Steps toward a Transdisciplinary and Community-Based Approach

To Health Disparity

Mark Nichter, University of Arizona, April 2003

Five Objectives

1. Propose ways of thinking about culture and ethnicity productive to a health disparity agenda.

2. Make a case for transdisciplinary research involving the health and social sciences

contributing to a eco-social epidemiological understanding of health problems

attentive to nested contexts and syndemic patterns of ill health

3. Describe cross disciplinary research as a continuum and transdisciplinary research as a process

Objectives:

4. Provide an overview of two broad areas of transdisciplinary research essential to a health disparity agenda

Translational research• Formative research process• Participatory research

Cultural competency training• Moving beyond first steps on a cultural

competence continuum • Using anthropologists as facilitators

Objectives

5. Revisit transdisciplinary research Identify challenges and stumbling blocks

Objective one

• Propose ways of thinking about culture and ethnicity productive to a health disparity agenda.

Ethnicity

• When ethnicity is employed as a category in public health and medicine, it is important to be clear about one’s assumptions (and intentions)

• How is ethnic designation going to be used in data analysis and how will this frame thinking about interventions?

Ethnicity

• Is an ethnic label being used to examine the possible role of biological differences?

• Is ethnicity a proxy for a whole bundle of social and economic factors associated with the position a group of people has been forced to assume as a result of a history of discrimination or oppression As a marker of social inequity and structural

violence

Ethnicity

• Is ethnicity being examined to determine whether the distinctive characteristics of an ethnic groups’ “culture” are protecting or exposing this group to particular types of risk?

How should we think about culture?

• Culture is commonly thought of as an enduring set of social norms and institutions that organize the life of members of particular ethnic groups giving them a sense of continuity and community.

Culture

• Often described rather vaguely as an all-encompassing associational field in which ethnicity is experienced.

• When “Culture” is thought about in terms of consensus and as a template for ideal behavior, the positions of different stakeholders (defined by gender, generation, class, power relations, etc.) are forgotten and heterogeneity is ignored.

• The tensions within are glossed over.

Culture

• Culture is more than a unique collection of beliefs, values, habits, customs

• Culture is more than a mental map: the map is not the territory!

Culture

Culture involves:

• Processes of control

• Expressions of agency

• Areas of conflict

Processes of control

• Control is exercised in variety of ways through ideas as well as practices, speech as well as action, perceptions of normative behavior and what constitutes morality as well as what is deemed deviant or abhorrent behavior

• Ideas about the normal and natural, abnormal and deviant are motivated social constructions. They often involve power relations They are not neutral. They have a history.

Agency

• Understanding culture requires more than being attentive to the rules of the game and dispositions to act and think in particular ways.

• How is the game being played in different public and private contexts?

• People are rule makers as well as rule breakers; rules may be broken in cultural ways.

• The game is being reinvented and finessed all the time: there are plenty of grey areas and lots of improvisation.

Conflict

Structural tensions exist within all cultures• Gender : within gender, across gender• Generation: varying expectations, dreams• Conflicting allegiances and alliances• Conflicting ideas about entitlement to scarce

resources• Individualistic aspirations and sociocentric norms• Jealousies and so on

Culture is a project, not a thing

• A processual rendering of culture is most productive. Such an approach directs attention to cultural dimensions of social transactions and asks what is cultural about particular types of behavior in different contexts.

• See culture as more as an adjective than a noun (Appadurai 1986).

Relevance to health field

• Instead of stereotypical characterizations of culture and folk illnesses, what we require for cultural competency training are more processual accounts of illness experiences, health care seeking, and follow through which get at what is cultural about courses of action.

• Circumstantial ethnographies that explore: contingencies, hard choices, and, in

situations when little choice exists, the coping strategies that favor illness being interpreted and responded to in particular ways.

Ethnicity is not a black box

• There has been mounting criticism about the way in which race/ethnicity has been used in public health research as a set of pigeon holes if not black boxes.

• This fosters an analysis of ‘difference’ that focuses on individual and group traits rather than the contexts in which people live.

Ethnicity: Risk marker or risk factor?

• Despite warnings against reading too much into aggregate (e.g., state, national) data on a specific health problem and ethnicity, it is all too easy to view ethnicity as a risk factor rather than a risk marker.

Example

• Are cultural factors responsible for ethnic differences in levels of smoking, drinking, consuming fast food, or engaging in fast sex?

• Or is ethnicity merely a marker of multiple social and economic factors predisposing such behaviors in particular environments by members of an ethnic group living in

circumstances not of their own making or choosing

The environment matters

Example : • Adults who say that they live in unsafe

neighborhoods are one and a half times more likely to be overweight than adults who say they live in safe communities

(Ross C. Brownson 2003)

• Interventions need to target spaces not just people

The environment matters

Example : • When broken down by race, not just wealth,

there are four times as many supermarkets in predominantly white neighborhoods as in the African American neighborhoods of Detroit. These people are also less likely to have a

car

• Point. On reason urban dwelling African Americans living in poverty have poor diets is because reasonably priced food sources are not accessible.The same is true of Native Americans living in rural

areas of the SW.

• This places them at greater risk for chronic diseases, such as diabetes and hypertension

•

• Their dietary behavior is responsive to the availability of foods, it is not merely a question of cultural preference. On the other hand children are socialized into food habits which persist over time.

• Poor food habits become a marker for an impoverished environment.

• Is the answer to just nutrition education?

More Productive Ways

Of

Studying Health Inequality

Objective two:

Make a case for transdisciplinary research involving the health and social sciences

contributing to a eco-social epidemiological understanding of health problems

attentive to nested contexts and syndemic patterns of ill health

To address health disparities we need to reconsider risk

• It is important to move from an examination of groups at risk: where the victim(s) may unintentionally be blamedAs if traits of the group are responsible for

the problem

• To a consideration of risky behaviors: those behaviors placing members of a group at risk

Risk reconsidered

• To environments of risk: the places where risky behaviors occur more commonly What factors contribute to the proliferation of

such environmentsWho spends time in these environments and

whyWho exploits these environments: who sets

up shop to make a profit

Eco-social epidemiology

An eco-social approach to epidemiology examines:

• Who and what is responsible for disease distribution in a population Current and changing patterns of social

inequality in health• Population based patterns of health and disease

are seen as biological expressions of social relations experienced in multiple contexts.

(Kreiger: 2001 Intern Journal of Epidemiology)

Eco-social epidemiology

• Investigates environments of risk and structural inequalities in health care provision

• Attention is directed to the cumulative interplay between exposure : susceptibility : resistance

• Focused upon is how nested contexts influence one another and predispose sections of a population to particular health problems (and clusters of problems).

Nested Contexts

• Home environment• Peer group environment• Neighborhood (schools, etc)• Work environment• Economic and political economic environment • Consumer environment• Media environment• Etc.

Application of eco-social thinking

• What are the reasons for higher rates of hypertension and diabetes or hospital admissions for asthma among particular ethnic groups

• Look at nexus of factors

Example: Hypertension in African Americans

Identified are linkages between (Kreiger 2001)• Economic and social deprivation: less access to

good food at an affordable price = high fat, high salt diet

• Exposure to toxic substances: older houses and crowded urban housing = more exposure to lead paint and car exhaust

• Socially inflicted trauma: discrimination, fear, anger = increase of allostatic load

• Targeting marketing of commodities: high alcohol beverages, menthol cigarettes

• Inadequate health care: poor detection of disease and poor clinical management

• Positive side: social capital, resistance to racism, community based programs which are accepted, new laws

Ecological to approaches to studying health problems

encourages us

• To adopt an “action is in the interaction” perspective

To appreciate the action in the interaction

Think beyond:

• the mere listing of contextual influences

• the measurement of contextual influences as if they operated independently of each other

Think beyond regression

Regression logic assumes:• Independent and generally additive

contributions of variables. • The emphasis is on disentangling variable

effects. • Interdependencies among variables are not the

focus; rather they are something to be “controlled for”.

How should we go about thinking about health disparities

Step one

Question what we think we know

• Correlations between ethnicity and various health problems are rife.

• What do they tell us?

• What don’t they tell us?

• Correlations are often misinterpreted as causal relationships.

• As if exposure to race/ethnicity explained something profound.

• Observations masquerade as discoveries.

• Instead of research beginning with the observation of ethnic differences, it often stops!

• This is one reason transdisciplinary thinking is badly needed to take research to the next level - to get at differences which make a difference. Differences which may be addressed by

interventions upstream as well as downstream.

• Approach prevalence data by ethnicity with caution

• Consider what is explained by a other variables, especially class and location

• Then consider how these variables interact with cultural norms, institutions etc.

Example: Tobacco use and ethnicity• It is productive to look for ethnic

differences in smoking after first considering other factors known to predispose individuals to smoke education, peer influences, social class,

economic insecurity, stressors (e.g., discrimination), other drug use, etc.

(Nichter Addiction: 2003)

Ethnicity and Smoking

• Follow up: What trends in smoking are not explained by social class, education, etc.Why is it that African Americans tend to have

a later age of smoking uptake than other ethnic groups?

Lower overall prevalence rates High rates of heavy smoking once smoking is

established

What is cultural about:

• smoking trajectories

• times of smoking transition

• patterns of smoking

• cigarette preference and topography

Ethnicity and smoking uptake

• To what degree do parenting styles influence smoking uptakeAfrican Americans: parenting more authoritarianNative Americans: autonomy valued even at young

age

• To what extent do differences in peer influence effect smoking uptakeAfrican Americans: peer influence less than white

• How do different ideas about style and aesthetics influence smoking uptakeSmoking is not a Black styling thing

When changes in rates of smoking prevalence are reported

We need to ask:

• In what sub-groups is this occurring (intercultural variability)

• What may be the reasons

• Are ethnic groups being targeted for social engineering: read marketing

• What else is going on

Trends in cigarette smoking* among 12th graders, by racial/ethnic group United States, 1977-1998+

50

40

30

20

10

0

*Smoking on >1 of the 30 days before the survey.+ 2-year moving averages are used to stabilize estimates.

Source: University of Michigan, Monitoring the Future Project.2000.

Pe

rce

nta

ge

1983 1979 19811977 1985 1987 1989 1991 1993 1995 1997

White

Hispanic

Black

Year

How should we go about thinking about health disparities

Step two

Step two

• Rather than focusing on one health problem or why there is a sudden rise in a particular type of unhealthy behavior (like smoking)

• Examine what else is going on and if there is a link between things which are co-occurring – look broadly

• Focus on the package, a specific behavior change or health problem may be a symptom of a much bigger shift

How should we go about thinking about health disparities

Step three

Look for

Syndemic patterns not just individual health problems

Syndemics

• Syndemics occur when multiple “health related problems cluster by person, place, or time.”

• They refer to the set of synergistic or intertwined and mutual enhancing health and social problems facing a population.

• http://www.cdc.gov/syndemics/overview-definition.htm.

Syndemics

• Preventing syndemics requires both control of the component afflictions and recognition of the relationships that tie those afflictions together and synergistically amplify their negative consequences.

A Syndemic Network

• To prevent a syndemic, one must prevent or control not only each affliction but also the forces that tie those afflictions together

Syndemic example

• Substance abuse, violence, and AIDS:

• Inextricable and mutually reinforcing connections between three conditions disproportionately afflict those living in poverty in U.S. cities (Singer 1994; 1996).

The SAVA Syndemic

» Adapted from Singer M, 1996

Syndemics

• A syndemic orientation is primarily distinguished from other perspectives by its explicit emphasis on examining connections between health-related problems.

• With this concern, it offers a broader framework for understanding how multiple health problems interact in particular communities.

Syndemics

• A syndemic orientation elevates public health inquiry beyond its many individual categories to examine directly the conditions that create and sustain overall community health.

• The notion of a syndemic shows that at the community level there is more to prevention science than the study of isolated health problems.

Health-related problems cluster for many reasons

• Caused by the same/similar biological agent (vector etc.)

• Common mode of transmission (e.g. water borne)

• Common risk factors (e.g. smoking, fast food: obesity)

• Result from same environment of risk

• Have reciprocal or interdependent effects (e.g., alcoholism and depression can reinforce each other)

• The syndemic model raises difficult questions and challenges public health to address the root causes of health disparities. By introducing a multi-level, dynamic epidemiological perspective, it points toward the need to develop and evaluate systems- and community-level interventions that target linked processes." (From: MacQueen KM, in Breslow et.al, 2002)

Objective 3

Why should we invest in transdisciplinary problem solving?

• Describe transdisciplinary research as a process.

• How does it differ from multidisciplinary or interdisciplinary research?

Taxonomy of cross-disciplinary research

Rosenfield PL, Soc. Sci. Med. 35(11):1343-57

Multidisciplinary research

• Multidisciplinary: Researchers work in parallel or sequentially from disciplinary-specific base to address common problem.

Interdisciplinary Research

• Interdisciplinary: Researchers work jointly but still from disciplinary-specific basis to address common problem.

Transdisciplinary Research

• Transdisciplinary: Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address common problem.”

There is a direct link between the level of disciplinary integration and the contribution to health policies and programmes (Rosenfield 1992:1353):

Contribution

• Multidisciplinary: Specific short-term problem solving.

• Interdisciplinary: New specific programs plus problem solving.

• Transdisciplinary: Broadly-based trans-sectoral programs and actions with longer life; new concepts, methods, and policies.

• Transdisciplinary thinking requires that a health problem be reconceptualised within the full complexity of the systems in which it is embedded (Albrecht & Higginbotham 2001).

TD science is a strategy and a

process for solving complex

problems, where determinants

are multiple, interacting,

reciprocal, & multi-level

Transdisciplinary Science

The transdisciplinary study of complex health problems demands:

• A consideration of interlocking levels of influence

• From cells to society to globalization

Interlocking levels of influence: Relevant disciplines

• Biobehavioral : clinical and behavioral sciences, public health

• Sociocultural: social sciences which study nested social interactional contexts

• Global : political economics, policy sciences which examine the flow of people, ideas, products and influence etc. and the politics of responsibility beyond the boundaries of nation states

Transdisciplinary research requires

• Listening across the gulfs that separate disciplines and scientists representing them

• Common language - conceptual translation among scientists from various disciplines

• Engaging in joint projects

• Collaboration on research that bridges disciplines

Kahn and Prager, 1992

What it takes...• Commitment: time, energy, intellectual work

• Focus: central theme, activity; meaningful and robust problem to solve

• Patience: takes time to learn how to engage other disciplines, to appreciate other lines of thought

• Vigilance: overcome forces of disciplines, departments, grants, promotions, products

• Fortitude: taking risks, tenacity, bravery

Adapted from: Dr. D. Prager

Objective 4

Provide an overview of two broad areas of transdisciplinary research essential to a health disparity agenda

Part one: Translational research

• Formative research process

• Participatory research

Translational Research

• Clarify what translational research covers as the term is now being used in relation to health.

• Describe the role of anthropologists

• Provide examples of a few important issues which urgently require translational research by transdisciplinary teams involving anthropologists.

Translational Research

General Use of the Term:

Translating science to practice through:

• Dissemination

• Diffusion

• Application of Scientific Findings

Translational Research

Focuses on the interface between:

1) Scientists (broadly defined)

2) Health care providers

3) Policy makers: all areas

4) “Communities” having diverse backgrounds (e.g., ethnicity, class, physical and political environment)

Translational Research

Focuses on the interface between:

5) Funding agencies/resources, etc.

6) NGOs representing local as well as transnational interests, etc.

7) Health care industry

8) Business interests: responsible for workers and consumer behavior.

Primary Goal of Translational Research (in Health)

To improve public health outcomes through :

More conscious communication between these eight sectors.

The development of more tailored interventions: beyond one size fits all approaches.

Involving more active community participation from development to evaluation stages of an intervention.

What is Called ForInterventions which are:• Relevant to specific populations• Understood by the population and

supported locally • Feasible given real life contingencies• Effective: as evaluated against a baseline

and secular trends• Sustainable

Expanded Scope of Translational Research

Goal of health equity at a time of shrinking resources and rationing

To reduce, if not alleviate, disparities in: Health status Access to essential health services Treatment outcomes and quality of care

The Role of Anthropologists in Translational Research

What do they bring to the table

Anthropologists Have an Established Track Record

Working on the interfaces between:

• Communities, health providers and policy makers Bringing local knowledge and the concerns of

the community to the table Describing stakeholder positions Placing community responses to health

problems and health programs within a broader context.

Anthropologists have a long history

• Serving as cultural brokers between patients and communities: Health care providers Health policy makers National/ International Health Agencies

Anthropologists

Also have a long history: Being asked to identify cultural

”barriers to” health programs. Emphasis on beliefs which determine

unhealthy behavior Prescription: Knowledge becomes

the key to behavior change

Cultural Barriers: Only One of Many Things Anthropologists Study

• Anthropologist often hired to examine “cultural barriers” to programs, especially when they are doing poorly.

Anthropologists look at this as a very limited use of their skills

Also a limited assessment of a problems given an eco-social perspective

Cultural Barrier Bias

Focusing on cultural barriers • Can deflect attention from other causes of

failure (e.g. racism, sexism and ageism; structural violence; inadequate resources; poor management; lack of trust) Can inadvertently promote victim

blaming and ethnic stereotyping, etc.

Pathogenic vs Salutogenic Focus

• Far more attention is directed toward looking at risk factors than protective factors when ethnicity is addressed.

• Focusing on “cultural barriers” to programs frames culture as a risk factor at large impeding progress.

What’s missing

• A consideration of positive aspects of cultural institutions, norms, local funds of knowledge, social capital etc.

• Consideration of resilience : a core theme in minority health

To Engage in Translational Research

A More Balanced View of Culture is Required

Translational Research Agenda

• Ideally involves an anthropological perspective at each of the eight stages of formative research.There are only a few examples of

anthropologists being supported to participate at all stages of formative research. This needs to change.

Formative Research

Eight Stages

(Nichter, http://medanthro.net/academic/tools)

Formative Research

1. To inform: What people are doing, saying, and thinking now about a health-related issue, and how history as well as globalization informs the present.

2. To identify: Important problems which need to be solved -- identified by experts as well as community members.

3. To generate: A list of options for interventions in the community, clinics, etc.

Formative Research

4. To foster critical assessment and problem solving: What are the pluses and minuses of possible interventions for various stakeholders?

5. To investigate : How best to implement promising interventions: Who, when, where, how much, what collaborations?

6. To monitor responses: To interventions affording mid-course correction, etc.

Formative Research

7. To evaluate success: Is the intervention really making a difference and if not, why not? Is the success or failure due to the program or other factors?

8. To examine: How is an intervention and its results being presented to the public and scientific community? What is the response to this production of knowledge?

Participatory research combined with formative research

Is very powerful

Participatory research

Within communities of practice• Raise the consciousness of practitioners

and policy makers by involving them in short research exercises

• Enable them to understand issues in new ways and appreciate the need for different types of information

Examples

• COPE : Practitioners follow patients as they access and negotiate the health care system; spend a few days with patients and tiers of staff as they work the system

• Focused ethnographies : Specific health problems are investigated from the position of patients, health providers, administrators : different stake holder positions

Participatory research

Community based problem solving requires: Mobilizing community : action sets are

mobilized around issues and tasks which matter to the community

Build capacity for critical thinking leading to action : one must invest in the process

Formative research empowers people

• Participatory research gives people a place to begin to think through a problem

• Engage community members through science, let them test their own hunches, not just yours

• Involve them: not just collecting data, but the research process; demystify the process

• Science if embraced by the community can be a tool of empowerment

• Encourage the community to take ownership of the data and participate in its dissemination

Translational Research:

Examples of pressing Issues

Demanding

Attention

Issue One

How does the public respond to health information

• Given all the time invested in conducting rigorous epidemiological research, shouldn’t as much effort be put into studying how it is received and used?

• When epidemiological data is released to the public, reported in the press, etc. how is it interpreted and responded to?

Epidemiological Data

• Does data on prevalence or risk place a community at further risk? Make a behavior appear more normativeMake a problem seem more inevitable, etc.

• When do surveillance and screening activities have the unintended consequence of making a problem appear far more prevalent, creating a sense of dread?

N.E. Thai Cervical Cancer Study

• Prevalence rate : 25/100,000• Perceived prevalence rate after PAP

smear screening program 3/10• All recurrent and chronic RTI problems are

associated with cervical cancer by local women

• Result: earlier recognition of cancer at the cost of tremendous suffering on the part of women.

Accountability

• Translational research has an ethical agenda.

• Information released to the community needs to be monitored : how is it interpreted?

• If interpretations of health messages are iatrogenic, they need to be corrected.

Issue Two

What form of information is most effective

• Beyond content of health and risk messages, what type of message best catches the attention of members of minority groups (by gender and generation, education)Statistics and numbersTestimonials : by whomImagesAnalogiesEtc.

Issue Three

Disinformation

• The deliberate, often subtle, propagation of misinformation by parties having vested interests in maintaining unhealthy behaviors.

“The evidence is not in”, “experts disagree” about whether smoking is “really all that unhealthy”

Disinformation

• Misinformation is often tied to harm reduction alternatives which appeal to wishful thinking.

Promotion of cigarettes which are lighter, milder, better filtered, more organic, giving the impression they are safer to smoke.

Food labels are misleading –how are they read and what kind of consumer education is needed

Direct to consumer advertising of medicines

• Minority group members , especially ones with no health insurance or access to care facilities, engage in self care

• We know little about : self care practices - what they use and how they use it

• What we do know is that they purchase products which are often promoted by companies in spurious ways

Issue four

The need for consumer education

• Reading : labels, critical thinking• Communication skills: how to report problems

and seek advice, writing and oral• Basic math : how to calculate costs, understand

measures etc. in real world context• Health consumer education :practical and

targeted to issues facing minority groupsHow to access health care, work the system,

pharmaceutical practice, self care

Health education for minority health

• We can learn lessons from primary health care programs in developing countries

• ORS, ARI (recognize pneumonia), nutrition which matches local food habits, budgets, seasonal availability of foods, breastfeeding

• New initiatives to teach about taking care of the elderly –health across the life course

Bottom Up Nutrition Education

• During the four years of high school, youth may be exposed to only five class periods or less on nutrition.

• In the absence of ethnography on teens’ everyday eating behavior, the content of nutrition classes is general with a focus on the food pyramid.

(Mimi Nichter, 2000)

Translational Research

• Is needed to address the many questions teens have about weight and foods that they typically consume.“What healthy choices can I make when

I go to a fast food restaurant?” “What do nutritional labels mean?” “What’s the difference between light and lo-

fat?”

Address Youth Concerns

• Rather than provide general nutrition messages, there is a need to: Build upon the questions which youth

already have Address their concerns related to body

image and development Reinforce positive behaviors which

youth already practice (Mimi Nichter, 2000)

Issue Five

Information flows

• We need to know far more about flows of information about health care ?

• How do people learn to access, navigate and work the health care system?

• What do minority populations see as factors which impede their use of health care facilities : language, forms, way they are treated, hidden costs, fear

Who are the care takers

• Who should we be providing health care information about the chronically ill?For example those with diabetes or

hypertension

• Who are the care takers of the chronically ill? Who influences their behavior?Consider migrant workers who travel with and

without their families

Issue six

Trust

Trust is crucial to the translational process:

• To what degree is trust in health information related to: Trust in the source of the information? Trust in the spokesperson conveying the

information and their connection to community?

Trust

• How do issues of trust and perceptions of health provider motivation impact: Health care seeking and “compliance” Participation in preventive and

promotive health programs, clinical trials etc.

Trust

• 42% of Blacks and 23% of Whites said they did not trust their doctors to fully explain medical research participation to them

• 37% of Blacks and 20% of Whites believed their doctor might ask them to participate in medical research even if it could harm their health

*Fackelmann Archives of Internal Medicine: Nov 25, 2002, N= 527 Blacks, 382 whites

Trust

• 45% of Blacks and 35% of Whites believed their doctors might expose them to unnecessary risks when prescribing treatment

• 63% of Blacks and 38% of Whites believed their doctors often prescribed medicines as a means of experimenting on people without their knowledge

• Twenty-five percent of African Americans and 8% of Whites believed that their doctor had given them an experimental treatment without their consent

Trust

• Medicine has attained such a privileged place in American society that many of those in the health have been lulled into the false belief that they are entitled to be trusted.

• Trust is earned, not owed• Once lost, trust is exceedingly difficult to

regain (Jordan Cohen, Pres. of AAMC 2002)

How do we go about

Regaining trust

Objective 4

Provide an overview of two broad areas of transdisciplinary research essential to a health disparity agenda

Part two: Cultural competency training

Cultural competency training

• Cultural competency training is a need medicine can no longer ignore given:

• Demographic trends in the US

• Federal legislation

• Potential law suits

• Competition for patients

• Growth of a cultural competency industry to fill this need

Cultural competency training: a continuum

• Employ translators : language assistance, as cultural brokersTraining becomes a big issue: medical

vocabulary or conceptual translation?

• Provide a few lectures – sensitivity training, curriculum varies greatly

• Two day workshops – generalities about ethnic groups aboundSome better than othersIn some cases people get accredited

as having expertise after 2 days!

• Grand rounds – often topical

• Cultural competence is seen as a process which is developmental All medical interactions are seen as cross –

cultural Issues related to health disparity and the cultural

dimension of care are integrated into teaching curriculum not compartmentalized

Patient centered care is carried outModeling occurs : learning by example, cases are

discussedCore competencies and skills are not just learned

but practiced and modeled

Practical training

• Inpatient rounds

• outpatient clinics

• off site electives in community as practicum

• Home visits arranged for students, students assigned families during part of training

• Therapy facilitation : an anthropologist or other health social scientist assumes a therapy facilitator role on the wardsCultural broker between patients/

their families: the health care system; different staff members on a clinical unit

Invest in Anthropologists: they will pay off in multiple ways

• Anthropologists can make major contributions at every stage of this continuum from training translators to giving workshops which explain cultural concerns and practices yet confront and caution against ethnic stereotypes

To be an effective facilitator training is needed

• To be a good transdisciplinary facilitator, an anthropologist or clinician/anthropologist needs the experience of working in a clinical setting as part of a transdisciplinary team.

• There is a need to grow such anthropologists / clinician/anthropologists

• A program is necessary

There a model for doing this

• Classroom training : Course work which issue driven, draws on case studies, class has transdisciplinary student body

• Behavioral rounds : anthropologists join teams on the wards

• Apprenticeship model

Behavioral rounds: How does it work

• One patient a week chosen for an illness interview : 30-45 minutes, then a 15-20 minute follow up.

• What is covered: Range of issues from illness experience of patient, to medication issues, to dealing with death, patients of different ethic groups

• So what analysis : how does a deeper understanding of the patient inform care management. Reflexivity on par of clinicians.

Behavior rounds takes an hour a week: it is well worth it

• Residents and interns see their mentors and peers taking culture seriously so they learn to do soHidden curriculum

• See one-do one-teach one process set into motion. Students learn to take the lead after watching.

• Case write ups: write ups acknowledged and used in future training of students

Discrimination is addressed

• Most health care providers do not intentionally discriminate –and do not see their actions in this light. Reflexivity needs to be built into the system beyond patient audits.

• Patients also discriminate : Practitioners need to learn how to addressed this when it occurs and interferes with patient care –such as undermining trust.

Cultural competency training

Not just for doctors, nurses, social workers

• Hospital techs

• Allied health staff

• CAM practitioners

Other areas where cultural competency

Is required

Research Partnerships need to be Established

• Cultural competence is needed to foster cooperation within ethnic communities to increase participation in research and clinical trials.

The challenge

• Historical mistrust: racism, bias, exploitation• Need to establish good will and trust:

Reciprocity, research findings need to be shared in such a way that they are seen as useful to the community

Groups need to be seen in positive light not just as ill or at risk

Research outcomes should not be seen as establishing racial superiority

Transdisciplinary Research

Challenges

Enough Time

• With continuing support to the same team over a sufficiently long period of time and covering several types of problems, it is more likely that disciplinary barriers can be transcended and increased understanding and confidence about the value of other disciplines can be achieved

(Rosenfield (1992:1345)

Cooperation

• Each team /network member must value the perspective of other disciplines not just in spirit, but in practice

• This requires some basic familiarity with the different perspectives each discipline brings to the table

• Team members need to teach each others through example, and be willing to demystify concepts and terminology

Methods

• Research. Issues related to methods need to be worked out early: especially issues related to the very different objectives, methods, and sampling frames used in qualitative and quantitative research

• Transdisciplinary science requires thinking out of the box

• Brainstorming out of the box is far easier than working in new ways. In practice, one often falls back to their

default: familiar models and procedures

Challenges

• Researchers need to be attentive to the issue of knowledge production and the fact that data is often the artefact of methods and instruments used.

• Triangulation of data driven by different methods and theories needs to be encouraged with the understanding that one source of data is not privileged above others.

• Example:• Standardized scales and instruments which

have been psychometrically validated and used in previous studies for particular reference populations must be open to scrutinyAre they the best measures for minority groupsAre other variables equally or more important for

these groups given their lifeworld

Leadership

• Transdisciplinary research works best when assisted by a facilitator who attends to the process of research as much as the content.

• This person insures that :Innovation is encouragedSingle disciplines do not dominate problem

solvingHybrid thinking is encouraged

Acknowledgement

• Cross-disciplinary work is often not given enough credit : how does one value a hybrid product and acknowledge participation in a multidisciplinary process of problem solvingHow does participation count for tenure?Publication can be more difficult as

professional journals often stick to familiar formats of data presentation

• “A crucial difference between basic mono-disciplinary research on the one hand and inter-disciplinary research on the other hand, is that the former finds its legitimisation within its own field. In this sense disciplines are bodies of knowledge or objects to which it is possible, even respectable, to add something. Inter-disciplinary research has no mechanism of intrinsic legitimisation and rather depends upon how well it illuminates the overarching problem being researched” (AHRQ 1997:17-18).