Term 1 Flashcards
White hemography
est. privilege, power and land ownership
Early social definition of Race Classification
Membership of N. Am, Europeans, and Blacks all based on social circle, appearance and non-white ancestry
blood quantum theory
one drop of blood- you=african decent
preserved labor force and black oppression
early views on race
marginalized N. Americans, helped lead to the power difference and removal of certain populations (Jewish, mentally disabled)
rule of hypodecent (english common law)
race of father determined the race of child.
black mother + white father=white child
Created a dynamic power- marginalization can occur VERY quickly (jr. high kids ex)
Hypodescent order
est mixed-race children as lower class, ignored kinship created a CAST SYSTEM- children of slaves born into low class roll (ignored common law)
Definition of White
less than 1/8 Black (before Civil War)
early expansion in US
led to further marginalization of N. Am
were given smallpox-infected blankets
forced migration
forced N. Am out of their homeland
Blacks forced into slavery, brought over during slave trade
Internal Migration
1 Underground Railroad-AA moved north for freedom
2 Post WWI- more AA moved north
3 Urbanization- brought people north for jobs
4 dust bowl- forced people to leave affected states
5 AC- brought people south
Jim crow laws
colored phone booths-Oklahoma
separate lines for license plates-Mississippi
separate tellers at 1st Nat’l bank-Atlanta
couldn’t play checkers together-Birmingham
different Bibles for races-throughout the south
2012 US census
Form from US Census-classification according to socio/political backgrounds. Attempt to classify a wider range of races. White pop in Tx will be minority by 2050
geography and race
whites-majority race in every region
Midwest-whites 85%
South-AA 55%
Melting Pot vs Multi-Cultural
where you embrace your new culture and your own culture is just cherished. Society has become MULTICULTURAL. Primary cultures/beliefs embraced BEFORE American concepts.. Cultural beliefs/ practices affect communication-must be able abide by other persons beliefs
Care Provider Challenges
need to be aware of different beliefs, diets, death expectations (west-maintain life funct. others-death is natural)
WE need to provide culturally competent health care- based on the rate of satisfaction of patient care**
Cultural Competancy satisfaction
WE must understand what factors contribute to satisfaction (religion,language, traditions, expectations and Belief practices)
factors of trust
societal racism
Experiences with discrimination
Prior experiences with system of others with providers, hospitals and insurance carriers
distrust of hospitals/insurance plans
attitudes in healthcare
Non-white providers are of lower quality
Minority providers allowed to practice only on minorities
Common belief- takes longer for minorities to get accredited
Patient Selection practices
Patient selection preferences- (concordance or match)- race concordance= person is more knowledgable, better interpersonal communication/understanding is perceived.
typically patient more likely to interact with physician
Concordance
Lang & Race( highest concordance achieved when races match)
Concordance= better patient satisfaction (concordance with lang, race ethnicity etc). You are more likely to follow instructions and come back to the same place where you found concordance
diversifying the health workforce
Institute of Medicine-
URM under rep. minority- placed in settings of lower minorities for longer before they could receive their credits and pract elsewhere
minorities in the workforce
Minority persons tend to receive better interpersonal care from providers of their own race and ethnicity
ESL persons experience increased understanding and greater likelihood of follow-up care with language concordant provider
service patterns hypothesis
Health professionals from minority/disadvantaged backgrounds- more likely than others to serve minority disadvantaged pop, improving access to care
Hypothesis is supported-more diverse medical community will help service those that are minority
Concordance hypothesis
AA children in US- looked at opinions of their parents- wanted access to quality care for child, concordance didnt matter as much. Concordance mattered for them as adults though
Increasing # of minority health professionals will increase opportunity for minority patients to see practitioner of own race or who speaks their primary language & understands their cultural practices
Trust in Healthcare
Greater diversity in health care workforce will increase trust in the healthcare delivery system among minority populations, and increase propensity to use health care services, improving healthcare outcomes.
Hypothesis holds to be TRUE
Professional Advocate Hypothesis
more diverse pop of care providers=more advocation for needs of those they serve
cultural competency training
Now must be accredited in CC for medical programs
will take time to diversify work force- edu, college, decision to stay in the field- as society becomes more diverse we need to be able to communicate b/c we cant diversify as fast as the society is
Patient Centeredness
Provider’s patient centeredness influences patient trust
how we interact with people we care for influences the trust process/ engagement of the patient. must keep cultural concordance in mind- more important w/ taking care of adults. Patient-centeredness=key for trust
Determinants of personal health
Biological-Genetics, Immunity, Nutritional status
Socioeconomic-Occupation, income, Family, social networks, Self-esteem
Behavioral-Risk-taking behaviors,Religious beliefs, Perceived susceptibility
Health disparity
health disparity- has different meaning for different people
Health field framework
endowed genetically w/ certain defects-determine whether low/high risk
social, physical environment play a role in already predetermined health
wellbeing becomes apparent-becomes feedback loop
exposed to vrus/disease-become well again and cycle reinstates BUT doesnt always happen that way
acute injury (MVC fire etc) and chronic disease affect us much more sig from a cost standpoint
Health field framework II
environments we are born into can determine our health cost standpoint
costs are also associated with our behaviors
Disparity as a definition -looking at person and enviroment
“Racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention. Institute of Medicine, 2002.
A particular type of difference in health closely linked with social, economic, or environmental disadvantage.” Healthy People 2020, DHHS, 2010.
Difference in outcomes
ANY DIFFERENCE FOUND- if also disadvantages person it is also considered a disparity. Cost 229 BILLION in 2006
Race, ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geography all contribute to an individual’s ability to achieve good health.
Social determinants I
Employment - Unemployment much higher among Blacks, Hispanics, and American Indian/Alaska Natives in 2010 with unemployed adults much less likely to report their health as very good or excellent
Social determinant II
Education - Highest percentage of adults not completing high school were Hispanic, persons below the poverty level, those with disabilities, and foreign born
Social determinant III
Nutrition - Persons living in rural census tracts were more often lacking a nearby food retailer (grocery store) within ½ mile
location is important but if below the poverty level, does not matter how close or far-do not have funds to buy what they need
Enviro hazard I
Air quality - Minorities, foreign-born persons and persons speaking a non-English language at home more likely to live near a major highway resulting in increased traffic-related pollution and elevated risks for adverse outcomes
exposure to poor air quality/ pollution, work related risk- higher among those who are less edu/ in lower skilled jobs
Enviro hazard II
Work-related risks - Hispanic persons, low wage earners, and foreign born are more likely to work in high risk occupation and an elevated I
less opportunity for advance/ lower wages= higher work related stress
Enviro hazard III
Mortality- Work-related death and homicide rates are highest for Hispanics, non-Hispanic Blacks and males.
high work stress linked to coronary heart disease, higher suicide/ traumatic injury rates
Behavioral risk I
Substance abuse - Binge drinking more common among persons 18-34 years of age, men, Whites and persons with higher household incomes
need resources to alcohol and drugs-typically misused among higher income
Behavioral risk II
Teen pregnancy - Birth rates among Black and Hispanic teenagers double that of other groups
Behavioral risk III
Smoking - Cigarette smoking rates remain high in persons of low socioeconomic status
less money people make- the Higher the chance that they smoke
Genetic link I
Infants born to black women are 1.5 to 3 times more likely to die than those born to women of other races/ethnicities.
Genetics II
American Indian and Alaska Native infants die from SIDS at nearly 2.5 times the rate of white infants.
Genetics III
African American men are more than twice as likely to die from prostate cancer.
Genetics IV
Hispanic women are more than 1.5 times as likely to be diagnosed with cervical cancer.
Genetics V
Hispanics, African Americans, American Indians and Alaska Natives are twice as likely to have diabetes.
minorities tend to be at higher risk for genetic issues
huge increases in obesity in youth, esp in minorities
Mortality
Rates of premature death from stroke & CAD higher in Blacks
Drug-induced deaths highest among Native Americans and Whites
Homicide rates highest in Black males
Motor vehicle-related deaths highest among Native Americans- alcohol link??
Morbidity
Periodontal disease -present in half of Black and Hispanic adults over 30
Tb rate remain high among racial/ethnic minority groups
Obesity increased significantly in minority boys and men
Non-Asian racial/ethnic minorities experienced higher HIV rates
Morbidity/ mortality contin
N. Americans-higher alcohol consumption + higher MVC death %
periodontal disease-lack of access/money?
why more obesity in boys/men- we are more sedentary, no more PE in schools, increased consumption (sodas, food
CDH Example
Occurrence has much to do with social features of society
low income=higher stress=more likely to smoke=poorer heath. cant afford= even worse health
CDH example
Migrants trend toward the rates of country of adoption:
Age, gender, family history,
Smoking, obesity, High blood pressure,
High blood cholesterol, Diabetes,
Physical inactivity, High stress
Disparities facts
Blacks had worse access to care than Whites for one-third of measures, and AI/ANs had worse access to care than Whites for about 40% of access measures .
Poor people had worse access to care than high-income people for all measures; and low-income people had worse access to care for more than 80% of measures
Disparities facts
Asians had worse access to care than Whites for about 20% of access measures.
Hispanics had worse access to care than non-Hispanic Whites for about 70% of measures.
Quality of care disparity
Blacks received worse care than Whites, and Hispanics received worse care than non-Hispanic Whites for about 40% of quality measures.
American Indians and Alaska Natives (AI/ANs) received worse care than Whites for one-third of quality measures.
Quality of care disparity
Asians received worse care than Whites for about one-quarter of quality measures but better care than Whites for a similar proportion of quality measures.
Poor and low-income people received worse care than high-income people for about 60% of quality measures
Treatment measures
About half of all process and outcome measures showed improvement.
Of the quality measures related to treatment of acute illness or injury, more than 80% showed improvement.
Acute treatment measures
In contrast, only about 40% of quality measures related to preventive care and chronic disease management showed improvement.
Acute treatment includes a high proportion of hospital measures, settings which often have more infrastructure to improve quality.
Areas needed attention
Health care quality and access are suboptimal, especially for minority and low-income groups.
Overall quality is improving, access is getting worse, and disparities are not changing.
Areas in need of attention
Urgent attention warranted to ensure improvements in:
Diabetes care, maternal and child health care, and adverse events.
Disparities in cancer care.
Quality of care among states in the South.
Affordable care act
Est. Federal infrastructures to reduce health disparities
Transferred Office of Minority Health within DHHS to the Office of the Secretary
Established six individual Offices of Minority Health within the DHHS.
Affordable care act
Designated National Institute on Minority Health and Health Disparities.
Created an Office of Minority Health within CDCP to monitor trends and evaluate programs and initiatives.
first step- collect people and system to collect data to track disparities
may give better markers to how quality of health is improving/ decreasing
Expansion of Medicaid
Medicaid covers nearly 40 percent of African American and Latino children.
.
Expansion will costs at 100 percent in 2014 then lowering to 90 percent by 2020.
Expansion of Medicaid
All individuals eligible for Medicaid up to 133 percent of federal poverty level ($14,404 for an individual in 2009).
Of the 46 million people currently uninsured, 47 are living in household with incomes at or below 133 percent federal poverty guidelines
Insurance regulation
ACA prevents companies from denying insurance coverage to people who have pre-existing conditions or charging higher premiums.
survey showed that a good portion of people have been denied due to pre-exist condition
found that people would like to leave job but wont because afraid of losing insurance
Insurance regulation
Prohibits higher premiums based on gender and determining insurance rates and coverage according to race and ethnicity.
Since minorities disproportionately affected by chronic conditions including, diabetes, heart disease, and cancer, this will be a significant factor in obtaining health insurance coverage
Health benefit exchanges
Create a marketplace for health insurance to provide choices to consumers in picking their health coverage
Fill the gaps for people who do not qualify for Medicaid or have employer sponsored insurance.
Health benefit exchanges
Provide premium assistance to individuals up to 400 percent of poverty level to ensure affordable options.
Hispanics and African Americans tend to have lower rates of employer sponsored coverage, making those groups more likely to take advantage of the new market created by health exchange
Summary thoughts
personal genetic makeup, environment, social environment and personal lifestyle- can all influence chance of disease
as a society we can moderate that but at current point, not making enough change
we will make change at a individual level- to maintain/minimize side effects of their current conditions
Communication facts
Less information given by providers to lower SES group patients
communication facts
Persons trained to ask questions and show assertive behavior received better care
communication facts
Provider IP skills more important than receiving health-related information
Perceptions of competence associated with interpersonal skills
Communication
you can train people to ask more effective questions
patient centeredness makes the info we convey more effective
communication
our competence judged by how well we can communicate-that we present ourselves well (correct pronunciation ect)
perceptions of our competance our based off our interpersonal disclosers
rationale of improvement
Despite improvement in the overall health of the majority of Americans, the burden of health disparities continues to disproportionately affect minority populations.
defining culturally sensitive
culturally sensitive- is different from competent (i.e. ability); sensitivity-refining a skill to identify a problem
assesment-make others aware of different practices spread knowledge about patient centeredness
we must have skills to care for people but its HOW we deliver those skills that makes us effective
Key strategies for enhancing competence
solutions -recruit and train more diverse workforce but what about those already present?
need to enhance CC/ sensitivity of those already in the field to improve care
key concepts for increasing competency
Enhancing cultural competence
& Expanding diversity within the health professions
Most cited strategies for decreasing health disparities for persons of color and ethnic/cultural minorities
professional competence
“The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice to benefit the individual and community being served”
Epstein & Hundret, JAMA, 287(2): 2002, p226
professional competence
Cultural competence should be part of our core professional competencies, rather than an isolated aspect of medical care
communication is key word added to JAMA statement
performance competence
C4.8: Physician assistants must demonstrate a … sensitivity to diverse patient populations…defined as…sensitivity and responsiveness to patients’ culture, age, gender, and disabilities (NCCPA)
A.2.3 Demonstrate an awareness of the humanity and dignity of all patients and related individuals within a diverse and multicultural society (NCOPE).
educational expectations
The curriculum must include instruction on multicultural issues and their impact on patient care. (ARC-PA Standard B6.01, 2010)
The curriculum must provide instruction that emphasizes respect for self and others, adherence to concepts of privilege and confidentiality, and a commitment to the patient’s welfare? (ARC-PA Standard B6.02, 2010)
educational expectations
competency statement not that prescriptive- expectation but doesnt tell you how to do it
legal
“No person in the United States shall, on the grounds of race, color, or national origin be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination” under any federally supported program (Civil Rights Act of 1964)
legal
US Office of Civil Rights extends this protection to language, viewing inadequate interpretation as a form of discrimination
CA of 1964 drives the legislation of language and communication skills
we may not deny someone b/c of lang barrier- obligation to provide interpreter if you use government dollars-w/o providing they can deny you
ethnocentrisim
Syndrome of attitudes and behaviors
See own in-group as virtuous and superior and out-group as contemptible and inferior
Cooperative relations with in-group, absence of cooperative relations with the out-group
ethnocentrism
Underpinning for ethnic conflict, war, consumer choice and voting
In-group favoritism or out-group hostility
privilege- impact on being in ‘in’ vs ‘out’ group. In group has control of the resources, if out group doesnt like it- not too much is done (tribes in Africa and Iraq ex-creates prob in society)
Favoritism does occur
muslim patient 1
language, traditions, practices differences
always ask for preferences and accommodate if possible (TCH patient, child, with mother) wanted the physician to knock and announce gender before entering- they did not- distrust was established-patient centeredness was forgotten at that moment
culture and encounters
initial visual impressions-form a lot of attitudes
patient #2 South-east asian
in a nursing home and wheelchair:
South-east Asian, although it doesn’t match current last name.. is she immobile or just weak?
if she entered US as older adult (70-80) don’t usually learn the lang