Cultural Competence in Caring for African Americans with HIV

Transcription

1 Cultural Competence in Caring for African Americans with HIV December 14, 2016 Alexis Powell, MD Assistant Professor, UM Dept. of General Medicine Division of Infectious Diseases

2 Objectives 1. Review the contribution of bias to health disparities. 2. Define cultural competence. 3. Review the HIV burden in African Americans. 4. Look at aspects of health care where cultural competence may be usefully applied.

3 Seminal Health Disparities Inquiry The Healthcare Research and Quality Act, 1999 Agency of HRQ within the DHHS The Institute of Medicine (IOM) was tasked with evaluating racial/ethnic disparities in health. - More than 100 studies were reviewed - Variables controlled: access, race vs. severity/progression, place of care etc.

4 IOM Findings: Disparities exist in a number of disease areas and are found across a range of procedures The majority of studies found disparities in clinical services that are equally effective for all racial and ethnic groups. l-treatment-confronting-racial-and-ethnic-disparities-in-health- Care/Disparitieshcproviders8pgFINAL.pdf

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6 National Standards for Culturally and Linguistically Appropriate Services in Health Care CLAS standards DHHS, Office of Minority Affairs Developed to address healthcare systems ecology Applies to any public or private institution involved in any aspect of health care delivery df

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8 Bias: a particular tendency, trend or inclination, feeling or opinion especially one that is preconceived or unreasoned Credit: NASA, ESA, and A. Feild (STScI)

9 Qualities of a Good Physician via Google i-studentglobal AUA WebMD Soliant Health Professionalism Compassion Confident Confident Empathy Strong Work Ethic Empathetic Empathetic Attentiveness Professionalism Humane Skilled Forward Thinking Knowledge Personal Focused Composure Confidence Forthright Knowledgeable Industrious Humility Respectful Passion Thorough Lives and Promotes a Healthy lifestyle Respectful Honest and Forthright Humane

10 Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities Elizabeth N. Chapman, 2013 Physicians demonstrate implicit bias favoring whites and view black patients as uncooperative

11 Provider Contribution to Health Disparities VanRyn, et al, AJPH 2003 * Lower expectations for minority patients (e.g. tight control of diabetes) * Less effort spent communicating with minority patients (e.g. influenza vaccine) * Gatekeeper bias- (e.g. African-Americans with renal failure less likely to be placed on renal transplant list - not related to patient preference)

12 Everyone has bias: Bias becomes evident at the age of 3 years. Recognizing and managing personal bias is essential to the development cultural competence.

13 Why Focus on Bias? Because Every Encounter is a Cross-Cultural One. Hippocratic Oath is inadequate Joint Commission mandates it Federal Laws State Laws Good Practice!

14 Cultural Competence Administration on Developmental Disabilities, 2000 services, supports or other assistance that are conducted or provided in a manner that is responsive to the beliefs, interpersonal styles, attitudes, language and behaviors of individuals who are receiving services, and in a manner that has the greatest likelihood of ensuring their maximum participation in the program. DHHS, Administration on Developmental Disabilities, 2000, retrieved from Curricula Enhancement Module Series, A Project of the National center for Cultural Competence, Georgetown University Center for Child and Human Development, May 6, 2016.

15 Cultural Competence Continuum Adapted from Cross, et al, 1988,1989 and Ponterotto,1988, retrieved from May Destructiveness Advanced Cultural Competence Incapacity>>>Blindness>>>Pre-competence

16 Variables of Systemic Vulnerability Discrimination and Segregation Healthcare access/outcomes gap Poverty and Incarceration Stigma

17 HIV in African Americans 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12% of population 44%New HIV DX 48%AIDS DX All Others African American

18 Adherence There has been a greater benefit of HAART on mortality in whites as compared to blacks In Non-Hispanic Blacks a higher risk of HIV mortality even among those without concurrent AIDS, indicating a need to identify and address barriers to HIV care in these populations. Examination of Inequalities in HIV/AIDS Mortality in the United States From a Fundamental Cause Perspective Marcie S. Rubin, MPH, MPA, Cynthia G. Colen, PhD, and Bruce G. Link, PhD Racial-ethnic differences in all-cause and HIV mortality, Florida, Trepka MJ1, Fennie KP2, Sheehan DM2, Niyonsenga T3, Lieb S4, Maddox LM5.

19 Adherence Bogart, et.al. Medical Decision- Making 2001 * Physicians less likely to prescribe antiretrovirals to patients that are likely to be non-adherent * Same physicians felt that African-Americans less likely to be adherent to treatment

20 Moskowitz, MD A study of pain treatment provided for 169 HIVinfected indigent patients: PCPs trusted white more than nonwhite patients despite similar rates of reported illicit drug use or opioid misuse. Dayna Bowen Matthew, Just Medicine: A Cure for Racial Inequality in American Health Care.

21 Adherence Blacks had a greater rate of HAART therapy at 94% compared to 83% of whites -Oramasionwu, et al, 2009 However, Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. - M C Kong, et al,

22 MACH14 Study J Acquir Immune Defic Syndr. 2012;60(5): A study of 1886 participants (54% white, 28% black, 14% Hispanic) from the HIV Cost and Services Utilization Study: 40% reported having a discriminatory health care experience since their HIV diagnosis 24% failed to completely or almost completely trust their health care providers

23 Stereotype Threat-induced Anxiety USC and Loyola Marymont University, published 2014 The affect of waiting room poster images depicting AA women in stereotypical health situations on anxiety levels of woman Black women who strongly self-identified as black reported the greatest amount of anxiety An unintended byproduct of public health campaigns is that they often communicate and reinforce negative stereotypes about certain groups of people. -Cleopatra Abdou

24 Patient Trust African Americans have been shown to have greater awareness of the documented history of racial discrimination in the health care system

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27 Jacobs, et al, the majority of respondents indicated that the race of the physician did not matter. Trust: Technical and interpersonal competence, compassion, reliability, dependability, communication Distrust: Experiences and expectations of racial and financial discrimination

28 Primary Care Assessment Survey, Kao, 2000 Highest Trust Correlates: Assessment physician s communication Level of interpersonal treatment Physician s knowledge of the patient Lowest Correlates: Longitudinal continuity of the patient-provider relationship Preventive counseling Patient s financial access to care

29 Racial Concordance Several studies have reported that racial discordant clinical scenarios are rated as less participatory and less satisfactory However, only 22% of AA stated a preference for an AA doctor- Arnold, Elser R, 2007 Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94: Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient physician relationship. JAMA. 1999;282: Saha S, Komarony M, Koepsell TD, Bindman AB. Patient physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 2005;159:

30 Tuskegee Syphilis Study Legacy Many participants perceived events that others would see as routine or incompetent medical care as experimentation and attributed this expectation to their knowledge of the Tuskegee Syphilis Study, whether or not they could identify the study by name

31 Clinic Ecology Finances Patient Provider Interpersonal communication Knowledge Insurance Compassion Health factors??? Trust??? Provider factors

32 Health Literacy Ratzan and Parker definition as used in a 2004 Institute of Medicine (IOM) report: the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Andrulis and Bach 2007: It s more than understanding words how a person interprets healthcare messages.

33 Health Literacy National Assessment of Adult Literacy 2003: 58% of Blacks exhibited basic or below basic health literacy compared to only 28% of whites. icals/ojin/tableofcontents/vol142009/no3sept09/cultural-and-linguistic- Barriers-.html

34 Health Literacy is Multifactorial Low Income Lack/Type of Insurance Low Education Low Health Literacy The Health Literacy of America s Adults, Results from the 2003 National Assessment of Adult Literacy. Retrieved May 7, 2016.

35 VanRyn, et.al. Soc Sci Med 2000 Race of patient affected physicians perceptions of, and attitudes towards patients after controlling for covariates African Americans perceived less: pleasant, intelligent, educated, adherent to medical advice

36 Low Literacy Does Not Equal Low Intelligence!! Health-Related Experience is a major factor in developing Health Literacy Health Literacy Health- Related Experience

37 Single Item Literacy Screener (SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written health materials from your doctor or pharmacy? Never or Rarely vs. Sometimes, Often, Always Norris NS, MacLean CD, Chew LD, & Littenberg B. The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice 2006, 7:21, available from

38 Health Literacy Intervention Culturally and Linguistically Appropriate Services(CLAS standards) Health Coaches Community Health Promoters Clinical pharmacists

39 Religion The Black Church misnomer trivializes the religious experience of African Americans *participate in the gamut of religious denominations *churches are diverse, reflect individual communities *ignores the privately experienced interiorized religion(described by Alport, 1958).

40 Religion African Americans are the most religious ethnic group in the U.S.- Pew Research Center, A study of YMSWM identified religion and spirituality as consistent sources of strength and coping regardless of ongoing affiliation with a specific church. Foster et al.

41 Religion 41% of patients want to discuss religion with their doctor, but only 8% have done so. 41% recalled an instance when religion played a part in medical decision- making. Williams, J., Meltzer, D., Arora, V., Chung, G., & Curlin, F. (2011). Attention to inpatients religious and spiritual concerns: Predictors and association with patient satisfaction. Journal of General Internal Medicine. July, 1 Published Online. McCord, Gary et al. Discussing spirituality with patients: A rational and ethical approach, Annals of Family Medicine,.

42 Religion Whitely(2012), proposes we adopt the notions of Cultural Safety or Cultural Humility in addressing religion (Polaschek, 1998; Tervalon & Murray-Garcıa, 1998) Puchalski, 2006 FICA assessment tool: Faith and Beliefs Importance Community Address in care

43 Spirituality in HIV Spirituality uniquely predicts health and wellbeing outcomes in those with HIV/AIDS such as improvements in life satisfaction, functional health status, and health-related quality of life after controlling for factors such as age and HIV symptoms (Pargament et al., 2004). Spirituality in HIV+ Patient Care Joni L. Utley, MA & Amy Wachholtz, PhD, MDiv

44 Spirituality Spiritual struggle, anger, or sense of punishment has been associated with poor adherence. (Parsons, Cruise, Davenport, & Jones, 2006) *Unpublished data from the Patient Centered Medical Home study at UM indicates the majority of patients seen in the HIV clinic feel less than human.

45 Acknowledging Religion may validate some patients who have become marginalized by Stigma or Stigma Threat Wellbeing Religion & Spirituality Patient

46 Summary 1. The exploring of Provider bias is an essential part of improving cultural humility/competence. 2. Reviewed the historical context of AA vulnerability and current HIV disparities. 3. Trust it s complicated. There s no protocol, but we identified some correlates. 4. The recognition that low health literacy does not equate low intelligence presents an opportunity for effective interventions that may improve outcomes and help decrease health disparities. 5. Religion and spirituality: our patients may be waiting for us to ask.