The Role of Culture in the Integration of
Physical Health Services in Mental Health
Settings
Leopoldo J. Cabassa, PhD
NYS Center of Excellence for Cultural Competence
New York State Psychiatric Institute
Department of Psychiatry, Columbia University
NYAPRS 7th Annual Executive Seminar
April 27, 2011
Outline
2

Discuss racial/ethnic
health disparities
among people with
SMI

Illustrate how culture
impacts the
integration of physical
health services in
mental health settings
Public Health Crisis
Among People with SMI
3

People with serious
mental illness die, on
average, 25 years
earlier than the general
population largely due
to preventable medical
conditions
Racial/Ethnic Health Disparities in the
SMI Population
4

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
Racial/Ethnic Differences in Diabetes
by Psychiatric Disorders
5
No psychiatric disorders
NHW vs. AA
OR
(95% Cl)
1.49 1.22, 1.83
NHW vs. H
OR
(95% Cl)
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
Any mood disorders
1.89
1.36, 2.61
2.54
1.67, 3.86
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 factors
Source: Cabassa et al., (In Press). Gen Hosp Psych.
Possible Reasons for Health Disparities among
Racial and Ethnic Minorities with SMI
6

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;
Determinants of
Health Care Disparities
7
Organization
-Service fragmentation
-Resources
-Location
-Reimbursement
policies
-Organizational
culture
-Cultural competence
policies and practices
Provider
-Training
- Knowledge/
Skills
-Stigma
-Bias/Stereotypes
-Professional
boundaries
Consumer
-Health insurance
-Language
-Competing demands
-Comorbdities
-Health literacy
-Norms & attitudes
-Body image
Culture Influences Health
8

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
Culture and Service Integration
9

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
Kleinman, 1995; Palinkas et al., 2005
Qualitative Study of Service Integration
10

Study Aim:


Sample:


Identify cultural factors in
the integration of physical
health services in
behavioral health
organizations
Purposive sample of 6
behavioral health
organizations in Northern
Manhattan
Methods:


Multi-stakeholder approach
Combination of qualitative
methods
What is most at stake for organizations?
11

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
What is most at stake for providers?
12

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
What is most at stake for consumers?
13

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
Conclusion
14

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
“Physical Health is Integral to Recovery”
15
“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”
Acknowledgements
16

Funding Sources



Research Team


New York State Office of Mental Health
National Institute of Mental Health (K01MH091108)
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
Thank You // Gracias
17
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
[email protected]