Miranda is a recent graduate of the University of Washington Department of Epidemiology Master of Public Health program on the Maternal and Child Health track through the University of Washington Center of Excellence in Maternal and Child Health. While completing her MPH, she was a Title V MCH Intern at the Wisconsin Department of Health Services in Madison, Wisconsin. Her thesis work examined the cross-sectional and longitudinal associations between teacher support, stressful life events, and depression outcomes among middle schoolers. In September 2019, Miranda will be beginning the PhD program in Epidemiology at the University of Washington and hopes to continue to engage with maternal and child health, mental health, and the life course approach in her future work.
“While people working in public health have wide ranging backgrounds, interests, and career paths, all are motivated by the desire to improve the health of populations. Paramount to this goal is understanding social and demographic factors that are associated with decreased access to healthcare and poorer health outcomes in order to effectively address the underlying causes. For example, as recently highlighted in major news outlets such as NPR and The Washington Post, Black and Native American and Alaska Native individuals are 3.3 and 2.5 times more likely to die due to pregnancy-related complications compared to White individuals, respectively. Racial and ethnic differences seen in obstetric and gynecological outcomes in the United States may be due to a myriad of factors beyond genetics, such as the experience of racism, the structure of the American healthcare system, and implicit biases of healthcare providers.
My perception of cultural competency is that it is often viewed as most relevant to individual-level interactions. However, as a budding epidemiologist, most of my time is spent reading journal articles, writing and running statistical code, and interpreting findings within the greater context of the study setting, meaning I often have little to no contact with the people that I hope will most benefit from my work. Yet, cultural competence plays a huge role in the day-to-day work of epidemiologists, especially for those working to understand and eliminate health inequities.
Let’s consider a hypothetical example. You are an epidemiologist at your state health department and you are tasked with preparing a summary of Type 2 diabetes among children and youth for the governor to use in upcoming policy decision-making. Surely, you will want to present an overall measure of prevalence (e.g. X percent of children have been diagnosed with Type 2 diabetes in their lifetime in your state). But what else is relevant? To answer these questions, you would need to carefully consider the communities in your state. Furthermore, you will need to recognize that you have implicit biases that may limit your ability to dig deep enough to elucidate underlying social determinants of health that may be at play. Perhaps you should spend some extra time reviewing the academic literature on risk factors for childhood diabetes and consult with stakeholders, such as pediatricians and caregivers, to ensure that you can provide the governor with a clear, unbiased snapshot.
Next, using all this information you have gathered, it would be important to examine stratified measures of Type 2 diabetes, such as the prevalence of diabetes among those living above and below the federal poverty level, and figures that highlight stakeholder concerns, such as access to resources for diabetes care. Your findings may show that there is substantial variation across different social and demographic characteristics. How do you interpret these differences? How do you communicate the role of social factors that you identified as important? In your report, how do you include the ways that local, state, and federal systems and policies may be influencing the trends you have highlighted?
At each step in this process, you (the epidemiologist) must carefully consider your own biases in analyzing and interpreting data, how individual-level characteristics (e.g. race, ethnicity, gender, sexuality) impact the numbers you are seeing and what the underlying reasons for any associations may be, and how both historical and existing systems may have influenced the current trends. In our hypothetical scenario, you have probably spent very little time with children who have Type 2 diabetes and their caregivers, but you still need to employ cultural competency at each step of the process.
To end our conversation about cultural competency, I want to acknowledge that cultural competence is a personal and ongoing process. In my public health training, I have learned that there is always more to learn! As we move throughout our careers in maternal and child health, we must actively and intentionally seek to improve our understanding of existing inequities, the systems that perpetuate inequities, and what we can do to eliminate inequities to our daily work.”
-Miranda Delawalla
For further resources on health equity and improving cultural competency, please see:
- The Maternal and Child Health Bureau page on Leadership Competency #7: Cultural Competency
- The Georgetown University National Center for Cultural Competence list of educational resources
- The World Health Organization on equity
- The Boston Public Health Commission on health disparities vs. health inequities
- Project Implicit, a resource of tests to help identify implicit biases
