Cultural Awareness, Health Cultural Awareness, Health Disparities, and Insurance Disparities, and Insurance

CoverageCoverageColorado Cover All Kids Initiative Colorado Cover All Kids Initiative

20102010

Tillman Farley, MDTillman Farley, MDSalud Family Health CentersSalud Family Health Centers

Fort Lupton, COFort Lupton, CO

BackgroundBackground

• Ethnicity and race are different– Hispanic is an ethnicity

• One culture can have several languages

• One language can span many cultures

Colorado PopulationColorado 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%

Languages spoken at home in Languages spoken at home in ColoradoColorado

• English 84%

• Spanish 12%

• 42 others 4%

The Problem…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

““While Colorado as a whole is a While Colorado as a whole is a healthy state, communities of healthy state, communities of color are disproportionately color are disproportionately affected by disease, disability, and affected by disease, disability, and death.”death.”

Racial and Ethnic Health DisparitiesRacial and Ethnic Health Disparitiesin Colorado 2005in Colorado 2005

Colorado Department of Public Health and Colorado Department of Public Health and EnvironmentEnvironment

Office of Health DisparitiesOffice of Health Disparities

Infant Mortality Rates, ’02-’06…Infant Mortality Rates, ’02-’06…

02468

1012141618

To put this in perspective…To put this in perspective…

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Colom

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Contributors to Health DisparitiesContributors to Health Disparities

• Genetics

• Poverty

• Low education level

• Lack of access to healthcare

• Racism – institutional and personal

What are we trying to achieve?What are we trying to achieve?

Good health!Access to healthcareInsurance coverage

HEY!! Don’t forget about

me!!

Uninsured PopulationUninsured Population

0%

5%

10%

15%

20%

25%

30%

35%

40%

White Asian Black Amer Ind Latino

“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 DisparitiesRacial and Ethnic Health Disparitiesin Colorado 2005in Colorado 2005

Colorado Department of Public Health and Colorado Department of Public Health and EnvironmentEnvironment

Office of Health DisparitiesOffice of Health Disparities

• Economic barriers• Geographic barriers• Insurance status• Language• Low literacy• Cultural Background• Immigration Status• Embarrassment• Lack of trust• Scams

Barriers to Health Care Access

• Discrimination– Including by health care providers

Say WHAT?!

Barriers to Health Care Access

Discrimination? By ME????Discrimination? By ME????

• Minority patients have significantly Minority patients have significantly poorer health status even when poorer health status even when controlling for socioeconomic statuscontrolling for socioeconomic status

• Institute of Medicine conclusion is that Institute of Medicine conclusion is that health care providers are partly health care providers are partly responsible for this health disparityresponsible for this health disparity

IOM Report 2002IOM Report 2002

• Ethnic minority patients perceive Ethnic minority patients perceive discrimination and disrespectdiscrimination and disrespect

• Particularly when the provider can’t Particularly when the provider can’t speak language in which patient is speak language in which patient is most comfortablemost comfortable

Survey of Latinos in ColoradoSurvey of Latinos in Colorado

• My doctor My doctor discriminates discriminates against meagainst me

• My doctor doesn’t My doctor doesn’t always respect mealways respect me

• My doctor can’t My doctor can’t speak my languagespeak my language 0

5

10

15

20

25

30

35

40

45

50

Lack of cultural Lack of cultural understanding, sensitivity and understanding, sensitivity and

competence plays a role in competence plays a role in health disparities.health disparities.

Cultural competence:Cultural competence:

• You can’t just take a class

• It’s an ongoing struggle

• No pain, no gain

Cultural ChauvinismCultural Chauvinism

• The implicit belief most of us have that our culture is best

• Defining the culture of the dominant group as “American culture”

NEW POLL: Plurality favor path to NEW POLL: Plurality favor path to citizenshipcitizenship

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.

What do Mexican immigrants want?What do Mexican immigrants want?

• To go home to Mexico To 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 For my kids to make something of their lives’lives’

• 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)

Three Tasks Towards Cultural Three Tasks Towards Cultural Competence:Competence:

• Develop awareness– Of your own culture as well as others– Of your own biases

• Acquire knowledge

• Develop and maintain cross-cultural skills

Evaluate your BiasesEvaluate 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/

Question your assumptions!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?

Health Beliefs: Which are true?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

What do you think?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.

Stage 1 of Cultural Awareness:Stage 1 of Cultural Awareness:

• My way is the only way

• Are there other cultures?

Stage 2 of Cultural Awareness: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=qxh4qY37Jdk

Stage 3 of Cultural Awareness: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

Stage 4 of Cultural Awareness:Stage 4 of Cultural Awareness:

• Creation of a new culture of shared meanings

• Requires repeated dialogue, good communication, creation of new rules

Common MythsCommon Myths

• I only need to be tolerant of things I agree with– The First Amendment myth

Common MythsCommon Myths

• We’re all the same underneath– The ‘skin deep’ myth

Common MythsCommon Myths

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

Opportunities to correct health Opportunities to correct health disparitiesdisparities

• Ongoing cultural awareness training

• Healthcare homes for everyone– Via meaningful insurance coverage– And a strengthened primary care

infrastructure