The Role of Culture in the Integration of Physical Health Services in Mental Health

Settings

Leopoldo J. Cabassa, PhDNYS Center of Excellence for Cultural Competence

New York State Psychiatric Institute Department of Psychiatry, Columbia University

NYAPRS 7th Annual Executive SeminarApril 27, 2011

Outline

Discuss racial/ethnic health disparities among people with SMI

Illustrate how culture impacts the integration of physical health services in mental health settings

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Public Health Crisis Among People with SMI

People with serious mental illness die, on average, 25 years earlier than the general population largely due to preventable medical conditions

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Racial/Ethnic Health Disparities in the SMI Population

Compared to non-Hispanic whites with SMI, African Americans and Latinos with SMI face serious health inequities due to: Higher rates of obesity, diabetes, metabolic

syndrome, and cardiovascular disease

Poorer access and quality of medical care

Cabassa et al., 2011; Chwastiak et al., 2008; Dixon et al., 2000; Frayne et al., 2005 Hellerstein et al., 2007; Lambert et al., 2005; Kato et al., 2004; Stecker et al., 2006

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Racial/Ethnic Differences in Diabetes by Psychiatric Disorders

NHW vs. AA NHW vs. HOR (95% Cl) OR (95% Cl)

No psychiatric disorders 1.49 1.22, 1.83 1.48 1.18, 1.84

Any psychiatric disorders 1.79 1.45, 2.20 2.05 1.61, 2.61

Any substance use disorders

1.89 1.36, 2.61 2.54 1.67, 3.86

Any mood disorders 1.89 1.19, 2.99 1.96 1.27, 3.01

Any anxiety disorders 1.58 1.13, 2.20 1.76 1.24, 2.51

Note: NHW: Non-Hispanic Whites; AA: African Americans; H: Hispanics; all models are adjusted for socio-demographic variables and diabetes risk factorsSource: Cabassa et al., (In Press). Gen Hosp Psych.

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Possible Reasons for Health Disparities among Racial and Ethnic Minorities with SMI

Higher rates of obesity and insulin resistance place African Americans and Latinos at increased risk for the negative metabolic abnormalities associated with second-generation antipsychotics

Social/cognitive deficits associated with psychiatric disabilities may amplify the communication problems minorities face in the medical encounter

Mistrust due to racism may be compounded by stigma

Higher enrollment in fragmented health care services

Ader et al., 2008; IOM, 2006; Kraokowski et al., 2009;

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Organization-Service fragmentation-Resources-Location-Reimbursementpolicies-Organizational culture-Cultural competencepolicies and practices

Provider-Training- Knowledge/ Skills-Stigma-Bias/Stereotypes-Professional boundaries

Determinants of Health Care Disparities

Consumer-Health insurance -Language-Competing demands

-Comorbdities-Health literacy-Norms & attitudes-Body image

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Culture Influences Health

Culture shapes: how consumers, providers, and organizations

perceive, define, label, and cope with physical and mental disorders

body image, dietary practices, and the value consumers and providers place on certain foods

consumer-provider interactions; the expectations and preferences each brings to these interactions

how people interact with the healthcare system

Caprio et al., 2008; Kleinman et al., 2006, Cross et al., 1989; Guarnaccia et al., 1996; Whitley, 2007

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Culture and Service Integration

Culture = what is most at stake for consumers, providers, and organizations in the receipt and delivery of health care services

Culture exists at multiple levels of the health care system

Service integration entails a cultural exchange or transformation process of ideas, norms, values, policies, and practice among different stakeholders

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Kleinman, 1995; Palinkas et al., 2005

Qualitative Study of Service Integration

Study Aim: Identify cultural factors in

the integration of physical health services in behavioral health organizations

Sample: Purposive sample of 6

behavioral health organizations in Northern Manhattan

Methods: Multi-stakeholder approach Combination of qualitative

methods

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What is most at stake for organizations?

Service integration strategies must fit with the organization’s culture and local context

Integration efforts must use existing resources, structures, and partnerships

High priority to help reduce service fragmentation and improve care coordination

Service integration is not a one-size-fits all approach. Instead it is a highly local process

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What is most at stake for providers?

Clarification of professional roles to reduce providers’ ambivalence about delivering physical health services Who should do what and when?

Improve care coordination to mitigate providers’ frustration of working in a broken system

Access and quality of care efforts must address primary care providers’ stigma and bias toward consumers with SMI

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What is most at stake for consumers?

The combination of stigma and racism contributes to consumers’ mistrust of the medical system and results in their disengagement from care

Medical care must be sensitive to cultural variations of body image and diets

Patient-centered care should not ignore cultural norms that shape the medical encounter

Attention to community factors should inform healthy lifestyle recommendations

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Conclusion

Cultural factors at multiple levels of the health care system should be considered in service integration efforts to improve the physical health of people with SMI

Service integration should focus on what is most at stake for organizations, providers, and consumers

Future research is needed to examine the effectiveness and sustainability of culturally appropriate physical health interventions in mental health settings

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“Physical Health is Integral to Recovery”

“There are multiple strategies to pursue in addressing morbidity and mortality . . . But for any of these strategies to be successful, our principal partnership must be with the people we serve”

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Acknowledgements

Funding Sources New York State Office of Mental Health National Institute of Mental Health (K01MH091108)

Research Team Roberto Lewis-Fernández, MD; Andel Nicasio, MS Ed;

Ron Turner, BA; Jerel Ezell, MPH; Madeline Tavarez, BS; Angela Parcesepe, MPH; MSW;Rebeca Aragon, BS

Consultants Peter Guarnaccia, PhD; Benjamin Druss, MD, MPH;

Pamela Collins, MD

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Thank You // Gracias

Leopoldo J. Cabassa, Ph. D.Assistant Director

NYS Center of Excellence for Cultural Competence

New York State Psychiatric Institute

Assistant Professor of Clinical Psychiatric Social Work Department of Psychiatry

Columbia University

cabassa@pi.cpmc.columbia.edu

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