CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review • To provide “a common understanding and consistent definitions of culturally and linguistically appropriate services in health care…Ideally, the issuance of national standards for CLAS should result in the replacement of the patchwork of different definitions and requirements with one universally understood set of guidance”; and finally • To “offer a practical framework for the implementation of services and organizational structures that can help health care organizations and providers be responsive to the cultural and linguistic issues presented by diverse populations” (Office of Minority Health 2001). The ‘ultimate aim’ of the standards is “to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans” (Office of Minority Health, 2001); The 14 CLAS standards are thematically organized around three themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Federally funded health care organizations are mandated to meet four of these standards (Standards 4-7) relating to language access services. This mandate derives from Title VI legislation of the 1964 Civil Rights Act which mandates that all institutions receiving federal funds provide adequate means of communication between English-speaking providers and individuals with limited English proficiency (LEP). The federal Office of Civil Rights defines an LEP individual as “someone who is unable to speak, read, write, or understand the English language at a level to interact effectively with health and social service agencies and providers” (cited in Rice 2007; also see Martinez et al., 2004). Promising state level policies, legislation and/or initiatives include: • New Jersey Senate Bill S-144, which was introduced in 1999 and signed into law in 2005. It requires that physicians in New Jersey to take cultural competency training as a condition of licensure by the State Board of Medical Examiners (see Salas-Lopez et al., 2007; also see Baquet et al., 2004); • The proposed Illinois Covered Act introduced into Illinois’ state legislature which would, among other things, establish a State Healthcare Workforce Council to provide an assessment of health care workforce trends with a focus on cultural competence and minority participation in health professions education (Smedley, 2008); • Pennsylvania’s governor, Ed Rendell's, proposed Cover All Pennsylvanians legislation which, if enacted, would similarly establish a Pennsylvania Center for Health Careers, among whose duties would be to develop recruitment and workplace tools that aim to improve health professional workforce diversity and promote the delivery of culturally appropriate care. In addition, this legislation would require charitable hospitals to produce a community needs assessment in consultation with community groups and local government officials (Smedley, 2008). • Various private, governmental, and non-profit organizations in the US have also increasingly come to adopt cultural competence policies, standards and training. Exworthy & Washington summarize the nature of such strategies and policies in Table 3.4 below: Table 3.4: Strategies to improve cultural competence at different levels in the US Source: Exworthy & Washington, 2006. Adapted from Betancourt et al., 2002. 68
The Culture, Diversity and Equity Project: Literature Review • Private health insurers such as Kaiser Permanente, Aetna, and BlueCross BlueShield of Florida, have been particularly active in developing cultural competence initiatives (see Betancourt et al., 2005 for more on these initiatives). The California Endowment, a private, state-wide health foundation that was created in 1996 as a result of Blue Cross of California's creation of WellPoint Health Networks (a for-profit corporation) has been especially active in developing research and initiatives aimed at improving the cultural and linguistic competence of the US healthcare system. Also of particular note in this respect is the Institute for Culturally Competent Care of the Kaiser Permanente - America's leading nonprofit integrated health plan, serving approximately 8.2 million people in nine states and the District of Columbia – which has established numerous ‘'Centers of Excellence' for different racial/ethnic groups in their efforts to raise the profile of cultural competency within their health-care provision. Various other philanthropic foundations, such as the Robert Wood Johnson Foundation and Commonwealth Fund in particular, have also actively pursued agendas seeking to widen access to health care through research and demonstration projects. Limitations and Challenges Among the challenges and limitations of American policy developments addressing health and healthcare disparities discussed in the literature are the following: • Failure to address broader determinants of health and structural patterns of socio-economic inequality and disadvantage as these impact upon health disparities (Raphael and Bryant, 2006; Exworthy et al., 2006; Exworthy & Washington, 2006); • Overly exclusive focus on ethnic and racial disparities in healthcare service, to the neglect of other bases and forms of disparity (Raphael & Bryant, 2006); • Narrow and exclusive focus on healthcare disparities and/or confusion or conflation of healthcare disparities with disparities in health status (Exworthy & Washington, 2006); • Dominance of medical model and individual-behavioural approaches to the neglect of broader public policy solutions to disparities. Fundamental reluctance to view such broader social inequities and determinants of health as a public policy matter (Raphael & Bryant, 2006); • Flawed tendency to ascribe all health inequalities to biological or cultural causes as a result of official US statistics near exclusive reporting of health inequalities by race rather than by socioeconomic status (Howden- Chapman & Kawachi, 2002). Dominant Framework • Healthcare Equity Frameworks, more specifically, cultural competence frameworks focusing on issues of race/ethnicity and accessibility to healthcare services. Rating on Whitehead’s Action Spectrum • The dominant state of affairs, as concerns health equity efforts in the broad (social determinants of health inclusive) sense, ranges from Awareness Raising to Denial/Indifference and Mental Block • As concerns healthcare equity and cultural competence in particular, the dominant state of affairs could be characterised as isolated initiatives and awareness raising. England Policy/Strategy Developments Over a short period of time following the election of the Labour government in 1997, the UK has rapidly become a, if not the, leader in governmental health equity policy and action aimed at not only the healthcare system but also addressing wider determinants of health/health equity. Among the landmark UK policies, strategies and initiatives described in the literature are: 69
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Appendix 1: Health Equity Literatur
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The Culture, Diversity and Equity P
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HEALTH EQUITY LITERATURE REVIEW INT
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REFERENCES ACAS [Advisory Conciliat
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