Restructuring Urban Healthcare: Beyond the Cultural Model for Immigrants’ Healthcare Disparities

| February 1, 2012 | 0 Comments

By Sarah McCuskee

Immigrant populations, including the Boston Haitian community, face staggering disparities in health. Structural issues are largely at fault—but more ambiguous “cultural” factors are often blamed as well. These factors—things like language and “health beliefs”—may be important: in 1970, Philip Tumulty wrote “what the scalpel is to the surgeon, words are to the clinician…the conversation between doctor and patient is the heart of the practice of medicine.”[1] But the role of culture in immigrants’ health disparities is frequently ill-defined and overestimated, and “cultural” effects are seen as immutable by policy.

When policymakers address healthcare disparities for Haitian minorities in several major cities in the US, dividing culture and structure allows them to treat the associated barriers differently. Immigrants’ “cultural” differences are seen as relatively immutable by policymakers, who argue that “cultural” barriers to health will only disappear with a process of acculturation.[2] Indeed, one study equates recent immigration with lack of acculturation and resulting poor language skills in order to explain differential patterns of cancer screening for ethnic minorities, including Haitians in U.S. cities.[3]

Acculturation is necessary, the conclusion goes, but it happens at different rates for different groups and individuals; policy can do little to affect this process. Structural factors–education, insurance/ability to pay for care, transportation, availability of childcare, leave from work–are the focus of policy, and they certainly merit examination and intervention.

A PACT community health worker helps bridge linguistic and administrative gaps between physicians and patients. (Courtesy of Partners in Health)

But there is growing evidence that this distinction between culture and structure is artificial and possibly even harmful. Pushing “culture” outside of policymakers’ responsibility may divert attention from solvable problems in healthcare, so examining the role that “culture” plays—and does not play—in immigrant communities’ health is necessary. For this purpose, healthcare can be divided into three necessary sequential components: access to care, willingness to seek treatment, and finally, communication between provider and patient.[2] What role does “culture” play in each step?

A vague but prominent “cultural” factor, “health beliefs”[4] are viewed as only mutable through acculturation; inversely, acculturation often means changing health beliefs.[3] But the link between culture and willingness to seek treatment is rarely examined. In the Boston Haitian community, commonly-cited “cultural factors” such as modesty may play a role in women’s willingness to seek screening for cervical cancer,[5] but for breast cancer especially, a patient’s access to a primary care provider is the largest determinant of screening prevalence.[6] This is hardly “cultural.” As Michele David, Co-Director of the Haitian Health Institute at Boston Medical Center, told the HCGHR, “If [women] had a primary care provider, they had all the appropriate health screenings. If they didn’t have the health provider, that made a huge difference.”[5]

Systematic factors may also masquerade as “health beliefs” and become general barriers to immigrants’ willingness to seek healthcare, especially preventive care. As Samuel Slavin, Coordinator of Training and Technical Assistance for Partners in Health’s Prevention and Access to Care and Treatment (PACT) Project in Boston, told the HCGHR, “people coming from Haiti or from other countries are…coming from a totally different healthcare system or the absence of a healthcare system in most parts of Haiti.”[7]

This leads to under-utilization of preventive, as opposed to acute, care; these preventive services are sparse in Haiti. Ignorance, misinformation, or cultural prejudices against prevention [3,4] are less important than familiarity with healthcare structures. Slavin summed this up: “It’s not so much about Haitian culture per se as coming from a really different [healthcare] system.”[7]

It may also be worth reconsidering the specificity of medical condition and type of medicine which guides much thought about disparities. For many patients in the Boston Haitian community, insurance, time off work, and childcare are the primary factors which influence their access to all healthcare. Rather than influencing patients’ likelihood to seek care for specific health concerns and not for others, these factors limit access to all non-urgent care. As Slavin told the HCGHR, “having children makes it a lot harder to keep medical appointments.”[7] Gendered differences in care-seeking behavior may therefore be due to structural factors like childcare and sick leave, rather than vague “cultural” factors.

An important caveat to this argument, however, is mental health care, which David argues is “under-addressed” in the Boston Haitian community.[5] Language, an element of culture, is critical here. Access to mental health services is limited because, as David points out, Boston has “a dearth of Creole-speaking mental health providers.”[5] Coupled with the prevalence of post-traumatic stress disorder symptoms after Haiti’s 2010 earthquake, this issue is worsening. Willingness to seek treatment can be affected by cultural beliefs too; Slavin and David say that mental healthcare is “stigmatized”[7] and “taboo,”[5] respectively, in Haitian culture. But fears of mistranslation or inadequate privacy may be just as important, especially because non-professional translators are frequently used.[7,8] This also makes communication between provider and patient problematic. David puts this plainly: “something gets lost in translation when you have…an interface between the mental health provider and the patient.”[5] Even Haitian-born providers may not have received medical training in a Haitian context7—and while providers may speak Creole, administrative services which do not include options for Creole speakers limit patients’ access to providers.[7]

Attributing disparities to “culture” tends to divert attention away from access barriers and toward problems in patients’ willingness to seek care and clinical communication. This can negatively affect immigrants’ health: first, it minimizes policymakers’ responsibility to eliminate barriers to care instead of waiting for acculturation to occur, and second, it delegitimizes practices, experiences, and models of understanding which affect patients’ roles in their own healthcare.

Health education and access to interpretive services and bilingual providers are crucial; but underestimating the structural elements of “culture” risks ignoring opportunities to eliminate health disparities among immigrant populations.

[1] Tumulty, Philip. “What is a Clinician and What Does He Do?” New England Journal of Medicine 283
(1970): 20-24.

[2] Page, J. Bryan. “The Concept of Culture: A Core Issue in Health Disparities.” Journal of Urban Health
82 (2005): iii35-iii43.

[3] Brown, William, et al. “Time Spent in the United States and Breast Cancer Screening Behaviors among
Ethnically Diverse Immigrant Women: Evidence for Acculturation?” Journal of Immigrant Health 8
(2006): 347–358.

[4] Consedine, Nathan, et al. “Breast Cancer Knowledge and Beliefs in Subpopulations of African
American and Caribbean Women.” American Journal of Health Behaviors 28 (2004): 260-271.

[5] David, Michele. Personal INTERVIEW. 17 October 2011.

[6] David, Michele. “Mammography Use.” Journal of the National Medical Association 97 (2005): 253-
261.

[7] Slavin, Samuel. Personal INTERVIEW. 28 October 2011.

[8] Woloshin, Steven, et al. “Language Barriers in Medicine in the United States.” Journal of the American
Medical Association 273 (1995): 724-728.

Category: Panorama, Policy, Spring 2011

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