develop a Plan of Action with Education,
  Licensure, and Accreditation
• Bind Cultural Competence to Vision/Goals

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Who Uses Cultural Competence?

• Coca Cola/Pepsi Cola Defense Department
• Budweiser NCQA
• General Motors JCAHO
• IBM Managed Health Care
• Time Warner California DMH
• HMOs Texas DMHRM
• Disney Europe Virginia DMHMR
• Makers of Viagra

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Coca Cola in the Bush
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DISNEY OF EUROPE
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DISNEYS CULTURAL ISSUES

• Marketing to Europeans
• Pricing Too high in Europe
• Alcohol Cannot ban drinks
• Language Uses six different languages
• Differences in Attitudes
• Films Must adhere to Euro standards
• History Must reflect Europe
• Famous Figures Limit American stars

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Disneys Outcomes

• Tenth anniversary this Year
• 2000 New hotel rooms under construction
• Visitors will exceed 17 million this year
• Profits are up
• Costs are down
• Food does not meet European expectations

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Resistance to Cultural Competence

• New Unfamiliar Concept
• Incongruence with Prior Education
• Non-traditional Source
• Degree of Change Required - Education
• Lack of Evidence Tools
• Not Linked to Licensure/Accreditation
• Conceptualization in Black White Terms
• Potential Cost of Implementation

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New Developments

• National Alliance of all Four Groups has been
  Formed Non-Profit Organization, Advocacy,
  Policy, Training, Research, Workforce
  Development, Interpretation Models
• Ethnic/racial behavioral health care non-profit
  advocacy associations African, Asian, First
  Nation, and Hispanic

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Development of Standards
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Broad Change Strategies

• Address the pipeline causes/issues
• Support alternative education models
• Focus on continuing education
• Provide training via technology
• Bundle licensure and cultural competence
• Bundle CC with accreditation
• Bundle federal research support to CC
• Provide federal incentives for retraining
• Support development of model curricula CC

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Personal Development Strategies

• Plan your careers and geographic moves well
• Build and use strong cross ethnic networks
• Develop new concepts and theory
• Conduct research and test hypotheses
• Publish present findings in key journals/books
• Teach in universities/key academic positions
• Hold influential positions in profession
• Advocate participate in politics
• Provide financial support
• Mentor your replacement (s)
• Maintain your bilingual and tri-lingual skills

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General Conclusions

• Too much new information (format) to
  access/digest or use
• Transformation cannot occur fully without
  addressing the complex issue of disparities
  knowledge, evidence, research, participation,
  help seeking
• Transformation comes at a time of significant
  reductions in state budgets for human services
• Evidence based approaches must be expanded to
  include the 4 populations of color
• Cultural competence offers promise but requires
  national field testing, cost estimation,
  educational trials, linkages to licensure,
  accreditation, and further development
• Cultural competence must demonstrate outcome and
  cost efficacy
• Poverty and related socio-economic issues will
  affect the application of evidence based
  approaches
• New epidemiological studies are needed on the
  four populations of color to increase knowledge
  of help seeking and utilization.