Cultural Competency and Coalitions In Action Cheza Garvin, PhD, MPH, MSW Program Director, Chronic Disease Prevention and Healthy Aging Public Health - Seattle & King County University of Washington School of Public Health and Community Medicine, Social and Behavioral Sciences Program ( )

Acknowledgment Mike Smyser, MS, Epidemiologist Epidemiology, Planning & Evaluation Public Health – Seattle & King County

OBJECTIVES  Learn which groups report experiences of discrimination in health care settings.  Learn recommendations for cultural competence.  Learn the six health priority areas targeted by REACH  Learn about Seattle & King County REACH community interventions.

IMPORTANCE: The Bad News  Health Disparities Data (some of the major killer diseases)  Social Indicators, including Individual Experience in Health Care Settings - Discrimination Factor

Definition of Health Disparities  Health Disparities describe the disproportionate burden of disease, disability and death among a particular population or group when compared to the proportion of the entire population.  Source:Washington State Board of Health

NATIONAL HEALTH DISPARITIES DATA  Disease Prevalence, Compared to White Americans: –Infant mortality: 2½ times higher in African Americans, 1½ times higher in Native Americans –Prostate Cancer: 2 times higher among African Americans

Infant mortality rates by race and Hispanic origin of mother, United States

Infant Mortality by Race/Ethnicity, King County,

NATIONAL HEALTH DISPARITIES DATA  Disease Prevalence, Compared to White Americans: –Cervical Cancer: 5 times higher in Vietnamese Women –Stomach Cancer: 2 to 3 times higher among Latinos –Colorectal Cancer: higher among African Americans and increasing among African American men

Pap test in last three years among women 18 years of age and older (age adjusted to the year 2000 standard population), United States

NATIONAL HEALTH DISPARITIES DATA  Higher Common Disease Prevalence among White Americans : –Breast Cancer (although mortality is higher among African American women)

NATIONAL HEALTH DISPARITIES DATA  Disease Prevalence, Compared to White Americans: –Heart Disease: ~ 2 times higher among African American men –Hypertension: higher among African Americans –Stroke: higher among African Americans

NATIONAL HEALTH DISPARITIES DATA  Disease Prevalence, Compared to White Americans or to Average Rate: –Diabetes: Nearly 3 times higher among Native Americans than the average rate; 70% higher among African Americans

Persons with diabetes and end-stage renal disease, United States Year 2010 target 78 per 1 million persons

Lower extremity amputations in persons with diabetes (age adjusted to the year 2000 standard population), United States

AIDS* case rates among persons 13 years of age and older, United States

Total Death Rate by Race/Ethnicity, King County,

Health Behaviors and Personal Risk Factors Access to Health Services Economic Opportunity and Equity Stress due to Social Factors Mental Health and Social Support Trust in Health System and Research Education Background and Opportunity Language and Other Cultural Factors Environmental Risk Institutionalized biases (racism, sexism, etc.) Understanding the Complexity of Health Disparities

Median household income by race and Hispanic origin United States,

Educational attainment among persons 25 years and over by race and Hispanic origin: United States, 1996

A King County, WA. Case Study: Racial and Ethnic Discrimination in Health Care Settings

Sources of information  Random surveys of King County residents  Ethnicity and Health Survey  Included 2,400 adults,  Communities Count 2000 Survey  Included 1,500 adults, late 1999  Personal Interviews  Interview Project  Included 51 African Americans, Jul-Sep 1999  Intended to describe range of experiences

INDIVIDUAL EXPERIENCE of HEALTH CARE DISCRIMINATION

Adults who experienced discrimination in the past year, most frequently cited* types of discrimination by race and ethnicity, King County, 1999 Source: Communities Count 2000 *All other types (language or accent, religion, disability, sexual orientation were cited by less than 10% of respondents.

What does discrimination in health care settings look like?

Example: Interview Project Findings Experiences Reported by 51 African Americans  Experiences ranged from incidents of differential treatment to rude behavior and racial slurs.  Most respondents were surprised by the incidents; they did not expect this type of treatment and considered the personal impact to be very severe.  Many respondents had more than one story.  Most of the events reported are recent.  All events were perceived to be racially motivated.  The events reported occurred in 30 facilities, both public and private, located all over King County

Examples of reported experiences:  “He treated the Caucasian woman better and differently.”  “The radiologist made a couple of crude remarks, like I was dumb.”  “I was in the emergency room at the hospital and I feel that I was ignored due to my race.”  “I know you shoot dope,” a nurse was reported to have accused one of the respondents.  “You people accepted pain as part of slavery because you tolerate pain so well,” said a nurse to a respondent who, before having a breast biopsy, requested a sedative due to a low tolerance for pain.

What was the response to the reported event?  About half made a complaint. Most were verbal; few were written or formal.  Many respondents mentioned actively avoiding offending personnel and/or facilities where the incident took place.  Some respondents reported delaying treatment due to the negative experience.  Others reported avoiding the health care system.

Comments from respondents:  “I vowed never to take my child to ____ Hospital.”  “It was the last time my son would see Dr. _____.”  “I was so ticked off when I went home that I cut up my ____ card.”  “I have not sought surgery for my other leg. I would like surgery but I guess that I’ll find someone else. Sometimes my leg hurts.”

Differential Treatment and Access to Medical Care by Race and Ethnicity  A review of many studies conducted in different parts of King County indicated significant differences in medical care received by persons of different racial and ethnic backgrounds.  Differential treatment and access to care in most studies could not be “explained by such factors as socioeconomic status, insurance coverage, stage or severity of disease, co-morbidities, type and availability of health care services, and patient preferences.“ (Mayberry et al., Med Care Res Rev 2000)

Examples of Differential Treatment and Access  Heart Disease  With respect to by-pass operations, in five studies African Americans were 32% to 80% less likely to receive these operations compared to whites with similar disease severity. (Mayberry et al., Med Care Res Rev 2000)

Examples of Differential Treatment and Access  Cancer  Several studies have documented differences with respect to certain types of cancer (e.g., lung and colon). African Americans were often less likely to receive major therapeutic procedures.  One study of nursing homes found African Americans with cancer to be 63% less likely to receive any pain medication. (Mayberry et al., Med Care Res Rev 2000)

Have you ever experienced, seen or heard discrimination against people of color? (not limited to medical settings)  Someone being passed over in a store (or other service) line?  Someone being stopped, or even arrested for “driving while black”?  A race-based joke?  Assumptions of addictions, criminal behavior, subservience, low (or unusually high) intelligence?  A racial slur or name calling?  Exclusion from housing, clubs, etc.?

What emotions did you experience?  Anger  Disgust  Disappointment  Fear  Loathing  Curiosity  Sympathy  Protectiveness  Empathy  Embarrassment  Confusion  Apathy

ASSURING CULTURAL COMPETENCE Study Recommendations (Some of these are things you may be able to do where you work….)  Health Care Staff Training  Health Care Staff Cultural Representation  Self Awareness (checklist)  Change Institutional Policies  Monitoring Progress  Community Examples

Recommendations  Train all health care providers and support staff in cultural competency –Incorporate cultural competency measures in individual performance evaluations. –Periodically evaluate training to improve effectiveness. –Providers should be able to respectfully obtain cultural and ethnic heritage information of clients when this information is a necessary component of quality service.

Recommendations  Change institutional policies in order to: –Maintain a non-discriminatory workplace –Assure a diverse workforce at all levels –Promote awareness among consumers regarding rights and grievance processes –Require subcontractors to report on racial and ethnic background.

Recommendations  Continue studies that will contribute to eliminating discrimination by: –Collecting information routinely regarding race and ethnic background –Monitoring and reporting differential treatment –Examining and reporting experiences of other racial and ethnic groups.

Eliminating Health Disparities What will it Take? Access to Health Services Economic Opportunity and Equity Reduced Stress due to Social Factors Mental Health and Social Support Trust in Health System and Research Educational Opportunity Respect for Language and Other Cultural Factors Lower Environmental Risks Freedom from Discrimination Promotion of Healthy Behaviors

NATIONAL TREND: The Good News  Department of Health and Human Services  Centers for Disease Control and Prevention  National Institutes of Health

REACH 2010 Racial and Ethnic Approaches to Community Health –National Goal: By the year 2010, eliminate disparities in health status experienced by racial and ethnic minority populations –Funding through the Centers for Disease Control and Prevention

6 REACH PRIORITY AREAS  Cardiovascular Health  HIV/AIDS  Immunizations  Infant Mortality  Breast and Cervical Health  Diabetes 34 REACH 2010 Communities Nationally

WASHINGTON STATE DIABETES DEATH RATES BY RACE AND AGE Rates are per 100,000 population Source: Washington Center for Health Statistics

KING COUNTY DIABETES DEATH RATES BY RACE AND GENDER

REACH 2010 SEATTLE & KING COUNTY  MISSION –“The mission of the REACH Coalition is to reduce diabetes health disparities experienced by communities of color. Through strong partnerships, we will support the empowerment of individuals, families, and communities, and create sustainable long-term approaches to prevention and control of diabetes utilizing all appropriate community resources in King County.”

MULTIPLE CULTURES WORKING TOGETHER TO REACH FOR HEALTH REACH COALITION African American Asian American/ Pacific Islander American Latino/Hispanic European American

LOCAL REACH HISTORY  PHASE I ACTIVITIES –Coalition Development –Community Assessment –Community Action Plan

REACH PHASE II  Continued Coalition Development  Implementation of Community Action Plan (CAP)  Evaluation, Feedback, Revisions and Reporting  Sustainability

REACH COALITION DEVELOPMENT  Multi-Cultural Focus  Attention to membership – Over 50 agencies and individuals  Training  Bi-Monthly Meetings  Sub-Committees  Coalition Structure

Coalition Challenges and Solutions  Multiple Cultures and Languages  Differences of Opinion - Managing Conflict  Distribution of Funds  Authority Hierarchy  7 Languages, Hire Bilingual/Bicultural Staff, Listen and Learn  Consensus Decision Making; Bring Concerns back to the Coalition - (Ops)  Coalition Selection Committee  Process Discussion; Take Backseat

REACH STAFFING  REACH Coalition Members  Principal Investigator (PI)  Co-PI  Program Manager  Community Liaisons  Peer Educators  Evaluation Manager  Evaluator Interviewers  Researchers  Case Coordinators  Administrators and Administrative Support

COMMUNITY ACTION PLAN ELEMENTS  Interventions conducted by contracting community agencies  Support Groups  Education Classes  Self Management Classes  Enhanced Diabetes Registry use  Case Coordination  Community Campaigns  Evaluation

SUPPORT GROUPS  Emotional Support  Shared Experiences  Shared Resources  Dealing with discrimination  Tips for talking about diabetes –family –providers –friends –each other

EDUCATION CLASSES  Physical Activity  Nutrition  Marketing  Weight Management  Glucose testing  Other topics

SELF MANAGEMENT CLASSES  Self care focus  Increasing self-efficacy  Increasing provider- patient communication by patient initiative

ENHANCED DIABETES REGISTRY USE  Tracking of –HbA1c –blood pressure –eye exams –foot exams –urine tests –referrals

CASE COORDINATION  Complete diabetes registry  Communicate with providers  Communicate with patients about recommended procedures for them  Inform patients of community activities and resources

COMMUNITY CAMPAIGNS  Grocery Stores  Restaurants  Pharmacies  Work Sites  Media

EVALUATION  Coalition Member Interviews  Participant Survey - pre/post  Focus Groups  Key Informant Interviews  Community Documentation

REACH CULTURAL COMPETENCE  Coalition Membership  Staffing  Listening to Participants  Language Capacity  Literature and Training  Community Feedback

REACH LIMITATIONS  Only King County  Only Diabetes  Native Americans Not Participating  Limited Language Capacity  Limited Geographic Scope

SUSTAINABILITY  Integrate activities into existing service system - Sea Mar example –Registry –Groups and Classes  Train peer educators and encourage continued work  Community network establishment  Seek additional funding

HOPES AND PLANS  Continue Diabetes Work  Expand to Other Chronic Disease Prevention  Expand to Primary Prevention  Convince Funding Agencies and Legislators to Support Efforts  Reduce/Eliminate Health Disparities over Time

WHAT MIGHT YOU DO TO INCREASE YOUR CULTURAL COMPETENCE AND HELP TO ELIMINATE HEALTH DISPARITIES?  Open your empathetic heart to humans of other hues  Recognize power differences and how they affect you  Learn what your own biases are and channel them in a positive direction  Discuss racism with friends/family, & how to prevent discrimination  Speak out against discrimination when you see it  Make your health/wellness practice one that welcomes all and/or targets the disenfranchised  Join a local coalition or community group with relevant goals  Be willing to learn

REACH Coalition At Work

AVOID COMPLICATIONS Neuropathy / Amputations Kidney Disease / Renal Failure Heart Disease Blindness

ELIMINATE RACIAL/ETHNIC DIABETES HEALTH DISPARITIES INCREASE HEALTH AND WELL BEING