Community Access to Child Health & Healthy Tomorrows Partnership for Children: The Meaning of Cultural Competence

1. Community Access to Child Health & Healthy TomorrowsPartnership for Children:The Meaning of Cultural Competence Danielle Laraque, MD, FAAP Professor of Pediatrics Mount Sinai School of Medicine

2. Disclosure • The speaker in this session has no relevant financial relationships with the manufacturer(s) of any commercial services discussed in this CME activity. The speaker will not discuss or demonstrate pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or “off label” use of an approve device or pharmaceutical.

3. Typical Definitions* Cultural competence is having the capacity to: • value diversity, • conduct self-assessment, • manage the dynamics of difference, • acquire and institutionalize cultural knowledge and • adapt to diversity and the cultural contexts of communities served. Laraque, 2008 *National Center for Cultural Competence, Georgetown University

4. Typical Definitions* Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. (adapted from Cross et al., 1989) Laraque, 2008 *National Center for Cultural Competence, Georgetown University

5. Cultural Competence • Organizational competence • Individual competence • Cultural • Linguistic Laraque, 2008

6. OrganizationalGuiding Values & Principles* • Systems and organizations must sanction, and in some cases mandate the incorporation of cultural knowledge into policy making, infrastructure and practice • CC embraces the principles of equal access and non-discriminatory practices in service delivery Laraque, 2008 *National Center for Cultural Competence, Georgetown University

7. Guiding Values &Principles • Practice & Service Design • Community Engagement • Family & Consumers Laraque, 2008 *National Center for Cultural Competence, Georgetown University

8. Linguistic Competence • Definition: the capacity of an organization and its personnel to communicate effectively, convey information in a manner that is easily understood by diverse audiences, including those of limited English proficiency, those with low literacy, those with disabilities. Laraque, 2008 *National Center for Cultural Competence, Georgetown University

9. Linguistic Competence • Responds effectively to the health literacy needs of populations served • Supported by policy, structures, procedures and dedicated services Laraque, 2008 *National Center for Cultural Competence, Georgetown University

10. National Standards for Culturally & Linguistically Appropriate Services (CLAS) • 14 standards • Theme based • Certain standards are mandated Federal requirements for federally funded programs • There are CLAS guidelines which are activities recommended by Office of Minority Health (OMH) • CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf Laraque, 2008

11. Awareness of CLAS at Academic Health Centers* • Survey of faculty and students • Response rate -300/1025 (29%) and 871/1956 (44%) of students • About 25% of each group reported little familiarity with standards • 46% and 70% of faculty and students, respectively were willing to learn medical Spanish • Web-based instruction was the preferred method • Use of interpreters was about 35% for each group Laraque, 2008 Carrillo-Zuniga G. et al, 2008

12. The Campinha-Bacosta model of Cultural Competence* • Awareness – to raise awareness • Skills –develop communication and patient interaction skills • Knowledge – obtain knowledge about culture, illness and society • Encounters –learn from encounters of those from diverse backgrounds • Desire – to continue the development of cross-cultural skills Laraque, 2008 *Campinha-Bacosta, 2003

13. Epistemologies: A Cultural Perspective • Emic knowledge: of, relating to, or involving analysis of cultural phenomena from the perspective of one who participates in the culture being studied noted in local cultures – the people have authority; an insider, native, indigenous; reflecting parts of ourselves • Etic knowledge: of, relating to, or involving analysis of cultural phenomena from the perspective of one who does not participate in the culture being studied standing external – the scientists have the authority Laraque, 2008

14. The Experience of Culture • Two examples: • Harlem ACTS – CATCH and HTPC -1995, 1997 • CFSP: A Focus on Mental Health –HTPC -2001 Laraque, 2008

15. A Personal Perspectives • The Emic perspective Let’s get personal “ good clinical medicine is always highly personal” - Morris Green, MD Laraque D, 2008

16. Where to Start? Laraque, 2007

17. ECOLOGICALMODEL Community Family Child Laraque, 2008

18. Immersion in the Community • Orientation to the social and physical environment in which one practices • Rooted in the concept that the best way to appreciate someone’s culture and background is through direct contact and life experiences (ML Kamaka) • Influences later physician-patient interactions • Influences provider assumptions • Influences previous stereotypes Laraque, 2008

20. Tools of Community Immersion • Community mapping of resources • Overlay mapping of services, environmental hazards and disease prevalence • Site visits: e.g. to human service agencies, family and housing court, legal aid, health practices and clinics, WIC offices, housing projects, etc… • Walkabout Laraque, 2008

21. The Programs • The context • CATCH Program: Harlem ACTS –CATCH & HTPC • The community need • Proposed solutions • Collaborations • Presence • Evaluation • Commitment and sustainability Laraque, 2008

22. The Harlem Adolescent and Child Total Services (ACTS) • Goal was: • to improve the health status of pregnant and parenting adolescents in Central Harlem by decreasing pregnancy complications and hospitalizations for severe violent injuries • To improve the health status of their children by decreasing the incidence of LBW and incidence of hospitalization for severe injury during the first year of life Laraque, 2008

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25. Teen Focus Groups • Needs assessment • Getting it right –program emphasis • Inclusion Laraque, 2008

26. The Talking Straight Group The New York Times ABOUT NEW YORK; Trying a Talking Cure In a Young, Ailing World By FELICIA R. LEE Published: July 24, 1993 Laraque, 2008

27. Acceptability of Programs • Acceptability of Telepsychiatry in American Indians* • Question – would this method of improving access to psychiatric services increase cultural differences between provider and the patient? *Shore HJ et al, 2008 Laraque, 2008

28. The Programs • The context • CFSP: A Focus on Mental Health Program • The community need • Proposed solutions – Staffing – linguistic competence • Collaborations, Coalitions • Presence • Commitment Laraque, 2008

29. The Child & Family Support Program: A Focus on Mental Health • Goal was to improve the health system’s response to child abuse by: • Linking the detection and evaluation of abused children in East Harlem with access to psychological treatment • Improving the non-offending parent’s access to psychosocial treatment and support Laraque, 2008

30. The Children Laraque, 2008

31. Understanding of Health from a cultural perspective* • Having the family characterize the illness or condition • What they believed caused it • What they think happens with the illness or problem, how things work • How severe or prolonged the illness or situation • How the illness or situation has affected them or their child • Describing their fears Laraque, 2008 *Kleinman A, Benson P. Anthropology in the clinic: the problem of cultural competence and how to fix it. PLoS Med. 2006. 3(10):e294.

32. Linguistic Competence • Veye zo w • Papa’s remembrance • Speaking Chinese in the elevator Clinical relevance • Beyond translation Laraque, 2008 Laraque, 2008

33. Lost in Translation Creole: Veye zo w “watch your back” Literal translation: “follow your bones” Laraque, 2008

34. Linguistic Competence • Veye zo w –literal translation • Papa’s remembrance – mixing languages • Speaking Chinese in the elevator –fear of using one’s own language • Clinical relevance–a case example • Beyond translation Laraque, 2008

35. Organizational Credibility and its role in Cultural Competence • Commitment to other programs • History with the community • Commitment to a diverse workforce • Engagement process • Empowerment Laraque, 2008

36. Influencing Health Status* Systems of Care Training of professionals Laraque, 2008 * Healthy People 2010

37. Approaching Communities Banishing Stereotypes Recognize Fears and Distrust Building Partnerships The Learning Process Toran &Laraque, 2007

38. Inclusion • Respecting individuals • Respecting Roles • Respecting Cultural behaviors and practice • Deferring to others • Understanding the history of collaborations Laraque, 2008

39. Principles of on Community-Based Participatory Research* • Lot to Learn Group • Vehicles Group • Community Group (Not necessarily) • Empowerment Group/Collaborator of Research Toran &Laraque, 2007 *Hatch J, 1993.

40. Question • Who in the audience considers themselves a researcher?

41. Question • Who in the audience considers themselves a researcher? • Who in the audience thinks research is important in informing the community work they do?

42. Conclusion • Describe what you did • Meticulous data collection* • Follow principles of community-based participatory research at its best • Reflect on the qualitative and quantitative accounts of the program *May want to review plan with a researcher

43. Community Coalitions*The Central Harlem Injury Prevention Project: A Model for Change • Identify all parties with an interest • Start only when all parties have agreed on a process • Listen carefully to community concerns and ideas • Be willing to hear criticisms of plans and the process • Give credit to every member of the coalition and be ready to support their separate projects Laraque, 2008 *Laraque D, Barlow B, Davidson L, Welborn C. AJPH 1994; 84(10)1691-2.

44. CommunityConcern Evaluation Environmental Change Education & Awareness Physical Environment Specific Programs Coalitions Social Environment Epidemiologic Data Outcome Data Model for Injury Prevention Laraque D. 1995

45. A Community Research Model: A Challenge to Public Health* • Community-based research programs • Merging evaluation rigor and service • Evaluation designs that are acceptable to the community • Four phases of community-based public health programs – building trust Building coalitions Laraque, 2008 *Brown-Peterside and Laraque, 1997

46. Community Advisory Board (CAB) Diversity • Affiliation • Knowledge • Experience/Interest • Influence (local and/or national) • Diversity in gender, age and social class • Various disciplines Toran &Laraque, 2007

47. CATCH & HTPC • Maintain focus on communities • Maintain focus on the improvement of the health status of children and the health systems that service children, families and communities • Fully adopt the concepts of cultural and linguistic competence in planning, programming and evaluation • Model programs that have the possibility of affecting policy Laraque, 2008

48. References • Laraque D. Health Promotion: Core Concepts in Building Successful Clinical Encounters. Pediatric Annals 37(4):225-231. 2008. • Laraque D, Barlow B, Durkin M, Heagarty M. Injury prevention in an urban setting: challenges and successes.Bull N Y Acad Med. 1995 Summer;72(1):16-30. • Laraque D, Mitchell J. Arch Pediatr Adolesc Med; 150:556-7. 1996. • Brown-Peterside P and Laraque D. A community research model: A challenge to public health. AJPH; 87(9):1563-64. 1997 • Laraque D et al. The Central Harlem Playground Injury Prevention Project: A Model for Change. AJPH 84(10): 1691-2. 1994 • Leung MW, Yen IH, Minkler M. CBPR: a promising approach for increasing epidemiology’s relevance in the 21st century. Int. J of Epi 2004;33:499-506. • Seifer SD. Service-Learning: Community-Campus partnerships for Health Professions Education. Academic Medicine, 1993. 73(3):273-277. Laraque, 2008

49. References • Swartz LJ et al. Methods and issues in conducting a community-based environmental randomized trial. Environmental Research 95(2004): 156-157 • Washington WN. Collaborative/Participatory Research. J of Health Care for the Poor and Underserved 15.1(2004) 18-29. • Carrillo-Zuniga G et al. Awareness of the National Standards for Culturally and Linguistically Appropriate Services at an Academic Health Center. The Health Care Manager; 27(1):45-53. 2008 • Shore JH et al. Acceptability of Telepsychiatry in American Indians. Telemedicine and e-Health; 14(5):461-466 2008 • Hatch J etal. Community research: partnership in black communities. Am J Prev Med. 1993 9 (6 suppl):27-31. Laraque, 2008