at Howard University College of Medicine

1. Welcome to the AIDS Education Training Center-National Multicultural Center at Howard University College of Medicine

2. Mission of the AETC-NMC To reduce HIV/AIDS disparity by: a) providing quality standardized training in Cultural Competency and HIV/AIDS care; b) to strengthen quality Cultural Competency 1 . (knowledge and practice) capacity of HIV providers and systems nationwide; and 2. to be a resource for the improvement of multicultural health care aimed at building sustainable individual, local, regional and national capacity in HIV care.

3. WEBINAR PRESENTER: Rani Srivastava RN, PhD Chief of Nursing & Professional Practice (CAMH) Toronto, Ontario Cultural Competence: Strengthening the Clinician’s Role in Delivering Quality HIV Care

4. Learner’s Pre-Assessment

5. Factors related to culture and ethnicity shape all but which of the following? The way people: • A. Interact with a health care system • B. Participate in programs of prevention and health promotion • C. Access financial resources available to support healthcare (correct response) • D. Implement health seeking behavior and adherence to treatment • E. Access health information and services

6. Moving from awareness to application of cultural competence as it relates to patient populations with HIV includes all but which of the following? A. Expecting and acknowledging differences B. Reliance on your professional judgment – (correct response) C. Looking for own biases, assumptions of normalcy and universality D. Looking for systemic barriers E. Appreciation of the unique strengths of others

7. Key Values for Cultural Competence in reducing HIV disparity includes all but which of the following? A. Inclusively B. Respect C. Valuing change D. Time– (correct response) E. Commitment

8. Cultural knowledge of patient populations with HIV involves knowing which of the following (chose one response only): A. Effects of migration, racism, and discrimination B. Concerns relative to disclosure of HIV status C. Perceptions of the trustworthiness of healthcare providers D. The incidence/ prevalence of HIV/AIDS in the population E. All of the above (correct response)

9. The 3 modes of action and decision making relative to culture are (chose one response only): A. Consensus Building, Information Exchange, and Constructive Critique B. Validation, Negotiation and Reframing (correct response) C. Fact Checking, Open Communication, and Collaboration

10. Objectives • Examine the Culture Care Framework as a guide for practice and service  in the delivery of quality HIV care. • Describe the core knowledge and skill necessary to understanding and addressing health disparities in HIV/AIDS care. • Discuss strategies to bridge the gap across cultures in providing quality health care. • Discuss how to apply the strategies of cultural care validation, accommodation and reframing in providing quality clinical care.

11. Rationale for Cultural Competence Respond to current and projected demographic changes in the United States. Reduce long-standing disparities in the health status of people of diverse racial, ethnic, & cultural backgrounds. Improve the quality of services & outcomes. Meet legislative, regulatory, & accreditation mandates. National Center for Cultural Competence, 1999

12. Adults and children estimated to be living with HIV/AIDS in 2009 Eastern Europe & Central Asia 1.4 million Western & Central Europe 820,000 North America 1.5 million East Asia 770,000 North Africa & Middle East 460,000 South & South-East Asia 4.1 million Caribbean 240,000 Sub-Saharan Africa 22.5 million Latin America 1.4 million Oceania 57,000 Total: 33.3 million UNAIDS, 2010

13. HIV - U.S. Trends New HIV infection rate steady. Increased cases in women, esp. in SE. Heterosexual transmission are increasing. Minority populations are disproportionately affected. Substance use and/or abuse is an important co-factor.

16. Influence of Culture on Health Disparities • Culture and ethnicity are products of both personal history and wider situational, social, political, geographic and economic factors. • Factors related to culture and ethnicity shape: • the way people interact with a health care system; • their participation in programs of prevention and health promotion; • their access to health information and services; • their health-related choices and decisions; • their understanding of and priorities re: health and illness; • help seeking behavior and adherence to treatment.

17. Health Disparities • 44% of new cases of HIV are seen in African-Americans. • Ethnic minorities have a cancer death rate about 33% higher than that of European Americans. • Ethnic minorities are least likely to receive early prenatal care. • African-Americans are 1.7 times more likely to have diabetes than are European Americans. • Coronary heart disease continues to decline at a much slower rate for African-Americans than any other ethnic group.

18. Health Equity vs. Inequity • Health inequity concerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable – and thus inherently unjust and unfair. • Health equity recognizes differences in health outcomes for members of marginalized communities– poverty, race, age, gender, sexual orientation, immigration or refugee status, etc, and aims to provide service in a manner that mitigates these health impacts.

19. Culture matters… • Access • Services in general • Specific interventions • Appropriate interventions • Engagement & Adherence But whose culture do we need to understand? • Patients? • Care providers? • Health care systems?

20. Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care • Clinical Appropriateness • and Need • Patient Preferences Non-Minority The Operation of Healthcare Systems and the Legal and Regulatory Climate Difference Quality of Health Care Minority Disparity Discrimination: Biases & Prejudice, Stereotyping, & Uncertainty Populations with Equal Access to Health Care From: IOM Report (2002): Unequal Access

22. Cultural Competence A congruent set of workforce behaviors, management practices and institutional policies within a practice setting resulting in an organizational environment that is respectful and inclusive of cultural and other forms of diversity and that leads to reducing inequities in health care Adapted from Cross et al.

23. Cultural Competent Care • Culturally competent care is about the creation of an environment in which the best medical practices can be safely accessed and implemented affirming all individuals, alienating none due to various differences, assisting clients to be comfortable with the skin they are in.

24. Key Values for Cultural Competence • Inclusivity • Respect • Valuing differences • Equity • Commitment RNAO, 2007

25. Culture Care Framework To care for someone I must know who I am To care for someone I must know who the other is To care for someone I must be able to bridge the gap between myself and the other Watson cited by Anderson

26. Cultural Competency Models and Theories

27. Culture Knowledge Culture Sensitivity Culture Resources Elements of HIV Cultural Competent Care

28. Elements of HIV Cultural Competent Care Health Equity through Culturally Congruent Care

29. ABC of Cultural Competence AFFECTIVE BEHAVIOURAL COGNITIVE

30. ABC of Cultural Competence AFFECTIVE Equity Environment Dynamics of difference BEHAVIOURAL COGNITIVE

31. How do others see You?

32. Culture Sensitivity Understanding of Professional / Organizational CULTURE Culture Sensitivity Culture knowledge Culture Resources • Understanding of OWN • Biases/Prejudices • Values / Beliefs • CULTURE • Understanding of issues re: • Power • Trust • Equity • RESPECT

33. Culture Knowledge GENERIC knowledge Culture knowledge Culture Sensitivity CUTLURE SPECIFIC knowledge Culture Resources • Application of Culture Specific Knowledge • Patterns vs. Stereotypes • Holding Knowledge

34. Culture Knowledge: Generic • Basic knowledge about the impact of culture on health that applies across a wide variety of groups • E.g. Cross cultural communication strategies; difference between individualistic cultures and collectivist cultures; Explanatory models of illness • Impact of migration, settlement, racism, and discrimination • Trust re: health system and care providers • Selective disclosure • Identify the languages spoken in the community and determine availability of interpreter for non-English speakers and those with disabilities.

35. Culture Knowledge: Generic • Achieve effective encounters with all patients • Send and receive both verbal and nonverbal messages accurately and appropriately in each culturally different context. • Communicate respect and inquire about greeting preferences: “How would you like me to refer to you? Mr.? Mrs.? First Name? Nickname? Title?” • Maintain a non-judgmental attitude.

36. What Produces Conflict? Ambiguity Elevated Stakes Cultural Differences Power Differences Differing Needs Anticipation of Conflict Time Pressures Value Differences Competition Feelings and Emotions Adapted from Mutha, S. (UCSF), 2002

37. Conflict Resolution • Identify the conflict and define the problem before escalation • Develop a range of acceptable solutions • Analyze the other party’s likely goals and objectives • Analyze the risks inherent in the conflict situation

38. Culture Knowledge: Specific • Review prevalence of HIV in the community/neighborhood served by your practice. • Obtaining knowledge regarding biologic variations based on ethnicity, age, generation, country of origin, language, worldviews, and cultural specific behavioral patterns.

39. Case Scenario • Black gentleman in his mid 30’s from the Carribean • Worked in the community health sector • Acute Renal Failure • HIV + • Requested the advanced practice nurse to “not have the West Indian nurses caring for me” What are the key factors to consider behind this request?

40. Culture Knowledge Culture Sensitivity Client/ Colleagues Culture Resources Internal / External Organizational Systems Policies, Tools Partnerships Commitment Resources Access to information Interpreters /Brokers Practice Expectations Culture Resources

41. Case Scenario Maria  a 42 year old Latina reported for the results of her HIV test a month after being tested. She is not fluent in English so she brought her two teenage sons, Miguel and Javier to help translate for her. The clinic does not have bilingual staff or hired interpreters. The counselor feels uncomfortable about sharing the results of Maria’s HIV test with her two sons but has no other way to communicate the results to Maria. As the counselor begins to inform the sons that their mother has tested positive for HIV, Miguel begins to cry. Javier, translates the results to his mother and accuses her of sexual promiscuity.

42. Linguistic Competence • Provided for persons with challenges in English as a Second Language (ESL) • Readily available • Culturally appropriate oral and written language service through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators U.S. Department of Health and Human Services, 2000

43. Three modes of Action/Decision Culture care preservation / Validation • Respect & Honor what we may not know • Look for strengths & not just deficits Culture care Accommodation / Negotiation • Does not need to be either / or • Ask – what would it take to…. Culture care Re-patterning / Reframing • Learn new ways of caring / healing/ meaning of behaviors • Applies to providers & recipients of care

44. From Awareness to Application • Expect and acknowledge differences • Look for systemic barriers • Remember Yourculture is personal, professional, reflective of your organization • Avoid judgements... Alter your perspective • Apply knowledge of cultural factors – barriers & strengths • Learn the art of apology and humility • Be open to new ideas, new ways of approaching something • Use your power and privilege to empower others • EARN trust • Create SAFE spaces for SENSITIVE conversations

45. Final Thought…. • The HIV epidemic will not be over unless and until we develop the capacity, infrastructure and commitment to deliver cultural congruent care. The time to reduce health disparities and inequities is now .

46. “Do not fear mistakes---fear only the absence of creative, constructive and corrective responses to those mistakes” Robert Kerr

47. Learner’s Post-Assessment

48. Factors related to culture and ethnicity shape all but which of the following? The way people: • A. Interact with a health care system • B. Participate in programs of prevention and health promotion • C. Access financial resources available to support healthcare (correct response) • D. Implement health seeking behavior and adherence to treatment • E. Access health information and services

49. Moving from awareness to application of cultural competence as it relates to patient populations with HIV includes all but which of the following? • A. Expecting and acknowledging differences • Reliance on your professional judgment – (correct response) • Looking for own biases, assumptions of normalcy and universality • Looking for systemic barriers • Appreciation of the unique strengths of others

50. Key Values for Cultural Competence in reducing HIV disparity includes all but which of the following? • A. Inclusively • B. Respect • C. Valuing change • D. Time– (correct response) • E. Commitment