Cultural Competence Seminar

Teresa M. Nesman, Ph.D.November 30, 2012

Department of Child and Family StudiesCollege of Behavioral and Community Sciences, USF

Culture definitions are developed for different purposes, emphasizing different aspects of life.

What Is Culture?

(Kao, Hsu, & Clark, 2004)

◦ 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])

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)

What is Culture?

Culture is general and specific Culture is shared Culture is learned Culture is symbolic Culture is adaptive and mal-adaptive Culture is integrated Culture is dynamic

Attributes of Culture

Everyone “has” culture

Why Focus on 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

Dimensions of 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).

Why Focus on Culture?

Culture influences most, if not all aspects of human social interactions

Why Focus on Culture?

(Cross, Bazron, Dennis, & Isaacs, 1989)

SelfActualization

Culture and Human Needs

Esteem and Identity

Love and Belonging

Safety and Security

Physiologic (e.g., Food, Water)

Cultu

re:The w

ay we g

o abou

t meetin

g ou

r

need

s

Maslow’s Hierarchy Of Human Needs

Culture influences health behaviors and expectations.

Why Focus on Culture?

Typical week’s groceries in Germany : $500.07

Typical week’s groceries in China : $155.06

Typical week’s groceries in Chad : $1.62

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

Culture and Health

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)

Culture and Help-Seeking

(Hernandez & Nesman, et al., 2006)

Understanding Cultural Influences in Yourself and Others

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?

Activity: Childhood Memories

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

Culturally Diverse ContextsIndividual In context of FAMILY

CULTURALLYDIVERSEENVIRONMENT

In context of

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.

Acculturation

The force that moves a culture learner across 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.

Cross Cultural Competence

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.

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.

Cross-Cultural Interactions

“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 respectfullyand effectively to people of all cultures, races, ethnicbackgrounds, sexual orientations, and faiths or religions in amanner that recognizes, affirms, and values the work of theindividuals, families, tribes, and communities and protects thedignity of each.” (Child Welfare League of America, 2002)

(Cross-)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

Levels of Action in Cultural Competence

(Stately & Clark, 2003)

Cultural Destructiveness

Cultural Incapacity

Cultural Blindness

Cultural Pre-Competence

Cultural Competence

Advanced Cultural Competence

Cultural Competence Continuum

(Cross, Bazron, Dennis, & Isaacs, 1989)

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

Cultural Competence Continuum- 1

(Cross, Bazron, Dennis, & Isaacs, 1989)

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

Cultural Competence Continuum- 2

(Cross, Bazron, Dennis, & Isaacs, 1989)

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

Cultural Competence Continuum- 3

(Cross, Bazron, Dennis, & Isaacs, 1989)

ALERT

Model

for

Service

Providers

Accept: Accept the family’s beliefs, values,

& practices, even if you don’t agree

Learn: Learn about the culture of the

community and the individualfamilies you serve; ask questionsrather than assuming you know

Explain: Explain to families why you need

information, why time &appointments are important, & howtheir child will benefit

Respect: Respect the family’s cultural ideas,

beliefs, values & practices. Findculturally appropriate ways to showrespect

Train: Support & elicit the participation of

families in the education & trainingof providers

Multi-Cultural Panel Discussion on Help-Seeking Behavior

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?

Questions: Help-Seeking

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?

Questions: Experiences with Accessing Services

Increasing Access to Services for Culturally Diverse Families: 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)

Organizational Cultural Competence

Cultural/Linguistic characteristics of a

community’s population(s)

Infrastructure Domain/

Functions

Direct Service Domain/Functions

Degre

e o

f co

mpati

bili

ty d

efines

level of

org

aniz

ati

onal/sy

stem

ic c

ult

ura

l co

mpete

nce

Outcomes: Reducing mental

health disparities

Compatibility

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).

Increasing Accessibility of Mental Health Services to Culturally/Linguistically Diverse Populations

Community Context

Hernandez, M., & Nesman, T. (2006).

Organization’s/System’s

Cultural View of Health History Language Characteristics Resource Characteristics Strength Characteristics Needs Characteristics

Knowledge/Awareness of Organizational and Community Characteristics

An organization’s/system’s

combined policies, structures and

processes

Cultural/Linguistic characteristics of a

community’s population(s)

Compatibility

Hernandez, M., & Nesman, T. (2006).

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.

AccessThe ability to

enter, navigate, and exit

appropriate services and

supports

AvailabilityServices and

supports exist in sufficient range and capacity to meet the needs of the population

UtilizationAppropriate

rates of use of needed mental health services

Compatibility between the infrastructure and

direct service functions of an organization

Compatible Organizational Strategies

Hernandez, M., & Nesman, T. (2006).

• 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

Key Aspects of Organizational Cultural Competence

(Cross, Bazron, Dennis, & Isaacs, 1989)

Organizational Cultural Competence: Assessment of Progress

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.)

Individual Competencies

(Seeleman, Suurmond, & Stronks, 2009; Stately & Clark, 2003; Suh, 2004; )

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

Organizational Competencies

(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, Mowery, Worthington, & Isaacs, 2006)

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

Organizational Competencies Detail- 2

(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)

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.)

Organizational Competencies Detail- 3

(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)

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)

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)

Linking Refugee Children to Services in the Community

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?

Questions

Using a Cultural Competence Assessment Tool

Individual Level Assessment

Cognitive Domain___ Cultural awareness- appreciation and sensitivity

to values, beliefs, lifeways, practices, & problem-solving strategies of clients

___ Cultural knowledge- learning about other cultures’ worldview, languages, & social contexts through cultural immersion or extensive training

Affective Domain___ Cultural sensitivity- intentional and affective

perception of cultural diversity and respect for cultural differences

(Suh, 2004)

Individual Level Assessment

Behavioral Domain___ Ability to conduct cultural and physical

assessments & communicate cross-culturally to learn patients’ cultural beliefs, values, and practices & determine proper interventions

Environmental Domain___ Cultural encounter experience with patients of

different cultural backgrounds, either in cultural immersion or international programs

(Suh, 2004)

Organizational Values_____ Cultural competence is incorporated into

the organization’s mission statement_____ Staff is familiar with and understands

cultural competence in the organization_____ Organizational leadership and staff say

cultural competence is important  

Cultural Competence Assessment Domains 1

Policies, Procedures, & Governance_____ Policies and procedures include cultural and

linguistic competence._____ Policies and procedures in the principal

language of the client._____ Administrators, the board of directors, and

committees support culturally competent practices.

_____ Proportional representation of diverse group members at all levels.

Cultural Competence Assessment Domains 2

Planning, Monitoring, & Evaluation_____ Baseline information on cultural groups is collected_____ Ongoing awareness of cultural group characteristics_____ Cultural competence plan is updated annually._____ Cultural competence planning involves staff and

clients._____ Systematic collection of information about groups

served and staff demographics._____ Monitoring of access to and quality of services for all

groups served._____ Programs fit the cultural and historical aspects of

communities and staff

Cultural Competence Assessment Domains 3

Communication_____ Leadership communicates with staff about cultural

competence._____ Community feedback is solicited and responded

to. _____ Organization décor and written materials

communicate a culture-affirming message. _____ Staff able to communicate effectively in ways that

are easily understood by diverse audiences._____Targeted outreach activities to communicate health

care information in appropriate languages & literacy levels.

Cultural Competence Assessment Domain 4

Human Resource Development_____ Diverse staff recruited with knowledge of

community served. _____ Diverse staff retained and promoted equitably._____ Staff knowledgeable about federal and state

statutes and regulations for cultural and linguistic competence.

_____ Staff evaluated on cultural and linguistic competence for promotion.

_____ Bilingual interpreters assessed for ability to accurately translate in health settings.

Cultural Competence Assessment Domains 5

Community and Consumer Participation_____ Organizational leadership and staff collaborate

with clients and community members in developing culturally competent services.

_____ Staff participates in cultural functions and community education activities.

_____ The organization purchases goods and services from community-based and minority businesses.

_____The organization values the opinions of clients, & solicits feedback.

_____Staff involved in community advocacy for social issues.

Cultural Competence Assessment Domains 6

Facilitation of a Broad Service Array_____Services are appropriate for community

culture & incorporate strengths in all aspects of care.

_____ Services are accessible, facilitate’ use, & provide for continuity of care.

_____ Facilitates obtaining health education materials & other resources in appropriate languages.

Cultural Competence Assessment Domains 7

Organizational Resources_____Database systems, set up to support planning,

monitoring, and evaluating services for diverse clients, including tracking disparities.

_____Financial resources support cultural competence, such as diversity training or compensation for bilingual capacity.

_____Communication resources support cultural and linguistic competence through appropriate technologies and staffing (e.g., interpreters, etc.).

_____ Culturally/linguistically appropriate educational media, forms, literature, and service directories.

Cultural Competence Assessment Domains 8

Data Sources Mission statement, other documents Website & other media Outreach activities Attendance records for meetings Meeting minutes Participant evaluation/satisfaction surveys Personnel files Clinical records; case records MIS data Opinion surveys Participant observation (journal) Interviews with staff; administrators; community

members

A developmental process: Cultural competence is a goal toward which professionals, agencies, and systems can strive; it can be learned & improved

A continuum: Responses to cultural difference move back & forth along the continuum, varying for individuals, groups, points in time, & contexts

An ongoing process: It is active, developmental, iterative, and aspirational rather than achieved

PROCESS OF CULTURAL COMPETENCE

Resources

http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/porch/default.cfm

http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/default.cfm

http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/protocol/default.cfm

Betancourt, J.R., & Green, A.R. (2010). Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85, 4: 583-585.

Callejas, L.M., Hernandez, M., Nesman, T., and Mowery, D. (2010). Creating a front porch in systems of care: Improving access to behavioral health services for diverse children and families. Evaluation and Program Planning 33,1:32-35.

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Toward a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: National Technical Assistance Center for Children’s Mental Health.

Harper, M., Hernandez, M., Nesman, T., Mowery, D., and Worthington, J., Isaacs, M. (Eds.) (2006). Organizational Cultural Competence Assessment: A Review of Assessment Protocols (Making Children’s Mental Health Services Successful series, FMHI pub. No. 240-2). Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Available: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/protocol/default.cfm

Hernandez, M., Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research &

Training Center for Children’s Mental Health. Hernandez, M., Nesman, T., Mowery, D., Acevedo-

Polakovich, I. D., and Callejas, L. M. (2009). Cultural competence: A review and conceptual model for psychiatric and mental health services. Psychiatric Services, 60, 8:1046-1050.

Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLOS Medicine 3, 10: 1673-1676.

Seeleman, C., Suurmond, J., & Stronks, K. (2009). Cultural competence: A conceptual framework for teaching and learning. Medical Education 43: 229-237.

Siegel, C., Davis-Chambers, E., Haugland, G., Bank, R., Aponte, C., & McCombs, H. (2000). Performance measures of cultural competency in mental health organizations. Administration and Policy in Mental Health 28, 2:91-106.

Stately, A.L., & Clark, R.L. (2003). AIDS Project Los Angeles & United American Indian Involvement, Inc.

Suh, E.E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing 15: 93-102.

U.S. Department of Health and Human Services [DHHS]. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

World Health Organization. (2001). The World Health Report 2001. Mental Health: New Understanding, New Hope. France. http://www.who.int/entity/whr/2001/en/whr01_en.pdf

References