Cultural Competence

1
Cultural Competence

• Robert L. Johnson, MD, FAAP
• Professor of Pediatrics and Psychiatry
• Director, Division of Adolescent and Young Adult
  MedicineInterim Chair, Department of Pediatrics
• Jim Norris
• Director OEO/Affirmative Action
• Newark, NJ Board of Education

2
Cultural Competence

• A presentation to the
• Ambulatory Pediatric Association,
• National Pediatric Development Scholars Program
• Orlando, Florida
• December 7, 2001

3
Where are we going?

• Significance
• Definitions
• Professional Societies Positions, Statements and
  Outcomes
• Suggested Curriculum

4
Why is Cultural Competence Important?

• Existing Differences
• Existing Disparities
• Link Between Disparities and Cultural Competency

5
Why is Cultural Competence Important?
Health Care Outcome Disparities
Diversity
6
Why is Cultural Competence Important?

• Complaints by black patients are taken less
  seriously.
• A study reported in The New England Journal of
  Medicine revealed that doctors were 40 less
  likely to order sophisticated cardiac tests for
  blacks who complained about chest pain than for
  whites with identical symptoms.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
7
Why is Cultural Competence Important?

• Minorities get less intensive treatment.
• Even though African Americans die of coronary
  heart disease at a higher rate than whites, black
  patients receive cardiac bypass operations and
  other advanced procedures about one fourth as
  often as whites.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
8
Why is Cultural Competence Important?

• Minorities are more likely to receive mutilating
  surgery--even when less severe or invasive
  alternatives are available.
• A survey by Newsday found that minority patients
  with diabetes are more likely to have their feet
  or legs amputated, while whites in a comparable
  condition are more likely to receive surgery
  designed to restore blood flow and save their
  legs.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
9
Why is Cultural Competence Important?

• African Americans with serious kidney disease
  wait longer for transplants, and are less likely
  to receive a donor kidney than whites.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
10
Why is Cultural Competence Important?

• Minority patients who suffer from emotional
  problems are less likely than whites to be
  referred for psychotherapy.
• When they are referred they are more likely to be
  sent to inexperienced therapists and given more
  drugs.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
11
Why is Cultural Competence Important?

• African Americans are less likely than whites to
  get lung cancer surgery during the early stages
  the disease. Consequently, they are more likely
  to die from a potentially curable condition.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
12
What is culture?

• The word culture implies the integrated pattern
  of human behavior that includes thoughts,
  communications, actions, customs, beliefs,
  values, and institutions of a racial, ethnic,
  religious, or social group.
•  
• Cross T, Bazron BJ, Dennis KW, Isaacs, MR.
  Towards a culturally competent system of care.
  Vol. 1Monograph on effective services for
  minority childrenwho are severely emotionally
  disturbed. Washington (DC) CASSP Technical
  Assistance Center, Georgetown University Child
  Development Center 1989.

13
What is the source of our culture?

• Your family racial/ethnic makeup, and their
  racial attitudes.
• Where and when you were born and grew up.
• The people with whom you socialize and form
  friendships.

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
14
What is the source of our culture?

• Where you went to school, and your level of
  education..
• Previous diversity experiences in everyday life,
  the workplace, social or professional context.
• Attitudes and impression from the media..

Johnson, Simring, The Race Trap, Harper Collins,
NY, NY 2000
15
Health Disparities Culture

• How does culture make a difference?
• Because ethnic minorities are underrepresented
  among health professionals, patients and
  providers often have different cultural
  backgrounds.
• In these instances, language, socioeconomic
  status, and ethnicity may influence the provision
  of health services.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
16
How Does Culture Make a Difference?
Cultural Conflicts

• When patients and families cultural perceptions
  of health, illness, and treatments conflict with
  the pediatricians diagnosis or management plan,
  cultural differences may become barriers to
  access to care or the provision of health care
  services.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
17

How Does Culture Make a Difference?
Cultural Differences

• Cultural differences in verbal and nonverbal
  communication also have the potential to serve as
  barriers to effective pediatric care.
• Culturally linked behavior styles may influence
  the provider-patient interaction, including eye
  contact and communication styles
• There may be communication anxiety during social
  interactions between individuals in
  underrepresented cultural groups and individuals
  holding expert roles such as physicians and
  social workers

Culturally Effective Pediatric Care, American
Academy of Pediatrics,Committee on Pediatric
Workforce, 19971998
18
How Does Culture Make a Difference?
Unique Health Issues

• Patients from some ethnic minority groups may
  also have unique health issues that the
  pediatrician must consider to provide optimal
  care.
• To provide effective health services, providers
  must be able to communicate clearly with patients
  and their families about these issues.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
19
How Does Culture Make a Difference?
Professional Miscommunications

• There may be communication barriers between
  providers who have different cultural
  backgrounds.
• Health care providers at all levels and in all
  disciplines must be aware of the potential for
  miscommunication, particularly when there are
  socioeconomic, racial, or ethnic differences
  between providers.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
20
Cultural Sensitivity? Cultural Competence?
Cultural Competency? Cultural Effective Health
Care?
Failures of the service delivery system to be
responsive to all segments of the population
Cultural Sensitivity
Cultural Competence,Competency, Efficacy
21
Cultural Competence What is it?

• .cultural competence is a process which
  requires individuals and systems to develop and
  expand their ability to know about, be sensitive
  to, and have respect for cultural diversity.

The California Cultural Competency Task Force,
Department of Mental Health 1993
22
Cultural Competence What is it?

• The result of this process should be
• an increased awareness,
• acceptance,
• valuing
• and utilization
• of and an openness to learn from
• general and health related beliefs,
• practices,
• traditions,
• languages,
• religions,
• histories
• and current needs
• of individuals and the cultural groups to which
  they belong.

The California Cultural Competency Task
Force, Department of Mental Health 1993
23
Cultural Competence What is it?

• Cultural competency
• appropriate and effective communication which
  requires the willingness to listen to and learn
  from members of diverse cultures,
• and the provision of services and information in
  appropriate languages, at appropriate
  comprehension and literacy levels, and in the
  context of an individuals cultural health
  beliefs and practices."

The California Cultural Competency Task Force,
Department of Mental Health 1993
24
Culturally Effective Pediatric Health Care
the delivery of care within the context of
appropriate physician knowledge, understanding,
and appreciation of cultural distinctions. Such
understanding should take into account the
beliefs, values, actions, customs, and unique
health care needs of distinct population groups.
Providers will thus enhance interpersonal and
communication skills, thereby strengthening the
physician-patient relationship and maximizing the
health status of patients.
Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
25
Culturally effective health care is related to
cultural competence and cultural sensitivity

• However, whereas cultural competence and
  cultural sensitivity refer to the providers
  attributes, the term culturally effective health
  care refers to the interaction between the
  provider and patient.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
26

• Thus, culturally effective health care is based
  on cultural sensitivity and cultural competence,
• but also goes beyond these concepts in
  describing the dynamic relationship between
  provider and patient.

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
27
Beliefs Values Actions Customs Unique health care
needs
Physician and knowledge, understanding, and
appreciation of cultural differences. Physician
competency skills.

• Enhanced interpersonal and communication skills
• Strengthened the physician-patient relationship
• Maximized patient health status

28
Educational efforts should

• Enhance the knowledge and understanding of
  pediatricians about the culture of their
  patients,
• Increase the ability of pediatricians to provide
  care in a manner that is responsive to the
  individual needs of each patient

Culturally Effective Pediatric Care, American
Academy of Pediatrics, Committee on Pediatric
Workforce, 19971998
29
ACGME/Residency Review Committee
structured educational experiences that
prepare residents for the role of advocate for
the health of children within the community and
the inclusion of the multicultural dimensions of
health care in the curriculum
30
The APAs Educational Guidelines for Residency
Training in General Pediatrics, includes goals,
objectives, and references that relate to family,
cultural, and ethnic issues.
31
Educational Guidelines for Residency Training in
General Pediatrics
C. THE CHILD IN THE CULTURAL, ETHNIC, AND FAMILY
CONTEXT GOAL 8.5 Cultural, Ethnic, and Community
Sensitivity. Recognize the importance of
understanding, accepting, and appreciating
cultural diversity in one's patients and learn
about the health-related implications of cultural
beliefs and practices of groups represented in
one's community.
Ambulatory Pediatrics Association
32
Educational Guidelines for Residency Training in
General Pediatrics
OBJECTIVES a. Integrate an understanding of
patients' cultural beliefs and practices into
one's diagnostic approach and therapeutic
plan. b. Identify different illnesses and
diseases that are more common in certain ethnic
groups (e.g., Beta ThalassemiaSoutheast Asian
population). c. Show respect for patients'
cultural and ethnic background and beliefs.
Ambulatory Pediatrics Association
33
Educational Guidelines for Residency Training in
General Pediatrics
OBJECTIVES d. Demonstrate ability to ask
open-ended questions during history taking to
avoid making assumptions about patient
information which may be influenced by their
cultural or ethnic background. e. Demonstrate
ease and competence in the use of a medical
interpreter. f. Describe special health issues
and barriers to care for culturally and
ethnically diverse populations.
Ambulatory Pediatrics Association
34
Educational Guidelines for Residency Training in
General Pediatrics
OBJECTIVES
g. Identify common home remedies or alternative
treatments which may be detrimental to the
pediatric patient, and identify physical signs or
symptoms of common folk therapies or home
remedies (e.g., cupping, coining). h. Avoid
stereotyping, recognizing that there is
"within-culture" variability regarding health
beliefs and practices.
Ambulatory Pediatrics Association
35
Educational Guidelines for Residency Training in
General Pediatrics
OBJECTIVES
i. Be sensitive to differences between cultures
in family decision-making processes, including
the role of the extended family. j. Recognize
different ethnic and cultural communities in
one's area (e.g., Southeast Asian, Latino,
African American), and for each
Ambulatory Pediatrics Association
36
Cultural Competence Training in Residency
Education

• The next 12 slides present final data from the
  Survey of Pediatric Residency Program Directors
  conducted by the Future of Pediatric Education II
  (FOPE II) Project

37
Proficiencies Skills
Has your program identified specific
proficiencies and skills that residents should
acquire as a result of their training in the
following competencies?
38
Proficiencies/Skills Standardized Curriculum
39
Standardized Curriculum
Has a standardized curriculum for training in
these general competencies been established in
your residency program?
40
Proficiencies/Skills Standardized Curriculum
41
Teaching Methods
How does/will your program teach the following
competencies?
42
Teaching Methods
43
Quality
How would you rate the current quality of your
program's training in the following competencies?
44
Quality of Training
45
Evaluation
How does/will your program measure/evaluate
acquisition of the following competencies?
46
Evaluation Methods
47
Evaluation Methods
48
Evaluation Methods
49
Implementation
Skills
Knowledge
Attitudes
Curriculum?
50
Like R, Prasaad S, Rubel A. Society Of Teachers
Of Family Medicine Core Curriculum Guidelines.
Recommended Core Curriculum Guidelines On
Culturally Sensitive And Competent Health Care.
Family Medicine 199628(4)291-7.
Developed by the Society of Teachers of Family
Medicine's Task Force on Cross-cultural
Experiences, Group on Multicultural Health Care
and Education, and Group on Minority Health Care
51
Suggested Curricular Objectives Attitudes

• Awareness of the impact of sociocultural factors
  on patients, practitioners, the clinical
  encounter, and interpersonal relationships
• Acceptance of the physician's responsibility to
  understand the cultural dimensions of health and
  illness as a core clinical task in the care of
  all patients

52
Suggested Curricular Objectives Attitudes

• Willingness to make their own clinical settings
  more accessible to patients by taking into
  consideration their
• residential location,
• means, and costs of transportation,
• working hours,
• language and communication needs,
• disability status,
• and other financial and environmental
  circumstances

53
Suggested Curricular Objectives Attitudes

• Appreciation of the heterogeneity that exists
  within and across cultural groups and the need to
  avoid overgeneralization and negative
  stereotyping
• Recognition of their own personal biases and
  reactions to persons from different minority,
  ethnic, and sociocultural backgrounds and the
  need to deal with cultural counter transference

54
Suggested Curricular Objectives Attitudes

• Appreciation of how one's personal cultural
  values, assumptions, and beliefs influence the
  clinical care provided
• Willingness to understand and explicate those
  values, assumptions, and beliefs and to examine
  how they affect the care provided to patients
  that share and do not share a similar perspective

55
Suggested Curricular Objectives Attitudes

• Understanding of the limitations of cultural
  analysis and the role played by other historical,
  political, economic, technologic, and
  environmental forces in shaping the delivery of
  health care to individuals, families, and
  communities
• Expressing respect and tolerance for cultural and
  social class differences and their value in a
  pluralistic society

56
Suggested Curricular Objectives Attitudes

• A moral and ethical obligation to challenge
  racism, classism, ageism, sexism, homophobia, and
  other forms of bias, prejudice, and
  discrimination when they occur in health care
  settings and society in general

57
Suggested Curricular Objectives Knowledge

• General Sociocultural Issues Relating to Health
  Care
• Anthropologic concepts that are essential for the
  provision of culturally sensitive and competent
  health care
• How all cultural systems-including those of both
  patients and physicians-are sources of (congruent
  and incongruent) beliefs about health,
  communication about symptoms, and treatment

58
Suggested Curricular Objectives Knowledge

• General Sociocultural Issues
• The impact of culture on the recognition of
  symptoms and behaviors related to illness
• How diversity within a culture affects the
  provision and utilization of care

59
Suggested Curricular Objectives Knowledge

• General Sociocultural Issues ..
• How health care systems reflect the prevailing
  values of the Cultures) in which they exist
• Developmental models of ethnosensitivity (e.g.,
  fear, denial, superiority, minimization,
  relativism, empathy, and integration) in relation
  to one's own ethnic and sociocultural background

60
Suggested Curricular Objectives Knowledge

• Multiculturalism in the United States
• Selected minority, ethnic, and sociocultural
  groups
• Selected vulnerable or "at-risk" groups
• The changing demographics of various population
  groups

61
Suggested Curricular Objectives Knowledge

• Cultural Perspectives on Medicine and Public
  Health
• The health-seeking process and illness behavior
• Cultural assumptions and their influence on the
  US health care system

62
Suggested Curricular Objectives Knowledge

• The Ethnosensitive (Cultural) Epidemiology of
  Health and Illness Problems of Diverse Population
  Groups
• Clinical problems relating to the nation's health
  promotion and disease prevention objectives
• Clinical problems having high mortality and
  morbidity rates

63
Suggested Curricular Objectives Knowledge

• The Ethnosensitive (Cultural) Epidemiology .
• Clinical problems relating to the stage of the
  individual and family life cycles and major life
  events (pregnancy, birth, marriage, death, etc)
• Clinical problems that are linked to culture
  shock from migration, intergenerational value
  orientation conflicts, and acculturation/assimilat
  ion processes

64
Suggested Curricular Objectives Knowledge

• The Ethnosensitive (Cultural) Epidemiology .
• Clinical problems relating to "folk illnesses"
  (eg, "high blood," "falling out," "evil eye,"
  "susto," "ghost sickness," "koro")

65
Suggested Curricular Objectives Knowledge

• Clinical problems present in country or
  geographic area of origin

66
Suggested Curricular Objectives Skills

• Clinical Practice
• Forming and maintaining a therapeutic alliance
• Recognizing and appropriately responding to
  verbal and nonverbal communication
• Constructing a medical and psychosocial history
  and performing a physical examination in a
  culturally sensitive fashion

67
Suggested Curricular Objectives Skills

• Clinical Practice
• Using the biopsychosocial model in disease
  prevention/health promotion, the interpretation
  of clinical signs and symptoms, and
  illness-related problem solving
• Prescribing treatment in a culturally sensitive
  manner

68
Suggested Curricular Objectives Skills

• Clinical Practice
• Using the negotiated approach to clinical care
• Berlin and Fowke's LEARN model

69
Berlin and Fowke's LEARN Model

• (L)-Listening to the patient's perspective
• (E)-Explaining and sharing one's own perspective
• (A)-Acknowledging differences and similarities
  between these two perspectives
• (R)-Recommending a treatment plan
• (N)-Negotiating a mutually agreed-on treatment
  plan

70
Suggested Curricular Objectives Skills

• Clinical Practice
• Using the negotiated approach to clinical care
• Explanatory model (EM) elicitation techniques
  Eliciting individual or family EMs (ie, "ideas
  about the etiology, onset, pathophysiology,
  prognosis, and treatment of disease and illness")
  

71
Suggested Curricular Objectives Skills

• Clinical Practice
• Using the negotiated approach to clinical care
• llness prototype (IP) and patient request (PR)
  elicitation techniques Eliciting individual or
  family (ie, "ideas about sickness based on
  previous personal experiences, the experiences of
  significant others, or media-transmitted
  information")
• Eliciting individual or family PRs ie, "the type
  of help clinical resource the patient would
  like hopes, wishes, wants to receive from the
  practitioner")

72
Suggested Curricular Objectives Skills

• Clinical Practice
• Using the negotiated approach to clinical care
• Pfifferling's cultural status exam
• Stuart and Lieberman's BATHE model
  (Background/Affect/Trouble/Handling/Empathy)
  Exploring the psychosocial context of the
  patient's visit to provide social support and as
  a basis for gaining insight

73
Suggested Curricular Objectives Skills

• Clinical Practice
• Using family members, community gatekeepers,
  translators/interpreters, and other community
  resources and advocacy groups
• Working collaboratively with other health care
  professionals in a culturally sensitive and
  competent manner

74
Suggested Curricular Objectives Skills

• Clinical Practice
• Working with alternative/complementary medicine
  practitioners and/or indigenous, lay, or folk
  healers when professionally, ethically, and
  legally appropriate
• Identifying how one's cultural values,
  assumptions, and beliefs affect patient care and
  clinical decision making

75
Suggested Curricular Objectives Skills

• Administrative Practice
• Analyzing the sociocultural dimensions of one's
  own practice site and the implications for
  practice management
• Implementing a cultural sensitization training
  program for office/clinic staff
• Promoting cultural competence in health care
  organizations as part of total quality management
  and continuous quality improvement activities

76
Suggested Curricular Objectives Skills

• Administrative Practice
• Using ethnographic and epidemiological
  techniques in developing a community-oriented
  family practice
• Influencing the cultures of health care
  organizations and professional groups (eg,
  managed care organizations, ambulatory care
  facilities, hospitals, nursing homes, specialty
  societies)

77
Suggested Curricular Objectives Implementation

• The implementation of this core curriculum should
  be longitudinal
• Culturally sensitive and competent health care
  should be integrated into existing educational
  clinical activities, including hospital attending
  rounds, morning report, grand rounds, lecture
  series, conferences, small group seminars,
  precepting, home visits, community experiences,
  and self-learning.

78
Suggested Curricular Objectives Implementation

• Block elective experiences are also desirable,
  which involve work with specific minority,
  ethnic, or cultural groups, folk or lay medical
  practitioners, or placements in
  cross-cultural/international settings.

79
Suggested Curricular Objectives Implementation

• Residency faculty should function as role models
  by conducting their personal and professional
  affairs to reinforce the concept of culturally
  responsive health care
• Ongoing faculty development activities are
  strongly recommended to deal with potential areas
  of discomfort and resistance and to identify
  attitudes, knowledge, and skills that need to be
  further improved or strengthened

80
Suggested Curricular Objectives Implementation

• Residency faculty should function as role models
  ..
• Locally available behavioral and social
  scientists who have expertise in clinically
  applied anthropology should be identified, and
  interdisciplinary collaborative work with them
  is highly recommended.

81
Suggested Curricular Objectives Implementation

• Residency faculty should function as role
  models..
• Linkages should also be sought with formal and
  informal community leaders, advocacy groups,
  culture brokers, and appropriate
  alternative/complementary medicine practitioners
  and/or indigenous healers.

82
Suggested Curricular Objectives Implementation

• Specific intercultural training strategies
  include cognitive training, behavior
  modification, experiential learning, cultural
  self-awareness, and attribution training.
• Relevant bibliographic, games/simulations, and
  audiovisual materials should be available in the
  residency library (see attached listing for some
  selected examples).

83
Suggested Curricular Objectives Implementation

• Specific intercultural training strategies
  include ..
• Implementation strategies will likely vary across
  residency programs and should be individualized
  to cover issues relating to the sociocultural
  groups in need of and receiving health care in
  local communities.

84
Suggested Curricular Objectives Implementation

• Specific intercultural training strategies
  include .
• Faculty and resident interests, existing
  resources, and available curricular time will
  also be important determinants of the planned
  intercultural training activities.

85
Suggested Curricular Objectives Implementation

• Systematic quantitative and qualitative
  evaluations of the impact of these educational
  programs need to be carefully designed and
  carried out and the results shared with
  interested audiences.

86
For the full list of references for this
presentation and guidance for further reading,
please consult the Resources on Cultural
Competence on the Division of Graduate Medical
Education Pediatric Workforce Web page at
http//www.aap.org/profed/gmepw
THANK YOU