Health disparities refer to differences between groups of people. These differences can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death. Although the term “disparities” often is interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health.If a health outcome is seen in a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.It is important to recognize the impact that social determinants have on health outcomes of specific populations. Healthy People 2020 strives to improve the health of all groups.
http://www.diversitycouncil.org/toolkit/Activities_DiversityBingo.pdf1. Each square of the bingo worksheet lists a quality representing some dimension of diversity. 2. Participants meeting the description (e.g. a grandparent) may sign that box. 3. Have participants mingle, looking for others to sign each box. 4. Have participants stop after 7 minutes or when one person finishes. 5. To win, you must have a complete row of boxes (vertical, horizontal, or diagonal) signed by other players. 6. When time is called, have participants return to their seats and discuss the questions below. To raise awareness of perceptions and assumptions with regard to different dimensions of diversity. 1. What happened? (This is a broad question. Participants may answer in any way they like.) 2. How did you perceive others? 3. How were you perceived by others? 4. What assumptions did you make about other people? 5. What assumptions were made about you? 6. What did you hesitate to ask about? Why?
In 2008, approximately 33 percent, or more than 100 million persons, identified themselves as belonging to a racial or ethnic minority population.1 In 2008, 51 percent, or 154 million, were women.1 In 2008, approximately 12 percent, or 36 million people not living in nursing homes or other residential care facilities, had a disability.2 In 2008, an estimated 70.5 million persons lived in rural areas (23 percent of the population), while roughly 233.5 million lived in urban areas (77 percent) In 2002, an estimated 4 percent of the U.S. population aged 18 to 44 years identified themselves as lesbian, gay, bisexual, or transgender.4
Map from RHIN via: http://rhin.org/EmergingPopulations.aspx Map of Emerging Populations Burundi, Burma, Iraq, Congo, Eritrea, Somalia, Iran, Former USSR And others from Africa and Middle EastSeveral key distinctions:Refugee status is applied for outside the U.S., before the individual enters the country. Individuals are granted refugee status by the Bureau of Population, Refugees, and Migration and the Bureau of Citizenship and Immigration Services (Dept. of State/Dept. of Homeland Security) Since 1975, U.S. has resettled about 2.6 M refugees. Refugee: “a person who is unable or unwilling to return to his or her country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.” ~Immigration and Nationality Act Immigrant: chooses “to move in order to improve the future prospects of themselves and their families,” usually for employment or education opportunities.~United Nations High Commissioner for Refugees (UNHCR) websiteIndividuals seeking asylum status are already in the U.S. or a U.S. port of entry.Immigrants generally intend to relocate permanently; refugees generally anticipate being able to return to their own country at some point in the future. Immigrants are treated differently from refugees under international law.LGBTQ immigrants/refugees 2011 study: The most significant result of this study pertains to the lack of cultural competence and an overall deficiency in terms of cultural awareness when it comes to the specific needs of LGBTQ migrants.
Before the beginning of each fiscal year (late September or early October), the President (with Congress) establishes refugee “cap” and allocation (which countries they come from and how many). Presidential Determination: 2010 = up to 76,000 2011 = up to 80,000Top 6: California, Texas, New York, Florida, Arizona, Georgia from U.S. Dept. of HHS, Office of Refugee Resettlement, Administration for Children & Families On the last two years, Chicago metropolitan area has resettled approximately 5000 refugeesESOL lack of peer education, short duration of classes, lack of consideration for native language illiteracySeveral key distinctions:Refugee status is applied for outside the U.S., before the individual enters the country. Individuals are granted refugee status by the Bureau of Population, Refugees, and Migration and the Bureau of Citizenship and Immigration Services (Dept. of State/Dept. of Homeland Security) Since 1975, U.S. has resettled about 2.6 M refugees. Refugee: “a person who is unable or unwilling to return to his or her country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.” Immigrant: chooses “to move in order to improve the future prospects of themselves and their families,” usually for employment or education opportunities.Individuals seeking asylum status are already in the U.S. or a U.S. port of entry.Immigrants generally intend to relocate permanently; refugees generally anticipate being able to return to their own country at some point in the future. Immigrants are treated differently from refugees under international law.LGBTQ immigrants/refugees 2011 study: The most significant result of this study pertains to the lack of cultural competence and an overall deficiency in terms of cultural awareness when it comes to the specific needs of LGBTQ migrants.
Pesticide photo: http://vivalagourmand.wordpress.com/2010/08/17/pesticide-levels-in-nz-food-unacceptable/Woman photo: http://www.unhcr.org/4dfa11499.html Refugees experience a number of unique health issues:May be less likely to have health insurance and/or coverage may be inadequate.May not be current with immunizations (adults and children)May have been exposed to high levels of pesticide.May be suspicious of Western medicine and avoid treatment. May also have different view of alternative/complimentary treatments. Higher rates of malnutrition, infection, lead poisoning, and mental disorders.May have been victims of trauma (including violence) and high levels of stress.1) psychiatric disorders precipitated by the refugee experience2) infectious and parasitic diseases endemic to countries of origin3) chronic diseases endemic to host countries
Objects (such as the owl or other bird or prey) symbolize different things in various cultures. This tail art used at one time by Frontier airlines may actually be a symbol of death for Native American and some Latin American cultures. Another example is the white lotus flower – another symbol of death in many Asian cultures. The provider and the patient each bring their individual learned patterns of language and culture to the health care experience. (Office of Minority Health, “What is cultural competency?”)
1997: Many Health care providers have no knowledge of Hmong beliefsabout health and illness. The ideas of soul loss, spirit possession and object intrusion are completely foreign to Western health care providers. Treatments using herbs, soul- calling ceremonies and other Hmong health care practices are strange to health care providers.\\Although the Hmong believe that illness can be caused by a variety of sources--including eating the wrong food, drinking contaminated water, being affected by a change in the weather, failing to ejaculate completely during sexual intercourse, neglecting to make offerings to one's ancestors, being punished for one's ancestors' transgressions, being cursed, being hit by a whirlwind, having a stone implanted in one's body by an evil spirit master, having one's blood sucked by a dab, bumping into a dab who lives in a tree or a stream, digging a well in a dab's living place, catching sight of a dwarf female dab who eats earthworms, having a dab sit on one's chest while one is sleeping, doing one's laundry in a lake inhabited by a dragon, pointing one's finger at the full moon, touching a newborn mouse, killing a large snake, urinating on a rock that looks like a tiger, urinating on or kicking a benevolent house spirit, or having bird droppings fall on one's head--by far the most common cause of illness is soul loss. Although the Hmong do not agree on just how many souls people have (estimates range from one to thirty-two; the Lees believe there is just one), there is a general consensus that whatever the number, it is the life-soul, whose presence is necessary for health and happiness, that tends to get lost. A life-soul can become separated from its body through anger, grief, fear, curiosity, or wanderlust. The life-souls of newborn babies are especially prone to disappearance, since they are so small, so vulnerable, and so precariously poised between the realm of the unseen, from which they have just traveled, and the realm of the living. Babies' souls may wander away, drawn by bright colors, sweet sounds, or fragrant smells; they may leave if a baby is sad, lonely, or insufficiently loved by its parents; they may be frightened away by a sudden loud noise; or they may be stolen by a dab. Some Hmong are careful never to say aloud that a baby is pretty, lest a dab be listening. Hmong babies are often dressed in intricately embroidered hats (Foua made several for Lia) which, when seen from a heavenly perspective, might fool a predatory dab into thinking the child was a flower. They spend much of their time swaddled against their mothers' backs in cloth carriers called nyias (Foua made Lia several of these too) that have been embroidered with soul-retaining motifs, such as the pigpen, which symbolizes enclosure. They may wear silver necklaces fastened with soul-shackling locks. When babies or small children go on an outing, their parents may call loudly to their souls before the family returns home, to make sure that none remain behind. Hmong families in Merced can sometimes be heard doing this when they leave local parks after a picnic. None of these ploys can work, however, unless the soul-calling ritual has already been properly observed. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures Anne Fadiman1.7 million Cambodians killed by Khmer RougeKhmer rouge killing fields 1975-79: mostly intellectuals, physicians, professionalsLost boys of SudanIlliterate in native language
Photo from http://www.flickr.com/photos/mimk/2051140079/in/photostream The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is a United States-based not-for-profit organization that accredits over 19,000 health care organizations and programs in the United States. [wikipedia]The Patient-Centered Communication standards were approved in December 2009 and released to the field in January 2010. The standards will be published in the 2011 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook. Joint Commission surveyors will evaluate compliance with the Patient-Centered Communication standards beginning January 1, 2011; however, findings will not affect the accreditation decision. The information collected by Joint Commission surveyors and staff during this implementation pilot phase will be used to prepare the field for common implementation questions and concerns. Compliance with the Patient-Centered Communication standards will be included in the accreditation decision no earlier than January 2012. “ … more than a patients’ rights issue … critical to safety and quality of care” From presentation on “Advancing Effective Communication, Cultural Competence, and Patient-and-Family-Centered Care,” for South Florida Hospitals by The Joint Commission, August 6, 2010. Industry Collaboration Effort: ICE is a volunteer, multi-disciplinary team of providers, health plans, associations, state and federal agencies and accrediting bodies working collaboratively to improve health care regulatory compliance through education of the public. ICE volunteers include interested individuals from across the nation. http://www.iceforhealth.org/ http://www.iceforhealth.org/library/documents/ICE_C&L_Provider_Toolkit_7.10.pdf
Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. (Office of Minority Health, “What is cultural competency?”)Ann Fadiman, the author of this novel discusses Kleinman’s 8 question approach that attempts to understand the cultural infleunce of a disorder: The questions in this framework are: What do you call your problem? What name does it have? What do you think caused your problem? Why do you think it started when it did? What does your sickness do to you? How does it work? How severe is your sickness? How long do you expect it to last? What do you fear most about your illness? What are the biggest problems that your illness has caused for you? What kind of treatment do you think you should receive? What are the most important results you hope to receive from treatment
MeSH terms [e.g., refugees, pesticides, PTSD, etc.]Emigrants and ImmigrantsProvides a search of scholarly literature across many disciplines and sources, including theses, books, abstracts and articles. http://scholar.google.com/Also: abstract of article from Journal of Transcultural Nursing, “Finding information on immigrant and refugee health.”
MedlinePlus content derived from other sites, not created (i.e., web “portal”)MedlinePlus – Health Information in Multiple Languageshttp://www.medlineplus.gov/ Selected topics now in 47 languages other than EnglishAccessible directly from the homepageSearch by language or health topicStrict criteria for translationsChinese - Traditional (繁體中文)Aging, Medicines and Alcohol老年, 藥物和酒精 - 繁體中文 (Chinese - Traditional) PDF Bilingual Substance Abuse and Mental Health Services Administration Good Mental Health Is Ageless心理健康與年齡無關 - 繁體中文 (Chinese - Traditional) PDF Bilingual Substance Abuse and Mental Health Services Administration Korean (한국어)Aging, Medicines and Alcohol노화, 약물 그리고 술 - 한국어 (Korean) PDF Bilingual Substance Abuse and Mental Health Services Administration Good Mental Health Is Ageless한국어 (Korean) PDF Bilingual Substance Abuse and Mental Health Services Administration Russian (Русский)Aging, Medicines and AlcoholСтарение, Лекарственные Препараты и Алкоголь - Русский (Russian) PDF Bilingual Substance Abuse and Mental Health Services Administration Good Mental Health Is AgelessSubstance Abuse and Mental Health Services Administration Spanish (español) Salud de las personas mayoresVietnamese (Tiếng Việt) Aging, Medicines and Alcohol Tiếng Việt (Vietnamese) PDF Bilingual Substance Abuse and Mental Health Services Administration Good Mental Health Is Ageless Tiếng Việt (Vietnamese) PDF Bilingual Substance Abuse and Mental Health Services Administration Alcohol Alert: Alcohol and Minorities: An Update NLM: American Indian Health
All websites are authoritative, up-to-date, and many are NLM funded or part of a collaborative with NLM. RHIN is guided by a steering committee of refugee health professionals and health information specialists. Languages needed (based on 3 top countries of origin): Arabic/Kurdish (Iraq), Burmese (Burma/Myanmar), and Bhutanese/Dzongkha/Nepali (Bhutan). Cultural importance: emerging populations Ability to share resources
The role of the emergency system: When do I call 9-1-1? Call 9-1-1…1. for severe difficulty breathing, gasping for air and or choking on something. 2. for a convulsion. 3. for severe injuries, including deep or extensive cuts. 4. for serious reactions. 5. for a permanent tooth that has been knocked out. 6. for a child underwater more than a couple seconds. 7. for burns larger than the child's fist. 8. for exposure to smoke or toxic fumes. 9. For head injuries. 10. For loss of consciousness. Call the Poison Control Center if you have a suspicion your child has ingested any harmful substance: 1-800-282-3171
Example from “Clinical Pearl”: Ramadan – Reminder to Health Care Practitioners. “The fourth requirement of Islam is fasting during Ramadan … during fasting, Muslims avoid eating, drinking and smoking from sunrise to sunset. … The diurnal pattern of caloric intake is obviously reversed and diabetic schedule will have to be adjusted to accommodate this significant change.” via http://ethnomed.org/cross-cultural-health/religion/ramadan-practitioners In the fall of 2009 EthnoMed agreed to collaborate and integrate material from 24 Languages Project. Also options for contributing materials.
The purpose of DiversityRx is to improve the accessibility and quality of health care for minority, immigrant, and indigenous communities. We support those who develop and provide health services that are responsive to the cultural and linguistic differences presented by diverse populations.Cambodian Foods that Affect Blood Sugar: A Guide for Cambodian Patients
Pew Internet: People living with disability are less likely than other adults to use the internet. 01.21.2011So much of health care is moving online that many physicians assume that everyone uses the internet. According to the survey, there are good predictors of who may be looking for health information online. Groups with less than 50% of their population doing so include African-Americans, Latinos, adults living with a disability, adults age 65 and older, adults with a high school education or less, and adults living in households with incomes less than $30,000.By age, patients older than 65 are least likely to be online, yet they are the highest users of health care and are most likely to be managing chronic illnesses, Fox said. This group is most likely to seek traditional sources of information, such as their physicians, and say they don't need the Internet.Some surveys also have found that the use of mobile technology is more prevalent in minority communities. A 2010 Pew study found that nearly two-thirds of African-Americans (64%) and Latinos (63%) are wireless Internet users and are more likely than their white counterparts to own a cell phone. Additionally, black and Latino cell phone owners take advantage of a much wider array of their cell phones' data functions compared with whites.But Warner said it's not only lack of access keeping patients from using online information and tools. She said a big challenge is simply educating patients on available information and how they can use it. "Patients don't realize what it is they can get or what they even need," she said. "And each patient is different."
Health Information Translations provides education resources in multiple languages for health care professionals and others to use in their communities. Resources are easy to read and culturally appropriate.
Disaster culture” in many countries where prospects of war, drought, and other threats are constant and preparedness is a way of life. In a Somali community, spiritual leaders were the preferred source of information rather than TV or the Internet.“Everything is from Allah”Limited economic resources are barrierPTSD AsyleesLimited economic resources found to be a barrier to personal preparedness behaviors. “Why should we spend money to buy something that we might not use?” National Resource Center on Advancing Emergency Preparedness for Culturally Diverse Communities http://www.diversitypreparedness.org/Cultural Competency Curriculum for Disaster Preparedness and Crisis Responsehttp://minorityhealth.hhs.gov/templates/content.aspx?lvl=2&lvlID=12&ID=7986According to some experts, there are over 16 million immigrant children in the US, and many experts believe that in the future this segment of the US population will grow the fastest. In many cases, immigrant children are born in the US to parents who are from other countries. However, for some immigrant children, their status is complicated by the fact that they are born to undocumented parents.When children are born to non-US parents who have immigrated to the US illegally, the children face some unique challenges. They may speak one language at home, for example, and another at school. They may also be caught between two cultures. In many cases, extended family may still be back in the country of origin, meaning that children have fewer relatives nearby. However, children born to parents who immigrate to the US legally at least have access to schooling and other public benefits, since they have legal status.In some cases, children are sent to the US by themselves, often as part of human trafficking organizations. If they successfully enter the country, these children are often victims of abuse. In cases where immigration authorities intercept them, these children may spend prolonged periods of time in immigration detention or caught in the immigration system. In 2010 alone, more than 8,000 unaccompanied children were detained by immigration authorities.Some advocacy groups have been formed to help immigrant children. Among them is the Young Center for Immigrant Children’s Rights. The group advocates for children who are held in immigration custody and raises awareness about the plight of immigrant children. They help immigrant children in custody find attorneys and help immigrant children get assistance when they need it.Green card through marriage is a good option for both U.S. citizens and permanent residents. Children can also immigrate with the foreign spouse as long as they meet the eligibility requirements. One requirement: legally married…marriage not recognized by federal governmentTransgender immigrants face a broad array of legal issues, from obtaining legal status to securing immigration documents that correctly reflect their identity.Granted, the White House has taken some welcome steps in stopping the actual deportation of some spouses. Under new guidelines announced by the administration, immigrants whose husband or wife — including lesbian and gay spouses — is a U.S. citizen are considered “low priority” for removal. The specific inclusion of gay and lesbian spouses, however, has yet to be put into writing, and even when observed in the field, they do not provide any legal protections for families. As the Vermont lawmaker pointed out, spouse like Takako “will accrue unlawful presence,” which can make obtaining residency when laws do change even more challenging.
http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story.htmlChimamandaAdichie: The danger of a single story
Do you speak "health care"?
Do you speak“health care”? Jacqueline Leskovec, MLIS, MA, RN National Network of Libraries of Medicine Greater Midwest Region DSLC St Mary’s College 21March 2012
National Network of Libraries ofMedicine Greater Midwest Region Who We Are This project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services, under Contract No. HHS-N-276-2011-00005-C with the University of Illinois at Chicago.
ObjectivesParticipants will:• Understand the meaning of health disparities• Be able to identify 4 population groups affected by health disparities• Learn 4 resources for addressing health disparities
Health Disparities• Racial, ethnic, sexual & other minorities• Residents of rural areas• Women, children, the elderly• Persons with disabilities• Immigrants, refugees, asylees
Health Equality• [The] attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities. ~Healthy People 2020 HealthyPeople.gov
Factors• A high-quality education• Nutritious food• Decent and safe housing• Affordable, reliable public transportation• Culturally sensitive health care providers• Health insurance• Clean water and non-polluted air
Culture and Patient Health • Beliefs about objects, symbols, food, the body, blood, non- traditional medicine, etc. • Communication styles and norms • Role of relationships • Ways of learning new information • Role of translations and interpreters
Culture and Clinical Practice• Integrating cultural information into clinical practice o Things to watch: styles of speech, eye contact, body language• Industry Collaboration Effort o Better Communication, Better Care: Provider Tools to Care for Diverse Populations o http://www.iceforhealth.org/• New Joint Commission recommendations for hospitals, policy makers, and researchers
The 4 C’s of Culture1. What do you call your problem?2. What do you think caused your problem?3. How do you cope with your condition?4. What are your concerns regarding the condition and/or recommended treatment? ~The 4 C’s of Culture: A Mnemonic for Health Care Professionals
Scholarly Resources/Databases• PubMed o MeSH Terms• Google Scholar• CINAHL• PsycINFO
o MedlinePlus/MedlinePlus Españolo Health topicso Drugs & Supplementso Demographic Groups • Children and Teenagers • Men • Population Groups • Seniors • Women
RHINRefugee Health Information Network• http://www.rhin.org• Multilingual health information (more than 80 languages) for health providers, refugees and asylees• Large section on cultural guidance• Country Conditions Reports• Multiple formats (print, audio, video)
EthnoMed• http://ethnomed.org• Merged material from former 24 Languages Project• Background information on cultures and cultural competency• Patient education materials
DiversityRx• Improving Health Care for a Diverse World o http://www.diversityrx.org o Webinars o Cultural Competence o Conference
o http://www.healthyroadsmedia.org/o Multiple languages; multiple formats • Includes iPod video and multimedia
Health Information Translationso http://healthinfotranslations.org/o Health topics include Diagnostic Tests and Disaster Preparednesso Linked to from MedlinePlus!
Not just what you see…• Disaster Culture• Profiling/Prejudice: 9/11• Prior Health & Mental Health Issues• Children: over 16 million• Green Card Through Marriage o Gender Inequality http://www.us-immigration.com/Green-Card-Through-Marriage.jsp