Disparity in Care:
A Problem with a Solution
Presented by Marcy Donley
Healthcare Communications Consultant
Data on Existence of Disparities
 In
2002, the IOM released Unequal
Treatment: Confronting Racial and Ethnic
Disparities in Health Care.
 It
reported evidence of healthcare
inequality  irrespective of income,
insurance status, or education.
Reasons for Inequalities
 Subtle
differences in the way individuals
respond to treatment.
 Variations
in individual help-seeking
behavior.
 Barriers
in language proficiency, literacy
level and cultural beliefs.
Reasons for Inequalities (cont.)

A healthcare professional’s beliefs may
influence patient interaction.
 The
healthcare professional may be
limited in the amount of time available to
gather information.
 An
unconscious prejudice or bias may
exist.
Why Is It Important?
 The
US Census Bureau estimates that by
2050, one in every two Americans will be
an African/American, Hispanic/Latino,
American Indian/Alaskan Native, or Native
Hawaiian/Pacific Islander.
“Health care providers should be made
aware of racial and ethnic disparities in
health care, and of the fact that these
disparities exist, often despite
providers’ best intentions. In addition,
all current and future health care
providers can benefit from crosscultural education programs.”
“Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare”
Institute of Medicine, March 2002
Title VI -- Civil Rights Act of 1964
“No person in the United States shall, on
the ground of race, color or national
origin, be excluded from participation in,
be denied the benefits of, or be subjected
to discrimination under any program or
activity receiving federal financial
assistance.”
CLAS Standards
 National
Standards for Culturally and
Linguistically Appropriate Services (CLAS)
in Health Care Final Report, OMH, 2001

The Standards
• http://www.omhrc.gov/templates/browse.aspx?lvl=2
&lvlid=15

Executive Summary
• http://www.omhrc.gov/assets/pdf/checked/executive
.pdf
Healthcare Disparities Report

The Agency for Healthcare Research and
Quality’s National Healthcare Disparities Report
was one of the first efforts (2003) to measure
differences in health care by various
populations.

An annual report is released along with the
National Healthcare Quality Report.

http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf
Purpose of NHDR

Identify the differences or gaps where some
populations receive poor or worse care than
others and to track how these gaps are
changing over time.

Emphasis is on disparities related to race,
ethnicity, and socioeconomic status.

Also includes “priority populations” (women,
children, older adults, rural, disabilities/special
needs).
2008 Report Key Findings
 Disparities
persist in health care quality
and access.

Magnitude and pattern of disparities are
different within subpopulations.

Some disparities exist across multiple
priority populations.
National Focus on Cultural and
Linguistic Competency
 Since
it has been found that cultural
expectations, assumptions, and language
affect the quality of care patients receive…
 Efforts
have focused on improving the
skills of health care professionals to
deliver culturally and linguistically
competent care for diverse populations.
Goals for Today

Make you aware that cultural expectations,
assumptions, and language affect the quality of
care patients receive.

Bring you the best of available research, tools
and resources to improve cultural and linguistic
competency.

Encourage self and organizational assessment
and improvement that facilitates bridging the gap
in healthcare disparities.
Health Literacy
Health Literacy
 Poor
health literacy is "a stronger predictor
of a person's health than age, income,
employment status, education level, and
race.“ (Source: AMA)
 90
million people in the United States
(nearly half the population) have difficulty
understanding and using health
information. (Source: IOM’s Health
Literacy: A Prescription to End Confusion)
What is Health Literacy
 Health
literacy is the “degree to which
individuals have the capacity to obtain,
process, and understand basic health
information and services needed to make
appropriate health decisions.”
Adopted by the IOM and Healthy People 2010
More Than Reading or Writing
 Health



literacy is the ability to:
Comprehend complex vocabulary and
concepts including medical terms or
probability and risk.
Share personal information with providers
about health history and symptoms.
Make decisions about basic behaviors like
healthy eating and exercise.
Health Literacy Definition (cont.)


Engage in self-care and chronic-disease
management.
Navigate a complex healthcare system  from
walking hospital corridors to filling out
insurance forms.
Source: HHS Office of Disease Prevention and Health Promotion
Low Literacy/
Limited English Proficiency
Myths About Low Literacy
 Myth:
People who have limited literacy
skills are dumb and learn slowly, if at all.
 Fact:
Most people with low literacy skills
have average IQs and function quite well.
Myths About Low Literacy (cont.)
 Myth:
 Fact:
People will tell you if they can’t read.
Since there is a strong social stigma
attached to limited reading and writing
skills, nearly all nonreaders or poor
readers will seek to conceal this fact. They
will use ruses such as “I forgot my
glasses” or “I’ll have to take this home for
my husband (or wife) to see it first.”
Myths About Low Literacy (cont.)
 Myth:
Years of schooling is a good
measure of literacy level.
 Fact:
Years of schooling tell what people
have been exposed to, not what reading
skill they acquired. Surveys show that, on
average, adults currently read three to five
grade levels lower than the years of
schooling completed.
Writing for Low Literacy
 Organize
information so the most
important behavioral or action points come
first
 Break
complex information into smaller,
understandable chunks
 Use
simple language or define technical
terms
Writing for Low Literacy (cont.)

Use short sentences and active voice.

Design for impact; use ample white space,
bullets for lists/numbers for steps.

Check reading level (MS Word can check RL
and grammar)

Test materials with audience.

Consider using translated or easy-to-read
patient materials.
Reading Level
Contact your insurance carrier at least 24 hours
before your planned admission time to obtain
needed referrals or authorizations. Because
many insurance companies have strict
guidelines about covered services, where they
can be done and which physicians can provide
them, your insurance company must be involved
in your admission to the hospital. Even though
the hospital's admissions office will contact your
insurance company, there may be information
only you can provide.
Speaking for Low Literacy
 Avoid
jargon and use everyday examples
to explain technical or medical terms.
 “Read”
written instructions out loud.
 Speak
slowly (don’t shout).
 Draw
pictures; use posters or models; use
video or audio.
$50,000 Words

A television news anchor asked a physician on
air about a celebrity’s cancer. The doctor stated:
“Well, the cancer has metastasized.”

The TV anchor immediately realized that most
viewers may not understand what the word
“metastasized” means. He asked the doctor to
explain.

The doctor was quick to say that metastasize
means the cancer has “spread” or “traveled” to
other parts of the body.
Teach Back Method

Ask the patient to restate the conversation in
their own words. Example: Ask them to repeat
back instructions on taking a prescribed
medication.

When their understanding is not accurate or
complete, repeat the information until is it
restated correctly.

You can also ask the patient to show you how
they will conduct a process, such as checking
and recording blood sugar.
Limited English Proficiency
 Assess
percentage of foreign language
use in your population, consider
translating commonly used materials
 Consider
using professional interpreters;
assess staff capabilities
 Consider
offering language translation
telephone service
Cultural Competency
What is Culture?
 Culture
refers to integrated patterns of
human behavior of racial, ethnic, religious,
or social groups that include:

Language/Communications

Actions/Customs

Beliefs/Values/Institutions
Cultural Considerations
 Style
of Speech  People vary greatly in
length of time between comment and response,
the speed of their speech, and their willingness
to interrupt.



Tolerate gaps; impatience may be seen as
rude
Modify your speech to match that of the other
person
Don’t interrupt or be offended by interruption
Source: Industry Collaboration Effort
Cultural Considerations (cont.)
 Eye
Contact  The way people interpret various
types of eye contact is tied to cultural background
and life experience.


Euro-Americans may interpret an indirect gaze
as a sign of disrespect. Other cultures may see
direct eye contact as rude.
If someone seems uncomfortable with direct
gaze, try sitting next to the person instead of
across from them.
Cultural Considerations (cont.)
 Body
Language  Sociologists say that 80%
of communication is non-verbal. Body language
varies greatly by culture, class, gender, and age.



Follow the patient’s lead on physical distance
and touching.
Be very conservative in your own use of
gestures and body language.
The way that pain or fear is expressed is
closely tied to a person’s cultural and personal
background.
Cultural Considerations (cont.)
 Communication
Style  English predisposes
us to a direct communication style, however
other languages and cultures differ.



Formal or informal? If the patient’s preference
is not clear, ask how they would like to be
addressed.
Patients from other backgrounds may not ask
questions or answer with narrative.
Avoid yes/no questions. Ask open-ended
questions.
Culture by Ethnicity - Latino





Illness may be seen as an imbalance between
internal and external. (hot vs. cold, natural vs.
unnatural, etc.)
Many patients seek care from folk healers.
The mother decides when to seek medical care, the
father gives permission.
La Familia is an important source of emotional
support.
Relationships are extremely important.
Source: “Culture Clues” University of Washington Medical Center
Culture by Ethnicity - Asian





Health may be viewed as finding harmony between
complementary energies.
May use foods to restore yin/yang balance.
May try traditional approaches first; may consider
Western medicine too strong.
Emphasis on loyalty to family/traditions; not on
individual feelings.
Family may not tell patient bad news.
Source: “Culture Clues” University of Washington Medical Center
Culture by Ethnicity - AI/AN




A holistic view in which people, community,
nature, and spirituality are interconnected and
interrelated.
Practices may include different rituals and
ceremonies as well as herbal remedies
(sweat lodge, talismans)
Family and community (tribe) may be
involved and source of support.
May resist expressions of pain.
Source: “Culture Clues” University of Washington Medical Center
Resources
Assessment Tools
 Organizational
 Policy
 Health
Practitioner
 http://www.hrsa.gov/culturalcompetence/
Cultural Competency Resources
– University of Washington
Medical Center
 EthnoMed
 Information
about cultural beliefs, medical
issues and other related issues pertinent
to the health care of recent immigrants.
 http://ethnomed.org
Cultural Competency Resources (cont.)
 National
Center for Cultural Competence
 http://www11.georgetown.edu/research/gu
cchd/nccc/
Health Literacy Resources
 NIH
“Clear Communication” Health
Literacy Initiative
 http://www.nih.gov/clearcommunication/ind
ex.htm
Low Literacy Resources
 MedlinePlus
Easy to Read Brochures by
Health Condition

http://www.nlm.nih.gov/medlineplus/easytorea
d/easytoread_a.html
LEP Resources
 Guide
to Implementing Language Access
Services
 Assists
healthcare organizations in
planning, implementing, and evaluating
language access services.
 https://www.thinkculturalhealth.org/Langua
geAccessServices.asp
In-Language Resources
 National
Network of Libraries of Medicine
Health Brochures in Other Languages

http://nnlm.gov/outreach/consumer/multi.html
#A2#A2
 Healthy
Roads Media (Health resources in
many languages and multiple formats.

http://www.healthyroadsmedia.org/index.htm
Quality Improvement Resources

Multicultural Healthcare: A Quality Improvement
Guide (Based on CLAS Standards)

New resource from the National Committee for
Quality Assurance, developed in collaboration
with Lilly USA

QI initiatives to improve culturally and
linguistically appropriate services (CLAS) and to
reduce disparities in health care

http://www.clashealth.org/
Continuing Education
Resources
 Think
Cultural Health -- free online
courses with continuing education credits
for physicians and nurses.
 Sponsored
by the Office of Minority Health
(OMH)
 https://www.thinkculturalhealth.org/
Conclusion
 The
2008 National Healthcare Disparities
Report concluded that some Americans
receive even worse care than other
Americans, due in part to differences in
access to care, provider biases, poor
provider-patient communication, poor
health literacy, and other factors.
Thank you for being part of
the growing nationwide
effort to help bridge the gap
in health disparities.