Cultural Competency in Clinical Settings: Improving the Care of Diverse Patients

1. Cultural Competency in Clinical Settings:Improving the Care of Diverse Patients Denice Cora-Bramble, MD, MBA Professor of Pediatrics, George Washington University Executive Director Goldberg Center for Community Pediatric Health Children’s National Medical Center

2. Overview • Case study • Definitions • Making the case for culturally competent care • Clinical applications of culturally competent care • Applying quality improvement methodology to ameliorate health disparities: conceptual framework and example • Conducting research in and with communities of color

3. Case Study

4. Clinical Case #1: When is it Abuse? • 18 mos old Laotian child presents with 2d h/o vomiting and diarrhea without fever • Physical exam was positive for patterned skin discoloration streaking diagonally across child’s abdomen • Mother had similar findings on forehead

6. Discussion • Differential diagnosis? • Treatment? • Referrals?

7. Differential Diagnosis • Bruises secondary to coagulopathy • Vasculitis • Child abuse • Traditional practices such as coining and cupping

8. Southeast Asian Cultural Perspectives • Traditional practices incorporates ritual healing, herbalism and dermabrasive techniques • Coining – shamans or healers repeatedly rubbing a coin over patient’s skin

9. Definitions

10. Cultural Competence:Practical Definitions “The ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter.” US DHHS, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, 2001

11. Cultural Competence:Practical Definitions “The ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences.” Cooper LA, Roter DL: Patient-Provider Communication. The Effect of Race and Ethnicity on Process and Outcomes of Health Care. In: Smedley DB, et al, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003:552-93

12. Making the Case for Culturally Competent Care

13. Making the Case for Culturally Competent Care • Demographic changes • Business of medicine • Quality of care • Health disparities • Federal and state laws

14. Making the Case:Demographic Changes

15. Making the Case:Business of Medicine Business Imperative - “Enhancing quality of care, expanding markets, maximizing retention rates, customizing care and containing costs…” Kaiser Permanente

16. Making the Case:Quality of Care Importance of equity: no variations in the quality of care according to patients’ personal characteristics, including race and ethnicity Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academies Press, 2001

17. Cultural Competence and Health Care Quality Emerging data, with one 2004 study providing some of the strongest available evidence: policies that promote cultural competence are associated with higher quality of care Lieu T et al.: Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics; 114(1) 2004

18. Making the Case:Health Disparities “Evidence of racial and ethnic disparities in healthcare is, with few exceptions, remarkably consistent across a range of illnesses and healthcare services.” IOM Report: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, 2003

19. Racial/Ethnic Disparities in Cardiac Care (1984-2001) 2 studies find the racial/ethnic minority group more likely than whites to receive appropriate care (2%) 11 studies find no racial/ethnic differences in care (14%) 84% (68 studies) find racial/ethnic differences in care • Total = 81 studies • Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. Kaiser Family Foundation, 2002

20. Understanding Health Disparities • Contributing risk factors • Race • Income • Insurance status • Language & culture • Unknown factors?

21. Making the Case:Federal and State Laws • Title VI of the Civil Rights Act of 1964 Requires that all entities receiving Federal financial assistance, including health care organizations, take steps to ensure that LEP persons have meaningful access to the health care services they provide • New Jersey: first stateto mandate cultural competence training as part of medical licensure requirement

22. Case Study

23. Clinical Case #2: “Jose” 7 y.o. Latino male presents with recurrent episodes of wheezing. Patient has been prescribed Albuterol and Flovent inhalers but mother uses only the Albuterol MDI during acute exacerbations. PMI positive for several asthma related hospitalizations in the last year.

24. Discussion • Next step? • What else do you want to know? • Therapeutic approach?

25. Pediatric Asthma • Most common chronic disease of childhood • Affects approximately 4.8 million children in US • One of the most common reasons for pediatric hospital admissions • Disproportionate burden of asthma related morbidity and mortality among racial/ethnic minority children

26. Sociocultural Determinants of Health • Parental and child health beliefs • Knowledge of asthma and asthma management • Competition with other basic life needs • Environmental factors • Can parents afford to control the environmental triggers? Mansour M et al.:Barriers to Asthma Care in Urban Children: Parent Perspectives. Pediatrics; 106(3);512-519

27. Sociocultural Determinants of Health • Racial and ethnic differences in health beliefs and concepts of disease • Differences in beliefs about the value of prevention • Fears about steroids • Lack of regularity in the life of the family Lieu T et al.: Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid; Pediatrics 109(5); 857-865; 2002

28. Understanding Pediatric Asthma Disparities While the control and treatment for asthma is primarily based on medications, some parents have strong personal and cultural beliefs against the use of medications

29. Belief Systems and Asthma • 60% of Dominican mothers believed that their child did not have asthma in absence of symptoms • 88% thought that medicines are overused in the US • 72% did not use prescribed medicines but substituted traditional practices instead Bearison DJ et al.: Medical Management of Asthma and Folk Medicine in a Hispanic Community. J Pediatr Psychol; 24(4);385-392;2002

30. Traditional Practices Used in the Treatment of Asthma • Ethnomedical therapies • Prayer • Vicks VapoRub or “alcanfor” • “Siete jarabes” • “Agua maravilla” • “Te de manzanilla” Pachter L et al.: Ethnomedical (Folk) Remedies for Childhood Asthma in a Mainland Puerto Rican Community. Arch Pediatr Adolesc Med, Vol149(9);982-988;1995

31. Obtaining a Complete Cultural History • Have you consulted anyone else about this problem? Traditional healers? • Is your child taking any other medicines or home remedies? • Was your child prescribed medicine that s/he is not taking? • What do you think caused the disease?

32. Applying Quality Improvement Methodology

33. Applying Quality ImprovementMethodology • Equity identified by IOM as one of six quality aims, in addition to safety, effectiveness, patient centeredness, timeliness and efficiency Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academies Press, 2001 • Few interventions have used quality improvement methodologies as a tool to achieve equity in care and thereby reduce health disparities

34. Applying Quality ImprovementMethodology • Two successful quality improvement interventions that targeted at-risk, poor, racial and ethnic minority children • Reduced disparities in two important child health quality domains: • Immunization compliance rates • Comprehensive preventive services

35. Target Outcome Improvement in Goldberg Center immunization rates* for children 19-35 months old to upper quartile of national benchmarks *4:3:1:3:3:1 series :4DPT:3IPV:1MMR:3Hib:3HepB:1Var Rationale: Immunization rates can be a proxy measure for child health status and adequacy of preventive care

36. Immunization Related Health Disparities • Children at risk for under-vaccination: children who are poor, African American, from a single parent household, and that live in inner cities • Minority children’s immunization compliance rate can be as much as 20 to 30 percentage points below those of children living in suburban areas McCaskill QE, Livingood W, Crawford PM, Dekle AM, Hou T, Wood DL. Immunization levels among inner city children enrolled in subsidized childcare. Journal of Health Care for the Poor and Underserved. 2008;19:596-610.

37. Poverty as a Barrier Children in families with incomes below the poverty level are less likely than are those with families with incomes at or above the poverty level to receive the combined series vaccination (4:3:1:3) (78 percent and 84 percent, respectively, in 2006).

38. CNMC Provider Level Immunization compliance record “Standing” immunization orders Eliminating “missed opportunities” Provider and staff training Data tracking Patient Level Patient education Patient recalls and reminders Community Level Active collaboration with DOH Immunization Program MCO’s: Patient outreach referrals Improvement Methodology:Identified Best Practices

39. Pre-Intervention CNMC Compliance rate: 75% Goldberg Center- NIS ranking: Third quartile DC – NIS State ranking: #17 Post-Intervention 88% Top 5% #6 Outcomes: Immunizations

40. Outcomes: Goldberg Center Immunization Rates Target

41. Research and Communities of Color

42. Impact of Culture on Research “Cultures” • Race/ethnicity • Study participants • Researchers • Interdisciplinary collaborations • Communities

43. Impact of Culture on Research: Participation of Minorities Are there differences in rates of participation of minorities in research studies?

44. Differential Participation • Distrust • Negative experiences • Fewer studies conducted in minority-serving institutions • Ineffective communication of research staff • Complex study medicine regimens • Complicated record-keeping requirements • Lack of feedback • Ineffective informed consent procedures El-Khorazaty M, Johnson A, Kiely M et al.: Recruitment and Retention of Low-Income Minority Women in a Behavioral Intervention to Reduce Smoking, Depression, and Intimate Partner Violence During Pregnancy. BMC Pub Health; 2007.7:233

45. Differential Participation • Fear of being used as “guinea pigs” • Lack of awareness of clinical trials • Influences of family and friends • Work schedules • Transportation and child care barriers • Literacy and language barriers • Priorities El-Khorazaty M, Johnson A, Kiely M et al.: Recruitment and Retention of Low-Income Minority Women in a Behavioral Intervention to Reduce Smoking, Depression, and Intimate Partner Violence During Pregnancy. BMC Pub Health; 2007.7:233

46. Counterargument? • A 2006 study by Wendler et al. suggests that differences in participation of minorities in research is small • Where differences did occur, minorities were more willing than non-minorities to participate in research • Lack of participation may be due to failure to invite minorities and to overcome barriers (transportation, childcare, study location) Wendler D, Kington R, Madans J et al.: Are Racial and Ethnic Minorities Less Willing to Participate in Health Research?; PLoS Med 2006,3:0001-0010.

47. Interdisciplinary Cultures • Cultural differences exist between and within disciplines • Each interdisciplinary team member must: • value diversity • develop the capacity for self-assessment • work towards understanding the disciplinary cultures • be sensitive to interactive dynamics Reich SM, Reich JA: Cultural Competence in Interdisciplinary Collaborations: A Method for Respecting Diversity in Research Partnership. Am J Community Psychol;2006. Sepr:38(1-2):51-62

48. Culture of the Community • Human subjects, study participants or partners? • Asset-based community model • Community-based participatory research

49. Final Thoughts

50. Final Thoughts “But culture in all its richness, does not simply explain health behaviors, nor does sensitivity to culture solve health disparities. Rather, culture works dynamically, in conjunction with economic and social factors, to affect health behaviors and to alleviate or exacerbate health disparities.” Gregg J, et al: Loosing Culture on the Way to Competence: The Use and Misuse of Culture in Medical Education. Academic Medicine;2006;81(6);542-547