what’s race/ethnicity got to do with it? the essential role that college health can play claire...
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What’s race/ethnicity got What’s race/ethnicity got to do with it? to do with it?
The Essential Role that The Essential Role that College Health Can PlayCollege Health Can Play
Claire Brindis, Dr. P. H.Claire Brindis, Dr. P. H.
Professor of Pediatrics and Health PolicyProfessor of Pediatrics and Health Policy
National Adolescent Health Information National Adolescent Health Information CenterCenter
University of California, San FranciscoUniversity of California, San Francisco
Today’s PresentationToday’s Presentation
Demographic Profile Risk-Taking Profile Opportunities for College Health as an
agent of change Tips for Implementing Culturally-
Appropriate Interventions
““Framing and Reframing”Framing and Reframing”
““It’s summer in Washington DC. A It’s summer in Washington DC. A hazy, hot and humid, “triple H” hazy, hot and humid, “triple H”
day with predictions of numbers day with predictions of numbers hovering in the mid 90’s. Imagine hovering in the mid 90’s. Imagine a 21 year-old young man of color. a 21 year-old young man of color.
What do you think he would be What do you think he would be doing that day? What do you think doing that day? What do you think his prospects for the future would his prospects for the future would be? On the floor of the Senate in be? On the floor of the Senate in Congress, what words would be Congress, what words would be
chosen to describe him and chosen to describe him and people like him?”people like him?”
Source: Hein, 1997
Defining DiversityDefining DiversityWide Casting - Narrow CastingWide Casting - Narrow Casting
AgeAge Cultural Cultural Race/ethnicityRace/ethnicity LGBTLGBT GenderGender DisabilitiesDisabilities Geographic VariabilityGeographic Variability Generational (including 1.5 generation)Generational (including 1.5 generation) IncomeIncome GeneticGenetic
SOCIOPOLITICAL CONTEXT
• Legal system• Income• Family Policy
SOCIALCONTEXT• Group history• Identity• Acculturation
NEIGHBORHOOD• Social support• Income inequality• Environmental
Exposures
PROVIDER FACTORS• Training• Cultural competence
ORGANIZATIONAL FACTORS
• Access• Reimbursement
GENETIC/BIOLOGICDIVERSITY
• Gender• Age
HEALTH BEHAVIORS• Adherence• Health promotion• Risk
Taking/Resilience
PSYCHOLOGICAL FACTORS
• Mood, affect• Self-efficacy
HEALTH DISPARITIES
CONTEXTUAL FACTORSHEALTH CARE
SYSTEM
PERSONAL FACTORS
Courtesy of Jill Joseph
Adolescents & Young Adults – Adolescents & Young Adults – Who are they?Who are they?
Between 1990 and 2020, the number of adolescents ages 10-19 is projected Between 1990 and 2020, the number of adolescents ages 10-19 is projected to increase from 35 to 42 million (A 20% increase); representing 13% of the to increase from 35 to 42 million (A 20% increase); representing 13% of the total population. Young adults ages 20-24 are expected to increase from 19 total population. Young adults ages 20-24 are expected to increase from 19 to 21 million between 2000 and 2020, an 11% increase; they represent to 21 million between 2000 and 2020, an 11% increase; they represent approximately 7% of the total population.approximately 7% of the total population.
0
10000
20000
30000
40000
50000
60000
1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
US Population, Ages 10-19, 1980-2050
# in
th
ou
san
ds
Sources: U.S. Census Bureau, 2000; U.S. Census Bureau, 2002
Young Adult Population (Ages 20-24) Young Adult Population (Ages 20-24) by Race/Ethnicity, 2000 vs. 2020by Race/Ethnicity, 2000 vs. 2020
20002000 20202020
61.1%13.5%
0.8%
4.4%
18.0%
2.1%White, non-Hispanic
Black, non-Hispanic
AmIndian/AlaskaNative, non-Hispanic
Asian/PacIslander, non-Hispanic
Latino
Other
57.7%
13.6%
0.9%
6.3%
21.5%
Sources: U.S. Census Bureau, 2000; U.S. Census Bureau, 2002
National Initiative to Improve Adolescent and National Initiative to Improve Adolescent and Young Adult HealthYoung Adult Health
Grounded in Healthy People 2010Grounded in Healthy People 2010
A comprehensive set of national A comprehensive set of national disease prevention and health disease prevention and health promotion objectives that promotion objectives that measure the nation’s progress measure the nation’s progress over time. over time.
Two overarching goals of Two overarching goals of Healthy Healthy People 2010People 2010::
Increase quality and years of life;Increase quality and years of life;
Eliminate health disparities.Eliminate health disparities.www.healthypeople.gov www.healthypeople.gov
Adolescent- and Young Adult-Specific Adolescent- and Young Adult-Specific Health ObjectivesHealth Objectives
21 Critical Health Objectives for Adolescent & Young Adult Health: Include individual health outcomes (injury, disease &
death), as well as related behaviors (e.g., substance abuse, physical activity, safety belt use).
21 Objectives fall into six general areas: Mortality;
Unintentional Injury;
Violence;
Mental Health and Substance Abuse;
Reproductive Health;
Chronic Disease Prevention.
Trends in Mortality by Age Group, Trends in Mortality by Age Group, Ages 10-24, 1980-2005 Ages 10-24, 1980-2005
Source: CDC Wonder, Compressed Mortality Database, 2009
Dea
ths
per
100
,000
132.7
97.597.9
65.1
30.8
18.0
0
50
100
150
1980 1985 1990 1995 2000 2005
Ages 20-24Ages 15-19Ages 10-14
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Females: Young Adult Females: Health CareHealth Care
0%
5%
10%
15%
20%
25%
30%
35%
No Health Insurance Last physical exam > 2 yrs ago
Need but did not get medical aid
WhiteBlackNative AmericanAsianHispanic
Source: Harris, K., et al, 2006
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Females: Young Adult Females: Risk FactorsRisk Factors
0%
10%
20%
30%
40%
50%
60%
Daily Cigarette Use
Marijuana Use
Hard Drug Use
Binge Drinking
Obesity
White
Black
Native American
Asian
Hispanic
Source: Harris, K., et al, 2006
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Females: Young Adult Females: Mental HealthMental Health
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Feelings of Depression Suicidal Thoughts
White
Black
Native American
Asian
Hispanic
Source: Harris, K., et al, 2006
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Young Adult MalesMales: : Health CareHealth Care
0%
5%
10%
15%
20%
25%
30%
35%
40%
No Health Insurance Last physical exam > 2 yrs ago
Need but did not get medical aid
WhiteBlackNative AmericanAsianHispanic
Source: Harris, K., et al, 2006
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Young Adult MalesMales: : Risk FactorsRisk Factors
0%
10%
20%
30%
40%
50%
60%
70%
80%
Daily Cigarette Use
Marijuana Use
Hard Drug Use
Binge Drinking
Obesity
White
Black
Native American
Asian
Hispanic
Source: Harris, K., et al, 2006
Prevalence of Leading Health Indicators in US Prevalence of Leading Health Indicators in US Young Adult Young Adult MalesMales: : Mental HealthMental Health
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Feelings of Depression Suicidal Thoughts
White
Black
Native American
Asian
Hispanic
Source: Harris, K., et al, 2006
How does the changing “face” of America and the Profile of Young Adult Health impact your health care delivery?
Lessons from Malcolm Gladwell’s Lessons from Malcolm Gladwell’s BlinkBlink::“Listening with Your Eyes”
Potential Impacts of Growing Student Potential Impacts of Growing Student Diversity on Health Care AccessDiversity on Health Care Access
Trust IssuesTrust Issues Fears of being judged and of poor quality Fears of being judged and of poor quality
carecare Lack of experience in utilizing health care Lack of experience in utilizing health care
resourcesresources Underlying levels of stress beyond “typical” Underlying levels of stress beyond “typical”
college student – mental health college student – mental health (acculturative stress, discrimination, etc.) (acculturative stress, discrimination, etc.) and other concernsand other concerns
“Physicians had more verbally dominant and less patient-centered communication with
African American patients compared with
Whites.”
“African American adults reported that
perceived racism and mistrust of Whites had a significant negative
impact on trust in their clinician and
satisfaction in their health care.”
Sources: Johnson, et al, 2004; Benkert, et al, 2006
What do diverse students from What do diverse students from their providers?their providers?
Respect and supportRespect and support Avoidance of negative Avoidance of negative
stereotypesstereotypes Quality CareQuality Care Tailoring messagesTailoring messages Concrete tools and guidanceConcrete tools and guidance Shared patient-provider Shared patient-provider
decision makingdecision making
Examples of Cultural Factors in Young Adult Health
Latino Students“Research has suggested that the utility of supporting the value of machismo, or manliness, which could encourage health-seeking behavior as a way of fulfilling cultural and familial obligations to be good fathers, husbands, and community members.”Asian American Students
“Youth wanted clinicians to be knowledgeable about Asian cultural values and traditional medicine and wanted clinicians to help them communicate with their parents about difficult issues.” Native American Students
“Research… has reported culturally specific variables associated with suicidal ideation, including perceived discrimination and lower identification with traditional ethnic culture.”
Sources: Sobralske, 2006; Vo et al, 2007, Yoder et al., 2006
Importance of College Health Programs
Focus on prevention and Focus on prevention and primary careprimary care
Identifiable health care Identifiable health care provider and care structureprovider and care structure
Increased access to care Increased access to care with fewer traditional with fewer traditional barriers in place.barriers in place.
Avoiding high out-of-Avoiding high out-of-pocket expenses in most pocket expenses in most cases.cases.
Source: Collins et al., Commonwealth, 2006
Transition to young adulthood: a critical time to be establishing Transition to young adulthood: a critical time to be establishing ties with primary care clinicians. ties with primary care clinicians.
Prevent higher use of acute care with access to primary care, Prevent higher use of acute care with access to primary care, with the exception of trauma. with the exception of trauma.
Source: Anderson, LM, et al. “Culturally Competent Healthcare Systems: A Systematic Review.” Am J Prev Med 24.3S (2003): 68-79.
Culturally Competent Interventions and Resultant Outcomes
Cultural Competence Broadening TipsCultural Competence Broadening Tips1. Use the University student profile and clinic data to 1. Use the University student profile and clinic data to
conduct a Needs and Assets Assessmentconduct a Needs and Assets Assessment
2. Incorporate critical moments for outreach: freshman & 2. Incorporate critical moments for outreach: freshman & transfer studentstransfer students
3. Adopt ecological approaches: link health center to 3. Adopt ecological approaches: link health center to special interest groups of students, race/ethnic-identified special interest groups of students, race/ethnic-identified groups, tutoring, community service, etc. groups, tutoring, community service, etc.
Example – Example – • • Cancer program manager at Howard University Cancer Center noted that the center was seeing an increase in the number of African American women in their 20s and 30s with breast cancer lumps.
• The Center partnered with 5 schools to create a long-term initiative; in an open class period, “cultural broker” Kimberly shared her story with 11th and 12th grade girls, while a health educator taught breast self-examinations.
Source: “Bridging the Cultural Divide in Health Care Settings,” 2004
Tips, contd.Tips, contd.4. Engage students in participatory research4. Engage students in participatory research
Example – Example –
• • Date rape and violent dating relationships are significant problems on the Date rape and violent dating relationships are significant problems on the Yankton Sioux reservation in South Dakota. Yankton Sioux reservation in South Dakota.
• • Focus groups for female teens were held at the Resource Center, in Focus groups for female teens were held at the Resource Center, in addition to regular independent meetings of youth that resulted in constant addition to regular independent meetings of youth that resulted in constant feedback on a developing curriculum. This resulted in a guide for teachers feedback on a developing curriculum. This resulted in a guide for teachers and a workbook for young women, which has been requested more than and a workbook for young women, which has been requested more than 300 times by schools, tribal youth programs, and shelters.300 times by schools, tribal youth programs, and shelters.
5. Use National Standards on Culturally and Linguistically Appropriate Services 5. Use National Standards on Culturally and Linguistically Appropriate Services (CLAS) to guide your efforts. (CLAS) to guide your efforts.
Example –Example –
“Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups represented in the service area.”
Sources: “Bridging the Cultural Divide in Health Care Settings,” 2004
Tips, contd. Tips, contd.
6. Use multi-media alternative health education, including e-mail reminders.6. Use multi-media alternative health education, including e-mail reminders.
7. Identify programs developed with different ethnic/racial groups, incorporating 7. Identify programs developed with different ethnic/racial groups, incorporating a cultural lens, in a variety of areas—from tobacco to obesity prevention.a cultural lens, in a variety of areas—from tobacco to obesity prevention.
Example –Example –
• • AMA workbook on culturally effective care for adolescents:
* cultural aspects of health care, such as distrust of government and medical systems,
* language barriers,
* cultural influences on worldviews, health beliefs, and health practices, and
* identity formation and acculturation among immigrant youth.
8. Celebrate diversity and strengths resulting from having a diverse campus.8. Celebrate diversity and strengths resulting from having a diverse campus.
9. Document your findings for different racial/ethnic groups and share 9. Document your findings for different racial/ethnic groups and share information.information. Source: Fleming & Towey, 2001
ResourcesResources University of California, Los Angeles (UCLA)’s Center for Mental Health in
Schools has coalesced a comprehensive clearinghouse for publications, reports, program descriptions, and more, all pertaining to “Cultural Competence and Related Issues”: http://smhp.psych.ucla.edu/qf/culturecomp.htm
The Asian and Pacific Islander Health Information Network (APIAHF) publishes census data, fact sheets, health briefs and research guides about the specific health needs of Asian Americans and Pacific Islander (AAPI) health information, resources and policy issues; and provides links to other AAPI youth focused groups http://www.apiahf.org/.
The Center for Women in Government and Civil Society’s Immigrant Women and State Policy department developed reports on immigrant youth and their specialized needs, including Creating Successful Programs for Immigrant Youth http://www.cwig.albany.edu/
Resources, contd. Resources, contd. Healthy Teen Network has resources addressing cultural competency and various
population groups: including resource kits on Young Men and LGBTQ Youth; provides information on cultural competency; research and resources on issues affecting various racial and ethnic groups, and links to relevant organizations: www.healthyteennetwork.org.
The American College Health Association’s National College Health Assessment (NCHA) provides recent reports, including both summaries and detailed information, on the results of their broad survey of college students’ health and behavior: http://www.acha-ncha.org/
ReferencesReferences““Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs.” Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs.” National National
Center for Cultural Competence Center for Cultural Competence (Spring/Summer 2004): 1-29. (Spring/Summer 2004): 1-29.
““National Standards on Culturally and Linguistically Appropriate Services (CLAS).” National Standards on Culturally and Linguistically Appropriate Services (CLAS).” The Office of Minority Health The Office of Minority Health 12 April 200712 April 2007. . Web. 26 May 2009. <http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15>Web. 26 May 2009. <http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15>
Benkert, R., et al. “Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care.” Benkert, R., et al. “Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care.” Journal of the National Medical AssociationJournal of the National Medical Association 98 (2006): 1532-1540. 98 (2006): 1532-1540.
Fleming, M. & Towey, K. “Delivering culturally effective health care to adolescents.” Fleming, M. & Towey, K. “Delivering culturally effective health care to adolescents.” American Medical AssociationAmerican Medical Association (2001)(2001)
Harris, Kathleen M., et al. “Longitudinal Trends in Race/Ethnic Disparities in Leading Health Indicators from Harris, Kathleen M., et al. “Longitudinal Trends in Race/Ethnic Disparities in Leading Health Indicators from Adolescence to Young Adulthood.” Adolescence to Young Adulthood.” Archives of Pediatrics & Adolescent Medicine Archives of Pediatrics & Adolescent Medicine 160 (2006): 74-81.160 (2006): 74-81.
Hein, Karen. “Framing and Reframing.” Hein, Karen. “Framing and Reframing.” Journal of Adolescent Health Journal of Adolescent Health 21 (1997): 215-217. 21 (1997): 215-217.
Johnson, R.L., et al. “Patient race/ethnicity and quality of patient-physician communication during medical visits.” Johnson, R.L., et al. “Patient race/ethnicity and quality of patient-physician communication during medical visits.” American Journal of Public HealthAmerican Journal of Public Health 94 (2004): 2084-2090. 94 (2004): 2084-2090.
Sobralske, M. “Machismo sustains health and illness beliefs of Mexican American men.” Sobralske, M. “Machismo sustains health and illness beliefs of Mexican American men.” Journal of the American Journal of the American Academy of Nurse PractitionersAcademy of Nurse Practitioners 18 (2006): 348-350. 18 (2006): 348-350.
Vo, D.X., et al. “Voices of Asian American youth: Important characteristics of clinicians and clinical sites.” Vo, D.X., et al. “Voices of Asian American youth: Important characteristics of clinicians and clinical sites.” PediatricsPediatrics 120 (2007): e1481-1493. 120 (2007): e1481-1493.
Yoder, K.A., et al. “Suicidal ideation among American Indian youths.” Yoder, K.A., et al. “Suicidal ideation among American Indian youths.” Archives of Suicide ResearchArchives of Suicide Research 10 (2006): 177- 10 (2006): 177-190.190.
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