CULTURALLY COMPETENT HEALTH PROMOTION AND DISEASE PREVENTION

1
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
2
OBJECTIVES

• 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

3
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

4
The Changing US Population
Percent of population
Source Bureau of the Census
5
U.S. Immigration - 2001 Statistics


N
Top Ten Countries of Birth
1. Mexico 2. India 3. China, Peoples
Republic 4. Philippines 5.
Vietnam 6. El Salvador 7. Cuba 8. Haiti 9.
Bosnia-Herzegovina 10. Canada
206,426 70,290 56,426 53,154 35,531 31,27
2 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
6
U.S. Immigration - 2001 Statistics


N
Top Ten States
1. California 2. New York 3. Florida 4.
Texas 5. New Jersey 6. Illinois 7.
Massachusetts 8. Virginia 9. Washington 10.
Maryland

282,957 114,116 104,715 86,315 59,920 48,296 28,96
5 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
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Within - Group Diversity
is often greater than
Between - Group Diversity
8
Institute of Medicine Reports

• 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)

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U.S. Department of Health
and Human
Services
HEALTHY PEOPLE 2010 INITIATIVE

• 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.

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HEALTHY PEOPLE
2010 INITIATIVE

• Infant Mortality
• Cancer Screening and Management
• Cardiovascular Disease
• Diabetes
• HIV/AIDS Infection
• Child and Adult Immunization

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CANCER EPIDEMIOLOGY
12
Cancer Facts Figures - 1997Cancer Incidence
Rates for all Sites Combines by Race, Ethnicity,
and Sex, US, 1988-1992Race or Ethnicity
560
326
282
213
274
224
340
321
322
241
266
180
326
273
372
348
196
180
469
346
319
243
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.

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AGE-ADJUSTED MORTALITY RATES FOR MAJOR CANCER
FOR WHITE AND MINORITY GROUPS, BY UNDERLYING
CAUSE OF DEATH, UNITED STATES, 1990.
American




Indian/




Alaska




Native
Asian/




Pacific




Islander

• Hispanic
  
  
  
  
  American

White




American
African-




American
Indicator

• 
  
  
  
  

Lung Cancer
54.0
27.9
26.8
67.5
35.6
Colorectal cancer
20.6
26.6
18.2
10.1
12.6
Breast cancer
16.3
6.5
13.9
6.6
19.5
Cervical cancer
1.8
0.9
0.5
0.7
1.1
Prostate cancer
23.5
10.2
6.0
5.8
10.7
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.
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CANCER PREVENTION
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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, DOnofrio 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.
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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, DOnofrio 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.
17
THIRD GENERATION
HEALTH PROMOTION

• 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

Pasick RJ, DOnofrio 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.
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TARGETING VS TAILORING
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COMMUNITY HEALTH
PROMOTION

• TARGETING

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
Pasick RJ, DOnofrio 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.
20
COMMUNITY HEALTH
PROMOTION

• TAILORING

adaptation of the intervention and/or total
redesign to best fit the needs and
characteristics of a target audience
Pasick RJ, DOnofrio 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.
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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.
22
THE HEALTH CARE SYSTEM
Popular Sector
Individual-based




Family-based




Social nexus-based




Community-based
Professional Sector
Folk Sector
Adapted 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
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CONFLICTING VALUES
Professional System Place High Value on
Families from Different Cultures
Place High Value on

• 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

• Facts rather than feelings and
  personal relationships
• Impersonal communication (written, documented)
• Formal appointments and strict
  timelines
• Cost effective services
• Speedy delivery of services

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.
24
Community Voices Exploring
Cross-Cultural Care Through Cancer

Harvard
Center for Cancer Prevention, 2001
Fanlight Productions
(www.fanlight.com)

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What is Cultural Competence?

• A system of care that acknowledges and
  incorporatesat all levelsthe 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)

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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.
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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 1181-217, 2000.
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Ecology of Health Care
Crabtree BF et al. Understanding practice from
the ground up, The Journal of
Family Practice 2001 50(10)883.
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BECOMING A CULTURALLY COMPETENT HEALTH CARE
ORGANIZATION
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National Standards on Culturally and
Linguistically Appropriate Services (CLAS)
in Health Care
Final Report
DHHS Office of Minority Health
Federal Register December 22, 2000, Volume
65, Number 247, pages 80865-80879
www.omhrc.gov/CLAS
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CLAS STANDARDS THEMES

• Culturally Competent Care Standards
  1-3
• Language Access Services Standards 4-7
• Organizational Supports Standards
  8-14

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Challenging Isms and Fears

• Ageism
• Sexism
• Racism
• Classism

• Ableism
• Homophobia
• Xenophobia
• Other

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Key Points

• Every encounter is a cross-cultural encounter.
• There is no cookbook approach to treating
  patients.
• Avoid stereotyping and overgeneralization.

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Guidelines for Health Practitioners LEARN
L Listen with sympathy and understanding to
the patients perception of the
problem. E Explain your perceptions of the
problem. A Acknowledge and discuss the
differences and similiarities. R Recommen
d treatment. N Negotiate agreement.
From Berlin EA, Fowkes WCJr A Teaching
Framework for Cross-Cultural Health Care,
Western
Journal of Medicine 1983, 139934-938.
35

Promoting Health in Multicultural Populations
A Handbook for Practitioners Editors RM
Huff, MV Kline
Thousand Oaks, CA SAGE, 1999.

36

A PLANNING FRAMEWORK
HEALTH PROMOTION AND DISEASE PREVENTION
PROGRAMS IN MULTICULTURAL
POPULATIONS

• Task 1 Planning the Program
• Task 2 Implementing the Program
• Task 3 Evaluating the Program

Adapted 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.
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The PEN - 3 Model
Health Education
Person
Extended Family Neighborhood
Cultural Appropriateness of Health Behavior
Educational Diagnosis of Health Behavior
Positive Existential Negative
Perceptions Enablers Nurturers
Adapted from Airhihenbuwa CO 1990. A
conceptual model for cultural appropriate health
education programs in developing countries.
International Quarterly of Community Health
Education 1153-62.
38
Wheres Shirley?
A Video Production About
Breast Cancer
The Womens Cancer Screening Project




3 Cooper Plaza, Suite 220




Camden, New Jersey 08103




[phone]




[phone] - Fax
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CD-ROM Cultural Competence in Breast Cancer
Care Medical College of Ohio Ohio Department
of Health/CDC

VERTIGO PRODUCTIONS LTD. 3634 Denise
Drive Toledo, Ohio 43614 Phone [phone]
FAX [phone]
40

Communicating Across Boundaries A Cultural
Competency Training on Breast and Cervical
Cancers in Asian American Women
National Asian Womens Health Organization
(NAWHO) http//www.nawho.wego.net/index.v3page?p1
8357
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INTERNET WEBSITES

• The Providers Guide to Quality and Culture
  http//erc.msh.org/qualityculture
  
• Resources for Cross-Cultural Health Care
  http//www.diversityrx.org

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THE NEED FOR COMMUNITY
PARTNERSHIPS
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Clients have
deficiencies and needs
Citizens have
capacities and gifts
Kretzmann, JP, McKnight, JL. (1993). Building
communities from the inside out A path toward
finding and mobilizing a communitys 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.
44
DEFICITS VERSUS ASSETS MAPPING
Neighborhood Needs Map
Unemployment
Truancy
Broken Families
Slum Housing
Grafitti
Illiteracy
Gangs
Crime
Child Abuse
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 communitys 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.
45
DEFICITS VERSUS ASSETS MAPPING
Community Assets Map
Local Institutions
Businesses
Schools
Citizens Associations
Churches
Block Clubs
Gifts of Individuals
Artists
Income
Parks
Libraries
Elderly
Labelled




People
Youth
Cultural Groups
Hospitals
Community Colleges
Kretzmann, JP, McKnight, JL. (1993). Building
communities from the inside out A path toward
finding and mobilizing a communitys 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.
46
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.
47
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.
48
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 others cultural
values, beliefs, and norms.
Michael V. Kline and Robert M. Huff
49
We need to comfort the afflicted,
and
afflict the comfortable.
Eleanor Roosevelt
50
Sometimes it is easier to change
the world than to change oneself.
Rabbi Yakov R. Hilsenrath
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Diversity in America
Kaleidoscope
Rainbow
Mosaic
What is your preferred image?
Salad
Cauldron
Melting Pot
Other?