Applying Culture to Managed Care Metrics

Note:  As of May 2013, I have a sister site for the national population health grid mapping project.  Though not as detailed as these pages, it is standalone that reads a lot easier and is easier to navigate.  LINK

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Note: this page and neighboring pages are from older teaching materials used for a lab on GIS and the corresponding lecture/discussion series developed on ‘GIS, population health surveillance, epidemiology and public health’.  The statements made here are timely now, as of 2013.   Fortunately, this project is currently being further developed, and may at times be locked up for changes underway or implementation related concerns.

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Three changes in the current methods used to assess population health are identified as essential to improving and updating the current system in place.

  1. Spatial analysis must be added to this routine.
  2. One year age-specific data must be included and applied to the development on population health evaluation and intervention processes.
  3. Culture, race and ethnicity must become a major focus for all studies.

Our data applied to public health analysis needs to be better understood. To improve upon the value of this data, each datum or collection of variables needs to be better defined in terms of its relevance and applicability to what ever public health projects are at large and whatever health monitoring ideas may be proposed. The most basic requirements of good data apply to the health data as well. meaning that this data must be collected in a fairly rapid and up-to-date fashion, and that the most appropriate form for this data be produced in an accurate fashion.

At first this all seems pretty standard. But the problems that I have seen surface due to poor data gathering practices include more than just the obvious, like missing data and an obviously wrong datum that is too small, too large, etc. The most common problem in medical data at the numbers level pertains to units. For cost data in which patients make a co-pay for a particular drug or health visit, there are two very different sets of numbers that can appear in the single column regarding patient cost. The first is the true co-pay value itself, such as 10, 15, 20, or even 17 dollars. The second is the percent of total cost paid by a patient, the total value for that particular form of health care practice provided in the adjacent column. Fortunately in most cases, that number appears as a percentage with a percentile sign as well detailing its unique trait, or its presence in the form of a decimal value. Were it not for these two features for percentages, it would probably be difficult to separate true cost for virtual cost in need of re-calculation based on the two columns of data.

One of the things about health data is that it is forever changing, and even some of the most basic values for people in a system, like age and gender can sometimes change. In the case of age, this is of course an ongoing actively changing value. In terms of gender however, accidental entries can sometimes be true in the form of a transgender case, but these are very rare, and hard to distinguish from gender entry mistakes without spending a little more time evaluating each case.

Ethnicity is one of the worst datum sets due to its ever changing characteristics. Whereas during the 1980s and 1990s, this datum became well established, and with each census was upgraded somewhat to allow for more options for participants to pick, now it is possible for someone to pick more than one ethnicity response. This latter addition could make for overreporting or not exactly correct reporting. The former is the production now of a mixed ethnicity dataset, each person having more than one ethnicity that he/she asks to be linked to. The second problem pertains to what some might consider false reporting, meaning that someone only reports their three-quarters descent profile, or decides he/she needs to point out his/her Native American heritage of 1/128th significance.

In medicine, culture has several impacts upon a person’s health. The first and most important effect of culture or ethnicity pertains to genetic traits, either with well defined autosomal and gender-linked dominance and recessive features, or with problems generated due to partial dominance (not always presenting). Genetic traits probably have to be recorded in such a way that they can be evaluated based upon how much they are presented, and if they are a trait that may not express until a later age, flagged as such within medical documents, such as certain forms of late onset of blindness, tissue change or degeneration, etc..

Culture also has a behavioral component that plays into the health of an individual. Its most immediate impact next to genetics pertains to disease related problems. These are not so much purely genetic features as they are somatic features partially linked to someone’s genetic profile. Certain somatic problems related to tissue type, form, and changes with growth and aging appear to have some racial or ethnic link, like African Cardiomyopathy and cardiac conduction disorders, a rare alpha-hyperlipoproteinemia trait of Dutch origin, or a Hawaiian blood vessel-induced BP related condition. With physiological and structural traits, culture introduces itself into the lifestyles of people as they age, thereby becoming more likely to express the disease characteristics, which unlike fully expressed genetic trait did not express itself at all in lab results or physiological measures taken during the earlier years.

These culturally linked physiological and anatomical syndromes and diseases are followed in importance by culturally-bound syndromes. The culturally-bound syndromes are conditions in which a sociological and psychological component exists and play a most important role in establishing the fact that such a disease exists and then allows its presence to continue on within the given living environment. Some culturally-bound syndromes can be completely self-contained and generated, whereas others very much depend upon two triggers–the first being personal, both physiological and psychological, the second being friends and family related and usually sociological or ethnological in origin.

This means that there is a trine of Applied Cultural Medicine statistics that have to be considered when reviewing culturally-focused population health features. This trine is as follows:

  • Genetics
  • Culturally-Linked Diseases or Conditions
  • Culturally-bound Syndromes

The Fourth Component

A fourth component–culturally-related–may be added as well that is very much sociological and national or political in nature. This pertains to the social inequalities that exist in a growing region, country, or the like. This is not included with the culturally-bound syndrome since it does not rely upon just culture to exist. It is a result of the impact of culture on other activities and behaviors related to disease onset. Social inequality, poverty and socioeconomics status, which may be correlated to culture, is what makes prevalences for these diagnoses greater. The differences in those who are socioeconomically depraved, versus those who are well off, will lead to different expressions of the same type of medical history. In the least, SES predefine an individual’s long term morbidity, mortality, and cost related factors for these conditions and diseases, and even determines the type and quality of care such individual receive. This latter point suggests a need for a focus on quality of care related metrics for this fourth class of cultural study questions.

One of the best examples of this fourth component has developed over the past 50-75 years, the massive obesity diagnosis linked to Arizona Pima Indians. One interpretation of this condition is that it exists due to a change in lifestyle, such that a former longevity trait (the ability to store calories for the next starvation period), now becomes a health risk due to lack of this social darwinian form of natural selection. During the late 1980s, this longevity was renamed “New World Syndrome” due to this change in lifestyle on behalf of the Pima, and a change in the interpretation of their lifestyle and health made by medical anthropologists. In actuality, this change in appearance and chronic disease tendencies is a result of a gene (genetic in nature), manifesting itself physiologically (resembling culturally-linked) due to behavioral lifestyle changes and available foodstuffs (cultural revival-bound). The end result is both a change in lifestyle, the re-expression of a genetic trait, due to the changes in lifestyle and re-acculturation. Now, other chronic diseases become attached to this situation, namely diabetes, hypertension, hyperlipidemia, gall bladder disease, heart failure, and liver problems. These diseases typical of most people are applied to this specific form of cultural medicine for cultural medicine research in order to determine the personal behavioral, social and cultural patterns responsible for their higher onset than in most other populations. Social inequity plays just as important a role as the more culturally-specific foodways and changes in eating and drinking habits, and modified physical exercise related activities that we often assign as the causes for this condition.

For this review of cultural health, separate pages are being or have been developed to review each of the types of cultural health metrics noted above. This page focuses specifically on how to improve our analyses of the third series of changes recommended for an evaluation of cultural health, namely a focus on culturally-bound syndromes. When ICD9 was the standard, it was difficult to assign an identifier to certain culturally-bound disease patterns, other than to assign them an American or Western European allopathic point of view for the conditions. The problem with this method of classifying diseases is in part what led to the early modification of psychological and psychiatric disease patterns to the newer, more detailed ICD10 system. But both systems of ICDs have some values in assessing culturally-related illness. The ICD10 is too detailed for some analyses of culturally-linked and culturally-related (generic chronic diseases influences in certain cultural groups more) and adds to the complexity and time needed to perfect such an analytic method. ICD10 however does assign new identifiers for culturally-bound syndromes, and even though it is nearly a decade behind by now with this list, allows for more accurate analyses to be made of many culturally-bound conditions.

For these reasons, I will first go over the dilemmas we are now facing with ethnicity and race that are independent of the ICD9-10 problem, to illustrate the other causes for any problematic outcomes probably developed by many early attempts to develop a way to study culture and disease. Then I will provide examples illustrating why this process is needed and how we can avoid making mistakes in our approach to health data applications due to ethnicity definition problems, and define how to make the best use of it. In the following items, culture defines not only race or ethnicity, but also religion, specific forms of lifestyle practices, and the variety of regional socioeconomic kinds of cultures that can exist. Of course, the easiest cultures to define will be those related to race of ethnicity, but with time and adequate records review, we should be able to develop some insights into other cultures as well such as those define by religion, sexual practices, and even the popular culture settings.

To avoid problems dealing with classification of “cultures” for cultural health studies, the following preliminary questions are recommended for review by researchers, before any data is collected for this project. If the following steps are taken, a more accurate culturally-related population health research can be developed.

The first three steps that follow are preparatory, requiring that the method of social analysis be well explored and developed before you begin. The next seven steps are all related to cultural geography and cultural epidemiology goals of this part of a regional public health oriented mapping project. Each questions is followed by a brief discussion defining its value, purpose and and potential contributions to a project.

Preliminary Research Questions

1. Define your region and its physiographic, transportation-related, and population density related boundaries and indicators.

This is self explanatory. It is helpful to determine your potential needs, distance and space limits, and possible overlaps with other regions, places or programs carrying out a similar task.

2. Define how the regions will be differentiated, or subdivided into subregions.

Allow for at least the following methods to be developed, in descending order of significance:

  • a) the definition of the principle cultural groups standard for the U.S. setting, namely Native American, African/Carribean, and Oriental.
  • b) the definition of the following major religious settings: Judaic clusters, Muslim or Islamic clusters, and alternative or small non-Christian sects not yet mentioned such as Church of Jesus Christ of Latter Day Saints (“Mormons”), Mennonites, Hassidi, Amish, etc. Other even smaller important groups to know include Seventh Day Adventists, Christian Scientists, Fundamental Mormonists. All of the above can be achieved by mapping the church locations.
  • c) the definition of socioeconomic status groups, followed by the breakdown of those groups in need of specific forms of local review.

3. Define specific small cultural groups that you might suspect to be a part of your locality or region.

Small cultural groups unique to a region need not have a religious or ethnic reason for their development. In the Pacific Northwest, it is not unusual for utopian communities to be established within rural areas where road names are a rarity, and road numbering with the use of mile markers to indicate a location a fairly common practice. In many western states, these utopian groups are very similar to some of the religious sects, with the exception that these groups are much smaller. If we review these groups based on their major principles, such as being communal-family-community oriented, anti-technological/anti-modernist, or anti-establishment/anti-government in nature, this provides us with helpful insights into how to keep track of such small population settings. More than likely there are unique epidemiological differences within these social systems, such as the increased likelihood of food poisoning due to bacterial contamination in utopian environmentally conscious community settings, versus the likelihood for behavior related condition or even culturally bound problems and conditions developing in certain highly philosophically driven communal settings, like a hispanic setting with the likelihood for presenting psychiatric and behavioral-psychological cases of “diablo”, a Native American setting with the possibility of developing poorly managed psychiatric patients or epilepsy patients, or a Laotian suburban setting with the likelihood of developing clusters of Sudden Unexplained Nocturnal Death Syndrome (SUNDS).

4. Define your region’s ethnic heritage and history..

This begins the GIS-focused portion of this work.

The goal is to develop a better understanding of the local pre- and post-Columbian cultural upbringing and the related economic development histories of the study region(s). Not all regions have just the Native American heritage we have all learned and stereotyped over the past decades or more. Some regions have a Spanish heritage, the members of which avoid any association with the Native American history. Parts of Alaska have a Russian and/or Aleutian heritage. Hawaii has an Asian-Filipino heritage. Puerto Rico and has a combined indigenous, Cuban, Mexican, and early African American/Slavery related heritage. Parts of the northern edge of the United States have townships with high loyalty towards the Canadian way of living, including lifestyle, foodways and environmental practices. The Tex-Mex border has a cultural setting in certain towns that are very non-U.S. in nature and probably more Mexican when it comes to disease ecological behaviors. In Florida, there are several very distinct Cuban or or Caribbean settings that need to be distinguished from other cultures known to be more of an African descent and Middle American Native or Native-Hispanic (Hispaniolic) descent. In New York and New Jersey, there are small communities where unique religious cultures reside, such as Judaism, the various Oriental traditions, and the Muslim ways of being.

5. Define your region’s permanent cultures.

In some regions, a culture might exist only for a short time. It is hard to predict the future of a given culture within the local setting, but based upon cultural change, history and size, we can determine the amount of time and manpower that might have to be developed to better the health care provided to each of these small communities. In the Pacific Northwest for example there are a number of very distinct and different Asian cultures that in the past have often been placed into a single set of guidelines concerning any care related concerns. The Hmong are actually occupants of the North Vietnam wilderness, who migrated there out of China, and who were not well respected by both Vietnamese and Chinese cultures; they have the greatest fertility rates in the U.S.. They were originally associated with the South Vietnamese, Laotians and Cambodians who also migrated to this country during the midst of the Vietnam War, a short time before the City of Saigon was taken by Northern Vietnam. Each country had its own religious followings, some indigenous in nature and others more modernized or even westernized. This resulted in mayhem in the Pacific Northwest with regard to culturally defined and sensitized care programs. Each group had its unique nuances about how care is to be traditionally provided for by the traditional community, which the U.S. Social Services providers had to learn to make major adjustments for. A lack of adequate preparation and adjustments for these in-migrations made it possible for new contagious and non-contagious infectious diseases to come to this country, the most prevalent of which was probably tuberculosis. We perhaps even still see sign of this past due to the high rates of congenital tuberculosis seen in young children in this region today.

6. Define your region’s socioeconomic cultures.

All regions have sub-regions with socioeconomic differences. The basic line of reasoning here is to try to compare various health measures for rich populations to the same for the poor populations. The questions to answer for this work are: are there regions in which poverty prevail and if so, where are they? and are there regions where the poverty lifestyle is more individualistic and integrated into places where the rich also reside? Chances are any region studying its health measures is going to have both of these forms of poverty to contend with. The latter form is most like to be found in a well established community with traditional residencies such as retirees residing in original homes within a community bearing homeowners of various middle and higher income ranges ranks and scores. The former will be associated with those social settings we tend to stereotype in our minds, the local poverty stricken apartment complexes, urban redevelopment neighborhoods, Section 8 communities. The reason we need to know about these is obvious. In nearly all prior non-GIS studies of local population health, there has never been the complete spatial focus on each of these issues, other than studies aimed at redesigning health care in certain predefined low income settings; these GIS programs were developed due to well established grant programs already developed and heavily promoted. By applying this method of modeling small populations for all communities out there, we can better understand where newer examples of these communities are developing, for example due to the influx of a small Russian, Hassidic or South American low income cultural group. Furthermore, by mapping this information, methods of prediction can be established and early warnings produced for places where improvements in local surveillance clinically and pathologically can be used to prevent the onset of predictable, preventible diseases.

7. Define your region’s brand new cultures.

Brand new cultures are those typically with small, local followings, not yet materialized with other social settings outside a given region. Some of these cultures will continue to grow and develop large following locally and elsewhere. Other might continue to survive but remain mostly a local, small to large regionally restricted movement. Examples of cultural movements that were very local when they formed and then expanded include the poverty stricken runaway teen communities of the Pacific Northwest, which in themselves bore several subcultures that were quite distinct from each other. There are the Gothic and non-Gothic communities, the skinheads versus faux mohawks, the users (of street drugs) versus non-users (some evangelical), the less frequently sexually active paupers versus the financially more self-sufficient teenage prostitutes. New cultures create new public health dilemmas because they introduce new avenues for disease and illness developments, like the spread of STDs due to new social relationship purposes that are defined, or the transmission of a culturally linked disease from one person to the next, like an imported virus or organismal disease. Diseases developed due to certain behaviors and lifestyle practices, certain culturally define mores and taboos, may come about due to these social relationships that have formed. The in-migration of new culturally based families, especially those with children, are apt to result in some form of change due to the shared cultural knowledge that is shared. The purpose of public health monitoring of these social events is to first define their local place(s), then learn to recognize these changes in lifestyle as they are developing, as well as identify their intellectual transmission routes and barriers, and determine if they have the chance for expanding.

8. Define your region’s past cultures that were formed and seemed temporary for the time, but which have since given rise to a fairly active social or behavioral movement.

Understanding why some cultures develop and rise in popularity and followings is important to any culturally based medical mapping study. Culturally and economically, we often try to categorize a setting based upon fairly recent parts of its economic history, such as interpreting its public health as a result of its former whaling, mining or logging history, or defining it to be a place with a long term moonshine, tobacco, or cannabis production history and a related social acceptance of these products. Some regions have stereotypes assigned to them that define their medical history and future. For example, a place once occupied by several big businesses but now a victim of a local recession, if it survives, will experience certain changes as a result of its local economy. A coal town could become a divers’ training facility. A former fishing town with a long history of low income families and retirees residing in cottage villages could turn into a surfer’s getaway with new yuppie based stores, products, food-related products and unique needs due to emergent or urgent care events.

As new people move in or pass through, new stresses on the local services develop. One type of community that has demonstrated this form of economic rejuvenation is the outdoor recreation setting. In Oregon, there was a small city, formerly a lumber industry setting, that was converted first to a popular ski haven active mostly in the winter, but then converted to a summer recreation site as well due to its rock-faces, woodland and rangeland ATV trails, remaining hikeable forests and peri-riparian settings, and its curiosity landforms such as the extensive lava flows used by NASA to train astronauts. In Colorado, the town of Grand Lake has taken on a similar history in its development, and due to the geology and visitor sites set up along the western edge of Colorado, Grand Junction is now experiencing such a change in its economic patterns, and the kinds of emergent, urgent and traditional forms of services needed for the upcoming years in medical care.

9. Try to define your region’s future cultural situations and stressors.

Based upon place, land use patterns and overall demographics, we can see where certain forms of change and development can happen. We can also the use these insights to define potential future health related needs. Once the base cultures of a large area are established, we can use this information to develop ways to monitor for future change. A specific range of childhood immunization behaviors for example would experience a sudden change should a new in-migration pattern develop. A region with low numbers of well immunized children, which in turn suddenly show a small cluster of immunized diseases developed at prevalence rates too small to be considered statistically significant, will in fact be significant regardless of the theory behind that equation and its probabilities for correctness, with a cause in need of definition like the in-migration of new families or the pass-through of unimmunized visitors who were also unknowingly disease carriers. For nearly all regional studies, unique stressors related to the above topics can be defined. Colorado for example has four very well defined cultural groups defined: Native American, African American, Very Old Mexican Family Settlers, and Jewish. It also has well defined high income and low income regions within rural and borderland suburban settings. It also has natural human resource generated unemployed, poverty stricken pockets, and uninhabited places with high level investments, and the potential for positively or negatively impacting the borderland communities, such as through environmental exposure generated diseases or development of new economic stressors due to the greater numbers of tourists and recreationists passing through.

10. Try to predict your region’s future health needs on behalf of each of its cultures.

Natural and human ecology features, demographics, population density, and commercial and public transportation routes define a region’s past, present and future public health status. By understanding cultural history and modern cultural behavioral patterns, we can develop some fairly useful models for monitoring and investigating a region’s public health patterns, using these to predict future health care needs and financial stressors or benefits. By implementing a GIS to monitor regional and local health, we are able to monitor the current health care markets, determine more precisely where specific changes need to be made, and identify where future changes in needs might exist. By adding culture to the population health monitoring program, we are able to use that system to define where the stressors exist and where specific types of changes need to be made. Rather than implement plans for expensive intervention activities across large regions, influencing too many people, we can better target the changes we want to make, substantially reducing whatever costs are involved and influencing those socioeconomic and cultural settings most in need of these changes.

To prepare for cultural surveillance program, the following changes have to be made before you begin arbitrarily documenting certain forms of cultural heritage and change, while ignoring the rest unintentionally.

  1. Identify culturally bound syndromes, culturally bound illnesses, and culturally prevalent disease patterns,
  2. Map out the basic cultures that are known exist in your region
  3. Identify and map the subcultures for these larger groups with internal socioeconomic and ethnogeographical differences
  4. Map out socioeconomics at various small area levels, ranging from block and bock group to zip code related levels
  5. Try to develop a method for point-mapping those groups of people and medical conditions most in need of surveillance and change, beginning with the highest risk subgroups
  6. Develop the knowledge base and resources needed to continue engaging in these efforts.

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