Download Healthcare Disparities - Ohio Association of Physician Assistants

Linking Cultural Competence
to Improved Health Outcomes
Dr Patricia Hogue, PhD PA-C
Assoc. Professor, Dept. Chair,
Assistant Dean of Diversity
College of Medicine and Life
Sciences
What Are “Health Care
Disparities”?
There are a number of definitions of
disparities.
-- Healthy People 2020 seeks the
overarching goal of eliminating health
disparities
--Considers all differences in its
measures as evidence of disparities.
Institute of Medicine (IOM), Unequal
Treatment: Confronting Racial and Ethnic
Disparities in Health Care definition:
-- Health care disparities are differences
that remain after taking into account
patient needs and preferences and the
availability of health care.
Differences in clinical care provided to
 Women
 Children
 Elderly /Older Adults
 Patients with chronic illnesses
 LGBT
These differences are often grouped together
under the broad heading of healthcare
disparities.
Differences vs. Disparities in Care
Differences
Disparities
Different outcomes
caused by:
•Biology
•Preferences
•Access
•Insurance
•Resources
Unexplained
differences in
outcomes
associated with
race or ethnicity
Unequal
healthcare
Social Factors and the Quality
Gradient
Education
Income
Higher Quality
Care
Gender
Language
Sexual
orientation
Lower Quality
Care
Many Axis of Inequity
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Race
Gender
Ethnicity
Labor roles and social class markers
Nationality, language, and legal status
Sexual orientation
Disability status
Geography
Religion
These are risk markers, not risk factors
Increased Attention to Health
Disparities in the Last Decade
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Pres. Clinton Health
Disparities Legislation
Healthy People 2010 &
2020
Institute of Medicine 2002
Report Unequal Treatment:
Confronting Racial and
Ethnic Disparities in
Healthcare
AHCQ Annual National
Health Disparities Report
since 2003
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WHO Social Determinants
Commission
CDC community Initiatives
Private foundations
Lets Move Campaign to
address childhood obesity
Patient Protection &
Affordable Care Act (ACA)
8
What is health equity?

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“Health equity” is assurance of the conditions for
optimal health for all people
Achieving health equity requires
 Valuing all individuals and populations equally
 Recognizing and rectifying historical injustices
 Providing resources according to need

Health disparities will be eliminated when health
equity is achieved
Source: Jones CP 2010, adapted from the National Partnership for Action to End Health Disparities.
Social Determinants of Health
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Recognizes that social conditions affect health & can
potentially be altered by social/health policies &
programs
It is a departure from efforts to address a single disease
and causes
Acknowledges that we need to take a multidisciplinary
approach to achieve health equity
It calls for improvement: health/medical care,
education, housing, economic development, labor,
justice, transportation, agriculture, etc.
Associated Factors
Socioeconomic factors
-- Lack of health care facilities in minority
and rural communities
-- Inability to afford high co-payments
Regardless of income or insurance
--Racial and ethnic healthcare disparities
persists
Source of Health Disparities:
1. Low Socio-Economic Status (SES)
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Low SES is one of the most powerful indicator & predictor
of poor health
Americans without a high school degree have a death rate
2 to 3 times higher than those who have graduated from
college
Adults with low SES have levels of illnesses in their 30s
and 40s similar to those seen among the highest SES
group after 65+
Minorities have lower levels of education, income,
professional status and wealth than whites
Source: Williams, 2001; 2003: ibid
12
Percentage of All Persons Below Poverty in
the U.S. by Race/Ethnicity, 1996-2007
35
30
25
%
20
All races
15
African American
10
5
White
Asian American
Hispanic/Latino
0
Source: 2010 Census of Population and Housing.
http://www.census.gov
13
Percentage of Persons with Less than 9th
grade by Race/Ethnicity, 2008
Universe: 2008 population
ages 25 +
35
30
25
All
20
Hispanic
%
Hispanic -Native Born
15
Hispanic - Foreign Born
Asian
African American
10
White
5
0
All
Hispanic
Hispanic - Hispanic Native
Foreign
Born
Born
Race/Ethnicity
Asian
African
American
White
Source: Pew Hispanic Center,
Statistical Portrait of Hispanics in the US, 2008
14
Source of Disparities:
2. Lack of Access to Health and Mental
Health Services

Measured by:
 Lack of regular source of care/medical home and
mental health services
 Lack of health insurance plan
 Inconveniences in obtaining care
 Transportation, waiting time in doctor/clinic, &
cultural, linguistic/health literacy barriers,
 Lower overall use of health services
15
Mental Health
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African-Americans and Hispanics are more likely to be
diagnosed as psychotic, but are less likely to be given antipsychotic medications.
African- Americans are more likely to be hospitalized
involuntarily, to be regarded as potentially violent, and to
be placed in restraints.
A recent report from the U.S. Surgeon General illuminates
the striking disparities in access and availability of mental
health services for minorities
There is a call for action to improve the quality of mental
health care available to racial and ethnic minority
populations.
Source of Disparities:
3. Institutional Racism & Sexism &
4. Poor Quality of Medical Care

Racial, ethnic minorities (& women as a group) receive
fewer procedures & poorer quality medical care than whites
across virtually every therapeutic intervention

Disparities exist in the Clinical Encounter as health
professionals tend to have negative stereotypes of LGBT,
racial and ethnic minorities, the poor & women as a group
Source: IOM, Unequal Treatment Report, 2002; AHCQ, NHDR, 2003)
17
Still others associate health
care disparities with adverse
health outcomes, personal
responsibility, or provider
prejudice.
Public Response for Health Disparities:
Blaming the Victim
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Eat healthy,
exercise more, etc.
Buy health
insurance
Don’t be poor
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Find a job, if you
don’t have one
Change your
neighborhood
19
19
Patients’ race affects clinical decision-making
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720 physicians were shown a
recorded interview and given
other data about a
hypothetical patient and
asked to recommend care.
Men and whites were more
likely to be referred for
cardiac catheterization than
women and blacks.
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Source: Schulman, et al. NEJM, 1999, 340: 618-626.
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Blacks were less likely to get
referred for cardiac
catheterization
Black women were referred
the least
Why Examine Disparities in Cardiovascular
Care?
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Heart disease is the leading
cause of death among
minorities
Scientific and medical literature
extensively document
disparities in cardiac care
There is strong consensus for
recommended treatments
There are widely-accepted
measures of quality of cardiac
care
Cardiovascular Disease
-- Minorities are less likely to be given appropriate cardiac
medications or to undergo bypass surgery.
Stroke
-- African-Americans suffer strokes as much as 35 percent
higher than whites.
-- African-Americans are less likely to receive major diagnostic
and therapeutic interventions.
Kidney Dialysis, Transplants
-- Minorities are less likely to be placed on waiting lists for kidney
transplants or to receive kidney dialysis or transplants.
HIV/AIDS
-- Minorities with HIV infection are less likely to receive
antiretroviral therapy and other state-of-the-art treatments, which
could forestall the onset of AIDS.
Understanding Why Healthcare
Disparities Exists
Although it is clear that racial and ethnic
disparities exist in U.S. healthcare, the
sources of these inequalities are not so
well understood.
Some evidence suggests that bias, prejudice
and stereotyping on the part of health
care providers may contribute to
differences in care.
Self-Awareness: Not Me
.
The IOM report states that it is reasonable
to assume that the vast majority of
healthcare providers find prejudice morally
abhorrent.
Several studies show that even wellmeaning people who are not overtly
biased or prejudiced typically demonstrate
unconscious negative racial attitudes and
stereotypes.
In addition, the time pressures that
characterize many clinical encounters, as
well as the complex thinking and decisionmaking required, may increase the
likelihood that stereotyping will occur.
Uncertainty about a patient's condition also may
contribute to disparities in treatment.
Education increases awareness
% of respondents
2008 Survey of 71 Internal
Medicine Residents in the CCU
100
90
80
70
60
Believe
disparities
exist in
50
40
30
20
10
0
88%
86%
Pre-Education
Post-Education
69%
45%
35%
32%
24%
12%
Healthcare
Overall
Cardiac Care
Source: Gregory et al, SGIM Poster 2008
Their
Hospital
Their
Practice
Increasing Education and Awareness
of Disparities Among Providers
1) Acknowledge Disparities
2) Don’t Make Assumptions
3) Eliminate Fear
Addressing Racial Disparities
in Health Care:
The Association of American Medical
Colleges (AAMC) developed A Targeted
Action Plan for Academic Medical Centers
Disparities based on location of care, often termed
between-provider disparities, are the result of
differences in care patterns across providers (hospitals,
health plans, or physicians).
Disparities related to individual care patterns among
patients treated by the same provider (hospitals, health
plans, or physicians) are called within provider
disparities.
Between Provider
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Recommendation 1: Increase the
Racial and Ethnic Diversity of the U.S.
Physician Workforce
Recommendation 2: Increase Medical
Trainees’ Exposure to Underserved
Settings
Recommendation 3: Increase
Knowledge Regarding Segregation of
Care and Disparities
Within Provider
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Recommendation 4: Increase
Physicians’ Awareness
Recommendation 5: Improve the
Quality of Clinical Interactions
Recommendation 6: Increase
Knowledge Regarding Improving
Clinical Interactions
Recommendation 7: Lead in the
Effort to Eliminate Disparities
Academic medical centers can target their activities to address health care disparities in a strategic
manner by considering whether their interventions will influence between-provider or within-provider
disparities. Model of Academic Centers’ Role in Addressing Health Care Disparities
Between Provider Disparities
Increase targeted physician supply
• Diversity building
• Clinical training exposure
Within Provider Disparities
Improve delivery of cross-cultural care
• Increase awareness of racial disparities
• Cultural competence training
• Research
Improve knowledge
• Community partnerships
• Research
Improve quality of interactions between minority patients
and health care system
Target clustering of care for minorities in low quality settings
Improving health care for minority patients
Improving health care for minority patients
Role of Cultural Responsiveness
But even when minorities are insured at the same
level as whites, they are less likely to enjoy a
consistent relationship with a primary care provider,
in part because of the lack of minority doctors in
minority communities.
"I don't think necessarily you have to be an
African-American to provide good care to
African-Americans, but if you're not you need
to be really aware of the culture and some of
the issues in that culture, and really look at
how you feel about dealing with people from
that culture."
African-American nurse
Role of Racial Concordance
The quality of care provided does not appear to be
better when minority patients and their providers
are of the same racial or ethnic group.
However, one study shows that concordance of race
is associated with greater patient participation and
satisfaction.
Race and Refusal of Treatment
A few studies have found that minority patients refuse
recommended treatments more often than do
whites.
However, the IOM report says differences in refusal
rates are small and do not fully account for racial
and ethnic disparities.
The Road to Patient Mistrust
Real or perceived discrimination in hospitals and
society in general has led many minorities to
mistrust doctors and nurses.
Language and Healthcare
Quality
Language barriers affect the quality of healthcare.
Nearly 14 million Americans are not proficient in
English.
As many as one in five Spanish-speaking Latinos
reports not seeking medical care due to language
barriers.
Access to Healthcare
Defined as the timely use of personal
health services to achieve the best health
outcomes.
-- An essential prerequisite to obtaining
high quality care and increasing the
quality and length of life = timely access.
SES, Health and Access
Individuals of lower socioeconomic
status (SES) and racial and ethnic
minorities have in the past,
experienced poor health and
challenges in accessing high quality
care.
Priority Populations
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Women
Children
Elderly
Racial and ethnic minority groups
Low income groups
Residents of rural areas
LGBT
Individuals with special health care needs,
specifically children with special needs, the
disabled, people in need of long-term care, and
people requiring end of life care.
Disparities are a quality failure
Qual●i●ty n. The degree to which health services for
individuals and populations increase the likelihood of
desired health outcomes and are consistent with current
professional knowledge
Safety
Patientcenteredness
Timeliness
Quality
Equity
Effectiveness
Efficiency
LGBT Healthcare Disparities
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LGBT individuals encompass all races and ethnicities, religions, and
social classes. Sexual orientation and gender identity questions are
not asked on most national or State surveys, making it difficult to
estimate the number of LGBT individuals and their health needs.
Research suggests that LGBT individuals face health disparities
linked to societal stigma, discrimination, and denial of their civil and
human rights.
Discrimination against LGBT persons has been associated with high
rates of psychiatric disorders, substance abuse, and suicide.
Experiences of violence and victimization are frequent for LGBT
individuals, and have long-lasting effects on the individual and the
community.
Personal, family, and social acceptance of sexual orientation and
gender identity affects the mental health and personal safety of
LGBT individuals.
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25
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Why Is LGBT Health Important?
Eliminating LGBT health disparities and enhancing efforts to improve
LGBT health are necessary to ensure that LGBT individuals can lead
long, healthy lives. The many benefits of addressing health concerns
and reducing disparities include:
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Reductions in disease transmission and progression
Increased mental and physical well-being
Reduced health care costs
Increased longevity
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Efforts to improve LGBT health include:
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Curbing human immunodeficiency virus
(HIV)/sexually transmitted diseases (STDs) with
interventions that work.
Implementing anti-bullying policies in schools.
Providing supportive social services to reduce suicide
and homelessness risk among youth.
Appropriately inquiring about and being supportive of
a patient’s sexual orientation to enhance the patientprovider interaction and regular use of care.
Providing students with access to LGBT patients to
increase provision of culturally competent care.
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25
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Efforts to address health disparities among
LGBT persons include:
 Expansion of domestic partner health
insurance coverage
 Establishment of LGBT health centers
 Dissemination of effective HIV/STD
interventions
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25
Transgender Care

Many providers can learn a great deal about
transgender care directly from their patients;
however, patients may receive inaccurate
information through community grapevines or
other non-medical sources. Providers are
encouraged to review the existing medical
research and clinical practice guidelines
developed by a small number of treatment
centers, and to be alert to new developments
in this emerging field.
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Professional associations such as the World Professional
Association for Transgender Health, www.wpath.org,
and the Gay and Lesbian Medical Association,
www.glma.org
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both of which hold biennial or annual symposia, and
provider networks, which are informal and newly
developing, are recommended sources for professional
development in this field.
It should be noted that this protocol is not a substitute for
The World Professional Association for Transgender Health
(WPATH) Standards of Care (SOC), which describe
diagnostic criteria and minimal, flexible guidelines
concerning eligibility for certain transition-related
treatments. Providers treating trans people who are
undergoing or have undergone transition-related
treatments should become familiar with the (WPATH SOC).
Lesbian, Gay, Bisexual, and Transgender Populations
In the 2011 National Healthcare Disparities Report
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Transgender people are more likely to be uninsured and less likely to have
employer based health insurance than the general population.
Half of transgender people postponed care when sick or injured and
postponed preventive health care due to cost.
Among uninsured transgender people, 88% postponed care due to cost.
About 30% of transgender people postponed care when sick or injured and
postponed preventive health care due to discrimination and disrespect by
providers.
Female-to-male transgender people were most likely to postpone care due
to discrimination.
One in five transgender people has been denied services by a doctor or
other provider due to their gender.
Racial and ethnic minority transgender people are more likely to be denied
services.
http://www.ahrq.gov/qual/nhqrdr11/nhdrlgbt11.htm
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Note: Patients may wish to be labeled 'Male' or 'Female'
according to their gender identity and presentation, their
legal status, or according to the way they are registered
with their insurance carrier. They may wish to be
referred to as 'Female' in one situation (e.g., in their
record with the physician's office and in personal
interactions with physician and office staff), but 'Male' in
other situations (e.g., on forms related to their insurance
coverage, lab work, etc.). The application of specific
terminology could change at various times over the
patient's lifetime. This principle cannot be overemphasized: Always ASK patients how they define
themselves, and respect and USE their preferred selfdefinitions.
Lesbian and Bisexual Women
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HRSA's October 2011 release of
Women's Health USA 2011, which
identifies priorities, trends, and disparities
in women's health. For the first time, this
report features data on the health of
lesbian and bisexual women and
recognizes that health disparities exist
among women by sexual orientation.
Research suggests that lesbian and bisexual women are at
increased risk for adverse health outcomes, including
overweight and obesity, poor mental health, substance
abuse, violence, and barriers to optimal health care
resulting from social and economic inequities.
Although frequently referred to as part of a larger group of
sexual minorities, including gay men and transgender
individuals, the health status and needs of lesbians and
bisexual women are uniquely shaped by a range of
factors including sexual identity and behavior, as well as
traditional sociodemographic factors, like age, education,
and race and ethnicity.
The terms “lesbian” and “bisexual” are used to define
women according to their sexual orientation which can
reflect sexual identity, behavior, or attraction.
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LGBT youth are 2 to 3 times more likely to attempt suicide.
LGBT youth are more likely to be homeless.
Lesbians are less likely to get preventive services for cancer.
Gay men are at higher risk of HIV and other STDs, especially
among communities of color.
Lesbians and bisexual females are more likely to be
overweight or obese.
Transgender individuals have a high prevalence of HIV/STDs,
victimization, mental health issues, and suicide and are less
likely to have health insurance than heterosexual or LGB
individuals.
Elderly LGBT individuals face additional barriers to health
because of isolation and a lack of social services and culturally
competent providers.
LGBT populations have the highest rates of tobacco, alcohol,
and other drug use.
LGBT - Conclusions
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The more risk factors a woman has, the greater the
chance that she will develop heart disease. Factors that
raise women’s risk for heart disease include physical
inactivity, obesity, and smoking—all of which have been
found to be more prevalent among lesbians than other
women.
Lesbians are at significantly higher risk for developing
breast cancer than heterosexual women. Risk factors for
breast cancer among lesbians include fewer full-term
pregnancies, fewer mammograms and/or clinical breast
exams, and being overweight.
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Heart disease remains a significant concern for
men of all sexual orientations. Major risk factors
for heart disease among men include tobacco
use and alcohol use—behaviors prevalent
among gay men.
In some cases, gay men are at an increased risk
for several types of cancer—including prostate,
testicular, and colon cancers. In addition, gay
men are at higher risk for anal cancer due to an
increased risk of becoming infected with human
papillomavirus (HPV), the virus that causes
genital and anal warts.
Asian-American Health Disparities
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Studies of disparities in health care quality often
exclude Asian Americans. Despite the large
Asian population living in the United States, few
studies have focused on the health care
experiences of Asian Americans.
Elderly Asians have the highest rate of uninsured
(6 percent) compared with whites (0.2 percent),
blacks (1 percent), and Hispanics (5 percent),
perhaps reflecting different work patterns.
Elderly Asian Medicare beneficiaries more
often report long waits to see doctors
compared with whites.
 Among Medicare managed care enrollees,
Asians rate their doctors and overall
health care the lowest of any group and
report more problems with getting needed
care, getting care quickly, doctor
communication, and office staff
helpfulness compared with whites.

Ernest Moy, Linda G. Greenberg and Amanda E. Borsky (2008)
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Asian Americans represent a wide variety of languages,
dialects, and cultures as different from one another as
from non-Asian groups. Asian Americans have
historically been overlooked due to the “myth of the
model minority”: the erroneous notion that Asian
Americans are passive, compliant, and without problems
or needs. The effects of this myth have been the failure
to take seriously the very real concerns of this
population.
Asian Americans represent both extremes of
socioeconomic and health indices: while more than a
million Asian Americans live at or below the federal
poverty level, Asian-American women have the highest
life expectancy of any other group.
http://www.cdc.gov/omhd/populations/asianam/asianam.htm#Disparities
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Asian Americans suffer disproportionately
from certain types of cancer, tuberculosis,
and Hepatitis B.
Factors contributing to poor health
outcomes for Asian Americans include
language and cultural barriers, stigma
associated with certain conditions, and
lack of health insurance.4
Overall, Asian Medicare beneficiaries were less
likely than whites to receive mammography and
colorectal cancer screening services and all three
diabetic services . Asian-white relative
differences were larger for cancer screening
than for diabetic services. Among cancer
screening services, differences were larger for
mammography than for colorectal cancer
screening. For diabetic services, differences
were largest for self-care instruction and
smallest for physiological testing.
Ernest Moy, Linda G. Greenberg and Amanda E. Borsky (2008)
Factors that Influence Clinical
Decisions and Communication
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Sociocultural factors impact providerpatient communication and
Non-medical factors (race, gender, age,
sexual orientation) influence clinical
decision making
Stigma and Illness
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Describes the knee jerk reaction of others
and social distancing of an individual who
has a discredited disease, condition, or
illness.
Stigma is classically defined as “an
attribute” that is deeply discrediting.

“People with a stigmatized illness face
problems on two fronts:
-- The disease itself
-- The shame and prejudice that come
with the diagnosis”.
Four Elements
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Labeling
Stereotyping
Status loss
Discrimination
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Stereotyping is the process of applying beliefs
and expectations about a group to a person
from that group.
Bias is a preference or an inclination, especially
one that inhibits impartial judgment.
Prejudice is the unjustified negative attitude
based on a person’s group membership.

Clinicians’ stereotyping, bias, and prejudice may
contribute to disparities in the quality of care received
by minorities and LGBT.
Stigmatized Illnesses and
Conditions
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Epilepsy
HIV-AIDS
Mental Health
Alcohol and Mental health
Cancer
Facial Disfigurement
Aging
Bladder Control
Bowel Control
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Obesity
Sexually Transmitted
Infections
Skin Conditions
A Patient-Based Approach to
Cross Cultural Care:
Cultural Responsiveness Matters!
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Assure effective communication
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Beware of stereotyping
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Assess core cross-cultural issues, explore the meaning
of the illness, determine the social context and
engage in negotiation
Understand mechanism, identify conditioning, doublecheck clinical decision making, work in diverse teams
Build trust

Be aware of mistrust, acknowledge potential, provide
focused reassurance, negotiate
Take Home Message

"Disparities in the health care delivered to
LGBT, women, racial and ethnic minorities
are real and are associated with worse
outcomes in many cases, which is
unacceptable. The real challenge lies not
in debating whether disparities exist,
because the evidence is overwhelming,
but in developing and implementing
strategies to reduce and eliminate them."
Robert Phillips - Case Questions
• Issue 1 – Disease and Illness
– What is the distinction between “disease” and “illness?”
• Issue 2 – Discrimination and racial/ethnic disparities in care
– For what conditions or procedures have racial/ethnic disparities
been documented?
• Issue 3 – Stereotyping and clinical decision-making
– What would it be like to be on the other end of a negative
stereotype like this?
• Issue 4 – Mistrust and communication style
– What are the different ways you might expect patients to act
when they are mistrustful?
Q&A
For more information and resources visit:
www.rwjf.org
• Healthy People 2020
www.healthypeople.gov