Rally Your State Coalition II: Cultural Competency

Tilly Gurman, DrPHJune 29, 2009

tgurman@gwu.edu

Session ObjectivesObjective 1:Explain why cultural competency matters in reducing disparities related to folic acid

Objective 2:Discuss how culture and language can impact the effectiveness of coalitions

Objective 3:Identify strategies to increase participation of diverse populations in coalition efforts

Group normsParticipate voluntarily Speak from your own experience

Take risks

Regarding your participation

Respect other opinions and experiences

Maintain an open mind Listen when others speak

Respect confidentiality

Regarding other’s

participation

Silence beeper/cellphoneTake care of yourselfFollow the time

Regarding logistics

Disclaimers

Usage of term Latino vs. Hispanic Brief introduction to topics and

skills I may speak from personal and

professional experience Distinction between cultural

patterns and stereotypes

What is culture?

When you hear the word “culture” what comes to

mind?

When you hear the word “culture” what comes to mind………

LanguageLanguage

Religion Traditions

Gender RolesAcculturation

VALUESIm

migration Family Structure

NORMS

PoliticalPower

Source: Helman (2001)

Definition of culture

A set of guidelines, (both explicit and implicit), that individuals inherit as members of a particular society, and which tell them how to view the

world, how to experience it emotionally, and how to behave in it

in relation to other people, to supernatural forces and gods, and

the natural environment.

Cultural competency

A life-long developmental and emotional process that requires

continued intellectual, emotional, and critical

understanding of specific values, attitudes, knowledge,

and skills that allow individuals to communicate and work with

others.

Source: Advocates for Youth (1994)

Reason 1: Diversification of the population

Why does cultural competency matter?

Population trends:Latinos in US In US, 3 largest

groups are 1. Mexican 2. Puerto Rican3. Cuban

Diversity of languages, socioeconomic status, immigration history, cultures

Source: Suarez and Ramirez (1999)

Source: Hobbs and Stoops (2002)

Growth of US Latino Population,

1980- 200035.3

22.4

14.69

12.5

6.4

05

10152025303540

1980 1990 2000Year

Latino Population(millions)

Percent Latino

Population trends:Latinos in US

Reason 2: Trends in public health indicate a

need to better reach diverse populations

Why does cultural competency matter?

First birth by age 20, among females

15–24 years of age: US, 2002

0.08

0.20.24

0

0.1

0.2

0.3

1

Prob

abili

ty

White African American Latina

Source: Abma (2004)

Compared to White women, Latinas are twice as likely to not begin prenatal care until after the first trimester or not at all.

Health care access

Source: Lillie-Blanton et al (2003)

Source: CDC, 2001

Folic acid A woman is less likely to be aware

of folic acid as a way to prevent birth defects if she…• is less educated (high school or less)• is Black, Hispanic, or other

race/ethnicty• entered prenatal care after the first

trimester• did not intend the pregnancy

Source: CDC, 2007

Folate Concentration by Race/Ethnicity,

1999-2004

HP2010 Objective: 220 ng/mL RBC folate

Reason 3: Ensures more successful coalitions

Why does cultural competency matter?

Why does cultural competency matter?

Welcomes variety of views and creativity when developing and implementing coalition activities

Increases accessibility and participation of collaborative partners from diverse backgrounds

Facilitates recruitment and retention of a more diverse and representative coalition

Improves sustainability of collaborative relationships

Why does cultural competency matter?

Ensures health education programming that is more culturally relevant and appropriate

Increases effectiveness of health education and communication interventions

Fosters word-of-mouth advertising in community

Builds trust and improves coalition’s credibility in community

Cultural competence skills

3. Ability to keep own cultural values and communication preferences in check

1. Ability to obtain knowledge of other cultures, recognize the diversity within groups, and understand the dynamics of difference

2. Ability to adapt communication style to fit the cultural context of others

Source: Monroe, Goldman, & Dube (1994)

Iceberg

1. What are characteristics of individuals that are immediately apparent to others?

2. What are characteristics of individuals that may not immediately apparent to others?

Ways in which ethnic groups differ

Sense of self, space, physical contact Communication styles and language Dress and appearance Food and eating habits Time, timeliness, time consciousness Focus of relationships, family, friends Valuing individual vs. group Beliefs about authority, control, fate Gender roles

Source: Gardenswartz L, & Rowe A. (1993)

La cultura se cura…

Five elements related to Latino culture with possible implications

for reducing disparities in folic acid

Culture and implications Language

• Spanish is not universal

• Generational differences

60% Spanish dominant

20% bilingual

20% English dominant

Source: Kaiser Permanente.

More acculturated less likely to need interpreter and more likely

to be familiar with biomedical approach of health•Regional US differences

Culture and implications

Language

1. Having a Spanish interpreter/Spanish-language materials is not always appropriate

2. Importance of having Spanish interpreter/Spanish language materials available

3. Non-English proficiency may suggest more traditional cultural perspectiveSources: Andrulis D, Goodman N, and Pryor C.

(2002) Kaiser Permanente.

Implications:

Culture and implications

Familismo… importance of family unit

1. Independent decision-making may not be the norm

2. Potential involvement of other family members in decision-making

3. More acculturated individuals may stress independence

Implications:

Culture and implications

Respeto… sense of respect for authority and deference to experts

1. Patient may defer to a provider, health educator, etc.

2. Patient may be reluctant to ask questions about diet, folic acid, etc.

3. Nod of head may be to show respect, not understanding

Implications:

Culture and implications Personalismo… importance of

personal relationships

1. Perception that provider should be personal

2. Patient may want to remain with one provider… especially at times of grief or crisis such as fetal death

3. Recruiting for events and coalitions may require more time for establishing rapport

Implications:

Culture and implications

Fatalism…being OK with whatever consequences

1. Fatalism may be confused for complacence

2. May affect preventive health behaviors … especially when combined with barriers to accessing care

Implications:

Feature films are the

result of years of

scientific study

combined with years of experience.

Communication self-assessment

Communication self-assessment

Share responses with partner.

Are there any hot buttons for you? How do you typically handle this situation?

Provide one example from your coalition involvement where one of the communication styles impeded effective communication.

Communication and culture: Sources of possible miscommunication

Verbal communication: Language and literacy Assumption that words have a set

meaning Slang, idioms, technical jargon “Yes” may not indicate that message is

understood Appropriate subjects for conversation Acceptability of asking personal questions “Small talk” vs. getting “to the point” Loudness/pitch/silence

Sources: Mutha S, Allen C, & Welch M. (2002) Anand (1999)

Koslow D, & Salett E. (1989)

Non-verbal communication: Assumption that gestures and non-

verbal cues have a set meaning Direct vs. indirect eye contact while

speaking, listening Physical contact and distance Speaking with emotional intensity vs.

emotional restraint

Communication and culture: Sources of possible miscommunication

Sources: Mutha S, Allen C, & Welch M. (2002) Anand (1999)

Koslow D, & Salett E. (1989)

Preconceptions and stereotypes:

Negative judgement based on different values

Assumption that accent or ability to speak a language reflects intellect

Assumptions about pacing/timing of speech

Communication and culture: Sources of possible miscommunication

Sources: Anand (1999) Koslow D, & Salett E. (1989)

How can we become more culturally competent?

Explore our own communities and cultures

Engage in self-awareness

Seek out information Increase culture-specific awareness

Make conscious effort not to act on our stereotypes and assumptions

Strive to prevent miscommunication

Within ourselves:

Source: Anand (1999)

As we interact with others:

Source: Anand (1999)

Listen with respect, openness, and patience

Establish trust

Show concern and empathy

Treat each person as a unique individual

Look at situation from other person’s view Be sensitive to face-saving needs

Tolerate ambiguity

How can we become more culturally competent?

Within coalitions: Revise coalition’s vision/mission/goals/

objectives to address inclusion of diversity

Recruit and retain diverse membership and leadership, including representation from the community served

Embrace and manage conflict and miscommunication

Incorporate diverse viewpoints in coalition-sponsored activities

Establish relationships

How can we become more culturally competent?

Within coalitions: Expand outreach activities (both for

coalition membership and activities)

Consider elements such as language, familismo, respeto, personalismo, and fatalismo when developing materials and activities

Create materials for populations that are low-literacy and limited English proficiency

Conduct on-going evaluation of coalition’s efforts at inclusion and diversity

How can we become more culturally competent?

1.Start2.Stop 3.Continue

We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter what their color.

-Maya Angelou

Sources CitedAbma JC, Martinez, GM, Mosher, WD, Dawson, BS. (2004) Teenagers in the United States: Sexual activitiy, contraceptive use, and childbearing, 2002. National Center for Health Statistics. Vital Health Stat 23(24).

Advocates for Youth. (1994). A youth leader's guide to building cultural competence. Washington, DC: Author.

Anand R. (1999). Cultural competency in health care: A guide for trainers (2nd Ed.). Washington, DC: National MultiCultural Institute.

Andrulis D, Goodman N, and Pryor C. (2002)What a difference an interpreter can make: Health care experiences of uninsured with limited English proficiency. Access Project:Boston.

CDC. (2001). Are Women with Recent Live Births Aware of the Benefits of Folic Acid? MMWR. 50;3-14. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5006a1.htm. Accessed: June 12, 2009.

CDC. (2007). Folate status in women of childbearing age, by race/ethnicity-United States, 1999-2000, 2001-2002, and 2003-2004. MMWR. 55:1377-80. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a2.htm. Accessed: June 12, 2009.

Flores, G., Laws, M. B., Mayo, S. J., Zuckerman, B., Abreu, M., Medina, L., & Hardt, E. J. (2003). Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics, 111, 6-14.

Gardenswartz L, & Rowe A. (1998). Managing diversity in health care. San Francisco: Jossey-Bass.

Sources Cited

Helman CG. Culture, health, and illness. (2001). London:Arnold.

Kaiser Permanente National Diversity Council and the Kaiser Permanente National Diversity Department. (2000). A provider’s handbook on culturally competent care: Latino population. San Francisco: Author.

Koslow D, & Salett E. (1989).Crossing cultures in mental health. Washington, DC: SIETAR International.

Lillie-Blanton M, Rushing OE, Ruiz S. (2003). Key facts: Race, ethnicity, and medical care. Kaiser Family Foundation.

Monroe A, Goldman R, & Dube C. (1994). Introduction and overview. In Dubé C.E., Lewis D.C. (eds.). Project ADEPT Curriculum for Primary Care Physician Training: Volume V Race, Culture and Ethnicity: Addressing Alcohol and Other Drug Problems. Providence, R.I.: Brown University.

Mutha S, Allen C, & Welch M. (2002). Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies. San Francisco, CA: Center for the Health Professions, University of California, San Francisco.

US Census Bureau (2000). Mapping Census 2000: The Geography of US Diversity. Census 2000 Special Reports (CENSR/01-1). Available at: www.census.gov/population/cen2000/atlas/censr01-104.pdf. Accessed: June 12, 2009.

Resources of InterestQuality Health Services for Hispanics: The Cultural Competency Component

Document from HRSA and Office of Minority Health, including information about cultural norms, history and demographics of the Latino population in the US, and public health trends.

Available at: www.hrsa.gov/culturalcompetence/qualityhealthservices/

A Provider’s Handbook on Culturally Competent Care Document from Kaiser Permanente National Diversity Council and the Kaiser Permanente National Diversity Department. Have publications related to racial/ethnic and sexual minority populations as well as individuals with disabilities

Contact:Kaiser Permanente National Diversity DepartmentOne Kaiser Plaza, 22 LakesideOakland, CA 94612 (510) 271-6663

Online Resources of Interest

Cultural Competency: An Agenda for Ending Health Disparities in Maryland

This site has presentations from a 2007 conference. Topics include mental health, language issues, and best practices.

Available at: dhmh.state.md.us/hd/presentations/index.htm

Cultural Competence Resources for Health Care Providers

This Health Resources and Services Administration (HRSA) comprehensive web site offers links to websites that address assessment tools, health issues, racial/ethnic groups, special populations (ie migrant farmworkers, elderly), and training.

Available at: www.hrsa.gov/culturalcompetence

Food and Nutrition Information CenterPart of the U.S. Department of Agriculture and the Agricultural Research Service. The link offers information about ethnicity and diet. Available at: www.nal.usda.gov/fnic/etext/000010.html

Online Resources of Interest

Office of Minority HealthThis website has information and resources related to ethnic minority populations, various health-related issues, as well as cultural competency.Available at: www.omhrc.gov

National MultiCultural Institute (NMCI)NMCI provides information on conferences, publications and resource materials (ie trainer manuals, books, videos.)Available at: www.nmci.org

National Center for Cultural Competence (NCCC)

NCCC provides publications and additional links to websites designed to assist in the design, implementation and evaluation of culturally competent services. Also has tools such as assessments and guidelines.

Available at: www11.georgetown.edu/research/gucchd/nccc