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on 11 December 2013

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Transcript of Diversity

Discrimination faced by the Disabled
Disparities Faced by the LGBTQ Community
Weight Based Discrimination
The baby boom of 1946-1964 caused a large spike in population in the United States

The first of these baby boomers turned 65 in 2010, and over the next few years, the rate of population aging will continue to increase

This burgeoning elder population calls for a revolution in ethicality of the treatment of senior citizens.

Individuals who fall victims to weight discrimination are more vulnerable to depression, low self esteem, poor body image, and even suicidal behaviors

Also, they are more likely to engage in unhealthy behaviors such as binge eating , and avoiding physical activity which ultimately reinforces weight gain

People with disabilities represent 20% of the population (2010 census).
Significantly more likely to report being in fair or poor health
Higher levels of risk factors such as obesity, smoking, and physical inactivity
Lower rates of preventive health care services
Higher prevalence of adverse conditions
Inadequate health promotion practices
Inadequate access to quality health care services
(Lezzoni, 2011)

Examples of
interpersonal discrimination
Women with mobility disabilities were 70 percent less likely to be asked about contraception during routine medical visits.

At increased risk of unintended pregnancy

Heightened risk of complications

It’s possible that clinicians erroneously assume that these women are not sexually active.
Accessing health care facilities
One in five specialty practices couldn't accommodate a wheelchair-bound patient

40% practices could accept disable patients but would have to transfer them manually to an examination table - risky for patients and healthcare workers.

9% practices would use a height-adjustable exam table or lift for transferring the patient.
(Pittman, 2013)

A case of a person on wheelchair
Rachel Markley, a 22-year-old student at The Ohio State University in Columbus, has to use an electric wheelchair.

Waiting rooms and examination rooms are hard to maneuver.

Someone may bang into her when opening the door.

Embarrassed when being carried on to the table and found herself sliding off.
(Pittman, 2013)

Cultural competence in providing
health care to people with disabilities
Develop understanding about the environmental context of the patient and the patient’s family

Be respectful of culturally divergent views on disability

Cultural competence in providing health care to people with disabilities
Feel comfortable with patients with complex disabilities and provide appropriate care to them with respect.

For example, communicate with patients who have cognitive and language disorders, avoid infantilizing speech.

Cultural competence in providing health care to people with disabilities
Acknowledge the values of disability culture and needs of people with disabilities

Patients with disabilities want to be interdependent rather than independent.

Health care providers need to provide them with accessible equipment

Cultural competence in providing health care to people with disabilities
In order to change physicians’ erroneous perspectives on patients with disabilities, there must be more community events and activities conducted for the disabilities so that health care professionals will understand that patients with disabilities may be very active and accomplished outside of their medical needs.
(Iezzoni, 2011)

Iezzoni, L. (2011). Analysis & commentary: Eliminating health and health care disparities among the growing population of people with disabilities. Health Affairs, 30(10),1947-1954. doi: 10.1377/hlthaff.2011.0613
Payne, J. (2011). Cultural competence in treatment of adults with cognitive and language disorders. The ASHA Leader. Retrieved from http://www.asha.org/Publications/leader/2011/111101/Cultural-Competence-in-Treatment-of-Adults-with-Cognitive-and-Language-Disorders.htm
Pittman, G. (2013). Disable people may struggle to get specialty care.Reuters. Retrieved from http://www.reuters.com/article/2013/03/18/us-disabled-specialty-care-idUSBRE92H11620130318

Sources of Discrimination
2,400 overweight and obese adults reported weight discrimination from professionals of all sorts including:

Physicians 69% (2nd most common)
Nurses 46%
Dieticians 37%
Mental Health Professionals 21%

(Leone, 2009)
“All my doctor ever saw was my weight”

“I was too heavy for the regular scale... they used a freight scale in the basement”

“My doctor said I was too fat for an exam… I haven’t seen a doctor since.”

(Leone, 2009)
More Consequences
The reluctance to discuss weight in an appropriate manner with patients also poses problems because healthier behaviors cannot begin unless they are addressed.

Overall, preventative care is compromised because overweight individuals are reluctant to seek medical care due to biased attitudes that they fear they are going to encounter at the hands of health care professionals

Diversity management can include workshops that allow health care professionals to go through sensitivity training and intrapersonal evaluations. Exercises can help employees self-identify their personal attitudes that they may have about overweight/obese individuals:

Do I make assumptions based on weight regarding character, intelligence, success, lifestyle, etc?
Am I comfortable working with patients of all sizes?
Do I give appropriate feedback to encourage healthful behavior change?
Am I sensitive to the needs and concerns of obese individuals?
Do I treat the individual or only the condition?
Impact of Combating Weight Bias
Statistically 6 out of 10 patients sitting in the waiting room are already overweight or obese, therefore each and every health care practice must take steps to be fair and sensitive toward this population.

Things that are done to make overweight/obese patients feel more comfortable and accepted will translate into
Better health outcomes for these patients
An improved work environment
A successful practice
Budd, G. M., Mariotti, M., Graff, D., & Falkenstein, K. (2011). Health care professionals' attitudes about obesity: An integrative review. Applied Nursing Research, 24(3), 127-137. doi:10.1016/j.apnr.2009.05.001

Carr, D., & Friedman, M. A. (2005). Is obesity stigmatizing? body weight, perceived discrimination, and psychological well-being in the united states. Journal of Health and Social Behavior, 46(3), 244-259. doi:10.1177/002214650504600303

Johnston, C. (2012). The impact of weight-based discrimination in the health care setting. American Journal of Lifestyle Medicine, 6(6), 452-454. doi:10.1177/1559827612456348

Rudd Center for Food Policy and Obesity (Producer), & Leone, R. (Director). (2009). Weight bas in health care. [Video/DVD] Yale University.

Lynch, H. F. (2013). Discrimination at the doctor's office. The New England Journal of Medicine, 368(18), 1668.

Puhl, R. M., Andreyeva, T., & Brownell, K. D. (2008). Perceptions of weight discrimination: Prevalence and comparison to race and gender discrimination in america. International Journal of Obesity, 32(6), 992-1000. doi:10.1038/ijo.2008.22

UCLA Center for Human Nutrition. (n.d). Supportive language for weight loss. Retrieved from http://www.cellinteractive.com/ucla/physcian_ed/supp_lang.html
In general, LGBTQ individuals are much more likely to face discrimination, harassment, and intolerance than their heterosexual counterparts.

This is true in most regards, and includes the utilization and interaction with the health care system.

As the next generation of health care administrators, there are things we can do to educate ourselves and improve upon this situation.

LGBTQ individuals are more likely to be subjected to interpersonal discrimination, structural discrimination, and institutional discrimination.

Discrimination in all three forms effects the health and well-being through psychosocial, psychological and physiological mechanisms.

Discrimination has a negative correlation with improved health outcomes, i.e., as the amount of discrimination an individual is exposed to increases, that same individual’s positive health outcomes decrease.

Examples of Interpersonal/Structural Discrimination
56% of lesbian, gay and bisexual individuals, 63% of HIV positive individuals and 70% of transgender individuals have experienced discriminatory practices in a health care setting.

This includes “refusal of needed services, refusal to touch the patient, use of excessive precautions, harsh language from providers, being blamed for health problems, or physical abuse in their health care.”

Examples of Institutional Discrimination
Although Section 3 of the Defense of Marriage Act was declared unconstitutional on June 26, 2013, in states that don’t recognize gay marriage, this is inapplicable regarding the extension of Federal benefits such as Social Security and Veteran’s benefits.

There are currently no Federal laws that prevent employment discriminatory practices based on sexual orientation and gender identity. (The Employment Non-Discrimination Act is currently pending in Congress but has been introduced to every Congress since 1994).

Why access and quality are important
Like many other minority groups, LGBTQ individuals are more likely to engage in high-risk health behaviors and have access and quality of health care limited.

This includes higher rates of obesity, and higher rates of cigarette, alcohol and narcotic use.

LGBTQ individuals are more likely to engage or be forceably exposed to high-risk sexual behaviors thus becoming more vulnerable to STDs and associated health complications

LGBTQ individuals are more likely to be under or uninsured and have specific needs, such as hormones or surgeries for transgender individuals transitioning, completed excluded from insurance coverage.

The Affordable Care Act and the LGBTQ
It is important to note that the Patient Protection and Affordable Care Act will certainly improve access to health care for LGBTQ individuals. However, the PPACA may not necessarily make an improvements to the quality of health care available to LGBTQ individuals or provider bias that LGBTQ individuals have to deal with.

Cultural competency is the best way to attempt to eliminate health care inequities in the LGBTQ community.

Things We Can Do as Administrators To Be More Culturally Competent
Conduct a “cultural competency audit” of staff members to get a good understanding of attitudes towards LGBTQ individuals.
Ensure that any LGBTQ staff members are aware it is acceptable to be “out” with their sexuality, presenting a more welcoming environment.
Have a visible policy in writing on display showing patients and staff alike the establishment as a whole stands for LGBTQ equality.
Ensure that we and all staff members understand that LGBTQ individuals have unique health needs and disparities. For example, understand men are more likely to be exposed to HIV, women are more likely to develop cervical cancer from HPV and adolescents are six times more likely to try to kill themselves.
Source: (Taibjee, 2012)

Things We Can Do as Administrators To Be More Culturally Competent (cont.)

Be cognizant of the needs of the LGBTQ elderly cohort. These individuals require more health care and grew up when LGBTQ discrimination was much more acceptable than it is today.

Treat partners with the same respect that martial spouses would receive.

Ensure providers are sensitive regarding use of language with patients. For example, when speaking with a new patient, don’t necessarily assume they have a husband or wife.

Source: (Taibjee, 2012)

In Conclusion
The LGBTQ community faces a great deal of obstacles regarding the equity of health care. In addition to this, LGBTQ individuals are more likely to suffer from health care disparities, making the need for quality and accessible health care much more paramount. If we as future health administrators are cognizant of the challenges that the LGBTQ community faces, we can ensure that the standards of care available to the LGBTQ community are the highest possible and we can significantly have a positive effect on LGBTQ health outcomes.

Addis, S., Davies, M., Greene, G., MacBride-Stewart, S., & Shepherd, M. (2009). The Health, Social Care and Housing Needs of Lesbian, Gay, Bisexual and Transgender Older People: A Review of the Literature. Health & Social Care in the Community, 17(6), 647-658. doi:10.1111/j.1365-2524.2009.00866.x

Alexsson, J., Moden, B., Rosvall, M., & Lindstrom, M. (2013). Sexual Orientation and Self-Rated Health: The Role of Social Capital, Offence, Threat of Violence, and Violence. Scandinavian Journal of Public Health, 41(5), 508-515. doi:10.1177/1403494813476159

California court: Doctors Can't Discriminate on the Basis of Sexual Orientation. (2008). Christian Century, 125(19), 19-19.

CHANCE, T. F. (2013). "Going To Pieces" Over LGBT Health Disparities: How an Amended Affordable Care Act Could Cure the Discrimination That Ails the LGBT Community. Journal of Health Care Law & Policy, 16(2), 375-402.

Gender, Sexuality and the Discursive Representation of Access and Equity in Health Services Literature: Implications For LGBT Communities. (2011). International Journal for Equity in Health, 10(1), 40-49. doi:10.1186/1475-9276-10-40

Gieseke, W. (2011). Making Health Care Equality a Reality. Retrieved November 8, 2013, from http://www.advocate.com/health/health-news/2011/03/09/making-health-care-equality-reality?page=full

Mojola, S. A., & Everett, B. (2012). STD and HIV Risk Factors Among U.S. Young Adults: Variations By Gender, Race, Ethnicity and Sexual Orientation. Perspectives on Sexual & Reproductive Health, 44(2), 125-133. doi:10.1363/4412512

Penn, D. (2009). Hospital Denies Visitation Rights to Lesbian Couple During "Meet in the Middle" Rally. Lesbian News, 34(12), 9-9.

Rosenstreich, G., Comfort, J., & Martin, P. (2011). Primary Health Care and Equity: The Case of Lesbian, Gay, Bisexual, Trans and Intersex Australians. Australian Journal of Primary Health, 17(4), 302-308. doi:10.1071/PY11036

Taibjee, R. (2012). Top Tips For Making Your Practice More Gay-Friendly. Pulse, 72(11), 33-34.

The Associated Press. (2008, Aug 19, 2008). California: Gays and Medical Treatment. New York Times, pp. A.13.

“Diversity in the health professions is paramount to eliminate inequities in the quality and availability of health care for underserved populations. Diversity among health professionals is important because evidence indicates that among other benefits, it is associated with improved access to health care for minority patients, and greater patient choice and satisfaction.”

Some facts about Los Angeles County
Cultural Competency
Obese patients may be viewed as less intelligent, overindulgent, unsuccessful, lazy, overly emotional, insecure, lacking motivation and therefore seen as less likely to change.

These patients may be given less time in consultations

They may also be discriminated against by not being provided appropriate resources to be properly cared for.
Weight Discrimination in Healthcare
Incorporating Weight-Based Discrimination in Diversity Management Plans


Diet Eating Style
Exercise Regiment Activity Style
Expectations Discoveries
Willpower Commitment
Compliance Exploration
Prescribe Negotiate
Should/Must Consider
Limit, restrict Choice, experience
Ideal Weight Healthy Weight
Elderly patients are particularly vulnerable when entering the health care system because of their lack of ability to control their life situation, protect against threats to their physical and emotional fullness, as well as existing ageist attitudes of health care professionals

Globally, older people may experience ageist attitudes and be considered of lesser value than younger and healthier people.

Supportive Language
Disparities in the way older people compared to younger people are treated can be divided into access to healthcare services in a general way, which is often related to insurance coverage, and access to particular treatments, specialists, surgeries, and diagnostic tests once the older person is under care.

At the present, conditions that are associated with aging receive less training than common conditions of midlife.

Healthcare professionals often make assumptions about their older patients on the basis of age rather than functional status

They may be considered poor risks for some procedures, even though age is not the only attribute that is used to estimate surgical risk

The systematic exclusion of older people from clinical trials

Fixing the Problem
UCLA Center for Human Nutrition
Doctors need to exhibit the right behaviors and act as role models to other staff

Avoid pejorative labels such as ‘social work medicine’, ‘bed blocker’
See the person in the bed as an individual with needs, preferences, a personal story and social connections
Give older people the same information, respect, choice, and control over decisions affecting their lives (even if risky) as working-age adults
Involve family as partners in care and keep them informed

Fixing the Problem
We need to correct poor practice when we see it and to set a personal example by our own behavior.

We should collaborate fully with primary, mental health and social care colleagues to re-design pathways that can ensure that patients of all ages are only in acute hospital beds when this is really required.

Fixing the Problem
We need to reject the false distinction between the medical-diagnostic model and essential nursing care. People with functional impairment, immobility, falls, confusion or a general failure to thrive at home are not ‘atypical’ or ‘non-specific ’, they are entirely typical of the frail older people who are a main patient group in hospitals.
Their conditions can often be reversed with appropriate diagnosis and treatment. Instead, they are often labeled as ‘social admissions‘ and later, while still having potential to improve, ‘medically discharged‘ or written off prematurely for nursing home.

Fixing the Problem
Hospital-based comprehensive geriatric assessment
: multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging

Delivers benefits to patients that exceed those of many more ‘high tech’ interventions
well on admission and being proactive during a patient’s stay can help prevent older patients from becoming immobile, incontinent, confused or dependent, help expedite their discharge and, in turn, reduce their chance of suffering the complications often associated with complaints about undignified care.

Our population will continue to be an aging one for the foreseeable future, and we have been slow to adapt to this change.

However, this has changed the very nature of healthcare for good and we need to change with it.

Cultural competency is a set of attitudes, behaviors and policies that exist in a health care setting to enable providers to effectively deliver health care in a culturally dynamic environment.

9.9-10 million people
Male 49.3%, Female 50.7%
Caucasian 50.3%, Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, other Asian) 13.7%, African-American 8.7%, American Indian and Alaskan Native 0.7%, Pacific Islander (Native Hawaiian, Guamanian, Samoan, other Pacific Islander) 0.3%
Latino or Hispanic 47.7%
< 5yrs 6.6%, 15-19 yrs 7.7%, 30-34 yrs 7.3%, 45-49% yrs 7.2%
65+ yrs 10.9%

Weight discrimination is aimed at overweight people based on a series of social attitudes that people develop. It can start very early in life and it is assumed that there is something wrong with these individuals and that they should be punished for their condition

It is an emerging problem that should now be taken into consideration when forming a diversity management plan in a health care setting
Irurita, V.F. (1999). The problem of patient vulnerability. Collegian, 6(1), 10-15.

Kane, R.L. and Kane, R.A. (2005). Ageism in Healthcare and Long-Term Care. Generation, 29(3), 49-54.

Oliver, D. (2012). Transforming care for older people in hospital: physicians must embrace the challenge. Clinical Medicine, 12(3), 230-234.

Rees, J., King, L., & Schmitz, K. (2009). Nurses' Perceptions of Ethical Issues in the Care of Older People. Nursing Ethics, 16(4), 436-452. doi: 10.1177/0969733009104608

Sade, R. M. (2012). The Graying of America: Challenges and Controversies. Journal of Law, Medicine & Ethics, 40(1), 6-9. doi: 10.1111/j.1748-720X.2012.00639.x

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