Cultural Competence in Women s Health: Implications for Cardiac Risk Factors and Disease JudyAnn Bigby, M.D.
Goals Describe disparities in women s health relevant to heart disease Describe factors that contribute to disparities Review an approach to achieving cultural competency Review relevance to heart disease prevention in women
Leading Causes of Death Among Women American Indian/Alaska Native heart disease, cancer, injuries, DM, CVD, liver disease Hispanic heart disease, cancer, CVD, DM, injuries, respiratory disease Black heart disease, cancer, CVD, DM, injuries, kidney disease Asian/PI cancer, heart disease, CVD, DM, injuries, respiratory disease White heart disease, cancer, CVD, respiratory disease, influenza, Alzheimer s disease
Age Adjusted Mortality Rates from Major Causes of Death AI/AN Black Asian/PI Hispanic White 300 290.4 Deaths per 100,000 250 200 150 100 138.3 121.6 146.6 218 200 172.1 109.1 104.1 101.4 78.1 59.6 50 38.3 48.2 36.3 0 Heart Disease Cancer Cerebrovascular Disease
Trends in Use of CABG in Elderly Jha AK et.al. N Engl J Med 353;683-91
Trends in Use of CEA in Elderly Jha AK et.al. N Engl J Med 353;683-91
Sex and Race Differences in Management of MI No change in differences in the use of reperfusion therapy and coronary angiography by sex and race between 1994-2002 Reperfusion therapy RR for white women, black men, black women.97,.91,.87 compared with white men Coronary angiography RR for white women, black men, black women.91,.82,.76 compared with white men Vaccarino V et.al N Engl J Med 2005;353:671
Overweight and Obesity in Women Aged 18 and Older Percent 50 45 40 35 30 25 20 15 10 5 0 45.3 34.5 31.6 32.7 31.7 29.7 27.3 26 27.3 14.5 Total White Black Hispanic Other Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey
Age-Adjusted Prevalence of Diabetes Mellitus in U.S. Population 12 11.4 Prevalence (%) 10 8 6 4 5.4 7.6 8.1 4.7 9.5 2 0 Men Women Non-Hispanic Whites Non-Hispanic Blacks Mexican Americans
Percentage of Obese Adults by Sex and Race and Ethnicity, Massachusetts 50 Percentage 40 30 20 10 0 18 15 White, non- Hispanic 21 31 Black, non- Hispanic 17 19 Hispanic 8 ** Asian, non- Hispanic men women Data Source: BRFSS, Mass DPH **insufficient numbers
Overweight and Obese Bostonians By BMI, based on self-reported height and weight Percent 70 60 50 40 30 20 10 0 62.4 55.6 45.8 42.6 10.7 Boston White Black Hispanic Asian Behavioral Risk Factor Survey, 1999. Data analysis by Boston Public Health Commission
Boston Adults with BMI > 25 by Neighborhood 70 60 50 40 30 66 61 58 60 58 55 55 53 49 51 46 48 35 38 41 35 32 Percent 20 10 0 Boston Back Bay Allston/Brighton Fenway East Boston Charlestown JP Hyde Park N Dorchester Matttapan Roslindale North End South Boston Roxbury South End S Dorchester West Roxbury Data source: BRFSS, Mass DPH Data analysis: Boston Public Health Commission Research Office
Percent of Women Exercising at Least Once Per Week 70 60 50 63 51 58 64 40 30 31 20 10 0 Hispanic US born Hispanic Immigrant Black Asian White Women of Color Health Data Book: NIH
What accounts for health disparities?
Factors Contributing to Disparities Individual Factors Social Context Access to Health Care Community and Environmental Factors Extent and Quality of Health Care Personal Health Behaviors
Access to Care
Women s Health Insurance Coverage, 2003 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 27.3 19.7 36.8 29.5 45.4 68.5 76.4 53.4 29.6 17.8 18.5 10.4 White Black Latina Asian U.S. Census Bureau, Current Population Survey Public Private Uninsured
Location of last medical check-up 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 17 3 7 27 38 80 66 51 White Black Latina Henry J. Kaiser Family Foundation Women s Health Survey ER Hospital clinic or health center Doctor's office
Women 18-64 Reporting Health Care Access Problems 35 30 25 24% 21% 32% 30% 20 15 10 5 0 All White Black Hispanic Commonwealth Fund Survey
Women 18+ Reporting Concerns about Quality of Care Percent 35 30 25 20 15 24% 21% 32% 30% 10 5 0 All White Black Latina Source: Kaiser Family Foundation. Women and Health Care: A National Profile, July 2005
Factors Contributing to Disparities Individual Factors Social Context Access to Health Care Community and Environmental Factors Extent and Quality of Health Care Personal Health Behaviors
Societal, Community, and Environmental Factors } Personal factors Sex Genetics Race Ethnicity (culture, language) Socioeconomic position (education, income) Attitudes and beliefs Preferences Health care literacy Health behavior Access to care Insurance Reimbursement level, OOP Public support Structure of health care Availability Appointments Organization (wrap around services) Transportation ANALYTIC FRAMEWORK FOR EQUITY IN HEALTH AND HEALTH CARE Health Care System Processes Visits Primary care Reproductive Health Specialty care Emergency Mental Health Oral Health Procedures and Treatments Preventive Diagnostic Therapeutic Expertise and competence of Providers Cultural competence Communication skills Medical Knowledge Technical Skills Bias Appropriateness of care Efficacy of treatment Patient adherence Outcomes Health status Mortality Morbidity Well-being Functional status Equity of Services Quality of Care Patient views of care Experiences Satisfaction Provider interactions Adapted from Cooper, et al. JGIM 2002;17:477
Intersection of Patient and Doctor Factors
Race and Health Care Kaiser, Commonwealth surveys report that >50% of blacks and Latinos and 20% of whites view racism in medicine as a problem Commonwealth Fund survey reports that blacks, Latinos, and Asians more likely than whites to report they have been disrespected by health care system due to race/ethnicity, language, or insurance
Effect of Race and Gender on Referral for Cardiac Catheterization. 1.00 White Male OR for referral to Catheterization*.. 1.00 (0.5, 2.1) Black Male 1.00 (0.5, 2.1) White Female. 0.4 (0.2, 0.7) Black Female 1.0 *Models include probability of CAD estimated after the results of ETT were known. Schulman KA, et al. N Engl J Med 1999;340: 618-26.
African Americans rate their physicians decision-making styles as less participatory than do whites 90 80 70 60 50 40 30 20 10 0 77.1 White Patient 73.9 African American Patient P=.007 59.3 56.6 Unadjusted Adjusted* *adjusted for pts age, gender, education, marital status, health status, length of pt-physician relationship, and patient gender Cooper-Patrick et.al, JAMA 1999 P=.02
Percent of respondents Involved in Care as Much as 90 80 70 60 50 40 30 20 10 0 Total Would Like to Be 75 78 White Black 73 Hispanic 65 Asian Amer Source: The Commonwealth Fund 2001 Health Care Quality Survey 56
The Doctor - Patient Interaction CULTURE, EDUCATION, KNOWLEDGE, GENDER, CLASS, SOCIAL STANDING, RACE... D FILTERS P PAST EXPERIENCE, RACE, CULTURE, EDUCATION, KNOWLEDGE, GENDER, CLASS... Assumptions Assumptions Doctor Behavior Patient Behavior Perceived Reality Perceived Reality Reality
Women s Learned Behaviors Withhold important information Delay presentation for care Don t follow recommendations Don t ask questions for fear of appearing ignorant
Physician Challenges and Learned Behavior Lack competence and fear being exposed Advocate more readily for patients with whom they feel a connection Code and label patients for expediency to get through quickly and keep moving Don t discuss differences Don t involve patient
Key Components of Cultural Competency for Individuals Cultural self-awareness Cultural knowledge (historic perspective, cultural context, epidemiological and biologic differences) Incorporation of cultural assessment into clinical encounters assess values, beliefs, and activities recognize that behaviors may be motivated by cultural views rather than by lack of knowledge
Key Components of Cultural Competency for Individuals Acknowledgment and recognition of the dynamics of difference Mastery of communication skills that enable providers to develop relationships with patients and their families regardless of English proficiency, literacy and other factors impacting language. Cultural desire (internal motivation)
The Doctor - Patient Interaction CULTURE, EDUCATION, KNOWLEDGE, GENDER, CLASS, SOCIAL STANDING, RACE... D FILTERS P PAST EXPERIENCE, RACE, CULTURE, EDUCATION, KNOWLEDGE, GENDER, CLASS... Assumptions Assumptions Doctor Behavior Patient Behavior Perceived Reality Perceived Reality Reality
Trust Building Behaviors Eye contact Don t appear rushed Ask personal questions Don t make assumptions Attention to cultural beliefs Respect different perspective Distinguish person as an individual Be responsive Make an effort to make patient feel comfortable Use understandable language Display genuine concern Listen to symptoms in the patient s style of telling Hold patient information as confidential Ask if satisfied with appointment Ask if patient understands Listen to questions Apologize when there is a problem Bigby, Cooper, Beck 2003 Soc Sci Med
RESPECT Respect - a demonstrable attitude involving both verbal and non-verbal communications. Explanatory model - What is patient s point of view? Sociocultural context - class, race, ethnicity, education, sexual norms and orientation, family and gender roles for example Power - power differential between patients and providers Empathy - putting into words the significance of the patient s concerns so patient feels understood Concerns and fears - eliciting the patient s emotions and underlying concerns of their symptoms Therapeutic Alliance/Trust - a measurable outcome that will enhance adherence and compliance RESPECT model developed by the Boston University Residency Training Program in Internal Medicine, Diversity Curriculum Task Force
Key Issues Cultural identity Communication verbal and nonverbal Gender roles Work issues Biologic differences High risk behavior Nutrition Pregnancy and reproductive health Mental health Spirituality Death and dying Health care practices attitudes about prevention, barriers to care
Factors Contributing to Disparities Individual Factors Social Context Access to Health Care Community and Environmental Factors Extent and Quality of Health Care Personal Health Behaviors
Low Birth Weight, by Education and Race/Ethnicity Boston 1996-2001 16 14 13.6 12.8 Percent 12 10 8 6 10.9 9.8 8.9 7.8 8 6.7 6.4 10.8 6.9 7 White Black Latina Boston 4 2 0 <HS HS+ Bachelor Degree+ Data analysis, Boston Public Health Commission
Infant Mortality, by Education and Race/Ethnicity Boston 1996-2001 14 12 11.2 12.4 Per 1,000 Live Births 10 8 6 4 5.2 9.6 3.9 5.7 4.2 4.7 6.5 3.4 5.6 4.6 White Black Latina Boston 2 0 <HS HS+ Bachelor Degree+ Data analysis, Boston Public Health Commission Differences among <HS not statistically significant Difference statistically significant between blacks with HS+ and all others and between blacks and whites and blacks and all Boston for Bachelor Degree+
Factors Contributing to Disparities Individual Factors Social Context Access to Health Care Community and Environmental Factors Extent and Quality of Health Care Personal Health Behaviors
Addressing Disparities in Obesity and Overweight Among Black Women Black women report fewer attempts at weight loss and for shorter duration compared to white women Components of moderately successful programs for black women Small groups with face-to-face social support Culturally tailored content Interactive learning
Social Action Theory Contextual Influences Motivation Social Interaction Generative Capabilities Problem Solving Cultural Influences Objectives Long-term dietary behavior change and maintenance Kumanyika SK, Ewart CK Diabetes Care 1990;13:1154-62
Promoting Change Recommendations for dietary changes have been made for more than 4 decades with little evidence of sustainable change Dietary choices are influenced by a variety of factors Knowledge of causative and preventive effects of certain foods Cost of food Availability of different foods
The Contextual Effect of the Local Food Environment on Diet Estimates of compliance with recommended food intakes to reduce atherosclerosis correspond to prevalence of supermarkets, grocery stores, and full and fast-food restaurants (Am J Pub Health 2002;92:1761) Black Americans fruit and vegetable intake increased by 30% with 1 supermarket in a census track and by 50% with 2 supermarkets White Americans fruit and vegetable intake increased by 11% with the presence of 1 or more supermarkets in a census track Fewer than 20% of grocery stores in East Harlem stock diabetic friendly foods compared to 58% of Upper Eastside stores (Am J Pub Health, September 2004) The cost of heart healthy food is more than what a food stamp award allows in Boston (Fulp)
Sister Talk Focus Groups Findings Black female identity Body image issues Communication styles Cultural symbols Family-centered Food preferences Physical activity practices Practical aspects of adherence Psychosocial stress Social connotations of eating and food preparation Social eating situations Social norms Social support for weight control Gans KM, et al. Preventive Med 2003;37:654
Sister Talk Approaches to Address Issues Use of ordinary women as role models Toll free number for feedback about show Emphasize improving healthy eating and benefits of physical activity over weight loss Encourage setting individual goals Testimonials from women on the street Ethnic dance as exercise Caring for self will allow better care of family Lower-fat makeovers of traditional foods Focus on moderate activities Role models for physical activities Hair care tips Teach stress reducing techniques Address environmental triggers Discussion of what constitutes social support Strategies for addressing nonsupportive behaviors Culturally acceptable alternatives for self-affirmation and support
Obesity and Obesity Management from a Community Perspective People don t become obese one person at a time Individual behavior exists within a social context Health behavior alone does not account for unequal burden of disease and death Approaches to overweight and obesity can not focus solely on individual behaviors but must consider broader approaches
It is not race or ethnicity per se but the social experiences of difference that help to shape particular value systems.