Emergent Diversity in American Communities
The changing demographics of the United States provide one of many compelling reasons for healthcare providers to consider the impact of cultural factors on health, disease, and healthcare. The population is increasingly diverse–aging, coming out, immigrating, and acculturating (Box 64-1). Currently, minorities represent one-third of the US population. Projections indicate that the United States will be a “majority-minority” nation by 2042, with the nation projected to be 54% minority in 2050 (Box 64-2).
Box 64-1:Terms to be familiar with ||Download (.pdf) Box 64-1:Terms to be familiar with
Culturally and Linguistically Appropriate Services
Services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of size) at every point of contact.
A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; sexual orientation or other characteristics historically linked to discrimination or exclusion.
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 healthcare disparities.
Box 64-2:A cautionary word about the term minority ||Download (.pdf) Box 64-2:A cautionary word about the term minority
|The term minority is often used with little consideration for its connotations. People feel uncomfortable with this reference because of its implied status of inferiority. A clear example expressed by an Hispanic patient toward her caregivers is the following. She states, “I felt weak, small and irrelevant when they used the term to talk about me among themselves. It sounded like they were being derogatory, which made me feel more powerless than I already was.…” Alternative terms have emerged in both the medical and lay literature, such as people, or communities of color, more defined country of origin delineations, or allowing patients to offer their own identification. |
Health and Healthcare Disparities
The performance of the US healthcare system reveals significant inequities across populations with missed opportunities in terms of preventing disease, disability, and morbidity and mortality indices. Disparities in health and healthcare are due to a complex interaction between many factors, from those that increase exposure to disease to those that decrease access to healthcare. The trends reveal that individuals from communities of color are in poorer health, face greater challenges in accessing care, experience significant navigation problems within the system, and receive a quality of care that is inferior to that of their nonminority peers. Individuals with limited English proficiency and low health literacy skills have also experienced lower-quality healthcare.
Examples of disparities include the following:
African Americans are 3 times more likely to die from asthma than non-Hispanic whites. Asian American adults are less likely than white adults to have heart disease; they are also less likely to die from heart disease.
Lesbians are less likely to obtain preventive services for cancer.
Family physicians should factor in population health, socioeconomic status, and structural barriers, such as number and location of public health centers, pharmacies, and hospitals that may not be easily accessible. Other factors to consider include access to fresh foods, transportation, adequate housing, and recreation, which also contribute to overall health and well-being. These ecological determinants influence health and disease prevalence, but are rarely included in patient histories. Expanding the biopsychosocial model to include ecological factors provides a larger contextual model to evaluate patient’s health risks, susceptibilities, and health outcomes. Asking salient questions that reflect the patient’s broader living situation is a more effective approach in guiding healthcare decisions and health interventions.
CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. Am J Public Health. 2010; 100(3):489–495.
et al.. Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest. Am J Public Health. 2010;100(3):460–467.
RC. Educating clinicians about cultural competence and disparities in health and health care. J Contin Educ Health Prof. 2011;31(3):197–207.
et al.. The Commonwealth Fund: Why Not the Best? Results from the National Scorecard on US Health System Performance. The Commonwealth Fund on a High Performance Health Care System; Oct. 2011.
et al.. Measuring social determinants of health inequalities: the CADH Health Equality Index. In: Hofrichter
R. Tackling Health Inequalities through Public Health Practice. Theory to Action. Oxford University Press; 2010.
Theorizing Health and Illness Causation and Establishing the Therapeutic Relationship
Health and disease are interrelated dynamic processes. Definitions of both include biomedical, social, ecological, spiritual, and psychological constructs. Illness is a socially influenced condition and must be viewed within the socially recognized reality defined by the patient. Illness causation and etiologies influence the physician-patient interaction, and a culture-centered approach to care encourages physicians to offer solace and relief from the patient’s viewpoint and experiences. There is a power differential with every clinical encounter, which impacts the physician-patient alliance. Medical and psychological problems are managed within this context and require the physician to mediate this imbalance through various techniques. These include affirmations and strengths that the patient may exhibit through healthy behaviors, lifestyle choices, beneficial existential cultural beliefs, and practices that advance health.
Family medicine offers helpful strategies through supportive and intentional counseling, such as motivational interviewing, which encourages affirmations and self-reflections that are patient-directed. Other skills that empower patients include expressing empathy during the encounter and exhibiting a practice style that encompasses and appreciates diversity. Physician attributes such as eliciting the patient’s goals and projecting a willingness to negotiate care options and patient preferences has been shown to increase visit satisfaction and adherence to treatment. Although time constraints create limitations on patient interactions, these activities do not add significantly to the length of the visit and do improve overall quality of care. Finally, cultural humility, a process of continual self-reflection, awareness, and growth in learning about diverse populations, change, and the relational dynamics between patients and physicians, is crucial to providing a mutually effective partnership in practice.
Explanatory Models of Health, Illness, and Care
Patient-centered care focuses on engaging patients and their families in the care management plan and healthcare decision making. Health advocacy is linked to this model of care and encourages patients to be actively involved in the design and planning of their own healthcare delivery, in addition to the larger medical system. Attributes associated with patient-centered care mirror some of the tenets of culturally competent care. They include care that is “whole-person”-focused; encourages patient empowerment and engagement; and emphasizes communication and coordination that is sensitive to the patient’s linguistic level, personal preferences, cultural strengths, and values. The foundation for these principles is derived from Engel and Roman’s biopsychosocial model, which maintains the patient’s human dimension as the central focus to the medical encounter. Physicians are required to go beyond the traditional reductionist biomedical approach and incorporate cultural variables regarding family and community, health beliefs, and expectations in the therapeutic process.
Engel’s biopsychosocial approach recognizes the complex interactions between healthcare delivery and the patient’s beliefs and behaviors concerning wellness, illness, and disease. It is supported and enhanced by the clinical lessons offered by Kleinman’s explanatory model, a tool for physicians to aid in providing culturally competent care. The model is elicited through open-ended questions, originally eight questions, focused on how patients perceive their illness state, their beliefs regarding causality, and perceived forms of treatment. This information provides contextual data, which strengthens the therapeutic alliance and informs the physician regarding diagnosis and management. The advantages in using this approach have been validated through qualitative and quantitative research that enriches medical practice as well as population health. Practical applications give physicians a living illness experience associated with their patients. It also provides information about sick roles and behaviors that are linked to care in various scenarios covering social health issues, including HIV-AIDS, domestic violence, and other community ills.
Mental and Behavioral Health
Mental health can be seen as the result of the complex interactions between biological, psychological, social, and cultural factors. The influence of any of these factors can be stronger or weaker depending on the illness or disorder. Cultural and social factors can affect a patient’s belief as to symptom causation and inform their reaction and reception to a diagnosis of mental illness.
Despite its prevalence in all cultures, mental health can carry with it a significant amount of shame and stigma around a diagnosis. In other cultures, acknowledging the illness can have consequences on the perception of the entire family. Cultural and religious communities have the power to demystify mental illness, while assisting and supporting individuals and their families.
Because of the complexities that exist around mental illness, numerous disparities exist and persist in culturally diverse communities. The US Surgeon General’s report on mental health found the following:
Minorities have less access to, availability of, and receive mental health services.
Minorities in treatment often receive a poorer quality of mental healthcare.
Minorities are underrepresented in mental health research.
Racial and ethnic minorities collectively experience a greater disability burden from mental illness than do whites; this higher level of burden stems from minorities receiving less care and poorer quality of care, rather than from the fact that their illnesses are inherently more severe or prevalent in the community.
Application of Cultural Information and Skills in Clinical Interactions
Several tools that are available to family physicians can provide guidance in interacting with patients and incorporate cultural elements as part of the clinical assessment. Beginning with the Berlin and Fowkes’ LEARN model (Box 64-3), others have been developed, including the BATHE, ESFT, ETHNIC, and CRASH frameworks. They provide the patient an opportunity to engage and elaborate on signs and symptoms from their cultural perspective.
Box 64-3 ||Download (.pdf) Box 64-3
Listen to patients’ perspectives.
Explain medical views.
Acknowledge similarities and differences.
Recommend a course of action.
AR. Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep. 1999;1(6):482–488. [ESFT mnemonic]
H. Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60(5): 545–553.
Institute of Medicine. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. IOM, Committee on Communication for Behavior Change in the 21st Century: Improving the Health of Diverse Populations. IOM; 2002.
JE. ETHNIC: a framework for culturally competent clinical practice. Patient Care. 2000;9(special issue):188. [ETHNICS mnemonic]
et al.. Patient-centered decision making and health care outcomes. An observational study. Ann Intern Med. 2013;158(8).