Health Disparities/ Cultural Competence Curriculum Clinical Addiction Research and Education Unit Section of General Internal Medicine Boston University Schools of Medicine and Public Health Supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) R25 AA013822

Health Disparities/Cultural Competence Curriculum Objectives To assure cross-cultural efficacy when screening for alcohol problems and assessing alcohol problem severity To encourage providers to approach patients with an understanding of and respect for the patient’s needs and cultural values To improve provider sensitivity to cultural characteristics including race, ethnicity, cultural identity and societal factors that may effect the patient-provider interaction To increase the awareness of current health disparities regarding alcohol (prevalence, morbidity, treatment)

Cross Cultural Efficacy Why is assuring cross cultural efficacy important?

Institute of Medicine Report Assessed the extent of racial and ethnic disparities in healthcare Reviewed >100 studies assessing quality of healthcare for various racial and ethnic minority groups Even when insurance, income, and medical profiles are the same as whites, minorities often receive fewer tests and less sophisticated treatment for their ailments

Alcohol-Related Health Disparities Hispanic men have higher rates of alcohol-related problems, intimate partner violence, cirrhosis mortality Black men have higher rates of intimate partner violence and cirrhosis mortality Compared with whites:

Potential Sources for Disparities in Care System-Level Factors: funding for mental health and substance abuse treatment, linguistic abilities of care providers Patient-level factors: patient beliefs and preferences, trust and spirituality, stress and coping behaviors, explanatory model Physician-level factors: the clinical encounter, default decision making, emphasis on prior expectations based on age, gender, race or ethnicity; bias, prejudice, stereotyping

Disparities: An integrated model Social, Economic and Cultural Influences Financial Incentives Institutional Design Legal Environment Cultural Influences Social, Economic and Cultural Influences Financial Incentives Institutional Design Legal Environment Cultural Influences Racially and Culturally Disparate Clinical Decisions Racially and Culturally Disparate Clinical Decisions Medical History Patient Input Subject to ambiguity And misunderstanding Medical History Patient Input Subject to ambiguity And misunderstanding Data Physical Examination Diagnostic Test Results Data Physical Examination Diagnostic Test Results INTERPRETATIONINTERVENTION Normative Values and Stereotyping Conscious Unconscious Normative Values and Stereotyping Conscious Unconscious Prejudice Conscious Unconscious Prejudice Conscious Unconscious

Cultural Competence Denial there is no difference Defense threatened by perceived differences Minimization trivializes difference; similarities means “like me ” Acceptance recognizes and values differences Adaptation skilled in communicating across differences and can take on other’s view Integration values a variety of cultures, integrates aspects of other cultures in own Where are you on this spectrum?

Race A social construct, varying by location, associated with certain physical attributes Some shared ancestry and common gene pools but: genetic variation depends on geographic dispersal and varies MORE WITHIN most common racial groups THAN BETWEEN groups

Minorities View of the Healthcare System Minorities report belief that: –They are more likely to be treated with disrespect –They would receive better care if not black –Staying healthy is luck Minorities report a greater difficulty communicating with physicians Health Quality Survey Commonwealth Fund 2002

Historical Relationship to the Healthcare System 63% of AA and 38% of whites believed MDs often prescribe meds to experiment without consent 25% of AA and 8% of Whites believe MD had given them experimental treatment without consent 45% of AA and 35% of Whites believed MDs would expose them to unnecessary risk 2 x as many AA as Whites felt they could not freely question their doctors Tuskegee as an event and metaphor

Bridging the Gap Respect Explanatory model Sociocultural context Power Empathy Concern and fears Trust RESPECT- a framework that can assure effective cross cultural communication

RESPECT Respect - a demonstrable attitude Explanatory Model - what is the patient’s point of view regarding his/her alcohol use Sociocultural context - in what context does his/her drinking occur Power - share the power in the patient-provider interaction

RESPECT Empathy - make sure the patient feels understood Concerns and fears - elicit patient’s fears regarding alcohol use Trust - provider’s goal to deliver appropriate, effective healthcare most easily achieved when there is a therapeutic alliance and shared objectives between provider and patient