WST Exam 1 material
RWJF's Annual Community Rankings
. . . show meaningful gaps in health outcomes among counties across America because of differences in opportunities for health. The location of our homes plays a critical role in shaping our health and the health of the whole community. Why? Question: What are the opportunities for health among children growing up in families in east vs west Gainesville? Meant to show the gaps in health opportunities in many scales
Ethnicity is defined as:
1. A group of people who share a common cultural or national heritage and often sharing a common language or religion. 2. People from different races may share a common ethnic identity, for example, Hispanic Americans (ethnicity) may identify as White or Black race.
Characteristics of Culture
1."Culture" is a social construct 2.It is not static 3.Learned and passed from generation to generation 4.Shared beliefs, attitudes, values and behaviors that guide the worldview of members and explain life events 5.Shared language (oral communication) 6.Shared alphabet (written communication) 7.Shared rites of passage Understanding values and differences enable us to be inclusive = comprehensive, all-encompassing, not exclusive
List the health problems associated with a lack of access to care in rural communities.
1.20% population lives in rural areas but only 10% of physicians establish rural practices 2.Mental health services are absent in 20% of rural communities 3.Dental care is inadequate 4.Most EMS first responders are volunteers 5.120+ rural hospitals have closed since 2005 6.Medicare payments to rural hospitals < urban 7.High poverty rates - abt. 24% of rural children live in poverty 8.Greater use of food stamps and federal assistance 9.Fewer residents have health insurance 10.Diets are less nutritious and residents exercise less 11.High school graduation rates are lower 12.Alcohol abuse and use of smokeless tobacco is higher among rural youth; more adults smoke 13.Higher prevalence of obesity and hypertension - higher death rate from MI (heart attack) 14.1/3 of MVA occur in rural areas - 2/3 are fatal 15.More residents die from unintentional injuries/gunshot wounds 16.Rural men have higher rates of suicide; women's rate is increasing
Generation to Generation
1.How are the shared attitudes, values, beliefs and behaviors identified and communicated? 2.Who is responsible for teaching the important aspects of culture? 3.What does acceptable oral communication include? Same sex? Between the sexes? 4.What does acceptable written communication include? Alphabet? Pictures? 5.What are the meaningful rites of passage?
Practical Application of cultural competence
1.Let's start by asking better and different questions. Your information about a patient is only as good as the questions asked. 2.Patient intake forms are out of step with contemporary society and do not reflect current social changes. Intake forms are physician-centered and not patient-centered
Four Types of IPV
1.Physical violence - intentional physical force that may cause death, disability, injury or harm 2.Sexual violence - forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent. 3.Stalking - a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one's own safety or the safety of someone close to the victim. 4.Psychological aggression - use of verbal and non-verbal communication with the intent to harm another person mentally or emotionally and/or to exert control over another person •Humiliation •Withholding information •Isolation •Deliberate actions to make victim feel diminished or embarrassed
Define and give an example of culturally inclusive care.
1.Visible non-discrimination policy 2.Staff training!! 3.Diversity represented in artwork displayed, educational handouts, reading materials 4.Use of inclusive language by all - e.g. marital status becomes relationship status 5.Gender neutral bathrooms 6.Collect information about sexual orientation and gender identity from ALL patients 7.Take routine sexual health histories from ALL adults and adolescents 8.Screen ALL patients for adverse childhood experiences (ACEs) and intimate partner violence (IPV) 9.Learn about health care needs unique to vulnerable populations - e.g. African American MSM have greater risk of HIV/AIDS 10.Know the community served by your practice and health care system
Race is defined as:
A group of people distinct from other groups due to physical or genetic traits shared by the group. Most biologists and anthropologists do not recognize race as a biologically valid classification, in part because there is more genetic variation within groups than between them. 2. A genealogical line; a lineage
Locus of Control
A psychological construct that describes the extent to which people believe they have power over events in their lives. •Internal LOC - individuals believe they can influence events and their outcomes •External LOC - events and their outcomes result from outside forces.
ACEs and the SDOH
ACEs are linked to mental illness, chronic health conditions, and premature death. The physical, social, and economic environment in which children live can influence their exposure to ACEs. More important, the SDOH reflect the: 1.quality and quantity of resources available to mitigate the damage caused by ACEs 2.access to intervention programs -------- Research ongoing in this area Spaces in pyramid indicate gaps of scientific knowledge Affects: Quality and quantity of resources available to navigate damage caused by ACEs & intervention programs SDOH affects access to resources for those that were ACE
Define Adverse Childhood Experiences (ACEs) and their relationship to health and chronic disease.
ACEs: History & Study Concept •Started in 1995 w/Kaiser Permanente HMO members •17,000 + middle class adults participated •Data collected from comprehensive physical exam •Information gathered about childhood experiences with neglect, abuse and family dysfunction •Study is on-going by CDC and Kaiser Permanente Stressful or traumatic childhood experiences are common pathways to cognitive, social and emotional impairments that increase risk for unhealthy behaviors, violence/re-victimization, disease, disability and early mortality. The emotional experiences of childhood exert lasting and powerful effects on the physical, social and mental health of adults.
Prevalence
About 1 in 5 women and 1 in 12 men
Abuse vs neglect
Abuse- what someone do toward someone Neglect- what is withdrawn or absence of what is needed for nurturing
Middle Eastern American
Anyone of Western Asian and North African extraction including indigenous Middle Eastern groups in diaspora [e.g. the Jewish diaspora, Kurdish Americans, Assyrian Americans] and current immigrants from modern-day countries of the Arab League, Armenia, Azerbaijan, Cyprus, Georgia, Iran, Israel and Turkey.
VHCPP enables providers to volunteer in clinics or to see eligible clients in their private offices or corporate facilities.
Alachua County Safety Net Clinics: •ACORN Clinic •Equal Access Clinics Network •Helping Hands Clinic •Mobile Outreach Clinic •RAHMA Mercy Clinic •Samaritan's Clinic
Explain the reasons for health differences between populations.
All health differences are NOT health disparities - A disparity is pointing to a difference that results from social injustice or economic or geographic inequities - Informed and unconstrained choices (free will, freedom of choice) - State of reserach - history of discrimination, prejudice - Healthcare system Health disparities describe more than differences in health, they have their roots in injustice
Who Are They?
American Indians Members of nomadic hunting and gathering cultures. These peoples traveled in small family-based bands that moved from Asia to North America during the last ice age. Eskimos (Inuit and Yupik/Yupiit) and Aleuts Closest genetic and cultural relations were and are with other Arctic peoples rather than with the groups to their south.
Define Intimate Partner Violence (IPV) and explain its relationship to power and control.
An ongoing pattern of control and domination in a relationship. Smith and Segal, 2015 Patterns of physical, psychological and/or sexual abuse in the home establish power and control of another person. IPV has 2 victims Primary - the person who is abused Secondary - children, family, friends who witness the violence IPV occurs worldwide; experienced by men and same sex couples Impacts are pervasive with short and long term health consequences IPV in adolescence is called teen dating violence (TDV) --------- Pattern of control and domination in relationship Establish power and control of another person We deserve to be treated with respect because you live 2 victims: abused and those around them (children, family, friends who witness) Occurs everywhere and to all kinds of people, impacts are long term In teens- TDV Power and Control wheel of how people can try to control others in an abusive way
Culture and Beliefs about Health
Answers to the question, "Why am I sick?" •Fate/destiny - "if it's meant to be, it will be" [do "all things happen for a reason"?] •Balance among physical, mental, spiritual •Internal bad winds/imbalances in hot & cold •Punishment for sin •Evil spirits •Evil intentions of others - evil eye •Personal weakness - mental illness •Lifestyle practices
Philosophical Approaches to Worldview
Anthropocentric - humans are the central or most significant entities in the world; separate from and superior to nature; human life has intrinsic value while other entities (animals, plants) are resources that may be exploited to benefit humankind. Cosmocentric - individuals exist as part of a larger universe composed of familial/divine spirits, ancestors, social relationships, and the natural world. It is seeing both ourselves and the source of life as being at one with nature... it is learning to live in harmony with the universal rhythms of life. Theocentric - God is the central aspect to our existence; human beings should look after the world as guardians in the way God desires; humans should be considerate to all, from animals to plants to humans themselves; human beings are here for a short time and should be looking after the world for future generations.
Asia: South, Southeast, and Middle East Immigrants
Asians are the fastest growing racial group in the U.S. More than 20 million Asians live in the U.S., and almost all trace their roots to 19 origin groups from East Asia, Southeast Asia and Indian subcontinent.
Assimilation vs. Acculturation definition
Assimilation: minority absorbed into majority Acculturation: minority changes but remains unique to their culture
Ten ACE Parameters
Before the age of 18, chronic: 1-3 Abuse - physical, emotional or sexual 4-5 Neglect (the most damaging of all) Physical Emotional 5-10 Household dysfunction •Household member incarcerated •Violence toward mother •Alcohol or drug abuse in household •Chronic depression or mental illness •Loss of one biological parent (any reason)
Identify the advantages and disadvantages of living in rural communities.
Benefits of rural living: Live with nature in a serene environment Low crime rates Low real estate prices Zoning laws are less restrictive Land for gardening/organic gardening Difficulties for patients and providers: Obstacles to delivery and participation in health care Health disparities are economic, cultural, social, educational, and personal Isolation is associated with rural life
Migration is due to conflict and economic opportunity.
Between 2005-2015, the number of migrants living in the Middle East more than doubled, from 25M to 54M
Summary of Module 3
Building healthy relationships reduces health care costs Intervention can break cycles of generational dysfunction, abuse and neglect It is less expensive to intervene than treat the outcomes of living with toxic stress, abuse, neglect and relationship violence later
Dental Care
Dental care = general practice dentists + pedodontists Goal is a geographic population to practitioner ratio of 5,000:1
As an administrator, explain how you would create a culturally competent clinic or culturally competent hospital.
Cultural competence includes the environment of care 1.What is the culture of the environment? 2.Leadership of the organization? 3.Leadership of the system? Evaluate the environment of care. Culturally competent systems have congruent behaviors, attitudes and policies that come together as a system to enable health professionals to work effectively in cross-cultural situations.
Describe the process (and stages) of cultural competence and its impact on health outcomes.
Cultural competence is a relatively new construct in health care - it began to appear in the literature in the 1990s It emerged from concerns about cultural and linguistic barriers between providers and patients Recognizes different Explanatory Models of Illness - all do not ascribe to the Biomedical Model The original goal was to bridge the "cultural gap" for immigrants with limited English proficiency (LEP) Called cross-cultural medicine, transcultural nursing, multicultural counseling "Cultural competence is the ability to interact effectively with people of different cultures and it ensures the needs of all community members are addressed." It begins with understanding your own identity and values. This skill enables providers to be respectful and responsive to the health beliefs and practices—and cultural and linguistic needs—of diverse population groups." Cultural competence is looking at a person in context to avoid stereotyping. It requires listening carefully and asking appropriate questions to discover health complaints AND beliefs about health and illness. Cultural competence is a developmental process that evolves over time. It is a process of lifelong learning. Individuals, organizations and systems must be culturally competent.
Removing Barriers to Care
Cultural competency is one strategy for eliminating disparities. Following the blueprint provided by the Culturally and Linguistically Appropriate Services (CLAS) Standards is another.
Culture and Social Identity
Cultural identity is the identity or feeling of belonging to a group. It is part of a person's self-concept and self-perception and is related to nationality, ethnicity, religion, social class, generation, locality or any kind of social group that has its own distinct culture. Culture shapes: •meaning of in-groups •relationship between group identity and trust •nature of in-group-outgroup biases Personal identities form around intersecting memberships in different social groups including race, ethnicity, language, immigration/assimilation, sex, gender identity, sexual orientation, religion/spirituality, SES, age/generation, social groups [political affiliation, veterans, incarceration], education, disability, geography USDHHS, Office of Minority Health Culture can also be described by professional membership; e.g. the culture of medicine.
Culture and Models of Health
Cultural memberships offer explanations for health and illness - they explain "why you are sick." Culture: •Defines health and illness •Explains reason(s) for disease •Determines health practices •Determines who is involved in care and their roles/responsibilities What happens when physicians and patients use different models?
Define worldview
Culture explains the worldview of different populations. A worldview is a mental model of reality - a comprehensive framework of ideas & attitudes about the world, ourselves, and life, a system of beliefs, a system of personally customized theories about the world and how it works - with answers for a wide range of questions including illness and health. The beliefs, values, and behaviors of a culture stem directly from its worldview.
The Explanatory Model of Illness
Culture informs health beliefs and practices: 1.What do you call the illness? 2.What do you think caused the illness? 3.Why do you think it started when it did? 4.What do you think the illness does? How does it work? 5.How severe is the illness? Will it have a long or short course? 6.What kind of treatment do you think you should receive? What treatment have you received? [Guyer's corollary] 7.What are the chief problems the illness has caused? 8.What do you fear about the illness?
Define culture,
Culture is a social construct. Culture describes "the values, beliefs, systems of language and communication, and practices that people share in common and that can be used to define them as a group or community. It is important to sociologists because it plays a significant role in the production of social order. Important to health professionals because it explains illness.
Language Differences Complicate Communication
Different cultural values, explanatory models of illness and health practices are difficult to navigate. Language poses another unique barrier and adversely affects access to health care, quality of care, and patient comprehension. Failure to provide care in someone's primary language violates their civil rights [Affordable Care Act, Section 1557]
Alachua County, Zip Code & Opportunity for Health
Disparities between E and W gainesville Half of alachua county lives in Gainesville Literacy comparisons with E and W elementary schools Literacy has many factors: Importance in households Education of parents/area surrounding
Education Is the Most Critical SDOH
Education is predictive of your income Education attainment-- affects what you know and skills you develop Predicts the work you do, related to your income Also effects your social standing, support, and control
Immigrants
English proficiency is higher among foreign-born blacks than the overall U.S. immigrant population 50% black immigrants are from the Caribbean Group membership explains degrees of acculturation and life experience with racism, prejudice and mistrust of medical community
Definitions - Important Distinctions
Equality = sameness, equivalence Inequality = not equal Equity = fairness, justness Inequity = injustice, unfairness Disparity = difference
Describe the purpose and services provided by county health departments, rural hospitals/critical access hospitals, rural health clinics and federally qualified health centers.
Every county in FL has a health department 67 counties = 67 county health departments Larger counties have satellite clinics
U.S. Census, Race, Ethnicity
First, the question is based on how you identify. Second, the race categories generally reflect social definitions in the U.S. and are not an attempt to define race biologically, anthropologically, or genetically. Race categories include racial and national origins and sociocultural groups.
Describe the relationships among race, access to resources and health.
Gaps in health by income and education are larger than the gaps in health by race. We have focused on gaps by race but not SES (and certainly not by education). Your residence determines where you go to school and the quality of your education determines access to resources. BUT, race still matters at every level of education and income. There is a residual effect due to racism and daily micro-aggressions. ------ Education + Income make a larger impact in health than race Greatest disparities are in education and income Our health data is reported by race, sex, but this doesn't occur in the industrial world Most industrialized nations report health data by income-- how can we compare our data to other nations?
Other Shortage Designations
HPSA designation is used by NHSC HRSA has designations for shortages based upon: •Geographic area = Medically Underserved Area (MUA) •Population characteristics = Medically Underserved Population (MUP) These designations are used by researchers, policy makers and others identify communities with provider shortages. MUAs are used to identify geographic area with shortages of health professionals or access to care MUP- populations that have special needs because of income, language, or both Updated randomly & are used by researchers and policy makers
Describe the three kinds of Health Professionals Shortage Areas (HPSAs) and list the health professions that they include.
HPSA is a designation that indicates health care provider shortages: •Primary care •Dental health •Mental health The shortage can be based upon: •Geography - a shortage of providers in a defined area •Population - a shortage of providers for a specific population group (e.g. low income, migrant farmworker) in a defined area •Type of facility - a shortage of providers vCAH, RHC, FQHC vState Mental Hospitals vState or Federal Correctional Facilities vIndian Health Facilities
Culture and Health Care Practices
Healers and healing are part of every culture •Herbal remedies - oral or topical •Amulets - prevent Evil Eye caused by jealousies of others •Cupping, coining - blood is mobilized to an area to promote healing •Chanting, rituals, prayer - affect energy, spiritual condition or impact of external forces •Bloodletting - illness due to too much blood (4 humours: imbalance among blood, phlegm, black bile, yellow bile) •Alternative medicine - acupuncture, chelation therapy •Prescription/OTC medication, surgery
Define health inequalities, inequities and disparities.
Health Inequality: differences in healthcare - differences linked to socioeconomic/environmental disadvantages Inequity: injustice, unfairness Disparities: differences
Define tradition.
Health behaviors reflect cultural identity and tradition Tradition •How we pass elements of a culture from generation to generation, especially by oral communication •a way of thinking or a set of behaviors that groups of people follow continuously from generation to generation; a custom or usage
Important Components of Culture
Health beliefs and practices exemplify areas of cultural difference. Here are other important hallmarks of culture: • Family structure and dynamics • Time orientation • Task vs. relationship • Comfort with change • Personal control over destiny • Self-sufficiency • Status • Individualism
Define and describe the purpose of sovereign immunity and the health care safety net.
Health care safety net systems provide essential care to low-income people in the United States, including those who are uninsured. Core safety-net providers by mandate or mission offer access to care regardless of a patient's ability to pay. Patients include a substantial share of uninsured, Medicaid, and other vulnerable patients. Safety net providers are distinguished by the commitment to provide access to care for people with limited or no access to health care due to financial circumstances, insurance status, or health condition" IOM, 2000 Sovereign Immunity: ~ allows health professionals to volunteer and not face lawsuits. In FL, the Volunteer Health Care Provider Program (VHCPP) [s. 766.1115, F.S.] allows private licensed health care providers to volunteer their services to the medically indigent residents of Florida with incomes at or below 200% of the Federal Poverty Level and be under the state's sovereign immunity. Providers sign a contract and are designated as agents of the state; sovereign immunity protects care provided for uncompensated (free) services rendered to clients.
We know that...
Health disparities are preventable differences in the outcomes of care. If preventable, health disparities can be eliminated. Social inequality plays a major role. Marginalized populations suffer most. Who are they?
Summary of Intro to Health Disparities:
Health disparities describe preventable disproportionate burdens of morbidity and early mortality. If preventable, they are avoidable. Health professionals can develop new skills to improve care today and better prepare for tomorrow.
Describe the value of knowing a patient's race and ethnicity.
Helps you to understand more of how the patient may view healthcare/treatment and their knowledge of it.
Describe HPSA and IMU scores. Who uses each one? Which IMU score shows the greatest amount of underservice?
IMU: Index of Medical Underservice Understanding the range of IMU scores: 0 = completely underserved 100 = best served To qualify for designation as a MUA/P, the IMU score < 62.0 The greatest needs are indicated by: •High HPSA score [26 = highest need for health professionals] •Low IMU score [0 = completely underserved] -------------- IMU score 0-100 range 0= totally underserved 100= best served Opposite to HPSA, in IMU the lowest score indicates highest need Cut off- IMU @62 or higher = HPSA doesn't consider it HPSA only looks at 0-61.9 scores on the IMU scales
Federally Qualified Health Centers (FQHC)
Increase primary care services to underserved areas/populations (MUA/P). Also called Community Health Centers (CHCs). [Local example is Palms Medical Group in Gilchrist County] •Qualify for enhanced reimbursement from Medicare/Medicaid •Offer a sliding fee scale •Provide comprehensive care-medical, dental, mental health, preventive care Sliding fee scale- pay based upon your salary
Re-framing Adult Disease
Is adult disease a developmental disorder that begins in childhood? Early and sustained exposure to violence (ACEs) is associated with telomere erosion equivalent to 5-10 years of age. Exposure to 6 + events reduces life expectancy by 20 years. Intervention - break cycles of generational dysfunction, abuse and neglect Less costly to intervene than treat later outcomes Increases likelihood of losing life expectancy or developing disorders
Significant differences exist by income, education and other characteristics among the nation's largest 19 Asian origin groups.
Key differences among Asian groups in U.S.: 1. Six groups - Chinese, Indian, Filipino, Vietnamese, Korean and Japanese - accounted for 85% of all Asian Americans as of 2015. 2. Bachelor's degree or more education - almost 50% from India, Malaysia, Mongolia; less than 20% from Cambodia, Laos, Bhutan or among Hmong 3. Seven-in-ten U.S. Asians ages 5 and older speak English proficiently - Japanese (84%), Filipinos (82%), Indians (80%) 4. Wide income disparities among Asian origin groups 5. Poverty rates are higher in some Asian groups. 6. Naturalization rates vary widely based upon year of immigration - among Hmong and Vietnamese (77% & 75%)
Changing National Demographics Compare the U.S. population in 2020 to projections for 2050 to understand why it is important to address health disparities.
Languages in the U.S.: •370+ languages spoken •1 in 5 Americans speak a language other than English at home •In FL 28+% speak English + at home By 2050 •Growth from 313 - 438M; 82% of increase due to immigration •1 in 5 Americans will be immigrants. Current rate is 1 in 8 •Second generation Americans will increase - 11.5% to 18.4% Asian Americans will increase from 4.8% to 8.2% population •Hispanic Americans will increase (1 in 6) to (1 in 3) •Non-Hispanic whites will be 47% of population [the majority becomes a minority] •Older adults (65+) are 1 in 7, will be 1 in 5 •Most older adults will be single-race Caucasians and younger will be minority or multi-racial U.S. Census Bureau & PewResearch We will be a nation of minority racial groups with ancestral origins in Europe, Asia and Africa. There will be no racial majority for the first time in U.S. history.
Latino, Latina, Latinx
Latinx is the gender-neutral alternative to Latino/Latina and even Latin@. Used by scholars, activists and an increasing number of journalists, Latinx is quickly gaining popularity among the general public. Language changes. "Latinx" seeks to move beyond gender binaries and be inclusive of the intersecting identities of Latin American descendants. In addition to men and women from all racial backgrounds, Latinx also makes room for people who are trans, queer, agender, non-binary, gender nonconforming or gender fluid.
Health Effect of "Place"
Living in a poor neighborhood is bad for health short and long term. Children are especially vulnerable to unhealthy conditions (social, political, and environmental) in homes and neighborhoods. The health effects of chronic stress have more impact at sensitive developmental periods in life (e.g., before age 5). Cumulative effects of poor socioeconomics, chronic social stress, racism/bias, micro-aggressions across the lifespan manifest in adult chronic disease.
Define MUAs and MUPs? How are they alike and different? What criteria are used to designate them? How are they different from HPSAs?
MUA experience shortages of health services for: •An entire county or group of contiguous counties •A group of county or civil divisions •A group of urban census tracts MUP have populations with barriers to health care due to: •Economics (low-income or Medicaid-eligible populations) •Culture •Language (limited English proficiency)
Mental Health HPSAs
Mental health care = psychiatrists + core mental health professionals (clinical psychologists, LCSW, psychiatric nurse specialists and marriage & family therapists) Goals are: •Psychiatrist - population to psychiatrist ratio of 20,000:1 •Core professionals - population to practitioner ratio of 6,000:1
Types of stress
Mostly live in tolerable stress Far left (positive)- can have positive stress: Eu stress, healthy stress Should have distress category- uh oh Toxic stress- stay in a state of stress for a prolonged time; stress you don't have many opportunities to recover Positive stress: a normal and essential part of healthy development (getting a vaccine, first day of school) Tolerable stress: Response to a more severe stressor, limited in duration (loss of a loved one, a broken bone) Toxic stress: experience strong, frequent, and/or prolonged activity (physical or emotional abuse, exposure to violence)
Define the Culturally and Linguistically Appropriate Services (CLAS) Standards and explain their purpose.
National committees released guidelines and standards for culturally and linguistically appropriate care. Called the Culturally and Linguistically Appropriate Services (CLAS) Standards. They address language barriers and suggest effective ways to work with medical interpreters to provide safe and effective care. National guidelines - a blueprint for individual providers and health care organizations 15 individual standards •1 principle standard •3 standards relate to governance, leadership and workforce •4 relate to language and communication •7 relate to engagement, continuous improvement and accountability Applying their principles affects policy and day-to-day procedures. CLAS Standards advance health equity, improve healthcare quality and eliminate health care disparities
Rural: Population and Real Estate
National outcomes from 2010 Census 19.3% population is rural 95+% of land area is classified as rural FL outcomes •30 of 67 counties have rural designations •Many counties have large rural areas but are not designated as 'rural' (Alachua, Columbia, Marion) •42% of state's total acres are in rural areas •7% of Floridians live in rural communities •11% live in rural areas of counties
The Science of Neglect
Neglect is more damaging than abuse because it activates the internal alarm of a developing child, "something is wrong" Four categories of neglect: 1.Occasional inattention 2.Chronic under-stimulation 3.Severe neglect in a family situation 4.Severe neglect in an institutional setting -------- Still face experiment Important to understand how neglect triggers warning system of brain 4 categories: occasional inattention, chronic under stimulation, severe neglect in family or institutional setting
Health Disparities Class Notes
No standard definition for health disparities Popular definitions Common threads: Equal access, equal need, equal use Differences linked to socioeconomic/environmental disadvantages Not a one time problem but a system that is denying access to others Unjust and unfair differences Socially and economically marginalzied populations
Alaska Native, Inuit or Eskimo?
Non-Hispanic whites with American Indian ancestry are 50% of the current population of mixed-race Americans but are among the least likely to say that they are multiracial. Many/most multiracial American Indian adults have few connections with Native Americans. The nomadic ancestors of modern Native Americans who hiked over a "land bridge" from Asia to what is now Alaska more than 12,000 years ago. By the time Europeans arrived in the 15th century A.D., scholars estimate that more than 50M people were already living in the Americas.
Personal Resilience with SDOH
Not every person exposed to socioeconomic adversity or chronic stress develops disease. Protective social factors (social support, self-esteem, and self-efficacy) mitigate the damaging effects of adverse social conditions. It is much more difficult if social determinants of health that have shaped you have been against your favor
Intersectionality & Identity
Our overlapping or intersecting social identities interact with related social systems of oppression, domination, or discrimination. Health providers must consider all aspects of a patient's identity as simultaneously interacting with one other. Interlocking, interacting identities affect our privilege, place and perception in society. Cannot separate the facets of identity and observe them separately Interlocking identities include gender, race, social class, ethnicity, nationality, sexual orientation, religion, age, mental disability, physical disability, mental illness, physical illness and other forms of identity.
Hispanic/LatinX Immigrants
Persons of Cuban, Mexican, Puerto Rican, South or Central American (not Brazil) or other Spanish cultures or origins regardless of race. Fastest growing ethnic group. The term Hispanic was first adopted by the United States government in the early 1970s
Describe characteristics of socially marginalized populations and give examples.
Persons with diminished social power and 'voice' Sociodemographic factors - race/ethnicity, immigration status, age, sex, gender identity, sexual orientation, religion Socioeconomic factors - homeless, migrant worker Social stigma - HIV/AIDS, mental/behavioral health, disability (physical, cognitive, social) Geographic location - rural or urban underserved
How do income and education influence health?
Policies and Programs-->Health Factors-->Health Outcomes (length of life, quality of life)
Primary Medical Care
Primary medical care = M.D. + D.O. NHSC recognizes these primary care specialties: •General or family practice •General internal medicine •Pediatrics •Ob-Gyn Goal is a geographic population to practitioner ratio of 3,500:1 (general population)
Eastern Health Model
Qi (chee) Life is a gathering of energy that is always in flux Yin Yang are manifestations of Qi described by opposites (hot v cold). Well-being results from harmony between them
Explain how race is different from ethnicity.
Race and ethnicity are social constructs. They can be used to predict experiences in life. Some disease conditions are closely associated with race/ethnicity: • Cystic fibrosis - northern Europeans • Sickle cell - sub-Saharan Africa, India, Arabia • Tay-Sachs - Ashkenazi Jews, old order Amish • Lactose intolerance - Africans, Latinos, and Asians
Explain the importance of personal resilience and list strategies for becoming more resilient.
Resilience - the outcome of dynamic interactions between a person's adverse experiences and protective factors. This interaction is what determines the developmental path towards health and well-being or towards illness and dysfunction. Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems, serious health problems or workplace and financial stressors. It means "bouncing back" from difficult experiences. Every person exposed to socioeconomic adversity or chronic stress does NOT develop disease. Protective social factors (social support, self-esteem, self-efficacy) mitigate the damaging effects of adverse social conditions.
Rural Health Clinics (RHC)
Rural Health Clinics promote delivery of outpatient primary care in rural and underserved areas using physicians, physician assistants (PAs), nurse practitioners (NPs), certified nurse midwives (CNMs). Also provide diagnostic and lab services. [Local example was ACORN Clinic] •RHCs must be located in non-urban shortage areas (HPSA) •Increase primary care services for Medicaid and Medicare patients in rural communities •RHC have enhanced reimbursement rate for Medicaid and Medicare services in rural areas
Rural Hospitals: Two Types
Rural Hospitals and Critical Access Hospitals Rural - an acute care hospital with <100 beds + emergency room [ Local example is Shands @ Starke in Bradford County] Critical Access Hospital (CAH) - a type of rural hospital with <25 beds; established (by law) for special payments under the Medicare program; must be located 35+ miles from other medical facilities [Local example is Lake Butler Hospital in Union County] Rural hospital- acute care hospital with no more than 100 beds with emergency room CAH- much smaller rural hospital No more than 25 beds
MUA/P Criteria
Scores are calculated using a weighted formula and data about: 1.ratio of primary medical care physicians per 1,000 population 2.infant mortality rate 3.% of population with incomes below the poverty level 4.% of population 65+ years
HRSA Uses Shortage Designations
Shortage designations help HRSA find communities with the greatest need There are three shortage designations: •Health Professional Shortage Areas (HPSAs) - updated annually •Medically Underserved Areas (MUAs) - updated periodically •Medically Underserved Populations (MUPs) - updated periodically
Define the social determinants of health and describe their role in health.
Social determinants of health (SDOH) - conditions in which people are born, grow, live, work and age. They are shaped by the distribution of money, power and resources at global, national and local levels. Social factors include access to stable housing, employment opportunities, healthy foods, health care, quality education and more. These social determinants typically strongly correlate with the health status of a given community, so much so that we know your zip code can be a very accurate predictor of health
The Cycle Continues
Social learning theory - new behaviors are acquired by observing and imitating others. Learning is a cognitive process that takes place in a social context; we learn indirectly through observation AND directly from instruction. We learn about relationships at home. What is acceptable speech? What is appropriate touch? How are power and control communicated? How is conflict resolved? Social learning theory- new behaviors are acquired by observing and imitating others We learn what we are taught through observation and instruction
Interlocking Community Systems
Socially disadvantaged populations include persons whose intersecting social identities are rooted in minority communities: race, ethnicity, language, immigration status, socio-economic status, education, gender identity, sexual orientation, age/generation, religion, disability, and geography. HP 2020 Interlocking complex systems: Social (political and economic) how can we apply social theories of inequality to create effective health policies? Structural (physical and environmental) how can we eliminate barriers within communities to improve health outcomes?
ACEs class note
Started to learn about in 1990s Middle class white people participated Pyramid: Ace leads to social, emotional, and cognitive impairment, then you adopt risky behaviors, which leads to disease, disability problems, and then early death Parameters: Before age of 18, chronic 1-3:abuse- physical, emotional, sexual 4-5: neglect (most damaging) Physical, emotional 5-10: Household disfunction
Theories and Models of Health
Theory provides a systematic way to understand events or situations. They tell us what patients believe. Theory = a set of concepts, definitions, and propositions that explain or predict events or situations by illustrating the relationships between variables. Theories are tools that help us design and evaluate health behavior and health promotion interventions based on understanding behavior. Models are the physical representations of theories.
Cultural Competence class notes
We want to remove barriers to care by asking better questions to all of our patients WE can never be fully culturally competent Benefits of learning by experience and training (prior knowledge) Recognizes that there are diff explanatory models of illness Platinum vs golden rules - Treat others they way they want to be treated Enables us to be respectful and responsive to their needs outside of medicine Avoid stereotyping by looking at individuals in context of their environment Requires more careful listening and asking questions that focus on the illness and the beliefs of the patients More of a mindset and demonstrated by skills and behaviors
Holistic Health Model
Wellness of the physical, physcological, social, and spiritual aspects of life
Maslow's Hierarchy of Needs
When needs are routinely unmet, growth and development are impaired. Greater impairment occurs with abuse and neglect Social determinants of heath and family systems At top. + Parenting--> affects all of the rest of the needs
Culture, Worldview and Behavior
When people come together to participate in rituals, they reaffirm the culture they hold in common, and in doing so, strengthen the social ties that bind them together. Emile Durkheim [1858-1917] Behavior does not exist in a vacuum. Behavior reflects a person's culture and worldview and it is shaped by an individual's knowledge (thoughts, beliefs and attitudes), traditions, interactions with others and community
Describe the relationship between the social determinants of health, trauma and toxic stress.
When we are exposed to stressful situations for prolonged periods of time (dangerous neighborhood, living with abuse or neglect, experiencing racism) our neurobiological defense system is constantly activated. This can create and environment known as "toxic stress." The experience of toxic stress, especially in childhood, impacts brain and physical development and has negative effects on learning, behavior and health. ----- Need to understand abuse vs neglect Neurological defense system always on and releasing stress chemicals changes chemical pathways and brain pathways
Health Disparities Definitions
Whitehead explained equity in health care as "equal access to available care for equal need, equal utilization for equal need, equal quality of care for all" Braveman, 2006 "a particular type of health difference closely linked with social, economic and/or environmental disadvantage . . . [they] adversely affect groups who have systematically experienced greater obstacles to health" Healthy People 2020 "a continual accumulation of unfavorable events connected to a person's social context" Carter-Pokras & Baquet, 2002 "differences which are unnecessary and avoidable, considered unfair and unjust" Whitehead, 1990 At risk for health disparities are members of socially and economically marginalized populations. Healthy People 2020
Telomeres
Telomeres - ends of chromosomes protect them from deterioration or damage Telomere length is a marker for biological aging, not chronological aging - they shorten as we age. Toxic stress ages the body faster biologically than chronological age would expect.
Define HRSA and explain its mission
The Health Resources and Services Administration is the Federal agency that improves access to health care by: •Strengthening the health care workforce •Building healthy communities •Working toward health equity HRSA provides health care to communities that are geographically isolated, economically or medically vulnerable. •Rural •Urban underserved - communities in urban areas with limited or no health care
Rural Health: More Than Medicine
The National Association for Rural Mental Health links the diverse voices of rural mental health, through its activities as a membership organization. NARMH provides a forum for rural mental health professionals, advocates, and consumers to identify issues and problems, share innovative solutions and model programs, and speak with a shared voice on issues of rural mental health concerns, visit https://www.narmh.org American Association of Public Health Dentistry https://www.aaphd.org accepts the challenge to improve total health for all citizens through the development and support of effective programs of oral health promotion and disease prevention.
HRSA and the NHSC
The National Health Service Corps (NHSC) is a federally funded scholarship and loan repayment program offered through HRSA. Health professions students apply for admission: •When accepted to professional school •When residency training/graduate school finishes The NHSC supports these primary care professionals: •Physicians (MD or DO) •Physician Assistants •Dentists •Nurse Practitioners and Certified Nurse-Midwives HRSA identifies communities that need health professionals. HRSA matches those admitted to the NHSC to areas/facilities with the greatest needs based upon HPSA score
Immigration, Assimilation, Acculturation
The U.S. has more immigrants than any other country in the world. More than 40M (13%) people in U.S. were born in another country, accounting for about one-fifth of the world's migrants. Assimilation - the minority culture is fully absorbed into the majority culture. Acculturation - the minority culture changes but still retains unique cultural markers of language, food and customs. Acculturation is also a two way process as both cultures are changed.
Culture, Health Beliefs and Practices
The U.S. is the most culturally diverse nation in the world. What knowledge and skills do 21st century health professionals need to provide competent, patient-centered care in a multi-cultural world and nation?
Identify the human, financial and social costs of disparities.
The US is different in the WAY we spend money on healthcare, spend our healthcare dollars on treatment of disease rather than prevention Our system rewards and pays when people are sick US spends more than any other country in the world on health care. Less on social services. 2014 - $2.9T was spent; most costly diseases are: •Diabetes •Ischemic heart disease •Low back and neck pain How to reduce rising costs? 30+ % of direct medical costs faced by African Americans, Hispanic Americans, and Asian Americans were excess costs due to health inequities. Over 4 yr. period: $230+ B in direct medical expenditures $1+T indirect costs associated with illness and premature deaths
Bio-medical (Western) Model
The biomedical model examines the physical and biological aspects of specific diseases and conditions. •focuses on the defect, or dysfunction, within the patient, using a problem-solving approach. •medical history, physical examination, and diagnostic tests provide information to identify and treat specific illness. •it is generally succinct, tangible, easily understandable and follows a scientific method which relies primarily on objective and measurable observation. •physicians lament - we were never taught to use anything else. In Western medicine health professionals focus on disease - the pathology, diagnosis, treatment Patients focus on the experience of being ill. Disease results from natural, physical scientific phenomena. Little emphasis on spiritual, relational or emotional dimensions of health. Physicians advocate medical treatments to combat microorganisms; use sophisticated technology to diagnose and treat disease Biomedical model - individuals have control of health; positive actions can help avoid poor health conditions - future orientation.
Toxic Stress, Chronic Disease & Aging
The brain interprets and responds to environmental signals. Frequent activation of the stress response increases allostatic load (wear and tear on the body) and leads to damage over time. Allostatic load increases when exposed to repeated, toxic stress. Telomeres shorten more quickly in face of chronic toxic stress.
Health Disparities
The burden of poor health is unevenly distributed. . . differences in health are avoidable and unjust. People in less-advantaged groups have worse health from the moment of birth and throughout life. . . suffer disproportionally Actions that lessen social disadvantage can reduce gaps in health and longevity and reduce health disparities. Not an even distribution Health disparities mean that they are sign posts indicating unfair things are taking place
Barriers to Leaving Relationships
The decision to leave abusive relationships escalates the violence and places the victim at risk for death and disability. Abuser fears losing control. Barriers: •Fear of retaliation •No alternatives - rural has few resources •Culture, faith or religious teaching •Stigma of divorce •Fear of losing children •Hope for change ------- Abusers fears losing control They fall in love with the potential of who this person could be Live in the reality of who they are or you'll make excuses
Trauma Informed Care
Trauma-informed care shifts the focus from "What's wrong with you?" to "What happened to you?" Trauma [physical, emotional, or sexual abuse; neglect; discrimination; and violence] increases a person's long-term risk of serious physical/behavioral health problems and often leads to costly health care utilization. We want a complete picture of a patient's life situation — past and present — to provide effective health care services with a healing orientation. Adopting trauma-informed approaches to care can: improve patient engagement improve enhance outcomes reduce avoidable care reduce costs of care - medical and social service
Define rural.
U.S. Census Bureau: Rural encompasses all housing, population and territory not found in an urban area. Census Bureau identifies 2 types of urban areas: 1.Urban areas - 50,000 + people 2.Urban clusters - at least 2,500 people and less than 50,000 Florida Statutes: "an area with a population density of less than 100 persons/square mile OR an area defined by the most recent US census as rural"
Western Culture
U.S. culture has been shaped by the cultures of Native Americans, Latin Americans, Africans and Asians. Early colonization by Western Europeans fleeing religious/political persecution and opportunity laid foundation favoring: • People can/should control nature, their own environment and destiny. The future is not left to fate. • Change (progress) is positive and good - less value for tradition. • Efficient use of time; efficiency; productivity • Individualism and independence • Opportunity comes from what you do, not who you are; egalitarianism • Value personal accomplishment; self-help; self-made person • Emphasis on "doing" (productivity) instead of "being" • Competition valued over cooperation • Future orientation • Informality • Efficiency • Material goods are rewards for work
summary of Global Cultures and Cross-Cultural Healthcare
Understanding cultural differences is a starting point for patient centered care. Acculturation or assimilation? Make NO assumptions. Avoid creating simplistic racial and ethnic stereotypes. Ask better questions. Learn to listen. Suspend judgments and identify your biases.
NHSC Assigns HPSA Scores
Used to: •identify areas with the greatest shortage of health professionals •prioritize assignment of medical, dental, mental health clinicians Scores range: 1 - 26 (practitioners) and 1 - 25 (facilities like CAH) Higher scores demonstrate greater need and greater priority HPSA scores are updated annually so current information about communities is available to match and place health professionals Calculates HPSA score KNOW HOW TO USE THE NUMBERS IN THE HPSA SCORES MEMORIZE RANGE OF NUMBERS 1-26 *practitioners* 1-25 *facilities* Not as great as a need (1) Greatest need (25) HPSA scored every year so that NHSC can meet HRSA's goals of insuring work force adequately throuhgout US
Preventing Violence in Relationships
Violence is a learned behavior. Teach conflict resolution skills Educate people about healthy relationships Teach parents about effects on children who watch violence Address this issue in routine screening - ask ALL patients Guyer's Question: Do you regularly feel like you are "walking on egg shells" at home?
Describe the role of ethnocentrism, bias and stereotype in understanding cultural differences.
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Describe the social structure and communication preferences of different racial and ethnic communities. How are they alike and different?
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Discuss Explanatory Models of Illness and explain how Kleinman's 8 questions improve health care outcomes and lower costs of care.
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Explain how different cultures explain health and illness.
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Explain the relationship among HRSA, NHSC, HPSA, MUA, and MUP?
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List different cultural beliefs and practices regarding health and illness.
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Use HPSA scores to identify the shortage area with the greatest need.
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Explain the role of abuse and neglect in creating toxic stress.
area where you live can influence exposure to toxic stress and influences overall health and wellbeing
2. If a classmate in WST 2322 tells you that they spent the weekend participating in a ceremony that connected them to the creator while they purified their physical body from toxins, they likely participated in ___. a. Blood-letting b. Ayurvedic medicine c. Gua-sha d. Sweat lodge e. Mal de ojo
d
1. In FL, EVERY county has at least one ___. a. FQHC or CHC b. Private, public or rural hospital c. Health department d. Health clinic
c?
Describe the relationship among, culture, worldview and behavior.
previous cards
SDOH: Interlocking Systems of Power/Inequity
systems are responsible for most health inequities. WHO, 2019 Community systems are not controlled by individuals but they have significant direct and indirect effects on populations. Interlocking systems of social determinants are often the root of illness and key to understanding health disparities. Factors not associated with medical care have the greatest influence on health.
Factors Influencing Health Beliefs and Practices
• As a group, health status is best in the country • Some want physicians to deliver bad news to patients only in stages (or directly to family) and believe they have important roles as "intermediaries." • Healing traditions are closely intertwined with philosophical systems [Buddhism, Confucianism, and Taoism] that differ from Western medicine. • Far Eastern Asians view health as a balance among physical, spiritual and social factors; South Asians - Ayurvedic medicine • Traditional medicine is often practiced in addition to Western
Hispanic/Latinx Health beliefs and practices as well as health and community education
• Belief that fate and destiny play roles in health • Religion (Roman Catholicism) is important influence • Christianity often mixes with nature religions (vodun/Santeria) • Traditional healers may be consulted • Folk/family/herbal treatments are common Health and Community Education • Greater success when family is involved in healthcare • Barriers to care may include language, limited money, poor transportation, no health insurance, undocumented status
Social Structure of American Indians & Eskimos and Aleuts
• Each tribe is a unique nation • Patriarchal families with tribes led by Chiefs • Individual responsible for own path • Cooperative system • Decisions made using patience, discussion and consensus
Factors Influencing Health Beliefs and Practices for American Indians & Eskimos and Aleuts
• Illness results from imbalance among physical, spiritual, social and mental factors • Least likely to participate in healthcare, even with traditional healers • Greater use traditional medicine • Trust is an issue due to history of abuse, racism, oppression and deceit; • Resistance to assimilation
Communication Preferences for Hispanic/Latinx
• Louder, more exuberant and highly expressive • More personal touch, less personal space
African and Afro-Caribbean Communication Preferences
• More openly expressive style • More physical closeness and contact • Older adults may view direct eye contact as confrontational
Hispanic/LatinX Social and Community Structure
• Patriarchal family structure • Family is central - familismo (close family ties) • Often live in extended nuclear families • Elders are respected and cared for by the family • Family pride and honor are valued • Emphasis on hard work and education • Collectivist, not individualistic • Social structure is characterized by respect, honor, dignity and simpatía (easy going, pleasant personal qualities)
Asian Social Structure
• Patriarchal family system • Extended multi-generational families are common • Children responsible for care of parents and for protecting them from bad news • Education and hard work highly valued • Respect is shown by less eye contact, less physical closeness, perhaps a small bow • May address elders with formal "Mr." or "Mrs." • As a group, least assimilated (Chinese School teaches culture)
Communication Preferences for Asian Culture
• Quiet tones and emotional reserve • High value on respect and 'saving face' • Less eye contact, physical touch and physical closeness • Consensus is valued over individuality • Cooperative - "We" preferred to "I" • Emphasis on balance, harmony (feng shui) translates into health belief model • Death of elders is viewed as loss of information and tradition = less future orientation
Communication preference of American Indians & Eskimos and Aleuts
• Quiet, less expressive tones • Less expressive • Less physical contact • More physical space • Emotional control • Silence is valued • Limited direct eye contact
Family and Community Relationships for Asian Culture
• Strong emphasis on family affiliation and community of friends • Large network of relationships • May distrust those outside social circle • Oldest and most educated male is usually family spokesman • Ask patients about who to involve in healthcare • Sexual segregation may be important
Factors Influencing Health Practices and Beliefs for African and Afro-Caribbean
• Strong religious affiliation (Christianity & Islam) • Some faith traditions combine Christianity with nature religions (Santeria, Vodun/Voudou, Rastafarianism) • Disease may be viewed as "God's will" or fate • Spirituality may be important component of health belief model • Traditional/folk/family herbal treatments Class notes: Take your healthcare program to the community African American community and having health come to churches or areas where people congregate
African and Afro-Caribbean Social Structure
• Strong sense of community (cooperative) • Patriarchal • Extended family is highly valued • Families value caretaking of elders • Elders are respected and opinions influence family decisions
Health and Community Education for African and Afro-Caribbean
• Work with recognized community leaders • Best place for health education may be the church • Other opportunities at barbershop and beauty salon • Trust may be an important issue because of past history (Tuskegee and HeLa cells) - start by building relationships
HPSA Designation Criteria
•Geographic area must be rational for delivery of services •Must meet the specified population to practitioner ratio •Evidence shows resources are over-utilized, excessively distant or inaccessible •HPSAs may also be designated by the Governor
Language: Who is at Risk?
•Patients with different cultural beliefs •Patients w/limited English proficiency (LEP) •Health professionals w/LEP •Communication impaired - hearing, sight, speech •Cognitive deficits •Low health literacy
