Alexander R. Green

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care.

Objectives. Racial/ethnic disparities in health in the U.S. have been well described. The field of “cultural competence” has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. Methods. The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers. Results. Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions— including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues—emerged to categorize strategies to address racial/ethnic disparities in health and health care. Conclusions. Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients

ContextStudies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions.ObjectiveTo test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes.Design, Setting, and ParticipantsAn internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient.Main Outcome MeasuresIAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire.ResultsPhysicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009).ConclusionsThis study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.

Interpreter services, language concordance, and health care quality. Experiences of Asian Americans with limited English proficiency.

AbstractBACKGROUND: Patients with limited English proficiency (LEP) have more difficulty communicating with health care providers and are less satisfied with their care than others. Both interpreter- and language-concordant clinicians may help overcome these problems but few studies have compared these approaches. OBJECTIVE: To compare self-reported communication and visit ratings for LEP Asian immigrants whose visits involve either a clinic interpreter or a clinician speaking their native language. DESIGN: Cross-sectional survey—response rate 74%. PATIENTS: Two thousand seven hundred and fifteen LEP Chinese and Vietnamese immigrant adults who received care at 11 community-based health centers across the U.S. MEASUREMENTS: Five self-reported communication measures and overall rating of care. RESULTS: Patients who used interpreters were more likely than language-concordant patients to report having questions about their care (30.1% vs 20.9%, P<.001) or about mental health (25.3% vs 18.2%, P=.005) they wanted to ask but did not. They did not differ significantly in their response to 3 other communication measures or their likelihood of rating the health care received as “excellent” or “very good” (51.7% vs 50.9%, P=.8). Patients who rated their interpreters highly (“excellent” or “very good”) were more likely to rate the health care they received highly (adjusted odds ratio 4.8, 95% confidence interval, 2.3 to 10.1). CONCLUSIONS: Assessments of communication and health care quality for outpatient visits are similar for LEP Asian immigrants who use interpreters and those whose clinicians speak their language. However, interpreter use may compromise certain aspects of communication. The perceived quality of the interpreter is strongly associated with patients’ assessments of quality of care overall.

Integrating Social Factors into Cross-cultural Medical Education

The field of cross-cultural medical education has blossomed in an environment of increasing diversity and increasing awareness of the effect of race and ethnicity on health outcomes. However, there is still no standardized approach to teaching doctors in training how best to care for diverse patient populations. As standards are developed, it is crucial to realize that medical educators cannot teach about culture in a vacuum. Caring for patients of diverse cultural backgrounds is inextricably linked to caring for patients of diverse social backgrounds. In this article, the authors discuss the importance of social issues in caring for patients of all cultures, and propose a practical, patient-based approach to social analysis covering four major domains—(1) social stress and support networks, (2) change in environment, (3) life control, and (4) literacy. By emphasizing and expanding the role of the social history in cross-cultural medical education, faculty can better train medical students, residents, and other health care providers to care for socioculturally diverse patient populations.

Seizure visits in US emergency departments: epidemiology and potential disparities in care

IntroductionWhile epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for “seizure” involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management.MethodsSeizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression.ResultsSeizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000–1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0–10.0), and children aged 1–5 years (7.4; 95% CI: 6.4–8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7–3.9], males (OR: 1.4; 95% CI: 1.3–1.5) and Blacks (OR: 1.4; 95% CI: 1.3–1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4–0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4–0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2–0.6) or Medicaid (OR: 0.5; 95% CI: 0.4–0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4–0.8).ConclusionSeizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.

Helping medical learners recognise and manage unconscious bias toward certain patient groups.

Medical Education 2012: 46: 80–88

Barriers to health promotion and disease prevention in the Latino population.

The Latino population of the United States is expected to increase substantially in the next 25 years. Although recent health promotion and disease prevention interventions have improved the health of the majority of Americans, the Latino community has derived less benefit from these advances. This is due to a number of interrelated factors, including a disproportionate representation of Latino Americans in the low socioeconomic strata and in the uninsured population. Even when insured, Latino Americans face significant barriers to health promotion and disease prevention. This policy analysis identifies barriers at the organizational and structural level of health care delivery, as well as at the level of the medical encounter. It provides a practical framework for intervention that is founded on the recruitment of Latino Americans into the health care workforce and leadership, the restructuring of health systems to be more responsive to the needs of diverse populations, and health care provider education on how to improve cross-cultural understanding and communication. By investing in a multifaceted approach that addresses barriers to health promotion and disease prevention in the Latino population, we can improve the quality of care delivered to this population and help eliminate racial and ethnic disparities in health care.

A Plan for Action: Key Perspectives from the Racial/Ethnic Disparities Strategy Forum

CONTEXT Racial and ethnic disparities in health care in the United States have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it. METHODS In 2006, the Disparities Solutions Center convened a one-and-a-half-day Strategy Forum composed of twenty experts from the fields of racial/ethnic disparities in health care, quality improvement, implementation research, and organizational excellence, with the goal of deciding on innovative action items and adoption strategies to address disparities. The forum used the Results Based Facilitation model, and several key recommendations emerged. FINDINGS The forums participants concluded that to identify and effectively address racial/ethnic disparities in health care, health care organizations should: (1) collect race and ethnicity data on patients or enrollees in a routine and standardized fashion; (2) implement tools to measure and monitor for disparities in care; (3) develop quality improvement strategies to address disparities; (4) secure the support of leadership; (5) use incentives to address disparities; and (6) create a message and communication strategy for these efforts. This article also discusses these recommendations in the context of both current efforts to address racial and ethnic disparities in health care and barriers to progress. CONCLUSIONS The Strategy Forums participants concluded that health care organizations needed a multifaceted plan of action to address racial and ethnic disparities in health care. Although the ideas offered are not necessarily new, the discussion of their practical development and implementation should make them more useful.

Primary Care Resident Perceived Preparedness to Deliver Cross-cultural Care: An Examination of Training and Specialty Differences

ObjectivePrevious research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents’ perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties.DesignCross-sectional, national mail survey of resident physicians in their last year of training.ParticipantsEleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%).ResultsMale residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty.ConclusionsAcross primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents’ preparedness to provide cross-cultural care.

The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management

ABSTRACTBACKGROUNDUncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients’ hypertension self-management have had lasting effects. Previous work has focused largely on patients’ beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients’ social contexts.OBJECTIVEThis study aims to explore how patients’ “explanatory models” of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.DESIGNSemi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.PARTICIPANTS (OR PATIENTS OR SUBJECTS)African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.APPROACHWe conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients’ explanatory models, social context and hypertension management behaviors.RESULTSPatients’ perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients’ daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.CONCLUSIONSDesigning interventions to improve patients’ hypertension self-management requires consideration of patients’ explanatory models and their daily-lived experience. We propose a new conceptual model — the dynamic model of hypertension self-management behavior — which incorporates these key elements of patients’ experiences.