The overall health of the American population has improved over the past few decades, but all Americans have not shared equally in these improvements. In King County, as in the nation, compelling evidence reveals that persistent and often increasing health disparities exist where a disproportionate burden of disease is experienced among certain groups. When thinking about what groups are impacted by health disparities we commonly think about racial and ethnic minorities, but it is important to keep in mind other groups where health disparities may exist, such as the elderly, groups based on gender, disabled populations, the poor, people living in rural areas, and groups based on sexual preference.

For our purpose, we will use the Washington State Board of Health's definition of health disparity which states: Health disparities describe the disproportionate burden of disease, disability and death among a particular population or group when compared to the proportion of the population. Many factors can contribute to health disparities. Some of these factors are access to health care systems, behavioral choices, genetic predisposition, environmental and occupational conditions, poverty, a myriad of social, cultural and economic factors, and discrimination in the health care setting. The King County Health Action Plan will form a sub-committee to focus on this last factor, discrimination in the health care setting, with the intention of generating recommendations that can be disseminated broadly in the county to address this very important issue.

Public Health - Seattle & King County recently concluded a report on racial and ethnic discrimination in health care settings. This report reveals that there are serious incidents of racial and ethnic discrimination and differential treatment across a broad spectrum of health care settings in King County. According to the report about one in ten persons of color overall (9%) and about one in six African Americans (16%) reported experiencing discrimination in health care settings in the past year compared to one in 20 (5%) of all King County residents. Discrimination experiences ranged from incidents of differential treatment to rude behavior and racial slurs. These reported events of discrimination were perceived to be racially motivated and occurred in 30 facilities, both public and private, across King County. In addition to possible feelings of stress, anger, and humiliation which can be suffered as a result of this type of experience, some respondents reported delaying to seek treatment due to the negative encounter and avoiding offending personnel and/or facilities where the incident took place. All of these potential consequences can result in poor health outcomes for the individual and deepens the problem of health disparity.

There is a substantial body of research that shows that race and ethnicity influence a patient's chance of receiving many specific procedures and treatments. Of nine hospital procedures investigated in one study, five were significantly less common among African American patients than among white patients; three of those five were also less common among Hispanics, and two were less common among Asian Americans. Another study showed that among preschool children hospitalized for asthma, only seven percent of black and two percent of Hispanic children, compared with 21 percent of white children were prescribed routine medications to prevent future asthma-related hospitalizations. Additionally, cultural and communication barriers can significantly affect the quality of care provided to persons of different ethnic heritage and/or non-English speaking persons.

In a preliminary discussion among members of the Action Plan's Steering Committee, it was widely recognized that discrimination is a real problem in the health care setting. Most institutions have policies in place to address the issue of discrimination, however, approaches and policies appear to be quite varied and often ineffectual. Difficulty was identified around evaluation of interventions in knowing if behaviors had changed "systemically". The role of inadequate translation was also identified as a problem area with "meaningful" translation differentiated from literal translation. It was also recognized that while racial and ethnic discrimination were the focus of the report conducted by Public Health, experiences of discrimination are not limited to those. Others who can be impacted by discrimination include: the elderly, groups based on sexual preference or gender, disabled populations, and the poor.

The Action Plan's sub-committee on discrimination will use the following list of "to do's" as a point of departure for their initial discussions and work:

• Share information on best practices for dealing with discrimination internally, "what works", and then with local health care organizations and agencies.
• Create a "safe place" for organizations experiencing discrimination in their health care setting to seek help.
• Expand the discussion beyond just one of 'cultural competency' to one of raising the bar of quality of care in much broader terms.
• Establish a collective approach for addressing discrimination and evaluating success.
• Explore ways to link with ongoing efforts of other organizations and agencies to diversify the health care workforce.
• Create mechanisms for moving "upstream" to institutions of higher education for earlier interventions.

It is expected that the sub-committee will meet four to five times over the next six months.

• Nancy Anderson
• Sister Susanne Hartung
• Catherine Kanda
• Dianna Kielian
• Pam MacEwan
• Tom Trompeter
• Cassie Undlin
• Greg Vigdor
• Nancy Woods

There are few places in our society where divisions of race, ethnicity and culture are more sharply drawn than in the health of people in the United States. Despite recent progress in the overall national health, there are continuing disparities in the incidence of illness, disease and death among racial and ethnic groups. Public Health - Seattle & King County recently concluded a report on racial and ethnic discrimination in health care settings. This report reveals that there are serious incidents of racial and ethnic discrimination and differential treatment across a broad spectrum of health care settings in King County. Current service delivery systems must undergo fundamental change in order to achieve the goal of eliminating health disparities. An essential tool in this endeavor is the incorporation of culturally competent values, attitudes, policies, structures and practices.

Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or professional and enable that system, agency or professional to work effectively and competently in cross-cultural and multiethnic situations. To the degree that cultural competence is enhanced within health care delivery systems and among providers, perceptions of discrimination among health care consumers can be reduced and racial and ethnic disparities in health can be achieved. Improvements in communication and cultural understanding as outcomes of enhanced cultural competency in a health care setting is demonstrated by improved diagnoses, treatment plans and patient satisfaction. Improved patient satisfaction leads to enhanced patient compliance with a treatment plan and reduces the likelihood of delays in seeking care.

The charge of the Health Action Plan in this area is to work with health institutions and community-based organizations to incorporate effective strategies to eliminate racial and ethnic discrimination and enhance cultural competence. Most agencies and institutions have policies in place to address these issues, however, approaches and policies appear to be varied and often ineffective. The goal of the of the Health Action Plan Subcommittee on Discrimination and Disparity in Health is to develop strategies for a collective approach addressing discrimination and disparity and evaluating the success of these strategies. The Health Action Plan Subcommittee on Discrimination in Health will compile several different tools for purposes of cultural competency self-assessment in different organizational health care settings. Informed by the work of this committee, the Health Action Plan Steering Committee recommends the following:

• As health care leaders and employers Steering Committee members will work to integrate into their own existing cultural competency policies the eight principles as identified by the Health Resources Services Administration as key elements of creative and successful policy:
  • Define culture broadly
  • Value clients' cultural beliefs
  • Recognize complexity in language interpretation
  • Facilitate learning between providers and communities
    
  • Involve the community in defining and addressing service needs
  • Collaborate with other agencies
  • Professionalize staff hiring and training
  • Institutionalize cultural competence
    
    
• Steering Committee members as representatives of health care systems will voluntarily conduct a cultural competency self-assessment in at least one service delivery area. A report on thematic findings will be presented to the Steering Committee by June 2002.
  
  
• Steering Committee members representing organizations that possess the capacity, will explore opportunities to qualify cultural competency training for required Certified Medical Education (CME) credits for their staff of physicians, nurses and other health care providers.
  
  
• As a means to identify community needs and concerns, Steering Committee members representing health care provider organizations will consider conducting a community conversation forum with leaders of one of the major racial/ethnic communities they serve to elicit comments and concerns regarding the delivery of health care services with a particular focus on issues of discrimination and worsening health trends that disproportionately impact racial/ethnic populations such as asthma, diabetes and cervical cancer.

The above recommendations were adopted by the King County Health Action Plan Steering Committee on December 11, 2002.