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6
What Do We Still Need to Learn
About Reducing Health Disparities?
T
he following panel addressed social determinants of health dispari-
ties and ways to reduce health disparities, promote health equity,
and move successful models to a larger scale. Each speaker was
asked the question, “What do we still need to learn about reducing health
disparities?”
PAULA BRAVEMAN
Paula Braveman is a professor of family and community medicine
and has published extensively on disparities in health and health care. She
explained that her presentation had three main points, which are outlined
in Box 6-1.
Research on Social Determinants of Health Disparities
First, not only is more research clearly needed, but also research that
better conceptualizes the social determinants of health. Braveman offered
some examples from the research effort behind the Robert Wood John-
son Foundation’s Commission to Build a Healthier America (http://www.
commissiononhealth.org). Figure 6-1 shows national data on health strati-
fied by the three largest racial and ethnic groups in the United States. Within
each of these groups, the prevalence of self-reported poor or fair health is
shown by family income level. These data show that as income goes up,
self-reported health improves. This is true within each of the three racial/
ethnic groups.
69
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70 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
BOX 6-1
Priorities for Health Disparities Research
• More—and better—research on the social determinants of health disparities
• ore intervention research (based on promising hypotheses)—understanding
M
pathways is not sufficient
§ Multilevel, critical mass, studied longitudinally
• More translational research
§ How to inform the public about health disparities
§ How to get them to care
§ How to create political will
SOURCE: Braveman (2010).
Percent of Adults, Ages ≥ 25 Years, with Poor/Fair Health*
40 Family Income
(Percent of Federal
36.1
Poverty Level)
35
30.8
<100% FPL
29.6
30
100-199% FPL
26.3
200-299% FPL
25
22.5
300-399% FPL
20.7
≥ 400% FPL
20 18
16.7
14.4
15 13.5
13.2
9.8 9.7 9.5
10
6.2
5
0
Black, Non-Hispanic Hispanic White, Non-Hispanic
FIGURE 6-1 Income is linked with health regardless of racial or ethnic group.
Differences in health status by income do not simply reflect differences by race or
ethnicity; differences in health can be seen within each racial or ethnic group. Both
income and racial or ethnic group matter.
*Age-adjusted.
SOURCE: RWJF (2009). Prepared for the Robert Wood Johnson Foundation by the
Center on Social Disparities in Health at the University of California, San Francisco.
© 2008 Robert Wood Johnson Foundation. www.commissiononhealth.org.
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71
WHAT DO WE STILL NEED TO LEARN?
However, when the poorest group is compared with all other groups,
it is clear that the size of the racial/ethnic disparities is much smaller than
the size of the income disparities. It is not enough, then, to look at racial
and ethnic differences; socioeconomic differences should also be considered.
Braveman explained that without considering both, the long-term effects of
the experience of racism are not captured.
Braveman noted that institutionalized racism, independent of socio-
economic differences, also affects health. The effects of institutionalized
racism may mean that a child born to an African American family is far
more likely to grow up in a neighborhood with fewer opportunities and
more adverse effects on health. Residential segregation systematically tracks
certain racial and ethnic groups into worse living and working conditions.
The effects of crime, toxic hazards, a lack of safe areas to play or exercise,
a lack of access to healthy foods, and an environment filled with despair
are all a part of an important potential pathway through which disparities
are played out, Braveman said.
From a historical perspective, the focus on disparities in health care at
the beginning of the disparities movement, Braveman explained, has had
both positive and negative effects. One unfortunate outcome of this focus
is that it has fed into racial and ethnic stereotypes and led to unfounded
assumptions about the basis of racial and ethnic health disparities. For
example, a common assumption is that disparities are based on the con-
struct of “culture.” The problem with this construct is that it implies that
culture is something that people freely choose.
More measurement work is needed, said Braveman, to enable the field
to do a better job of tracing the pathways by which different social factors
contribute to the creation of health disparities. A better understanding of
those factors, how they operate, and how they perpetuate and exacerbate
health disparities is needed.
Figure 6-2 from the Karolinska Institute in Sweden (Burstrom et al.,
2010) outlines a simple way to demonstrate how health inequities are cre-
ated. Differential exposure is related to social position, and social position
is reflected by racial/ethnic group. (Social position can also be reflected by
sexual orientation, disability status, or any number of other characteristics
that define the likelihood that an individual will experience discrimination
on the basis of that social position.) Furthermore, social position determines
the extent to which a person is exposed to either factors that promote
health or factors that have adverse effects on health.
Differential vulnerability should also be considered; that is, social posi-
tion also affects the extent to which a given level of exposure is likely to
result in a given level of damage to health outcomes. For example, increas-
ing knowledge about the physiology of stress—and, particularly, of chronic
stress—demonstrates how experiences associated with a lower social posi-
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72 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
SOCIETY INDIVIDUAL
1. Social stratification
Social position
Social A. Reduce social stratification
context
2.
B. Decrease exposures
Differential
exposure
Specific exposure
C. Decrease vulnerability 3. Differential
vulnerability
Disease or injury
4. Differential
Policy D. Prevent unequal consequences
consequences
context
Social
5. Further social stratification
consequences of
ill health
FIGURE 6-2 A way to demonstrate how health inequities are created.
Figure 6-2, color
SOURCE: Burstrom et al. (2010).
tion can result in physiological outcomes that create a greater vulnerability
to negative health outcomes.
Disease, injury, and the differential consequences of being ill or physi-
cally disabled also affect social position and lead to further social strati-
fication. Social stratification—that is, how people sort themselves into
hierarchical groups according to characteristics like race or income—in turn
affects access to more resources or more opportunities.
Figure 6-2 is also useful in that it indicates the potential points of inter-
vention and puts social stratification, which most researchers do not include
in their models, on the table, Braveman said. Most researchers, in fact, do
not consider the ways in which the underlying differences in opportunities
and resources can result in worse health outcomes.
Braveman noted that another feature of the model in Figure 6-2 is that
it shows how disadvantages accumulate across a person’s life span and how
they can accumulate across generations as well. The consequences of social
stratification for the parents can determine the kind of neighborhood in
which a child grows up, the influences to which that child is exposed, and
even the quality of the schools in that neighborhood.
Poor school quality is one of the most important ways in which place
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73
WHAT DO WE STILL NEED TO LEARN?
Poor Health
Low Educational
Poverty Poverty
Poor Job
Attainment
Poor Health
FIGURE 6-3 Vicious cycle of poverty and poor health.
SOURCE: Braveman (2010).
influences health. Figure 6-3 highlights the role of low educational attain-
ment as a critical pathway to poor health. The role of racial segregation,
for example, is one of the ways that people are systematically tracked
into schools with lower levels of educational attainment. Lower levels of
educational attainment, in turn, lead to lower wage earnings, poverty, and
poor health outcomes. Although educational attainment influences health
by several potential pathways, Figure 6-4 shows the pathway for which the
knowledge base is the most limited (inside box).
In short, said Braveman, although more research is needed to better
understand how social factors influence health disparities, more research
on how to interrupt the pathways is needed. Furthermore, more research is
needed to discern how these pathways play out with different populations
and in different settings.
Research on Promising Interventions
Second, a massive expansion in intervention research is needed.
Braveman noted that a number of promising hypotheses are ready to be
tested in the field. Additionally, she said that “going to scale” is the next
step because research has already demonstrated success on a small scale. A
large body of research, in fact, demonstrates success at a small scale.
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74 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
§ Nutrition
Educational Health knowledge, § Exercise
HEALTH
attainment literacy, & behaviors § Drugs & alcohol
§ Health/disease management
§ Exposure to hazards
Working § Control / demand imbalance
conditions § Stress
§ Health insurance
Work-
Educational § Sick leave
HEALTH
Work related
attainment § Retirement benefits
resources § Other benefits
§ Housing
Income § Neighborhood environment
§ Nutrition
§ Stress
§ Work-related factors
Sense of control § Health-related behaviors
§ Stress
Educational § Social & economic resources
Social standing HEALTH
§ Stress
attainment HEALTH
§ Social & economic resources
§ Health-related behaviors
Social support § Family stability
§ Stress
FIGURE 6-4 How could education affect health?
SOURCE: Braveman (2010).
Braveman also cautioned against the “silver bullet trap.” This is the
expectation that a single intervention is enough. For example, knowledge
about what really works to make schools better is one of the least developed
areas. No single program will make a school better; what is needed is a
multifaceted approach.
One challenge to conducting research on multifaceted interventions is
to convince funding institutions and policy makers to take chances on this
Figure 6-3, color
research, Braveman said. Because this research involves going at a problem
from multiple directions and on multiple levels, it is necessarily messy and
complex.
Translational Research
Finally, Braveman stated that more translational research that will
translate the existing knowledge base into action is strongly needed. She
said that the biggest barrier to reducing health disparities is not a lack of
knowledge; rather, it is a lack of political will. Attention should be paid
to translational research if reductions in health disparities are to be seen.
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75
WHAT DO WE STILL NEED TO LEARN?
Ideas that seem radical in the United States are considered mainstream
public health interventions by Europeans, she said; the basic level of social
solidarity that exists in Europe is not present here. So how, then, can a
greater level of social consensus be created in the United States? This lack
of political will, Braveman concluded—not a lack of knowledge—is the
biggest obstacle to ending health disparities.
ANNE BEAL
Anne Beal is president of the Aetna Foundation, the independent and
charitable arm of the Aetna Insurance Company. She is a physician who
specializes in pediatrics and public health.
History of the Disparities Agenda
Beal began her comments by outlining the evolution of research on
health disparities in the United States. Initially, the focus was on minority
health, that is, the health of “those other people,” she said. The focus then
shifted to acknowledgment of a gap between whites and people of color
and finally to an interest in closing that gap. It is here that the language
of health disparities was first used. The initial research on health dispari-
ties was descriptive in nature. It then became clear that disparities could
be seen everywhere: in Medicare, Medicaid, health care access, and health
care outcomes.
The next step was to look at questions of whether the data were
adequate and whether the data were appropriate to capture the extent of
disparities. This work was critically important, Beal said, and is reflected in
federal legislation such as the Patient Protection and Affordable Care Act
(ACA) of 2010. The law includes language around the need for high-quality
data on race and ethnicity.
Once the data became available, the next step was to begin to look at
the root causes of health disparities. One of the first findings to emerge, said
Beal, was that where one lives and where one goes to receive health care
are major drivers of health disparities. In other words, Beal said, “where
you live makes a difference.” Just as the saying states that “all politics is
local,” Beal said that “all disparities are local” as well. Although national
data are useful for moving to an evidence-based action plan, what is needed
are more localized and focused action plans.
The data on health care quality make it clear that providers who care
for more racial/ethnic minority patients have more challenges with deliv-
ering high-quality care to those patients. This occurs in nursing homes,
hospitals, and health plans. Obviously, challenges related to quality do not
exist because a provider who has a large number of minority patients is a
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76 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
bad provider; rather, something about the milieu in which those providers
practice leads to challenges to delivering high-quality health care. Health
disparities are thus actually an issue of health care quality; when measures
of disparities are considered, those measures are, in fact, showing differ-
ences in the quality of care received. Beal said that it is impossible to “talk
about quality without talking about quality for everyone.”
It is not a good use of our time and effort, Beal said, to focus on a
particular factor such as health literacy, access to health care, or the patient-
centered medical home. When health and wellness for people of color are
considered, researchers need to look at all of those indicators; this type of
research is complicated. This runs counter to the traditional bench research
approach in which, ideally, one variable is changed and all other variables
are controlled for.
Need for an Evidence-Based Action Plan
What is needed, said Beal, is what Paula Braveman called “intervention
research,” that is, research that “tells us where to go in terms of next steps.”
This is what Beal called an “evidence-based action plan.” Beal reiterated
Braveman’s statement that research to describe disparities is not needed.
What is needed is an evidence-based action plan for improving health care
quality.
One example that has seen real success in improving health care qual-
ity is in the checklist used in intensive care units. Use of a basic checklist
to ensure that certain things are done and that patients are appropriately
cared for led to significant reductions in the incidence of infections and
pneumonia in patients (e.g., Berenholtz et al., 2004).
Unfortunately, Beal pointed out, it is not always easy to get quality-
improvement research published. Quality-improvement research does not
fit into the randomized controlled trial model. A new paradigm for assess-
ing quality-improvement research is needed, as it does not have the same
methodological rigor as bench research that uses the randomized controlled
trial model.
For example, when children of color are admitted to the hospital
with asthma, they are less likely than white children to be sent home with
medications that control asthma. A number of strategies could be taken to
address this issue: creation of guidelines to distribute to all staff, patient
education, collaboration with pharmacies to ensure that each child is sent
home with medications, and working with primary care providers to ensure
that appropriate follow-up occurs. As a pediatrician, Beal said that she
would keep doing all of these things until 100 percent of her patients were
sent home with asthma-controlling medication. By consideration of the data
for each of these steps, improvement can take place.
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WHAT DO WE STILL NEED TO LEARN?
The research that is needed should be linked with a concerted commu-
nication plan to share the information from that research with those people
who do not know that health disparities are a problem in this country. Health
disparities are a national issue that affects the country’s economic stability
and life expectancy rates for all groups, Beal stated. Furthermore, given the
growing diversity of the U.S. population, this issue cannot be ignored.
One of the challenges to creating an evidence-based action plan is that
it requires a fresh approach to research. One of the basic tenets of experi-
mental research is the availability of a clear, concise, narrowly focused
question to be answered. This kind of reductionist approach will not work
when health disparities are addressed.
The reductionist approach also lends support to the idea that a “silver
bullet” that can address disparities does exist. The reality is that to get
to the root cause of disparities, it is not going to be just one factor. For
example, poor health literacy perpetuates health disparities, as does a lack
of access to care, a lack of access to a regular provider, and a lack of access
to a medical home. No single factor can be considered to be the root cause
of disparities.
It is also clear that although national data can provide a direction, local
data are needed to determine an appropriate intervention. Beal used as an
example the implementation of an intervention to address obesity in The
Bronx, New York, versus one to address obesity in rural Mississippi. How
an intervention gets implemented on the ground is going to be extremely
different in these two locales. This means that everyone must be prepared
for complexity.
Beal described a patient she once had, a young Latina, who was deal-
ing with an unplanned pregnancy. She was already 2 months pregnant
when she realized that she was pregnant. She then took another month
to decide to keep the baby. At 3 months pregnant, she tried to go see a
physician. The physician explained to her that she needed to have health
insurance, so she had to apply for Medicaid. The young woman did apply
for Medicaid, which took another 6 weeks to process. At this point, the
young woman was 4.5 months pregnant. The next step was to find a pro-
vider who would accept Medicaid. By the time she found a health care
provider who would accept Medicaid, she had to wait 6 weeks for an
appointment. At 6 months pregnant, she was ready for her first prenatal
visit. Several days before her appointment, the young woman went into
labor and delivered triplets. The babies ended up doing well, because the
mother was quite capable and had strong family support. Clearly, however,
said Beal, this is an example of a disparity in access to health care.
What could have been done to help this mother? First, she could have
been insured right from the start and provided with coverage that includes
access to contraception. She could have had easier access to care. She could
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78 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
have had easier access to Medicaid providers in her community; however,
an inadequate number of providers were willing to accept Medicaid. A
situation like this one would have needed several interventions to prevent a
disparate outcome. Again, this research is not simple, and all involved need
to be prepared for what is not going to be clean research.
Cultural Competence
Cultural competence is critically important, said Beal. Patients need to
feel valued, and patients need to be able to talk with their providers. At
the same time, this is not enough to eliminate disparities. Beal stated that
“cultural competence is important in and of itself, but it is not the panacea,
and it is not going to do all that we need to do to address disparities.”
As an example, she talked about her father, who has end-stage renal
disease. He reported that he often feels that he is not treated with respect
by the hospital staff (for example, they call him by his first name, which he
does not find acceptable). Beal’s father also reports challenges with poor
care coordination and challenges with payment for home care. This takes
the policy discussions about health disparities back to the real world and
out of the realm of policy discussions.
The paradigm needs to be shifted from a deficit model of describing
health disparities to an asset model that considers solutions, stated Beal.
Rather than looking at a community’s disparities, look for a community
with no disparities and study them. Those pockets of excellence need to be
found and studied. Much as Elliot Fisher demonstrated with the Dartmouth
Atlas (www.dartmouthatlas.org), it is essential to look for the communities
with high-quality care and low levels of health disparities and to study those
communities. Beal concluded by emphasizing several future needs: the need
for a paradigm shift from health disparities to health equity, the need for
an evidence-based action plan, and the need to be prepared for complexity.
DENNIS ANDRULIS
Dennis Andrulis is a senior research scientist at the Texas Health Insti-
tute, where he conducts research with vulnerable populations on the topics
of urban health, cultural competence, and language assistance. He was pre-
viously associate dean for research in the Drexel University School of Public
Health. Andrulis began his comments by stating the three main themes for
his presentation, which can be identified by the following questions:
• Where are the knowledge gaps?
• Where does cultural competence stand today?
• What are the next steps?
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WHAT DO WE STILL NEED TO LEARN?
Knowledge Gaps
In discussing the knowledge gaps in the field of health disparities today,
Andrulis acknowledged that research on the incidence and prevalence of
health disparities has matured. However, although a base has been estab-
lished, knowledge gaps persist. Andrulis explained that the knowledge gaps
occur at three key levels: the individual, organizational, and community
levels.
Individual Level
On the individual level, Andrulis said, although research and knowl-
edge regarding the incidence and prevalence of health disparities–related
conditions have matured in many ways, gaps persist in knowledge about
why disparities in health outcomes have not narrowed more significantly.
The persistence of these knowledge gaps, in turn, leads to three questions:
• Do historic or generational issues (such as poverty) that might
change over time exist? He described some earlier research con-
ducted in Prince George’s County, Maryland, that found that very
high levels of chronic disease and mortality continue to exist there,
even though it is one of the wealthiest counties with a predomi-
nantly African American population in the United States. In fact,
the rates for many conditions or causes of mortality (for example,
infant mortality, smoking, and irregular seat belt use) were similar
to those seen in inner-city Washington, DC (Lurie et al., 2009).
• To what extent are current and intensifying concerns (such as
overweight, obesity, and diabetes) mitigating efforts to reduce
health disparities? In other words, are there contributing factors
that are superseded by other emerging factors now coming to the
fore? Efforts to reduce the effects of these emerging factors on
chronic conditions could be mitigating progress in reducing health
disparities.
• How and to what extent do race and culture-specific impediments
to effective care and management (such as language, health literacy,
and communication challenges) contribute to health disparities?
This broad set of issues around race, culture, language, and cultural
competence should be addressed.
Organizational Level
Health care reform, the ACA, has implications for reductions in
health disparities through system incentives, such as reimbursement rates.
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80 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
In responding to these system incentives, health care organizations can have
an effect on reducing disparities. However, resistance to change to address
diverse patient needs can intersect with new incentives to improve patient
access and quality; therefore, it is critical to note the characteristics of
low-performing health systems and compare them with the characteristics
of high-performing health systems. Understanding the implications and
impact of pay for performance should also be considered in the context
of efforts to reduce health disparities. Andrulis noted both an opportunity
and an obligation to engage these organizations more fully, directly, and
in a measured way to address health disparities, as health care institutions
play a key role in affecting institutional racism in the health care system.
Community Level
The influences of place and geography as contributors to health dis-
parities have a very limited research base and several questions remain
unanswered. For example, what are the community factors that contribute
to and help perpetuate health disparities, aside from the usual suspects
(for example, poverty and a lack of education)? What is the importance
of each factor to an understanding of health disparities? What about the
importance of the mix of factors in different communities?
What Is the Current Status of Cultural Competence?
Although knowledge about the role of cultural competence in access
to and quality of health care is growing, more specific detail on the opera-
tionalization of cultural competence is needed, said Andrulis. In fact, the
National Center on Minority Health and Health Disparities (NCMHD) has
included cultural competence in its solicitations for proposals, indicating
the importance of cultural competence among access and quality measures.
Lieu et al. (2004) conducted research funded by The Commonwealth
Fund on the effects of cultural competence–related policies and practices on
outcomes of care for asthma in children and found that cultural competence
did play a role in the more positive health outcomes. Although this finding
is promising, little research that might flesh out the particular components
of cultural competence that make a difference has followed. Much more
needs to be done in this area.
Work in the area of standards development for cultural competence
has also taken place. For example, the Joint Commission, the Office on
Minority Health in HHS, and the National Quality Forum are all develop-
ing standards for interpreter qualifications as well as language and culture
measures. Although movement in the area of cultural competence is clearly
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WHAT DO WE STILL NEED TO LEARN?
happening, it is not clear where the movement toward the development of
these standards will go next.
Specific Elements of a Cultural Competence Model
Perhaps the biggest knowledge gap in the implementation of cultural
competence interventions and the creation of measures involves the specific
elements of a cultural competence model. Andrulis asked what works,
when, and how. Much work remains to be done in this area. Although
practitioners who believe in the concept accept the concept, some skepti-
cism about cultural competence remains.
A second knowledge gap is that little research on what constitutes effec-
tive training in cultural competence has taken place. Training should also be
standardized, and this has not yet occurred. Again, a much larger literature
around training in cultural competence needs to be created.
Finally, the importance of community engagement in the provision of
culturally competent care is acknowledged but has not been fully expli-
cated. For example, the Centers for Medicare and Medicaid Services (CMS)
is working with quality-improvement organizations participating in diabe-
tes management programs to require these organizations to engage com-
munities and include community-based workers in their programs. Overall,
however, much more work is needed in this area.
Next Steps
Andrulis closed his presentation with some suggestions about what
needs to happen next in health disparities research. He outlined his sugges-
tions in three separate areas.
First, research is needed to identify effective strategies for tailoring
chronic disease and wellness management programs to diverse individuals.
Clinical care models (and the components of those models) that might be
adapted to the management of health and wellness for diverse populations
have not been adequately reviewed or analyzed to date.
Self-management should also be considered a part of these models.
What specific strategies of self-management will help diverse populations
take charge of their health and wellness? What strategies will help diverse
populations respond and adhere to treatment? Models of care management
and wellness management should take into account issues around race,
culture, literacy, and language. Development of an evidence base for the
management of chronic diseases in diverse patients should also be a part
of this process.
Second, provision of support for research and assessment activities
that link health care organizations with efforts to reduce disparities is a
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82 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
necessary next step. Organizations should conduct cultural audits of their
activities and ensure that the consumer’s perceptions match the organiza-
tion’s perceptions of their actions to reduce health disparities and improve
cultural competence. A body of work is needed to determine whether it is
possible to differentiate actions that work better from others that work
less well.
The third area of research needed is the creation and testing of specific
interventions that train and educate health care organizations and practitio-
ners to use broader intersectoral strategies to promote health and prevent
chronic illness. It is not enough to look at the health care system, because
the health care system often serves as the funnel for other problems facing
diverse populations (for example, domestic abuse, poor housing options,
and homelessness). All of these systems should be considered together, and
the barriers across systems should be broken down.
One potential strategy to promote intersectoral work is to change the
ways that health care practitioners are rewarded. For example, a physician-
practitioner advocate role could be formalized in a way that allows incen-
tives for health care institutions to work with agencies beyond the health
care clinic.
Andrulis proposed that the Institute of Medicine (IOM) undertake a
comprehensive study to provide guidance about cultural competence to the
health care field. With the enactment of health care reform, this would be
a very helpful document, he suggested. The report should cover the follow-
ing issues:
• Define what constitutes the field of cultural competence.
• Identify what data are needed to create an evidence base.
• Develop applicable measures of effectiveness.
• Establish the link between cultural competence and health care
quality, cost, and effectiveness.
• Identify what constitutes effective diversity training and education.
• Clarify the role of cultural competence in achievement of preven-
tion outcomes.
A federal strategy to promote intersectoral programs, initiatives, and
policies should be created and formalized, Andrulis said. Interagency and
community collaborations to promote prevention and health care goals
should also be promoted at the state and local levels. Furthermore, the
research base should be broadened to include successful demonstrations
of collaborative initiatives between health care organizations and housing,
transportation, and other relevant agencies with the goal of improving
health.
Finally, although CLAS (Culturally and Linguistically Appropriate Ser-
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WHAT DO WE STILL NEED TO LEARN?
vices) standards are in place, demonstrations and evaluations of programs
implementing these and other relevant standards should be conducted. It is
important to begin to measure the effects of these standards.
DISCUSSION
William Vega, describing himself as “having been a gardener in the
vineyard of cultural competence,” commented that cultural competence is a
heterogeneous concept. This makes it difficult to standardize measures and
then link them to a specific form of training. Vega explained that because
supervisors and chief executive officers set and sustain policies, they should
be willing to experiment. And as they experiment, those in leadership roles
should be aware of the complexity of measuring cultural competence and
the tentative nature of the process that Anne Beal described and have the
willingness to go the distance in order to achieve cultural competence.
Andrulis responded that leadership should play a key role and that lead-
ership is where the process should begin. At the same time, building cul-
tural competence within an organization among an array of practitioners
might assist with sustainability. The recognition that every organization has
strengths and assets and the tying of those assets to the measurement of
cultural competence can lead to a strategy to build on those assets.
Valerie Welsh, the performance improvement evaluation officer at
OMH (Office of Minority Health), described research looking at public
awareness of health disparities over time. She reported that although the
general public’s awareness of health disparities has increased, the increase
has been relatively modest. Awareness of health insurance disparities is
higher, and African Americans are more aware of health disparities than are
other racial/ethnic groups. The public has a very low level of awareness of
health disparities affecting Asian Americans, even among Asian Americans
themselves. Welsh said that increasing awareness is the first step in trying
to address the problem. Awareness of disparities is markedly higher among
physicians than among the general public; nonetheless, physicians too
underestimate the degree of the disparities in many areas.
OMH released a strategic framework addressing health disparities
in 2008. Welsh said that as the framework was being created, the office
found much research about the nature of the problem of health disparities
and on the contributing and causal factors. In particular, more Americans
are aware that disparities in health insurance coverage exist. However,
what was not found was research identifying the specific outcomes at the
individual, societal, and systems levels. This raised questions of how those
outcomes should be measured so that methodologically sound evaluations
of interventions designed to ameliorate those factors can be conducted.
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84 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES?
Welsh noted that the research community could be doing a better job of
identifying and testing measures of intervention outcomes.
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