As health systems across the nation move to achieve more ethical practices, it's helpful to identify the current shortcomings within areas such as data analysis and patient outcomes. Many of today's health inequities derive from deeply rooted historical foundations that require consistent and deliberate change on behalf of providers. Part of this reform is a subtle, yet powerful approach to health equity known as cultural humility.
Read on to learn how healthcare providers are addressing these issues and implementing cultural awareness in their work. You can also listen to the accompanying audio here, part one of our three-part series:
Health equity challenges one-size-fits-all healthcare delivery
Francoise: Jarrod, let's jump right in. What core issues does the pursuit of health equity address?
Jarrod: What we have discovered through research is that this one-size-fits-all approach to healthcare delivery does not work. It's not safe to assume that how care is delivered to one group of patients will work and produce the same results in a second group of people. As a scientist and epidemiologist, I was taught against approaching a study with biases. It must be as unbiased as possible. Before I can compare outcomes between two independent samples, I must first account for those differences. And those differences can be both clinical and/or demographic differences by way of study design and statistical methodology. We must apply this same principle of approaching situations without any presumptions or biases to how healthcare is delivered. We also know from research that healthcare is failing some populations because we see disparities in outcomes.
Black American, American Indians and Asian populations are at higher risk for many chronic conditions such as hypertension, diabetes, and this COVID-19 pandemic that, started in 2020 and that we're still going through right now in 2022. It put a spotlight on these disparities, as we saw that people of color were more likely to be hospitalized and that the average life expectancy for Blacks, Latinx, American Indian, and Alaskan Native populations saw an exponential fall compared to their White counterparts. Vulnerable populations that the healthcare system is currently failing are not only restricted to people of color, but also to those that live in rural areas, those that have more restricted access to care, and those with high social needs and low economic stability.
To reach health equity, we must realize that we cannot offer the same thing to everyone. The one-size-fits-all approach does not fit in healthcare. We must understand that some populations do not have the same opportunities as others, and we must direct more effort and resources to assist them in reaching those opportunities and a healthier future with improved quality of life and wellbeing.
Francoise: You're right, health equity only exists when everyone has the opportunity to be as healthy as possible. And without consideration of those items that you've addressed, healthy equity is not achieved.
Historical approaches often overlook increased needs in specific communities
Francoise: What risks do you feel the historical approaches and presumptions present to patients?
Jarrod: We are a more tech-savvy society and we are collecting data more and utilizing data to make informed decisions and identify opportunities. A review of the data just shows that this historical approach is not working. In this approach, we overlook individual lived experiences and historical prejudice. For example, the enslavement of Blacks in the American colonies lasted for centuries. And this lifestyle was embedded and woven into the American society, and that lifestyle and the behavior and the morals associated with it was passed down through generations. As cruel and as heartless as slavery was, it was seen as a way of life, and the differences over it even led to a civil war between northern and southern colonies. This lifestyle was more pronounced in the deep south, so in states like Alabama, Mississippi, Louisiana, Georgia, South Carolina, and all of the states along the I-95 corridor, we see the outcomes, such as declines in cardiovascular mortality, is less among Black people compared to White people in those same areas. You see, enslavement had a lasting effect and its lifestyle and the morals and behaviors surrounding it lasted long after the people who pushed for it and capitalized on it were gone.
We can say the same thing for indigenous people in America. Now, they were forced to relocate from their native lands to live on reservations with dependence on the government to distribute food, which was processed, unhealthy food consisting of high fat and carbs, and that puts them at a disadvantage of developing conditions, such as diabetes. However, this was their life, and it was a norm for them, and they cultivated their lives around it. It was part of their culture, and it passed down from generation to generation. So those lived experiences are immortal since they are passed down, and it has rippling negative consequences on health outcomes. We've also seen the effects of national legislation at that macro level, such as redlining, in which mortgages were restricted to certain people of color because of their race or ethnicity.
When providers and others who are delivering care to patients overlook these historical prejudices and differences and lived experiences, we lose the trust of the patients since they will think that the provider does not have their best interest at heart. Deliverers of healthcare services must understand that say, for example, Mrs. Jones and Mr. Smith may not be able to execute healthy behaviors because they live in food deserts, or they cannot afford their medications, or they cannot seek care because they're uninsured, or they have no transportation and/or they cannot exercise because they live in communities where there are no sidewalks. When the provider approaches the relationship aware of factors driving SDoH with an open mind and listens to the patient, and identifies their needs from the forefront, the provider can draft care goals more aligned and more appropriate for the patient and his or her situation. Thereby gaining the patient's trust and reassurance that their best interest is truly at heart.
Difference between cultural competence and cultural humility
Francoise: Can you help us to better understand where cultural competence and cultural humility enter the equation?
Jarrod: As it relates to healthcare, I find that cultural competency is a process of educating healthcare providers on the varying populations in which they serve and bridging the gaps in cultural and belief systems between patient and provider that exist. However, cultural humility is different than cultural competence. The NIH, National Institutes of Health, defines cultural humility as a lifelong process of self-reflection and self-critique where an individual not only learns about one's culture, but begins to examine his or her own beliefs. I like to think of it like, I'd already learned about who you are, or how you identify, to now I'm transitioning to humility where I am curious to learn more about you, tell me more about your culture. That's the difference between culture humility versus cultural competence.
And humility, that's when we get into the root of being humble and appreciating the cultural differences surrounding people that really and truly make us unique. Since culture is woven into behaviors and attitudes, beliefs, and morals, it's going to impact how one appreciates and approaches healthcare and the outcomes and risks associated thereof. We know that the relationship and dynamics between patient and provider have shifted and they're continuing to shift. Historically, providers were authoritative in the relationship; they gave direction and the patient followed suit. However, in a more informative society where information is literally at our fingertips and the patients are more informed, providers are acting more like facilitators in that relationship.
A more knowledgeable and connected society is not the only driver behind this. There's also the push from a traditional fee-for-service environment to a more value-based environment where more value is placed on outcomes and quality of care. To assure patient adherence and satisfaction and subsequent body of care and outcomes, patients need to be able to trust their healthcare providers. If that trust isn't there, the patient may feel attacked or disadvantaged, and may even forego receiving and seeking care. Thereby it leaves them prone to experiencing more adverse outcomes and more acute episodes.
Francoise: I want to thank you, Jarrod, for joining me in this conversation today and bringing the topic of cultural humility as it impacts health equity to the forefront of our conversation for our audience. Tackling health equity in all forms is such an important pillar in today's healthcare delivery system.
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