Cultural Competency to Reduce Health Disparities: Techniques and Strategies in Clinical Settings Haner Hernandez, Ph.D., CPS, CADCII, LADCI 413-627-1601 hanerhernandez@aol.com

 Disclosures The development of these training materials were supported by grant  H79 TI080209  (PI: S. Becker) from the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services. The views and opinions contained within this document do not necessarily reflect those of the US Department of Health and Human Services, and should not be construed as such.

Objectives Develop working definitions of Culture and Cultural Competency; Engage in interactive exercises to help identify barriers when working with culturally diverse populations; Explore the role of internalized oppression (subordination and domination); and Identify strategies, techniques, and resources to improve outcomes.

Introductions: ● Name ● Cultural Trait ● Expectation(s)

Ground Rules: ● Confidentiality ● Respect ● No Cross Talk ● Cell Phones Beepers ● Breaks ● Pass Rule ● Fun/Humor ● Agree to Disagree ● Share Time

Define Culture

Culture Is……… ● The integrated pattern of human knowledge, beliefs, and behaviors that depends upon a person’s capacity for learning and transmitting knowledge to succeeding generations; ● The customary beliefs, social forms, and material traits of a racial, religious, or social group; and ● The set of shared attitudes, values, goals, and practices that characterizes a group.

What is Cultural Competence?

Cultural Competence is…… “A set of behaviors, attitudes and policies that come together in a system, agency, or program or among individuals, enabling them to function effectively in diverse cultural interactions and similarities within, among, and between groups.” National Center for Cultural Competence: http://nccc.georgetown.edu/

Defining Health Disparities A health outcome that is seen to greater or lesser extent between populations Particularly linked with social, economic, and/or environmental disadvantage Team: I removed reference to “behavioral” health disparity so that we have consistent language in the training. Is there a need to include “behavioral?” Yes, we should include. Define behavioral health disparities here. Define behavioral health. Talking Points A health disparity, simply put, is a difference in health between populations or groups of people. In particular, it is linked with social, economic, and/or environmental disadvantage. Health disparities affect groups of people who have systematically experienced greater obstacles to health linked to discrimination or exclusion In December 2010, the Department of Health and Human Services launched Healthy People 2020, which has four overarching goals. One of the four overarching goals is to Achieve health equity, eliminate disparities, and improve the health of all groups; For those of you who have talked about how important it is to address health disparities, you are in good company. It is one of the four overarching goals that should guide all health promotion efforts in our country. [Note to Trainer: The other three HP2020 goals are to Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; Create social and physical environments that promote good health for all; and Promote quality of life, healthy development, and healthy behaviors across all life stages.] U.S. Department of Health and Human Services, Healthy People 2020 (n.d.). Disparities. Retrieved from http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

Health Equity Molly: The STJ webinar offered to share slides with participants. Will we make the same offer for the daylong training? Talking Points This image gives us a pretty clear idea of what we mean by health equity. Equality is giving all three children the same size box to stand on, which, though it is equal, still does not allow the smaller child to see the game. Equity is giving all three children the number of boxes that they need to watch the game. In prevention, this means giving certain populations additional support (e.g. programming, prevention efforts, support) that they need in order to reduce disparities to ultimately create health equity. When equity is our goal, we adjust resources and services so that all the kids have an equal opportunity to see the game. We achieve a positive outcome for more people. This visual also reminds us of the connection between health disparities and health equity. We address disparities in order to achieve equity. The reduction in health disparities is not the ultimate goal; the increase in health equity is the ultimate goal and reducing health disparities helps us get there. We want to make sure to give you tools you can use today. The visual on this slide is a useful tool to use while talking with others about health disparities. We will share today’s slides with you so you can use them in your work. Optional point to make, if time allows. Trainer should feel free to adapt to meet personal experience and style. Key point is: some people may focus on equal treatment and may be challenged by equity. In reality, does everyone support equity? [Include personal story. Example: all kids get a special birthday outing with a grandparent, but both kids are upset on the other’s special day.] Sometimes people focus on what is equal as an indicator of what is fair. In our communities, we may need to help people appreciate that even though the tallest boy didn’t get a box to stand on, or (your brother is going with grandpa today), or we have a class specifically for LGBQ youth, we have achieved equity because all the children can see the game, everyone will get a birthday outing with grandpa, or all youth have classes available to meet their expressed needs.

National CLAS Standards The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services. Adoption of these Standards will help advance better health and health care in the United States.

How We Claim We Treat People…. Non-biased Non-Judgmental As they come As we want to be treated and The Same

Stages of Change……. Behavior change occurs in Five Stages: Pre-Contemplation Contemplation Preparation Action Maintenance

Five Essential Elements of Cultural Competence…… Valuing diversity Awareness of the “dynamic of difference” Ability to institutionalize cultural knowledge Adaptation to diversity Cultural self-assessments

Spectrum of Attitudes…. People Viewed as Objects People Viewed as Recipients People Viewed as Resources

Cultural Competency Continuum…. Destructiveness Incapacity Blindness Pre-competence Competence Proficiency

Cultural Destructiveness This represents the most negative end of the continuum. Example: Culturally destructive people and/or agencies are those that support attitudes, policies and practice that are destructive to a particular culture.

Cultural Incapacity In this instance, the agency or individual does not intend to be destructive to a culture; rather, it simply lacks the ability to be responsive. In this instance, there is a basic assumption of superiority of the dominant culture.

Cultural Blindness An agency or individual that falls at this point along the continuum is one that purports to be totally unbiased. Its philosophy is the well-intended view that all people are the same. “We are all equal.” This view does not allow for modification strategies to meet the needs of clients, but rather feels that those strategies that apply to most should apply to all.

Cultural Pre-Competence The pre-competent individual or agency recognizes its inability to provide appropriate services to clients of a different culture as it is currently structured and attempts to improve some aspects of its service delivery in order to do so.

Cultural Competence These agencies and individuals are characterized by respect for difference among cultural groups, continuous self-assessment, expansion of cultural knowledge and attention to the dynamics of difference.

Cultural Proficiency All of the concepts of cultural competence are incorporated into an agency’s policy, practice and attitude. This agency or individual has the ability to add to the body on knowledge and to teach those concepts to others.

Barriers and Strategies……

Why Should We Consider Doing Things Differently? Folks who are working with culturally diverse communities must be sensitive as to how culture impacts their thoughts, feelings and actions. Some characteristics may include, but are not limited to, values, beliefs, sense of space, sense of time, male and female relationships, gender roles, rites of passage, ways of seeking help, influence of religion, and communication.

Techniques That Work: 1. Clarify with the person what work is about and educate the them on late appointments, payments, and cancellations. Be patient. Some are quick to learn, but others may require extra time and patience; 2. Make sure that the person understands your role and position;

Techniques That Work (cont.): 3. Try to be flexible. Allow yourself some extra time when you see people. Be prepared to do more outreach than you would do with others; 4. Self-evaluate at all times. Are you reacting to what the person says or to what is different from your cultural norms?; 5. Be open and warm, respond to personal questions and move on;

Techniques That Work (cont.): 6. Don’t be threatened or out of control if the person brings different family members to each session without consulting you. It is uncomfortable for workers not to know who folks are. For some people, bringing additional family members is a sign of support and caring. Try to include the spouse and other family members. If confidentiality is an issue, mention it to the person, and let them decide whom she or he wants to include in the sessions;

Techniques That Work (cont.): Have a listing of agencies and resources in your area. Learn about the services they provide in case you need to refer folks to them for additional help and support; Workers should consider the client’s historical, political, and socioeconomic background in the US and country of origin;

Techniques That Work (cont.): 9. Complete the Cultural Competency Individual Self Assessment; Complete the Cultural Competency Organization Self Assessment; Utilize the Practical Guide for Implementing the Recommended National Standards for Culturally and Linguistically Appropriate Services in Healthcare;

Techniques That Work (cont.): 12. Review, revise, or develop agency/program policies that address issues of Cultural Competency; and 13. Participate in, or recommend the development of a committee that will address Cultural Competency at your organization.

Key Questions for Organizations and Programs….. What is our working relationship with the community? How do we gain community buy-in, support, approval? How do we make sure that we are collecting cultural competence-related data? How do we make sure that the data are culturally appropriate and responsive? Are your priority populations represented at the agency/program levels?

Key Questions for Organizations and Programs..(cont.) ● What policies are in place or need to be developed to improve cultural competence? ● How do we ensure tools and technology are culturally competent? ● Are there cultural considerations that need to be considered in the adaptation and tailoring of evidence-based approaches?

Resources https://www.thinkculturalhealth.hhs.gov/content/clas.asp http://www.samhsa.gov/recoverytopractice/RTP-Contribution-Detail-For A_Practical_Guide_for_Implementing_the_Recommended_National_Standards_for_Culturally_and_Linguistica-374.aspx National Center for Cultural Competence: http://nccc.georgetown.edu/ Individual and Organizational Self Assessments: http://nccc.georgetown.edu/resources/assessments.html Additional Readings: http://nccc.georgetown.edu/resources/publicationstitle.html

Thank You! ¡Muchas Gracias!