Rally Your State Coalition II: Cultural Competency

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Rally Your State Coalition II Cultural Competency

• Tilly Gurman, DrPH
• June 29, 2009
• tgurman_at_gwu.edu

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Session Objectives

• Objective 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

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Group norms

• Participate 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 others participation

• Silence beeper/cellphone
• Take care of yourself
• Follow the time

Regarding logistics
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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

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What is culture?

• When you hear the word culture what comes to
  mind?

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When you hear the word culture what comes to
mind
Traditions
Religion
VALUES
Language
FOOD
Political Power
HEALTH BELIEFS
Immigration
Communication Styles
Family Structure
NORMS
Gender Roles
Acculturation
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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.

Source Helman (2001)
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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)

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Why does cultural competency matter?
Reason 1 Diversification of the population
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Population trendsLatinos in US

• In US, 3 largest groups are
• Mexican
• Puerto Rican
• Cuban
• Diversity of languages, socioeconomic status,
  immigration history, cultures

Source Suarez and Ramirez (1999)
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Population trendsLatinos in US
Source Hobbs and Stoops (2002)
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Why does cultural competency matter?
Reason 2 Trends in public health indicate a
need to better reach diverse populations
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Source Abma (2004)
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Health care access

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

Source Lillie-Blanton et al (2003)
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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, 2001
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Folate Concentration by Race/Ethnicity,
1999-2004
Source CDC, 2007
HP2010 Objective 220 ng/mL RBC folate
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Why does cultural competency matter?
Reason 3 Ensures more successful coalitions
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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

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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 coalitions credibility
  in community

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Cultural competence skills

• 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

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

Source Monroe, Goldman, Dube (1994)
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Iceberg

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

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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)
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La cultura se cura
Five elements related to Latino culture with
possible implications for reducing disparities in
folic acid
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Culture and implications

• Language

• Spanish is not universal

• 60 Spanish dominant
• 20 bilingual
• 20 English dominant

• Generational differences

• More acculturated less likely to need
  interpreter and more likely to be familiar with
  biomedical approach of health

• Regional US differences

Source Kaiser Permanente.
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Culture and implications

• Language

Implications

• Having a Spanish interpreter/Spanish-language
  materials is not always appropriate
• Importance of having Spanish interpreter/Spanish
  language materials available
• Non-English proficiency may suggest more
  traditional cultural perspective

Sources Andrulis D, Goodman N, and Pryor C.
(2002) Kaiser Permanente.
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Culture and implications

• Familismo importance of family unit

Implications

• Independent decision-making may not be the norm
• Potential involvement of other family members in
  decision-making
• More acculturated individuals may stress
  independence

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Culture and implications

• Respeto sense of respect for authority and
  deference to experts

Implications

• Patient may defer to a provider, health educator,
  etc.
• Patient may be reluctant to ask questions about
  diet, folic acid, etc.
• Nod of head may be to show respect, not
  understanding

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Culture and implications

• Personalismo importance of personal relationships

Implications

• Perception that provider should be personal
• Patient may want to remain with one provider
  especially at times of grief or crisis such as
  fetal death
• Recruiting for events and coalitions may require
  more time for establishing rapport

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Culture and implications

• Fatalismbeing OK with whatever consequences

Implications

• Fatalism may be confused for complacence
• May affect preventive health behaviors
  especially when combined with barriers to
  accessing care

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Feature films are the result of years of
scientific study combined with years of
experience.
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Communication self-assessment
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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.

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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)
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Communication and culture Sources of possible
miscommunication

• 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

Sources Mutha S, Allen C, Welch M. (2002)
Anand (1999)
Koslow D, Salett E. (1989)
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Communication and culture Sources of possible
miscommunication

• 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

Sources Anand (1999) Koslow D,
Salett E. (1989)
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How can we become more culturally competent?
Within ourselves

• 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

Source Anand (1999)
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How can we become more culturally competent?
As we interact with others

• Listen with respect, openness, and patience
• Establish trust
• Show concern and empathy

• Treat each person as a unique individual
• Look at situation from other persons view

• Be sensitive to face-saving needs
• Tolerate ambiguity

Source Anand (1999)
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How can we become more culturally competent?

• Within coalitions

• Revise coalitions 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

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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 coalitions
  efforts at inclusion and diversity

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• Start
• Stop
• Continue

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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
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Sources Cited

• Abma 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 ProjectBoston.
• CDC. (2001). Are Women with Recent Live Births
  Aware of the Benefits of Folic Acid? MMWR.
  503-14. Available at http//www.cdc.gov/mmwr/pre
  view/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. 551377-80. 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.

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Sources Cited

• Helman CG. Culture, health, and illness. (2001).
  LondonArnold.
• Kaiser Permanente National Diversity Council and
  the Kaiser Permanente National Diversity
  Department. (2000). A providers 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/censr01-10
  4.pdf. Accessed June 12, 2009.

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Resources of Interest

• Quality 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/qua
  lityhealthservices/
• A Providers 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 [phone]

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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/in
  dex.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 Center
• Part 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.h
  tml

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Online Resources of Interest

• Office of Minority Health
• This 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