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 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. American Hispanics buying power: larger than that of any Spanish speaking country in Latin America. $600 billion in buying power. $600 billion in buying power. 1 out of 7, year olds is Hispanic 1 out of 7, year olds is Hispanic

Age Distribution by Sex and Hispanic Origin: 2002 MaleFemale Male Hispanic Non-Hispanic White Source: Current Population Survey, March 2002, PGP-5 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.

Percent Distribution of Hispanics by Type: 2002 Source: Current Population Survey, March 2002, PGP-5

Northeast Midwest South West Hispanic Regional Population Distribution by Hispanic Origin: 2002 Source: Current Population Survey, March 2002, PGP-5

What is culture? It is an established way of understanding the interpreting the world 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. 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 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 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 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 Awareness—knowledge—skills— encounters—celebration--incorportate

Smoking Cessation Counseling Percent of current smokers counseled by a physician to quit Source: Commonwealth Fund 2001 Health Care Quality Survey White African American Hispanic Asian American Total Hispanic English Speaker Hispanic Sp anish Speaker

How do disparities arise? Differences in the quality of care/service received Differences in the quality of care/service received Differences in access to care/service Differences in access to care/service Differences in social, political, economic, or environmental exposures which result in differences in quality of life/health 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 Institutional Personally mediated Personally mediated internalized internalized

Institutional cultural incompetence Differential access to the goods, services, and opportunities of society by ethnicity or race. Differential access to the goods, services, and opportunities of society by ethnicity or race. Examples Examples Housing, education, employment, income Housing, education, employment, income Medical facilities Medical facilities Information, resources, voice Information, resources, voice

Personally mediated Differential assumptions about the abilities, motive, and intents of others by race or ethnicity Differential assumptions about the abilities, motive, and intents of others by race or ethnicity Prejudice and discrimination Prejudice and discrimination Examples Examples Police brutality, physician disrespect, shopkeeper vigilance, waiter indifference, teacher devaluation 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 Acceptance by the stigmatized race/ethnicity of negative messages about our own abilities and intrinsic worth Examples Examples Self devaluation Self devaluation White man’s ice is colder White man’s ice is colder Resignation, helplessness, hopelessness Resignation, helplessness, hopelessness Accepting limitations to our full humanity Accepting limitations to our full humanity

Cultural incompetence and racism What is racism? What is racism? A system of structuring opportunity and assigning value based on phenotype (race, ethnicity) that A system of structuring opportunity and assigning value based on phenotype (race, ethnicity) that Unfairly disadvantages some individuals and communities Unfairly disadvantages some individuals and communities Unfairly advantages other individuals and communities Unfairly advantages other individuals and communities Undermines the potential of the whole society 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 Set the agenda Collect data Collect data Coordinate action Coordinate action

Reactions to race Behavioral risk factor surveillance system Behavioral risk factor surveillance system How do people classify you? How do people classify you? How often do you think about your race/ethnicity? 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? 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? 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? 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 Scan for evidence of racial/ethnic disparities Routinely monitor outcomes by race/ethnicity Routinely monitor outcomes by race/ethnicity “Could racism or cultural incompetence be operating here?” “Could racism or cultural incompetence be operating here?” Identify mechanisms Identify mechanisms Examine written policies Examine written policies Query unwritten norms and practices Query unwritten norms and practices “how is racism or cultural incompetence operating here?” “how is racism or cultural incompetence operating here?”

Advancing cultural competence Coordinating action Coordinating action Promulgate cultural competence protocols Promulgate cultural competence protocols Implement reminder systems Implement reminder systems Monitor provider practice Monitor provider practice Train a diverse workforce Train a diverse workforce Provide cultural competence training Provide cultural competence training Train and deploy translators Train and deploy translators Community oversight? Community oversight?

Advancing cultural competence Conversations on cultural incompetence and racism Conversations on cultural incompetence and racism Define it Define it Acknowledge impacts on corporate well being in a global economy, on health Acknowledge impacts on corporate well being in a global economy, on health Acknowledge waste to the nation Acknowledge waste to the nation

Advancing cultural competence Confronting institutional racism and cultural incompetence Confronting institutional racism and cultural incompetence Put it on the organizations agenda Put it on the organizations agenda Ask “how is racism and cultural incompetence operating here?” Ask “how is racism and cultural incompetence operating here?” Organize and strategize to act Organize and strategize to act Dismantle, remodel, create a structure, a policy, a practice, a norm Dismantle, remodel, create a structure, a policy, a practice, a norm

“best practices” in cultural competency Define culture broadly Define culture broadly Value client’s cultural beliefs Value client’s cultural beliefs Recognize complexity in language interpretation Recognize complexity in language interpretation Facilitate learning between providers and communities and customers Facilitate learning between providers and communities and customers Involve the ethnic group in defining and addressing service needs Involve the ethnic group in defining and addressing service needs Institutionalize cultural competence 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 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 is that information applied to improve service How to talk about sensitive issues How to talk about sensitive issues Be willing to explore the individual life experiences to find the underlying causes of their behaviors 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 Being able to speak the language is not enough Recognize the linguistic variation within a cultural group Recognize the linguistic variation within a cultural group Recognize the cultural variation within a language group Recognize the cultural variation within a language group Recognize the variation in literacy levels in all language groups Recognize the variation in literacy levels in all language groups

Hispanics Who Speak Spanish as Primary Language Have More Problems Communicating with Their Physicians Base: Hispanics with health care visit in past two years. Source: The Commonwealth Fund 2001 Health Care Quality Survey. Percent of adults

Facilitate learning between providers and communities Create environments where learning can occur Create environments where learning can occur Learn about the cultural context, knowledge, beliefs, and attitudes of the communities you serve Learn about the cultural context, knowledge, beliefs, and attitudes of the communities you serve Communities need to learn about the providers Communities need to learn about the providers Both need to learn how collaboration benefits both 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 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 Clients and community play an active role in needs assessment, program development, implementation, and evaluation Community voting members of boards, focus groups, advisory boards Community voting members of boards, focus groups, advisory boards

Institutionalize cultural competence Integral part of the strategic plan Integral part of the strategic plan Sustainable funding for cultural competence Sustainable funding for cultural competence Design replicable activities Design replicable activities

Twenty guidelines for success The 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. 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 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 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 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 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 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 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 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 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 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 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 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 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 Don’t glorify your experimentation with substances; today’s drugs are more dangerous Be a coach not a judge; set firm limits; avoid overpunishment 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 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… 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 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 Teach them to value challenge, contribution, and creativity. Teach them how to be daring and courageous; role play skills