Cultural Competence “It is not what we don’t know that hurts us; it is what we know that isn’t so”
Hispanics: can no longer be ignored • 40 million and growing, 14% of the U.S population, 40% of the U.S. population growth in 2002 • American Hispanics buying power: larger than that of any Spanish speaking country in Latin America. • $600 billion in buying power. • 1 out of 7, 18-49 year olds is Hispanic
Age Distribution by Sex and Hispanic Origin: 2002 Non-Hispanic White Hispanic Male Female Male Female Note: Each bar represents the percent of the Hispanic (non-Hispanic White) population who were within the specified age group and of the specified sex. Source: Current Population Survey, March 2002, PGP-5
Percent Distribution of Hispanicsby Type: 2002 Source: Current Population Survey, March 2002, PGP-5
Regional Population Distribution by Hispanic Origin: 2002 Hispanic Northeast Midwest South West Source: Current Population Survey, March 2002, PGP-5
What is culture? • It is an established way of understanding the interpreting the world • Every group has a different way of expressing life, religion, and art; it has a set of values, traditions, beliefs, social ways, language, and history that differ from other groups.
What is cultural competence? • It is the integration and transformation of knowledge about a people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes • It is more than awareness or sensitivity!
It is a journey not a destination. It is when persons are able to honor the integrity of another’s unique differences while demonstrating abilities to work effectively even synergistically with them • Awareness—knowledge—skills—encounters—celebration--incorportate
Smoking Cessation Counseling Percent of current smokers counseled by a physician to quit Hispanic English Speaker Hispanic Spanish Speaker Total Asian American African American White Hispanic Source: Commonwealth Fund 2001 Health Care Quality Survey
How do disparities arise? • Differences in the quality of care/service received • Differences in access to care/service • Differences in social, political, economic, or environmental exposures which result in differences in quality of life/health
Racial and Ethnic Distribution of Selected Health Professions: Source: HRSA, U.S. Census 2000
Levels of cultural incompetence • Institutional • Personally mediated • internalized
Institutional cultural incompetence • Differential access to the goods, services, and opportunities of society by ethnicity or race. • Examples • Housing, education, employment, income • Medical facilities • Information, resources, voice
Personally mediated • Differential assumptions about the abilities, motive, and intents of others by race or ethnicity • Prejudice and discrimination • Examples • Police brutality, physician disrespect, shopkeeper vigilance, waiter indifference, teacher devaluation
Internalized cultural incompetence • Acceptance by the stigmatized race/ethnicity of negative messages about our own abilities and intrinsic worth • Examples • Self devaluation • White man’s ice is colder • Resignation, helplessness, hopelessness • Accepting limitations to our full humanity
Cultural incompetence and racism • What is racism? • A system of structuring opportunity and assigning value based on phenotype (race, ethnicity) that • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities • Undermines the potential of the whole society
Cultural incompetence like racism is a conveyer belt Don’t get carried away!
Advancing cultural competence • Set the agenda • Collect data • Coordinate action
Reactions to race • Behavioral risk factor surveillance system • How do people classify you? • How often do you think about your race/ethnicity? • Do you feel you were treated worse than, the same as, or better than people of other races? • When seeking services do you feel your experiences were worse than, the same as or better than for people of other races? • Have you felt upset, sad, frustrated because of how you were treated based on our race?
Measure institutional incompetence/racism • Scan for evidence of racial/ethnic disparities • Routinely monitor outcomes by race/ethnicity • “Could racism or cultural incompetence be operating here?” • Identify mechanisms • Examine written policies • Query unwritten norms and practices • “how is racism or cultural incompetence operating here?”
Advancing cultural competence • Coordinating action • Promulgate cultural competence protocols • Implement reminder systems • Monitor provider practice • Train a diverse workforce • Provide cultural competence training • Train and deploy translators • Community oversight?
Advancing cultural competence • Conversations on cultural incompetence and racism • Define it • Acknowledge impacts on corporate well being in a global economy, on health • Acknowledge waste to the nation
Advancing cultural competence • Confronting institutional racism and cultural incompetence • Put it on the organizations agenda • Ask “how is racism and cultural incompetence operating here?” • Organize and strategize to act • Dismantle, remodel, create a structure, a policy, a practice, a norm
“best practices” in cultural competency • Define culture broadly • Value client’s cultural beliefs • Recognize complexity in language interpretation • Facilitate learning between providers and communities and customers • Involve the ethnic group in defining and addressing service needs • Institutionalize cultural competence
Value client’s cultural beliefs • The extent to which you learn about and value the target community’s knowledge, attitudes, and beliefs • How is that information applied to improve service • How to talk about sensitive issues • Be willing to explore the individual life experiences to find the underlying causes of their behaviors
Recognize complexity in language interpretation • Being able to speak the language is not enough • Recognize the linguistic variation within a cultural group • Recognize the cultural variation within a language group • Recognize the variation in literacy levels in all language groups
Hispanics Who Speak Spanish as Primary Language Have More Problems Communicating with Their Physicians Percent of adults Base: Hispanics with health care visit in past two years. Source: The Commonwealth Fund 2001 Health Care Quality Survey.
Facilitate learning between providers and communities • Create environments where learning can occur • Learn about the cultural context, knowledge, beliefs, and attitudes of the communities you serve • Communities need to learn about the providers • Both need to learn how collaboration benefits both
Involve the community in defining and addressing service needs • More than satisfaction with services, involve your client and community in identifying community needs, assets, barriers and in creating the appropriate responses • Clients and community play an active role in needs assessment, program development, implementation, and evaluation • Community voting members of boards, focus groups, advisory boards
Institutionalize cultural competence • Integral part of the strategic plan • Sustainable funding for cultural competence • Design replicable activities
Twenty guidelines for successThe Rimm Report • Set high educational expectations, expect them to complete college and beyond, whether you did or not. Discuss careers, expect them to have careers, educational attainment is the highest priority. • Pressure teaches resilience; expect much and they will expect much of themselves; coach for success
Twenty guidelines for success • Motivation is as critical as ability; IQ is not a limitation; motivation, interest, perseverance • View your child as intelligent, good thinkers and problem solvers. Value their work, be positive about your own work, have family projects. Promulgate a work ethic, love of accomplishment, build a sense of personal competence
Twenty guidelines for success • Assertiveness can be learned; if necessary get professional help that will help your child view themselves as hardworking, smart, and independent • Middle and high school years are more important; search for schools with dedicated and inspiring teachers
Twenty guidelines for success • Encourage development of math and science skills; begin in preschool; play with toys that involve spatial relationships – puzzles/blocks. Reading is a high priority. Begin reading during infancy, let them see you enjoy reading. • Encourage taking advanced courses even it means a B rather than a A
Twenty guidelines for success • Skip a grade if they are not academically challenged • Extracurricular activities are important- music, art, dance, orchestra, drama and sports. Learning to handle busy schedules teaches them how to handle complexity and ambiguity as adults
Twenty guidelines for success • Competition – encourage entering contests, debates, creative problem solving meets. Winning builds confidence, losing builds character. To be successful in a competitive society they will have to experience winning and losing • Travel with your child
Twenty guidelines for success • Teach them that popularity is not important; to value independence from peers; that they can be different • Don’t glorify your experimentation with substances; today’s drugs are more dangerous • Be a coach not a judge; set firm limits; avoid overpunishment
Twenty guidelines for success • Make sure your child gets leadership opportunities and responsibilities; don’t label your child • Parents were the most frequent role model; your children are watching you… • Believe in your child’s survival skills; let them know they too can persevere
Guidelines for success • Teach them to value challenge, contribution, and creativity. Teach them how to be daring and courageous; role play skills