Reducing healthcare disparities in the military through cultural competence.
Abstract: Healthcare disparities are fast encroaching upon equal access healthcare systems like the military. While this growth has been attributed to the same antecedents as those found in the general civilian population, four additional assumptions are posited as contributing factors to healthcare disparities that are peculiar to the military. Research on certain segments of the veteran population in the Veterans Administration (VA) is profiled as the most analogous healthcare system to that of the military's and a meta-analysis of studies on similar populations in the military are also examined. Like the general civilian population, cultural competence is viewed as an imperative component of healthcare delivery to help to narrow the healthcare disparities gap between majority (men and whites) and minority (women and nonwhites) populations in the military.

Keywords: military, veterans, healthcare disparities, cultural competence, equal access
Article Type: Report
Subject: Health care disparities (Social aspects)
Health care disparities (Management)
Military personnel (Health aspects)
Veterans (Health aspects)
Cultural competence (Health aspects)
Author: Harris, G.L.A.
Pub Date: 09/22/2011
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 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Fall, 2011 Source Volume: 34 Source Issue: 2
Topic: Event Code: 290 Public affairs; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 9104111 Active Military Personnel; E198380 Veterans NAICS Code: 92811 National Security
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304050531
Full Text: INTRODUCTION

Healthcare disparities have been advanced as a national issue. The empirical evidence supports this move in light of such disparities adverse impact on the general civilian population (U.S. General Accountability Office (GAO) 2003, Institute of Medicine (IoM) 2003, National Healthcare Disparities Report (NDHR) 2007). Although it appears that these inequities are not unique to the civilian population, less is known about the incidence of healthcare disparities among military personnel.

Through a meta-analysis of various studies, this paper explores healthcare disparities among military personnel relative to the healthcare outcomes of priority populations identified in the civilian population as those most at risk. These disparities reflect the differences in levels of disease burden between different groups (Center to Reduce Cancer Health Disparities). First, at issue is whether or not healthcare disparities exist within an equal access healthcare system like the military. Second, if so, to what should these inequities be attributed? The antecedents of healthcare disparities are well known for the civilian population but four suppositions are offered by the author as those most responsible for the growth of healthcare disparities in the military. Third, the growing incidence of healthcare disparities within the civilian population is said to be ascribed to individual and collective cultural indifference on the part of healthcare providers and the healthcare system as a whole. Cultural competence has been endorsed as a viable skill set to reduce, if not eradicate, the rate at which healthcare disparities occur. Similar efforts show promising results for the military and the Uniformed Services University of the Health Sciences (USUHS) Center for Health Disparities Research has been enlisted as a partner in helping to stave off this looming problem. Finally, the author discusses the above in terms of its implications for public administration and the prospects for future research.

Because the military constitutes a subset of the civilian population, its population may also be susceptible to the same healthcare anomalies that are present in the civilian population, although what distinguishes the military's healthcare system from that of its civilian counterpart is that everyone has access to and is assured of healthcare coverage and treatment (TriCare Management). Yet, the demographical composition of the civilian population has so changed to dispel traditionally held myths that challenge preconceived notions about people and culture. So, too, have there been commensurate shifts in the diversity of the military's population, shifts that have caused the military to act in kind. Cultural competence is viewed as a necessary and integral component to delivering quality healthcare to enhance patients' overall healthcare experience and outcome. The topic of cultural competence and its impact on reducing healthcare disparities in the military is important to public administration because, although more often than not the military is perceived as an entity onto itself, it is a public sector organization and therefore a part of public administration. Further, the military, more so than any other American institution, has served as a model employer in understanding the role that culture and thus race, gender and ethnicity play in achieving its mission (Evans 2003, Defense Equal Opportunity Management Institute (DEOMI) 2002). Race and/or ethnicity have also been critical factors in gauging recruitment and retention patterns of military personnel (Bachman et al. 2000, Department of Defense (DoD) 1999, Hosek et al. 2001, Segal et al. 1999, Smith 2001, Segal and Wechsler Segal 2004). To that end, cultural competence can be an effective tool for military healthcare providers to better serve their clientele, and in doing so, facilitate the achievement of the mission.

ANTECEDENTS OF INEQUITY

Healthcare disparities represent a complex confluence of factors that predispose priority populations to conditions that render them vulnerable to disparate healthcare treatment. Patient level factors due to patients' own lack of trust in healthcare providers, the healthcare system and the government (GAO 2003, Healthy People 2010) are believed to be one such cause, especially when there are racial and/or ethnic differences between patients and providers (Boulware et al. 2003). Provider level factors also hinder positive healthcare outcomes for patients (IoM 2003). The patient provider relationship is said to be paramount to this encounter (Ngo-Metzger et al. 2006, Cooper and Powe 2004, Burgess et al. 2004, Burgess et al. 2007, Street et al. 2008, Clark et al. 2004, Cooper et a l. 2006, Blanchard et al. 2007, Schouten and Meeuwesen 2006, Betancourt et al. 2002, Betancourt and Maina 2007, Bender 2007, Koerber et al. 2004). However, stereotypical thinking on the part of providers about certain patient groups may unwittingly influence their prognosis (IoM 2003). Moreover, pressures for efficiency in the healthcare system force providers to take what the Institute of Medicine (IoM) calls "cognitive shortcuts" (IoM 2003, p.11) to preserve the system's flow, albeit at the expense of the patient. A Wilson et al. (2004) study illustrates this prophetic imbalance. First year medical students, or those least socialized in the medical field, were far more likely than fourth year medical students to perceive healthcare inequities for certain patient groups. A far more sinister finding was that physicians were the least likely of the three cohorts to perceive the presence of these inequities. Consequently, the more the socialization to the medical field and the presumed closer proximity to the patient, the greater the likelihood for provider indifference towards patients.

System level factors have also been blamed for healthcare disparities within the civilian population (IoM 2003). For example, although African Americans as a group disproportionately experience disparate healthcare treatment, Hispanics and Asians are particularly challenged given cultural and language barriers (Collins et al. 2002). This experience is compounded by the disproportionate levels of being uninsured (Collins et a. 2002, Lillie-Blanton et al. 2000), residence in low income locales (Collins et al. 2002, NDHR 2003, Ngo-Metzger et al. 2006) and inaccessibility to healthcare facilities (IoM 2003). Some cite evidence that points to the scarcity of pharmacies in these neighborhoods (Morrison et al. 2000) while others contend that the disincentives in the healthcare system discourage providers from serving in these communities (IoM 2003).

Provider and system level factors though have been declared as the most contributors to healthcare disparities (IoM 2003). Provider bias about certain groups (Burgess et al. 2004) may unintentionally reinforce already held stereotypes. Explicit cognition, or that which initially forces providers to think unconventionally when presented with treatment anomalies, also potentially results in providers' acquiescence to customary ways of thinking and doing. The research also indicates that such encounters are destructive to the patient provider relationship (Collins et al. 2002, Ngo-Metzger et al. 2006, Cooper and Powe 2004, Street et al. 2008, Blanchard et al. 2007, Street et al. 2007, Saha et al. 2000) and become disconcordant to adversely impact the decision making of patient diagnoses (Cooper and Powe 2004). This finding demonstrates the importance of clear communication between patients and providers to the healthcare delivery outcome (Clark et al. 2004, Bender 2007, Koerber et al. 2004). Equally noteworthy is that although a provider's race and/or ethnicity more than likely contributes to the concordance of the patient provider relationship, resolving cultural and language challenges is essential to quality healthcare. Providers who are perceived as disrespectful or fail to actively engage patients in decisions about their treatment leave patients the most frustrated (Johnson et al. 2004).

Healthcare Disparities and the Military

While much of the research on healthcare disparities has showcased those within the civilian population, few have focused on military personnel that call attention to these issues, though there has been a continuous stream of studies on veterans with posttraumatic stress disorder (PTSD), and more recently on those with traumatic brain injury (TBI). However, owing to the military's unique equal access healthcare system (TriCare Management) and an increasing presence of healthcare disparities among certain groups served by the system, empirical research highlighting these inequities has increased.

But, in addition to the already known antecedents that are generally believed to cause healthcare disparities, four primary reasons account for the purported increase of healthcare disparities in the military. First, any changes in the demographical makeup of the civilian population will result in like changes or at least carry over effects to the military. However, such variances in the military's population may occur at significantly lower rates given the assurance of healthcare access. What may also be similar to the civilian population is the degree to which some segments of the military's population may perceive that, despite equal access to healthcare, they may not be afforded the same level of healthcare treatment as certain groups. Second, a small but gradual increase in the number of foreign born personnel have joined the ranks of the military (Kennedy et al. 2007). Third, given the communal nature of the military's culture of a "stiff upper lip norm" (Langston et al. 2007, p.933), military personnel are less likely than their civilian counterparts to voluntarily seek medical treatment, especially for mental health given the perceived stigma of weakness (Langston et al. 2007, Nayback 2008). And, fourth and somewhat related to the above, is a disengaged provider culture that may have become more immersed in the medical culture than in the military culture.

PREVALENCE OF HEALTHCARE DISPARITIES IN THE VETERANS ADMINISTRATION

Perhaps some of the most poignant examples of healthcare disparities within an equal access system come from the Veterans Administration (VA) where there is reliable research evidence of disparate treatment within certain segments of the veteran population. The VA more so than any other organization, and given the constituency served, appears to most closely exemplify the military as no less immune from the blight of healthcare disparities brought about by individual, collective and organizational variables as in the civilian population, although the VA, unlike the military, secures its clientele through self selection, not the mandatory selection of personnel.

In a study of black and white veterans with PTSD, black veterans showed poorer attendance for treatment than white veterans who were similarly paired, appeared to be less committed to treatment, received more treatment for drug abuse, were less likely to be prescribed antidepressant medication and were seen as having less improvement in the control of violent behaviors (Rosenbeck et al. 1995). Incidentally, of those black or white clinician pairings, while some black clinicians reported some of the same results for black veterans with whom they were paired, these same results became more pronounced when black veterans were paired with white clinicians. According to Rosenbeck et al. (1995), part of the reason why black veterans when paired with white clinicians did not appear to be as committed as white veterans, and as a consequence, experienced more negative healthcare treatment outcomes, is rooted in history and culture. While black veterans were as equal as white veterans in the degree to which they sought and accessed mental healthcare treatment, African American veterans were reluctant to engage in the personal disclosure of their experiences. A little known ethos among black men, it is said, is that "you don't tell your secrets in the streets" (Rosenbeck et al. 1995, p.561). Consequently, this disengagement by black male veterans must be understood in terms of its historical context even though they are in the presence of fellow veterans. Black men are deeply aware of this perceived powerlessness and "If Black patients believe that the goal of therapy is to maintain the status quo and their place in society, they may be suspicious of the motives of Black as well as White psychiatrists" (Rosenbeck et al., p.563).

Other studies on the VA signify high healthcare disparity rates among racial and/or ethnic groups especially in the area of cardiac care as is found in the civilian population (Peterson et al. 2002, Mirvis et al. 1994, Schulman et al. 1999). While black patients were just as likely to receive beta blockers as white patients, more likely than white patients to receive aspirin, and only slightly more often than whites to receive angistensin converting enzyme inhibitors, they were far less likely than white patients to receive thrombolytic therapy and were less likely to go through bypass surgery, even when deemed as high risk (Peterson et al. 2002). For those with coronary artery disease, blacks were far less likely than whites to undergo cardiac catherization and less likely than whites to undergo surgery (Mirvis et al. 1994; Schulman et al. 1999). Black and Hispanic veterans were also less likely than white veterans to receive carotid endorterectomy and experienced more postoperative complications for stroke and death from stroke than white veterans (Horner et al. 2002). A 1992 survey revealed that American Indian/Eskimo, black and Hispanic veterans were 4.4, 1.9 and 2.5 times more likely than white veterans to self report that they were unable to secure ambulatory services as part of their overall healthcare needs (Washington et al. 2002). However, a 2001 national survey of veterans suggested that, regardless of race and/or ethnicity or even gender, the intensity of usage of the VA is determined by physical and/or mental health fitness (Elhai et al. 2007). These results also reflected the use of services by a younger generation of veterans such as those from Operations Enduring and Iraqi Freedom who lacked access to private health insurance. Thus, the use of the VA, at least by younger veterans, may be more need based.

In another study, stratified focus groups of Native American veterans from urban and rural geographic regions of California and Nevada, as well as from an intergenerational representation from World War II to Operation Enduring Freedom, showed that while Native Americans were no different from the veterans of other races and/or ethnicities in their motivation for joining the military (i.e., to explore career opportunities), they were more apt to utilize the services of the Indian Health Services (IHS) than those of the VA even though the IHS did not provide such services as treatment for PTSD (45 percent suffered from service connected illnesses) (Harada et al. 2005). Use of the IHS over the VA was primarily attributed to access, geographic location and distance and the waiting times for such services, and despite the negative military experiences of some respondents who were personally discriminated against and/or witnessed discrimination against African American and Hispanic cohorts. Another stratified sample of veterans across diverse racial and/or ethnic groups from WW II through the Vietnam Era, yielded even more sobering results that the rationale and the extent to which veterans used the services of the VA depended upon their expectations of the system (Damron-Rodriguez et al. 2004). Many veterans believed that this privilege (using the VA) has been earned but should be used only by veterans who need the services the most. Caucasian Americans from WW II were the most satisfied with the VA while Asian American veterans from the Vietnam Era rated such services the lowest. And, overall, Vietnam Era veterans were the most likely to link a stigma with using the VA. The study concluded that veterans' military experiences framed their perceptions and expectations of the VA.

Other evidence revealed that African American veterans were far less likely than Caucasian veterans and those of other racial and/or ethnic groups to be classified as PTSD in order to receive medical treatment for a service connected disorder (Murdochet al 2003, Nayback 2008). Similar studies on the VA showed disparate care in the treatment of African American veterans for cardiac care (Ngo-Metzger et al. 2006, Cooper and Powe 2004, Murdoch et al. 2003), laparoscopic cholecystectomy (Whittel et al. 1993) and carotid artery imaging (Conigliaro et al. 2000). Ironically, a more recent and comprehensive review of the VA exposed systemic patterns of healthcare disparities across a broad array of treatments and services that were based on patient race and/or ethnicity, health literacy, trust, and decision making, among many others (Saha et al. 2008). But unlike the VA where access to healthcare is regularized but not mandated and based on the self selection of its clientele to use such services, in the military such access to healthcare is not only equal, it is mandated for all personnel. What then would account for variances in healthcare treatment among groups in the military?

HEALTHCARE DISPARITIES: A GROWING PRESENCE IN THE MILITARY

A meta analysis of studies on the military suggests that, at least in part, the resultant healthcare disparities among certain groups may be due to the nuances of culture coupled with preexisting health conditions before personnel join the military. And, despite a healthcare system that calls for a rigorous and mandatory regimen as a condition for fitness for duty and readiness, because of prevailing cultural norms and health and healthcare disparities that predispose some groups as at risk, once they join the military, while these inequities decrease over time, certain health and healthcare disparities can persist.

Studies on the military reflect a mixed record of quality healthcare treatment across racial and/or ethnic groups. A comparison of civilian and military treatment facilities found that the utilization of prenatal care was marked by a higher use of such services by Caucasian patients than African American patients in both civilian and military facilities (Barfield et al. 1996) although the variances between the groups were far lower in military facilities. Still, variances were discernible between African American and Caucasian patients in the military. Further, additional research on caesarean births in military hospitals showed elevated levels of caesarean births for both black and Asian women as compared to white women.(Linton and Peterson 2004). While the disparity was partly due to higher levels of preexisting hypertension and genital herpes in African American mothers, higher levels of diabetes among Asian mothers and other unknown factors, it was the preexistence of these chronic conditions that led to the disproportionate levels of birth deliveries by caesarean section for African American and Asian women as compared to Caucasian women.

Bibb (2000, 2001) purposefully discounted non economic barriers on research on late stage diagnosis for breast cancer in order to determine why in an equal access healthcare system African American women in the military were more likely than Caucasian women to delay seeking diagnosis. African American women experienced disproportionate rates of late stage diagnosis of breast cancer. While rank and race correlations were not directly made (i.e., African American and/or Caucasian women between certain rank ranges who were more likely to be identified as either late or early breast cancer diagnosis), the findings showed that the lower the women's rank, the greater the likelihood that they would receive late breast cancer diagnoses. Women between the ranks of E1 through E5 (allegedly the least educated and in the enlisted corps) were thrice more likely to receive late breast cancer diagnoses than those between the ranks of 05 through 010 (allegedly the most educated and in the commissioned or officer corps) and twice more likely than women in other ranks to be diagnosed with late stage breast cancer. These findings inferred that the higher the rank and the higher the education level, the less likely would women be diagnosed with late stage breast cancer. Women who conducted breast self examinations (BSE) had a six times higher chance of being diagnosed with late stage breast cancer than those who made the discovery through regular mammograms. The study also suggested that higher mortality rates among African American women than Caucasian women were due to the disproportionate rates of late stage breast cancer diagnoses.

According to Bibb (2000, 2001), the above findings would suggest that it is important to look beyond socio economic factors for the causes of disparities in healthcare, especially within an equal healthcare access system like the military as disparities can be attributed to cultural beliefs, values and expectations that may be based upon patients' experiences. Yet, what Bibb unintentionally revealed was that socioeconomic factors cannot be discounted. In this case, it appeared that the education levels of individuals within the sample made a difference. In an earlier study (Optenberg et al., 1995) to distinguish the practices and/or the degree to which individuals (active duty, dependents and retirees) sought medical care, although African Americans were more likely than Caucasians to present younger and higher levels of cancer, there were no survival rate differences between the groups. A later study on the health seeking behaviors of African American men attributed early screening for prostate cancer to providing education that included the use of brochures that depicted African American men as the clients of such services (Edwards et al. 2002).

A more recent study on the impact of race on colon and rectal cancer screening found that although there were no disparities among groups in treatment for surgical resection, adjuvant therapy and the rate at which the diseases recurred, there were racial differences in the prevalence of the diseases at a younger age and in the incidence of the American Joint Committee on Cancer (AJCC) stages II, II and IV (Hassan et al. 2008). The limited nonwhite samples showed an association between race and/or ethnicity and age in the increased presence of AJCC stage III but less of stages II and IV at the time of screening. The occurrence of the diseases was partly ascribed to patient factors (i.e., delay in screening), provider factors (i.e., failure of physicians to improve preventive protocols by reminding patients of routine check ups) and system level factors (i.e., no computer generated reminders to patients for check ups based on physicians' lack of input).

Using secondary data, stratified for different periods from 1980 through 1999 of over 23,000 women who were treated in the Department of Defense (DoD) for breast carcinoma, the survival rate between African American and Caucasian women was analyzed (Jatoi et al. 2003). Results showed that the mortality rates between the two groups significantly diverged with race over time. For example, the significance level at which these rates diverged increased with time (1980-1984, p=.03; 1985-1989, p=.001; 19901994, p=.001; 1995-1999, p<.001). The study speculated that within an equal access system that shows variances in healthcare treatment and outcomes according to race and/or ethnicity, these variances may be explained by variables other than race and/or ethnicity. Some studies assert that obesity and diet, for instance, may be contributing factors (Rock and Demark-Wahnefired 2002) for disparities in healthcare treatment. This claim is supported by the incidence of obesity especially among African Americans (McTigue et al. 2002). Yet, Jatoi et al. (2003) acknowledged that even in an equal access healthcare system, bias based on patient race and/or ethnicity cannot be ruled out as a possible reason for disparate healthcare treatment. Recent research on PTSD among veterans of Operations Enduring and Iraqi Freedom, for instance, found that certain demographical variables, such as gender, race and culture, play important roles in the type of healthcare treatment that was received (Paulson and Krippner 2007) or sought (Nayback 2008).

Using a military model, Hyman et al. (2006) showed how the rate at which healthcare disparities in oral healthcare can be controlled through the examination of racial disparities in untreated caries, use of dental services and loss of teeth to compare the oral health of black and white males in the military with their civilian cohort. One sample consisted of white and black non Hispanic males across all services (Army, Navy, Marines and Air Force) between 18 years to 44 years. A second sample consisted of civilian males within the same age range while a third sample consisted of new military recruits between the ages of 18 to 19 who had not yet received dental care at their duty stations. Results showed that in the civilian sample whites exceeded blacks in the number of dental visits made within the preceding year but that both blacks and whites showed lower dental visits when compared to the military sample. But, in comparison with the civilian sample, a lower number of new recruits had visited the dentist during the previous year. Also found was that a higher number of recruits had untreated decay or dental caries. However, the black and white male military sample was equal in the number of dental visits. This high number was attributed to the mandate from the military to report for dental examinations coupled with repeated reminders for such periodic visits. A final and more recent study on the mortality rates of military retirees in military hospitals showed similar results. There were no racial and/or ethnic differences in mortality rates based on race and/or ethnicity (Meyers et al. 2008). These results were credited to equal and uninterrupted access to comparable levels of healthcare at military installations even following retirement. However, there was no distinction in care between officer and enlisted personnel. Other studies on healthcare treatment rendered in the military either yielded similar results or no statistically significant differences in healthcare treatment outcomes between groups (Johnstone et al. 2002, Farley et al. 2007, Gallentine et al. 2001).

In a congruent study, significant improvements were found in the rates of dental caries over a 4 year period (FY2001-FY2004) (Bartoloni et al. 2006). While the decrease in dental caries was attributed to the dedicated work of the Air Force Dental Service (AFDS), higher rates in dental caries were attributed to both the socioeconomic status of personnel joining the military as well as the frequency of tobacco use by younger enlisted personnel who it was believed were less likely to be concerned about dental hygiene. Such demographical variables as rank and corps, tenure in the Air Force, education level and age, were highly correlated with the number of dental caries found. And, although the initial cohorts significantly diverged with race, the rates of dental caries almost converged or showed no discernible differences over time. However, given fewer providers, rising costs and limited resources, the researchers called for greater efficiency in service delivery. Yet, using the secondary data of military personnel, other studies showed no racial differences in the treatment of catherization and coronary revascularization procedures, for instance, following acute myocardial infarction (AMI) (Taylor et al. 1997), unlike the findings within the civilian population.

An examination of the existing literature, though overwhelmingly on the VA, hence demonstrates that healthcare disparities can occur in an equal access healthcare system like the military, although at far lower rates than in the civilian population and at questionably still higher rates in the VA (See Table 1 below for the contributing causes of these disparities across healthcare systems within the civilian sector, the VA and the military). This evidence has established that the military, too, can become vulnerable to healthcare disparities. Patient, provider and system level challenges can be experienced and, as one subject matter expert (SME) at USUHS' Center for Health Disparities Research acknowledged, being in the military does not preclude biases from occurring (SME 2006). The incidence of these disparities is presumed to also be exacerbated by the diversity of incoming personnel into the military in terms of race and/or ethnicity; the growing presence of foreign born personnel who are joining the military; the propensity for military personnel to not seek medical treatment to avoid the perception of weakness; and of healthcare providers who may have become more indoctrinated into the subculture of their own professions than that of the military's and at the expense of their patients.

CULTURAL COMPETENCE AND THE MILITARY

To combat the rate at which biases are likely to occur in the military, DoD routinely conducts a Military Equal Opportunity Climate Survey (MEOCS) of all military branches as a continual gauge of its personnel's perception of their work environments (DEOMI). Race and/or ethnicity more than gender was significant in how the overall climate in the military was perceived (DEOMI 2002). Whites were positive about such issues but most minorities, particularly blacks and Hispanics, rated the equal opportunity climate in the military lower than whites as they were more likely to encounter racism. A 1999 study of the cultural climate in a military medical center found that overall personnel attitudes were less positive about discrimination and the equal opportunity climate (Brannen et al. 1999). Statistical differences were found between men and women and between majority (men and whites) and minority populations' (women and nonwhites) perceptions of the cultural climate. An interesting finding was that majority populations viewed reverse discrimination much less favorably than minority populations. However, the low response rate of the survey was cause for concern because making sweeping generalizations from the results would render the study suspect.

One study of Army nurses' attitudes toward African American and Hispanic patients found that female nurses were more positive towards African American patients (Joseph 1997). The attitudes of male nurses were not statistically significant for Hispanic patients although male nurses showed more positive attitudes towards African American patients. But further examination of the nurses' individual scores revealed many were ambivalent in their responses and so appeared to be mixed in their attitudes towards both groups of patients. These findings also indicated that female nurses as well as those who had received cultural diversity as part of their nursing education were more positive towards African American patients. African American nurses also rated same race patients higher than Hispanic patients while the next highest ratings of African American patients came from Caucasian nurses. But although African American and Hispanic nurses rated Hispanic patients positively, the limited sample of both Hispanic nurses and patients might have contributed to lower scores from nurses because of limited exposure. A recent study pointed to the need for increased cultural competence on the part of healthcare providers in the military as a result of the experiences of active duty psychologists who were themselves multicultural in makeup (Kennedy et al. 2007).

According to Kutz (1996), military physicians first become ensconced in the medical culture, not the military culture, especially those who join the military through non traditional channels such as direct commission. As a consequence, they may become disconnected from those they serve. Given the demographical changes in the military population, the increasing number of overseas deployments, the steady rise in the number of foreign born nationals who join the military, the ensuing healthcare disparities among certain groups and the propensity of military personnel to not seek out healthcare treatment, education and acculturation in cultural competence become an imperative in rendering quality healthcare treatment to all in the military. As indicated, when cultural diversity was an integral part of healthcare providers' education, they viewed patients of different races and/or ethnicities more favorably (Joseph 1997).

The Uniformed Services University of the Health Sciences (USUHS)

An infusion of cultural competence which combines cultural awareness with sensitivity on the part of healthcare providers is believed to be vital in helping to close the healthcare disparities gap wherever they occur (IoM 2003). Although the state of emergency at present lies within the civilian population, much more can be done to stem the tide of incidence that is being experienced by some segments of the military population. While it appears that the military model has so far offered the best hope for equity in healthcare treatment although in the aforementioned studies neither the patient and provider relationship nor the differences in rank structure were discussed at length, the tendency for the increased presence of these disparities should be promptly addressed. The empirical evidence points to inconsistent patterns of healthcare disparities being experienced among different racial and/or ethnic groups, even in the military. The USUHS Center for Health Disparities Research was established as a partner to capitalize on its expertise in research, education, training and outreach in the quest towards healthcare disparities reduction (USUHS' Center). The Center's credo is that with equal access to health should come equal healthcare treatment as well.

The Role of Cultural Competence

The military has been ahead of the civilian sector in recognizing the crucial role that race and/or ethnicity and thus culture play in how people relate to one another in their work environments (Evans 2003, DEOMI 2002). As such, the increasing diversity of the military population accompanied by an increase in the rate of healthcare disparities among certain groups, warrants remedy. A simple yet practical technique known as cultural competence has been hailed as an essential skill set for healthcare providers to combat disparate healthcare treatment (IoM 2003) among military personnel. And, given the stark differences in the overall perceptions of the cultural climate in the military by various groups, there will unknowingly be differences in how some providers render healthcare treatment as well as those systematic structures that make it conducive for healthcare treatment inequities to thrive.

Cultural competence is often seen as a simple skill or capacity. To the contrary; cultural competence is a life long journey. It constitutes a continuous process that healthcare providers must strive to follow (SME 2008). Betancourt et al. (2002) see cultural competence as critical to system change. Yet, to facilitate change, healthcare providers must be willing to recognize their own biases; foster relationships with patients with respect as the foundation for communication; and utilize remediation methods that can be streamlined into larger organizational policies, procedures and practices (IoM 2003) for concordant relationships between patients and providers. The absence of underrepresented minorities from the healthcare professions is also a major concern (IoM 2003, Sullivan Commission 2004). Ironically, the military assigns a disproportionate number of women and underrepresented minority officers to support fields like healthcare (Hosek et al. 2001). This skewed distribution should be better managed for a more balanced representation of these groups in the healthcare professions. More targeted recruitment of these groups to the health professions (Sullivan Commission 2004, IoM 2003, Cooper and Powe 2004) should be conducted along with retention and research efforts (IoM 2003) to sustain progress over time.

CONCLUSION

As with certain segments of the civilian population that are disproportionately burdened by healthcare disparities, a similar trend among these same groups is evident in the military. As in the civilian population, healthcare disparities are to be attributed to a convergence of patient, provider and system level factors. They also maybe encumbered by other factors. First, the military, as a subset of the civilian population, increasingly reflects the diversity and changes of that population. Therefore, the health and healthcare disparities experienced are also being mirrored in the military. Further, the associated cultural norms of these groups persist even as their health and healthcare disparities decrease after joining the military; these rates may only begin to converge over time with majority populations the longer that these personnel remain in the military. In essence, to some degree, healthcare disparities in the military may not be a matter of equal access to healthcare. Healthcare disparities may also be a function, at least in part, of the cultural beliefs of military personnel to delay visiting a healthcare provider for elective treatment outside of mandatory fitness for duty physicals, for instance. Second and partly related to the above, the cultural norms of the military are such that to admit or display any signs of perceived weakness discourages help seeking behaviors for medical treatment by its personnel. Third, the military also faces the cultural nuances of foreign born personnel who are increasingly joining its ranks. And, what is being realized is that though an equal access healthcare system markedly reduces the degree to which certain segments of the population become predisposed to risks, this does not altogether immunize the military from these inequities. Finally, the professional socialization of healthcare providers as physicians may engage them more in the medical culture at the expense of the military culture where they may become disconnected from the people they serve. A selective analysis of research on the VA and a meta analysis of studies on the military show that equal access healthcare systems do not guarantee equal healthcare treatment and, as a result, can become vulnerable to healthcare disparities.

But the military has been at the forefront of civilian organizations in recognizing the importance of race and/or ethnicity to human relations. By taking a regular pulse of its environment, the military completes assessments of how its personnel perceive that environment. Research on the military's cultural climate has consistently revealed mixed reviews about how different segments of its population view its environment. Women and underrepresented minorities do not perceive the military's cultural climate as positively as their male and white counterparts. Similar findings were found in a military medical center as well. These results reveal that creating an acceptable cultural climate for all is a work in progress, specifically with regard to rendering quality and positive healthcare treatment outcomes for all patients. The cultural competence of healthcare providers then offers the best opportunity for achieving this goal, particularly in light of an increasingly diverse military population, an increasing healthcare disparities presence, a military culture that directly or indirectly promotes a sense of invincibility among its personnel, a nominal but noticeable increase in foreign born nationals who are entering the military, the increasing number of overseas deployments by military personnel, and a suspected detachment of providers from certain patient groups. Given all of these conditions, the cultural competence of military healthcare providers should become a requisite skill set.

Implications for Public Administration and Future Research

The military has shown its prowess for meeting the healthcare needs of its own population. However, as a subset of the increasingly diverse civilian population, without an on par healthcare access system in the civilian sector, the rate at which health and healthcare disparities occur in the military will only continue to reflect that increase. The current national debate about the need for universal healthcare for all Americans as well as the prospect for an equal access healthcare system that would follow to help narrow the health and healthcare gaps between majority and minority populations will result in like changes in the degree to which variances are reflected in the military. Even if inequities in health and healthcare disparities already exist among those joining the military, these rates will converge over time to fall more in line with those of the military's majority populations. But in addition to healthcare providers becoming culturally competent, the military can also do more to create a climate where those who voluntarily seek medical care are not stigmatized and develop recruiting and retention strategies for a more even distribution of especially underrepresented minorities in the healthcare professions to help meet these diverse needs of its changing population. Finally, some healthcare providers may be acculturated more as medical professionals than as military professionals. USUHS is one avenue through which health professionals can simultaneously become indoctrinated in both the health and military cultures.

With concurrent wars in Iraq and Afghanistan that are testing the military's will to medically care for its population and the disproportionate rate at which PTSD increasingly in the forms of traumatic brain injury (TBI) and military sexual trauma (MST) and other maladies occur, possessing a culturally competent healthcare workforce is essential. Perhaps future research on healthcare disparities in the military could benefit from such questions as: Would military personnel, if they could, choose healthcare providers of their own race, ethnicity or gender? Did they ever feel that they were either being treated differently and/or were less satisfied when they did not share the same race, ethnicity or gender with a healthcare provider? What has been their actual experience with the military's healthcare system? Was rank, for instance, a factor in how they felt that they were being treated? And, what are the experiences of their dependent civilian families with the military healthcare system?

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G.L.A. HARRIS

Portland State University
Table 1

Antecedents of Inequity: A Comparison across Healthcare
Systems

Type                             Causative Factors
Healthcare
System
                     Patient          Provider           System

                 Race and/or       Race and/or       Determines
                 ethnicity         ethnicity         type of access
                                                     received

                 Gender            Gender            Workforce
Civilian: An                                         should reflect
Unequal Access                                       clientele
System                                               served
(no mandatory
coverage)        Age               Age

                 Socioeconomic                       Incentives
                 status                              offered

                 Health            Experience with   Pressures for
                 insurance         diverse           efficiency
                 status            populations       (i.e., time)

                 English fluency   Cultural
                                   indifference

                 Culture           Culture
                 (beliefs,         (beliefs,
                 values)           values)

                 Mistrust          Biased decision
                                   making

                 Language          Propensity for
                 disconcordance    shortcuts
                                   (i.e., patient
                                   diagnoses)

                 Access to care    Customary6
                 Expectation of    ways of
                 services          thinking and
                                   doing

Veterans         Race and/or       Race              Race and/or
Administration   ethnicity         and/ethnicity     ethnicity
(VA): An Equal
Access System    Gender            Gender            Gender
for all
veterans based   Culture           Culture
on self          (beliefs,         (beliefs,
selection (no    values)           values)
mandatory
coverage)        Expectation of    Classification    Classification
                 services          for benefits      for benefits

                 Access to care    Decision          Decision
                                   making            making

                 Health literacy   Referral for      Referral for
                                   certain           certain
                                   procedures        procedures

                 Mistrust          Mistrust

Military: An     Race and/or       Race and/or       Race and/or
Equal Access     ethnicity         ethnicity         ethnicity
System
(mandatory       Gender            Gender            Gender
coverage for
all military     Culture           Culture           Culture of
personnel)                                           stiff upper lip

                 Pre-existing      Preoccupation     Small bit
                 health            with medical      increasing
                 conditions        culture at the    foreign born
                 before entering   expense of        members
                 the military      military          entering the
                                   clientele         military

                 Delay seeking     Rank              Rank
                 behavior

                 Avoid the         Educational       Educational
                 perception of     level             level
                 weakness

                 Not wanting to
                 disappoint
                 superiors,
                 coworkers and/
                 subordinates
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