The authors of this Fund report consider the intersection of patient-centered care and cultural competency. Affordable, quality health care. Access to health care is a supply side issue indicating the level of service which the health Table 2 shows the relationship between social class and death. .. of race, skin colour, language, religion, nationality, country of origin, and 'culture'. nic differences in the quality of health care that are not due to access-related . the relationship among race, ethnicity, culture, or accultura- tion and health.
As we will see, a barrier that only afflicts us under certain circumstances is, for instance, irregular public transport. If there is no need to use the public transport, irregular public transport does not act as a barrier e.
If public transport is needed, irregular public transport acts as a barrier. A barrier that only afflicts some of us is for instance health insurance coverage. For the socioeconomic vulnerable ones, the price of health services can act as a barrier if a health service is not covered by their health insurance, or is only partly reimbursed.
Use of health services The use of health services is defined as the process of seeking professional health care and submitting oneself to the application of regular health services, with the purpose to prevent or treat health problems. In this paper we focus on all possible barriers in relation to this process. Although the decision to use health services is stated to be an individual choice, we imagine that these choices are mostly framed in the social context through cultural, social and family ties; especially for ethnic minorities.
The help of regular health services is often only called upon after an escalation of the complaints of illness. It refers to many different ethnic groups of extreme heterogeneity. The concept is used for groups that share minority status in their country of residence due to ethnicity, place of birth, language, religion, citizenship and other cultural differences.
It sets apart a particular group in both numerical and often socioeconomical terms. Members of these groups are considered to practice different cultural norms and values from the majority culture and often a different mother tongue. They are in fact the original inhabitants of the country.
Patient, provider and system level Barriers can present themselves to patients, health care providers and the organization of health services, in other words the health care system itself. Therefore we say that barriers occur at patient level, provider level and system level. By patient level we mean related to patient characteristics, such as sex, ethnicity, income, etc. By provider level we mean related to provider characteristics, such as sex, skills, attitudes, etc.
By system level we mean related to system characteristics, such as policy, organizational factors, structural factors, etc. The searches were limited to articles published between and and performed by the first author of this paper in September The different keywords used to search are presented in the appendix.
Selection The articles were selected through titles and abstracts by the first author of this paper. The selection was based on inclusion and exclusion criteria. The results of the search were completed by tracking references from studies already included.
Inclusion criteria The articles had to report on the results of research and contain information pertaining to migrants, health care and factors that may hinder health services use. The following inclusion criteria were employed in this study.
Women's Health Care Physicians
The articles had to be published between and The articles had to report on the use of health services by ethnic minorities. The study of potential barriers to the use of health services among ethnic minorities is still a relatively uncharted course. Therefore, not only articles on quantitative research were included, but also articles on qualitative research, as well as literature reviews and a few published essays too. The studies had to report on health research, i.
Type of outcome measures: Outcome measures had to be factors that hinder the use of health services and that can act as a barrier. Exclusion criteria The following exclusion criteria were employed in this study. Articles in summary form only were not included in this study. Articles on health education were excluded. Analysis Quality assessment Due to the heterogeneity of the included studies, the studies are not sufficiently comparable to each other.
Therefore, the assessment of the methodological quality of each study seemed not appropriate to us. Although the literature search, the selection of studies and the extraction of data were done systematically, the review cannot to be compared with a systematic review; there was no quality assessment done. The aim of the study was to explore and identify as many potential barriers as possible. Also, the extracted potential barriers are not exclusively evidence-based phenomena.
Data extraction Data extraction of the articles was compiled by the first author of this paper. The first author read the available titles and abstracts identified in the different database searches, as well as the selected articles. The articles were screened for the different variables as presented by the theoretical framework used.
Theoretical framework We used Andersen's behaviour model of health services use as the theoretical framework. Rather, working with social services to address her housing issues would more likely enable her to manage her diabetes. Another example is a pregnant patient with poor weight gain who is evaluated for medical comorbidities when deeper probing into the etiology reveals she was fired from her job and cannot afford enough food for herself and her two children. Ordering tests or discussing the importance of good nutrition in pregnancy would be meaningless if not accompanied by referrals for food assistance.
Another commonly encountered scenario influenced by social determinants of health is the ability of patients to arrive at scheduled appointments on time. Many low-income women rely on often unreliable public transportation and may arrive late to appointments and be forced to reschedule, which creates the impression of nonadherence. Such examples highlight the importance of inquiry into the underlying reasons for these care challenges.
In fact, asking about certain social factors can be time-saving in some circumstances and can help to address systematic barriers to health care. This strategy has been shown to reduce clinician burnout, decrease health disparities, and also may reduce health care spending Most physicians recognize the importance social determinants play in health outcomes.
Indeed, addressing the root cause of many of these problems requires wide-reaching, policy-level changes, and most health care settings are generally under-resourced to address the social needs of individual patients. However, tools have been developed to assist clinicians in screening for some conditions, such as food insecurity and housing instability, and to incorporate these questions into electronic medical records 19, Including social indicator prompts in physician encounter tools has been shown to increase referrals to social services Providing referrals to housing or food services while patients are in the clinic can improve their health care usage This framework recognizes that the way society is structured for example, through racial, economic, and gender inequalities influences clinical interactions and health outcomes.
Structural competency aims to help clinicians intervene on these upstream contributions to disparate health outcomes, and also to recognize that these structural explanations have limitations and are not comprehensive 5. Cultural Awareness, Humility, and Sensitivity In the s, a concerted recognition emerged among health care professionals and educators that patients come from diverse cultural backgrounds that may influence their understanding of health and illness, interactions with health care providers and institutions, and engagement with treatment recommendations Although this approach has elevated discussions of diversity in health care settings, an over-emphasis on culture frequently conveys stereotyped representations of individuals from various ethnic groups while also overlooking diversity within groups by equating individual beliefs with group beliefs Categorizations like race and class often are reduced to cultural positions, rather than complex political, social, historical, and economic phenomena.
The relationship between ethnicity and health
Moreover, cultural competency overlooks the cultural dimensions of health care systems and clinicians themselves. Despite the limitations of a cultural competence approach, it is nonetheless critical for health care providers to recognize that both patients and clinicians hold their own set of values stemming from individual life experience and, in some cases, cultural backgrounds.
It may be especially helpful, for instance, for a clinician working in a locale with a large population of immigrants from a particular country to learn about cultural specificities of that group, recognize variations within that group, and understand the overlaying general experience of being an immigrant. Practical Tools Although attention frequently is focused on reducing health inequities through public health initiatives and state and national policies, obstetrician—gynecologists and other health care providers can have a significant effect by designing their own clinical practice with an awareness of the importance of the key social and structural determinants of health.
Even small changes in practice can make a significant difference with minimal financial sacrifices if deliberate planning is done to address these determinants. Some changes to consider include the following: Screening for Social Determinants of Health—Provide patient-completed intake questionnaires, expanded medical history questions, and integrated electronic medical records prompts. When purchasing or customizing electronic medical records for the office, obstetrician—gynecologists and other health care providers should request structured fields that capture information on social and behavioral determinants 12, 21, 2829 see Table 1.
Medical—Legal Partnerships—Obstetrician—gynecologist practices that are part of a community health care clinic or network should encourage the facility to establish medical—legal partnerships. Medical—legal partnerships are available in many federally funded health care clinics and have been shown to positively affect health outcomes, including adverse pregnancy outcomes such as low birth weight 5, Individual obstetrician—gynecologist practices may not be able to have such services on location, but relationships can be developed with existing medical—legal partnerships to provide needed services.
Liaisons with Community-Based Social Needs Programs—Obstetrician—gynecologists and other health care providers should develop partnerships with social workers and local community advocates who provide assistance with basic resources such as food pantries and home utility bills. Patients in need may feel less inhibited from using assistance programs when the obstetrician—gynecologist frames the referral letter to the community assistance program as a prescription, for example, to promote a healthy pregnancy.
For more details on methods linking physicians to community social services see the Health Leads website at www. In-person interpretation can enhance interpersonal interactions, but when this is not possible, using a phone service or video interpretation service is a good option with high patient-satisfaction ratings Transportation and Logistics—Underserved populations often have difficulties obtaining transportation to health care facilities.
Therefore, access to public transportation should be considered when planning office locations. In addition, underserved women often must bring family members to an office visit.
In order to facilitate attendance at health care appointments, obstetrician—gynecologists and other health care providers should avoid making arbitrary rules that prevent children and other family members from attending office visits. Modified from Health Leads. Social needs screening toolkit. Conclusion Social and structural determinants of health affect health outcomes as much as biological and individual level factors.
Although cultural competency is advocated to improve patient—health care provider communication with the ultimate goal of reducing racial and ethnic inequities in health outcomes, the model has significant limitations. Obstetrician—gynecologists and other health care providers should be aware of these limitations and, rather than solely explain health inequities by cultural differences, recognize that inequities are largely the result of forces that influence health at a point upstream from individual behavior.
By understanding these inequities as manifestations of larger social pathologies, health care providers may begin to address patient needs in a deeper and more effective way. Obstetrician—gynecologists and other health care providers may address social determinants of health by implementing key practices such as employing multilingual staff, ensuring adequate interpreter services, partnering with medical—legal organizations, and engaging with community resources.
These small steps can have a significant effect on health outcomes at the individual level and can help reduce health inequities at a population level. For More Information The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.
These resources are for information only and are not meant to be comprehensive. The resources may change without notice. Rudolf Virchow and social medicine in historical perspective. Patients and healers in the context of culture: University of California Press; Kaiser Family Foundation; Soc Sci Med ; Rio political declaration on social determinants of health.
Estimated deaths attributable to social factors in the United States. Am J Public Health ; Socioeconomic disparities in adverse birth outcomes: