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Published on January 16, 2008

Author: Calvin1

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Slide1:  5TH Annual Primary Care & Prevention Conference MULTICULTURAL MEDICINE AND ENSURING GOOD HEALTH FOR ALL Rubens J. Pamies, M.D., FACP UNMC, Vice Chancellor for Academic Affairs/Dean for Graduate Studies Professor of Internal Medicine September 21-23, 2005 Wyndham Atlanta Hotel, Atlanta GA IOM REPORT: UNEQUAL TREATMENT:  IOM REPORT: UNEQUAL TREATMENT “Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factor as such as patient’ insurance status and income are controlled. The sources of these disparities are complex, are rooted in historic and contemporary inequities, an involve many participants at many levels . . .” IOM REPORT: UNEQUAL TREATMENT:  “The [IOM] study committee focused part of its analysis on the clinical encounter itself and found evidence that stereotyping, biases, and uncertainty on the part of healthcare providers can all contribute to unequal treatment.” Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002), Institute of Medicine. http://www.nap.edu/books/030908265X/html/ IOM REPORT: UNEQUAL TREATMENT IOM REPORT: UNEQUAL TREATMENT:  “The Physician-Patient interaction is a contributing factor causing health disparities.” IOM REPORT: UNEQUAL TREATMENT Recommendations: Training programs should incorporate curriculum that will help health care providers gain the skills needed to navigate the cross-cultural interaction. CURRENTLY:  CURRENTLY Only 9% of U.S. Medical schools offers a separate course in the curriculum that addresses cultural competency Less than half offer course work in health disparities ISSUES THAT NEEDS TO BE INCLUDED IN CROSS-CULTURAL CURRICULUM:  ISSUES THAT NEEDS TO BE INCLUDED IN CROSS-CULTURAL CURRICULUM Stereotyping and bias Perception of health and illnesses Communication and language Knowledge of health disparities Understanding the role of culture in health care Cultural competency training DEMOGRAPHICS AND IMMIGRATION:  DEMOGRAPHICS AND IMMIGRATION DOCUMENTED IMMIGRATION By Area of Origin:  DOCUMENTED IMMIGRATION By Area of Origin Slide10:  White 69% White 67% White 53% Asian 4% Asian 8% Asian 5% African American 12% African American 3% African American 14% Hispanic 13% Hispanic 14% Hispanic 25% UNITED STATES CENSUS 2002 2000 2050 2010 AVERAGE ANNUAL RATE OF NATURAL INCREASES AND NET IMMIGRATION Rate per 1,000 Population:  AVERAGE ANNUAL RATE OF NATURAL INCREASES AND NET IMMIGRATION Rate per 1,000 Population Race Natural Net Ethnicity Increase Immigration White 5.1 0.5 Hispanic 21.2 17.1 African American 14.8 1.6 Asian/Pacific Islander 20.2 46.2 American Indian 22.9 *Lewit, E.M. and Baker, L.G., Race and Ethnicity-Changes for Children The Future of Children, Vol. 4, No. 3 Winter 1994 DEMOGRAPHICS:  DEMOGRAPHICS By the year 2050: 80 million people in the U.S. will be from immigrant groups who came here after 1994 They will make up 25% of the total U.S. population DEMOGRAPHICS:  DEMOGRAPHICS 1 out of every 5 children under age 18 is the child of an immigrant. 75% of these children are from regions of the world where English is not spoken. The most common language spoken in these groups is Spanish. These children are disproportionately minorities, poor, and uninsured. Table 18-4 TOP 10 COUNTRIES WITH HIGHEST PROPORTION OF MEDICAL GRADUATES IN THE UNITED STATES:  Table 18-4 TOP 10 COUNTRIES WITH HIGHEST PROPORTION OF MEDICAL GRADUATES IN THE UNITED STATES SOURCE: The Educational Commission for Foreign Medical Graduates, 1992. GROWTH IN MIDWEST’S POPULATION BY RACIAL AND ETHNIC GROUP U.S. CENSUS 1990 AND 2000 :  GROWTH IN MIDWEST’S POPULATION BY RACIAL AND ETHNIC GROUP U.S. CENSUS 1990 AND 2000 FACTORS LEADING TO DISPARITIES:  FACTORS LEADING TO DISPARITIES HEALTH BEFORE CARE:  HEALTH BEFORE CARE HEALTH CARE DELIVERY:  HEALTH CARE DELIVERY HEALTH CARE ACCESS:  HEALTH CARE ACCESS Slide22:  What Difference Can I Make? Socio- economic Status Lifestyle Choices Employment Education Level Environmental Conditions Poverty Distrust Health Literacy Legal Barriers Diversity of Workforce Pts Cultural Preference Language Barriers Medical Home Transportation Proximity of Providers Availability of Providers Finance Effectiveness of Care Appropriateness of care Pt. adherence to tx plan Pt. Preference Provide Bias Ethnic/Racial Predilection Of Diseases Patient- Provider Communication Cultural Competency Insurance Health Care Delivery Health Before Care Health Care Access HEALTHY PEOPLE 2010 GOALS:  HEALTHY PEOPLE 2010 GOALS Increase quality and years of healthy life Eliminate health disparities AGE ADJUSTED MORTALITY RATES, UNITED STATES 2000:  AGE ADJUSTED MORTALITY RATES, UNITED STATES 2000 HIV/AIDS DEATH RATE AGE> 13, RATES PER 100,000 POPULATION:  HIV/AIDS DEATH RATE AGE> 13, RATES PER 100,000 POPULATION ADULT IMMUNIZATIONS AGE >65, PERCENT OF POPULATION:  ADULT IMMUNIZATIONS AGE >65, PERCENT OF POPULATION CANCER DEATH RATE DEATHS PER 100,000 POPULATION:  CANCER DEATH RATE DEATHS PER 100,000 POPULATION CARDIOVASCULAR DISEASE DEATH RATE DEATHS PER 100,000 POPULATION:  CARDIOVASCULAR DISEASE DEATH RATE DEATHS PER 100,000 POPULATION DIABETES-RELATED DEATH RATE DEATHS PER 100,000 POPULATION:  DIABETES-RELATED DEATH RATE DEATHS PER 100,000 POPULATION INFANT MORTALITY DEATHS PER 100,000 POPULATION:  INFANT MORTALITY DEATHS PER 100,000 POPULATION RACIAL & ETHNIC DISPARITIES INFANT MORTALITY:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY 13.5 RACIAL & ETHNIC DISPARITIES LOW BIRTH WEIGHT < 2500g:  RACIAL & ETHNIC DISPARITIES LOW BIRTH WEIGHT < 2500g RACIAL & ETHNIC DISPARITIES VERY LOW BIRTH WEIGHT <1500g:  RACIAL & ETHNIC DISPARITIES VERY LOW BIRTH WEIGHT <1500g RACIAL DISPARITY PRETERM BIRTHS <37 WEEKS :  RACIAL DISPARITY PRETERM BIRTHS <37 WEEKS NCHS 2003 RACIAL DISPARITY VERY PRETERM BIRTHS < 32 WEEKS :  RACIAL DISPARITY VERY PRETERM BIRTHS < 32 WEEKS Percent of Live Singleton Births Year 2010 Goal NCHS 2003 INFANT MORTALITY FOR AFRICAN AMERICANS & WHITES, U.S. 1980-2000:  INFANT MORTALITY FOR AFRICAN AMERICANS & WHITES, U.S. 1980-2000 NCHS RACIAL & ETHNIC DISPARITIES INFANT MORTALITY - Per 1,000 Live Births:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY - Per 1,000 Live Births NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY, HISPANIC:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY, HISPANIC RACIAL & ETHNIC DISPARITIES CAUSES OF INFANT DEATHS - Per 1,000 Live Births:  RACIAL & ETHNIC DISPARITIES CAUSES OF INFANT DEATHS - Per 1,000 Live Births NCHS 2001 RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES Why? RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  Race? RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  Race has no clear biologic or genetic basis Genetic diversity appears to be a continuum, with no clear breaks delineating racial groups. Science 1998 RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  Many birth outcomes have no clear genetic basis RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY:  RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY:  RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY Slide46:  RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & NATIVITY RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES Behavior? RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & CIGARETTE SMOKING:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & CIGARETTE SMOKING RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & CIGARETTE SMOKING:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & CIGARETTE SMOKING RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  Prenatal Care? RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL & ETHNIC DISPARITIES FIRST TRIMESTER PRENATAL CARE:  RACIAL & ETHNIC DISPARITIES FIRST TRIMESTER PRENATAL CARE NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & PRENATAL CARE:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & PRENATAL CARE NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & PRENATAL CARE:  RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & PRENATAL CARE RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  SES? RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION:  NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION:  NCHS 2002 RACIAL & ETHNIC DISPARITIES INFANT MORTALITY & EDUCATION RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES:  Stress? RACIAL AND ETHNIC DISPARITIES BIRTH OUTCOMES RACIAL & ETHNIC DISPARITIES STRESS AND CRH IN PREGNANCY:  RACIAL & ETHNIC DISPARITIES STRESS AND CRH IN PREGNANCY Hobel 1998 Slide59:  Safety Preterm Birth Stress Low Birth Weight Infant Mortality Intrauterine Growth Retardation Abuse Health Relations Work Money Racism STRESS AND PRETERM BIRTH STRESS AND PRETERM BIRTH:  Safety Preterm Birth Stress Low Birth Weight Infant Mortality Intrauterine Growth Retardation Abuse Health Relations Work Money Racism STRESS AND PRETERM BIRTH RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & RACISM:  RACIAL AND ETHNIC DISPARITIES LOW BIRTH WEIGHT & RACISM RACIAL AND ETHNIC DISPARITIES CULTURE AND RACISM:  RACIAL AND ETHNIC DISPARITIES CULTURE AND RACISM While it is true that other US racial and ethnic minorities have suffered economic and social discrimination, few, if any, have faced these exposures for as long as have African Americans, nor have they faced them standing on an economic and cultural base that was systematically undermined by the larger society. James (1993) Slide63:  Puberty Pregnancy Poor Nutrition, Stress Abuse, Tobacco, Alcohol, Drugs, Poverty Lack of Access to Health Care Exposure to Toxins Poor Birth Outcome 0 5 Age White African American LIFE COURSE PERSPECTIVE ALLOSTASIS:  ALLOSTASIS McEwen 1998 STRESS AND ALLOSTASTIC LOAD:  STRESS AND ALLOSTASTIC LOAD McEwen 1998 ALLOSTASIS:  ALLOSTASIS Chikanza 2000 LBW & VLBW INCREASE WITH INCREASING AGE IN BLACKS BUT NOT IN WHITES:  LBW & VLBW INCREASE WITH INCREASING AGE IN BLACKS BUT NOT IN WHITES Geronimus 1996 AMONG AFRICAN AMERICANS, LBW INCREASES WITH INCREASING AGE IN LOW SES BUT NOT HIGH SES:  AMONG AFRICAN AMERICANS, LBW INCREASES WITH INCREASING AGE IN LOW SES BUT NOT HIGH SES Geronimus 1996 AS AFRICAN AMERICAN WOMEN GET OLDER, THEY ARE MORE LIKELY TO SMOKE CIGARETTES:  AS AFRICAN AMERICAN WOMEN GET OLDER, THEY ARE MORE LIKELY TO SMOKE CIGARETTES Geronimus 1996 Slide70:  Lu 2003 LIFE COURSE PERSPECTIVE Slide71:  ORAL HEALTH DISPARITIES Slide72:  Over one third of the U.S. population (100 million people) has no access to community water fluoridation. is Over 108 million children and adults lack dental insurance, which over 2.5 times the number who lack medical insurance. Professional care is necessary for maintaining oral health, yet 25 percent of poor children have not seen a dentist before entering kindergarten. Americans make up 2.2 % of dentists, Hispanic Americans accounting for 2.8% and Native American representing .2% ORAL HEALTH FACTS Slide73:  56 Schools of Dentistry in US. 4,618 First Year dental students (2003 7,987 applicants (2003) 5.4% of dental students are African-American (vs. 12% of US population) 5.9% of dental students are Hispanic/Latino (vs. 12% of population) SUPPLY OF DENTIST R. Strauss, U of North Carolina/L. Tedesco, U. of Michigan Slide74:  HEALTHCARE MANPOWER DISTRIBUTION OF SELECTED HEALTH PROFESSIONS BY RACE AND ETHNICITY:  DISTRIBUTION OF SELECTED HEALTH PROFESSIONS BY RACE AND ETHNICITY Table 18-2 Table 18-1 HEALTH PROFESSIONS WITH THE GREATEST PROJECTED JOB OPENINGS, 2000-2010:  Table 18-1 HEALTH PROFESSIONS WITH THE GREATEST PROJECTED JOB OPENINGS, 2000-2010 Source: Bureau of Labor Statistics (2001b). Employment by Occupation, 2000and Projected 2010available at http://www.bls.gov/emp/emptab21.htm. HEALTH DISPARITY IN THE IMMIGRANT POPULATION:  HEALTH DISPARITY IN THE IMMIGRANT POPULATION 10 MOST COMMON PROBLEMS SEEN IN THE AFRO-CARIBBEAN COMMUNITY:  10 MOST COMMON PROBLEMS SEEN IN THE AFRO-CARIBBEAN COMMUNITY Reported domestic violence is #1 among Afro-Caribbean in Boston Lack of insurance/unemployment Language barriers Fear of immigration Led Poisoning, HIV/AIDS TB/(reactivation) Breast & Cervical Cancer - diagnosed very late Untreated D.M./CVD Immunization HEATH ISSUES:  HEATH ISSUES Increase risk for childhood vaccine – preventable illnesses, ex: chronic Hep.B, Rubella Other conditions, includes: Intestinal parasite Malaria Typhoid Fever Malnutrition, (Iron Folate and B-12 deficiency) HEATH ISSUES:  HEATH ISSUES Asthma – very common in all immigrant groups, most common in non-Hispanic Blacks Dental disease – 77% of immigrants needed emergency dental care (study in San Francisco immigrant population) Mental Health: PTSD Depression (many goes undiscovered because of cultural differences) BARRIERS IN THE HEATH CARE SYSTEM:  BARRIERS IN THE HEATH CARE SYSTEM Prevents optimum care for immigrants, ex: Clinic vs. private physician’s office. Delay in providing medical emergency care. PRWORA (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) Availability of translators Slide82:  CULTURAL COMPETENCE CULTURAL COMPETENCE, OUTCOMES, AND QUALITY OF CARE:  CULTURAL COMPETENCE, OUTCOMES, AND QUALITY OF CARE Cultural differences between providers and patients affect the provider-patient relationship. How patients feel about the quality of that relationship is directly linked to patient satisfaction, adherence, and subsequent health outcomes. Stewart M, et al, Cancer Prev Control. 1999 CULTURAL COMPETENCE:  CULTURAL COMPETENCE CULTURAL COMPETENCE:  CULTURAL COMPETENCE CULTURAL COMPETENCY LEARN Model:  CULTURAL COMPETENCY LEARN Model Listening to the patient’s perspective Explaining and sharing one’s own perspective Acknowledging differences & similarities between these two perspectives Recommending a treatment plan Negotiating a mutually agreed-on treatment plan Berlin EA, Fowkes, WC Jr. West J Med 1983; 139(6):934-8 Slide87:  Do you speak another language? Do you work with staff who speak another language? Do you offer health materials and/or appointment materials in other languages? Do you have a list of community resources that serve a variety of ethnic groups? Do you ask you patients about heir use of alternative health practices? Do you ask about the use of home remedies, medicines, or treatments? Have you attended a cultural diversity seminar workshop in the past year? Does your screening procedure include cultural lifestyle issues such as dietary practices, health beliefs, home remedies, medicines, or other treatments? Do you have an interpreter system for non-English-speaking patients? Do you know key words and phrases in the languages of your patients? Good morning!/How are you?/Thank you! CULTURAL DIFFERENCES AND EXPECTATION OF IMMIGRANT POPULATION:  CULTURAL DIFFERENCES AND EXPECTATION OF IMMIGRANT POPULATION Need to have a prescription after every visit. Injected medicine are preferable. Decision maker – father or grandmother. Use of alternative/home remedies Gender preference of health professional How they express pain or discomfort RESOURCES:  RESOURCES Bureau of Primary Health Care of the US Dept of Health and Human Services (DHHS) Cultural Linguistically Appropriate Health Care Service (CIAS) Cultural Brokers: Individuals who are bicultural and bilingual that can assist in the delivery of culturally appropriate care Other resources: mental health for immigrant program (MHIP); National Center for Cultural Competency (NCCC). WHAT IS NEEDED?:  WHAT IS NEEDED? National guidelines and standards. Funding to assist hospital, physician’s office, clinics and community health centers to assist in providing culturally appropriate and comprehensive care Research Slide91:  “In the end, it’s not what we don’t know that will destroy us… but rather the failure to respond appropriately to what we do know”

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