Cultural competence: its promise for reducing healthcare disparities.
Abstract: Healthcare disparities have reached such disproportionate levels of disease burden for certain groups that the issue has become a national priority. This article examines the most recent iteration of the healthcare disparities movement, the aggressive legislative steps by the federal government to disrupt its destructive path and the promise that cultural competence holds for healthcare providers and the healthcare industry as a whole in placing the patient back at the center of healthcare treatment. Such efforts, it is argued, will be instrumental in helping to reduce healthcare disparities and make the healthcare delivery experience a more positive outcome for all patients.
Subject: Administrative agencies (Services)
Discrimination in medical care (Control)
Public health (Management)
Author: Harris, G.L.A.
Pub Date: 06/22/2010
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2010 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Summer, 2010 Source Volume: 33 Source Issue: 1
Topic: Event Code: 360 Services information; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 250033490

Confronting the issue of healthcare disparities is by no means a new phenomenon. Unfortunately, such disparities are among the nation's most intransigent problems (General Accountability Office (GAO)) (GAO, 2003). Further, the extant literature is rife with empirical research that validates the magnitude of its existence. What is new, however, is the degree to which those inside and outside of the medical and healthcare related communities are becoming more knowledgeable about the routine practices that foster healthcare disparities and about the need to adopt techniques towards their reduction.

This article examines the nation's most recent healthcare disparities movement. First, it highlights why the matter has become a national priority that has galvanized a successive series of legislative initiatives to achieve equity in healthcare delivery and outcomes. Second, specific at-risk groups, known as priority populations, have been identified as those most vulnerable to healthcare disparities (Human Resources and Services Administration (HRSA), 2009). As an important part of the discourse, the author illustrates how cultural ignorance, especially on the part of healthcare providers, has largely contributed to the problem and furthered the plight of those who have been traditionally marginalized by the healthcare system. Finally, this article advances cultural competence as a crucial element in quality patient care and a promising tool in helping to make healthcare disparities a thing of the past.

While there has been a history of disparity in healthcare among certain groups, it was not until 1964 that the Surgeon General began calling attention to the state of the nation's general health (Surgeon General (SG), 1979). In 1979, the Surgeon General assembled ample evidence of disproportionate disease burden. For example, the prevalence of smoking and its adverse consequences were associated with certain high risk populations, including minorities, then identified as primarily African Americans because this is the cohort where much of the research has focused. Previously, such connections were speculative at best and admittedly complex in discerning specific cause and effect factors. During that same year, the Surgeon General issued a companion report that was based upon the Canadian model to highlight the importance of combating healthcare disparities with proactive measures like preventive medicine and healthy lifestyles (SG, 1979). Additionally, the report cited the overwhelming economic and medical burdens to society if these disparities were not curtailed. While these reports on tobacco use have been informative, it was the nation's relatively recent and rapid demographical shifts, along with the acknowledgment that given segments of the population are not only prone to unique medical disorders but are predisposed to a disproportionate level of sub par treatment in the delivery of healthcare to them (Steel Fisher, 2004; Betancourt et al., 2005; IoM, 1999, 2001, 2003),that has brought the issue of healthcare disparities to the center stage.

What is most alarming, however, is that even when members of these high risk populations are given access to the same levels of healthcare, i.e., those with private health insurance or other insurance such as federally subsidized Medicare, they remain equally susceptible to healthcare disparities (IoM, 2003). Accordingly, many of these lapses in healthcare are also mired in systemic problems that make them vulnerable to conditions for "overuse, misuse and underuse" (Berwick, 2002, p.82). The increasing diversity of the nation's population therefore poses cultural challenges, that, unlike the past, call for paradigm shifts in how we think about achieving equitable healthcare for all. These demographic shifts are projected to create an even more diverse population by 2042 when minorities will comprise more than one third of the U.S. population (U.S. Census Bureau News, 2008). Already that representation stands at 31.8 percent of the overall population (U.S. Census Bureau, 2000). One novel approach that has gained footing over time is that of integrating cultural competence as a long term strategy towards helping to combat and in turn reduce healthcare disparities.

What are Healthcare Disparities?

Healthcare disparities are defined as differences in treatment experienced in the quality of healthcare received by racial and/or ethnic minorities even when access to care is equal (IoM, 2003). In essence, when all conditions are equal, members of racial and/or ethnic minority groups with similar or in many cases the same levels of health insurance and access to healthcare providers, disproportionately receive disparate healthcare treatment. Hence, healthcare disparities are primarily about issues of accessing equal and quality healthcare (GAO, 2003). According to the Institute of Medicine (2003), even when controlling for socioeconomic status, although socioeconomic status invariably either contributes to improved levels of healthcare or hinders such treatment, across the board, racial and/or ethnic minorities still receive sub par levels of healthcare. It is believed that historically persistent and negative discriminatory attitudes and prejudice against racial and/or ethnic groups (conscious or unconscious) explain the current level of healthcare disparities experienced by these groups (IoM, 2003; Berwick, 2002; National Healthcare Disparities Report (NDHR), 2007)). These attitudes are exacerbated by the fact that many racial and/or ethnic minorities remain at the lowest rungs of the socioeconomic ladder. Thus, the pervasiveness of healthcare disparities among these groups reflects the entrenched discrimination and prejudice in the larger society. This vicious cycle of inequities continues when, because of unequal access and/or compromised care, illness and premature death are correspondingly and disproportionately borne by members of these same groups when compared to the rest of the population. Further, limited access to the healthcare system restricts access to the care the system is capable of providing or reduces the likelihood that care will be sought when needed (NDHR, 2007).

To determine the degree to which healthcare disparities exist, certain groups have been designated by the federal Department of Health and Human Services (DHHS) as priority populations or at risk groups that not only represent an uneven burden for healthcare disparities, but they are additionally disadvantaged by healthcare trends that predispose them to particular medical maladies (GAO, 2003). These groups include such racial and ethnic minorities as African Americans, Asians, American Indians or Alaska Natives, Native Hawaiians and other Pacific Islanders and Hispanics or Latinos (GAO, 2003; NDHR, 2003) and the poor (NDHR, 2007), a more recent addition. And, the services identified as those most likely to reflect the propensity for disparities in healthcare delivery and thus most likely to produce negative healthcare outcomes for priority populations are diabetes; immunizations; infant mortality; cancer screening, management and treatment; cardiovascular disease; and HIV infection and AIDS testing (GAO, 2003; IoM, 2003).

So, the preponderance of compromised healthcare is found in the designated priority populations or racial and/or ethnic minorities. For example, while there have been significant and positive results in the quality of healthcare received in some areas in addition to the eradication of healthcare disparities between blacks and whites in the treatment of hemodialysis and between Asians and whites in the use of primary care physicians, overall, healthcare disparities have not fallen for these groups since the publication of the first National Healthcare Disparities Report (NHDR) in 2003 (NHDR, 2003, 2007). In fact, the most recent national report on healthcare disparities reveals even more disturbing trends. According to the most recent NHDR (2007), blacks are now 10 times more likely than whites to contract AIDS, American Indians and Alaska Natives are two times more likely than whites to lack prenatal care during the first trimester of pregnancy, and Hispanics are reporting 3.5 times more new AIDS cases than in previous years. In all cases, whites serve as the reference group for comparison with all racial and/or ethnic minorities. An unexpected, yet consistent finding throughout the data has been that one's insurance status determines the quality of healthcare. Such statistics clearly reveal the depth of healthcare disparities as a national crisis. Table 1 is a comparison of data that reflects the status of the three largest healthcare disparities gaps for selected priority populations, including the poor, between the 2005 and 2007 annual reporting periods. Note that core measures with a less than one (1) percent improvement are considered as not showing any improvement; core measures with greater than a one (1) percent improvement are considered to be improving; and core measures where the relative differences between the two reporting periods are becoming larger, are considered to be worsening.

A National Priority

The prevalence of healthcare disparities and the need for a remedy moved the federal government to enact legislations in an attempt to mitigate the situation. Consequently, the issue of healthcare disparities was elevated to a national priority on behalf of the many disenfranchised. Through the Healthcare Research and Quality Act of 1999 (Health Research and Quality Act (HRQA), 1999), Congress directed the Agency for Healthcare Research and Quality (AHRQ) to develop dual annual reports. One, the National Healthcare Quality Report (NHQR), is a comprehensive summary of the quality of the nation's health in the general U.S. population (NHQR, 2007). The other, the National Healthcare Disparities Report (NHDR), delineates the extent of healthcare disparities for given segments of the population (NDHR, 2007). Since 2003, both reports, together with other sources of information that are provided at regular intervals such as the Health, United States (2007), a joint publication by the U.S. Department of Health and Human Services (DHHS), the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS), inform Congress and other interested parties on the condition of the nation's health.

The Institute of Medicine's (IoM) (1999; Leape & Berwick, 2005) seminal work, To Err is Human: Building a Safer Health System, functioned as the backdrop for its subsequent study. Congress commissioned the IoM to study the extent to which healthcare disparities exist within the priority populations, examine those factors contributing to such inequities, and, using these findings, recommend appropriate policies and practices for eliminating inequities. According to Leape and Berwick (2005), it was the earlier IoM (1999) study that redirected the focus of patient safety to the need for fundamental changes in the healthcare system and to do so by involving its multiple stakeholders as part of the solution. In some instances, changes were instituted regarding the adoption of new practices surrounding patient safety. But, more importantly, the study provided the impetus for putting the patient at the center of the discourse for change. IoM's (2003) study on healthcare disparities served as a wakeup call to reveal a complex and institutionalized system of unequal treatment in healthcare for priority populations. While the study attributed some healthcare disparities to factors beyond the control of healthcare providers, the IoM chided the healthcare system for creating structures that undermine the quality of healthcare delivery for certain groups. It also noted the absence of cross-cultural training for providers and pointed to the under representation of racial and/or ethnic minorities among healthcare professionals. IoM also emphasized the importance of developing data collection measures to monitor progress of the above.

The IoM's work has been buttressed by the efforts of the National Center on Minority Health and Health Disparities (NCMHD), a monitoring arm of the National Institutes of Health (NIH), to promote minority health issues and engage in critical endeavors including research to track the health trends and progress of minority populations (National Center on Minority Health and Health Disparities (NCMHD). Other legislation has also created substantive measures for closing the healthcare gap. The Minority Health and Health Disparities Research and Education Act (2000) mandated research, education, training and the promotion of public awareness to specifically address issues of minority health. The Act also required the collaboration of agencies within the federal DHHS and that of public and private organizations. It specifically named as participants in this endeavor the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), Human Resources and Services Administration (HRSA), the Office of International and Refugee Health (OIRH), the Office of Civil Rights (OCR), and the National Academy of Sciences (NAS) of which IoM is a part. The Closing the Healthcare Gap Act (2003) was passed to address the healthcare gap in priority populations as well as to allocate dedicated funding to cover the uninsured. But unlike previous legislations, this Act built on the strength of existing laws to combine the resources of federal agencies to promote cultural competence training as one of the many ways of reducing healthcare disparities.

However, the passing of legislation towards the reduction of healthcare disparities was only due to the overwhelming research evidence that the nation's healthcare disparities were "serious and pervasive" (GAO, 2003; Schulman et al., 1999). First, the extent to which such disparities exist is measured by using those areas of care that are most egregious in administering disparate healthcare treatment, as in the case of cancer screening and management where African American women were twice as likely as white women to die of cervical cancer (Centers for Disease Control (CDC). African American women are also more likely than women of other racial and/or ethnic groups to die of breast cancer. In early stage lung cancer, for instance, the rates of surgery as well as the survival for African American women were lower than whites (GAO, 2003), and racial and/or ethnic minority women were less likely to receive either mammograms or pap smears as preventive measures (Tuckson, 2004). The data suggest that the lower survival rates for African American women may also be explained by lower rates of surgical treatment. Second, in the area of cardiovascular disease, heart disease and stroke were the leading causes of death for all racial and/or ethnic groups and were at least contributing factors in 58 percent of all deaths in 2002 (American Heart Association, 2006). African Americans are more likely than whites to die of cardiovascular disease, have higher rates of hypertension than whites, and have greater mortality rates for stroke than whites.

Third, in diabetes care, American Indians and Alaska Natives stood a 2.6 times higher chance than whites to be diagnosed for diabetes, while African Americans and Hispanics were twice and almost twice as likely to have the disease (Green, 2003). Hispanics have been perceived as the "healthy immigrant" (Green, 2003, p.305) as well as more homogeneous as a group than is often understood, and as a result, African Americans have received more attention in the research of this disease. While the research community has failed to realize that there is heterogeneity among Hispanic subpopulations, the research focus on African Americans may be justified. African Americans with diabetes are 7 times more likely than whites to have amputations and are more likely to develop kidney failure (Resnick, Valsania & Phillips, 1999), although as earlier indicated, healthcare disparities between blacks and whites in hemodialysis treatment have been eradicated (NHDR, 2007, 2003).

Fourth, it appears that while other groups, including Hispanics, are steadily showing increases in the number of new HIV/AIDS cases, blacks have a disproportionate presence of the existing as well as the new cases for the disease. Blacks continue to show an unusually high rate of new cases (NHDR, 2007). The concern is the rate at which the disease remains a constant presence among African Americans who are the least likely to either seek or receive the necessary treatments for controlling the disease (IoM, 2003). It is also believed that access to a regular regimen of healthcare treatment could go far in helping to control the number of cases (NHDR, 2003; NHQR, 2007). In the area of immunizations, Hispanics and African Americans 65 years and older are less likely than whites to self report that they received either influenza or pneumococcal vaccines, as compared to 69 percent of whites who reported having such treatments (GAO, 2003). Finally, because pregnant women are increasingly at risk for such conditions as high blood pressure and diabetes (NHDR, 2003), prenatal care becomes critical as a preventive measure in identifying risk factors to pregnancy, especially within the first trimester. Further, following birth, immunizations are equally critical in preventing infant mortality and morbidity.

However, prenatal and postnatal studies reflect conflicting data and inconsistent efforts at reducing healthcare disparities, particularly for women who are low income, uninsured and in any of the priority populations. A study of 21 hospitals showed that African Americans and other racial and/or ethnic minorities were more likely than whites to receive caesarean sections (Aron et al., 2000). Yet, other studies such as by Braveman et al. (1995), showed that African American women were less likely than white women to undergo caesarean sections. Prenatal studies demonstrate that, even after adjusting for insurance, African American women and those of other racial and/or ethnic minorities were less likely than white women to receive adequate prenatal advice (Barfield et al., 1996; Kogan et al., 1994; Brett, Schoendorf & Kiley, 1994). Consequently, the rates for infant mortality among African Americans are two times higher than those of whites, and for low birth weight and premature births are four times higher than whites (Tuckson, 2004).

Healthy People 2000 and the more recent Healthy People 2010 were launched as national initiatives to improve the nation's overall health (Healthy People). These high profile campaigns are intended to complement the work of the Agency for Healthcare Research and Quality (AHRQ), for instance, and its dual publications on the condition of the general population. For this purpose, 10 leading performance indicators to achieve 28 broader goals through 467 objectives were identified to monitor both the progress and status of the population and its general access to healthcare. Such collaborative efforts, it is hoped, will help to close the healthcare gap between majority and minority populations, as well as provide the general population with proactive measures for maintaining good health.

Determinants of Healthcare Disparities

The IoM (2003) identified three main causes of healthcare disparities within priority populations. Patient level variables contribute to healthcare disparities (GAO, 2003; Interview with subject matter expert 1 (SME), 2006). It is suggested that these behaviors, knowingly or unknowingly, are displayed by patients and prevent them from receiving optimum healthcare. Patients' own levels of mistrust may also contribute to healthcare disparities. Lack of trust in the healthcare system, the government and healthcare professionals, may in turn cause patients to put off visiting a healthcare professional, and when they do, it is at the point where the illnesses have already progressed to severe stages for treatment. For African Americans, for example, this heightened level of suspicion, particularly of the government, is understandable given the federal government's role in the longitudinal study of largely illiterate black males that came to be known as the Tuskegee syphilis experiment where men were deliberately deceived into believing that they were receiving free medical care when they were actually being exploited (Graham, 2007). The men were injected with the virus for the disease so that when they died data could be collected to discern how blacks and whites reacted to syphilis. This level of distrust by African Americans is again understandable (Todd, Green & Bonham, 2006; Blanchard & Lurie, 2004).

Trust in the patient-provider relationship is thus tantamount. Instances like the Tuskegee syphilis experiment can explain why African Americans either refuse or fail to follow through with treatment from their physicians (IoM, 2003), though there is no definitive data to suggest that their doing so adversely impacts patients' ability to receive care. Yet, Boulware et al. (2003) have suggested that African Americans were one third less likely than whites to trust their physicians, especially when the physician's race and/or ethnicity was different from their own (IoM, 2003). Other patient variables, such as patient bias, are also suspected of contributing to healthcare disparities (Steel Fisher, 2004; Collins et al., 2002; Hughes et al., 2006; Cooper et al., 2003; Ngo-Metzger et al., 2006), communication problems (Ngo-Metzger et al., 2006; Cooper & Powe, 2004; Burgess, Fu & van Ryn, 2004; Burgess et al., 2007; Street et al., 2008; Clark, Sleath & Rubin, 2004; Cooper, Beach & Johnson, 2006; Blanchard, Nayar & Lurie, 2007; Schouten & Meeuwesen, 2006),P Pand low trust of providers in the healthcare system (Cooper et al., 2003).

Provider level variables have also been identified as a major contributor to healthcare disparities amongst priority populations (IoM, 2003). Studies point to the profound influence of the relationship between the patient and the provider as the main reason (Ngo-Metzger et al., 2006; Cooper & Powe, 2004; Burgess, Fu & van Ryn, 2004; Burgess et al., 2007; Street et al. 2008; Clark, Sleath & Rubin, 2004; Cooper, Beach & Johnson, 2006; Blanchard, Nayar & Lurie, 2007; Schouten & Meeuwesen, 2006; Betancourt, Green & Carrillo, 2002).p Even uncertainty on the part of the provider can impact the level of treatment provided (IoM, 2003). The provider must thus establish a balance between what is actually known and/or observed about the patient with his or her own preconceived notions in making impartial and accurate diagnoses. Known stereotypes about priority populations may in turn influence providers' own judgment about patients and can potentially and adversely affect the provider patient relationship and the eventual healthcare treatment outcome. For example, a Schulman et al. (1999) study showed that physicians were far less likely to refer nonwhite patients, especially African American women, for cardiac catheterization, even after controlling for patient symptoms, physicians estimate of the likelihood for patients' propensity for coronary disease, and clinical characteristics. The study concluded that both race and gender were factors in physician decision making for treatment. Subliminal exposure to certain images, whether through the media or photographs, can cause individuals to perceive others in certain ways, and as a result, act in kind towards them (Chen & Bargh, 1997). These attitudes and corresponding behaviors can transfer to clinical settings which suggest that majority providers may unknowingly feel and then transfer negative affects towards minority patients. When providers are uncertain as to how they should view patients, they intentionally or unintentionally defer to popularly held stereotypes about minority groups to fill in the gaps (Burgess, Fu & van Ryn, 2004). In short, prejudices persist.

Time pressures on providers to make decisions with limited information about the patient and limited resources also contribute to healthcare disparities (IoM, 2003). Physicians are therefore forced to make "cognitive shortcuts" (IoM, 2003, p.11) in order to prevent problems in the process. Here, when providers experience clinical uncertainty about the patient's malady and diagnosis, they may again resort to bias by relying on group stereotypes which help them to expedite their decisions. Again, this practice over time not only short circuits the patient provider relationship, but may affirm patient mistrust about majority providers and the healthcare system at large. The result is another negative healthcare treatment outcome for the patient. A study of first and fourth year medical students showed that the extent to which they perceived healthcare disparities among racial and/or ethnic minority groups was a condition of the students' level of exposure to the medical field (Wilson et al., 2004). First year medical students were more likely than fourth year medical students to perceive that unequal treatment exists in healthcare among minority groups. Even worse, physicians were the least likely to perceive that such conditions existed. In essence, providers' perception of the existence of healthcare disparities declined with their increased experience in the medical field.

Finally, the general belief is also that the structure of the healthcare system is partially responsible for healthcare disparities and is thought to institutionalize fragmentation that is more than often the experience for priority population patients (IoM, 2003). Language and cultural barriers, in many ways, challenge an already resource strapped system. Although in many cases African Americans experience a disproportionate level of healthcare disparities overall, some studies point to Hispanics and Asians as the least well served by the healthcare system because of language barriers (Collins et al., 2002). More Hispanics did not speak English as their primary language. As a result, they experienced communication problems with the healthcare system. And even when Hispanics identified English as their primary language, they still encountered more problems than whites in receiving equitable healthcare treatment. Those who sought language assistance (i.e., interpreters) from the healthcare system received such services less than half of the time that they were requested. Additionally, compounding an already daunting situation, many Hispanics reported that they were uninsured (Lillie-Blanton et al., 2000; Collins et al., 2002; NHDR, 2003) and lived in low income communities (Collins et al., 2002; NHDR, 2003; Ngo-Metzger et al., 2006). So, racial and/or ethnic minorities have less satisfactory experience with the healthcare system (Lillie-Blanton et al., 2000; Collins et al., 2002; NHDR, 2007; Ngo-Metzger et al., 2006). The geographic proximity of healthcare facilities also presents an added burden for these groups (IoM, 2003). Morrison et al. (2000) showed that less than 25 percent of pharmacies were located in minority neighborhoods. Further, the economic incentives offered to healthcare providers reward the conservation of the system's resources (IoM, 2003). This includes the receipt of low reimbursement payments, a counterproductive measure that reduces the number of providers who are willing to serve in underserved communities, as well as other financial incentives that may undermine the patient provider relationship and in turn treatment. But more than likely, these cost savings for the system come at the expense of those who need the services most. Patient level, provider level and system level variables together compound and confound the degree to which particular racial and/or ethnic minorities stand the chance of securing on par treatment in the healthcare system as we know it.

The Unintended Consequences of Inequity

A healthcare provider's dictum and obligation as a professional as well as to society is memorialized in the Hippocratic Oath. To this end, it is believed that there must be alignment between one's personal and professional values. Any deviation from this commitment questions who we are and to whom we are accountable. Providers' responsibilities are further codified in their Code of Ethics. Healthcare providers are subject to certain forms of scrutiny like those from society, the media and the government in ensuring that, with professional responsibility, comes accountability (Interview with SME 1, 2006). The Patients' Bill of Rights and the Health Insurance Portability and Accountability Act (1996), for instance, are additional measures to ensure that both the healthcare professional and industry comply for the protection of the consumer. The threat of litigation, a last resort, also serves as an additional line of defense for the consumer.

In light of the above, and given patient level, provider level and system level variables, the primary suspects for the presence of healthcare disparities among racial and/or ethnic minorities can then be placed into context and viewed as the unintended consequences of an imperfect but well intentioned healthcare system. However, the research overwhelmingly shows that provider level and system level variables should bear much of the blame for the state of healthcare disparities, and as such, require the most remediation. As stated, providers appear to become more indifferent the more that they become socialized to the medical field (Street, Gordon & Haidet, 2007; Wilson et al. 2004). According to Burgess et al. (2004), this implicit cognition or unconscious prejudice comes about as a result of learning to fear or distrust certain groups. This slow learning over time may teach providers to behave in given ways to members of these groups. However, this attribution bias may also force providers to retreat to customary ways of thinking when challenged to think differently. Providers may then engage in explicit cognition when, say, a patient's symptoms are out of the ordinary and presents the provider with an anomaly. While the provider may be forced to think outside of the box, at least initially, in an attempt to correctly diagnose the patient, it is far easier for that provider to revert to familiar ways of thinking. Moreover, in the interest of time pressures, to fill in the gaps about the patient, and to avoid any deviation from service procedures all to accommodate oneself, the provider may choose the path of least resistance. The patient's condition might be potentially misdiagnosed, the provider's stereotypes are still in play and the patient leaves dissatisfied and distrustful of both the provider and healthcare system.

These subliminal messages of stereotyping are consistently being reinforced by society and are unknowingly transferred to patients (Chen & Bargh, 1997). They are most evident in discordant relationships, where given language and/or cultural barriers, patients may view that healthcare providers have excluded them from the decision making process to determine their diagnoses (Cooper & Powe, 2004). Cooper and Powe (2004), among others (Collins et al., 2002; Ngo-Metzger et al., 2006; Street et al., 2008; Blanchard, Nayar & Lurie, 2007; Street, Gordon & Haidet, 2007; Saha et al., 2000; Saha, Arbelaez & Cooper, 2003), show the importance of clearly communicating with patients and making them a part of the decision making process for their treatment. Surprisingly, other studies point more to either the physician and/or patient's ability to clearly communicate or to be perceived as clearly communicating for a concordant relationship (Clark, Sleath & Rubin, 2004; Bender, 2007; Koerber et al., 2004). The relationship between the patient and provider was less about concordance with either the physician's race and/or ethnicity.

A Johnson et al. (2004) study revealed the extremes to which disconcordance can occur between patients and providers. Asians and Hispanics were less likely than whites and even African Americans to say that physicians listened to them, that they understood everything that the physicians said, that the physicians involved them in the decision making about their care, and that the physicians spent enough time with them. This level of dissatisfaction by patients may have also been attributed to race, ethnicity and language differences. However, in the same study, members of these same groups believed that had they belonged to a racial and/or ethnic group other than their own, they would have received far better treatment as the staff judged them unfairly because of their race and/or ethnicity and disrespected them because of how they spoke English. These problems persisted even when controlled for age; gender; education level; socioeconomic status; health literacy; self reported status; source of care; whether or not they were native, foreign born and/or how long they have resided in the United States; and whether or not English was their primary language. Yet, Johnson et al. revealed that being older and attaining a higher level of education were statistically significant with having a regular physician, being listened to, understanding what the physician had to say, having fewer unanswered questions, perceiving more participation in care and perceiving that they had enough time with the physician. Still, what appeared to be evident, or at least was considered as one source of patient dissatisfaction, was that physicians did most of the talking during the patient visits and were being perceived as less patient centered by African Americans than whites. Physicians showed a similar level of displeasure with African Americans than with whites.

The Johnson et al. (2004) study demonstrates the importance of healthcare providers who are perceived as insensitive to patients' circumstances. Further, as the IoM (2003) noted, the time constraints, as practiced in the healthcare system given demands placed upon providers to conserve resources as well as the shortsighted financial rewards attached for doing so, may have contributed to patient frustration. African American patients in particular viewed the visible time pressures as inconsiderate of their needs, and the fact that the physicians verbally dominated the time with patients and were not considered to be patient centered, exacerbated the dissatisfaction of patients overall. Patient and provider experiences in these studies convey the importance of concordance in the patient provider relationship. Clearly, providers need to be perceived as culturally sensitive to patients' needs.

Figures 1 through 3 demonstrate the extent to which patients are satisfied with their providers given race and/or ethnicity. Figure 1, based on a survey of 1,816 adults (women=65%, white=43%, African American=45%; physicians: male=63%, white=56%, African American=25%) enrolled in managed care in a large urban region, revealed that patients who shared the same race and/or ethnicity with their primary physicians rated those physicians as significantly more participatory, even though female physicians had more participatory visits (Cooper-Patrick et al 1999). Figure 2 is based on a study of 2,301 black, Hispanic and white adults. While Hispanics and blacks were more likely than whites to rate their primary physicians as satisfactory when those physicians shared either their race and/or ethnicity, they were also far more likely to rate their physicians as less than satisfactory when they did not share the same race and/or ethnicity with their physicians (Saha 1999). Figure 3, a study of 16 urban regions across the United States, found that patient-provider race concordant relationships resulted in longer visits and higher physician satisfaction ratings (positive affect score) than those in race disconcordant relationships (Cooper et al. 2003). Figures 4 through 6 show the extent to which patients understand their diagnoses, use certain services as a result and are more satisfied with their providers given the assistance of interpreter services. In a study of English and Spanish speaking Hispanic patients (Figure 4), while English speaking patients rated their understanding of their diagnoses from good to excellent 67 percent of the time, those who used interpreters versus those who thought they should have had interpreters rated their visits as 57 percent and 38 percent, respectively. Thus, language concordance and the availability of interpreter services were highly correlated with an increased understanding of the perceptions of patients' diseases at 86 percent, 82 percent and 58 percent (Baker et al., 1996). Figure 5, a study of 4,380 patients, showed that compared to all other eligible adults (comparison group (CG)), when patients with limited English skills received interpreter services (interpreter services group (ISG)), their use of such services significantly increased (Jacobs 2001). Finally, for Figure 6, researchers found that the users of professional interpreter services were significantly more satisfied than those who used family or untrained interpreters for patient services (Lee 2002).







The Confounding Nature of Healthcare Disparities

The disproportionate rates at which healthcare disparities occur in at risk populations and the multiple demographical variables responsible, confound the healthcare disparities dilemma (Interview with SME 2, 2006). Failure to consider any and all of these factors (even generational differences) in the delivery of healthcare could prove detrimental to the process for both the patient and the provider, and in doing so, further harms the effectiveness, efficiency and reputation of the healthcare system.

It is therefore equally important for healthcare providers to be sensitized to the role of culture to help to explain the nuances of certain patient behaviors (Vaughn, 2001). For example, within the African American community there is a heightened fear of death. This fear though may not be unjustified as national statistics validate its rationale. Homicide rates for black males between the ages of 15 to 24 are the highest of any racial and/or ethnic group (NHDR, 2003). Recent data show the multi-tiered levels of crisis that is ravaging the black community such as the high rates of new HIV/AIDS cases. It is thus an imperative for the healthcare system, and by extension healthcare providers, to understand the implications of traditions, culture and story telling, for instance, that have been passed down in certain cultures. Because they are very real to patients, these long held beliefs should not be casually dismissed, especially by majority healthcare providers. The grievous history of African Americans is perhaps one of the most profound examples. Slavery, the Tuskegee syphilis experiment, routine discrimination and ethnocentrism, are some of the most gruesome yet memorable events that not only resonate but wreak havoc in many African American communities. Consequently, cultural awareness may help to explain why, despite the hope and promises of Western medicine, many racial and/or ethnic minorities fail to seek or even access the healthcare system. Many racial and/or ethnic minorities do not believe that healthcare providers respect their decisions to use either alternative and/or complementary forms of medicine with or instead of Western remedies (Ngo-Metzger et al., 2006). Additionally, delayed health seeking behaviors reflect the lack of trust in the healthcare system and where patients only seek assistance when their conditions become acute.

It has long been established that whites, unlike racial and/or ethnic minorities, are far more likely to seek early healthcare intervention (Lauver, 1994; Ell et al., 1994). Racial and/or ethnic minorities are predominantly at the lowest socioeconomic levels, do not possess the means of securing health insurance and are disproportionately among the uninsured (NHDR, 2003; Collins et al., 2002). Understanding cultural nuances could serve as a conduit for providers to achieve patient provider concordance to reduce healthcare disparities among the underserved. Also important is that many racial and/or ethnic minority patients describe racism as endemic to the healthcare system and blame it as the primary reason for sub par treatment by the industry (Johnson et al., 2004; NHDR, 2003). Many collaborative and national initiatives such as the Healthy People campaigns recognize then that one of the key strategies for addressing disparate experiences in the healthcare system other than access to healthcare and securing insurance for the uninsured is cultural awareness.

The Promise for Cultural Competence

Cultural competence stands out as one of the most promising tools for curbing the slide and reducing the devastating effects of healthcare disparities resulting from a complex interaction of being uninsured, poor, racial and/or ethnic identity, gender, education and geography (NHDR, 2003).p P The IoM (2003), among others (Blanchard, Nayar & Lurie, 2007), have proposed an intervention technique in which culture and society play an integral role. The IoM model calls for a 360 degree interdependency, examination and evaluation of all factors within the healthcare system, while leveraging the attitudes, knowledge and skills of providers to make improvements in the patient provider encounter to reduce healthcare disparities. Similarly, Betancourt et al. (2002) see the utilization of organizational, systemic and clinical cultural competence as imperative to system change. Others like Mayberry et al. (2006) recommend that in addition to providers executing their tasks in a safe, timely, effective and efficient manner, such work should be carried out with equity and the practice of patient centeredness. One way of achieving these goals is through cultural competence.

Defining Cultural Competence

The literature has been wide ranging in its definition of cultural competence. According to the Office of Minority Health, cultural competence is "....a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations." This definition is a variant of that espoused by mental health researchers some 20 years ago (Cross, Bazron & Isaacs, 1989). Other definitions recognize the importance of such components as cultural sensitivity, responsiveness, effectiveness and humility (Betancourt et al. 2003). Regardless of the definition, all share the fundamental requirements for providers to be sensitized to their patients by adjusting their own cultures to understand those of their patients (Johnson et al. 2004). By understanding the sociological and cultural factors that influence patients' beliefs and behaviors and how they interact at multiple levels (i.e., organizational, structural and clinical) to affect decision making, intervention techniques can be designed to improve healthcare treatment and delivery outcomes (Betancourt et al. 2003; Ngo-Metzger et al. 2006). The goal of cultural competence is to develop a culturally competent workforce and healthcare system for delivering the best quality of care possible to patients regardless of race, ethnicity, culture or language ability (Betancourt et al., 2005). Figure 7 describes a conceptual framework of the interactions between patient, provider and system level variables for delivering culturally competent healthcare. The outcomes for patients (i.e., experiences leading to trust or mistrust) are highlighted where the Venn diagrams intersect.


Intervention Techniques

A number of ingredients are essential for laying the groundwork before change towards cultural competence can occur (IoM, 2003). First, because prejudice is not always recognizable or even deliberate, providers should become aware of as well as acknowledge their own biases, and because as providers they rely on the observable behaviors of patients, providers are more inclined to take shortcuts in making medical decisions. The data point to physician bias as a factor in promoting healthcare disparities (Chen & Bargh, 1997). Some whites believe, for instance, that minorities are less intelligent, desire to be on welfare, and are more prone to violence. Yet, many with such biases do not believe that they harbor these stereotypes. Studies have consistently shown how provider bias significantly and negatively impacts the diagnosis, treatment and referrals for additional care that racial and/or ethnic minorities receive (Schulman et al., 1999; Weisse et al., 2001). Second, the basis for a good relationship with patients should be one of respect (IoM, 2003).P PWhen patients believe that they are being disrespected, they become uncooperative, clam up by failing to provide information to the provider that maybe critical to their diagnosis, may fail to show and/or follow up with provider advice, and may manifest a kind of acquiescence orientation where the patient deliberately behaves in a manner that is expected by the healthcare provider. Third, intervention techniques employed by healthcare providers should be incorporated into system policies, procedures and practices to improve the nature of the patient provider relationship (IoM, 2003). Finally, providers should be taught to recognize that, despite their well intentioned efforts, disparities will exist. Therefore, striving for culturally competence through training is imperative for effective patient provider relationships that facilitate appropriate healthcare delivery leading to more positive outcomes for all patients. Table 2 delineates a number of intervention techniques or programs to create a culturally competent healthcare workforce.

Other Essential Ingredients for Change

Recent studies have noted that the under representation of racial and/or ethnic minorities in the healthcare professions contributes to healthcare disparities. While fully 25 percent of the nation's population is comprised of underrepresented minorities (African Americans, Hispanics and Native Americans), only 9 percent are found as nurses, 6 percent as physicians and 5 percent as dentists (Sullivan Commission, 2004). See Figure 8 for the representation of underrepresented minority nurses, physicians and dentists as a percentage of the overall population. Minorities also comprise less than 10 percent of undergraduate nursing faculties, 8.6 percent of dental school faculties and 4.2 percent of medical school faculties (Sullivan Commission, 2004). See Figure 9 for the representation of underrepresented minority faculty in nursing, medical and dental schools. Note that the information from both Figures 8 and 9 are uneven as current data for dentists, for instance, are only available on dental school enrollments and graduates. The IoM (2003) also highlighted the general absence of these underrepresented groups as a major part of the healthcare disparities problem. Further, studies, such as those by Cooper and Powe (2004), showed that underrepresented minority physicians are more likely than majority physicians to practice in underserved and minority communities.



Other than the under representation of minorities in the healthcare professions as a cause for healthcare disparities, recent affirmative action restrictions by the U.S. Supreme Court decisions on behalf of the University of Michigan lawsuits, Grutter v. Bollinger (2003) and Gratz v. Bollinger (2003) (Pynes, 2009), also threaten to reduce the already low number of underrepresented minority medical school students (Lakhan, 2003). The amicus briefs filed as well as the show of force by both the private sector and senior military leaders in support of the University's decision to diversify its student body, point to the significance of race as a selection criterion. According to the military leaders, "Race is of compelling government interest" and it is in the interest of the country's national security when selecting personnel (Karabel, 2003, p.2).. It is also in the country's national interest and national security to increase the number of underrepresented minorities in medical schools and it is worth noting that race-blind policies have been ineffective in achieving this goal.

Therefore, traditional cognitive selection criteria (MCAT and GPA) should be used in conjunction with non cognitive criteria (compassion and commitment to the profession) as a common sense approach to the selection process (Lakhan, 2003). Additionally, the recent and formal public apology by the American Medical Association (AMA) acknowledging more than a century of blatant discrimination against African Americans (AMA, 2008), the call for reconciliation given the apology (2008), and in light of the seemingly intractable problem of under representation of underrepresented minorities in healthcare, it is hoped, will help to forge new relationships with minority organizations and communities to address past wrongs and actively work to increase underrepresented minorities within the healthcare professions.

In response to the under representation of minorities as healthcare providers, the following recommendations have been made to significantly increase that number from underrepresented minority groups over time (IoM, 2003; Sullivan Commission, 2004; Cooper & Powe, 2004). The targeted and active recruitment of underrepresented minorities to these fields must be sought; and dedicated efforts should be pursued to retain those already in the field to act as mentors and encourage them to serve in underserved and minority communities. These efforts can be accomplished through the use of well placed financial incentives and more research to continue to assess as well as develop additional strategies to bridge the healthcare gap between those of majority and minority and disadvantaged populations. These approaches should be sustained over time if they are to make a discernible difference. This three pronged approach--recruitment, retention and research should simultaneously occur on two fronts. First, the academic front, to admit and successfully graduate students from professional schools specializing in the various healthcare disciplines, and second, on the employment (practitioner and/or scholar) front, to ensure that there are viable pools of talent to consistently move into the workforce.


The healthcare disparities problem appears intractable, especially with regard to the increasing gaps in healthcare among racial and/or ethnic minorities who are also for the most part the poorest in the general population. But the issue is not solely about priority populations' access to healthcare, but about their experience of healthcare once they gain access to it. Recognizing a national problem, the federal government has been aggressive in bringing to light the prevalence of healthcare disparities through meaningful legislations intended to remedy the system's continuing disparities. Multiple and high profile national initiatives, in collaboration with federal agencies and the private sector, have been launched towards this effort. Research has shown that healthcare disparities represent a complex web of other yet similar endemic problems of society like poverty, racism and prejudice and the lack of access to healthcare insurance that are further confounded by unique patient level, provider level and system level forces at play.

Provider level and system level factors bear the brunt of the burden and for which solutions must be sought. At first glance, and for all intents and purposes, the problem of healthcare disparities appears to be largely about equal access to healthcare and equitable quality treatment. However, in delving deeper, we must appreciate how much individual patient language and especially culture complicate the already complex problem of healthcare disparities. While both providers and the healthcare system face ongoing challenges in the forms of time pressures and lack of adequate resources, the challenge of cultural awareness for healthcare providers and the healthcare system should be faced. Making cultural competence an integral part of patient care is critical to improving the patient provider relationship It offers the most promising means for reducing the rate at which healthcare disparities occur and increasing the likelihood of more positive healthcare delivery outcomes for all patients.

The notion of universal healthcare as a fundamental right and not a privilege for every American has once again surfaced as a topic of national discussion during the Presidential election. But unlike the political divisiveness of the past that coalesced around businesses to thwart any endeavor that signified a government controlled healthcare system, today such lobbies have become nonpartisan in their push for universal healthcare. Should universal healthcare become a reality, it could create an equal access system and help to narrow the ever widening healthcare gap between majority and minority and poor populations. The need for this move becomes ever more urgent as our nation becomes increasingly more diverse. Together with cultural competence and ongoing educational efforts at increasing such competence for healthcare providers, this public policy would offer the most viable opportunity yet in helping to render healthcare disparities a distant memory.


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Portland State University
Table 1 Three Largest Healthcare Disparities Gap by Priority
Population between 2005 and 2007

           2005 NHDR                    2007 NDHR

                             Relative                     Relative
Group          Measure         Rate         Measure         Rate

Black/     New AIDS cases    10.4       New AIDS cases    10.0
African    per 100,000                  per 100,000
American   population age               population age
           13/>                         13/>

           Hospital          4.0        Hospital          3.8
           admissions for               admissions for
           pediatric asthma             pediatric asthma
           per 100,000                  per 100,000
           population ages              population ages
           2-17                         2-17

           Percent of        1.9        Hospital          3.8
           patients who                 admissions for
           left the                     lower extremity
           emergency room               amputations in
           without being                patients with
           seen                         diabetes per

Asian      Persons age 18/>  1.6        Adults who        1.6
           with serious                 reported poor
           mental illness               communication
           who did not                  with health
           receive mental               providers
           during the past

           Adults who can    1.6        Long stay         1.5
           sometimes/never              nursing home
           get care for                 residents who
           illness/injury               were physically
           as needed                    restrained

           Adults age 65/>   1.5        Adults age 65/>   1.5
           who did not                  who did not
           receive                      receive
           pneumococcal                 pneumococcal
           vaccination                  vaccination

American   Women not         2.1        Women not         2.1
Indian/    receiving                    receiving
Alaska     prenatal care in             prenatal care in
Native     the first                    the first
           trimester                    trimester

           Adults who        1.8        Adults who        1.8
           reported poor                reported poor
           communication                communication
           with health                  with health
           providers                    providers

           Children ages     1.3        Women age 40/>    1.8
           2-17 with no                 who reported not
           advice about                 receiving a
           physical                     mammogram within
           activity                     the past 2 years

Hispanic   New AIDS cases    3.7        New AIDS cases
           per 100,000                  per 100,000
           population age               population age
           13/>                         13/>

           Adults who can    2.0        Hospital          2.9
           periodically/                admissions for
           never receive                lower extremity
           care for                     amputations in
           illness/injury               patients with
           as needed                    diabetes per

           Children whose    1.8        Women not         2.0
           parents reported             receiving
           poor                         prenatal care in
           communication                the first
           with their                   trimester
           health providers

Poor       Children whose    3.3        Children whose    3.0
           parents reported             parents reported
           poor                         poor
           communication                communication
           with their                   with their
           health providers             health providers

           Adults who can    2.3        Adults who can    2.4
           periodically                 periodically
           receive care for             receive care for
           illness/injury               illness/injury
           as needed                    as needed

           Children ages     2.0        Women age 40/>    2.1
           2017 who did not             who reported
           have a dental                they did not get
           visit                        a mammogram
                                        within the past
                                        2 years

Core Measures < 1 per year = No Improvement; Core Measures > 1
per year = Improving; Core Measures where relative differences
are becoming larger at a rate of >1 per year = Worsening

Adapted from: National Healthcare Disparities Report (NHDR), 2007

Table 2 Towards Developing a Culturally Competent Health Provider

    Type           Description         Target         Responsibility
   Program                            Audience             for

Cultural        Evidence            All health      Educational
Competence      based training      and             organization
Education       in cultural         healthcare      (i.e., medical
                competence          professionals   school)
                                    in training
                                    and practice    Continuing

Monitoring      Collection,         All health      Healthcare
and             analysis,           and             organization
Evaluation of   dissemination       healthcare
healthcare      of information      professionals
processes       according to        in practice
                information on
                the processes
                of care
                according to
                race, ethnicity,
                social class
                and language
                of patient

Certification   Certificate of      All             Professional
and             Cultural            healthcare      society
Accreditation   Competence          professionals   (i.e., AMA)
                training            in practice

                Healthcare          Healthcare      Accrediting body
                professional        organization    (i.e., JCAHO)
                certified as

Clinical        Oversight           Healthcare      Healthcare
practice        board on            organizations   organizations
governing       cultural
boards          competence.
                Should be
                of all
                (i.e., healthcare
                3rd party
                members of
                and societies,

Promotion of    Mentoring and       Healthcare      Healthcare
Workforce       support             professional    professional
Diversity       programs for        schools and     schools
                pre-college,        healthcare
                undergraduate       organizations
                and graduate
                URM students

                Utilize                             Federal government

                Enforcement of                      Federal government
                Title VII

                Monetary                            Local, state or
                incentives to                       federal government
                organizations to
                recruit minority

    Type           Timeline

Cultural        Identify or
Competence      create
Education       programs
                of study in
                w/in 2

                win 3 years

Monitoring      Develop
and             instructions
Evaluation of   (i.e.,
healthcare      programs)
processes       w/in 1 year

                w/in 3

Certification   Develop
and             criteria for
Accreditation   evaluation
                w/2 years

                w/in 3

Clinical        Create and
practice        implement
governing       governing
boards          boards w/in 2

Promotion of    Identify or
Workforce       develop a
Diversity       mentoring
                program w/in 2
                years and
                w/in 3 years



                Identify or
                programs w/in
                2 years for
                w/in 3 years

Adapted from: Horner et al, 2004
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