Written by James McIntosh
Obesity is a serious public health problem in the US and can affect anyone regardless of age. In particular, childhood obesity prevalence remains high. As well as compromising a child's immediate health, obesity can also negatively influence long-term health dramatically. Unfortunately, some racial and ethnic groups are affected by obesity much more than others.
For example, the US Department of Health and Human Services Office of Minority Health (OMH) report that African-American women have the highest rates of being overweight or obese, compared with other racial or ethnic groups in the US.
Approximately 4 out of 5 African-African women were found to be overweight or obese and, in 2011, African-American women were 80% more likely to be obese than non-Hispanic white women.
Researchers have identified that disparities in obesity prevalence can be found just as readily among children as among adults. It is alarming that these disparities exist to begin with, but more so that they exist so early in life for so many.
In this Spotlight feature, we take a brief look at the prevalence of childhood obesity in the US and the disparities in childhood obesity prevalence that exist among different racial and ethnic groups. We will examine what factors may contribute to this disparity and what action can be taken to remedy the situation.
A growing problem
"Obesity is the terror within," states Dr. Richard Carmona, the former Surgeon General. "Unless we do something about it, the magnitude of the dilemma will dwarf 9-11 or any other terrorist attempt."
These are strong words, but they illustrate the scope of the obesity problem. According to the Centers for Disease Control and Prevention (CDC), in 2009-2010, over a third (35.7%) of adults in the US were obese.
On average, childhood obesity in the US has not changed significantly since 2003-2004, and overall, approximately 17% of all children and adolescents aged 2-19 years are obese - a total of 12.7 million.
There are a number of immediate health problems that childhood obesity can lead to, including:
- Respiratory problems, such as asthma and sleep apnea
- High blood pressure and cholesterol
- Fatty liver disease
- Increased risk of psychological and social problems, such as discrimination and low self-esteem
- Joint problems
- Type 2 diabetes.
In the long term, obese children are much more likely to grow up to be obese as adults than children with healthy weights. Not only that, but the obesity experienced by these children is likely to be more severe, leading to further and more extreme health problems.
Significant disparities exist in obesity prevalence between different racial and ethnic groups. The CDC report the following obesity prevalence percentages among different youth demographics:
- Hispanic youth - 22.4%
- Non-Hispanic black youth - 20.2%
- Non-Hispanic white youth - 14.1%
- Non-Hispanic Asian youth - 8.6%.
From these figures taken from 2011-2012, we can see that levels of obesity among Hispanic and non-Hispanic black children and adolescents are significantly above average.
When the parameters are extended to include overweight children as well, the disparity persists. Around 38.9% of Hispanic youth and 32.5% of non-Hispanic black youth are either overweight or obese, compared with 28.5% of non-Hispanic white youth.
In 2008, Dr. Sonia Caprio, from the Yale University School of Medicine, CN, and colleagues wrote an article published in Diabetes Care in which they examined the influence of race, ethnicity and culture on childhood obesity, and what their implications were for prevention and treatment.
"Obesity in children is associated with severe impairments in quality of life," state the authors. "Although differences by race may exist in some domains, the strong negative effect is seen across all racial/ethnic groups and dwarfs any potential racial/ethnic differences."
However, if there are specific factors contributing to these disparities that can be addressed, the numbers involved suggest that attention should be paid to them. The long-term health of thousands of children in the US is at stake.
"Rarely is obesity in children caused by a medical condition," write the National Association for the Advancement of Colored People (NAACP) in their childhood obesity advocacy manual. "It occurs when more calories are eaten than calories burned."
The NAACP outline a number of factors that contribute to increases in childhood obesity, including:
- The development of neighborhoods that hinder or prevent outdoor physical activity
- Failure to adequately educate and influence families about good nutrition
- Ignored need for access to healthy foods within communities
- Limited physical activity in schools
- Promotion of a processed food culture.
The CDC report that childhood obesity among preschoolers is more prevalent in those who come from lower-income families. It is likely that this ties in with the disparity with obesity prevalence among different racial and ethnic groups.
"There are major racial differences in wealth at a given level of income," write Caprio, et al. "Whereas whites in the bottom quintile of income had some accumulated resources, African-Americans in the same income quintile had 400 times less or essentially none."
Fast food and processed food is widely available, low cost and nutritionally poor. For these reasons, they are often associated with rising obesity prevalence among children. According to Caprio, et al., lower-cost foods comprise a greater proportion of the diet of lower-income individuals.
If adults need to work long hours in order to make enough money to support their families, they may have a limited amount of time in which to prepare meals, leading them to choose fast food and convenient processed food over more healthy home-cooked meals.
Living in high-poverty areas can also mean that children have limited access to suitable outdoor spaces for exercise. If the street is the only option available to children in which to play, they or their parents may prefer them to stay inside in a safer environment.
Hispanic youth and non-Hispanic black youth are more likely to come from lower-income families than non-Hispanic white youth. According to The State of Obesity, white families earn $2 for every $1 earned by Hispanic or non-Hispanic black families.
Over 38% of African-American children aged below 18 and 23% of Latino families live below the poverty line. This statistic suggests that the effects of living with a low income that increase the risk of obesity may be felt much more by African-American and Latino families and their children.
Not only do these socioeconomic factors increase the risk of obesity among these demographic groups but equally obesity can compromise a family's economic standing.
The NAACP point out that families with obese children spend more money on clothing and medical care. Additionally, as obese and overweight girls frequently start puberty at a younger-than-average age, there is a possibility that their risk of adolescent pregnancy is also higher.
Alongside these socioeconomic factors, a number of additional factors exist that may be linked to an increased prevalence of childhood obesity among Hispanic and non-Hispanic black youth.
The NAACP give one such example, stating that one component of body image is how a person believes others view them or accept their weight:
"This also poses unique challenges in African-American communities because of cultural norms that accept, uplift and at times reward individuals who are considered 'big-boned,' 'P-H-A-T, fat,' or thick.'"
Cultural norms such as these may lead to parents remaining satisfied with the weight of their children or even wanting them to be heavier, even if they are at an unhealthy weight. Other sociological studies have also suggested that among Hispanic families, women may prefer a thin figure for themselves but a larger one for their children, according to Caprio, et al.
As well as being influenced by socioeconomic status, the type of foods eaten by children can be influenced by the cultural traditions of their families.
"Food is both an expression of cultural identity and a means of preserving family and community unity," write Caprio, et al. "While consumption of traditional food with family may lower the risk of obesity in some children (e.g., Asians), it may increase the risk of obesity in other children (e.g., African-Americans)."
As mentioned earlier, the promotion of a processed food culture may be a contributing factor to childhood obesity. As fast food companies target specific audiences, favoring cultural forms associated with a particular race or ethnicity could increase children's risk of being exposed to aggressive marketing.
Caprio, et al., report that exposure to food-related television advertising - most frequently fast food advertising - was found to be 60% among African-American children.
The amount of television that is watched may contribute as well; one study conducted by the Kaiser Family Foundation observed that African-American children watched television for longer periods than non-Hispanic white children.
A number of these cultural factors are associated with socioeconomic factors. African-American children may be more likely to watch television for longer, for example, if they live in areas where opportunities for playing safely outside are limited.
What can be done?
This subject area is far too detailed to do justice to in an article of this size, but these brief observations suggest that there should be ways in which the disparity in childhood obesity between racial and ethnic groups can be addressed.
Having more safe spaces to walk, exercise and play in low-income areas would give children a better opportunity to get the exercise need to burn the required number of calories each day. Improving the availability of and access to healthy food would give families more options when it came to maintaining a healthy, balanced diet.
The NAACP state that low-income neighborhoods have half as many supermarkets as the wealthiest neighborhoods, suggesting that for many low-income families, accessing healthy food can be a challenge.
These problems are ones that would need to be solved by local government and businesses that have influence over the planning and development of public living spaces.
Caprio, et al. propose that a "socioecological" framework should be adopted to guide the prevention of childhood obesity. Such a framework would involve viewing children "in the context of their families, communities, and cultures, emphasizing the relationships among environmental, biological and behavioral determinants of health."
This approach would require large-scale collaboration, involving peer support, the establishment of supportive social norms and both the private and public sector working together.
"For health care providers to have a meaningful interaction about energy intake and energy expenditure with children/families, providers should have training in cultural competency in order to understand the specific barriers patients face and the influence of culture and society on health behaviors," the authors suggest.
In order for this disparity to be adequately addressed, a lot of work will need to be done. Not only might certain cultural norms need to be altered, but most importantly, environments will need to be provided in which children will have the opportunity to live as healthy lives as possible.
The healthcare industry is in a constant state of flux. But while technologies are rapidly changing, the industry is still cast in monochrome with little racial or gender diversity. There are definitely large societal issues at root – like the massive expense of becoming a doctor and lack of adequate STEM education in many inner-city elementary schools – that will take a generation to solve. But while these massive gaps remain, it is often hard to see incremental progress.
Recently, I found a study that gave me a small glimmer of hope that progress is happening. According to Professional Diversity Network, recruiters and HR professionals accelerated their search for diverse talent in healthcare in January. Specifically, the Professional Diversity Network’s Diversity Jobs Index, which tracks the demand for diverse talent across sectors, jumped 11 percent from December 2014 in healthcare.
The Professional Diversity Network pointed to a few factors that could have attributed to the change. For example, the study suggests that many more small clinics across the country, particularly in urban settings, have increased their workforces.
While the Professional Diversity Network pointed to trends that could be the cause, I believe this is evidence that diversity programs like the Institute for Diversity, Ms. Tech and Instituto Health Sciences Career Academy are finally beginning to have an impact not just on awareness, but also on behaviors.
Diversity programs are crucial because they not only acknowledge that problems exist, but they create communities to offer training and support to help women, minorities, and other under-acknowledged groups succeed. For example, IHSCA prepares inner city high school students for a career in healthcare with tutoring and mentorship programs.
This is great news not only for the women, minorities, veterans or disabled professionals being employed, but also for the healthcare industry as a whole. Healthcare professionals service every ethnic group and gender, so the more that doctors and nurses can empathize and understand their patients, the better care they will give. In part, that empathy and understanding relies on working in a diverse environment.
So to answer the question I posed in the headline: yes we should get our hopes up. Healthcare executives are in fact beginning to value and invest in diversity, which is a sign of positive change. There is still a long way to go, and who knows if there will ever be an all minority board of a hospital, but we’re heading in the right direction.
The award-winning documentary “The American Nurse” (DigiNext Films) will be shown at special screening engagements May 6 in honor of National Nurses Week. The film highlights the work and lives of five American nurses from diverse specialties and explores topics such as aging, war, poverty and prisons.
“At some point in our life each of us will encounter a nurse, whether it’s as a patient or as a loved one,” Carolyn Jones, director and executive producer of the film, said in a news release. “And that one encounter can mean the difference between suffering and peace; between chaos and order. Nurses matter.”
The American Academy of Nursing recognized Jones, an award-winning filmmaker and photographer, as the winner of its annual Johnson & Johnson Excellence in Media Award for the documentary. The award recognizes exemplary healthcare journalism that incorporates accurate inclusion of nurses’ contributions and perspectives. “I intended to make a film that celebrated nursing,” Jones said in the release. “I ended up gaining deeper insights into some of the social issues we face as a country, through the eyes of American nurses. I’ve grown to believe that nurses are a truly untapped and under-appreciated national resource.”
The documentary also was awarded a Christopher Award in the feature film category, alongside films “Selma” and “St. Vincent.”
The film, which was made possible by a grant from Fresenius Kabi, is being presented locally through sponsorship by the Future of Nursing: Campaign for Action, a joint initiative of the Robert Wood Johnson Foundation and AARP, together with the American Nurses Foundation and Carmike Cinemas.
The campaign’s state action coalitions and other campaign partners are expected to host at least 50 screenings of the film. Ten percent of the proceeds will go to help local efforts to advance nursing. A portion of all proceeds from the film will benefit the American Nurse Scholarship Fund.
To find a screening near you or to learn how to host a screening, go to http://americannurseproject.com/national-nurses-day-screenings.
Like many healthcare providers in the Los Angeles area, and well beyond to healthcare organizations throughout the United States, City of Hope has recognized the growing need for clinical professionals and staff that more closely mirror the patients it serves in its catchment area. And with a local population that is nearly half Hispanic, that means recruiting more Hispanics into the industry, as well as providing much needed career development opportunities. But whereas most in the industry are just beginning to acknowledge the need, City of Hope has taken the lead to recruit more Hispanics into the industry and also has started to build a Hispanic talent pipeline for the immediate and not so distant future.
According to Ann Miller, senior director of talent acquisition and workforce development, "Even when people in the industry recognize the need for more Hispanics, or just a more diverse workforce, it can feel overwhelming trying to figure out what actions to take and how to build a strategy around it. But once you see the data laid out in front of you, and see that 46 percent of your primary service area is Hispanic, you realize it would be optimal to figure out how to recruit a workforce that looks more like the population you are serving. Beyond that, it's also important to employ a bilingual staff that can speak the language and understand the culture to best meet the needs of the community being served."
Once you recognize the need, it's time to start asking the questions that will help you fill the gaps:
- How do you find and appeal to the types of people you need to start building relationships with? Who are the influencers and the connectors?
- How do you get your recruitment team looking toward the future and building a pipeline, when limited resources are focused on more immediate needs?
- How do you get buy-in from senior management and enlist other departments throughout the organization?
- How do you partner with others in the industry who recognize the need but have yet to become active in the pursuit of common goals?
Here's how City of Hope has started to answer these questions as it takes the lead in addressing these timely industry issues. Stephanie Neuvirth, Chief Human Resources and Diversity Officer, has said that it's not easy to build a diverse healthcare or biomedical pipeline of talent, even when you understand the supply and demand of your primary service area and the business case becomes clearer. "Few in the industry are taking the helicopter perspective that is needed to really see the linkage between the different variables that must be factored in to solve the problem," she says.
Even in healthcare, it's not simple, and it takes time to develop the paths, the relationships and the pipeline to cause real and sustainable change. It takes linking a workforce talent strategy to the broader mission and strategic goals of the organization. And it takes collaboration with the community, schools, government, parents and everyone who touches the pipeline to help achieve the necessary and vital missing pieces of the puzzle.
Talent Acquisition and Workforce Development
What you first have to realize is that there is an immediate but also a long-term gap to fill, which represent two sides of the same coin: talent acquisition and workforce development. We know we can best serve our community by mirroring the community that we serve, and that doesn't stop with the talent that we attract today; it's an imperative that depends on the talent pipeline that we build for the future.
City of Hope's approach has been to start fast and strong with some immediate steps that can then be built upon and cascaded out into a longer term strategy for the future. The good news is that if your goal is to look like the community you serve, you don't have to look far for the talent you need. It's right in your own backyard. But there's still a lot of work to be done in terms of educating people about potential careers in healthcare -- clinical and otherwise -- developing the workforce skills and knowledge that they will need, and planting the seeds in the next generation.
It's particularly disheartening to hear about the young people graduating from high school and college who can't get jobs, when there are growing shortages in the healthcare industry - the nation's third largest industry, and projected to be its second largest in just seven years. According to a recent report by The Economist, U.S. businesses are going to depend heavily on Latinos - the country's fastest-growing and what it calls "irreversible" population -- to fill the gaps not just in healthcare but across all industries.
If you look just at nursing, the single largest profession in California, you can see how far we have to go. Only 7 percent of the 300,000 nurses in the state are Hispanic. The clinical gaps extend to doctors, just 6 percent Latino; pharmacists, less than 6 percent; and the list goes on and on.
Teresa McCormac, nurse recruiter, is one of the people at City of Hope working to build the Hispanic talent pipeline, beginning with the need for Spanish speaking nurses. She is responsible for elevating City of Hope's presence in the community through word of mouth referrals and by getting active in broader outreach online, in publications and at local, college and national events, such as the National Association of Hispanic Nurses (NAHN) annual conference taking place in Anaheim, CA this July.
"It's important to have a passionate champion for the candidates, as well as our hiring managers and the organization. My role is to get the word out into the community about City of Hope and connect with the talent we need to fill our current and future openings," she says.
This requires a multi-prong approach to recruitment efforts, where you must act to attract candidates not only for current needs, but down the road five-ten years, and even further into the future.
This begs the question: how do you get more Hispanics and other diverse students interested in the sciences and considering careers in healthcare?
Traditionally, recruiters focus on those currently working in healthcare to fill immediate gaps, as well as those working in other industries with transferable skills, who might be interested in working in healthcare in a non-clinical capacity, such as IT or marketing. They also look at colleges with nursing and other clinical programs -- particularly those with high concentrations of Hispanics and other diverse students -- where they can conduct outreach efforts, build partnerships and establish a presence.
But building a talent pipeline requires that you reach students well before the college years, when they are still in high school, and even earlier as middle and grade-schoolers. It takes time to get the message out there and have it stick, so the bigger and bolder you can go, the better. That was City of Hope's thinking behind the launch of its Diversity Health Care Career Expo in September 2014, which made quite an impact with the community and opened eyes to the variety of career opportunities within healthcare. It also opened City of Hope's eyes to the level of interest from the community when 1500 people showed up for this first of its kind event.
What started as an idea for a diversity career fair to fill immediate positions quickly grew to encompass a workforce development component to include students, parents, as well as working professionals interested in transitioning into healthcare. The Career Expo brought a level of awareness never seen before in the community -- and did so very quickly. For example, it allowed healthcare professionals to connect the dots between math and science classes students were taking and how this learning applied in the real world of healthcare -- and the different careers these types of classes are helping to prepare them for if they stick with them. It also allowed parents to understand how to help their children prepare for jobs that are available and will continue to be available in the future. They also gained insights into how growing up with smartphones and other electronic devices has given their children a distinct advantage that previous generations didn't have -- enabling them to leverage their everyday use of technology into transferable skills that could lead towards a career in Information Technology, which offers a very promising career path within the healthcare and biomedicine industries.
Catching students early on to spark their interest and expose them to healthcare careers and professionals who can encourage and support them along the way requires that you go out into the community as well. Toward that end, City of Hope has partnered with Duarte Unified School District and Citrus College on a program called TEACH (Train, Educate and Accelerate Careers in Healthcare).
According to Tamara Robertson, senior manager of recruitment, the TEACH partnership provides students with the opportunity to gain college credit while still in high school by taking college-level classes at no cost. This puts them on the fast track to higher education and career readiness by giving them essential skills and capabilities to enter the workforce soon after graduating high school, or to continue their education with up to one year of college coursework already completed. Eighteen students were accepted into the program in its first year.
Each partner plays a valuable role in the program. City of Hope provides students with opportunities to gain first-hand exposure to healthcare IT by giving overviews of the various areas within IT, providing summer internships, and offering mentoring and development interactions. Duarte High School is the conduit for the program by selecting the students for the program and facilitating the learning, and Citrus College develops the curriculum that enables students to earn college credits and IT certifications. It's ideal for students who may not have the means to continue on to college, but can work for an organization like City of Hope that offers opportunities to start their IT career as a Helpdesk or Technology Specialist. In addition, they can take advantage of tuition reimbursement should they choose to further their education and development.
In today's world, social media must be in the recruitment mix, especially if you want to engage with Hispanics who index higher on time spent on social media than the general population and any other group. Statistically, 80 percent of Hispanics utilize social media compared to 75 percent of African Americans and 70 percent of non-Hispanic whites. It's also a great way to reach not just active candidates in search of a new position, but passive ones employed elsewhere whose interest may be peaked when a more interesting opportunity presents itself.
This is where Aggie Cooke, branding and digital specialist, comes in -- leveraging social media as a core component of City of Hope's outreach efforts to potential candidates. She takes a three-legged approach to the use of social media for recruitment:
1. Branding - offering relevant content that portrays the culture and appeals to a candidate's values and broader career aspirations;
2. Targeting - identifying potential candidates who have skills and experiences that the organization needs today and in the future; and
3. Engaging - creating a relationship by inviting candidates to dialog with City of Hope.
You can reach more people through social media -- even if they're not active job seekers -- by posting information that is relevant to their field and interests. For example, oncology nurses will be interested in what you have to say about the latest developments in the world of oncology.
Though it can seem overwhelming with so many messages out there competing for people's attention, you can break through with content that is authentic, timely and purposeful. You can also make an impact by tailoring your content to the medium you are using. For example, a story about a scientific breakthrough at City of Hope would play well on LinkedIn, while pictures of happy employees taking a Zumba class together would engage potential candidates on Instagram. Social media also enables you to expand the reach and prolong the life of live events. For example, attendees of the Career Expo last year engaged online with live tweets and Instagram pictures from the event and later provided comments and feedback about their experience that will be instrumental in planning this year's event.
Going forward, successful programs and events, like TEACH and the Diversity Health Care Career Expo, will be expanded upon, as City of Hope continues to lead the way in talent acquisition, workforce development and creating a talent pipeline for Hispanics and the future of healthcare.
Source: University of California - Los Angeles
Latinos are the largest ethnic minority group in the United States, and it's expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers. Latinos' low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.
Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA: The consequences of not covering undocumented residents. The growth of the Latino population in states that are not participating in the ACA's Medicaid expansion program. The heavier demand on public and private health care systems serving newly insured Latinos. The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.
"As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels," Ortega said. "Resolving these four key issues would be an important first step."
Insurance for the undocumented
Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.
For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA's expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.
For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA's exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.
In addition, previous research has shown that undocumented people often delay seeking care for medical problems.
"That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients," Ortega said.
Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.
"Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems," Ortega said.
The growing Latino population in non-ACA Medicaid expansion states
A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.
As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.
"It's estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law -- the undocumented and those who have been in the U.S. less than five years," Ortega said. "Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate."
New demands on community clinics and health centers
Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.
But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.
"These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time," he said. "So it remains unclear how these clinics will continue to provide care for them."
Need for diversity in health care workforce
Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers -- Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.
The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.
The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.
"That, of course, is the goal -- to see improvements in the overall health for everyone," Ortega said.
Historically, both men and women have filled the challenging and rewarding role of a nurse. It wasn’t until the Civil War, when nearly 3 million men filled the ranks of two competing American armed forces, that women began to dominate the field.
Today, over 43 million Americans are aged 65 or older – a number that is expected to double over the next 35 years. A larger elderly population means a greater need for long-term health services, and as a result, the healthcare field is one of the fastest-growing industries.
Why does this matter?
1. The U.S. is already on the verge of a nursing shortage.
The American Association of Colleges of Nursing reports that the U.S. is experiencing a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows.
Did you know only 7 percent of nurses are currently men? According to the latest National Sample Survey of Registered Nurses conducted by the Health Resources and Services Administration, the percentage of male nurses has more than doubled in the past three decades, but still lingers at 7% today. This number is expected to triple within the next few decades as the need for both male and female healthcare professionals continues to grow.
2. A diverse population needs a diverse nursing staff.
According to the American Association of Colleges of Nursing (AACN), men are enrolling in nursing programs at a higher rate compared to the past. The IOM report states that there still need to be an emphasis on gender diversification and inclusion in the workforce.
The IOM Report also states that the nursing profession “needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity in the workforce.” The increase in men pursuing a nursing career will help create a more diverse healthcare environment.
3. Discrimination issues must be overcome.
The idea that men cannot be nurses will never be eradicated until men take to the profession in greater numbers. While nursing is seen as a nontraditional career for men today, the stereotype must change -- nursing is simply too important of a job, and too attractive of a career.
“There are just far too many benefits that come along with nursing, such as a flexible schedule, a secure position, and high pay,” notes the website NursingWithoutBorders.org, “and so it’s therefore difficult for anyone to refuse to pursue a field that only continues to grow.”
In a Johns Hopkins Outpatient Center exam room, medical interpreter Julie Barshinger is working with a Spanish patient, a woman in her early 40s with a stocky build and a dark ponytail, who is concerned about complications related to her recent nose surgery.
But first, the woman must complete a medical history form. “¿Qué significa vertigo?” (“What is vertigo?”) she asks, as Barshinger goes through the list of symptoms on the form, verbally interpreting them from English to Spanish. Then later, “No sé qué es un soplo cardiac … ” Barshinger interprets the question — “I don’t know what a heart murmur is” — for the nurse who is preparing a nasal spray for the patient that will allow the doctor to look inside her nose.
“If it doesn’t apply to her, don’t answer it,” the nurse says kindly.
“I just want you to know that I have to interpret everything she says,” explains Barshinger, who is one of 18 full-time interpreters in Johns Hopkins Medicine International’s Language Access Services office. Part of Barshinger’s job is educating providers about her role.
Later, the nurse starts to leave the room to see another patient before the woman has completed her medical history form. “I can’t continue if you’re not in the room with me,” Barshinger says. The patient is consistently giving additional information about her symptoms: She doesn’t see well since her operation; she has some nasal bleeding; she sees the room spinning when she lies down. It’s crucial for Barshinger to communicate these potentially important details to the nurse, who stays in the room, answering questions when needed, until the form is complete.
Throughout the interaction, Barshinger knows little about the full scope of the patient’s health history. But she doesn’t need to know. “I’m not in charge of her care,” she says. “I’m only her voice. I want to make sure her voice is being heard by the right people. I’m also the voice of the provider, so she can communicate the very necessary and important information that she has to the patient.”
While Johns Hopkins, like other hospitals that receive federal funding, has been providing interpretation services for 50 years — since passage of the Civil Rights Act of 1964, which prohibits discrimination based on national origin — requests for interpreters at The Johns Hopkins Hospital have grown dramatically since 2010, jumping from 23,000 to more than 50,000 annually.
This is due in part to the slightly rising limited English proficiency population in Baltimore City, which grew by about 4,000 people between 2000 and 2012, according to the U.S. Census. Today, the hospital also serves more refugees, about 2,500 of whom settled in Baltimore City between 2008 and 2012.
But Susana Velarde, administrator for Language Access Services at Johns Hopkins Medicine International, says the increase in requests is also due to the growing understanding among health care providers that they can do a better job treating their patients with limited English proficiency with the help of interpreters.
Because they prevent communication errors, certified interpreters improve patient safety. A 2012 study in the Journal of General Internal Medicine found that patients with limited English proficiency who did not have access to interpreters during admission and discharge had to stay in the hospital between 0.75 and 1.47 days longer than patients who had an interpreter on both days. Moreover, when the interpreter has 100 hours of medical interpretation training — a qualification that researchers have found is more important than years of experience — they made two-thirds fewer errors than their counterparts with less training, according to a 2012 Annals of Emergency Medicine study.
The Language Access Services office’s full-time interpreters—who speak Spanish, Chinese-Mandarin, Korean, Russian, Arabic and Nepali — participate in an extensive two-year training program, which includes classes, tests and shadowing. Fifty percent of the team is certified; the rest are working toward certification, if available in their language. The office also has 45 medical interpreter floaters, and interpretation services are available 24/7 in person, over the phone or through a video monitor for patients with limited English proficiency who live in the Baltimore area and international residents who come to Johns Hopkins for treatment.
“We are the conduit, but also the clarifier,” says Spanish interpreter Rosa Ryan. “We are not simply repeating words but making sure the message is understood.”
For example, at the end of her visit on the otolaryngology floor, Barshinger walks to the front desk with the ponytailed Spanish woman to help her make a follow-up appointment. With Barshinger interpreting, the woman learns that she must get a Letter of Medical Necessity from her current insurer or change insurance companies before coming back to Johns Hopkins. When the administrator walks away, Barshinger checks in with the woman to make sure she understands the instructions.
“The patient might nod, but the information might not be registering,’” she says. “I try to check for clarification if I sense there is a disconnect.”
Interpreters are also cultural brokers. Yinghong Huang, a Chinese-Mandarin interpreter, remembers when a nurse in labor and delivery tried to give a Chinese patient a cup of ice water. “In China, for a woman who has just delivered a baby, we don’t want her to touch anything cold, let alone ice,” Huang explains. This is one of the many rules that Chinese women abide by for a month to help the body recover from childbirth. With Huang present, providers knew to give the patient hot water with her medicine instead.
Despite the increasing demand for interpreters, their expertise too often goes untapped, says Lisa DeCamp, assistant professor of pediatrics at the school of medicine. She is the lead author of a 2013 Pediatrics study that found that 57 percent of pediatricians who completed national surveys in 2010 still reported using family members as interpreters.
This is a bad practice for many reasons, she says. For one thing, family members often don’t have specialized knowledge of medical terminology. Moreover, both patients and family members may censor information. “If you’re talking about something that is intimate or personal and your son is translating for you, you might not want to disclose something about your sexual activity, your drug use or anything else sensitive that could be contributing to your problem,” says DeCamp, who is also a pediatrician at Johns Hopkins Bayview Medical Center.
Even physicians with basic skills in a particular language should use an interpreter to prevent misunderstandings. “I [know] some high school Spanish, but I’m nowhere near fluent, so I need an interpreter,” says Cynthia Argani, director of labor and delivery at Hopkins Bayview, where about 70 percent of her department’s patient population speaks Spanish. “It’s not fair to the patient not to use one. The message can get skewed.”
DeCamp, who has passed a test certifying her as a bilingual physician, offers a real-life example from the literature that shows how this can happen. A pediatrician with limited Spanish language skills instructed parents to use an antibiotic to treat their child’s ear infection. In Spanish, “if you use the preposition, it really means, ‘put in the ear,’” she says. “So the family was putting the specified amount of amoxicillin that should be taken by mouth in the ear. That child is not going to die from an ear infection, but he’s having pain and a fever, and the family doesn’t have clear instructions on how to provide medication.”
On Barshinger’s rounds, after her otolaryngology visit, she walks at an impressively fast pace to The Charlotte R. Bloomberg Children’s Center, where a mother recognizes her and asks her to be her interpreter. The provider who requested Barshinger’s services is not ready yet, so she has time to help.
A doctor carrying a sheaf of papers joins them in a busy hallway. She points to a long list of care instructions translated into Spanish, then begins to explain them to the mother. Because the doctor is verbally giving the instructions, Barshinger interprets. The mother needs to buy an extra-strength, over-the-counter medication and give her daughter a second medication three times a day, which she will need to “swish and spit,” the doctor says. A third medication will be applied to the daughter’s face two times a day, and a special shampoo is needed to wash her hair. Before an upcoming dentist appointment, she’ll also need to give her daughter three amoxicillin. When the doctor steps away, the mother asks Barshinger a question about her daughter’s dental visit, which Barshinger interprets when the doctor returns.
While interpreting, Barshinger stands to the side of the patient’s mother, allowing the doctor and the mother to face each other and communicate directly with one another. This simple tactic encourages providers to develop a rapport with their patients with limited English proficiency.
The goal? “To make the patient feel like the appointment is with him and not with the interpreter,” says Velarde. “The interpreter is just the voice. We want providers to have a bond with their patients, like they do when everyone is speaking English.”
Tapping the expertise of interpreters doesn’t have to complicate things for physicians, says Lisa DeCamp, a bilingual physician at Johns Hopkins Bayview Medical Center. Her advice for colleagues:
Educate the interpreter about what you’re doing so they’re not going in blind. Say a patient has severe abdominal pain. Providers can quickly explain to the interpreter that the first job is to rule out appendicitis.
Sit across from the patient, with the interpreter standing at the patient’s side, and talk directly to the patient. The goal is for the provider and the patient to feel like they have a relationship with each other despite language barriers. When possible, use short phrases to help the interpreter keep up with the conversation.
Found In Translation
Arabic translator Lina Zibdeh remembers the first time she saw the recommendation in a patient education document that leftover medications should be discarded in used cat litter or coffee grounds.
There isn’t a direct translation for this concept in Arabic, a language that is spoken in different dialects by 22 countries but written in one common form. “It can take hours and extensive research to make sure a concept like this is translated correctly,” says Zibdeh, who translates written materials, such as informed consent forms, welcome packets, care instructions, brochures, video scripts and more. In this case, Zibdeh had to add an additional sentence to explain that medications should be disposed of in this way so they are not enticing to children and pets.
While translation programs like Google Translate are readily available and easy to use, they often produce inaccurate translations, which can confuse patients and lead to poor health outcomes. This is because words in sentences can be organized in different ways from one language to another. Thus, when online programs translate those sentences from, say, English to Chinese, they can change the meaning, says Chinese-Mandarin interpreter and translator Yinghong Huang. Some English words, such as discharge, also have multiple meanings. “It’s very rare for a program to get the right meaning,” Huang says. Even Huang has to use tools, such as her cellphone and an online dictionary, to produce accurate translations.
Along with improving health outcomes, documents that are available in a patient’s own language can make him or her feel more comfortable and secure, says Zibdeh, who organized the American Translators Association’s first webinar for the Arabic Division on Arabic Medical Translation in early 2014. “It helps that patient feel closer to home,” she adds.
By JOANN S. LUBLIN
Is there such a thing as a diversity dividend?
A new study of 366 public companies in the U.S., Canada, U.K., Brazil, Mexico and Chile by McKinsey & Co., a major management consultancy, found a statistically significant relationship between companies with women and minorities in their upper ranks and better financial performance as measured by earnings before interest and tax, or EBIT.
The findings could further fuel employers’ efforts to increase the ranks of women and people of color for executive suites and boardrooms — an issue where some progress is being made, albeit slowly.
McKinsey researchers examined the gender, ethnic and racial makeup of top management teams and boards for large concerns across a range of industries as of 2014. Then, they analyzed the firms’ average earnings before interest and taxes between 2010 and 2013. They collected but didn’t analyze other financial measures such as return on equity.
Businesses with the most gender diverse leadership were 15% more likely to report financial returns above their national industry median, the study showed. An even more striking link turned up at concerns with extensive ethnic diversity. Those best performers were 35% more likely to have financial returns that outpace their industry, according to the analysis. The report did not disclose specific companies.
Highly diverse companies appear to excel financially due to their talent recruitment efforts, strong customer orientation, increased employee satisfaction and improved decision making, the report said. Those possible factors emerged from prior McKinsey research about diversity.
McKinsey cited “measurable progress” among U.S. companies, where women now represent about 16% of executive teams — compared with 12% for U.K. ones and 6% for Brazilian ones. But American businesses don’t see a financial payoff from gender diversity “until women constitute at least 22% of a senior executive team,’’ the study noted. (McKinsey tracked 186 U.S. and Canadian firms.)
The study marks the first time “that the impact of ethnic and gender diversity on financial performance has been looked at for an international sample of companies,’’ said Vivian Hunt, a co-author, in an interview. Yet “no company is a high performer on both ethnic diversity and on gender,’’ she reported.
And “very few U.S. companies yet have a systematic approach to diversity that is able to consistently achieve a diverse global talent pool,” Ms. Hunt added.
McKinsey has long tracked workplace diversity. A 2007 study, for instance, uncovered a positive relationship between corporate performance and the elevated presence of working women in European countries such as the U.K., France and Germany.
The UCLA Health Interpreter/Translation and Deaf Services program provides services to all UCLA Health inpatients, outpatients, and their relatives at no cost. Every attempt is made to provide services in any language. The service will be provided by an in-person interpreter, video conference or by telephone.
By Caitlyn Coverly
A few weeks ago, senior vice-president Laszlo Bock took to Google’s official blog to publicly share the company’s employee demographics, revealing a predominately white male workforce and admitting a reluctance to come forward with the data earlier.
The announcement was deemed a groundbreaking disclosure, because U.S. companies are not obligated to make their workforce demographics public. However, citing that transparency is key to finding a solution, Mr. Bock wrote, “Simply put, Google is not where we want to be when it comes to diversity … our efforts, including going public with these numbers, are designed to help us recruit and develop the world’s most talented and diverse people.”
In Canada, many companies have come to realize the strategic importance of a diverse workforce and, much like Google, have initiated comprehensive diversity strategies. But developing and executing those strategies is no easy feat.
Financial institutions were among the first organizations to act on the long-term demographic and labour-market significance of Canada’s Employment Equity Act, which requires special measures and the accommodation of differences for four designated groups in Canada: women, aboriginal peoples, persons with disabilities and members of visible minorities.
“As a regulated organization, we looked at diversity from a compliance perspective at first,” said Norma Tombari, director of Global Diversity at the Royal Bank of Canada. “However, with the appointment of Gordon Nixon as CEO in 2001, came the revitalization of a very robust diversity strategy; what we refer to as our Diversity Blueprint.”
RBC has been recognized in recent years for its achievements in diversity and inclusion practices. Its 2013 Diversity and Inclusion Report shows RBC’s workforce is comprised of 64% women, 31% visible minorities, 4.6% people with disabilities and 1.5% aboriginal persons — numbers that are fairly representative of the general workforce in Canada.
So, how do companies reach this level?
“Education becomes key when you are managing a multicultural and multigenerational workforce,” Ms. Tombari said. “There will be unconscious bias and blindspots, as well as a lack of cultural understanding and awareness throughout all levels of the organization, so it is our job to put programs in place that counter those attitudes.”
RBC takes a multifaceted approach, offering employees various workshops and webcasts on raising cultural acumen, as well as access to self-assessment tools where employees can rate their own level of understanding.
“The goal is to provide learning that is focused on the topic of diversity and inclusion and the rest is about embedding it in the cultural landscape of an organization,” Ms. Tombari said.
Canada’s energy giant Suncor is at a different stage of the diversity and inclusion-implementation process. After merging with Petro-Canada in 2009, changes in corporate structure created a tidal wave of new systems and strategies.
“With so much change and turnover, some things — such as our diversity strategies — got pushed to the side,” said Kelli Stevens, a company spokeswoman.
The company’s 2012 diversity report shows Suncor’s workforce is comprised of 23% women, 11.1% visible minorities and 2.7% Aboriginal persons. “We don’t look at our current percentages and think that’s okay,” Ms. Stevens said. “We are, and always will be, trying to improve them.”
Suncor, similar to Google, faces the uphill battle of recruiting from a rather homogenous talent pool. “We are a male-dominated field,” Ms. Stevens said.
In 2011, women earned only 16.5% of degrees/diplomas categorized within the fields of architecture, engineering and related technologies, Statistics Canada data shows. In fields relating to mathematics, computer and information sciences, women earned only 27% of degrees/diplomas. However, out of those pursuing post-secondary education, women account for more than half at 58%.
Suncor is in the process of developing a strategy that makes those desires a reality. Part of that strategy is supporting various programs that work to broaden the talent pool.
In March 2013, the Suncor Energy Foundation approved a five-year, $1.5-million program aimed at helping Women Building Futures (WBF), an organization that specializes in encouraging and preparing women for careers in skilled trades, to refine its business model and expand its impact.
Suncor also provides funding for Actua, the Ottawa-based national science, technology engineering, and mathematics (STEM) program, to help develop and deliver STEM programs to Aboriginal youth across Canada.
“Many of the communities we have a strong presence in have a high representation of aboriginal people,” Ms. Stevens said. “We want to be reflective of where we work and build strong relationships with those communities.”
Echoed in both companies’ strategies is the hard fact that implementing a diversity strategy is not easy; it is a long-term commitment with results as well as challenges at all stages.
Susan Black, managing partner at Crossbar Group, and Keith Caver, North America practice leader for talent management and organizational alignment at Towers Watson, offer the following advice for corporations undergoing a significant change in workforce demographics:
Inclusion is about making the numbers count: “Companies tend to jump right into programs without clearly defining their goals,” Ms. Black said. “This is often the result of a disconnect in their understanding of their own issues. In an ideal world, having a 50/50 split between male and female employees would be considered success, however, companies really need to look at their corporate structure and their client base to determine if that is what is best for their organization.”
Don’t define diversity too narrowly: “Companies tend to frame all diversity efforts around the four groups and they end up leaving a lot of white space,” Ms. Black said. “As a result people get left out of the diversity conversation. We are all a part of diversity and the thoughts and opinions of everyone should be valued in an organization.”
Culture isn’t something you can change overnight: “It typically goes one of two ways,” she said. “Either organizations declare victory too soon or they fall prey to diversity fatigue. The fact is it takes a long time to change workplace cultures. Don’t rush the process.”
You must address cultural differences and unconscious bias: “It is not good enough to just have the people in place,” Mr. Caver said. “There is an array of information available about shifting demographics and leveraging human capital. There must be an unwavering commitment to educating and preparing leaders so companies are not held back by hidden biases.”