THE CASE FOR CULTURAL AND LINGUISTIC COMPETENCY

1. THE CASE FOR CULTURAL AND LINGUISTIC COMPETENCY Organizational Cultural & Linguistic Competency Department of Behavioral Health and Developmental Services Richmond, VA September 30, 2009 Larry Merkel, MD, PhD Department of Psychiatry and Neurobehavioral Sciences University of Virginia

2. What’s Wrong With This Picture? “Hmong’ may be hard to pronounce, but it’s likely that nearly every staffer at St. John’s Hospital in Maplewood, MN, knows that and much more about this unique population from Somalia.” (Patient Safety Alert, Healthcare Benchmarks & Quality Improvement. 14(10): Suppl. 1-2, 2007)

3. Cultural and Linguistic Competency • Where did they come from? • Why are they important? • What are the problems?

4. Cultural and Linguistic Competency History • Civil Rights Act of 1964 • Social Security Act of 1965 • 1990 – American’s with Disability Act • 1990 – Healthy People 2000 • 1998 – GAP Conference on Culture and Psychiatric Education • 1999 – APA /FCMHS Conference • 1999 – AMA Cultural Competence Compendium

5. Cultural and Linguistic Competency History • 1999 Surgeon General’s Report on MH • 1999 Surgeon General’s Report on Culture, Race, and Ethnicity • 2000 HHS/OMH CLAS Standards • 2000 NIMH Strategic Plan for Reducing Disparity • 2001 ACGME Requirements for Psychiatry Training • 2002 IOM – Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care • 2007 National Health Care Disparities Report

6. Increasing Diversity of US Population

9. Mental Health Disparities

10. Summary of Problem • Minority members are less likely to use mental health resources • Minority members generally receive poorer mental health care • Minority members have a higher percentage of unmet needs • Minority members are over represented in vulnerable populations

12. National Survey of American Life (Williams et al 2007) • Blacks have less risk for depression • Once depressed, Blacks have more persistent and impairing depression • Blacks have higher levels of social domain impairment • Blacks are less likely to seek treatment

13. National Survey of American Life (Williams et al 2007)

14. African AmericanUtilization • Half the rate of receiving services as whites • More likely to terminate prematurely • More often use PCP • More likely to be hospitalized

15. Depression Treatment Disparities (Alegria et al 2008)

16. Increasing Treatment Disparities (Cook et al 2008)

17. Disparities in Alcohol, Drug and Mental Health Treatment (Wells et al 2001) • Perceived unmet need: • White 12.5% • African American 25.4% • Hispanic 22.6% • Likelihood of receiving active treatment: • White 37.6% • African American 25% • Hispanic 22.4%

18. Latino Mental Health Treatment Disparities • Mexican Americans twice as likely to leave treatment AMA compared to whites. (Andrulis 1977) • Immigrant Mexican Americans seek treatment 2/5s as often as US born Mexican Americans. (Vega et al 1999) • Between 1993 and 2002 Hispanic patients were decreasingly likely to have mental health care compared to non-Hispanics. (Blanco et al 2007)

21. Barriers to Mental Health Care • Cost • Stigma • Racism and discrimination • Fragmented services • Language • Culturally different models of illness and treatment • Clinician’s lack of cultural competence • Client’s fears and mistrust

22. Interpersonal Barriers • Racism • Mistrust • Stigma • Misdiagnosis • Miscommunication

23. Racism • Linked to increased incidence of hypertension among African Americans • Associated with psychological distress, lower well-being, self-reported ill health, and number of days confined to bed • Associated with a lower quality of life for African Americans

24. Client Perceived Disrespect • African Americans 12% • Latinos 15% • Whites 1% (Brown et al., 1999) • African Americans 43% • Latinos 28% • Whites 5% (LaViest et al., 2000)

25. Racism (van Ryn and Burke 2000) • Physicians tend to perceive Black patients more negatively • Black patients were seen as more at risk for noncompliance, substance abuse, and having inadequate social support • Black patients were seen as less intelligent • Physicians had less affiliative feelings toward Black patients

26. Impact of Race on Medical Care • Physicians are more likely to withhold or underprescribe opioid medications for minority patients • Less likely to prescribe antiretroviral drugs for African American patients • Oncologists tend to use lower doses of chemotherapy agents in cancer treatment with African Americans • Less likely to recommend cardiac catherization in African American patients

27. Minority Medical Students • Receive fewer positive comments • Receive more negative comments • Feel less assertive • Have lower grades on clerkships • Score lower on communication section of CPX • Report more incidents of discrimination • Have equal amounts of depressive symptoms • Have lower rates of burnout (Lee et al 2007, 2009; Fernandez et al 2007; Dyrbyre et al 2007)

28. African AmericanDiagnosis and Treatment • Less often diagnosed by PCP if depressed • More often diagnosed with Schizophrenia • Less likely to receive adequate treatment for depression and anxiety • Slower metabolism of medications • Increased rates of side-effects • Increased use of higher doses of neuroleptics

29. Race/Ethnicity and Psychiatric Diagnosis • In scripted case with alterations in race and gender, African American males were more likely to be diagnosed with Schizophrenia even by African American Psychiatrists. (Loring and Powel 1988) • In DSM-IV field trials African American males more likely diagnosed with Schizophrenia than psychotic depression, because of increased severity of first rank symptoms. (Strakowski et al 1996)

30. Race/Ethnicity and Psychiatric Diagnosis • Diagnosis made in psychiatric ER only agreed with SCID diagnosis 42% of time. • There was increased disagreement if the patient was non-white. • Due largely to emergency psychiatrist not soliciting information gathered in structured interview and primarily missing information about affective symptoms. (Strakowski et al 1997)

31. Race/Ethnicity and Psychiatric Diagnosis • Large study of 22 clinical sites in New Jersey • African Americans were twice as likely to be diagnosed with a Schizophrenia spectrum disorder. • Self-reported psychotic symptoms were no higher among African Americans as whites • African Americans diagnosed with psychosis had higher functioning than other with similar diagnosis. (Minsky et al 2003)

32. Race/Ethnicity and Psychiatric Diagnosis • Studies of community based psychosocial rehabilitation for schizophrenia showed little improvement or deterioration for African Americans diagnosed with Schizophrenia before 2001 (Phillips et al 2001) • Study done in 2004 showed equal but slower improvement by African Americans (Bae et al 2004)

33. Race/Ethnicity and Psychiatric Diagnosis • Latinos were more likely diagnosed with depression than whites. • Yet Latinos had higher rates of self-reported psychotic symptoms that whites or African Americans. • Both Latinos and African Americans were less likely diagnosed with Bipolar Disorder. (Minsky et al 2003)

34. Why? • There are significant difference in the relationship of key symptoms and diagnosis of psychiatric disorders by racial/ethnic categories. (Alegria and McGuire 2003) • Clinicians focused on building rapport over diagnostic information. • Rate of exploration of symptom clusters varied with ethnic group. (Alegria et al 2008)

35. Trust African Americans vs. Whites

36. Stigma • Would mention mental health problem to a friend or relative – Asian 12% White 25% • Would go to a mental health specialist – Asian 4% White 26% • Would seek help from a physician – Asian 3% White 13%

37. What Can be Done? Cultural and Linguistic Competency

38. Culturally and linguistically Appropriate Services • Culturally Competent Care • Language Access Services • Organizational Support

39. What will they do? • Provide more effective treatment within a cross-cultural setting • Close the health disparity gap

40. Cultural Competency • “A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable them to work effectively in cross-cultural situations.” Focal Point 1988: 3(1)

41. What is Cultural Competency? • Attitudes - appreciation of differences and similarities, respect • Skills - sensitive interviewing techniques, attention to dynamics • Behaviors – flexibility • Knowledge - cultural, epidemiological, efficacy • Policies - implementing the above

42. Medical and Psychiatric Diversity

43. History of Cultural Competency Training • 1977 – 33% of programs had some content • 1984 – Follow-up, 75% had dropped it • 1989 – 92% had some content • 1992 – Of 126 US Medical Schools only 1 had cultural sensitivity training • 1993 – 92% had some content • 2007 LCME mandated cultural competency training • 2008 90% of medical schools have specific training

44. Culturally Sensitive Interventions • Cultural Training • Patient Activation and Empowerment Training • Professional Linguistic Services • Culturally Adapted Therapy • Provider-Client Racial/Ethnic or Linguistic Matching • Specialty Programs

45. Intercultural Communication • The tendency to ask questions varies with ethnic group. (Schouten et al 2007) • GPs showing more positive affective response increases the tendency to ask questions. (Schouten et al 2007) • Effective intercultural communication correlates with patient satisfaction. (Ulrey & Amason 2001) • Providers tend to be less affectively responsive with ethnic minority patients. (Schouten & Meeuwesen 2006)

46. Review of Studies Testing Cultural Competency Training • Improves health providers knowledge. • Improves health providers attitudes and skills. • Improves patient satisfaction. • Minimal evidence that it impacts on patient adherence. • No evidence that it affects health status outcome • Poor evidence as to cost of training. • Results have only been measured short-term. (Beach et al 2005)

47. Cultural Competency Training – Individual or Organization • Providers with positive attitudes toward CC learning more likely worked in clinics with increased % of non-white staff, that offered training, and that had culturally adapted educational material. • Culturally appropriate provider behavior was more likely in clinics with increased % of non-white staff and culturally adapted educational material. • Synergism? (Paez et al 2008)

48. Other Evidence for the Effectiveness of Cultural Competency Training • Residents from HRSA Title VII programs feel more prepared to provide cross-cultural care (Green et al 2008). • Providers who are more motivated to learn about culture, more sensitive to power issues, or who reported more CC behaviors were • perceived by their clients as more facilitative • clients were more willing to share information. • clients were more satisfied (Paez et al 2009)

49. How is it Done?

50. Effective Prejudice Reduction Techniques (Paluck & Green 2009) • Cooperative Learning • Media Interventions • Reading Interventions • All support Extended Contact Hypothesis