1. Cultural Awareness, Health Disparities, and Insurance Coverage Colorado Cover All Kids Initiative 2010 Tillman Farley, MD Salud Family Health Centers Fort Lupton, CO

2. Background Ethnicity and race are different –Hispanic is an ethnicity One culture can have several languages One language can span many cultures

3. Colorado Population 2009 estimate – 5 million Non-Hispanic white 71.0% Hispanic 20.2% African American 4.3% Native American 1.2% Asian/PI 2.9%

4. Languages spoken at home in Colorado English 84% Spanish 12% 42 others 4%

5. The Problem… Ethnic, racial, and other minority groups are disproportionately affected by worse health outcomes –Life expectancy –Neonatal death rates –Childhood immunizations –Access to a medical home

6. “While Colorado as a whole is a healthy state, communities of color are disproportionately affected by disease, disability, and death.” Racial and Ethnic Health Disparities in Colorado 2005 Colorado Department of Public Health and Environment Office of Health Disparities

7. Infant Mortality Rates, ’02-’06…

8. To put this in perspective…

9. Contributors to Health Disparities Genetics Poverty Low education level Lack of access to healthcare Racism – institutional and personal

10. What are we trying to achieve? Good health! Access to healthcare Insurance coverage HEY!! Don’t forget about me!!

11. Uninsured Population

12. “In 2005, Colorado ranked 50th, last in the nation, in children in poverty who were uninsured. With 37 percent of poor children uninsured in Colorado, we are nearly double the national average of 19 percent.” Racial and Ethnic Health Disparities in Colorado 2005 Colorado Department of Public Health and Environment Office of Health Disparities

13. Economic barriers Geographic barriers Insurance status Language Low literacy Cultural Background Immigration Status Embarrassment Lack of trust Scams Barriers to Health Care Access

14. Discrimination –Including by health care providers Say WHAT?! Barriers to Health Care Access

15. Discrimination? By ME???? Minority patients have significantly poorer health status even when controlling for socioeconomic statusMinority patients have significantly poorer health status even when controlling for socioeconomic status Institute of Medicine conclusion is that health care providers are partly responsible for this health disparityInstitute of Medicine conclusion is that health care providers are partly responsible for this health disparity

16. IOM Report 2002 Ethnic minority patients perceive discrimination and disrespectEthnic minority patients perceive discrimination and disrespect Particularly when the provider can’t speak language in which patient is most comfortableParticularly when the provider can’t speak language in which patient is most comfortable

17. Survey of Latinos in Colorado My doctor discriminates against meMy doctor discriminates against me My doctor doesn’t always respect meMy doctor doesn’t always respect me My doctor can’t speak my languageMy doctor can’t speak my language

18. Lack of cultural understanding, sensitivity and competence plays a role in health disparities.

19. Cultural competence: You can’t just take a class It’s an ongoing struggle No pain, no gain

20. Cultural Chauvinism The implicit belief most of us have that our culture is best Defining the culture of the dominant group as “American culture”

21. NEW POLL: Plurality favor path to citizenship By Michael O'Brien - 05/04/10 10:34 AM ET A plurality of Americans favor a path to citizenship for immigrants in the U.S. illegally, a new poll found Tuesday. 43 percent of respondents to a CBS/New York Times survey said they most favored allowing illegal immigrants to stay in their jobs and eventually apply for U.S. citizenship, compared to 32 percent who said illegal immigrants should require to leave their jobs, as well as the United States.a CBS/New York Times survey

22. What do Mexican immigrants want? To go home to MexicoTo go home to Mexico To own their own homeTo own their own home ‘For everything to turn out okay’‘For everything to turn out okay’ ‘For my kids to make something of their lives’‘For my kids to make something of their lives’

23. Immigrants come to the United States to access our services –(because that’s what I would do) You can always trust an American –(its other cultures that are untrustworthy)

24. Three Tasks Towards Cultural Competence: Develop awareness –Of your own culture as well as others –Of your own biases Acquire knowledge Develop and maintain cross-cultural skills

25. Evaluate your Biases Implicit associations –Biases that we all harbor Because they are implicit, we don’t know we have them https://implicit.harvard.edu/implicit/demo/

26. Question your assumptions! How does your culture affect YOUR behavior? For example: –What health beliefs do YOU hold? –What are YOUR culture bound syndromes? Are your deeply held beliefs the ‘truth’? Or simply one way to see things through your particular cultural glasses?

27. Health Beliefs: Which are true? Looking at someone intently can cause the evil eye Going outside with wet hair can cause a cold A sudden fright can cause your soul to be temporarily lost from your body When you get bronchitis you should take antibiotics

28. What do you think? I trust hospitals. They are safe places where healing occurs. I don’t trust hospitals. They are dangerous places where unethical experiments are conducted on people.

29. Stage 1 of Cultural Awareness: My way is the only way Are there other cultures?

30. Stage 2 of Cultural Awareness: My way is the better way Cultural differences can cause problems Cultural differences can be corrected by having everyone behave like me –Tom Tancredo, Betty Brown, English as the National Language, French action against headscarves, etc, etc, etc –http://www.youtube.com/watch?v=qxh4qY37J dkhttp://www.youtube.com/watch?v=qxh4qY37J dk

31. Stage 3 of Cultural Awareness: My way is the better way sometimes Sometimes other cultures have a better way Cultural differences can cause problems but can also confer benefits I can choose based on the situation

32. Stage 4 of Cultural Awareness: Creation of a new culture of shared meanings Requires repeated dialogue, good communication, creation of new rules

33. Common Myths I only need to be tolerant of things I agree with –The First Amendment myth

34. Common Myths We’re all the same underneath –The ‘skin deep’ myth

35. Common Myths If I ignore racial and ethnic diversity, I can’t be biased –The “color doesn’t matter” myth

36. Opportunities to correct health disparities Ongoing cultural awareness training Healthcare homes for everyone –Via meaningful insurance coverage –And a strengthened primary care infrastructure