Category Archives: Barriers to Care: cultural, gender and racial
Martin Schiavenato, PhD, RN, is an assistant professor at the University of Miami School of Nursing and Health Studies, and a Robert Wood Johnson Foundation Nurse Faculty Scholar. This is part of a series of posts looking at diversity in the health care workforce.
It is human nature. The old adage “opposites attract” is a myth; in fact, the contrary is true. We feel more comfortable with and welcome those who share in our definition of “us” than not. Accordingly, this also forms the basis to how we define “them.” It is intuitive that we feel connected to and prefer those who share in what we believe to be our experience, and that we are suspicious and even spurn those who we feel do not. This phenomenon is referred to by psychologists as “in-group bias.”
"When it comes to providing best clinical care, race and culture matter."
In my field of pain research, there is ample documentation of how clinician preferences impact the care of patients. Clinicians better address pain management in patients who “match” their reference group or their preferences more closely. For example, better pain care is given to patients who speak the same language, are of similar socioeconomic status, or even those considered more attractive to the clinician. Subtle cues from the patient—their physical appearance, the circumstances that brought them to seek care, their behaviors and expressions—all will have a consequence on the nature of the care that they will receive. Thus, the race and culture of the clinician have the potential to be significant contributors in the quality of care that a patient will receive. This inherent tension between “us” and “them” may be particularly relevant in a country with a history of institutionalized racism.
Carmen R. Green, MD, is an alumna of the RWJF Health Policy Fellows program. She is the associate vice president and associate dean for health equity and inclusion at the University of Michigan Health System, and a professor of anesthesiology, obstetrics and gynecology, and health management and policy. This is part of a series of posts looking at diversity in the health care workforce.
More than a decade into the 21st century, Americans still face diminished health and tremendous variations in health care, depending on what they look like, where they come from, where they live, what they earn, and other factors. Significant and persistent variability in clinician decision-making also exists based upon these factors.
The reasons for these inequities lie in part in disparities in the infrastructure for screening, diagnosing, treating and supporting patients leading to unequal treatment.
In an increasingly aging, female, and diversifying society, it is vital to have a diverse workforce to not only help put patients of varying backgrounds at ease but to provide care that is responsive to their needs and to achieve the best health care outcomes. It may be difficult for underrepresented and vulnerable people to trust the health care system if the employees largely come from the same place and have one perspective. Some of those perceptions actually become realities as biases can negatively affect patients that are marginalized and lower on the socioeconomic totem pole.
Keon L. Gilbert, DrPH, MA, MPA, is an assistant professor in the Department of Behavioral Science & Health Education at St. Louis University's College for Public Health and Social Justice. As a Robert Wood Johnson Foundation New Connections grantee, his research focuses on the social and economic conditions structuring disparities in the health of African American males. His work seeks to identify sources of individual, cultural, and organizational social capital to promote health behaviors, and health care access and utilization, to advance and improve the health and well-being of African American males. This is part of a series of posts looking at diversity in the health care workforce.
I became a public health professional because I recognized a need to find opportunities and strategies to prevent the chronic diseases I saw silently killing African Americans in the community where I grew up. I vividly recall as a child the whispers surrounding the deaths of community members about cancer, diabetes (or sugar-diabetes, as it is commonly referred to in many communities still today), heart attacks, and strokes. I knew there was stigma and fear, but never heard of programs, interventions, or opportunities to stop these trends.
My interest in addressing these problems led me to pursue summer programs and internships during high school that allowed me to witness amputations of uncontrolled diabetic patients who had a range of clinical and social co-morbid conditions. Many of these amputees were living in poverty, they had Medicare or Medicaid, and the majority happened to be African American. This experience raised the question about prevention: How could I prevent African American men and women from having amputations? I never heard this conversation around prevention in my community. Many people seemed to accept the reality of developing these chronic conditions as a fate that could not be controlled.
I knew there had to be another way.
Male Entry into a Discipline Not Designed to Accommodate Gender: Making Space for Diversity in Nursing
Michael R. Bleich, PhD, RN, FAAN, is Maxine Clark and Bob Fox dean and professor at the Goldfarb School of Nursing at Barnes-Jewish College in St. Louis, Mo. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2000-2002).
With help from co-authors Brent MacWilliams, PhD, ANP, and Bonnie Schmidt, PhD(c), RN, in our recent American Journal of Nursing article summarizing research on men in nursing—and further inspired by a manuscript by Dena Hassouneh, PhD, ANP, entitled Anti-Racist Pedagogy: Challenges Faced by Faculty of Color in Predominantly White Schools of Nursing in the July 2006 issue of the Journal of Nursing Education—I am in a reflective place. After a nearly 40-year journey as a male in nursing, I now realize the discipline was never designed for me.
"Why did the faculty not do more to buffer me from faculty who were overtly gender-disparaging? Why were the gloves in procedural kits always sized for smaller hands?"
That is not to say that I have not had a fabulous career, worked with the finest colleagues one could imagine, or had opportunities that provided continuous challenge and opportunity. But as a discipline, nursing has had its broad shifts. Florence Nightingale was a master of evidence-based practice and spent a lifetime elevating nursing to a discipline in a world that was political, gender-biased against women, scientifically evolving, caste-oriented, and more. The gift of structure, process, and outcomes she gave nursing are irreplaceable.
Human Capital News Roundup: Testing for genetic conditions, discussing spirituality with patients, using emergency rooms, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
Patient-centered end-of-life care leads to happier patients who are in less pain and whose care costs less, RWJF/U.S. Department of Veterans Affairs Clinical Scholar Jonathan Bergman, MD, and his colleagues write in the journal JAMA Surgery. Such care is already provided, the Los Angeles Times reports, at the UCLA Health System, where urology residents are receiving education about end-of-life care, and at the West L.A. Veterans Affairs Medical Center where researchers are integrating palliative care into cancer treatment.
The current system used to evaluate the appropriateness of emergency department visits—and sometimes to deny payment—is flawed, according to a study co-authored by RWJF Physician Faculty Scholars alumna Renee Hsia, MD, MSc, because it only takes into account a patient’s discharge diagnosis (for example, acid reflux), which is often not the reason they originally presented at the ER (chest pain). The researchers warn this could have serious implications, including dissuading patients from using the ER even when their symptoms indicate that they should, United Press International reports.
Susan Wolf, JD, recipient of an RWJF Investigator Award in Health Policy Research, spoke to the Boston Globe about new recommendations from a national organization of genetics specialists that “urge doctors who sequence a patient’s full set of genes for any medical reason to also look for two dozen unrelated genetic conditions, and to tell the individual if they find any of those conditions lurking in the DNA.” All of the genetic mutations on the list are rare, but some indicate an increased risk of cancer or heart disease. In some cases, the genetic results could also indicate that the patients' blood relatives have increased risk, as well.
Though it remains a predominantly female profession, a new study from the U.S. Census Bureau finds that the percentage of nurses who are male more than tripled from 1970 to 2011, from 2.7 percent to 9.6 percent.
The Census Bureau’s Men in Nursing Occupations also finds the proportion of male licensed practical and licensed vocational nurses increased, from 3.9 percent to 8.1 percent. Men's representation was highest among nurse anesthetists (41%).
“The aging of our population has fueled an increasing demand for long-term care and end-of-life services," said the report's author, Liana Christin Landivar, a sociologist in the Census Bureau's Industry and Occupation Statistics Branch, said in a news release about the study. “A predicted shortage has led to recruiting and retraining efforts to increase the pool of nurses. These efforts have included recruiting men into nursing.”
The study also found that men typically earn more in nursing fields than women, but not by as much as they do across all occupations. Male nurses earned an average of $60,700 in 2011—16 percent more than the average earnings for female nurses, which was $51,100. The difference in earnings is due partly to the concentration of men in higher-paid nursing occupations, like nurse anesthetics. “Men have typically enjoyed higher wages and faster promotions in female-dominated occupations,” the study says, a phenomenon known as the “glass escalator” effect.
The American Indian Physicians and Association of American Medical Colleges will host a Cross Cultural Medicine Workshop, March 1-3 in Washington, D.C. The workshop is designed to provide physicians, faculty, medical students, health care professionals, and others with a greater understanding of Western and Traditional Medicine in order to enhance their cultural competence.
Participants will learn to identify strategies to improve cultural competency and communication between American Indian/Alaska Native patients and health care professionals, and learn about the role of traditional healers and the American Indian/Alaska Native approaches to healing and health.
The Association of American Medical Colleges provides technical assistance to the Robert Wood Johnson Foundation Summer Medical and Dental Education Program.
Learn more and register here.
The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the second of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.
Challenges in the Urban Context: Discussants converged upon care fragmentation and community diversity as the most difficult challenges associated with working in urban settings. There may be enormous heterogeneity within populations in urban areas with respect to racial, ethnic, and sociodemographic characteristics. Subgroups may vary with regard to exposures, behaviors, and values. The sense of community that can be essential to leveraging social groups may not necessarily be present or uniform throughout a geographic area, necessitating multiple tailored communication strategies. Even between cities, there is significant heterogeneity, such that non-clinical interventions may be less transferable than, say, a chronic disease model.
Communities that do exist may not necessarily conform to geographic boundaries, and the geopolitical boundaries and layers of jurisdiction in place may mean little to those communities. This changes how confident clinical systems can be for outreach and aspects of care that might reach beyond the office, and in general it can be particularly challenging to know what services are being provided for a patient, where, and by whom. This accountability problem makes it easier for high-risk patients to fall through the cracks.
-- Dr. Martin Luther King Jr., in a speech to the Medical Committee for Human Rights, 1966
Nalo Hamilton, PhD, RN, WHNP/ANP-BC, is an assistant professor of nursing at the University of California, Los Angeles School of Nursing; and Cheryl Woods Giscombé, PhD, RN, PMHNP-BC, is an assistant professor in the School of Nursing at the University of North Carolina at Chapel Hill. Both are Robert Wood Johnson Foundation Nurse Faculty Scholars.
The New Year has begun and for some 2013 marks a time of celebration and progress, while for others it is a time of uncertainty and despair. As we pause to remember the rich contributions of Dr. Martin Luther King, Jr., we should also reflect on how his legacy can be used to eliminate the health care disparities that so disturbingly affect the underserved and underrepresented in our nation today.
The World Health Organization has determined that geographic locale, ethnicity, education, environmental stress, and access to a health care system are social determinants of health and health inequities. These factors are influenced by the disparate distribution of resources, wealth, and power.
In the United States:
- African Americans, Hispanic Americans, and Native Americans have rates of diabetes that far exceed those in non-Hispanic whites.
- African American women are more likely to be diagnosed with advanced stage breast cancer compared to white women and have the highest rate of mortality.
- Native Americans report more alcohol consumption and binge drinking than other racial/ethnic groups.
- Hispanic males age 20 or younger have the highest prevalence of obesity compared to non-Hispanic whites and African Americans.
- African American men and women are more likely to die of cardiovascular disease than non-Hispanic whites.
- Infant mortality occurs in African Americans 1.5 to 3 times more than in other races or ethnicities.
By Elizabeth A. Kostas-Polston, PhD, ARNP, WHNP-BC, Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar and assistant professor, University of South Florida; and Versie Johnson-Mallard, PhD, MSMS, ARNP, WHNP-BC, RWJF Nurse Faculty Scholar alumna and assistant professor, University of South Florida.
On November 14, 2012, we met a princess. No, we were not at Disneyworld or Disneyland. The princess was beautiful, talented and focused on making a difference in her country for girls and women. The princess’s name is Princess Bajrakitiyabha Mahidol, her Royal Highness of Thailand. We met her when we were invited to Thailand to present at the International Council on Women’s Health Issues (ICOWHI) 19th International Congress on Women’s Health 2012: Partnering for a Brighter Global Future.
During the conference we unveiled our national/international initiative, The Blue Bra Campaign: Leading Global Change in Women’s Health. The Blue Bra Campaign is housed at the University of South Florida College of Nursing, under our leadership. The name for the campaign was inspired from an international event that occurred in 2011, when a young Egyptian woman was beaten, stomped on and nearly stripped while participating in a political demonstration. Aside from the sheer brutality inflicted upon her by Egyptian police, what stood out to millions viewing the nightmare as it unfolded on international television was the young woman’s abaya falling open to reveal a lacey, bright-blue bra. That moment was so unexpected, so shocking—so transforming! The young woman, covered from head to toe in traditional dress, refused to remain invisible demonstrating her femininity through her choice of undergarment—a blue bra!