Cultural Competence in Public Health (or anywhere else)

1. Cultural Competence in Public Health(or anywhere else) Robert Lucio, Ph.D., MSW College of Public Health Department of Community and Family Health College of Behavioral & Community Sciences Department of Child and Family Studies 2010 Cultural Competence Seminar Tampa, FL – December 03, 2010

2. Purpose • What is culture? • Why is culture important to health? • What is cultural competence? • What is meant by the concept of “health disparities?” • To share a framework for building organizational cultural competence

3. Assumption Underlying The Training • Culture and society play pivotal roles in health, illness, and health services • Understanding the wide-ranging roles of culture and society enables the health field to design and deliver services that are more responsive to the needs of culturally and linguistically diverse people • Cultural Competence Starts with the recognition & awareness of one’s own Biases/Prejudices

4. Culture Exercise • Know your potato

5. What Is Culture? • Culture has been defined in various ways by different disciplines and for numerous purposes (Kao, Hsu, & Clark, 2004) • Culture represents the histories, attitudes, behaviors, languages, values, beliefs and uniqueness, which distinguished each racial or sub-cultural group in a society. Each of us has a historical heritage and a contemporary heritage that comprise our present culture (Coggins, 2004)

6. What Is Culture? • Culture is the customs, beliefs, values, knowledge, and skills that guide people along shared paths (Linton, 1947) • Culture is reflected in the social norms, mores, sanctions, and in the art, history, folklore, and institutions of a group of people • The term culture refers to the way of life of people and includes the tools or methods by which they extract a livelihood from their environment (Corsini, 1987)

7. Maslow’s Hierarchy Of Needs: Humanistic Theory Self Actualization Culture: Esteem and Identity Love and Belonging The way we go about meeting our needs Safety and Security Physiologic (e.g., Food, Water) (Cross, Bazron, Dennis, & Isaacs, 1989)

8. Why is culture important?

9. Background • Culture has been conceptualized as either a static trait characteristic of a group of people or a dynamic process. • Static – People are subjected to cultural structures and are seen as passive carriers of culture inter-generationally. • Dynamic process – People are seen as more active learners of their cultures. (Kao, Hsu, & Clark, 2004)

10. Seeing Culture • Culture is omnipresent and frequently invisible, especially to those enmeshed within a particular culture • Since one is born into a culture, one experiences that culture as always already there, part of the world that one sees, not as a way of seeing the world (Steeves & Kahn, 1995, p. 183)

11. Underlying Assumptions • Everyone in the room has a culture • Understanding your own culture is key • Culture influences most, if not all aspects of human social interactions • Although culture is omnipresent, it is frequently invisible, especially to those enmeshed within a particular culture.

12. What is culture? • Material Culture • What we see • Artifacts • Language • Dress • Behaviors • Color • Food • Songs • Immaterial Culture • Hidden Culture • Myths • Folklore • Stories • Feelings • Values • Oral Culture • Spiritualism (Coggins, 2010)

13. Why Culture is Important • The dramatic change in our nation’s ethnic composition is altering the way we think about ourselves • The deeper significance of America’s becoming a majority nonwhite society is what it means to the national psyche, to individuals’ sense of themselves and their nation – their (our) idea of what it is to be American (Takaki, 1993) • American society is increasingly diversified. The federal funding agencies require participation of multicultural populations for health research

14. Why Culture is Important • Hispanic and Latino Americans accounted for almost half (1.4 million) of the national population growth of 2.9 million between July 1, 2005, and July 1, 2006 • Immigrants and their U.S.-born descendants are expected to provide most of the U.S. population gains in the decades • There are 45.5 million Hispanics living in the United States, accounting for 15 percent of the U.S. population • Blacks comprise the second-largest minority group, with 40.7 million (13.5 percent), followed by Asians, with 15.2 million (5 percent). (The Office of Minority Health, 2010)

15. Why is culture important • Colors • Perhaps explaining why some native English-speaking children, familiar with the rainbow of colors in the Crayola 64-pack, actually can tell “rust” from “brick” or “moss” from “sage,” while children who grow up speaking languages with fewer color names lump such hues together (Namibia) • Math Skills • The lack of number-words seems to preclude the ability to entertain concepts of exact number in certain cultures (Pirahã) Dingfinger, S. F. (2005). Fuzzy Math. Monitor on Psychology, 36(2), 30-31. Adelson, R. (2005). Hues and Views. Monitor on Psychology, 36(2), 26-29

16. Why is culture important? • Intelligence • Intelligence cannot be fully or even meaningfully understood outside its cultural context. • Research that seeks to study intelligence without considering the context risks the imposition of an investigator’s world-view on the rest of the world. • Moreover, research on intelligence within a single culture may fail to do justice to the range of skills and knowledge that may constitute intelligence broadly defined and risks drawing false and hasty generalizations. Sternberg, R. (2004). Culture and Intelligence. American Psychologist, 59, 325-338.

17. Why is culture important? • Intelligence and Development • Some things are constant across cultures (mental representations and processes), whereas others are not (the contents to which they are applied and how their application is judged) • African infants sit and walk earlier than do their counterparts in the United States and Europe Sternberg, R. (2004). Culture and Intelligence. American Psychologist, 59, 325-338.

18. Why is culture important? • Behavior • Behavior that in one cultural context is smart may be, in another cultural context, stupid (Cole, Gay, Glick, & Sharp, 1971) • Stating one’s political views honestly and openly, for example, may win one the top political job, such as the presidency, in one culture and the death penalty in another Sternberg, R. (2004). Culture and Intelligence. American Psychologist, 59, 325-338.

19. Why is culture important? • health, healing, and wellness belief systems; • how illness, disease, and their causes are perceived; both by the patient/consumer • the behaviors of patients/consumers who are seeking health care and their attitudes toward health care providers • as well as the delivery of services by the provider who looks at the world through his or her own limited set of values, which can compromise access for patients from other cultures

20. Why is culture important? • The increasing population growth of racial and ethnic communities and linguistic groups, each with its own cultural traits and health profiles, presents a challenge to the health care delivery service industry in this country • The provider and the patient each bring their individual learned patterns of language and culture to the health care experience which must be transcended to achieve equal access and quality health care

21. Some Points to Remember About Cross-Cultural Relationships • What seems to be right, logical, sensible, important, or obvious to a person in one culture may seem wrong, irrational, silly, unimportant, or confusing to someone in another culture • When people talk about cultures, they tend to emphasize the importance of differences and tend to neglect explaining human commonalities • Differences between cultures are too often perceived as threatening or bothersome and are described in negative terms

22. Cultural Competence

23. A class divided A class divided part I A class divided part II

24. Definition Of Cultural Competence • The ability to work effectively across cultures in a way that acknowledges and respects the culture of the person or organization being served • “Cultural Competence” is a set of congruent behaviors, attitudes, and policies that come together in an agency that enables employees to work effectively in cross-cultural situations J. H. Hanley (1999) - Beyond the tip of the Iceberg: Five Stages toward cultural competence Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Online at:http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf

25. Cultural Competence Continuum Cultural Proficiency (Level 6) Culture Competence (Level 5) Cultural Pre-Competence (Level 4) Cultural Blindness (Level 3) Cultural Incapacity (Level 2) Cultural Destructiveness (Level 1) (Coggins, 2010)

26. Cultural Destructiveness “See the difference; stomp it out.” Using one’s power to eliminate the culture of another. Represented by attitudes, policies, and practices that are destructive to cultures and the individuals within the culture. Examples • Genocide or Ethnocide • Exclusion Laws • English only Speaking laws • Forms not available in another language • Denying clients access to their natural healers. • Shun/Avoid certain curriculum topics • Dress policies that single out specific ethnic groups Cecil County Public Schools

27. Cultural Destructiveness “See the difference; stomp it out.” What you might hear “When we redistrict we can get rid of THAT neighborhood!” “Why are those kids speaking Chinese here?” “There are so many problems coming from Southside.” “If we could get rid of the special needs students, our scores would improve.” Cecil County Public Schools

28. Cultural Incapacity “See the difference; make it wrong.” Believing in the superiority of one’s own culture and behaving in ways that disempower another’s culture Examples • Lacks the capacity or will to help minority clients and employees • Disproportionate allocation of resources to certain groups • Lowered expectations • Expecting “others” to change: My way or the highway • Practices of discrimination in hiring and promotion; • Subtle messages that some cultural groups are neither valued nor welcomed • Sending away domestic violence victims in Albuquerque from a hospital to Indian health clinic • Lack of an equal representation of staff/administrators that reflect diversity Cecil County Public Schools

29. Cultural Incapacity “See the difference; make it wrong.” What you might hear “Another generation to never leave the trailer park.” “His mom admitted he was special education when she went to school, so we can’t expect him to do well” “The apple doesn’t fall far from the tree.” Cecil County Public Schools

30. Cultural Blindness “See the difference; act like you don’t.” Acting as if cultural differences do not matter or as if there are not differences among or between cultures Examples • Beliefs/actions that assume world is fair and achievement is based on merit • Color or culture make no difference and that all people are the same. • Ignores cultural strengths • Believes that the helping approaches by dominant culture are universally acceptable and applicable • Encourages assimilation; thus, those who don’t are isolated • Blames victim for their problems • Views ethnic minorities as culturally deprived • Using light colored band aids in hospitals that are marked as flesh colored (but only to fair skinned people) Cecil County Public Schools

31. Cultural Blindness “See the difference; act like you don’t.” What you might hear “Our organization does not need to focus on multicultural education- we have no diversity” “We treat everyone the same” “That isn’t a problem in our organization” “Just don’t recognize their religion. We don’t want to offend” “I’m not prejudiced. I don’t see color ” Cecil County Public Schools

32. Cecil County Public Schools Cultural Pre-Competence “See the difference; respond to it inappropriately.” Recognizing the limitations of one’s skills or an organization's practices when interacting with other cultural groups. Examples • Delegate diversity work to others, to a committee • Quick fix, packaged short-term programs • What can we do?” Desire to deliver quality services; commitment to civil rights. • Realizes its weaknesses and attempts to improve some aspect of their services. • Explores how to better serve minority communities. • Agency may believe that their accomplishment of one goal or activity fulfills their obligation to minority communities; may engage in token hiring practices. • Often only lacks information on possibilities and how to proceed • May feel a false sense of accomplishment that prevents further movement.

33. Cultural Pre-Competence “See the difference; respond to it inappropriately.” What you might hear “I’ll do my best to make the Special Education student feel part of the Honors course.” “Make sure you do an activity for Black History month.” Cecil County Public Schools

34. Cultural Competence “See the difference; understand the difference that difference makes.” Interacting with others using the five essential elements of cultural proficiency as the standard for behavior and practice. Examples • Acceptance and respect for difference. • Expands cultural knowledge and resources. • Continuous self-assessment. • Pays attention to dynamics of difference to better meet client needs. • Variety of adaptations of service models. • Seeks advice and consultation from the minority community. • Commits to policies that enhance services to diverse clientele. • Advocacy • On-going education of self and others • Adapts evidence based promising practices that are culturally and linguistically competent. Cecil County Public Schools

35. Cultural Competence “See the difference; understand the difference that difference makes.” What you might hear “I think it is interesting to look at another’s perspective through another lens.”

36. Cultural Proficiency “See the difference; respond positively. Engage and adapt.” Esteem culture; knowing how to learn about organizational culture; interacting effectively in a variety of cultural groups. Examples • Holds cultures in high esteem. • Agency seeks to add to its knowledge base. • Agency advocates continuously for cultural competence throughout the system. • Differentiate to the needs of all patients. • Cultural Empowerment is reflected in a philosophy that the client/staff are co-equal partners in the treatment and learning process Cecil County Public Schools

37. Cultural Proficiency “See the difference; respond positively. Engage and adapt.” What you might hear “With the addition of _____, our staff experience has become richer. The other employees are learning from him also.” “Thank you for talking to the patients and explaining in Spanish about our services.” Cecil County Public Schools

38. The culturally competent system of care is made up of culturally competent institutions, agencies, and professionals. Five essential elements contribute to a system’s, institution’s, or agency’s ability to become more culturally competent. The culturally competent system would: Value diversity; Have the capacity for cultural self-assessment; Be conscious of the dynamics inherent when cultures interact; Institutionalize cultural knowledge; and Develop adaptations to diversity Essential Elements ofCultural Competence Cross, Bazron, Dennis, & Isaacs, (1989).  Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.

39. Organizational Cultural Competence

40. A Value Base forCultural Competence • Respects the unique, culturally-defined needs of various client populations. • Acknowledges culture as a predominant force in shaping behaviors, values, and institutions. • Views natural systems (family, community, church, healers, etc.) as primary mechanisms of support for minority populations and are different for various subgroups • Starts with the “family,” as defined by each culture, as the primary and preferred point of intervention. • Believes that diversity within cultures is as important as diversity between cultures. • Acknowledges and accepts that cultural differences exist and have an impact on service delivery. • Acknowledges that when working with minority clients process is as important as product. Cross, Bazron, Dennis, & Isaacs, (1989).  Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.

41. A Value Base forOrganizational Cultural Competence • Culturally competent agencies are characterized by acceptance of and respect for difference • continuing self-assessment regarding culture, careful attention to the dynamics of differences • continuous expansion of cultural knowledge and resources, and adaptations of service models. • Culturally competent agencies work to hire unbiased employees and seek advice and consultation from their clients; • They seek staff who represent the racial and ethnic communities being served and whose self-analysis of their role has left them committed to their community and capable of negotiating a diverse and multicultural world. • Culturally competent agencies understand the interplay between policy and practice, and are committed to policies that enhance services to diverse clientele. Cross, Bazron, Dennis, & Isaacs, (1989).  Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.

42. A foundational definition for cultural competence states that it includes behaviors, attitudes, and policies within a system, agency, or among professionals that enable them to work effectively in cross-cultural situations (Cross, Bazron, Dennis, & Isaacs, 1989) Underlying the definition by Cross et al. (1989): Children’s health services must acknowledge and incorporate the importance of culture, race, and ethnicity at all levels of functioning and treatment to provide optimal access to quality services The recognition that culture, race, and ethnicity have significant influence on the behavior and thinking of providers and service recipients is an important feature of cultural competence. Background

43. Operationalizing cultural competence is an important step toward being able to test its effectiveness in improving health service delivery. A definition of organizational cultural competence and conceptual model were developed by Hernandez and Nesman (2006) based on a thematic analysis conducted for a literature review and protocol assessment. Defining Organizational Cultural Competence

44. Within a framework of addressing health disparities, the level of a human service organization’s/system’s cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate access, availability, and utilization of needed services/supports Implementation-focused Definition of Cultural Competence (Hernandez & Nesman, 2006)

45. Conceptual Model for Accessibility of Health Services to Culturally/Linguistically Diverse Populations Definition: Within a framework of addressing health disparities within a community, the level of a human service organization’s/system’s cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate access, availability and utilization of needed services/supports (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997). Community Context Cultural/Linguistic characteristics of a community’s population Degree of compatibility defines level of organizational/systemic cultural competence Outcomes: Reducing health disparities Compatibility Organization’s/System’s Direct Service Domain/ Functions Infrastructure Domain/ Functions (Hernandez & Nesman, 2006)

46. Conceptual Model for Accessibility of Health Services to Culturally/Linguistically Diverse Populations Community Context Cultural/Linguistic characteristics of a community’s population • The compatibility between the organization’s/system’s structures and processes and the community’s populations determines the level of organizational cultural competence. Degree of compatibility defines level of organizational/systemic cultural competence Outcomes: Reducing health disparities Compatibility Organization’s/System’s combined policies, structures, and processes • The model shows the need to adapt an organization’s structures and processes to the characteristics of the community being served. • Compatibility between the community’s populations and organizational structures and processes are determined by the level of access and utilization of appropriate services. (Hernandez & Nesman, 2006)

47. Important in the development of compatibility between organizations and populations served. Based on the recognition that children/adolescents and their families respond to health problems and concerns within a context of the larger social environment that guides or pushes them toward or away from various types of services. Also recognizes that organizations and systems function within larger community, state, and national contexts that impact their attempts to serve their local community. Community Context (Hernandez & Nesman, 2006)

48. Assessing compatibility (cultural competence) is dependent on having information about the community’s populations, context, and the organization’s policies, structures, and processes. This includes awareness of the influences of culture, ethnicity, race, socioeconomic status, and related social factors on the provision of services and help-seeking. Important to link interventions the factors that contribute to a lack of engagement and to recognize that these factors will vary across groups and service types (Staudt, 2003). Development of compatible strategies will not be possible without this information. Cultural/Linguistic characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes Characteristics of theCommunity Population (Hernandez & Nesman, 2006)

49. Facilitators Cultural View of Health: The common perception of health that is related to the culture and facilitates service use History: History of the community or population and the effects of that history Language Characteristics: Primary language of the population Resource Characteristics: Resources of the population Strength Characteristics: Strengths of the population Cultural/Linguistic characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes Characteristics of theCommunity Population (Hernandez & Nesman, 2006)

50. Inhibitors Cultural View of Health: Common cultural perceptions of health that present barriers to service use Need Characteristics: Needs of the population Cultural/Linguistic characteristics of a community’s population Compatibility An organization’s/system’s combined policies, structures and processes Characteristics of theCommunity Population (Hernandez & Nesman, 2006)