Steps toward a Transdisciplinary and Community-Based Approach

1
Steps toward a Transdisciplinary and
Community-Based Approach

• To Health Disparity
• Mark Nichter, University of Arizona, April 2003

2
Five Objectives

• Propose ways of thinking about culture and
  ethnicity productive to a health disparity
  agenda.
• Make a case for transdisciplinary research
  involving the health and social sciences
• contributing to a eco-social epidemiological
  understanding of health problems
• attentive to nested contexts and syndemic
  patterns of ill health

3

1. Describe cross disciplinary research as a
   continuum and transdisciplinary research as a
   process

4
Objectives

• Provide an overview of two broad areas of
  transdisciplinary research essential to a health
  disparity agenda
• Translational research
• Formative research process
• Participatory research
• Cultural competency training
• Moving beyond first steps on a cultural
  competence continuum
• Using anthropologists as facilitators

5
Objectives

• Revisit transdisciplinary research
• Identify challenges and stumbling blocks

6
Objective one

• Propose ways of thinking about culture and
  ethnicity productive to a health disparity agenda.

7
Ethnicity

• When ethnicity is employed as a category in
  public health and medicine, it is important to be
  clear about ones assumptions (and intentions)
• How is ethnic designation going to be used in
  data analysis and how will this frame thinking
  about interventions?

8
Ethnicity

• Is an ethnic label being used to examine the
  possible role of biological differences?
• Is ethnicity a proxy for a whole bundle of
  social and economic factors associated with the
  position a group of people has been forced to
  assume as a result of a history of discrimination
  or oppression
• As a marker of social inequity and structural
  violence

9
Ethnicity

• Is ethnicity being examined to determine whether
  the distinctive characteristics of an ethnic
  groups culture are protecting or exposing this
  group to particular types of risk?

10
How should we think about culture?

• Culture is commonly thought of as an enduring set
  of social norms and institutions that organize
  the life of members of particular ethnic groups
  giving them a sense of continuity and community.

11
Culture

• Often described rather vaguely as an
  all-encompassing associational field in which
  ethnicity is experienced.
• When Culture is thought about in terms of
  consensus and as a template for ideal behavior,
  the positions of different stakeholders (defined
  by gender, generation, class, power relations,
  etc.) are forgotten and heterogeneity is ignored.
• The tensions within are glossed over.

12
Culture

• Culture is more than a unique collection of
  beliefs, values, habits, customs
• Culture is more than a mental map the map is not
  the territory!

13
Culture

• Culture involves
• Processes of control
• Expressions of agency
• Areas of conflict

14
Processes of control

• Control is exercised in variety of ways through
  ideas as well as practices, speech as well as
  action, perceptions of normative behavior and
  what constitutes morality as well as what is
  deemed deviant or abhorrent behavior
• Ideas about the normal and natural, abnormal and
  deviant are motivated social constructions. They
  often involve power relations
• They are not neutral. They have a history.

15
Agency

• Understanding culture requires more than being
  attentive to the rules of the game and
  dispositions to act and think in particular ways.
• How is the game being played in different public
  and private contexts?
• People are rule makers as well as rule breakers
  rules may be broken in cultural ways.
• The game is being reinvented and finessed all the
  time there are plenty of grey areas and lots of
  improvisation.

16
Conflict

• Structural tensions exist within all cultures
• Gender within gender, across gender
• Generation varying expectations, dreams
• Conflicting allegiances and alliances
• Conflicting ideas about entitlement to scarce
  resources
• Individualistic aspirations and sociocentric
  norms
• Jealousies and so on

17
Culture is a project, not a thing

• A processual rendering of culture is most
  productive. Such an approach directs attention to
  cultural dimensions of social transactions and
  asks what is cultural about particular types of
  behavior in different contexts.
• See culture as more as an adjective than a noun
  (Appadurai 1986).

18
Relevance to health field

• Instead of stereotypical characterizations of
  culture and folk illnesses, what we require for
  cultural competency training are more processual
  accounts of illness experiences, health care
  seeking, and follow through which get at what is
  cultural about courses of action.

19

• Circumstantial ethnographies that explore
• contingencies, hard choices, and, in situations
  when little choice exists, the coping strategies
  that favor illness being interpreted and
  responded to in particular ways.

20
Ethnicity is not a black box

• There has been mounting criticism about the way
  in which race/ethnicity has been used in public
  health research as a set of pigeon holes if not
  black boxes.
• This fosters an analysis of difference that
  focuses on individual and group traits rather
  than the contexts in which people live.

21
Ethnicity Risk marker or risk factor?

• Despite warnings against reading too much into
  aggregate (e.g., state, national) data on a
  specific health problem and ethnicity, it is all
  too easy to view ethnicity as a risk factor
  rather than a risk marker.

22
Example

• Are cultural factors responsible for ethnic
  differences in levels of smoking, drinking,
  consuming fast food, or engaging in fast sex?
• Or is ethnicity merely a marker of multiple
  social and economic factors predisposing such
  behaviors in particular environments
• by members of an ethnic group living in
  circumstances not of their own making or choosing

23
The environment matters

• Example
• Adults who say that they live in unsafe
  neighborhoods are one and a half times more
  likely to be overweight than adults who say they
  live in safe communities
• (Ross C. Brownson 2003)
• Interventions need to target spaces not just
  people

24
The environment matters

• Example
• When broken down by race, not just wealth, there
  are four times as many supermarkets in
  predominantly white neighborhoods as in the
  African American neighborhoods of Detroit.
• These people are also less likely to have a car

25

• Point. On reason urban dwelling African Americans
  living in poverty have poor diets is because
  reasonably priced food sources are not
  accessible.
• The same is true of Native Americans living in
  rural areas of the SW.
• This places them at greater risk for chronic
  diseases, such as diabetes and hypertension

26

• Their dietary behavior is responsive to the
  availability of foods, it is not merely a
  question of cultural preference. On the other
  hand children are socialized into food habits
  which persist over time.
• Poor food habits become a marker for an
  impoverished environment.
• Is the answer to just nutrition education?

27
More Productive Ways

• Of
• Studying Health Inequality

28
Objective two

• Make a case for transdisciplinary research
  involving the health and social sciences
• contributing to a eco-social epidemiological
  understanding of health problems
• attentive to nested contexts and syndemic
  patterns of ill health

29
To address health disparities we need to
reconsider risk

• It is important to move from an examination of
  groups at risk where the victim(s) may
  unintentionally be blamed
• As if traits of the group are responsible for
  the problem
• To a consideration of risky behaviors those
  behaviors placing members of a group at risk

30
Risk reconsidered

• To environments of risk the places where risky
  behaviors occur more commonly
• What factors contribute to the proliferation of
  such environments
• Who spends time in these environments and why
• Who exploits these environments who sets up shop
  to make a profit

31
Eco-social epidemiology

• An eco-social approach to epidemiology examines
• Who and what is responsible for disease
  distribution in a population
• Current and changing patterns of social
  inequality in health
• Population based patterns of health and disease
  are seen as biological expressions of social
  relations experienced in multiple contexts.
• (Kreiger 2001 Intern Journal of Epidemiology)

32
Eco-social epidemiology

• Investigates environments of risk and structural
  inequalities in health care provision
• Attention is directed to the cumulative
  interplay between exposure susceptibility
  resistance
• Focused upon is how nested contexts influence one
  another and predispose sections of a population
  to particular health problems (and clusters of
  problems).

33
Nested Contexts

• Home environment
• Peer group environment
• Neighborhood (schools, etc)
• Work environment
• Economic and political economic environment
• Consumer environment
• Media environment
• Etc.

34
Application of eco-social thinking

• What are the reasons for higher rates of
  hypertension and diabetes or hospital admissions
  for asthma among particular ethnic groups
• Look at nexus of factors

35
Example Hypertension in African Americans

• Identified are linkages between (Kreiger 2001)
• Economic and social deprivation less access to
  good food at an affordable price high fat, high
  salt diet
• Exposure to toxic substances older houses and
  crowded urban housing more exposure to lead
  paint and car exhaust
• Socially inflicted trauma discrimination, fear,
  anger increase of allostatic load

36

• Targeting marketing of commodities high alcohol
  beverages, menthol cigarettes
• Inadequate health care poor detection of disease
  and poor clinical management
• Positive side social capital, resistance to
  racism, community based programs which are
  accepted, new laws

37
Ecological to approaches to studying health
problems encourages us

• To adopt an action is in the interaction
  perspective

38
To appreciate the action in the interaction

• Think beyond
• the mere listing of contextual influences
• the measurement of contextual influences as if
  they operated independently of each other

39
Think beyond regression

• Regression logic assumes
• Independent and generally additive contributions
  of variables.
• The emphasis is on disentangling variable
  effects.
• Interdependencies among variables are not the
  focus rather they are something to be
  controlled for.

40
How should we go about thinking about health
disparities

• Step one

41
Question what we think we know

• Correlations between ethnicity and various health
  problems are rife.
• What do they tell us?
• What dont they tell us?

42

• Correlations are often misinterpreted as causal
  relationships.
• As if exposure to race/ethnicity explained
  something profound.
• Observations masquerade as discoveries.

43

• Instead of research beginning with the
  observation of ethnic differences, it often
  stops!
• This is one reason transdisciplinary thinking is
  badly needed to take research to the next level -
  to get at differences which make a difference.
• Differences which may be addressed by
  interventions upstream as well as downstream.

44

• Approach prevalence data by ethnicity with
  caution
• Consider what is explained by a other variables,
  especially class and location
• Then consider how these variables interact with
  cultural norms, institutions etc.

45

• Example Tobacco use and ethnicity
• It is productive to look for ethnic differences
  in smoking after first considering other factors
  known to predispose individuals to smoke
• education, peer influences, social class,
  economic insecurity, stressors (e.g.,
  discrimination), other drug use, etc.
• (Nichter Addiction 2003)

46
Ethnicity and Smoking

• Follow up What trends in smoking are not
  explained by social class, education, etc.
• Why is it that African Americans tend to have a
  later age of smoking uptake than other ethnic
  groups?
• Lower overall prevalence rates
• High rates of heavy smoking once smoking is
  established

47

• What is cultural about
• smoking trajectories
• times of smoking transition
• patterns of smoking
• cigarette preference and topography

48
Ethnicity and smoking uptake

• To what degree do parenting styles influence
  smoking uptake
• African Americans parenting more authoritarian
• Native Americans autonomy valued even at young
  age
• To what extent do differences in peer influence
  effect smoking uptake
• African Americans peer influence less than
  white
• How do different ideas about style and
  aesthetics influence smoking uptake
• Smoking is not a Black styling thing

49
When changes in rates of smoking prevalence are
reported

• We need to ask
• In what sub-groups is this occurring
  (intercultural variability)
• What may be the reasons
• Are ethnic groups being targeted for social
  engineering read marketing
• What else is going on

50
Trends in cigarette smoking among 12th graders,
by racial/ethnic group United States, 1977-1998
50
40
White
30
Hispanic
Percentage
20
10
Black
0
1983
1979
1981
1977
1985
1987
1989
1991
1993
1995
1997
Year
Smoking on gt1 of the 30 days before the
survey. 2-year moving averages are used to
stabilize estimates.
Source University of Michigan, Monitoring the
Future Project.2000.
51
How should we go about thinking about health
disparities

• Step two

52
Step two

• Rather than focusing on one health problem or why
  there is a sudden rise in a particular type of
  unhealthy behavior (like smoking)
• Examine what else is going on and if there is a
  link between things which are co-occurring look
  broadly
• Focus on the package, a specific behavior change
  or health problem may be a symptom of a much
  bigger shift

53
How should we go about thinking about health
disparities

• Step three

54
Look for

• Syndemic patterns not just individual health
  problems

55
Syndemics

• Syndemics occur when multiple health related
  problems cluster by person, place, or time.
• They refer to the set of synergistic or
  intertwined and mutual enhancing health and
  social problems facing a population.
• http//www.cdc.gov/syndemics/overview-definition.h
  tm.

56
Syndemics

• Preventing syndemics requires both control of the
  component afflictions and recognition of the
  relationships that tie those afflictions together
  and synergistically amplify their negative
  consequences.

57
A Syndemic Network

• To prevent a syndemic, one must prevent or
  control not only each affliction but also the
  forces that tie those afflictions together

58
Syndemic example

• Substance abuse, violence, and AIDS
• Inextricable and mutually reinforcing connections
  between three conditions disproportionately
  afflict those living in poverty in U.S. cities
  (Singer 1994 1996).

59
The SAVA Syndemic

• Adapted from Singer M, 1996

60
Syndemics

• A syndemic orientation is primarily distinguished
  from other perspectives by its explicit emphasis
  on examining connections between health-related
  problems.
• With this concern, it offers a broader framework
  for understanding how multiple health problems
  interact in particular communities.

61
Syndemics

• A syndemic orientation elevates public health
  inquiry beyond its many individual categories to
  examine directly the conditions that create and
  sustain overall community health.
• The notion of a syndemic shows that at the
  community level there is more to prevention
  science than the study of isolated health
  problems.

62
Health-related problems cluster for many reasons

• Caused by the same/similar biological agent
  (vector etc.)
• Common mode of transmission (e.g. water borne)
• Common risk factors (e.g. smoking, fast food
  obesity)
• Result from same environment of risk

63

• Have reciprocal or interdependent effects (e.g.,
  alcoholism and depression can reinforce each
  other)

64

• The syndemic model raises difficult questions and
  challenges public health to address the root
  causes of health disparities. By introducing a
  multi-level, dynamic epidemiological perspective,
  it points toward the need to develop and evaluate
  systems- and community-level interventions that
  target linked processes." (From MacQueen KM, in
  Breslow et.al, 2002)

65
Objective 3

• Why should we invest in transdisciplinary
  problem solving?
• Describe transdisciplinary research as a process.
• How does it differ from multidisciplinary or
  interdisciplinary research?

66
Taxonomy of cross-disciplinary research

• Rosenfield PL, Soc. Sci. Med. 35(11)1343-57

67
Multidisciplinary research

• Multidisciplinary Researchers work in parallel
  or sequentially from disciplinary-specific base
  to address common problem.

68
Interdisciplinary Research

• Interdisciplinary Researchers work jointly but
  still from disciplinary-specific basis to address
  common problem.

69
Transdisciplinary Research

• Transdisciplinary Researchers work jointly using
  shared conceptual framework drawing together
  disciplinary-specific theories, concepts, and
  approaches to address common problem.

70

• There is a direct link between the level of
  disciplinary integration and the contribution to
  health policies and programmes (Rosenfield
  19921353)

71
Contribution

• Multidisciplinary Specific short-term problem
  solving.
• Interdisciplinary New specific programs plus
  problem solving.
• Transdisciplinary Broadly-based trans-sectoral
  programs and actions with longer life new
  concepts, methods, and policies.

72

• Transdisciplinary thinking requires that a health
  problem be reconceptualised within the full
  complexity of the systems in which it is embedded
  (Albrecht Higginbotham 2001).

73
Transdisciplinary Science
TD science is a strategy and a process for
solving complex problems, where determinants are
multiple, interacting, reciprocal, multi-level

74
The transdisciplinary study of complex health
problems demands

• A consideration of interlocking levels of
  influence
• From cells to society to globalization

75
Interlocking levels of influence Relevant
disciplines

• Biobehavioral clinical and behavioral sciences,
  public health
• Sociocultural social sciences which study nested
  social interactional contexts
• Global political economics, policy sciences
  which examine the flow of people, ideas, products
  and influence etc. and the politics of
  responsibility beyond the boundaries of nation
  states

76
Transdisciplinary research requires

• Listening across the gulfs that separate
  disciplines and scientists representing
  them
• Common language - conceptual translation
  among scientists from various disciplines
• Engaging in joint projects
• Collaboration on research that bridges
  disciplines Kahn and Prager,
  1992

77
What it takes...

• Commitment time, energy, intellectual work
• Focus central theme, activity meaningful and
  robust problem to solve
• Patience takes time to learn how to engage other
  disciplines, to appreciate other lines of thought
• Vigilance overcome forces of disciplines,
  departments, grants, promotions, products
• Fortitude taking risks, tenacity, bravery
• Adapted from Dr. D. Prager

78
Objective 4

• Provide an overview of two broad areas of
  transdisciplinary research essential to a health
  disparity agenda
• Part one Translational research
• Formative research process
• Participatory research

79
Translational Research

• Clarify what translational research covers as the
  term is now being used in relation to health.
• Describe the role of anthropologists
• Provide examples of a few important issues which
  urgently require translational research by
  transdisciplinary teams involving
  anthropologists.

80
Translational Research

• General Use of the Term
• Translating science to practice through
• Dissemination
• Diffusion
• Application of Scientific Findings

81
Translational Research

• Focuses on the interface between
• 1) Scientists (broadly defined)
• 2) Health care providers
• 3) Policy makers all areas
• 4) Communities having diverse backgrounds
  (e.g., ethnicity, class, physical and political
  environment)

82
Translational Research

• Focuses on the interface between
• 5) Funding agencies/resources, etc.
• 6) NGOs representing local as well as
  transnational interests, etc.
• 7) Health care industry
• 8) Business interests responsible for workers
  and consumer behavior.

83
Primary Goal of Translational Research (in Health)

• To improve public health outcomes through
• More conscious communication between these eight
  sectors.
• The development of more tailored interventions
  beyond one size fits all approaches.
• Involving more active community participation
  from development to evaluation stages of an
  intervention.

84
What is Called For

• Interventions which are
• Relevant to specific populations
• Understood by the population and supported
  locally
• Feasible given real life contingencies
• Effective as evaluated against a baseline and
  secular trends
• Sustainable

85
Expanded Scope of Translational Research

• Goal of health equity at a time of shrinking
  resources and rationing
• To reduce, if not alleviate, disparities in
• Health status
• Access to essential health services
• Treatment outcomes and quality of care

86
The Role of Anthropologists in Translational
Research

• What do they bring to the table

87
Anthropologists Have an Established Track Record

• Working on the interfaces between
• Communities, health providers and policy makers
• Bringing local knowledge and the concerns of the
  community to the table
• Describing stakeholder positions
• Placing community responses to health problems
  and health programs within a broader context.

88
Anthropologists have a long history

• Serving as cultural brokers between patients and
  communities
• Health care providers
• Health policy makers
• National/ International Health Agencies

89
Anthropologists

• Also have a long history
• Being asked to identify cultural barriers to
  health programs.
• Emphasis on beliefs which determine unhealthy
  behavior
• Prescription Knowledge becomes the key to
  behavior change

90
Cultural Barriers Only One of Many Things
Anthropologists Study

• Anthropologist often hired to examine cultural
  barriers to programs, especially when they are
  doing poorly.
• Anthropologists look at this as a very limited
  use of their skills
• Also a limited assessment of a problems given an
  eco-social perspective

91
Cultural Barrier Bias

• Focusing on cultural barriers
• Can deflect attention from other causes of
  failure (e.g. racism, sexism and ageism
  structural violence inadequate resources poor
  management lack of trust)
• Can inadvertently promote victim blaming and
  ethnic stereotyping, etc.

92
Pathogenic vs Salutogenic Focus

• Far more attention is directed toward looking at
  risk factors than protective factors when
  ethnicity is addressed.
• Focusing on cultural barriers to programs
  frames culture as a risk factor at large impeding
  progress.

93
Whats missing

• A consideration of positive aspects of cultural
  institutions, norms, local funds of knowledge,
  social capital etc.
• Consideration of resilience a core theme in
  minority health

94
To Engage in Translational Research

• A More Balanced View of Culture is Required

95
Translational Research Agenda

• Ideally involves an anthropological perspective
  at each of the eight stages of formative
  research.
• There are only a few examples of anthropologists
  being supported to participate at all stages of
  formative research. This needs to change.

96
Formative Research

• Eight Stages
• (Nichter, http//medanthro.net/academic/tools)

97
Formative Research

• To inform What people are doing, saying, and
  thinking now about a health-related issue, and
  how history as well as globalization informs the
  present.
• 2. To identify Important problems which need to
  be solved -- identified by experts as well as
  community members.
• 3. To generate A list of options for
  interventions in the community, clinics, etc.

98
Formative Research

• 4. To foster critical assessment and problem
  solving What are the pluses and minuses of
  possible interventions for various stakeholders?
• 5. To investigate How best to implement
  promising interventions Who, when, where, how
  much, what collaborations?
• 6. To monitor responses To interventions
  affording mid-course correction, etc.

99
Formative Research

• 7. To evaluate success Is the intervention
  really making a difference and if not, why not?
  Is the success or failure due to the program or
  other factors?
• 8. To examine How is an intervention and its
  results being presented to the public and
  scientific community? What is the response to
  this production of knowledge?

100
Participatory research combined with formative
research

• Is very powerful

101
Participatory research

• Within communities of practice
• Raise the consciousness of practitioners and
  policy makers by involving them in short research
  exercises
• Enable them to understand issues in new ways and
  appreciate the need for different types of
  information

102
Examples

• COPE Practitioners follow patients as they
  access and negotiate the health care system
  spend a few days with patients and tiers of staff
  as they work the system
• Focused ethnographies Specific health problems
  are investigated from the position of patients,
  health providers, administrators different
  stake holder positions

103
Participatory research

• Community based problem solving requires
• Mobilizing community action sets are mobilized
  around issues and tasks which matter to the
  community
• Build capacity for critical thinking leading to
  action one must invest in the process

104
Formative research empowers people

• Participatory research gives people a place to
  begin to think through a problem
• Engage community members through science, let
  them test their own hunches, not just yours
• Involve them not just collecting data, but the
  research process demystify the process
• Science if embraced by the community can be a
  tool of empowerment
• Encourage the community to take ownership of the
  data and participate in its dissemination

105
Translational Research

• Examples of pressing Issues
• Demanding
• Attention

106
Issue One
107
How does the public respond to health information

• Given all the time invested in conducting
  rigorous epidemiological research, shouldnt as
  much effort be put into studying how it is
  received and used?
• When epidemiological data is released to the
  public, reported in the press, etc. how is it
  interpreted and responded to?

108
Epidemiological Data

• Does data on prevalence or risk place a community
  at further risk?
• Make a behavior appear more normative
• Make a problem seem more inevitable, etc.
• When do surveillance and screening activities
  have the unintended consequence of making a
  problem appear far more prevalent, creating a
  sense of dread?

109
N.E. Thai Cervical Cancer Study

• Prevalence rate 25/100,000
• Perceived prevalence rate after PAP smear
  screening program 3/10
• All recurrent and chronic RTI problems are
  associated with cervical cancer by local women
• Result earlier recognition of cancer at the cost
  of tremendous suffering on the part of women.

110
Accountability

• Translational research has an ethical agenda.
• Information released to the community needs to be
  monitored how is it interpreted?
• If interpretations of health messages are
  iatrogenic, they need to be corrected.

111
Issue Two
112
What form of information is most effective

• Beyond content of health and risk messages, what
  type of message best catches the attention of
  members of minority groups (by gender and
  generation, education)
• Statistics and numbers
• Testimonials by whom
• Images
• Analogies
• Etc.

113
Issue Three
114
Disinformation

• The deliberate, often subtle, propagation of
  misinformation by parties having vested interests
  in maintaining unhealthy behaviors.
• The evidence is not in, experts disagree
  about whether smoking is really all that
  unhealthy

115
Disinformation

• Misinformation is often tied to harm reduction
  alternatives which appeal to wishful thinking.
• Promotion of cigarettes which are lighter,
  milder, better filtered, more organic, giving the
  impression they are safer to smoke.
• Food labels are misleading how are they read
  and what kind of consumer education is needed

116
Direct to consumer advertising of medicines

• Minority group members , especially ones with no
  health insurance or access to care facilities,
  engage in self care
• We know little about self care practices - what
  they use and how they use it
• What we do know is that they purchase products
  which are often promoted by companies in spurious
  ways

117
Issue four
118
The need for consumer education

• Reading labels, critical thinking
• Communication skills how to report problems and
  seek advice, writing and oral
• Basic math how to calculate costs, understand
  measures etc. in real world context
• Health consumer education practical and
  targeted to issues facing minority groups
• How to access health care, work the system,
  pharmaceutical practice, self care

119
Health education for minority health

• We can learn lessons from primary health care
  programs in developing countries
• ORS, ARI (recognize pneumonia), nutrition which
  matches local food habits, budgets, seasonal
  availability of foods, breastfeeding
• New initiatives to teach about taking care of the
  elderly health across the life course

120
Bottom Up Nutrition Education

• During the four years of high school, youth may
  be exposed to only five class periods or less on
  nutrition.
• In the absence of ethnography on teens everyday
  eating behavior, the content of nutrition classes
  is general with a focus on the food pyramid.
• (Mimi Nichter, 2000)

121
Translational Research

• Is needed to address the many questions teens
  have about weight and foods that they typically
  consume.
• What healthy choices can I make when I
  go to a fast food restaurant?
• What do nutritional labels mean?
• Whats the difference between light and lo-fat?

122
Address Youth Concerns

• Rather than provide general nutrition messages,
  there is a need to
• Build upon the questions which youth already
  have
• Address their concerns related to body image and
  development
• Reinforce positive behaviors which youth already
  practice
• (Mimi Nichter, 2000)

123
Issue Five
124
Information flows

• We need to know far more about flows of
  information about health care ?
• How do people learn to access, navigate and work
  the health care system?
• What do minority populations see as factors which
  impede their use of health care facilities
  language, forms, way they are treated, hidden
  costs, fear

125
Who are the care takers

• Who should we be providing health care
  information about the chronically ill?
• For example those with diabetes or hypertension
• Who are the care takers of the chronically ill?
  Who influences their behavior?
• Consider migrant workers who travel with and
  without their families

126
Issue six
127
Trust

• Trust is crucial to the translational process
• To what degree is trust in health information
  related to
• Trust in the source of the information?
• Trust in the spokesperson conveying the
  information and their connection to community?

128
Trust

• How do issues of trust and perceptions of health
  provider motivation impact
• Health care seeking and compliance
• Participation in preventive and promotive health
  programs, clinical trials etc.

129
Trust

• 42 of Blacks and 23 of Whites said they did not
  trust their doctors to fully explain medical
  research participation to them
• 37 of Blacks and 20 of Whites believed their
  doctor might ask them to participate in medical
  research even if it could harm their health
• Fackelmann Archives of Internal Medicine Nov
  25, 2002, N 527 Blacks, 382 whites

130
Trust

• 45 of Blacks and 35 of Whites believed their
  doctors might expose them to unnecessary risks
  when prescribing treatment
• 63 of Blacks and 38 of Whites believed their
  doctors often prescribed medicines as a means of
  experimenting on people without their knowledge

131

• Twenty-five percent of African Americans and 8
  of Whites believed that their doctor had given
  them an experimental treatment without their
  consent

132
Trust

• Medicine has attained such a privileged place in
  American society that many of those in the health
  have been lulled into the false belief that they
  are entitled to be trusted.
• Trust is earned, not owed
• Once lost, trust is exceedingly difficult to
  regain
• (Jordan Cohen, Pres. of AAMC 2002)

133
How do we go about

• Regaining trust

134
Objective 4

• Provide an overview of two broad areas of
  transdisciplinary research essential to a health
  disparity agenda
• Part two Cultural competency training

135
Cultural competency training

• Cultural competency training is a need medicine
  can no longer ignore given
• Demographic trends in the US
• Federal legislation
• Potential law suits
• Competition for patients
• Growth of a cultural competency industry to fill
  this need

136
Cultural competency training a continuum

• Employ translators language assistance, as
  cultural brokers
• Training becomes a big issue medical vocabulary
  or conceptual translation?
• Provide a few lectures sensitivity training,
  curriculum varies greatly

137

• Two day workshops generalities about ethnic
  groups abound
• Some better than others
• In some cases people get accredited as having
  expertise after 2 days!
• Grand rounds often topical

138

• Cultural competence is seen as a process which is
  developmental
• All medical interactions are seen as cross
  cultural
• Issues related to health disparity and the
  cultural dimension of care are integrated into
  teaching curriculum not compartmentalized
• Patient centered care is carried out
• Modeling occurs learning by example, cases are
  discussed
• Core competencies and skills are not just learned
  but practiced and modeled

139
Practical training

• Inpatient rounds
• outpatient clinics
• off site electives in community as practicum
• Home visits arranged for students, students
  assigned families during part of training

140

• Therapy facilitation an anthropologist or other
  health social scientist assumes a therapy
  facilitator role on the wards
• Cultural broker between patients/ their families
  the health care system different staff members
  on a clinical unit

141
Invest in Anthropologists they will pay off in
multiple ways

• Anthropologists can make major contributions at
  every stage of this continuum from training
  translators to giving workshops which explain
  cultural concerns and practices yet confront and
  caution against ethnic stereotypes

142
To be an effective facilitator training is needed

• To be a good transdisciplinary facilitator, an
  anthropologist or clinician/anthropologist needs
  the experience of working in a clinical setting
  as part of a transdisciplinary team.
• There is a need to grow such anthropologists /
  clinician/anthropologists
• A program is necessary

143
There a model for doing this

• Classroom training Course work which issue
  driven, draws on case studies, class has
  transdisciplinary student body
• Behavioral rounds anthropologists join teams on
  the wards
• Apprenticeship model

144
Behavioral rounds How does it work

• One patient a week chosen for an illness
  interview 30-45 minutes, then a 15-20 minute
  follow up.
• What is covered Range of issues from illness
  experience of patient, to medication issues, to
  dealing with death, patients of different ethic
  groups
• So what analysis how does a deeper
  understanding of the patient inform care
  management. Reflexivity on par of clinicians.

145
Behavior rounds takes an hour a week it is well
worth it

• Residents and interns see their mentors and
  peers taking culture seriously so they learn to
  do so
• Hidden curriculum
• See one-do one-teach one process set into motion.
  Students learn to take the lead after watching.
• Case write ups write ups acknowledged and used
  in future training of students

146
Discrimination is addressed

• Most health care providers do not intentionally
  discriminate and do not see their actions in
  this light. Reflexivity needs to be built into
  the system beyond patient audits.
• Patients also discriminate Practitioners need
  to learn how to addressed this when it occurs and
  interferes with patient care such as undermining
  trust.

147
Cultural competency training

• Not just for doctors, nurses, social workers
• Hospital techs
• Allied health staff
• CAM practitioners

148
Other areas where cultural competency

• Is required

149
Research Partnerships need to be Established

• Cultural competence is needed to foster
  cooperation within ethnic communities to increase
  participation in research and clinical trials.

150
The challenge

• Historical mistrust racism, bias, exploitation
• Need to establish good will and trust
• Reciprocity, research findings need to be shared
  in such a way that they are seen as useful to the
  community
• Groups need to be seen in positive light not just
  as ill or at risk
• Research outcomes should not be seen as
  establishing racial superiority

151
Transdisciplinary Research

• Challenges

152
Enough Time

• With continuing support to the same team over a
  sufficiently long period of time and covering
  several types of problems, it is more likely that
  disciplinary barriers can be transcended and
  increased understanding and confidence about the
  value of other disciplines can be achieved
• (Rosenfield (19921345)

153
Cooperation

• Each team /network member must value the
  perspective of other disciplines not just in
  spirit, but in practice
• This requires some basic familiarity with the
  different perspectives each discipline brings to
  the table
• Team members need to teach each others through
  example, and be willing to demystify concepts and
  terminology

154
Methods

• Research. Issues related to methods need to be
  worked out early especially issues related to
  the very different objectives, methods, and
  sampling frames used in qualitative and
  quantitative research

155

• Transdisciplinary science requires thinking out
  of the box
• Brainstorming out of the box is far easier than
  working in new ways.
• In practice, one often falls back to their
  default familiar models and procedures

156
Challenges

• Researchers need to be attentive to the issue of
  knowledge production and the fact that data is
  often the artefact of methods and instruments
  used.
• Triangulation of data driven by different methods
  and theories needs to be encouraged with the
  understanding that one source of data is not
  privileged above others.

157

• Example
• Standardized scales and instruments which have
  been psychometrically validated and used in
  previous studies for particular reference
  populations must be open to scrutiny
• Are they the best measures for minority groups
• Are other variables equally or more important for
  these groups given their lifeworld

158
Leadership

• Transdisciplinary research works best when
  assisted by a facilitator who attends to the
  process of research as much as the content.
• This person insures that
• Innovation is encouraged
• Single disciplines do not dominate problem
  solving
• Hybrid thinking is encouraged

159
Acknowledgement

• Cross-disciplinary work is often not given enough
  credit how does one value a hybrid product and
  acknowledge participation in a multidisciplinary
  process of problem solving
• How does participation count for tenure?
• Publication can be more difficult as professional
  journals often stick to familiar formats of data
  presentation

160

• A crucial difference between basic
  mono-disciplinary research on the one hand and
  inter-disciplinary research on the other hand, is
  that the former finds its legitimisation within
  its own field. In this sense disciplines are
  bodies of knowledge or objects to which it is
  possible, even respectable, to add something.
  Inter-disciplinary research has no mechanism of
  intrinsic legitimisation and rather depends upon
  how well it illuminates the overarching problem
  being researched (AHRQ 199717-18).