By: Daphney Dorcius, MPH
The United States is an increasingly global society; currently, immigrants make up 30% of the nation’s population, and this percentage is projected to increase to 50% by 2050 (7). The U.S. Census Bureau reports that Florida has the largest immigrant population in the country, making it one of the contributing the most to the diversity of the nation. Minority populations including African Americans, Asian Americans, Native Americans, and Latinos have a higher prevalence of chronic disease, higher mortality rates, and poorer health outcomes, compared to the White population. In order to make improvements in health equity, disparities-focused interventions in health care delivery will be necessary (1).
Although health disparities have been documented across minority populations, each subpopulation faces specific challenges and risks. There are nearly 53 million Hispanics living in the United States, making up about 20% of the population (9). Poorer health outcomes among Hispanics can be largely attributed to linguistic and cultural barriers as well as the lack of access to preventive care. Heart disease, stroke, and diabetes are the main causes of death within this population, with the rate of obesity being higher than non-Hispanic Whites. African Americans make up the second largest minority group in the U.S., with a population of approximately 43 million in 2012 (1,9). Similarly to Hispanics, African Americans face a higher mortality rate than Whites. Causes of death, chief among being stroke, cancer, asthma, diabetes, HIV/AIDS, and homicide, can be largely attributed to socioeconomic and cultural forces. Similarly to African Americans, American Indians/Alaska Natives face barriers such as geographic location and culture, that prevents them from receiving quality medical care. As a result, some of the leading causes of death seen within this ethnic group include heart disease, diabetes, and stroke. Although Asian Americans have the highest life expectancy than any other group in the US, it is worth noting that due to factors such as fear of deportation and language/cultural barriers, a high prevalence of chronic obstructive pulmonary disease and liver disease has been reported within this population, together with an increased risk for heart disease, stroke, and diabetes (US Department of Health and Human Services) (9). Significant health disparities faced by minority populations indicate that cultural factors present a unifying barrier to quality health care in the U.S., and are largely responsible for the disproportionate burden of negative health outcomes among non-Whites.
The consideration of cultural factors in dialogue surrounding health care and patient- centered care has been absent for too long. Health care providers are now facing the reality of having to adapt their current methods of health care delivery to become more culturally responsive. Such an approach requires providers to think differently when addressing the physical and behavioral health needs of patients. Consequently, National CLAS standards were put into place as a form of Blueprint for the acquisition of Cultural Competency within the health sector (10). Critics questioned CLAS’s applicability due to the underlying notion that competency necessitates measurement scales that could not be applied to assess cultural awareness. In the effort to resolve this issue, Cultural Responsiveness was proposed. Many prefer this term “Responsiveness” because it places an emphasis on one’s ability to respond to the diversity of communities by focusing on social and cultural factors impacting patients’ lives (8).
A clear understanding of culture is crucial in health care delivery because culture has the ability to influence the decisions, attitudes and beliefs of patients in relation to their access and engagement in healthcare, and can exponentially impact health outcomes. Culture plays a critical role in the patient’s perception of health care delivery, their experiences in relation to health and illness, and their ability to reject, accept, and commit to proposed treatment options (6). The literature acknowledges the importance of cultural awareness within the health sector because of the impact it has on prevention and health promotion initiatives, but emphasizes the necessity for responsiveness to enhance of patient-provider relationship and improvement in health outcomes within minority communities (4,5,6).
Dr. Erin Kobetz, whose research into the cultural barriers that prevent Haitian women from accessing breast cancer screening methods in Miami, Florida, exemplifies cultural responsiveness to healthcare in minority communities. Although mammography screening has been recognized as the screening method of choice to decrease morbidity and mortality from breast cancer in women in the U.S., women from minority ethnic groups, especially those who are foreign born, have not used these resources adequately. Consequently, a disproportionate number of women from these groups die of late-stage breast cancer, which, if caught at a treatable stage, could have been prevented (3). The findings of the research showed that Haitian women in Miami did not receive routine mammograms due to barriers including language and communication problems, citizenship and immigration, and social-cultural customs. Her work emphasizes that these barriers should be considered within the social context of patients’ lives in order to develop and implement effective interventions (3).
More than half (57%) of Haitian women are monolingual Kreyol speakers (3). Therefore, these women would be less likely to access care because of the discomfort and fear caused by their inability to understand the language their being spoken to. As a result, poor quality of communication and a lack of trust between Haitian women and health care providers are likely to impact diagnostic reliability and decrease treatment adherence. Furthermore, the cultural depiction of health differs across cultures. Haitian women describe health as absence of obvious physical or psychological symptoms (3). For diseases that are asymptomatic and can be prevented via screening, it is highly likely that these women will have a higher morbidity and mortality rate than women of other groups because they will not access health care on a timely manner. Being able to understand this aspect of the culture of a population will therefore allow health care providers to respond in the appropriate manner via education, screening intervention, and counseling, all of which can be tailored to their beliefs. For example, plant based remedies are highly valued within the Haitian culture. Understanding that the usage of oil and plant based mixtures for cleansing of the body inside and outside is important for appropriate response, prevention of Drug-Drug interactions, and even for preventative methods. Finally, diagnostic is associated with death within the Haitian community. As a result, the people will be less likely to go to health care facilities out of fear. Being able to understand that can strongly affect the deliver of messages regarding diagnostic in a manner that would promote continue of care by the patient.
Skin color should not be used as an indicator of similarity of cultural beliefs and practices because of differences in heritage (1,4). For instance, many similarities exist between the African American culture (people of African descent) and Caribbean, but there are key cultural differences that have the capacity of impacting health outcomes. For example, African American families tend not to be restricted to blood related members to often include non-related individuals (5). Therefore, when acquiring information on family history, and when counseling patients on inheritable conditions, it is important to be mindful of the formulation of the questions. Beyond this, older generations tend to be more conservative and traditional. They tend to have a strong voice in the decision making within families while also holding housekeeping task within their households (2,5). Because of the strong families ties and their cultural norms, institutionalization of the Elders has been historically avoided.
Minority populations face an array of interconnected social factors that ultimately determine health outcomes at the population level. The literature has shown that living in disadvantaged neighborhoods increase the risk of negative health outcomes such as obesity, and the prevalence of chronic illnesses increase because of limited access to healthy affordable food (4,6). The relationship between faith and health outcomes plays a crucial role in addressing health disparities. People within the African American ethnic group have a strong affiliation to their parish. A good understanding on this aspect of their culture allows for better management of health related behavior that could be linked to their faith. Finally, understanding the type of diet that a person consumes based on their culture, and being able to link this information with convenience and cost is another avenue to influence the dietary habits of individuals from minority groups impacted by economical barriers.
Health equity has become the main topic of interest within our heath care system because of the common goal among health care providers, policy makers, and the community at large. In addition to contributing to better health outcomes and improvement of diagnostic accuracy, cultural responsiveness in health care has the capacity to increase adherence to recommended treatment by allowing health care providers to obtain complete health information from the patient due to better communication between health care provider and patient. Because the provider is much more informed, he/she is able to make more accurate assessment mindful of the patients’ cultural background. Because social-cultural barriers are understood when this type of care is applied, there a decrease in the delay in health care seeking and therefore, increase the quality of life and care. The patient is much more comfortable in seeking care because they feel that their culture is respected, and therefore, they, themselves feel respected. It is widely accepted that quality of care is a right for all regardless of cultural norms present witting a certain group. Thus, culturally responsive health care delivery has emerged as the new blueprint of health care practices.
Daphney Dorcius earned her Masters in Public Health from University of Miami is now a first-year medical student at Florida International University. She has a strong interest in the field of community health and an intense desire to fight against health disparities.
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2. Carteret, M. (2011, Summer). Health Care for African American Patients/Families. Dimensions of Culture Newsletter .
3. Erin Kobetz, J. M. (2010). Barriers to Breast Cancer Screening Among Haitian Immigrant Women in Little Haiti, Miami. Journal of Immigrant Minority Health , 12, 520-526. 4. Maria, C. (2008). Cross-Cultural communications of health care professionals . Retrieved 2016, from Dimensions of culture : http://www.dimensionsofculture.com/2010/10/576/
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9. US Department of Health and Human Services. (2014, March 1). Minority Health HHS. Retrieved 2016, from OMH: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlID=26
10. US Department of Health and Human Services. (n.d.). ClAS and CLAS Standards. Retrieved from Think Cultural Health: https://www.thinkculturalhealth.hhs.gov/content/clas.asp