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Race/Ethnicity
Ethics, Health, Healthcare
John R. Stone, MD, PhD
Center for Health Policy and Ethics
Creighton University
OTD/2010
[email protected]
http://chpe.creighton.edu/
Learning Objectives
• Explain ethical frameworks and strategies for
addressing racial/ethnic inequalities in OT care.
• Outline ethical bases of professional obligations
to improve racial/ethnic health inequalities.
• Summarize racial/ethnic health & healthcare
inequalities.
Strategies, Topics
•
•
•
•
Background: health & healthcare inequalities
Cases  ethics & methods  cases
Ethical theories, principles/values, codes, rights
Concepts: race/ethnicity, disparities,
equity/inequity, respect, justice,
consequentialism, care, solidarity
• Areas of focus
 Individual client/patient
 System and community
 State-Region-Nation-Globe
Defining Race/Ethnicity
• Social or political ascriptions or constructions
that:
▫ Relate to social and political agendas
▫ May reflect presumed ancestral or geographical
origin
▫ Often are meant to imply and/or sustain level of
social status or value
FYI: http://www.census.gov/population/cen2000/phc-2-a-B.pdf
Biology and Race/Ethnicity
• Socially constructed identities have biological
consequences.
• Different biology does not imply or mean
different genetics.
• Racial/ethnic labeling can have connections to
ancestral migration patterns that may correlate
with genetic differences.
Racial/Ethnic Inequalities
Health
Healthcare
• Mortality/survival
• Morbidity/life-quality
▫ Pain, disability and
suffering that is healthrelated
• Access
• Quality
Case: Front Office-1
• You are a practitioner in the OT section of one
hospital in a health system. You are White and of
European descent.
• You notice that a front office person is
commonly less patient with patients that appear
to be Latino or Asian.
Case: Front Office-2
• What ethical principles, values, and or rights are
violated?
• What should you do?
• Who might you consult for advice?
Case: Front Office-3
Moral Anchors/Foundations
• Equal human worth
• Respect for persons
▫
▫
▫
▫
▫
▫
▫
Equal
Substantial
Principles
Regard
Values
Preservation/honoring dignity
Recognition
Empowerment
Ensuring autonomy
Case: Front Office-3
Moral Anchors/Foundations
•
•
•
•
•
√ Equal human worth
√ Respect for persons
Justice
Care
Solidarity
Case: Front Office-4
Moral Anchors/Foundations
Fairness
Justice
Remediation
Repair
Restoration
Case: Front Office-5
Moral Anchors/Foundations
Respect
Care
Equal
Action
Substantial
Solidarity
Justice
Action
Fairness
Relationships in Ethics
Theory
Principles,
values
Cases
Codes
Case: Front Office-6
Moral Problems/Infractions
Disrespect
Unequal
Less
substantial
 value
DAMAGE
Justice
Unfairness
Unjust
HEALTH
DAMAGE
Case: Front Office-7
Strategic Responses
•
•
•
•
•
Get advice
Assess the evidence
Reflect (moral framework/anchors)
Speak to the leadership
Respect the person who is treating people
unequally
• Try informal approaches
• Consider formal action
Case: Front Office-8
Strategic Responses
• Value/principle affirmation
• Cultural competence training
• Coalition/partnership building
Case: Front Office-9
Variations
• A professional peer is at fault
• A higher level person is the agent of disrespect
• A system issue may be a cause
Perception to Action
Act
Perceived
moral
problem
Consider
actions
Moral/ethical
reflection
Case: Racial/Ethnic (R/E) Outcomes-1
• Hypothetical: R/E minorities commonly receive
unequal and inferior OT care.
• Extensive evidence in healthcare generally*
▫ Common inferior care of R/E minorities
▫ Probable causes: system, hospital, practitioner
*Institute of Medicine 2003, numerous other studies
Case: R/E Outcomes-2
• Your organization does not assess the quality of
any care according to race and ethnicity.
• What should you do?
• What are some options for action?
• What ethical considerations, principles, values,
or theories might be helpful?
Health Inequalities & OT-1
• Health disparities have been identified as a
national priority for health care during the past
decade.
• Multiple definitions of health disparities.
Bass-Haugen 2009
Racial/Ethnic Health/Healthcare Equality
Terminology
•
•
•
•
Disparities/Parity
Equality/Inequality
Equity/Inequity
Gap
AHRQ National Healthcare Disparities
Report 2009
• Key themes
▫
▫
▫
▫
Disparities common
Uninsurance big factor
Many disparities are not decreasing.
Some disparities merit particular attention,
especially care for cancer, heart failure, and
pneumonia.
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf (Accessed 05Dec2010)
Distribution
of core
quality
measures
AHRQ NHDR 2009, P. 3
AHRQ National Healthcare Disparities
Report 2009
• AHRQ and HHS are trying to accelerate the pace
of improvement by:
▫ Training providers.
▫ Raising awareness.
▫ Forming partnerships to identify and test
solutions.
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/qual/nhdr09/nhdr09.pdf (Accessed 05Dec2010)
Health Disparities/Inequalities
Definitions: Health Disparities
• NIH definition: “differences in the incidence,
prevalence, mortality, and burden of diseases
and other adverse health conditions that exist
among specific population groups in the [USA]
• Healthy People 2010 disparities groups:
“gender, race or ethnicity, education or income,
disability, geographic location, or sexual
orientation”
Bass-Haugen 2009
Health Inequalities & OT
Evidence Review
• “There was evidence of health disparities in
children and adults that are relevant for
occupational therapy as it relates to
race/ethnicity and socioeconomic status.”
• Bass-Haugen JD. Health disparities: Examination of evidence
relevant for occupational therapy. Am J Occup Ther. 2009;
63(1):24-34.2. (Underlining added)
Health Inequalities
Causal Factors
Social Determinants
Person-related
•
•
•
•
•
•
•
•
•
•
•
Environment
Income/wealth
Education
Healthcare Access
Oppression
Discrimination
Lifestyle
Preferences
Views & Attitudes
English proficiency
Literacy
Bass-Haugen 2009
Health Inequalities & OTMulticulturalism & Health Disparities
• “The national goal of eliminating health
disparities is important for [OT].”
• 1990s: [OT increased] awareness of
multicultural issues and promoted studies and
publications that explored…diversity.”
• However, OT focus on health disparities is quite
recent.
Bass-Haugen 2009
Health Inequalities & OTOT Literature & Studies: Limited
Topics
Emerging Topics
•
•
•
•
• Social/occupational justice
• Occupational deprivation
• Client advocacy
Prejudice
Healthcare justice
Minorities
Access
Bass-Haugen 2009
Health Inequalities & OTNational Data Review: OT-Related
Adult Activity & Participation
• Negative emotions
• Activity performance
limitations & difficulties
• Infrequent participation in
physical activity
Black, Multiple Race,
Hispanic, Poor
• More likely than Whites
Bass-Haugen 2009
Health Inequalities & OTNational Data Review: OT-Related
Children: All & Special Needs
Occupations & Environments
Black, Multiple
Race/ethnicity, Hispanic, Poor
• Activity profiles
• Environment
▫ School
▫ Safety & supportiveness of
schools, neighborhoods,
communities
• Health characteristics
• Healthcare needs
• Worse
Bass-Haugen 2009
Center for Health Policy
and Ethics
DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in
cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.
Center for Health Policy
and Ethics
DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in
cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.
Center for Health Policy
and Ethics
DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in
cancer mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(11):2908-2912.
National (DHHS) Health Disparities
Priorities
CDC 2010
Focus Areas-Disparities
• “The Department of Health
and Human Services (HHS)
has selected six focus areas in
which racial and ethnic
minorities experience serious
disparities in health access and
outcomes.”
•
•
•
•
•
•
Cancer screening, management
Cardiovascular disease
Diabetes
HIV Infection/AIDS
Immunizations
Infant mortality
http://www.cdc.gov/omhd/AMH/dbrf.htm (Accessed 08Dec2010)
Chartbook, Health, United States, 2009, p. 45. http://www.cdc.gov/nchs/data/hus/hus09.pdf (Accessed 04Dec2010)
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1
111.pdf?section=4039 (Accessed 05Dec2010)
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?
section=4039 (Accessed 05Dec2010)
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?se
ction=4039 (Accessed 05Dec2010)
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?se
ction=4039 (Accessed 05Dec2010)
Chart 3-10. Percentage of people age > 20, 2003
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Chart 3-10. Percentage of people age > 20, 2003
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Chart 3-10. Percentage of people age > 20, 2003
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Chart 3-10. Percentage of people age > 20, 2003
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Chart 4-1. P. 47
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Chart 6-24, P. 89
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Health Inequalities & OTNational Data Review: OT-Related
Healthcare Outcomes and
Experiences: OT Relevance
• Healthcare experiences
• Nursing facility outcomes
• Home health outcomes
Black, Multiple
Race/ethnicity, Hispanic, Poor
• Generally less positive
• NF and HH outcomes
inconsistent by R/E
• “It is clear, however, that
disparities exist on measures of
health directly related to
occupational therapy practice.
These trends need further study
to understand the influencing
factors on incidence.”
Bass-Haugen 2009
Social Justice & OT
• “Occupational therapy’s vision is to promote
social justice by enabling people to participate as
valued members of society despite diverse or
limited occupational potential. The profession
promotes social justice through practical
approaches that enable people to develop their
occupational potential. (Townsend, 1993, p. 176)”
Elizabeth Townsend, quoted in Braveman & Bass-Haugen 2009
Social Justice & OT
• “Social justice is a broad term that encompasses
several interrelated concepts, such as equality,
empowerment, fairness in the relationship
between people and the government, equal
opportunity, and equal access to resources and
goods.”
Braveman & Suarez-Balcazar 2009, italics added
Occupational Justice
• “Occupational justice asks us to consider the
inequities that arise when participation in
occupations is “barred, confined, restricted,
segregated, prohibited, undeveloped, disrupted,
alienated, marginalized, exploited, excluded, or
otherwise restricted” (Townsend & Wilcock, 2004, p. 77).”
Braveman & Suarez-Balcazar 2009
Addressing Healthcare Inequalities
Moral Frameworks
Justice: Equality of
Opportunity (Daniels)
Social Justice: Sufficient Level
of Health (Powers & Faden)
• Health as normal
functioning is important
for fair equality of
opportunity to envision
and pursue diverse and
reasonable life goals.
• Equal human worth and
respect for persons
justifies a conception of
social justice in which all
should be provided
sufficient aspects of wellbeing, including health.
• How to advance this
heath goal depends on
circumstances.
•
Daniels N. Just Health Care. New York: Cambridge
Univ. Press, 1985. Daniels N. Just Heath: Meeting
Health Needs Fairly. New York, NY: Cambridge
Univ. Press, 2008.
•
Powers M, Faden R. Social Justice: The Moral
Foundations of Public Health and Health Policy.
New York: Oxford Univ. Press, 2006.
Case: R/E Outcomes-2
• Your organization does not assess the quality of
any care according to race and ethnicity.
• What should you do?
• What are some options for action?
• What ethical considerations, principles, values,
or theories might be helpful?
Healthcare Disparities/Inequalities
What should your institution do?
Train Providers
• “Cultural expectations, assumptions, and
language affect the quality of care patients
receive. Some efforts have focused on training
health care personnel to deliver culturally and
linguistically competent care for diverse
populations”
AHRQ NHDR 2009, P. 11.
Healthcare Disparities/Inequalities
What should your institution do?
Raise Awareness
• “Other efforts to address health care disparities
leverage key partnerships to raise awareness of
disparities by using data and research.”
AHRQ NHDR 2009, P. 12.
Healthcare Disparities/Inequalities
What should your institution do?
Form Partnerships To Identify and Test
Solutions
• “Other partnerships leverage both public and
private partners to address health care
disparities at the community and provider level.”
AHRQ NHDR 2009, P. 11.
Chart 7-10, P. 106
Better Quality of Care: Myocardial Infarction
http://www.commonwealthfund.org/usr_doc/Mead_racialethnicdisparities_chartbook_1111.pdf?section=4039
(Accessed 05Dec2010)
Hospital Equity Reports
Monitor
Center for Health Policy
and Ethics
Assess
Equality
in Quality
Race
Ethnicity
Language
SES
Intervene
Weinick 2008
Quality Improvement
Example: Beta Blockers in Acute Myocardial Infarction
(Heart attacks)
Center for Health Policy
and Ethics
Exclusions
Record
review
Criteria
Intervene
Data
Interpret
Hospital Equity Reports
Policy  Institutional Change
Center for Health Policy
and Ethics
• “In order to assess and address racial and ethnic
disparities on an ongoing basis, all relevant
performance improvement data should be
collected and stratified by race and ethnicity.”
(MGH)
Weinick 2008, p. 13
Case: Hostility/Anger-1
• You are a White OT practitioner.
• A 68-year old African American man is referred
for OT care after a stroke that leaves him
significantly hemiparetic, but cognitively intact.
• Over 2-3 visits he exhibits continued hostility
and anger.
• Neurological assessment in hospital did not
suggest that his stroke caused these attitudes.
• These attitudes seem directed at you, not
reactions to his stroke-induced problems.
Case: Hostility/Anger-2
• You express concern to his wife and learn from
her that he has long experienced many “microaggressions” or small racial affronts from
Whites. His hostility and anger toward you are a
consequence, she believes.
• She adds that her husband often has these
attitudes when he has to deal with White people.
• She expresses her appreciation for your care and
asks that you be patient with him.
Case: Hostility/Anger-3
• You are quite challenged by his anger/hostility.
• You recognize the challenge and want to develop
more constructive responses.
• Your main objective is to improve his OT-related
outcomes.
• Of course, you believe that caring and respectful
approaches are professionally essential and
important for healing.
Case: Hostility/Anger-4
• What strategies might you employ to gain
insight and improve the relationship?
• What ethical approaches, values, and theories
might be useful?
Case: Hostility/Anger-5
Narrative Ethics Guidance
• Imagine walking in his shoes for decades.
• Envision multiple micro- and some macroaggressions and/or discrimination.
• Study some related literature
• Feel the injury and injustice
• Appreciate the reasonableness of
anger/hostility.
Case: Hostility/Anger-6
Narrative Ethics Guidance
• Write his hypothetical story.
• Employ that understanding & empathic
connection to be:
▫
▫
▫
▫
▫
▫
Caring
Concerned
Patient
Respectful
In Solidarity
Appreciative (of his life)
Case: Distrust-1
• You are providing OT services to a 45 year-old
Latina woman. She is recovering from
significant musculo-skeletal and head injuries
from a car accident.
• English is her second language and she only
speaks and understands it moderately well.
• You are a White Anglo who only speaks English.
Case: Distrust-2
• You sense that she distrusts you, an impression
that the family confirms. They also exhibit some
distrust that you are failing to show her the same
respect and care as you do Anglos.
• Initially you feel insulted. Your professional
character seems under attack.
• You feel hurt and somewhat outraged. After all,
you are a caring and dedicated OT professional.
Case: Distrust-3
• What should you do?
• What strategies might you employ?
• What ethical approaches, values, and theories
might be useful?
Case: Distrust-4
Narrative Ethics
• Learn and imagine her history.
• Envision repeated ethnic slurs, discrimination,
and devaluation.
• Imagine repeated treatment with disrespect by
practitioners.
• Reflect on background principles of respect,
justice, and care.
Case: Distrust-5
• Consider ignorance about her culture and
beliefs.
• Perceive the rationality of her distrust.
• Accept the distrust.
• Bridge the divide with her and family.
• Look for many small ways to show care and
respect.
• Get help.
Case: Distrust-6
Cultural Humility
• Assume ignorance
• Presume you have stereotypical assumptions
and ethnic bias
• Accept that you may need professional growth.
• Inquire about how to show respect and care
(family may be a helpful source).
• Get help from colleagues and those with more
cultural knowledge.
Tervalon & Murray-Garcia 1998
Case: Unequal OT Services-1
• In your community, a disadvantaged racial or
ethnic subgroup:
▫
▫
▫
▫
Lives mainly in one geographic area
Has higher unemployment and low income
Has significant transportation challenges
Has limited access to OT and related services, all
contributing to reduced occupational
opportunities
Addressing Healthcare Inequalities
Moral Frameworks
Justice: Equality of
Opportunity (Daniels)
Social Justice: Sufficient Level
of Health (Powers & Faden)
• Health as normal
functioning is important
for fair equality of
opportunity to envision
and pursue diverse and
reasonable life goals.
• Equal human worth and
respect for persons
justifies a conception of
social justice in which all
should be provided
sufficient aspects of wellbeing, including health.
• How to advance this
heath goal depends on
circumstances.
•
Daniels N. Just Health Care. New York: Cambridge
Univ. Press, 1985. Daniels N. Just Heath: Meeting
Health Needs Fairly. New York, NY: Cambridge
Univ. Press, 2008.
•
Powers M, Faden R. Social Justice: The Moral
Foundations of Public Health and Health Policy.
New York: Oxford Univ. Press, 2006.
Moral Anchors/Guides/Sources
Elaborations
• Ethical Theories
▫
▫
▫
▫
Justice
Consequentialism/utilitarianism
Feminist
Narrative
• Ethical Principles/values (frameworks)
• Ethical Professional Codes
Case: Unequal OT Services-2
Center Planning & Service
• To enhance health and employment, the Health
Department decides to establish a multidisciplinary center in the subgroup’s area.
• An OT professional, you are invited to join the
planning group for the center.
• Whether you help plan it, you could provide
voluntary OT services at the center.
Challenges
• Social inequalities causing racial/ethnic
inequalities
• Social inequalities causing unequal health
• Social inequalities causing unequal healthcare
• Unequal healthcare
Case: Unequal OT Services-3
Ethical Obligations-1
• Professionally, whether you help the plan Center
or voluntarily serve there is:
▫ Ethically neutral, a matter of personal choice.
▫ Ethically obligatory or required, provided that
other moral obligations are not more or equally
important important.
• Is there enough information to decide?
Case: Unequal OT Services-4
Ethical Obligations-2-Core Issues
• Are OTs professionally obligated to work toward
elimination of social inequalities that adversely
affect population health or to serve
disadvantaged groups? Examples:
▫ Activism or advocacy to change policies and
enhance services, environments, and other social
factors that advance health
▫ Collaborative leadership and partnering
▫ Voluntary or lower-pay services
OT Professional Obligations
Social Influences, Inequitable Services
• Equal moral worth
• Respect for persons
• Social justice
▫ Sufficiency of health: part of well-being
• Care
• Solidarity
OT Professional Obligations
Social Influences on Health
•
•
•
•
Social contract
Societal benefits
Reciprocity
Society’s main focus on health
OT Professional Obligations
Social Influences on Health
• Obligation to address “upstream” social
influences on health
• Options
▫
▫
▫
▫
▫
▫
Help plan new center
Advocate for additional funding
Promote community partnering
Build colleague coalitions
Provide voluntary service
Many others
Moral Theories
•
•
•
•
Justice
Consequentialism/utilitarianism
Feminist
Rights
Relationships in Ethics-Conception 1
Theory
Principles,
values
Codes
Relationships in Ethics-Conception 2
Theory
Rights
Principles,
Values
Codes
Relationships in Ethics-Conception 3
Theory
Principles,
values
Cases
Codes
Intersections: Moral Theories
Justice
Consequentialism/Utilitarianism
Core Ethical Concepts for Theories
• All people have equal and significant moral
worth.
• Equal worth means that all are due equal
respect.
• Respect includes honoring dignity, empowering
those with inferior capability, extending
recognition, and enabling autonomous choices.
Ethical Theory:
Utilitarianism/Consequentialism
• What is right to do what maximizes the net good.
• Net good: sum of all benefits less all harms
• “Equalitarian”
▫ Everyone’s good counts equally
▫ Everyone’s outcomes matter
▫ Same outcomes matter equally
Ethical Theory: Utilitarianism/Consequentialism
Problematic Features
• Problematic description: greatest good for the
greatest number.
• Can imply sacrificing some interests or even
persons for the great good.
Ethical Theory: Feminist Theory
Some key elements
•
•
•
•
We function in relationships
Care considerations are pervasive
We are or will be dependent
Structures by default reflect ways to maintain
power differences, including by gender (add
race/ethnicity, culture, and others)
• Styles of discourse, exchange, and/or expression
often maintain power relationships.
Ethical Theory: Rights
• Legal rights
• Ethical rights
▫ Derived from ethical theories and principles
▫ Intrinsic, such as by virtue of our humanity
• Political traction issues
Conclusions: Race/Ethnicity, Health, Healthcare
• R/E inequalities or disparities are:
▫ Common
▫ Generally unjust and inequitable
▫ Reflect lack of




Respect
Justice
Care
Solidarity
Conclusions
Race/Ethnicity, Health, Healthcare
• OT (and other) practitioners are professionally
obligated to:
▫ Understand the extent of such inequalities
▫ Spend part of their time addressing these
disparities, including upstream causal factors in
society
▫ Work toward quality improvement of their care
and that of their system/institution.
References: Race/Ethnicity and Healthcare
• AHRQ. Agency for Healthcare Quality and Research. National Healthcare
Disparities Report, 2009. Key Themes.
http://www.ahrq.gov/qual/nhdr09/Key.htm. (Accessed 13Nov2010)
• Bass-Haugen JD. Health disparities: Examination of evidence relevant for
occupational therapy. Am J Occup Ther. 2009; 63(1):24-34.2.
• Braveman B, Bass-Haugen JD. Social justice and health disparities: An evolving
discourse in occupational therapy research and intervention. Am J Occup Ther.
2009; 63(1):7-12.3.
• Braveman B, Suarez-Balcazar Y. Social justice and resource utilization in a
community-based organization: A case illustration of the role of the
occupational therapist. Am J Occup Ther. 2009; 63(1):13-23.
• CDC 2010. Office of Minority Health & Health Disparities. Disease Burden &
Risk Factors. http://www.cdc.gov/omhd/AMH/dbrf.htm (Accessed
04Dec2010)
• Chartbook, Health, United States, 2009.
http://www.cdc.gov/nchs/data/hus/hus09.pdf (Accessed 04Dec2010)
• Crossing the Quality Chasm: A New Health System for the 21st Century.
Institute of Medicine (IOM). Washington D.C.: The National Academies Press,
2001. http://books.nap.edu/openbook.php?record_id=10027&page=R1
(Accessed 12Nov2010)
• Dula, Annette and Stone, JR. “Wakeup Call: Healthcare and Racism,” Hastings
Center Report. 2002; 32(4):48.
References: Race/Ethnicity and Healthcare
• Slater, Deborah Yarett. (Ed.) The Reference Guide to the
Occupational Therapy Code of Ethics. AOTA Press. 2006.
• IOM 2003: Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. Institute of Medicine. Smedley BD, Stith
AY, Nelson AR (Eds). Washington D.C.: The National Academies
Press, 2003.
http://www.nap.edu/openbook.php?isbn=030908265X (Accessed
12Nov2010)
• Stone JR and Dula A. “Race/Ethnicity, Trust, and Health
Disparities: Trustworthiness, Ethics, and Action.” Book chapter,
Cultural Proficiency in Addressing Health Disparities. Editors:
Kosoko-Lasaki S, Cook CT, O'Brien RL. Sudbury, MA: Jones &
Bartlett, 2008, pp. 37-56.
• Tervalon M, Murray-Garcia J. Cultural humility versus cultural
competence: A critical distinction in defining physician training
outcomes in multiculural education. J of Health Care for the Poor
and Underserved. 1998; 9(2):117-125.
• .Weinick, Robin M; Flaherty, Katherine; Bristol, Steffanie J.
Creating Equity Reports: A Guide for Hospitals. The Disparities
Solutions Center, Massachusetts General Hospital, 2008.
http://www2.massgeneral.org/disparitiessolutions/z_files/Disparities%20Hospital%20gui
de.qxp.pdf