Rally Your State Coalition II: Cultural Competency

1. Rally Your State Coalition II:Cultural Competency Tilly Gurman, DrPH June 29, 2009 tgurman@gwu.edu

2. 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

3. Group norms Regarding your participation • Participate voluntarily • Speak from your own experience • Take risks • Respect other opinions and experiences • Maintain an open mind • Listen when others speak • Respect confidentiality Regarding other’s participation • Silence beeper/cellphone • Take care of yourself • Follow the time Regarding logistics

4. 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

5. What is culture? When you hear the word “culture” what comes to mind?

6. When you hear the word “culture” what comes to mind……… Traditions Religion VALUES Language FOOD Political Power HEALTH BELIEFS Immigration Communication Styles FamilyStructure NORMS Gender Roles Acculturation

7. 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)

8. 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)

9. Why does cultural competency matter? Reason 1: Diversification of the population

11. Population trends:Latinos 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)

12. Population trends:Latinos in US Source: Hobbs and Stoops (2002)

13. Why does cultural competency matter? Reason 2: Trends in public health indicate a need to better reach diverse populations

14. Source: Abma (2004)

15. 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)

16. 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

17. Folate Concentration by Race/Ethnicity, 1999-2004 Source: CDC, 2007 HP2010 Objective: 220 ng/mL RBC folate

18. Why does cultural competency matter? Reason 3: Ensures more successful coalitions

19. 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 Why does cultural competency matter?

20. 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 coalition’s credibility in community Why does cultural competency matter?

21. 3. Ability to keep own cultural values and communication preferences in check 1. Ability to obtain knowledge of other cultures, recognize the diversity within groups, and understand the dynamics of difference Cultural competence skills 2. Ability to adapt communication style to fit the cultural context of others Source: Monroe, Goldman, & Dube (1994)

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

23. 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)

24. La cultura se cura… Five elements related to Latino culture with possible implications for reducing disparities in folic acid

25. Culture and implications • Spanish is not universal • Language • 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.

26. Culture and implications • Implications: • Language • 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.

27. 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

28. 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

29. 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

30. Culture and implications • Fatalism…being OK with whatever consequences • Implications: • Fatalism may be confused for complacence • May affect preventive health behaviors … especially when combined with barriers to accessing care

32. Feature films are the result of years of scientific study combined with years of experience.

33. Communication self-assessment

34. 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. Communication self-assessment

35. 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)

36. 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)

37. 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)

38. Explore our own communities and cultures Engage in self-awareness Seek out information How can we become more culturally competent? Within ourselves: • Increase culture-specific awareness • Make conscious effort not to act on our stereotypes and assumptions • Strive to prevent miscommunication Source: Anand (1999)

39. 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 person’s view • Be sensitive to face-saving needs • Tolerate ambiguity Source: Anand (1999)

40. Within coalitions: How can we become more culturally competent? • Revise coalition’s 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

41. Within coalitions: How can we become more culturally competent? • 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 coalition’s efforts at inclusion and diversity

43. Start • Stop • Continue

44. 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

45. 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 Project:Boston. CDC. (2001). Are Women with Recent Live Births Aware of the Benefits of Folic Acid? MMWR. 50;3-14. Available at: http://www.cdc.gov/mmwr/preview/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. 55:1377-80. 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.

46. Sources Cited Helman CG. Culture, health, and illness. (2001). London:Arnold. Kaiser Permanente National Diversity Council and the Kaiser Permanente National Diversity Department. (2000). A provider’s 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/censr01-104.pdf. Accessed: June 12, 2009.

47. 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/qualityhealthservices/ A Provider’s 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 (510) 271-6663

48. 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/index.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.html

49. 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