Articles

Addressing Healthcare Inequities in Black and LGBTQ+ Communities

Danielle Jackman, PhD, CDP and Dennis McWhorter MHA

June represents a time to honor and celebrate some big historical wins. It is a time when people take to the streets to celebrate Juneteenth, African Americans' emancipation from slavery, and march for continued LGBTQ+ equality. It's a time to join the festivities, eat fantastic soul food, and walk alongside our Black and LGBTQ+ colleagues. However, these celebrations cannot overshadow the growing concerns about health inequities in Black and LGBTQ+ communities. The problem is even more significant for individuals with multiple intersecting identities.

Addressing the Suicide Crisis Among Black Youth

National statistics highlight rising suicide rates among Black children and youth. In 2019, suicide was the second leading cause of death among Black youth aged 10 to 14, and the third leading cause of death among teenagers ages 15 to 19. Black youth make up 13% of the Black communities and account for approximately 37% of deaths by suicide. In fact, according to the National Institute of Mental Health, Black children were at higher risk of dying by suicide than their White counterparts but less likely to receive treatment.

The reasons contributing to the lack or limited treatment of mental health concerns, including depression and suicide among Black communities, are nuanced and complex. Researchers suggest institutional racism is a significant factor. Institutional racism in healthcare suggests that the health concerns of Black people are seen as less severe than their White counterparts. Therefore, this results in late diagnoses and late treatment.

Additionally, the CDC suggests that Black youth are less likely to see a doctor due to multiple structural barriers. Such barriers include access to a hospital or healthcare facility, high costs, lack of transportation, and a low number of providers of color. These healthcare inequities are further emphasized in Black LGBTQ+ communities.

The LGBTQ+ community is facing a significant healthcare crisis. Many states, including Florida and Utah, have passed laws restricting youth from receiving gender-affirming care. Many other states are hoping to pass similar laws. These laws also indicate penalties for any person perceived to have their child receive gender-affirming care. This law, coupled with other laws such as those that grant doctors and insurers the ability to deny any person from receiving care based solely on "conscience," placed an increased burden and suffering on Black LGBTQ+ youth.

Ways to Support Black LGTBQ+ Youth

While many Colorado healthcare institutions have done a lot to support LGBTQ+ and Black communities separately, more work needs to be done to help and elevate the needs of Black LGBTQ+ youth. As healthcare leaders, we are responsible for better serving the people we often see and elevating our spaces to be welcoming for those we do not often see. Consider the following approaches in doing so. This is not an exhaustive list, but it can offer a start to those unsure where to turn.

1. Provide continuous and iterative anti-racism and anti-oppression listening sessions, training, and workshops for healthcare practitioners.
2. Hire more practitioners of color. This should include but is not limited to: doctors, surgeons, nurses, and other mental/behavioral health specialists such as psychiatrists and psychologists.
3. Conduct a cultural audit of your healthcare facility.
4. Provide staff space, budget, and guidance to establish and/or increase Employee Resource Groups.
5. Advocate for your Board of Directors to be gender, ethnically, and diverse in other groups or forms.

Most importantly, it is time for us to end silencing the pains of our Black youth and keep at the helm that healthcare is a right, not a privilege, and everybody deserves to be served.

References

• Racial and ethnic differences in depression: current perspectives - PMC (nih.gov)
• NIMH » Addressing the Crisis of Black Youth Suicide (nih.gov)
• full_taskforce_report.pdf (house.gov)
• https://focus.psychiatryonline.org/doi/10.1176/appi.focus.20210034
• https://ebrary.net/211748/health/problem_heteronormativity_medicine
• Rights & Protections | HealthCare.gov
• Florida bill expanding a doctor's ability to refuse services based on 'conscience' sparks debate | Health News Florida (usf.edu)

CULTURAL HUMILITY IN HEALTHCARE: WHAT IS IT AND HOW CAN WE APPLY IT?

Jesse Vazzano, Julia Lamb, Sanjeev Sah, & Brian M. Leonard

Over the past thirty years, cultural competence has become a familiar concept in healthcare to understand and meet the holistic needs of patients. However, what does cultural competence imply, and how do we know if we are competent in providing care that genuinely incorporates the culture of those we serve? These questions have prompted a conceptual shift in modern healthcare from cultural competence to cultural humility. Tervalon and Murray-Garcia proposed that the problem with using the word "competence" implies "a detached mastery of a theoretically finite body of knowledge" (p.117). In comparison, "cultural humility incorporates a lifelong commitment to self-evaluation and self-critique" (p.117). Furthermore, cultural humility implies a continuous sense of curiosity and a life-long approach to seeking and incorporating different viewpoints, values, and practices, as well as reflecting on our biases.

In the healthcare setting, cultural humility is observed through patient-centered and open conversations that reveal what is essential to each client. In this way, we gain insight into the unique strengths, beliefs, and barriers a patient might possess. While this work can seem labor intensive, a reflective conversation and culturally respectful interventions can significantly impact the patient's health outcomes and satisfaction with their care, particularly when compared to simply completing a demographic questionnaire (Bullard, 2022). Taking the time to learn from individuals served by the healthcare system about what motivates them to seek care and what prevents them from accessing care is vital to find avenues for equity. We can gain insight into factors that might force a patient to decide between filling a prescription or putting food on the table. As we adapt our approach and navigate under-developed systems to allow for integrating different cultures and beliefs more effectively, it is okay to be uncomfortable. Wherever we are, is a great place to start.

Expanding one's practice to include cultural humility can consist of individual acts of care or examining how a whole system of care operates. As a single care provider or small practice, one can take the time to speak with a patient about what is going on in their life, to identify significant changes, or ask about demographic information that may help inform care (i.e., religious beliefs and how active they are in their religious community, what part of town they live in, changes in a job, or other life events). For example, suppose a care provider notices a lack of prescription medication compliance. They've also identified that the patient lives in a part of the community that relies on public transportation or has a language barrier. In that case, there could be an opportunity to work with pharmacy providers that offer a free or reduced-rate delivery service.

On a larger scale, as a system, looking at how an interdisciplinary team can work together to provide care and services proactively may be more difficult but can incorporate more cultural aspects. This may include having a social worker conduct a pre-visit assessment that allows for collecting clinical information along with significant social and cultural knowledge. Then the social worker returns this information to the entire team (primary care, specialty care, nursing, etc.), summarizing what the patient has identified as important to them personally and in care, along with what they want and need from care. When the patient comes into their appointment, this can allow for a more patient-centered approach versus a series of questions and clinical reminders being completed. As a care team, being able to huddle before a patient's appointment is critical to this type of change in the system. It can proactively determine who will assist a patient with different needs. 

Modern healthcare is expanding beyond what was traditionally provided to incorporate a more holistic understanding of the social drivers of health and cultural humility. In this way, we ensure that our patients' basic needs are met so our communities can thrive. As an interdisciplinary collective, we can address the social determinants of health by working proactively and collaboratively with patients and communities to improve outcomes.

This article is the first of many supports and resources the CAHE Diversity, Inclusion, and Equity Committee will bring to CAHE members. We are excited to share more information in the upcoming months.

References

1. Barsky, A. (n.d.). Ethics alive! Cultural competence, awareness, sensitivity, humility, and responsiveness. What's the difference?. The New Social Worker. Link
2. Bullard, J. (2022, September 13.) Cultural humility improves patient experiences, health outcomes, hospital readmissions. RTI Health Advance. Link
3. Lekas, H. M., Pahl, K., & Fuller Lewis, C. (2020). Rethinking cultural competence: Shifting to cultural humility. Health services insights, 13, 1178632920970580. Link
4. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved, 9(2), 117-125. Link