Cultural Competence Seminar

1. Cultural Competence Seminar Teresa M. Nesman, Ph.D. November 30, 2012 Department of Child and Family Studies College of Behavioral and Community Sciences, USF

2. What Is Culture? Culture definitions are developed for different purposes, emphasizing different aspects of life. (Kao, Hsu, & Clark, 2004)

3. What is Culture? • Traits, abilities, and habits that signify membership in a society • Volksgeist or the "spirit of the folk” - cultural traits are shaped by ancestral history & physical environment; include language, literature, religion, the arts, customs, & folklore (Herder, 1769) • “Complex whole”- includes knowledge, belief, art, morals, law, custom, & any other capabilities & habits acquired by man as a member of society" (Tylor, 1958 [1871])

4. What is Culture? • Shared behavior, lifestyle, and meanings: • “Customs, beliefs, values, knowledge, and skills that guide a people’s behavior along shared paths” (Linton, 1947) • “Means by which a local population maintains itself in an ecosystem” (Rappaport, 1968 [1980]) • “Pattern of meanings embodied in symbols…by means of which men communicate, perpetuate, & develop their knowledge about and attitudes toward life" (Geertz 1973)

5. Attributes of Culture • Culture is general andspecific • Culture is shared • Culture is learned • Culture is symbolic • Culture is adaptiveandmal-adaptive • Culture is integrated • Culture is dynamic

6. Why Focus on Culture? Everyone “has” culture

7. Dimensions of Culture • Sense of self • Group membership- individualism vs. collectivism • Communication & language • Relationships • View of time • Values & norms • Beliefs & attitudes • Mental processes & learning styles • Work styles & practices • Dress & appearance • Food & eating habits • Art & aesthetics Stately & Clark, 2003

8. Why Focus on Culture? Culture is often invisible to people until they find themselves in cross-cultural situations • 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).

10. Why Focus on Culture? Culture influences most, if not all aspects of human social interactions

11. Culture and Human Needs 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) Maslow’s Hierarchy Of Human Needs (Cross, Bazron, Dennis, & Isaacs, 1989)

12. Why Focus on Culture? Culture influences health behaviors and expectations.

13. Typical week’s groceries in Germany : $500.07

14. Typical week’s groceries in China : $155.06

15. Typical week’s groceries in Chad : $1.62

16. Culture and Health Life trajectories and health status are impacted by culture: • Lifestyles • Help-seeking behaviors • Values/beliefs/norms of families & individuals • Values/beliefs/norms of service systems

17. Culture and Help-Seeking Lack of cultural compatibility between health care organizations and clients reduces access to appropriate services and can result in: • Misdiagnoses (Fabrega, Ulrich, & Mezzich, 1993; Kilgus, Pumariega, & Cuffe, 1995; Malgady & Constantino, 1998; U.S. DHHS, 2001; Yeh et al., 2002) • Mistrust and low utilization of services (Snowden, 1998; Takeuchi, Sue, & Yeh, 1995; Theriot, Segal, & Cowsert, 2003; U.S. DHHS, 2001) (Hernandez & Nesman, et al., 2006)

18. Understanding Cultural Influences in Yourself and Others

19. Activity: Childhood Memories • What was in your “back yard” when you were a child? • What did your kitchen look like? What was in it? Who spent most time in it? • What were common foods you ate? When & where did you eat? • How did you learn to read? Who helped you? • What was a common saying related to health, hygiene, or well-being? • What did your parent(s)/caregivers do when you were sick with a cold?

20. Cultural Competence: What is it and Why is It Important?

21. Culturally Diverse Contexts Individual In context of FAMILY In context of Family CULTURALLY DIVERSE ENVIRONMENT Individual Cultural diversity

22. Acculturation • Process of becoming adapted to a new culture, either within the natural culture or among strangers, at home or in a foreign land. • Process of learning to adjust. • Involves re-orientation of thinking, feeling, and communicating.

23. Cross Cultural Competence The force that moves a culture learneracross a continuum from a state of no understanding of, or even hostility to, a new culture to a near total understanding. Moving from mono-culturism to bi- or multi-culturism.

24. Cross-Cultural Interactions • 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. • Differences between cultures are too often perceived as threatening or bothersome and are described in negative terms. • Most people take their own language for granted until they encounter another language.

25. Cross-Cultural Interactions • Understanding another culture requires personal experience and time spent interacting with members of that cultural group. • Stereotyping is most likely to occur in the absence of frequent contact with people from other cultures. • Understanding another culture is a continuous and not a discrete process. • Culture is negotiated whenever two or more groups come in contact.

26. (Cross-)Cultural Competence “The acquisition of awareness, knowledge and skills needed to function effectively in a pluralistic democratic society (e.g., ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds)” (Stately & Clark, 2003) “The ability of individuals and systems to respond respectfully and effectively to people of all cultures, races, ethnic backgrounds, sexual orientations, and faiths or religions in a manner that recognizes, affirms, and values the work of the individuals, families, tribes, and communities and protects the dignity of each.” (Child Welfare League of America, 2002)

27. Levels of Action in Cultural Competence • Individual level- engage in actions or create conditions that maximize the optimal development of clients and client systems • Organizational and societal level- develop theories, practices, policies, and organizational structures that are responsive to all groups (Stately & Clark, 2003)

28. Cultural Competence Continuum • Cultural Destructiveness • Cultural Incapacity • Cultural Blindness • Cultural Pre-Competence • Cultural Competence • Advanced Cultural Competence (Cross, Bazron, Dennis, & Isaacs, 1989)

29. Cultural Competence Continuum- 1 • Cultural destructiveness: assumes one race or culture is superior to another, e.g. social or medical experiments without knowledge or consent • Cultural incapacity: unconscious bias, paternalistic posture, may support segregation, disproportionately applies resources (Cross, Bazron, Dennis, & Isaacs, 1989)

30. Cultural Competence Continuum- 2 • Cultural blindness: believes ethnicity or race makes no difference, views self as unbiased yet is ethnocentric in service delivery, views minorities as culturally deprived, encourages assimilation • Cultural pre-competence: commitment to civil rights, realizes weaknesses and makes attempts to improve, hires staff that match the service population but may be only token efforts (Cross, Bazron, Dennis, & Isaacs, 1989)

31. Cultural Competence Continuum- 3 • Basic cultural competence: accepts and respects difference, continuously self-assesses, adapts service models, seeks advise and input from minority communities and includes informal supports • Advanced cultural competence: holds culture in high esteem, seeks to add to knowledge base, advocates continuously for cultural competence across service systems (Cross, Bazron, Dennis, & Isaacs, 1989)

32. ALERT Model for Service Providers

33. Multi-Cultural Panel Discussion on Help-Seeking Behavior

34. Questions: Help-Seeking • How does the family talk about illness? What questions are asked of a person who doesn’t feel well? • Who in the family decides what to do for a sick family member? • Where or who does the family go to for help outside the home? What kind of help is sought? • What kind of service provider is most often contacted? • What do family members believe about the help they will get at a medical facility? • Where do they go in emergencies? • How do families talk about insurance, financial, or legal status? • How do families address any literacy or linguistic challenges?

35. Questions: Experiences with Accessing Services • What are the most difficult barriers to accessing medical services for someone from your background? • What is the worst situation you’ve ever seen that limited access to services for someone from your background? • What is the best situation you’ve seen that facilitated access to services for someone from your background?

36. Increasing Access to Services for Culturally Diverse Families: Organizational Cultural Competence

37. Organizational Cultural Competence “A set of congruent behaviors, attitudes, and policies that come together in an agency that enables employees to work effectively in cross-cultural situations.” (Cross, Bazron, Dennis, & Isaacs, 1989) “A culturally competent program possesses the skills and abilities to work effectively with diverse populations. This is demonstrated by serving particular subgroups of the larger population in a way that understands, is relevant to and respects the unique features, cultural beliefs, language and lifestyles within these populations” (Amherst H. Wilder Foundation, 2002)

38. Increasing Accessibility of Mental Health Services to Culturally/Linguistically Diverse Populations Definition: Within a framework of addressing mental health disparities in 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 (Hernandez,& Nesman, 2006). Community Context Cultural/Linguistic characteristics of a community’s population(s) Degree of compatibility defines level of organizational/systemic cultural competence Outcomes: Reducing mental health disparities Compatibility Organization’s/System’s Direct Service Domain/ Functions Infrastructure Domain/ Functions Hernandez, M., & Nesman, T. (2006).

39. Knowledge/Awareness of Organizational and Community Characteristics • Cultural View of Health • History • Language Characteristics • Resource Characteristics • Strength Characteristics • Needs Characteristics Cultural/Linguistic characteristics of a community’s population(s) Compatibility An organization’s/system’s combined policies, structures and processes Hernandez, M., & Nesman, T. (2006).

40. Compatible Organizational Strategies Infrastructure Domain Direct Service Domain • Organizational Values • Policies/Procedures/ Governance • Planning/Monitoring/ Evaluation • Communication • Human Resources Development • Community & Consumer Participation • Facilitation of a Broad Service Array • Organizational Infrastructure/ Supports- language, technology, etc. Access The ability to enter, navigate, and exit appropriate services and supports Compatibility between the infrastructure and direct service functions of an organization Utilization Appropriate rates of use of needed mental health services Availability Services and supports exist in sufficient range and capacity to meet the needs of the population Hernandez, M., & Nesman, T. (2006).

41. Key Aspects of Organizational Cultural Competence • Specific behaviors, knowledge, attitudes, policies, and procedures that demonstrate: • Acceptance, respect, regard, flexibility, knowledge about culture and ethnicity • Working effectively when faced with cultural differences including: • Responding effectively, linguistic competence, improving access to and quality of care for underserved • Congruence across system components/levels: • Policies and procedures that enable effective work in cross/multi-cultural situations at all organizational levels • Self-assessment and quality assurance • On-going development of knowledge, resources, and service models: • Knowledge and skills to use appropriate assessment and treatment methods (Cross, Bazron, Dennis, & Isaacs, 1989)

42. Organizational Cultural Competence: Assessment of Progress

43. Individual Competencies • Awareness of one’s own and others’ culture (beliefs, values, assumptions), and one’s own prejudices & stereotypes • Knowledge about and sensitivity to diverse clients being served (e.g., epidemiology, social context, resources, etc.) • Developing appropriate service strategies and techniques (e.g. cross-cultural communication skills, openness, flexibility & adaptability, knowing when interpretation is needed, etc.) (Seeleman, Suurmond, & Stronks, 2009; Stately & Clark, 2003; Suh, 2004; )

44. Organizational Competencies • Acknowledgement of culture • Observable behaviors & attitudes demonstrate acceptance, respect, regard, flexibility, & knowledge about communities served. • Policies, procedures, & documents demonstrate acceptance, respect, regard, flexibility, & knowledge about communities served. • Ongoing assessment • Ongoing self-assessment of cross-cultural relations • Ongoing quality assurance (Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, Mowery, Worthington, & Isaacs, 2006)

45. Organizational Competencies Detail- 2 • Responsiveness to cross-cultural dynamics • Organization recognizes and responds effectively to cross-cultural issues that impact access to care • Linguistic adaptations meet client needs • Organization facilitates equal access to and utilization of quality care • Cultural knowledge development • Ongoing development of knowledge about characteristics of communities served • Ongoing assessment of organizational compatibility with the communities served (Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)

46. Organizational Competencies Detail- 3 • Adaptation for compatibility • Adaptations are made to policies and procedures to increase compatibility with community characteristics • Input and feedback is regularly sought from community members & clients • Infrastructure supports the delivery of compatible & effective direct services • Outcomes are meaningful to providers, families, & community members (quality of life, satisfaction with services, treatment effectiveness, costs effectiveness, etc.) (Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)

47. Cautions • Avoid stereotyping- culture is not static, and varies by individuals and families, it’s not a single variable, it’s a dynamic process • Attention to culture may be interpreted as intrusive or singling out as “different” (i.e., not normal, an outsider) • Cultural assumptions may hinder practical understanding (e.g., access may be hindered by work hours rather than cultural beliefs) • Medical terms can stigmatize- use culturally appropriate explanations & terms, ask “What do you call this problem?” • Don’t assume that health goals are the same, ask “What matters most to you?” (Kleinman & Benson, 2006)

48. Cultural Competence Outcomes • More effective, holistic care for diverse patients • Improved quality of life of patients • Increased health care satisfaction • Improved perception of health care providers • Better adherence to prescribed treatments • Personal & professional growth of health care providers • Improved quality of care • Improved provider-patient rapport • Treatment effectiveness • Cost effectiveness (increased adherence, reduced emergency care) • Reduced disparities in health outcomes for diverse groups (Suh, 2004)

49. Linking Refugee Children to Services in the Community

50. Questions • What cross-cultural issues are identified? • How has the organization developed knowledge about the population? • How has the organization facilitated access to services? • How does the organization determine its effectiveness in serving the population?