global-ny.com
prime-access.com
Cross-Cultural
Competency in
US Health Care:
Reach Beyond Your Longitude.
TM
What you should know about
disparities, demographics, and disease
NovemBER 2012
02Overview
04
Looking at the Numbers
05
General Market Demographic Insights
06
The Hispanic Paradox
09
Diabetes and Hispanic Americans
10
Case Study: Venice Family Clinic
11
Race in a Post-racial America
12
Social Class in America?
13
African American Mothers and infant mortality
16
LGBT: Lesbian, Gay, Bisexual,
and Transgendered People
19
Patient-Physician Encounter:
Physician’s News excerpt
21
Where Are You on the Cultural Openness Scale?
25
Race, Ethnicity, Culture
26
Quiz: How Culturally Competent Are You?
35
Links and Bibliography
Foreword
by Anthony Marucci
What hasn’t already been said about the recent emergence
of the US cross-cultural population? Since the 2010
Census confirmed that Hispanic, African American, and
Asian American families have become the fastest growing
segment of our society, marketers have had to face the
reality that their lack of cultural fluency is now affecting
them where it hurts them the most—their bottom line.
The US health care system in particular—originally
designed as a one size fits all system—is faced with a
dual conundrum. A clear shift toward treating patients
as consumers has now been augmented with a culturally,
behaviorally, and linguistically different audience.
Over 100 million consumers experience health and
disease through a unique cultural lens composed of
family dynamics, lifestyle habits, chronic condition
prevalence, and language preferences, among others.
As an example, let’s look at the Hispanic patient audience
in the US. Out of 52 million Hispanics, 31% self-identify
as non acculturated, with limited English language
proficiency. Statistically, these patients are more likely
to have difficulty understanding health information and
communicating with doctors, resulting in a reactive role
when dealing with health care. The remaining two-thirds
of bicultural and acculturated US Latinos take on the
role of seeking out health information, interpreting it,
and guiding their family members through the health
care system. According to the Association of American
Medical Colleges (AAMC), nearly half of all US
Hispanics (46%) report having no regular doctor, not
getting all of the questions answered during their doctor
visits, and not having access to an interpreter when
needed. As a result, Hispanic patients continue to miss
scheduled appointments, fail to adhere to medication
regimens, and turn to the ER for care.
Recently, Global Advertising Strategies and Prime
Access—two cross-cultural marketing pioneers—
joined forces to form the largest independently owned
health care communications firm that focuses on
engaging with US Hispanic, African American, Asian
American, LGBT, and other diverse US audiences.
The newly formed agency brings an unprecedented
value to the changing health care market—from
patient education, community outreach and advocacy,
DTC awareness and acquisition, prescription to
OTC conversion programs, CRM analysis, and HCP
cultural competency, to the team of professionals whose
breadth of experience is based on their insights of the
health care industry dynamics as well as clinical and
behavioral cultural nuances across diverse audiences.
As a health care marketing veteran with over two
decades of experience, I do remember the good old
days of big name drugs, large campaigns, and high
profit margins. Today, we are looking at a more
intricate way of communicating with the health care
consumer—engaging with them on a more personal,
authentic level. Albeit complex at first glance, if done
correctly, it offers higher ROIs and develops deep and
long-lasting consumer relationships. The document
that follows is an assessment of how culture influences
our health care choices. As we say at the agency, it’s not
about cross-cultural marketing; it’s about marketing
to a cross-cultural America. Let’s get it done right!
02
Overview
No matter your country of origin, race, sexual orientation,
insurance status, or job status, any of these factors—even if
temporary—can make you a victim of unequal health care.
We are all vulnerable. Even as inequity has become more
apparent to many health care stakeholders, real and continued
disparity persists and seems intractable, no matter how many
initiatives, directives, programs, policies, or regulations
are enacted.
In this paper, we share current social thinking about crosscultural patients and the health professionals who care for
them. Through awareness and education, we seek to provide
you with intelligence that will help you conceive and plan
marketing and educational programs that bring health care
to all people—with a greater consciousness of cultural and
ethnic contexts.
Overview
The articles in this document encourage you
to reflect on the human toll of inequities.
What does it mean to be fully understood? And conversely, what does it feel like to be overlooked, misheard, or
miscomprehended? Imagine being sick or undergoing an unfamiliar procedure, or in any way transacting with
America’s complex health care system. Often we focus on one-way communication, but an effective experience
between HCP and patient is dynamic and needs to be reciprocal. A clinician’s inability to adequately decode a
patient’s nonverbal emotional expressions can contribute to patient dissatisfaction with the physician. Oftentimes,
this dissatisfaction is reflected in a patient’s failure or inability to comply and adhere to recommended medical
treatments.1 Satisfaction and empowerment should accrue to both members in this relationship. We discuss these
interactions in two case examples from the PBS series, Unnatural Causes.
You can read about a program in California for Hispanic patients with diabetes, and how the Venice Health Group
has significantly reduced complications by maintaining tighter glucose control.
We reprise an interview with Joseph R. Betancourt, M.D., M.P.H., director of the Disparities Solutions Center at
Massachusetts General Hospital, and an expert in physician cultural training.
Cultural competence needs to include aspects of gender and persons with disabilities, older adults, gays, lesbians,
bisexuals, and transgendered people. We highlight recent policy and institutional developments, and how these
will improve access and treatment—particularly for LGBT patients who are disproportionately affected in several
disease categories.
Elevating our own cultural competence can be a daily exercise. To that effect, we have included a self-test that
may further enlighten our readers.
The national conversation regarding health care over the past two years has occurred against a backdrop of a
contracting economy, an election year, Supreme Court hearings, and the passage and upholding of the Affordable
Care Act. The pharmaceutical industry was an important party to this major legislation. Now, at a time of fiscal
constraints and heated debate about scarce resources, how do we insure inclusiveness and maintain our
commitment to the health care needs of our diverse nation?
We are experiencing a dynamic industry period, marked by both exciting drug developments and disappointing
failures, patent losses, issues of access, costs, fragmentation, and increased demand from a growing aging
population. Could it be any more complex?
As daunting as the health care landscape is, we support you in your mission by specifically pushing for culturally
competent initiatives. The insights you gain will hopefully help you re-imagine your strategies in providing health
care efficacy to all of our citizens.
1
International Journal of Family Medicine Volume 2012, Article ID376907,5 pages doi:10.1155/2012/376907;
Physician Cross-Cultural Nonverbal Communication Skills, Patient Satisfaction and Health Outcomes in the Physician-Patient Relationship
Ken Russell Coelho and Chardee Galan
03
Looking at the Numbers:
Cross-cultural demographics,
demands, disparities
The 2010 US Census
As the most-referenced database, it quantifies the trends that help us grapple with
the shifts that are impacting the cultural lives of many Americans. The trends are
staggering—and tell us that cross-cultural intelligence is crucial to working with
these important segments that are becoming more critical by the day.
Hispanic culture is big
and getting bigger
Accounting for most of the US future population
growth, Hispanics have reached a plurality in some
states. This trend, also known as “majority-minority”
(the very terms will eventually become defunct),
includes Hawaii (77.1% minority), California (60.3%),
New Mexico (59.8%), Texas (55.2%), and the District of
Columbia (64.7%).1
Hispanics are the most populous minority, 52 million
in 2011—16.3% of the total US population—and have
increased 3.1% since 2010. According to the recent
Adweek report, California is the state with the largest
Hispanic population (14.4 million) and New Mexico
has the greatest percent of Hispanics at 46.7%.1
And as you’ve likely noted, this year’s presidential
candidates are sharply focused on reaching Hispanic
voters—giving further credence to their emerging
significance as a political block.
African Americans
are the second largest
minority in the US
At 42.3 million in 2011, up 1.6% from 2010. New York
has the largest population of African Americans, and
Texas has the largest numeric increase in one year (up
84,000) from 2010 to 2011.1
America’s age
The nation’s median age ticked up slightly to 37.3
years in 2011 (from 37.2). The ≥ 65 group increased
from 40.3 to 41.4 million and included 5.7 million
people ≥ 85 years. Maine had the highest median
age (43.2) and Utah the lowest (29.5). Florida had the
highest percentage of ≥ 65 (17.6%), followed by Maine
(16.3%). Utah had the highest percentage of total
population younger than 5 (9.3%).1
Asians are the second
fastest-growing group
Numbering 18.2 million in 2011, they grew by 3.0%
since 2010. California has the highest Asian population
(5.8 million) and the largest annual increase
(131,000).1
1
Adweek: The Start of Majority-Minority. Non-Hispanic Whites Now Account for Less Than Half of New Births.
http://www.adweek.com/sa-article/start-majority-minority-140665
04
General Market
Demographic Insights
Multicultural women: African Americans,
Asian Americans, and the Hispanic consumer
Our roles are changing for the better1
86% 90% 90% 94%
Asian
American
women
African
American
women
Caucasian
women
Hispanic
women
Women are caregivers: Make
it easier, less stressful for them
in the health care setting. They
are caregivers by nature….
Empower them with tools that
let them be effective. Recognize
them for their efforts and hold
them to a higher standard—
they are extremely capable and
resourceful.
“Value” is superior to “price”:
a product or service that satisfies
multiple “need states”—such as
time and convenience.
Like their counterparts in mainstream American culture,
multicultural women are the health care “providers” for the
family. In terms of marketing, women are the single most
powerful demographic target to reach. They wield the most
power in many household purchasing decisions. They take
the kids, and often their parents or other family members, to
the doctor, and care for sick relatives at home or in health care
settings. With all the dramatic changes that have occurred—in
family structures, ethnic diversity, and income—women believe
that their roles are changing for the better. 2
This optimism is rooted in the belief that they have had it better
than their mothers, and that the future is even brighter for
their daughters; this is true particularly among Hispanic and
African American women. Education is more accessible due
to technology, which their children easily adopt. Continued
educational strides improve financial stability. Women’s own
earning power in these groups has increased their belief that
they will be contributing even more to their household income
in the coming five years. (There was no increase in this
“optimism” measure for Caucasians or Asian Americans).
Women’s priorities are to pay off debt and/or increase general
savings, followed by groceries, vacations/holidays, and
clothes. Caucasian women in the study also included home
improvement and/or redecorating.
Women across the board experience stress in juggling their many
roles, but in Nielsen research it was highest among Asian American
women. For all women, how can we as health care marketers make
it easier, simpler, convenient, or time-saving for them?
Women are media-connected and are growing users of
smartphones, as they are regarded as a highly valuable tool
for communication and making their lives easier. Surprisingly,
Nielsen found that Caucasian women have much lower
smartphone ownership—33% vs. 61–65% of Hispanic, African
American, or Asian American women. The smartphone
becomes a way to manage health care and other commercial
transactions that can answer these women’s needs as they
conduct their daily lives. Television, internet, and word of
mouth are predominant media choices. A balanced approach
between new and traditional media is the ideal reach.
The Nielsen Company. Women of Tomorrow. US Multicultural Insights. November 2011. p2.
2
05
The Hispanic Paradox:
Becoming American
Mrs. Rodriguez, age 59, arrives with her daughter for her appointment at her primary care
center. Born in the Dominican Republic, and having brought her family to the United States
with her husband 15 years ago, she was diagnosed with type 2 diabetes and hypertension two
years ago. Mrs. Rodriguez takes care of her grandchildren so that her daughter can attend
school and work part-time for a small signage business. But today her daughter has taken
time off from work to go to the doctor with her. Her physician, as typical in this community,
is overworked, understaffed, and underpaid.
Nonetheless, he has scheduled 20 minutes with Mrs. Rodriguez today because he notes that on
her last visit her diabetes and hypertension were both uncontrolled. Mrs. Rodriguez is 59, too
young for Medicare, and has insurance through her husband’s job. Dr. Mike Alexander is 45
and is a family practitioner who shares the office with 3 other physicians—an FP, a cardiologist,
and a pediatrician—in addition to a nurse practitioner and a receptionist/office manager. “How
are you doing this morning, Mrs. Rodriguez?” She smiles, but her daughter speaks for her…
Steve Larson (Associate Professor of Emergency Medicine,
University of Pennsylvania School of Medicine) shares his
experience treating the immigrant migrant population in
Pennsylvania in the PBS series, Unnatural Causes: Is inequality
making us sick? In the 90s, he worked with the Mexican
population in Kimmet Square, PA. The myth among some
health workers was, “They’re always late, they’re always dirty,
and they all have infectious diseases.” His experience told
him they were way off. After crunching the health data for this
population, “Well, you’re actually quite wrong. These are young,
healthy people, for the most part. They’re not here to drain the
system. So that’s a myth!”
“After only 5 years in the US, Latino
immigrants are 1.5 times more likely to
have hypertension than when they first
arrive… and to be obese.”
Consider: outreach, nutrition, and
education, particularly for the children
who become “latch-key.”
And in California, Tony Iton (Director, Alameda County Public
Health Dept.): “(Our) data told us, in our health department, that
immigrant Latinos had the best health of anybody in the county
(Alameda), by far. They had the lowest rates of death, lowest
rates of heart disease, lowest rates of all the major killers. And
that was a startling finding to us. We couldn’t understand why
the poorest, most socially marginalized population actually had
the best health. Better health, not just than other poor people,
but better health than the wealthiest segments of our societies.
And that’s profound.”
Unnatural Causes: Is Inequality Making Us Sick? – Becoming American. Produced by California Newsreel with Vital Pictures. Presented by the National Minority Consortia.
Public Engagement Campaign in Association with the Joint Center for Political and Economic Studies Health Policy Institute.
06
The Hispanic Paradox
After a few years in the US, however, the data also show that
Mexican families lose their advantage within a generation.
“Instead of improving their health, life in the US often has the
opposite effect… they see their health advantages within a
generation undermined by the same social forces that erode
the health of all of us.”
As cultural experts, we know that Hispanic families are extended
and tight-knit. They bring a strong culture, a tradition, and a social
network that provides an immunity bubble. But with time, and
like many Americans today, two parents are working, kids are in
school, there’s less time for meals, and maintaining community
and close family ties has become increasingly difficult.
When stress increases,
optimism wanes.
Consider social media
tools that link to mobile
technology because
Hispanics “over-index” in
mobile and smartphone
adoption and use.
Uncover ways to support
worktime screenings.
There are two operating hypotheses for this paradoxically
positive effect for Mexican immigrants. One is that immigrants
who arrive here have on average better health than the ones
who stay in Mexico. But the other, more likely reason is related
to culture. According to Margarita Alegria (psychologist, Harvard
Medical School, Cambridge Health Alliance), “I think the other
explanation… is the role of very strong, cohesive family ties that
hold Latino families together, even under hardship; and these
very strong family ties facilitate people struggling through…
disadvantageous conditions.”1
In the last few years, researchers are looking at the idea of
“social isolation,” and trying to understand its role in health
trends among all American families. One manifestation of social
isolation is that one in four Americans says there is no one with
whom they can discuss important matters… that number has
tripled over the last 2 decades. Seminal research shows that
isolation can kill. Lisa Beckman (epidemiologist, Harvard School
of Public Health) says, “It was astounding. Overall, people who
are really isolated are at increased risk not only of CV disease,
but for infectious diseases, for diabetes, for strokes, for cancer…
Being isolated is a chronically stressful situation.”2
In Unnatural Causes, we learn that after only 5 years in the US,
Latino immigrants are 1.5 times more likely to have hypertension
than when they first arrive. And to be obese. Rates of heart
disease and diabetes also increase. According to Iton, the Public
Health Director of Alameda County, “Immigrant Latinos, as
they acculturate, as the stress levels accumulate, their children
start to lose that sense of why it is that they are here, they lose
that connection to their parent’s hopefulness. They become
more American, they acquire American habits, American diets,
American sensibilities. They’re gaining traction in the American
way of life, but they’re losing that hopefulness that their immigrant
parents brought with them that might actually be healthprotective.”2
Page 3 Unnatural Causes: Becoming American. www.unnaturalcauses.org
Ibid Page 4
1
2
07
The Hispanic Paradox
As a society, we can build hope. And we do that by giving people
access to those things that give them the potential for success: that’s
good education, access to good jobs, decent housing, and then a sense
of belonging to a community, belonging to
something larger than yourself, larger than
your family.
The potential right now is to try to take what we can see obviously in
new immigrant communities—the health protective benefits of being a
new immigrant—and understand and translate that into public health
interventions now that affect the broader community.
Anthony Iton (Director, Alameda County Health Dept.)
“See, these protective factors begin to wear down.
And then subsequently, over multiple generations, we
can anticipate that they’ll look increasingly just like the
American people as a population, because they live
here. They become Americans.”
Initiatives for migrant workers at three farms in
southeast Pennsylvania; the farms are coordinating
with La Comunidad Hispana, a social service agency,
to open clinics on site. Like almost half of America’s
workforce, these farm workers get no paid sick days.
“If nothing else,” according to William Vega
(psychiatric epidemiologist, David Geffen School of
Medicine-UCLA), “the paradox is putting a spotlight on
the fact that the US has very high levels of depression.”
He found that among immigrants who are here 13
years or less, the depression rate is very low—8%. For
US citizens, the rate is 18%–20% over their lifetime. But
for immigrants, these depression levels increased in
people who have been in the US over 13 years.
Margeurite Harris (Clinical Health Director, Project
Salud): “Workers don’t like to take time off… it’s money
not being earned.” They often do not seek health care
until symptomatic. Obesity is the main health issue
here. They conduct screenings for the spectrum of
chronic diseases arising from obesity.
By 2050, one in four Americans will be Latino.
“If well-being isn’t prioritized now, then what’s the
landscape of our country going to look like twenty,
thirty years from now?” asks Steve Larson.
08
Diabetes and Hispanic
Americans
(CDC 2012)
Diabetes and Hispanic Americans
In 2008, Hispanics were 1.6 times as likely to start treatment for end-stage
renal disease related to diabetes, compared to non-Hispanic white men.
In 2008, Hispanics were 1.5 times as likely as non-Hispanic whites to die
from diabetes.
Situation
Results
In response to the grave situation in New York and
around the country regarding diabetes incidence
among Latinos, Mount Sinai and the Hispanic
Federation partnered to launch the first Latino Diabetes
Awareness Day in New York City. Simultaneously,
a Latino diabetes public education campaign focused
on early detection, prevention, and proper care
was announced.
This initiative, along with a concentrated and targeted
plan of Latino initiatives throughout the year, resulted in:
Strategy
Engage and connect policy makers, health
professionals, activists, the media, and the community
at large.
A press conference was held on the Mount Sinai
campus, followed by a community briefing which
included participants from Mount Sinai, the Hispanic
Federation, the American Diabetes Association, HHS,
local and state lawmakers and key influentials.
The ¡Infórmate! ¡Examínate! ¡Cuídate! (Get Informed!
Get Tested! Get Healthy!) campaign unveiled, designed
to draw local and national attention to the diabetes
crisis; highlight healthy lifestyle choices; increase
diabetes testing in NYS, identify leading care and
treatment options; and encourage NY policy makers,
health professionals, and residents to respond more
forcefully and effectively. A public and media outreach
plan was implemented before, during, and after, to
ensure maximum exposure.
Mount Sinai being named #1 Hospital by El Diario
La Prensa readers, announced at Press Conference.
Over 100 attendees were present at the press
conference and community briefing, representing
hospital staff, steering committee members,
community-based organizations, and the National
Association of Hispanic Nurses, among other partners
and leading media vehicles, such as Telemundo, HITN,
NSN, Queens Latino, and El Diario La Prensa.
Over 140M impressions garnered in no-cost editorial
coverage in leading online, print, television, and radio
English and Spanish language media vehicles around
the country.
09
Case Study: Venice Family Clinic
Eliminating disparities in care: Diabetes
management among the Latino population
Project goal:
To effectively manage diabetes, prevent costly and painful
complications, and reduce unnecessary hospitalizations.
Reason for project:
Diabetes was prevalent in the Clinic’s patient population and
taking a heavy toll on resources. There was a desire to track
and demonstrate an effective use of the substantial resources
being spent.
Demonstrable outcome:
What advice would you give
By effectively capturing and measuring clinic outcomes and
comparing them among providers, clinic sites, and national
to organizations wanting to
quality benchmarks, the clinic was able to show improved
outcomes.
improve care in similar ways?
Sustained accomplishments:
Take small steps. Don’t take
There has been a sustained drop in the average blood glucose
on too much at once. Starting levels in an increasing number of patients—a sign of more
effective self-management.
small allows one to measure
Summary:
what’s been done, which can
Over 200,000 Americans die from diabetes-related
complications each year. Deaths attributable to diabetes have
inform future steps. Achieve
increased by 48% in Los Angeles County since 1991. Mexicanearly success upon which
Americans, who comprise the largest Latino population in the
United States, are twice as likely to have diabetes as nonyou can build. Diabetes
Hispanic whites.
management is expensive and
The goal of the Diabetes Care Management Program is
to effectively manage diabetes, prevent costly and painful
resource intensive. The focus
complications and reduce unnecessary hospitalizations.
must shift to prevention. If the A majority of Clinic patients are Latino immigrants, with low
levels of formal education and health literacy.
health care field succeeds in this The program provides culturally competent and comprehensive
disease management services free of charge. Strategies
transition by helping patients
include culturally appropriate curricula; health education
implement the necessary
materials and resource guides that help multiple races and
better manage their diabetes; and programmatic
lifestyle changes, we will all be ethnicities
efforts that include prevention strategies for family members
and other at-risk patients, particularly those who are overweight
rewarded with a reduction in
and sedentary.
health care disparities.
http://www.venicefamilyclinic.org/
10
Race in a Post-racial
America
In the African American community, health disparities are
strongly linked to socioeconomic status. In fact, all health in the
US is strongly correlated to socioeconomic status. In the phrase,
“Wealth equals health,” epidemiologic research reveals that even
if you control for economic status, race trumps. In the PBS series
Unnatural Causes, we learn about the social gradient of health.
In America, the “wealth-health gradient” looks like this:
“Over 70% of affluent Americans report very good to excellent
health—almost twice as many as poor Americans. No surprise.
But in the middle levels, good health decreases significantly.
This translates into a reverse slope for chronic disease.”1
As a physician, I’ve been followed
around the store. When I go in to buy
something, I’ve been looked at askance.
I’ve seen a woman grab her purse
when I come into the elevator. And for
goodness’ sake—I’m Dr. Troutman!
You know, why?… This shouldn’t
happen to me, but it does.
Adewale Troutman, MD
(Director, Louisville Metro, Public Health
& Wellness)
“There are ways in which our
society is organized that are bad
for our health. And there’s no
doubt that we could reconfigure
ourselves in ways that would
benefit our health.”
NICHOLAS CHRISTAKIS
(Medical sociologist, Harvard University)
Diabetes: low-income Americans have twice the rate of disease
as the affluent. And for those in the middle, it’s still almost twice
the rate. A similar pattern holds for stroke and heart disease,
eventually contributing to excess death, especially for middle
and low-income Americans.
Further, according to the research, if you’re an African American,
no matter what your socioeconomic status, your health
outcomes are going to be worse than your white counterpart.
And it’s not genetics. Being black in America means you face
a constant low-grade stress—being watched in a video store,
being pulled over on the highway, being pulled out of the line by
the TSA at the airport security. Recently, Mayor Bloomberg has
had to respond to the “stop and frisk” policy in NYC that affects
minorities more than whites.
Racial discrimination can be an added stressor—overproduction
of cortisol is linked with high blood pressure, increased rates
of infant death, and coronary artery disease, all of which have
high prevalence rates among African Americans. In a national
landmark study conducted by former Surgeon General David
Satcher and Adewal Troutman, MD (Director, Louisville Metro,
Public Health & Wellness), “We found over 83,000 excess deaths
per year in the African American community alone… That’s the
equivalent of a major airliner filled with black passengers falling
out of the sky every single day, every year.”
According to Michael Marmot (epidemiologist, University College
London), “If these inequalities in health, this gradient in health,
was a fixed property of society and never changed, then you’d
say, ‘We’re stuck.’ But that’s not the case. The magnitude of the
inequalities in health changes over time. It can get rapidly worse,
and if it can get rapidly worse, it ought to be possible to make it
rapidly better.”
Taken from the “Unnatural Causes Discussion Guide,” a project of California Newsreel.
Copyright © 2008 California Newsreel.
1
11
Social Class in America?
The most important determinant of health
Class | Stress | Health
When we consider health disparity in cross-cultural populations
and their place in American society, we look at where new
immigrants fit in the social class. According to Marmot and
Syme, social class is the most important determinant of health
above any other risk factor.
“But what does social class mean? Is it housing, or medical
care? Education? Or is it power? Confidence? A sense of
security?” According to Syme, “They are all inextricably
intertwined, we can’t take them apart. So it’s really a challenge.”
“Racial discrimination can
be an added stressor—
overproduction of cortisol
is linked with high blood
pressure, increased rates of
infant death, and coronary
artery disease, all of which
have high prevalence rates
among African Americans.”
But how do we carry social class in our bodies? How does
it get under our skin? Consider life in the United States today.
We worry about losing our jobs. We are uncertain about
the economy, about our own health care. How much control
do we have over our day-to-day life? Our own destiny? Are
we working for “the man” or for ourselves? Where are we in
the hierarchy? Syme asks, “What is your ability to influence
the events that impinge on your life, even if it means not
doing anything—but one way or the other, managing those
pressures?”
Marmot states, “There’re all sorts of ways we’ve devised for
depriving people of a sense of control over their lives. Living
in a community where it’s not safe to go out.” Or where there
are no grocery stores (the so-called fresh food desert); where
your company can downsize or force you to relocate or lose
your job.
The science of stress
When we feel threatened or don’t have control in our lives, one
critical biological reaction kicks in: the stress response. When the
brain perceives any threat, it signals the adrenal glands to release
potent stress hormones. Among them, cortical hormones. They
flood your bloodstream with glucose, increase your heart rate,
raise blood pressure. They put your body on alert.1
A normal stress response strikes when needed, then turns off.
But what happens when pressures are relentless, and you lack
the power and resources to control them? When the stress
response stays turned on for months? Or years?2
McEwan: “Chronic cortisol can impair immune function. It
can actually inhibit memory and can even cause areas of the
brain to shrink.” This leads to inability to handle glucose and
insulin, which is believed to lead to diabetes and cardiovascular
disease.
1, 2
Pages 6, 7 Unnatural Causes: In Sickness and In Wealth, Transcript.
www.unnaturalcauses.org
12
African American Mothers
and infant mortality
We know that a healthy lifestyle should lead to a healthy
baby. Women who eat well, exercise, get prenatal care, and
avoid alcohol, drugs, and cigarettes are more likely to have a
good pregnancy. But one of the best predictors for a healthy
pregnancy outcome is higher education. Kim Anderson was the
picture of this profile. She is a successful Atlanta executive and
lawyer, and she is African American. Her first pregnancy was
proceeding on course, but she went into early labor and gave
birth to a daughter 2.5 months pre-term. She weighed less than
2 lbs 13 oz and was in the neonatal unit for several weeks.
Prematurity and low birth weight are the leading reasons that
the US claims the dubious distinction of having one of the worst
infant survival rates in the industrialized world. We fall behind
dozens of countries. Babies born in Slovenia, Cyprus, Malta and
Croatia stand a better chance of living to the age of one than a
baby born here. Why do African American women—even healthy,
educated, high socioeconomic ones—deliver a statistically
significant number of premature infants?
According to a segment in Unnatural Causes: When the Bough
Breaks, as a country we pay an enormous price for our high
rate of premature and low birth weight babies. Pre-term birth is
the second leading cause of death for infants. If they’re lucky
enough to survive, many face a lifetime of learning and medical
problems. Studies show that prematurity increases the risk for
hypertension, diabetes, and coronary artery disease. And the
high cost of their medical care begins the moment they’re born.
One month’s stay in a neonatal intensive care unit averages
$68,000 dollars. According to James Collins (neonatologist,
Children’s Memorial Hospital, Chicago): “Neonatology is a lot
of things. Inexpensive is not one of them. And we spend a
disproportionately high amount of our income as a society taking
care of infants, a lot of whose problems probably could have
been prevented if they had stayed in the womb until term.”
Collins investigated the disparity in premature births and
originally assumed that they were related to socioeconomic
differences between African Americans and whites. He believed
if we corrected the differences in economics and education
levels to create parity, the gap would disappear. “We were very
surprised to find that the gap actually widened as education
and socioeconomic status improved, and then began to look
at it from a bigger perspective and broader perspective, and
really started to realize, well, maybe it’s something about lifelong
minority status which is the driving factor here.”
From Unnatural Causes: When the Bough Breaks, Transcript
© California Newsreel 2008
13
Education Levels of African
American Women and infant mortality
The equation breaks down for educated Black mothers
Predictors of full-term healthy births result from a healthy lifestyle of the mother: sound nutrition, exercise, prenatal checkups, not smoking and not using drugs. But in the end, one of the best correlates is higher education. But African American
women with high levels of education are still at greater risk than would be expected. For example, infant mortality among
white women with a college degree or higher is 4/1,000 births. While African American women with the same level of
education or higher have infant mortality rates of 10/1,000—worse outcomes than white mothers who haven’t even
graduated from high school. Based on continued study, the effect is not genetic, there is no “African gene for prematurity.”
Instead it is believed to be related to something in the social milieu African American women grow up and live.
When have infant mortality rates been closer between whites
and African American mothers? During the 60s and 70s, with
the civil rights movement, introduction of the War on Poverty, the
health of African Americans improved overall, closer to whites.
Education opportunities opened up with Affirmative Action, and
hospitals were more integrated, there were more opportunities
for better jobs and the health of African Americans improved.
Infant mortality rates improved closer to the rate of white mothers.
The 80s produced a serious recession that forced the cutting of
many initiatives. In many ways, there has been no recovery from
the backslide. Even so, something else is at play because the
disparity between educated African American and white mothers
still exists.
Education… predicts infant
mortality for both black
women and white women.
And the more educated you
are, the less likely you are to
have a low birth-weight baby,
a preterm baby, or an infant
death.
Camara Phyllis Jones
(Medical epidemiologist, Centers for
Disease Control and Prevention)
Like the case before, a study conducted by Collins and David2
indicates racism is contributing to the premature mortality.
Being the subject of racism and discrimination is an unrelenting
stressor that takes a toll over a lifetime. And despite the notion
(hope) that we are living in a post-racial time, it is belied by
the persistence of the effects of prejudice. Since you cannot
escape the color of your skin, it’s hard to escape the chronic
sense of disempowerment—leading to stress in the form of
elevated cortisol. It’s an insidious, persistent hopelessness. In
terms of infant mortality, researchers believe stress hormones
are a normal part of the pregnancy cycle, and as they increase
enough they trigger labor. But if a woman is producing excess
amounts, premature labor can ensue. Hormones can also
constrict the blood flow to the placenta, which could limit fetal
growth and lead to prematurity.
“Research suggests it’s not so much stress during pregnancy
that may determine the health of a mother’s baby, but the
cumulative experiences of the mother over the course of her
entire life, regardless of race. Dr. Lu calls this hypothesis the ‘lifecourse perspective.’ ”
From Unnatural Causes: When the Bough Breaks, Transcript
© California Newsreel 2008
2
RICHARD DAVID (Neonatologist, Stroger Hospital of Cook County, Chicago);
JAMES COLLINS (Neonatologist, Children’s Memorial Hospital, Chicago)
1
14
African American Women
and infant mortality
Racism is a societal-level
problem. It’s institutionalized;
it’s part of our educational
system; it’s part of our media;
it’s part of our culture. It’s one
of the [pillars] that reinforces
inequality in the society we
live in.1
Richard David
(neonatologist, Stroger Hospital
of Cook County, Chicago)
Imagine this: Camara Phyllis Jones is a family physician and
epidemiologist at the CDC. She has studied the connection
between health outcomes and racism. She looked at chronic
diseases in 100,000 women. She asked them, “How often do
you think of your race?” She wanted to understand how women
internalize their race. Over half of white women said they never
think about their race. For black women, nearly half think about
their race every day, with over a fifth reporting they think about
race constantly.
Fleeda Jones from Emory University: “We wanted to understand
more about what it feels like, what it means to a mother to be
race-aware/vigilant.” Jones and her colleagues conducted focus
groups with hundreds of black women to understand this.
“If you have to take children outside of your neighborhood for the
best educational opportunities; if you have concerns that they will
be racially profiled; if there are concerns about the opportunities
that they will have, all of that represents serious kinds of stresses
that are experienced by African American women on a constant
basis.”
Jones: “It’s like gunning the engine of a car without ever letting
up. Just wearing it out, wearing it out without rest. And I think that
the stresses of everyday racism are doing that.”
The everyday disempowerment is evidenced by a woman
who provides this example: “You have a doctor that comes in
that doesn’t really pay attention to what it is you’re saying, that
invalidates what it is you’re saying.”
Social determinism: the domino effect
The search for answers to these perplexing questions led the Health Policy Institute of the
Joint Center for Political and Economic Studies to establish a national commission to study
infant mortality within a new context of “relationality”—the notion that relationships are
constitutive of what it means to be human. The central role of relationships and their associated
effects upon maternal and infant well-being have generated a new understanding of the
infant mortality challenge. This new approach is grounded in social determinants of health
theory; women and their babies must be viewed not only as individuals, but as members of
families, communities, and larger systems that have either positive or negative impacts upon
their psychological and physical states. The economies, opportunities, and environmental
influences, as well as risk and the protective factors within their places of work, life, and play
must be considered.3
From Unnatural Causes: When the Bough Breaks Transcript © California Newsreel 2008
Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality. Copyright 2007 by the Joint Center for Political and Economic Studies. 1090 Vermont Ave.,
Suite 1100, NW, Washington, D.C. 20005 www.jointcenter.org
1
3
15
LGBT: Lesbian, Gay, Bisexual, and
Transgendered People are affected by the
same health care access issues as other Americans
Strides have been made over the last decade in establishing rights for
the LGBT population. For example, support for same-sex marriage and
same-sex parents is growing steadily among Americans. A Pew Research
Center survey conducted in July and released in September 2012 found
for the first time that a majority of people surveyed—52%—said that
gay men and lesbians should be allowed to adopt children, up from
46% in 2008 and 38% in 1999.1
AMA initiative focused
on LGBT Americans
Despite this progress, however, members of the
LGBT population continue to experience worse health
outcomes than their heterosexual counterparts.
Contributing factors can be organized into four
categories: 1) access to health care and health
insurance; 2) impact of societal biases on physical
health and well-being; 3) impact of societal biases
on mental health and well-being; and 4) how
societal biases can lead to risky behavior.3
Medical school training:
Well-conceived, wide-spectrum curriculum
offerings in this area are emerging. To meet this
need, many schools are studying the approach
of the School of Medicine at the University of
California in San Francisco (UCSF). San Francisco
is estimated to have the highest LGBT population
in the United States. UCSF has been a pioneer in
LGBT health—and it established the UCSF LGBT
Resource Center, the only such office in a health
education or health care setting in the nation.
Initiative at UCSF
For example: Rising second-year students, guided by
the UCSF LGBT Center, examined each preclinical
curriculum unit, noting whether it included any LGBTrelated content (and, if so, what). The resulting grid,
complete with faculty contact information, was then
carefully reviewed to identify each area in which
LGBT content might be added, augmented, or
revised. Identified areas included not only infectious
disease, mental health, and sexual history-taking,
but also cancer, endocrinology, cardiovascular
disease, neurological development, addiction,
tobacco use, hypertension, nutrition, geriatrics, and
pediatric and adolescent medicine. The Department
of Health and Human Services issued a response
to inquiries from LGBT organizations, including the
HRC (Human Rights Campaign), affirming that the
nondiscrimination provision in the Affordable Care
Act prohibits discrimination based on gender identity
and sex stereotyping. These protections are critical.
As many as one in five transgendered patients report
being refused care because of their gender identity.
16
LGBT: Lesbian, Gay, Bisexual, and
Transgendered people are affected by the
same health care access issues as other Americans
These protections are sorely needed.
As many as one in five transgendered patients reports being refused care because of their gender identity.
An estimated 8.8 million Americans (3.8% of the population) say they are lesbian, gay, bisexual or transgendered.
Experts say the actual figure probably is higher, but data on this population are limited, and there are many LGBT
people who do not report their sexual identity for fear of discrimination.1
Nearly 40% of lesbian, gay, and bisexual people put off medical treatment because they are concerned about the cost
of health care, and nearly 40% said they do so because of a lack of adequate health insurance, according to a 2005
Harris Interactive survey of more than 2,000 adults (patients could give more than one answer).
A survey conducted by the Rainbow Health Initiative of over 1,100 respondents, 834 of whom identified as LGBT/Queer
and 48% of whom were people of color, indicated that the top three health priorities for the LGBT community are:
HIV/AIDS, particularly for men of color who have sex with men
Sexually transmitted diseases and infections (in addition to HIV)
Chemical dependency, including tobacco addiction
More than 20% of LGBT adults said they did not have health insurance coverage, compared to 6.7% of
heterosexual adults in Minnesota statewide
Almost one-third (32%) had not disclosed their sexual orientation or gender identity to their health care provider
The majority of respondents (79%) prefer that their medical provider/clinic be LGBT competent, yet over one-third
(36%) feel that their medical provider/clinic is not knowledgeable and/or competent about LGBT health
Social Science & Medicine, Volume 74, Issue 11, Pages 1783–1790 Corinne Reczek, Debra Umberson
http://www.ama-assn.org/amednews/2011/09/05/prsa0905.htm
Virtual Mentor American Medical Association Journal of Ethics August 2010, Volume 12, Number 8: 638–643. MEDICAL EDUCATION The Medical School Curriculum and
LGBT Health Concerns
Statement of the American Medical Association to the Institute of Medicine RE: Lesbian, Gay, Bisexual and Transgender (LGBT) Health Issues and Research Gaps and
Opportunities Presented by Saul Levin, MD, MPA American Medical Association Vice President, Science, Medicine and Public Health Gal Mayer, MD Vice Chair, AMA-GLBT
Advisory Committee Medical Director, Callen-Lorde Community Health Center February 1, 2010
1
17
Awareness and Advocacy
Efforts
Tips for Health care
Providers:
Educate yourself.
Learn about the specific health
issues facing LGBT people.
1. Be sensitive. Make sure you and
your staff know which pronouns are
appropriate to use when referring to
a transgendered patient or a samesex couple. Present visual cues.
Displaying an HRC equal sign or
another LGBT-friendly emblem will
demonstrate that your office is
a safe space for all.
2. Revise client forms. Allow options
for male/female/transgendered and
use neutral terms like “partner”
or “spouse” rather than “single,”
“married,” or “divorced.” Use
“parent 1” and “parent 2” to include
same-sex couples raising children.
3. Don’t assume. Avoid making
assumptions about a patient based
on their appearance. When taking a
sexual history, ask, “Are your current
or past sexual partners men, women,
or both?”
4. Listen attentively. Be sensitive to
the fact that this disclosure may be
difficult for your patients.
The National LGBT Cancer
Network
Lesbian cancer
Because the large national cancer registries and surveys have
not collected data about sexual orientation, lesbian-specific
data are “hidden” in the research. There is evidence, however,
that lesbians have a 2–3 times greater risk of developing breast
cancer, as well as several other types of cancer.
And as indicated in the earlier section on the stress impact
of racism, the increased risks are not due to any physiologic
or genetic differences between homosexual and heterosexual
people. Rather, they are the result of the stress and stigma of
living with homophobia and discrimination. This often results
in behaviors that carry an increased risk.
Health equity index
Patient-centered care is the universal standard, regardless
of race, gender, or sexual or gender identity. The one’s right
to choose our HCP and is key to removing all barriers to
equitable treatment.
Center of Excellence for Transgender Health on Facebook
18
Patient-Physician Encounter:
Physician’s News excerpt
How does a physician strike a balance between being sensitive to the
cultural background of his/her patients and treating each individual as
a unique person, without stereotyping them?
There are a set of core cross-cultural issues that vary across
cultures but are important hot-button issues for all patients,
such as styles of communication: the stoic patient versus the
very expressive patient; issues of mistrust that might be more
prevalent among certain populations; issues of decisionmaking; sexual and gender issues; traditions, customs, and
spirituality. These are all issues that might play a role.
Joseph R. Betancourt, M.D., M.P.H.,
Director of the Disparities Solutions Center,
program director for multicultural education,
and a practicing internist at Massachusetts
General Hospital.
Some cultural groups, such
as South Asian patients,
have higher expectations of
health care quality and in this
country feel less understood
and acknowledged by their
physicians.2
Personalizing, being present
with the patients—in their
world—so that they feel
understood.
In years past, a lot of what was done in the area of cultural
competence was what we called the manual-based approach,
where you’d pick up a small text that would have five to seven
key things you needed to know to take care of a Hispanic or
African American patient, for example. I’m Puerto Rican myself,
and I would often read these things, and a lot of them didn’t
apply to me or my family.
A lot of them were stereotypical and I worried about that. It
became clear to many people in the field that there’s no five-toseven unifying facts that you could teach about any large racial,
ethnic or cultural group. The way to walk the balance is to learn
about a particular community and whether there are prevalent
health beliefs and behaviors, but also to have a set of tools and
skills to explore the particular social and cultural factors that
impact that patient in front of you.
A simple question might get at the root of nonadherence:
“You know, you’ve really had a tough time controlling your
blood pressure. Before I go on and explain the pros and
cons, and the evolution of hypertension, I want to get an
understanding of how you view hypertension. What do you
think makes your condition better or worse, and how do
you think it should be treated?” By exposing the patient’s
perspective in a very patient-centered way, you could then
engage in a negotiation with them about how they can best
address their hypertension, perhaps letting them know that,
“Yes, your blood pressure can be higher in particular situations,
but in fact, it’s higher than others almost all the time, and so
medication will help it.” I think sometimes, as clinicians, we
might be too quick to check “Patient noncompliant” or “Patient
refusing,” and not take the time to ask that second- or thirdlevel question about the root of that nonadherence.
19
Patient-Physician Encounter:
Physician’s News excerpt
From a practical standpoint, how serious an obstacle is the time burden
of a typical 15-minute clinical encounter to doing this right?
Best Practice
Time constraints on visit:
Push for cultural
competence, and
Reimbursement that meets
“pay for performance”
standards
JRB: Without a doubt, time is a challenge. In our 15-minute
patient visits, it’s challenging to do anything well. Clearly, this is
an added dimension that poses an additional challenge. All that
being said, asking some of these questions—asking about a
patient’s health beliefs, getting at their understanding—might, in
fact, save time in the clinical visit. Too often, we’ll sit and explain
things to a patient using the medical model and take up a lot
of those 15 minutes speaking our “medicalese,” when in fact a
cross-cultural patient-centered question might reveal a patient’s
perspective quicker, put you in a position to negotiate faster,
and use your time more effectively.
Now, I’m not trying to be “Pollyannaish” or naive about this.
I clearly think that this is an issue that we need to be careful
about, but I do think that some of the better curricula around
the country is [sic] cognizant of that practical challenge and
tries [sic] to give providers key questions that they could use,
in an as-needed fashion, that could help them save time.
Also, this type of work should be done with an eye towards
continuity—you don’t necessarily need to do it all in one visit.
Effective communication actually saves time and makes the
visit generally more efficient and higher-quality. In fact, some
health insurers are offering pay-for-performance incentives
for completion of cultural competency training, including
Blues plans in Florida and Massachusetts, Aetna, as well as
several larger employer groups around the country—such
as Marriott, which understands that a quarter to a third of their
[sic] employee base may be from ethnic minority groups.
20
Where Are You
on the Cultural Openness Scale?
CULTURAL OPENNESS SCALE
A Metric for Tracking Increasing Multiculturalism
CULTURAL OPENNESS is the degree to which the historic boundaries
between ethnic and racial groups are perceived as being highly porous and easily
crossed. Such porousness allows people to navigate without self-consciousness
or social constraint within and across different cultural groups, absorbing the
elements that work within their preferred lifestyle, but not necessarily at the cost
of pride and participation in their native culture.
12345
Intercultural
influence is
a source of
concern, and
people who are
different are
eyed with
mistrust.
Acknowledge
and understand
the benefit of
intercultural
influences
within society.
Personally
recognize and
appreciate
the benefits of
intercultural
influences in
their own lives.
Actively pursue
and immerse
oneself in
intercultural
experiences
and situations.
Organically
and nonselfconsciously
navigate
within and
across multiple
cultural group
boundaries.
http://www.added-value.com/source/wp-content/uploads/2011/01/Cultural-Opennes_Cheskin-Added-Value-The-Futures-Company_January-2011.pdf
http://www.added-value.com/source/2012/07/growing-pains-for-a-total-market-approach-to-diversity/
21
What Does It All Mean?
Illustrated through Mrs. Rodriguez
Remember Mrs. Rodriguez?
At the beginning of this paper, we left
her as she and her daughter entered the
examination room. Let’s consider what
will make her time with her physician
a valuable learning and teaching
moment.
Doctor: “Mrs. Rodriguez, it would
help me if I could understand some
of your thinking about diabetes.
Would it be alright if I asked you
about how diabetes affects your
life?”
Mrs. Rodriguez: “Yes, that’s OK
with me, Doctor.”
Doctor: “What do you think your
diabetes does to you?”
Mrs. Rodriguez: “As long as your
body can get rid of the sugar, you
are OK. But sooner or later you can’t
handle the sugar, and you get sick.
My uncle lost his eyes to diabetes.”
Doctor: “Yes, those are all linked
to diabetes and I agree with what
you’ve said… Here’s another way
to see it…”
A culturally competent interaction will include several
teaching moments for her disease(s):
Acknowledgement of her daughter, while remaining clear
that Mrs. Rodriguez is the patient (extended family members
influence patient’s health care).
Uncovering her cultural preferences relating to diet, exercise,
natural or home remedies.
How does Mrs. Rodriguez understand her disease? This
allows the physican to correct misconceptions, or fill any
gaps. “You are right about controlling sugar and the need to
monitor… but there’s a bit more I’d like to share with you…”
HCP clarifies by sharing appropriate biomedical details.
Nutrition and family: How best to work with Mrs. Rodriguez
to modify her nutrition based on her native Mexican diet,
one with which she is already comfortable, and which will
likely help her achieve better control upon modification. It is
unreasonable to expect a patient to convert completely to
a culturally unfamiliar diet.
Her adherence: What barriers prevent her from fully
complying? For example, the cost of replacing monitor strips.
22
What Does It All Mean?
Illustrated through Mrs. Rodriguez
An HCP, in this case Mrs. Rodriguez’s family physician, can
never really know what the patient’s culture is unless he or she
asks the patient. Likewise, the patient has a limited knowledge of
the physician’s culture, including his or her understanding and
acceptance of the biomedical model of health and disease.
It is equally important for HCPs to share information about their
background with their patients. 2
Mrs. Rodriguez’s physician negotiated a plan with her to keep
a food diary. He provided her coupons for testing strips to
supplement her supply. They agreed that if she needed more
and could not afford them, he would provide further coupons.
They agreed to schedule an appointment in 3 months.
Race:Hispanic
Ethnicity: Mexican American
Culture: Homemaker, wife, mother/grandmother
Being aware of a patient’s values, spirituality, and relationship
dynamics, the physician can uncover and follow Mrs. Rodriguez’s
cultural preferences. By negotiating in a culturally aware
framework, the HCP and the patient will experience greater
trust through a sense of being understood. By being culturally
attuned to each other, Mrs. Rodriguez and her doctor (along
with respecting her daughter’s role) are more likely to have a
relationship based on mutual respect and to realize better overall
health outcomes.
In summary, we’ve illustrated the Four Steps to culturally
competent care:
1. Ask about health beliefs and behaviors
2. Share biomedical point of view
3. Compare both views
4. Negotiate a plan
http://www.vlh.com/shared/courses/course_info.cfm?courseno=1787.
23
What Does It All Mean?
Conclusion
Ethnic minorities make up more than one third of the population of the United States.
The US model of health care—which values autonomy in medical decision making—
is not easily applied to members of some racial or ethnic groups.
Cultural factors strongly influence patients’ reactions to serious illness. Similarly, with
regard to decision-making, the emphasis in the US on patient autonomy may contrast with
preferences for more family-based, physician-based, or shared physician- and family-based
decision-making among some cultures.1
Too many racial and ethnic minority patients experience lower-quality health care compared
to white patients. This disparity is unacceptable. Access to quality care—which has been
at the forefront of disparity policy discussion—is only part of the issue. Research has
demonstrated that even when access to care is equal, racial and ethnic minority patients tend
to receive lower quality care than do white patients.
So even equal access can result in unequal care. Likewise, quality improvement that only
focuses on the overall population and fails to address racial and ethnic differences can result
in unequal quality.
Consequently, cultural “intelligence” in health care has emerged as a crucial “pivot” point
in reducing health outcomes disparity. As people who operate within the health care
community, it is incumbent on us to increase our cultural competence and work within our
organizations to take on this issue. The unmet need is there, and the opportunity to make
a difference is pressing.
Global Strategies, Inc. is committed to furthering stakeholder education through our insights and technology in the crosscultural health care community. Test your knowledge by taking the quiz, “How Culturally Competent Are You?,” on page 27.
Also feel free to reach out to us. Providing cross-cultural intelligence to the health care community is our mission.
Contact Anthony Marucci, VP of Business Development: amarucci@global-ny.com or 212.964.0030.
Am Fam Physician. 2005 Feb 1;71(3):515-22.
24
Race, Ethnicity, Culture:
What’s the difference?
Culture is a more meaningful concept in the
clinical encounter than race or ethnicity. In this
context it has been defined as:
Culture
“The unique shared values, beliefs, and practices
that are directly associated with a health-related
behavior, indirectly associated with a behavior, or
influence acceptance and adoption of the health
education message.” (Pasick et al., 1994).
Identity
Race
What is Ethnicity?
Ethnicity
Ethnicity is based on an individual’s
identification as a member of a social group
with a common background. This background
is often geographic, political, or linguistic.
Ethnic labels are an attempt to further
differentiate racial categories. (Egede, 2006).
The ethnic categories used in the 2010
US Census were:
What is Race?
Categories:
– Hispanic or Latino
US Census 2010
White
– Not Hispanic or Latino
Although historically treated
as genetically discrete,
racial categories are socially
constructed and originally
were based on morphological
differences. Yet experts now
contend that racial categories
are not genetically discrete, are
not reliably measured, and have
little scientific meaning.
Black, African American,
Negro
(Smedley & Smedley, 2005;
Egede, 2006).
Vietnamese
American Indian
Alaska Native
Asian Indian
Chinese
Japanese
Korean
Hispanics or Latinos may be of any race.
(Mexican Americans, for example, who
derive their ancestry from the varied peoples of
Mexico, can be considered a subgroup under
Hispanic or Latino. Cuban Americans and
Puerto Rican Americans would represent other
subgroups. Many other ethnic groups exist,
including German American, Haitian American,
or Japanese American. Ethnicity, however, does
not equal culture.
Native Hawaiian
Guamanian or Chamarr
Samoan
Pacific Islander
Other
J Gen Intern Med. 2006 June; 21(6): 667–669. doi: 10.1111/j.1525-1497.2006.0512.x PMCID: PMC1924616
Race, Ethnicity, Culture, and Disparities in Health Care. Leonard E. Egede, MD, MS
25
How Culturally
Competent Are You?
1.Cross-cultural misunderstandings between providers and patients can lead to mistrust and frustration,
but are unlikely to have an impact on objectively measured clinical outcomes.
a. True
b. False
2.When the patient and provider come from different cultural backgrounds, the medical history obtained may
not be accurate.
a. True
b. False
3.When a provider expects that a patient will understand a condition and follow a regimen, the patient is more
likely to do so than if the provider has doubts about the patient.
a. True
b. False
4.A really conscientious health care provider can eliminate his or her own prejudices or negative assumptions
about certain types of patients.
a. True
b. False
5.When taking a medical history from a patient with a limited ability to speak English, which of the following is
LEAST useful?
a. Asking questions that require the patient to give a simple “yes” or “no” answer, such as
“Do you have trouble breathing?” or “Does your knee hurt?”
b. Encouraging the patient to give a description of her/his medical situation,
and beliefs about health and illness.
c. Asking the patient whether he or she would like to have a qualified interpreter for the medical visit.
d. A
sking the patient questions such as “How has your condition changed over the past two days?” or “What
makes your condition get better or worse?”
6.During a medical interview with a patient from a different cultural background, which is the LEAST useful
technique?
a. Asking questions about what the patient believes about her or his illness, what caused the illness, how severe
it is, and what type of treatment is needed.
b. Gently explaining which beliefs about the illness are not correct.
c. E xplain the “Western” or “American” beliefs about the patient’s illness.
d. D
iscussing differences in beliefs without being judgmental.
7.When a patient is not adhering to a prescribed treatment after several visits, which of the following approaches
is NOT likely to lead to adherence?
a. Involving family members.
b. Repeating the instructions very loudly and several times to emphasize the importance of the treatment.
c. Agreeing to a compromise in the timing or amount of treatment.
d. S
pending time listening to discussions of folk or alternative remedies.
http://erc.msh.org/mainpage.cfm?file=3.0.htm&module=provider&language=English
26
How Culturally
Competent Are You?
8.When a patient who has not adhered to a treatment regimen states that s/he cannot afford the medications
prescribed, it is appropriate to assume that financial factors are indeed the real reasons and not explore the
situation further.
a. True
b. False
9. Which of the following are the correct ways to communicate with a patient through an interpreter?
a. Making eye contact with the interpreter when you are speaking, then looking at the patient while the interpreter
is telling the patient what you said.
b. Speaking slowly, pausing between words.
c. Asking the interpreter to further explain the patient’s statement in order to get a more complete picture of
the patient’s condition.
d. None of the above.
10.If a family member speaks English as well as the patient’s native language, and is willing to act as interpreter,
this is the best possible solution to the problem of interpreting.
a. True
b. False
11. Which of the following statements is TRUE?
a. People who speak the same language have the same culture.
b. T
he people living on the African continent share the main features of African culture.
c. C
ultural background, diet, religious, and health practices, as well as language, can differ widely within a given
country or part of a country.
d. An alert provider can usually predict a patient’s health behaviors by knowing what country s/he comes from.
12. Which of the following statements is NOT TRUE?
a. Friendly (non-sexual) physical contact is an important part of communication for many Latin American people.
b. M
any Asian people think it is disrespectful to ask questions of a health provider.
c. M
ost African people are either Christian or follow a traditional religion.
d. Eastern Europeans are highly diverse in terms of customs, language and religion.
13. Which of the following statements in NOT TRUE?
a. The incidence of complications of diabetes, including lower-limb amputations and end-stage renal disease,
among the African American population is double that of European Americans.
b. J apanese men who migrate to the US retain their low susceptibility to coronary heart disease.
c. H
ispanic women have a lower incidence of breast cancer than the majority population.
d. Some Native Americans/American Indians and Pacific Islanders have the highest rate of type II diabetes mellitus
in the world.
14.Because Hispanics have a lower incidence of certain cancers than the majority of the US population, their
mortality rate from these diseases is correspondingly lower.
a. True
b. False
27
How Culturally
Competent Are You?
15.Providers whose patients are mostly European-American, US-born, and middle-class still need to know about
health practices from different world cultures.
a. Trueb. False
16. Which of the following is good advice for a provider attempting to use and interpret non-verbal communication?
a. T
he provider should recognize that a smile may express unhappiness or dissatisfaction in some cultures.
b. T
o express sympathy, a health care provider can lightly touch a patient’s arm or pat the patient on the back.
c. If a patient will not make eye contact with a health care provider, it is likely that the patient is hiding the truth.
d. When there is a language barrier, the provider can use hand gestures to bridge the gap.
17.Some symbols—a positive nod of the head, a pointing finger, a “thumbs-up” sign—are universal and can help
bridge the language gap.
a. Trueb. False
18.Out of respect for a patient’s privacy, the provider should always begin a relationship by seeing an adult patient
alone and drawing the family in as needed.
a. Trueb. False
19.In some cultures, it may be appropriate for female relatives to ask the husband of a pregnant woman to sign
consent forms or to explain to him the suggested treatment options if the patient agrees and this is legally
permissible.
a. Trueb. False
20. Which of the following is NOT TRUE of an organization that values cultural competence:
a. T
he organization employs or has access to professional interpreters that speak all or at least most of the
languages of its clients.
b. The organization posts signs in different languages and has patient education materials in different languages.
c. The organization tries to hire staff that mirror the ethnic and cultural mix of its clients.
d. The organization assumes that professional medical staff do not need to be reminded to treat all patients
with respect.
21. A female Muslim patient may avoid eye contact and/or physical contact because:
a. S
he doesn’t want to spread germs.
b. Muslim women are taught to be submissive.
c. Modesty is very important in Islamic tradition.
d. She doesn’t like the provider.
22. Which of the following statements is NOT TRUE:
a. D
iet is an important part of both Islam and Hinduism.
b. North African countries have health care systems that suffer because of political problems.
c. Arab people have not historically had an impact on the medical field.
http://erc.msh.org/mainpage.cfm?file=3.0.htm&module=provider&language=English
28
29
Answers to Quiz
1.Cross-cultural misunderstandings between providers and patients can lead to mistrust and frustration,
but are unlikely to have an impact on objectively measured clinical outcomes.
(False: Low levels of cultural competence can impede the process of making an accurate diagnosis, cause the
provider to order contraindicated medication, and reduce patient adherence to recommended treatment.)
2.When the patient and provider come from different cultural backgrounds, the medical history obtained may
not be accurate.
(True: Because of language and cultural barriers, the patient may not understand the questions or may be
reluctant to report symptoms; in turn, the provider may misunderstand the patient’s description of symptoms.)
3.When a provider expects that a patient will understand a condition and follow a regimen, the patient is more
likely to do so than if the provider has doubts about the patient.
(True: This is an adaptation of the “Pygmalion theory” which has proven that students generally live up—or
down—to the expectations of their teachers. (Rosenthal and Jacobson 1968).)
4.A really conscientious health provider can eliminate his or her own prejudices or negative assumptions
about certain types of patients.
(False: Most of us harbor some assumptions about patients, based on race, ethnicity, culture, age, social and
language skills, educational and economic status, gender, sexual orientation, disability/ability, and a host of other
characteristics. These assumptions are often unconscious and so deeply rooted that even when an individual
patient behaves contrary to the assumptions, the provider views this as the exception to the rule. A conscientious
provider will not allow prejudices to interfere with making an accurate diagnosis and designing an appropriate
treatment plan.)
5.When taking a medical history from a patient with a limited ability to speak English, which of the following is
LEAST useful?
a. Asking questions that require the patient to give a simple “yes” or “no” answer, such as
“Do you have trouble breathing?” or “Does your knee hurt?”
b. Encouraging the patient to give a description of her/his medical situation,
and beliefs about health and illness.
c. Asking the patient whether he or she would like to have a qualified interpreter for the medical visit.
d. Asking the patient questions such as “How has your condition changed over the past two days?” or “What
makes your condition get better or worse?”
(Answer: a. While it may seem easier to ask questions that require a simple “yes” or “no” answer, this technique
seriously limits the ability of the patient to communicate information that may be essential for an accurate history
and diagnosis. The most effective way to put the patient at ease and to ensure that the patient provides essential
information about his or her symptoms is to combine two types of questions: 1) open-ended questions such as
“Tell me about the pain in your knee,” and 2) more directed questions, such as “What makes the pain get better
or worse?” Always get a qualified interpreter when possible.)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
30
Answers to Quiz
6.During a medical interview with a patient from a different cultural background, which is the LEAST useful
technique?
a. Asking questions about what the patient believes about her or his illness: what caused the illness, how severe
it is, and what type of treatment is needed.
b. Gently explaining which beliefs about the illness are not correct.
c. E xplain the “Western” or “American” beliefs about the patient’s illness.
d. Discussing differences in beliefs without being judgmental.
(Answer: b. Although the provider may be tempted to correct the patient’s different beliefs about illness, this
may lead the patient to simply withhold his/her thoughts in the future and interfere with building a trusting
relationship. It is more effective to be nonjudgmental about differences in beliefs. The provider should keep in
mind two goals: 1) the patient should reveal her/his medical history and symptoms to help the provider make an
accurate diagnosis, and 2) the patient should develop trust in the provider’s medical advice and be willing and
able to adhere to that advice. To accomplish these goals, it is essential to treat the patient with respect, openly
discussing differences in health beliefs without specifying “correctness” or “incorrectness.”
7.When a patient is not adhering to a prescribed treatment after several visits, which of the following approaches
is NOT likely to lead to adherence?
a. Involving family members.
b. Repeating the instructions very loudly and several times to emphasize the importance of the treatment.
c. Agreeing to a compromise in the timing or amount of treatment.
d. Spending time listening to discussions of folk or alternative remedies.
(Answer: b. Non-adherence can be the result of many different factors that may require a variety of interventions.
Simply repeating the instructions may not address the real issues that are keeping the patient from adhering
to the regimen. In fact, repetition of instructions may be inappropriate and quite offensive if the patient has a
communication disability. Family members can provide valuable support. It may also be necessary to set small,
realistic goals in order to achieve long-term behavioral change. Finally, an understanding of the patient’s beliefs
about other remedies may offer valuable clues to her/his reluctance to adhere to treatment.)
8.When a patient who has not adhered to a treatment regimen states that s/he cannot afford the medications
prescribed, it is appropriate to assume that financial factors are indeed the real reasons and not explore the
situation further.
(False: In addition to exploring payment options with the patient, it is important for the provider to inquire about
cultural and psychological factors that may impede adherence to the prescribed treatment regimen.)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
31
Answers to Quiz
9. Which of the following are the correct ways to communicate with a patient through an interpreter?
a. Making eye contact with the interpreter when you are speaking, then looking at the patient while the interpreter
is telling the patient what you said.
b. Speaking slowly, pausing between words.
c. Asking the interpreter to further explain the patient’s statement in order to get a more complete picture of
the patient’s condition.
d. None of the above.
(Answer: d. Although it may seem natural to look at the interpreter when you are speaking, you want the patient
to feel that you are speaking to her/him, so you should look directly at her/him, just as you would if you were able
to speak her/his language. It is best to speak in a normal tone of voice, at a normal pace, rather than pausing
between words. Because of differences in grammar and syntax, the interpreter may have to wait until the end
of your sentence before beginning to interpret. Do pause after one or two sentences to allow the interpreter to
speak. When you need further information, or need to clarify what the patient has said, clearly tell the interpreter
what you want asked of the patient. Although you may ask the interpreter to add his or her opinion of what the
patient really meant, try to get as close as possible to the patient’s actual words and intent.)
10.If a family member speaks English as well as the patient’s native language, and is willing to act as interpreter,
this is the best possible solution to the problem of interpreting.
(False: This is an inappropriate responsibility for families to take on and may actually place the provider in
violation of the Civil Rights Act of 1964 and the August 30, 2000 Office for Civil Rights (OCR) Policy Guidance.
The rationale for using professional interpreters is clear. Professional interpreters have been trained to provide
accurate, sensitive two-way communication and uncover areas of uncertainty or discomfort. Family members are
often too emotionally involved to tell the patient’s story fully and objectively, or lack the technical knowledge to
convey the provider’s message accurately.)
11. Which of the following statements is TRUE?
a. People who speak the same language have the same culture.
b. The people living on the African continent share the main features of African culture.
c. Cultural background, diet, religious, and health practices, as well as language, can differ widely within a given
country or part of a country.
d. An alert provider can usually predict a patient’s health behaviors by knowing what country s/he comes from.
(Answer: c. The only assured similarity among people from around the world who come to you for care is the
fact that they are your patients and they hope to be treated with respect and with concern for their individual
health needs. As a health care practitioner, it is important to have a basic understanding of your patients’
cultures—and to recognize the similarities and differences among people from the same region of the world
and the same country. Differences in cultures within a region can be pronounced. Each patient is the product of
many cultural forces. People from the same continent, the same country, the same part of the country, and even
the same city, may have major differences in cultural heritage, traditions, and language, as well as differences in
socioeconomic status, education, religion, and sexual orientation. It is the combination of all of these factors that
makes up a person’s “culture.”)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
32
Answers to Quiz
12. Which of the following statements is NOT TRUE?
a. Friendly (non-sexual) physical contact is an important part of communication for many Latin American people.
b. Many Asian people think it is disrespectful to ask questions of a health provider.
c. Most African people are either Christian or follow a traditional religion.
d. Eastern Europeans are highly diverse in terms of customs, language and religion.
(Answer: c. A large percentage of Africans are Muslims, most of them living in North and West Africa, but there
are also many Muslims in East Africa.)
13. Which of the following statements in NOT TRUE?
a. The incidence of complications of diabetes, including lower-limb amputations and end-stage renal disease,
among the African American population is double that of European Americans.
b. Japanese men who migrate to the US retain their low susceptibility to coronary heart disease.
c. Hispanic women have a lower incidence of breast cancer than the majority population.
d. Some Native Americans/American Indians and Pacific Islanders have the highest rate of type II diabetes mellitus
in the world.
(Answer: b. The longitudinal NI-HON-SAN study and Honolulu Heart Program showed that dietary changes
contributed to a significant increase in coronary heart disease among Japanese men who migrated to Hawaii
and California. It highlighted the role that environmental factors can play in counteracting predispositions to
disease.)
14.Because Hispanics have a lower incidence of certain cancers than the majority of the US population, their
mortality rate from these diseases is correspondingly lower.
(False: Despite the lower rate of breast, oral cavity, colorectal, and urinary bladder cancers among Hispanics,
their mortality rate from these cancers is just as high as that of the rest of the population.)
15.Providers whose patients are mostly European American, US-born, and middle-class still need to know about
health practices from different world cultures.
(True: A growing number of people from majority US cultures are turning to traditional medicines as part of their
health care strategies. Providers should be aware of any such practices that may affect their patients’ health.)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
http://erc.msh.org/quiz.cfm?action=question&qt=all&module=provider&language=english
33
Answers to Quiz
16. Which of the following is good advice for a provider attempting to use and interpret non-verbal communication?
a. The provider should recognize that a smile may express unhappiness or dissatisfaction in some cultures.
b. To express sympathy, a health care provider can lightly touch a patient’s arm or pat the patient on the back.
c. If a patient will not make eye contact with a health care provider, it is likely that the patient is hiding the truth.
d. When there is a language barrier, the provider can use hand gestures to bridge the gap.
(Answer: a. Although smiling is an expression of happiness in most cultures, it can also signify other emotions.
Some Chinese, for example, may smile when they are discussing something sad or uncomfortable. The other
pieces of advice are incorrect. The use and interpretation of body language depends entirely on the patient’s
culture and personal preferences. What is appropriate in one culture may be embarrassing or offensive in
another culture. Interpersonal greeting behaviors, for example, vary widely from one culture to another. Beliefs
about touching are also highly variable, with some cultures placing a high value on physical contact, and
others believing that physical contact of any kind is a sign of intimacy. Similarly, some cultures perceive direct
eye contact as a sign of respect, while in other cultures, eye contact with elders and authority figures is to be
avoided. Hand gestures in particular can lead to serious misunderstandings. For example, the “ok” sign, widely
used in the US, is the symbol for coins or money in Japan. In several other cultures, the gesture represents a
bodily orifice and is highly offensive.)
17.Some symbols—a positive nod of the head, a pointing finger, a “thumbs-up” sign—are universal and can help
bridge the language gap.
(False: Each of these symbols has a very different meaning in different cultures, and may be offensive.)
18.Out of respect for a patient’s privacy, the provider should always begin a relationship by seeing an adult patient
alone and drawing the family in as needed.
(False: In many of the world’s cultures, an individual’s health problems are also considered the family’s problems,
and it is considered threatening to exclude family members from any medical interaction. The provider should
ask the patient whether she/he would prefer to be seen alone or with the family. It should be the provider’s goal
to help the patient to express her/his true preference about this—without offending any family members. The
provider might ease any tension around this issue by assuring family members that they will be asked to return
to the examining room in a short time.)
19.In some cultures, it may be appropriate for female relatives to ask the husband of a pregnant woman to sign
consent forms or to explain to him the suggested treatment options if the patient agrees and this is legally
permissible.
(True: In many cultures, men are not involved in the activities surrounding pregnancy or childbirth. Yet they
maintain the responsibility for making decisions and giving permission for treatment, medication, and hospital
stays. A female relative may have to intervene between the provider and the husband.)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
34
Answers to Quiz
20. Which of the following is NOT TRUE of an organization that values cultural competence:
a. The organization employs or has access to professional interpreters that speak all or at least most of the
languages of its clients.
b. The organization posts signs in different languages and has patient education materials in different languages.
c. The organization tries to hire staff that mirror the ethnic and cultural mix of its clients.
d. The organization assumes that professional medical staff do not need to be reminded to treat all patients
with respect.
(Answer: d. Even the most conscientious, committed staff who have been trained in cultural competence may
need periodic reminders. In a busy practice, it is easy for providers to seek shortcuts, slipping into assumptions
about the diverse populations they serve and failing to take the time needed to fully understand the health beliefs
and values of each patient.)
21. A female Muslim patient may avoid eye contact and/or physical contact because:
a. She doesn’t want to spread germs.
b. Muslim women are taught to be submissive.
c. Modesty is very important in Islamic tradition.
d. She doesn’t like the provider.
(Answer: c. Modesty is a very important aspect of a Muslim’s life. Handshakes between unrelated men and
women are inappropriate according to Islamic norms. In addition, eye contact will often be avoided, especially in
mixed-gender situations.)
22. Which of the following statements is NOT TRUE:
a. Diet is an important part of both Islam and Hinduism.
b. North African countries have health care systems that suffer because of political problems.
c. Arab people have not historically had an impact on the medical field.
(Answer: c. Health and healing has been a part of Arab tradition since the earliest historical recordings. Not only
has Arab medicine been in existence for over one thousand years, but Arab medical texts and practices were
very influential in the development of the Western medical tradition.)
http://erc.msh.org/mainpage.cfm?file=1.1.2.htm&module=providerquiz&language=English
Links and Bibliography
End Notes | Sources for further study
America’s Demographic and Cultural Transformation: Implications for Cancer. President’s Cancer Panel. 2009–2010
Annual Report. US Department of Health and Human Services. National Institutes of Health. National Cancer Institute.
March 2011.
Race, Ethnicity, Culture, and Disparities in Health Care. Editorial. Journal J Gen Intern Med. 2006 June; 21(6): 667–669.
Leonard E. Egede, MD, MS, Division of General Internal Medicine, Center for Health Disparities Research, Medical
University of South Carolina, Charleston, SC, USA; 2 Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
Physician Cross Cultural Nonverbal Communication Skills, Patient Satisfaction and Health Outcomes in the PhysicianPatient Relationship. International Journal of Family Medicine, Volume 2012. Ken Russell Coelho and Chardee Galan
Department of Psychology, University of California, Berkeley, CA 94720, USA.
http://www.hindawi.com/journals/ijfm/2012/376907/ref/
Marketing Intelligence:
AdAge Insights. The Cultural Connection. How Hispanic Identity Influences Millenials. May 2012. Trend Report.
Crain Communications.
Resources:
Johns Hopkins Center for Health Disparity Solutions
http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-health-disparities-solutions/
Culture and Language Training for the Healthcare Workforce.
http://www.callearning.com/tinymce/filemanager/files/one-sheet_CALLeaning.pdf
The Culturally Competent Healthcare Provider.
Blog: http://tasteslikechicken2me.wordpress.com/2009/03/17/the-culturally-competent-healthcare-provider/
Accessed August 2012.
Building Cultural Intelligence: Nine Mega Skills by Richard D. Bucher, PhD.,
http://buildingcq.com/sampleassessment.htm
Accessed August 2012.
The Provider’s Guide to Quality and Culture.
http://erc.msh.org/mainpage.cfm?file=4.7.0.htm&module=provider&language=English
EthnoMed: Focusing on African-Americans, Asian, Pacific Islanders and Hispanic/Latinos. 1995–2012; University of
Washington. Harborview Medical Center | Health Sciences Library.
http://www.kingcounty.gov/healthservices/health/chronic/reach.aspx
New Research Defines Cultural Openness and Its Impact on Marketing Strategy
http://www.added-value.com/source/2011/01/new-research-defines-cultural-openness-and-its-impact-on-marketingstrategy/
Edelman Hosts Cheskin Added Value and The Futures Company Panel Discussion on the Influence of Ethnic Identity
on Consumer Behavior. January 11, 2011, NEW YORK
35
Links and Bibliography
Virtual Mentor, August 2010—Vol 12 www.virtualmentor.org.
LGBT Health Concerns. Shane Snowden. American Medical Association. All rights reserved.
The Agency for Healthcare Research and Quality
Healthy People 2020
National Institute on Minority Health and Health Disparities.
http://www.solvingdisparities.org/
Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation at the
University of Chicago. Accessed September 6, 2012.
http://www.youtube.com/watch?v=3FyAqHhcTV8&feature=player_embedded.
Virtual Lecture Hall. Delivering Culturally Competent Care: Managing Type 2 Diabetes in Diverse Populations. Accessed
August 2012. http://www.vlh.com/myvlh/myvlh.cfm. Medical Directions, Inc.
Diabetes Epidemiology in US Hispanics. Centers for Disease Control and Prevention. National Diabetes Fact Sheet:
national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
http://diabetes.niddk.nih.gov/statistics/index.aspx
Eliminating Disparities in Care. Case Study: Diabetes Management among the Latino Population. Venice Family Clinic.
Venice California. www.aha.org/content/00-10/08dispcase-diabmgmtlat.pdf
Social Work in Public Health. Volume 25, Issue 3-4, 2010. Special Issue: Health Disparities.
www.tandfonline.com/loi/whsp20
State of the Hispanic Consumer: The Hispanic Market Imperative. 2012.
http://www.nielsen.com/us/en/insights/reports-downloads/2012/state-of-the-hispanic-consumer-the-hispanic-marketimperative.html
An Elective Course in Cultural Competence for Healthcare Professionals. Emily Evans, PharmD, Am J Pharm Educ.
2006 June 15; 70(3): 55. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1636952/
Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality. Dr. Fleda Mask Jackson. Joint Center
for Political and Economic Studies, Health Policy Institute.
www.jointcenter.org/hpi/sites/all/files/IM-Race%20and%20Stress.pdf
Asian & Pacific Islander American Health Forum. Policy, Advocacy, and Data.
http://www.apiahf.org/policy-and-advocacy/policy-priorities/health-equity
The Myth of the “Model Minority” and What it Means for Health Care. June 27, 2012.
http://www.rhrealitycheck.org/article/2012/06/27/model-minority-myths-and-maternal-health
36
Global Advertising Strategies is a fullPrime Access is a full-service marketing
service cross-cultural and international
and advertising agency that creates
marketing and communications agency
customized marketing programs targeted
headquartered in New York. Its client base
to the multicultural consumers and social
consists of some of the world’s leading
networks of the New American Marketplace,
pharmaceutical, health care, wellness, and
inclusive of Hispanic, African American
Beyond
Your
lifestyle brands. Reach
With over
a decade
of Longitude.
and GLBT consumers. This includes the
experience in cultivating and executing
creation and execution of messaging for its
successful campaigns within cross-cultural
clients’ brands, across traditional, digital
and international markets, Global knows
and other new media. Prime Access and
what it takes to establish and build a brand
its award-winning campaigns have been
identity across the many diverse cultural
featured on CNBC Business News and
groups within the US, and in unique
in The New York Times, The Wall Street
markets around the world.
Journal, Fortune and Advertising Age. Our
work has been honored by awards from the
ANA, Medical Marketing & Media, and
DTC Perspectives, among others.
TM
For more information,
please visit Global’s website at:
www.global-ny.com
For more information,
please visit the company website at:
www.prime-access.com