Health disparities: a barrier to high-quality care.

PURPOSE: Disparities in the treatment of cardiovascular disease, diabetes mellitus, and cancer among the sexes and racial groups and possible interventions are discussed. SUMMARY: The ongoing process to identify and reduce health disparities has engaged numerous federal agencies as they monitor the nation's progress toward policy-driven and health-related objectives. Cardiovascular disease disproportionately affects minority groups and is the leading cause of death among women in the United States, and both groups receive suboptimal care for the disease. Disparities in the treatment of diabetes mellitus in African Americans, women, patients with less than a high school education, and the elderly have been found. Many minority groups continue to suffer disproportionately from cancer. Racial disparities also exist in cancer screening and treatment. Minorities are underrepresented in clinical trials for multiple reasons, many of which may be related to cultural beliefs. At all levels of coinsurance, the poor are less likely to seek preventive care. Adherence to national screening and treatment guidelines, clinical trial recruitment and participation, addressing language and geographic barriers, and increasing access to insurance are part of the coordinated efforts required to reduce health disparities. Because pharmacists influence patients' health status directly through pharmaceutical care and indirectly by engaging patients in their treatment, it is essential for pharmacists to be able to provide culturally competent care. CONCLUSION: Despite significant efforts over the past several years, health disparities continue to exist, particularly among minority groups. Interventions aimed at eliminating these disparities should include ensuring cultural competence among health care providers and improving health literacy among patients.     

Disability in cultural competency pharmacy education

Improving health care providers' knowledge and ability to provide culturally competent care can limit the health disparities experienced by disadvantaged populations. As racial and ethnic cultures dominate cultural competency topics in education, alternative cultures such as disability have consistently been underrepresented. This article will make the case that persons with disabilities have a unique cultural identity, and should be addressed as an important component of cultural competency education in pharmacy schools. Examples of efforts in pharmacy education to incorporate cultural competency components are highlighted, many of which contain little or no mention of disability issues. Based on initiatives from other health professions, suggestions and considerations for the development of disability education within pharmacy curricula also are proposed.     

Issues of cultural competence in mental health care

As the United States’ population continues to grow in its diversity, health care providers, including pharmacists, need to be able to provide culturally competent care to their patients. Cultural competence allows patients to feel comfortable with their provider and leads to their continuing to seek out care. Mental health is one of the most underused services in health care, particularly in underrepresented minority communities. This review looks at different published literature that assessed the reasons why individuals from minority communities may avoid seeking mental health care, cultural competence in psychiatric care for underrepresented minority communities, strategies for implementation for training providers in cultural competency, and barriers to implementation in mental health services. Current ideas include providing cultural competency training to students in their respective professional school or residency, incorporating the cultural formulation interview into psychiatric sessions, or increasing minority representation in the psychiatric services. On the basis of the literature examined, research is still needed to identify the best approach to improve culturally competent care in psychiatric services in the United States.     

Cultural Competency in Health Care and Its Implications for Pharmacy

As the United States becomes more diverse, a patient's cultural influences on health outcomes and health care decision-making and delivery need to be considered. Cultural influences affect a patient's decision to take drug therapy and concomitant alternative therapies. Seven components have been identified to improve culturally competent care in a variety of practice sites. The first component to developing culturally competent practices involves the analysis of self and system attitudes and practices toward various cultures. In the second component, health care providers should increase their knowledge about the cultures they serve through different patient assessment techniques, readings, and community activities. The third component involves improving cross-cultural communication by being aware of differences in social norms, assessing health literacy, using interpreters, knowing another language, and using bilingual patient education materials. In the fourth component, pharmaceutical care plans should accommodate cultural preferences such as the use of herbs, spiritual healers, and additional family decision-makers. Therapeutic plans should be negotiated between patient and provider to optimize outcomes. The fifth component discusses health care provider and system involvement in the community through health fairs, ethnic festival participation, and communication with cultural decision-makers to help provide culturally competent care by fostering communication ties. In the sixth component, knowing and following regulations such as the federal Culturally and Linguistically Appropriate Services and the Joint Commission standards for organizational cultural competency can help enhance care for patients from various cultures. In the last component, quality assurance assessments of procedures to improve care for various diverse cultures should be conducted, with findings (in terms of strengths and areas of improvements) shared with other providers and systems. Pharmacists and pharmacy technicians in a variety of systems and practices can improve care to patients with differing cultures by using these seven components to enhance culturally competent care.     

Inclusion of Health Disparities,Cultural Competence,and Health Literacy Content in US and Canadian Pharmacy Curriculums

Objective. To determine how US and Canadian pharmacy schools include content related to health disparities and cultural competence and health literacy in curriculum as well as to review assessment practices.Methods. A cross-sectional survey was distributed to 143 accredited and candidate-status pharmacy programs in the United States and 10 in Canada in three phases. Statistical analysis was performed to assess inter-institutional variability and relationships between institutional characteristics and survey results.Results. After stratification by institutional characteristics, no significant differences were found between the 72 (50%) responding institutions in the United States and the eight (80%) in Canada. A core group of faculty typically taught health disparities and cultural competence content and/or health literacy. Health disparities and cultural competence was primarily taught in multiple courses across multiple years in the pre-APPE curriculum. While health literacy was primarily taught in multiple courses in one year in the pre-APPE curriculum in Canada (75.0%), delivery of health literacy was more varied in the United States, including in a single course (20.0%), multiple courses in one year (17.1%), and multiple courses in multiple years (48.6%). Health disparities and cultural competence and health literacy was mostly taught at the introduction or reinforcement level. Active-learning approaches were mostly used in the United States, whereas in Canada active learning was more frequently used in teaching health literacy (62.5%) than health disparities and cultural competence (37.5%). Few institutions reported providing professional preceptor development.Conclusion. The majority of responding pharmacy schools in the United States and Canada include content on health disparities and cultural competence content and health literacy to varying degrees; however, less is required and implemented within experiential programs and the co-curriculum. Opportunities remain to expand and apply information on health disparities and cultural competence content and health literacy content, particularly outside the didactic curriculum, as well as to identify barriers for integration.     

The case for cultural competence in health professions education

Health profession schools in the United States have to be able to meet the health and pharmaceutical care demands of a rapidly growing racial and multiethnic population. One tactic is to develop and implement or expand existing resources and didactic courses to address cultural competence in the curricula of every college and school of pharmacy. The curriculum should require a focus on the reality of evidence-based health disparities among racial and ethnic minority populations; importance of providing culturally competent care and communication to meet the health needs of diverse patient populations; and exposure to cultural diversity. Students should be grounded in cultural awareness and cultural sensitivity. This article establishes a case for integrating cultural competence into the curricula of health professions schools.     

A scoping review of the minority stress processes experienced by sexual and gender minority individuals in pharmacy settings: Implications for health care avoidance

BackgroundSexual and gender minority (SGM) people may avoid or delay health care interactions. The minority stress model describes distal (discrimination, violence) and proximal (expectation of rejection, concealment, internalized self-dislike) stress processes as possible contributors to the health disparities and avoidance behaviors observed when encountered in health care settings. Pharmacies are accessible health care settings, yet the extent to which SGM individuals experience minority stress processes while using services at the pharmacies is unknown.ObjectiveThis scoping review aimed to identify distal and proximal minority stress processes experienced by SGM individuals and health care avoidance behaviors related to pharmacies or pharmacists.MethodsAn electronic search of PubMed, Embase, and PsycINFO databases was conducted to search for relevant literature up to September 2022. The search was supplemented with a review of reference lists and contact with experts in the field. Articles were included in the review if they described SGM individuals’ perceived experiences within pharmacies or with pharmacists and reported an outcome that could be mapped to a distal or proximal minority stress process.ResultsEleven articles met the eligibility criteria and were included in the review. Of these, 6 reported the presence of distal stress processes, such as perceived stigma, negative pharmacy staff attitudes, and a lack of awareness of population needs. For proximal stress processes, 5 articles reported on concealment, 4 reported on expectation of rejection, and 1 reported on internalized transphobia. Developing rapport and increasing competence were identified as ways to help mediate the impact of minority stress processes.ConclusionMinority stress processes and avoidance behaviors are experienced by SGM individuals that relate to pharmacies and pharmacists. Coordinated efforts between professional stakeholders are required to reduce minority stress processes and ensure pharmacy-based services are accessible to all individuals.     

DIFFICULT CHALLENGE FOR HEALTHY PEOPLE 2010: PUTTING POLICY INTO PRACTICE. A COMMENTARY

ABSTRACT

Claude Earl Fox, M.D., M.P.H., Director, Johns Hopkins Urban Health Institute, public health professor in the Johns Hopkins Bloomberg School of Public Health and former Administrator of the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services, outlines the difficulties in achieving the stated goals of Healthy People 2010 for one population identified within the document as having health disparities – i.e., lesbian, gay, and bisexual (LGB) individuals in the United States. [Gender identity and transgender health issues were not addressed in Healthy People 2010.] The dearth of data on LGBT health disparities is discussed, as are many of the social, economic, systemic, and attitudinal barriers that prevent many LGBT persons from achieving equal access to comprehensive, culturally competent, community-based health care services. Health care providers, health purchasers, policymakers, researchers, academicians and consumers are urged to learn more about LGBT health care issues; to revamp the public health system's approach to health care delivery, research, and education; to include sexual orientation and gender identity measures in research proposals; to address sexual orientation and gender identity in health professions curricula; to include sexual orientation as part of cultural competency in the development of cultural competence standards; and to involve LGBT persons in all phases of health services planning, delivery, and evaluation.     

Determining the Sufficiency of Cultural Competence Instruction in Pharmacy School Curriculum

Objective. To assess the change in the level of cultural competency and knowledge of health disparities among students in the third year of the doctor of pharmacy (PharmD) program at the University of Florida and to explore the demographic correlates.Methods. A cross-sectional survey was conducted in 3 consecutive academic years. Chi-square tests, analysis of variance (ANOVA), and multivariate regression were used for data analysis.Results. Following the inclusion of relevant instruction, there was some increase in knowledge of health disparities and self-awareness, but no significant increase in cultural competency skills. More students reported receiving relevant instruction within the pharmacy school curriculum than outside the curriculum. Conclusion. Current effort to incorporate cultural competence and health disparities instruction into the pharmacy curriculum has met with some success. However, there is a need to establish standards on how much relevant training is required and further explore ways to effectively incorporate it into pharmacy education.     

A Cultural Competency Course for Pharmacy Students

Objective

To design, implement, and evaluate a course on health promotion and literacy.

Design

Course objectives such as the development of cultural competency skills, awareness of personal biases, and appreciation of differences in health beliefs among sociocultural groups were addressed using a team-based learning instructional strategy. Student learning outcomes were enhanced using readiness assessment tests (RATs), group presentations, portfolio reflections, and panel discussions.

Assessment

Comparing precourse and postcourse Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals (IAPCC-R) scores and portfolio responses indicated enhanced progress toward cultural competency. The Student Evaluation of Teaching (SET) provided suggestions for course enhancements.

Conclusions

Evidence supporting enhanced cultural competency after completing the course affirms its value as we prepare pharmacy students to provide patient-centered care in a culturally diverse world.     

Drinking patterns,gender and health III: Avoiding versus seeking health care

Background: Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care.

Methods: A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals’ reasons for seeking or avoiding care.

Results: Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher body mass index, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care.

Conclusions: Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.     

Clinical cultural competency and knowledge of health disparities among pharmacy students

Objective. To evaluate the level of competency and knowledge about health disparities among third-year doctor of pharmacy (PharmD) students at 2 Florida public colleges of pharmacy and to explore the demographic correlates of these variables.Methods. A cross-sectional survey study design was used to collect data from participants.Results. The students had low health-disparities knowledge and moderate skills in dealing with sociocultural issues and cross-cultural encounters. Speaking a language(s) other than English and having exposure to cultural-competency instruction were the demographic variables found to be most significantly associated with clinical cultural competency and/or knowledge of health disparities.Conclusions. Clinical cultural competency and health-disparities instruction may not be adequately incorporated into the pharmacy school curricula in the institutions studied. Relevant education and training are necessary to enhance cultural competency among pharmacy students.     

小儿推拿在儿童保健中的应用研究

概述了小儿保健推拿的发展过程,归纳小儿推拿在儿童保健中的研究和应用现状,如小儿推拿可促进早产儿、新生儿和婴儿生长发育,预防反复呼吸道感染和支气管哮喘,治疗厌食症,预防新生儿高胆红素血症,防治体弱儿等。认为小儿保健推拿虽起步较晚,但以其独特的优势和效果,在儿童保健领域中独树一帜。     

Home health care in France

Home health care in France has a long tradition, but is limited in its development. Since 1970 hospitals are by law permitted to extend services at home. Apart from this, patient associations are a driving force in the organization of home health care. There is a trend to more home health care, but this is hampered by splitting of responsibilities of local, departmental or central authorities. The hospital pharmacist is recommended to focus on his scientific and technical competence. Improved relations between community pharmacists and hospital pharmacists are advocated.     

健康教育在妇女保健中的作用分析

目的分析健康教育在妇女保健过程中所起的作用，以为妇健工作提供有效建议。方法以2012年前往我院妇科体检就诊的100名妇女作为分析的对象，对全部妇女展开系列健康教育，即在进行健康教育前后展开问卷调查，并分析调查结果，评估健康教育的实施效果。结果经过健康教育之后，100名妇女对妇女保健的有关知识、行为以及意识等均有了显著提高，健康教育前后的差异有统计学意义（P〈0．05）。结论加强健康教育，有利于提升妇女对保健的认识，促使妇女积极参与各种妇幼保健工作，促进妇女保健工作的开展。     

Obtaining pharmacoeconomic data in health care organizations

The article illustrates the process and techniques of obtaining or collecting pharmacoeconomic data in various health care organizations, focusing on hospitals, physicians' offices, and pharmacies as the research settings. The role that pharmacoeconomic data have in the decision-making process as well as the perspective of the decision maker are also discussed. The three primary components needed to conduct a complete pharmacoeconomic analysis (clinical outcomes, humanistic outcomes, and economic outcomes) are described in relation to the health care organization. The strengths, weaknesses, advantages, and disadvantages of such data are discussed. Various databases that are accessible within each organization are also outlined.     

Engaging Pharmacy Students with Diverse Patient Populations to Improve Cultural Competence

Objective

To develop and implement learning activities within an advanced pharmacy practice experience (APPE) to improve students'' cultural competence.

Design

During their AAPE at Community Access Pharmacy, students participated in topic discussions with faculty members, used interpreters to interview Hispanic patients, visited a Mexican grocery store, evaluated nontraditional medicine practices in the Hispanic community, and served as part of a patient care team at a homeless shelter and an HIV/AIDS clinic. The students reflected on these activities in daily logs and completed a final evaluation of their experiences.

Assessment

Forty-three students completed the rotation from 2004-2007. Almost all learned something new about counseling patients with cultural/language differences (98%) and became more aware of financial barriers to health care and potential solutions to overcome them (93%). Students'' reflections were positive and showed progression toward cultural competence.

Conclusion

A culturally diverse patient population provided opportunities for APPE students to develop the skills necessary to become culturally competent pharmacists. Future work should focus on potential evaluation tools to assess curricular cultural competency outcomes in APPE''s.     

Gender disparities in health care

The existence of disparities in delivery of health care has been the subject of increased empirical study in recent years. Some studies have suggested that disparities between men and women exist in the diagnoses and treatment of health conditions, and as a result measures have been taken to identify these differences. This article uses several examples to illustrate health care gender bias in medicine. These examples include surgery, peripheral artery disease, cardiovascular disease, critical care, and cardiovascular risk factors. Additionally, we discuss reasons why these issues still occur, trends in health care that may address these issues, and the need for acknowledgement of the current system's inequities in order to provide unbiased care for women in the future. Mt Sinai J Med 79:555-559, 2012. ? 2012 Mount Sinai School of Medicine.