\f\fChapter 12 Non-Ethnic Cultures Overview of Chapter Topics Chapter introduction Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations Migrant farm workers Chapter summary Case study: The Healthcare Equality Index survey regarding LGBT issues Model program: The Mpowerment Project for Gay and Bisexual men 18-29 Gay, Lesbian, Bisexual, and Transgender (LGBT) Americans LGBT Culture and Individuals: Overview and Definitions History of LGBT Americans LGBT in the United States Healing Traditions Among LGBT Americans Behavioral Risk Factors and Common Health Problems Among LGBT Americans Considerations for Health Promotion and Program Planning for LGBT Americans LGBT Culture and Individuals: Overview LGBT individuals exist in all American cultures, communities, and subgroups LGBT culture, though distinctive, has historically remained concealed and so is not well-defined or widely understood - Secrecy long seen as essential for self-preservation of LGBT individuals LGBT culture is increasingly emerging from concealment and demanding acceptance by wider society LGBT Culture and Individuals: Definitions Sexual identity: one's physical, romantic, emotional, and/or spiritual attraction to another Gender identity: one's self-identification as either male or female Homosexual: persons whose gender identity is consistent with his/her physical sexual characteristics but whose sexual identity is same-sex LGBT Culture and Individuals: Definitions Transgender: Individuals living full- or part-time in gender role opposite that of their physical sexual characteristics; may be either hetero- or homosexual Bisexual: People sexually attracted to both men and women Gay: Homosexuals in general, but usually used in reference to homosexual men Lesbian: Homosexual woman History of LGBT Americans Homosexuality recognized throughout the ages For most of American history, homosexual activity was outlawed by state laws Homosexuals began to emerge and to demand rights during the mid/late 20th century LGBT People in the United States Post-WWII struggles against discrimination - Stonewall riots (1969) a major milestone 1973 AMA declassification of homosexuality as a mental disorder Subsequent overturning of sodomy laws by many states - As of 2009, homosexuality is still outlawed in 16 states LGBT People in the United States Provision by many states for same-sex domestic benefits Recent legalization of gay marriage movements in a few states Healing Traditions Among LGBT Americans Little data available regarding interaction of LGBT populations with the health care system - Small number of available studies of LGBT individuals are uninformative regarding this point - Even basic demographic and statistical data is unavailable Available information points to patterns of discrimination toward LGBT people within the health care system Healing Traditions Among LGBT Americans Access to care often a problem for LGBT people - Important health issues may remain unreported due to a fear of stigmatization - LGBT people may have lower socioeconomic status than equivalently educated heterosexuals - Extension of health care benefits to LGBT partners may not be allowed by insurance companies or state governments Where such extension is allowed, fear of exposure and stigmatization often prevents LGBT couples from taking advantage of their rights Healing Traditions Among LGBT Americans In hospitalizations and crisis care situations, LGBT couples are often denied basic rights granted to married heterosexuals Difficulty in communication with health care providers is widely reported by LGBT people Significant misconceptions exist concerning lesbians' heath care issues Healing Traditions Among LGBT Americans 2007 Healthcare Equality Index project study of 78 hospitals in 20 states regarding LGBT issues found: - 50 hospitals provided same access to LGBT partners of patients as they provided to married partners - 56 allowed the designation of a domestic partner or someone else as medical surrogate - 57 provided staff training regarding issues related specifically to LGBT patients and their families Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans HIV/AIDS - Since the early 1980s, it is estimated that 700,000+ Americans have been diagnosed with AIDS - 54% of these are men who have had sex with other men - African American and Latino men account for the majority of cases since 1998 - Recent research results emphasize the importance of sexual behavior, rather than sexual identification, in creating heightened risk for AIDS infection Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans Safe-sex education remains key to prevention Little research data is available concerning AIDS incidence within Lesbian and transgender populations - The small number of studies conducted of Lesbians indicates low AIDS incidence and no evidence of female-female transmission - Small number of available studies of transgender suggests a high rate of AIDS infection Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans HIV/AIDS carries high risk for Kaposi's sarcoma and non-Hodgkin's lymphoma Recent research indicates that bisexuals are at heightened risk for anal cancer and Hodgkin's disease Lesbians found to be at heightened risk for breast cancer, possibly due to less-frequent breast cancer screening and gynecological care than heterosexual women Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans Substance abuse - Limited studies of alcohol and substance abuse among LGBT populations are inconclusive Societal anti-gay attitudes and negative attitudes internalized by LGBT people put them at increased risk for various mental disorders, substance abuse, and suicide - The small number of studies conducted concerning these issues have been inconclusive Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans Studies indicate heightened rates of depression, substance abuse, and anxiety disorders among transgender - Suicide attempts and completed suicides occur at a higher rate among trangenders than in general population - High rates or genital self-mutilation reported Behavioral Health Risk Factors and Common Health Problems Among LGBT Americans Aging - Little research data available regarding LGBT individuals' aging issues Recent studies indicate LGBT elders are more likely than heterosexual elders to live alone - Long-term care facilities do not exist that meet the needs of this group - Few social service agencies exist to address their needs Considerations for health promotion and program planning for LGBT Americans Lack of reliable information about LGBT people and barriers to their obtaining health care pose significant problems - Consequently, providers need to make special efforts to achieve cultural competency regarding this group Health care providers should strive to establish a nonjudgmental environment for LGBT patients and their families Migrant Farm Workers History of Migrant Farm Workers Migrant Farm Workers in the United States Beliefs about Causes of Health and Illness among Migrant Farm Workers Behavioral Risk Factors and Common Health Problems among Migrant Farm Workers Considerations for Health Promotion and Program Planning for Migrant Farm Workers History of Migrant Farm Workers Statistics from various sources indicate that U.S. migrant farm worker population totals 3-5 million Accurate statistical information difficult to compile because over 50% of migrant farm workers do not have legal status within U.S. - Members of this group reluctant to provide information due to fear of deportation Migrant Farm Workers in the United States 7 in 10 migrant farm workers are foreign born - 94% of foreign-born workers are from Mexico - Other countries of origin lie in Central America, the Caribbean, and Southeast Asia Mexican immigration increased significantly during WWII - Bracero Treaty legalized immigration for Mexicans Approximately 4 million Mexican bracero workers supported U.S. agriculture between 1942 and 1964 Migrant Farm Workers in the United States Recent trade agreements have affected the legal status and numbers of foreign-born migrant farm workers Migrant farm workers are found in nearly every state, but the largest concentrations are in California, Texas, Florida, Washington, and North Carolina - California's migrant farm worker population = approximately 1.3 million Migrant Farm Workers in the United States 75% of migrant farm workers earn less than $10,000 yearly Although many qualify for social services or housing assistance, many of these fail to apply due to fear of deportation Most migrant farm workers are poorly educated, with low overall literacy rates Beliefs about Causes of Health and Illness Among Migrant Farm Workers Hispanic migrant farm workers tend to reject the modern germ theory of medicine - Illness widely believed to result from imbalances between the individual and the environment - Ailments often characterized as either \"hot\" or \"cold\" Beliefs about Causes of Health and Illness Among Migrant Farm Workers Traditional beliefs, while varying with country of origin, strongly influence general medical beliefs - Mal de ojo (\"evil eye\") - Susto (\"soul loss\") - Fatalistic acceptance of events or of one's status is common Behavioral Risk Factors and Common Health Problems Among Migrant Farm Workers In general, health standards for members of this group resemble those common in Third World countries Working and housing conditions put migrant farm workers at heightened risk for numerous health problems Most are unable to take time off from work to attend doctor's appointments, even if they could be made Behavioral Risk Factors and Common Health Problems Among Migrant Farm Workers Skin disease is an especially prevalent problem - These problems are often self-treated with household products and herbs - Causes include exposure to wind and sun, pesticides, fertilizers, petroleum products, and plants Other significant health problems include injuries, respiratory illness, tuberculosis, and HIV Considerations for Health Promotion and Program Planning for Migrant Farm Workers Be aware of their concerns over their legal status and their fears of deportation Ensure that appropriate translation services are available Include the family in decision making Before planning, assess the patient's living situation Be sensitive to the fear and mistrust common to members of this group Summary Culture is not only related to race and ethnicity Lesbians, gays, bisexuals, and transgender people have faced a great deal of discrimination, which continues today Migrant farm workers are mostly Hispanic people who face poverty, unsettlement, legal issues, low educational levels, and harsh working conditions Chapter 13 Closing the Gap: Strategies for Eliminating Health Disparities Health Disparities The U.S. Department of Health and Human Services (HHS) has selected six focus areas in which racial and ethnic minorities experience serious disparities in health access and outcomes: - - - - - - Infant Mortality Cancer Screening and Management Cardiovascular Disease Diabetes HIV Infection and AIDS Immunizations Strategies for Reducing or Eliminating Health Disparities Research Improving the Environments of People Affected by Health Disparities Increasing Access to Health Care Improving Quality of Care Policy Changes and Laws Research Increase knowledge Identify and share best practices Identify what is working and also what is not Obtain more specific information about subgroups within cultures Research Gather information about a range of contextual variables, beyond socioeconomic status alone, that have been found to be explanatory in health differences, such as - - - - - - - Social support, social networks, and family supports Levels of acculturation Social cohesion Community involvement Perceived financial burdens Discrimination Differences in the health status of foreign-born versus U.S.-born individuals Improving the Environments of People Affected by Health Disparities Residents of socially and economically deprived communities experience worse health outcomes on average than those living in more prosperous neighborhoods. Minorities are more likely to live in poor neighborhoods. Policies are needed to reduce or eliminate environmental inequalities. - Environmental Justice Renewal Act Increasing Access to Health Care More than half of the uninsured people in the United States are racial and ethnic minorities (McDonough, et al., 2004). Accessibility is not just related to financial barriers; there are people who can afford coverage but are denied based on their medical history. Poor neighborhoods tend to have a lower person-to-health care provider ratio than more affluent regions. Increasing Access to Health Care Possible solutions? - Universal health care - Telemedicine that offers incentives and competitive salaries to providers who work with low-income regions - Training community members as peer educators and outreach workers Improving Quality of Care Train health care providers to be culturally competent Provide equal care Reduce language barriers Increase diversity in the workforce Policy Changes and Laws Policies and laws that mandate cultural competency training for medical professionals - New Jersey, Senate Bill (SB) 144 requires medical professionals to receive cultural competency training to receive a diploma from medical schools in the state - Washington, SB 6194 in 2006 requires all medical education curricula in the state to include multicultural health training and awareness courses Policy Changes and Laws - California, Assembly Bill 1195 requires mandatory continuing medical education courses to include cultural and linguistic courses. SB 853 requires commercial health plans to ensure members' access to linguistic services and to report to state regulators steps being taken to improve the cultural competency of their services. Medi-Cal, requires all health plans providing services for Medicaid patients to ensure their linguistic needs are met, including 24-hour access to interpretive services and documents in native languages. Cultural Competence In general, cultural competence is a set of congruent behaviors, attitudes, structures, and policies that come together to work effectively in intercultural situations (National CASA Association, 1995-1996). Cultural Competence Can be adopted and practiced by a solitary professional or an entire organization Requires a set of skills by individuals and systems that allows an increased understanding and appreciation of cultural differences as well as the demonstrated skills necessary to work with and serve diverse individuals and groups Cultural Competence According to the National CASA Association (1995-1996), the culturally competent organization: - Values diversity - Conducts cultural self-assessments - Is conscious of and manages the dynamics of difference - Institutionalizes cultural knowledge - Adapts services to fit the cultural diversity of the community served Cultural Competence Includes activities such as policy development and implementation, governance, education, promoting workforce diversity, and the reduction of language barriers. Is an ongoing process dedicated to growing with a changing society Cultural Competence Improving cultural competency levels should begin with an assessment to determine where an individual and/or organization can improve. It can assist with directing training and education for the workforce, policy development, and other systematic changes. Summary Health care reform needs to include concrete steps to eliminate health disparities Strategies include diversifying the health care workforce, changing policies, training health care professionals in cultural competence, and conducting research Cultural competence is a life-long process