Presentation--Disparities and Cultural Competence in STD Programs
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Transcript Presentation--Disparities and Cultural Competence in STD Programs
Responding to Multicultural Training
Needs and Resource Development
Some Intersections of TB and HIV
Federal Training Centers
Collaboration Meeting
Kansas City
July 14-16, 2010
Stephanie Spencer, MA
California Department of Public Health
TB Control Branch
How does culture shape TB & HIV and
identify cross-cultural training needs?
System factors: Culture shapes U.S. economic
and political systems; Culture shapes the
healthcare system Disparities exist in access to
health care
Provider factors: Culture shapes attitudes and
beliefs about cultural groups; culture influences
clinician / staff attitudes/ beliefs about groups
and about health care
Patient factors: Culture shapes patients’
health beliefs and practices, patients’
experiences of health care system, patients’
abilities to deal with health concerns
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Specific Cultural Aspects of HIV/AIDS & TB
(sexual activity; expression, regulation of desire)
death and dying
cleanliness and contamination
guilt or innocence; reward and punishment
tradition and culture change
gender roles & relationships
social class relationships
economic and power structures
meaning/symbolism of body fluids
ideas about personal and social responsibility
prevention and treatment/latent vs. active disease
personal and affinity-group identity
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substance use
Epidemiology Helps Identify Cultural Groups
and Cross-cultural Factors
Epidemiologic information on HIV/AIDS and TB…
When are people being diagnosed?
Is incidence changing over time?
Who is affected?
Where are affected people…
…living when they are diagnosed?
…being diagnosed?
How are people becoming infected?
…points to the groups of people that programs
need to target for prevention and treatment
But, epi data doesn’t give enough information
about these groups to design specific, effective
interventions or disease investigations
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HIV Disparities: Interaction of Environment,
Culture, and Sexual Networks
Environment
Culture
Sexuality-related
beliefs, attitudes,
values, norms,
behaviors, gender
roles; internalized
Racism; language;
immigration
Experience; etc.
External Racism
Discrimination
Crime/Incarceration
Homicide
Gender Imbalance Ratio
Education/Drop-Outs
Health Care Access
Sexual Networks
Structure
Segregation
Concurrency
Dissortative Mixing
Duration of Infection
STD Prevalence
TB Infection
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TB Risk Factors in U.S. Present
Cross-cultural Training Needs
Birth
in a high TB incidence country
Drug/Alcohol abuse
Incarcerated
Homeless
U.S.-born racial/ethnic minority,
especially if at least one parent is
foreign-born
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TB Risk Factors in California
75% are born in TB high incidence countries
Top five countries of origin of TB cases:
China
India
Mexico
Philippines
Vietnam
10% have these risk factors
Drug/Alcohol abuse
Incarcerated
Homeless
U.S.-born racial/ethnic minority, especially if at
least one parent is foreign-born
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All factors present cross-cultural training needs
Beliefs are not mutually exclusive
A Paul Farmer example...
Source: Tracy Kidder. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer,
a Man Who Would Cure the World. Random House, 2003, pp. 33-35.
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Continuum of Cultural Competence
Lacks cultural
awareness and
thinks there is
only one way of
doing things
Recognizes
different cultures
and seeks to
learn about them
Culturally
Incompetent
Views
themselves as
culturally
superior to
other cultures
Sees all the same
people, and thinks
everyone should be
treated the same
Actively seeks
knowledge about
other cultures;
educates others about
cultural differences
Culturally
Competent
Accepts, appreciates
and accommodates
cultural differences.
Understands the effect
his/her own culture has
in relating to others
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Developing Cross-Cultural Competence
Understanding the background, cultural values, and
beliefs of patients, and applying that understanding in a
health context.
Cultural competency is the genuine sensitivity and
respect given to people regardless of their ethnicity, race,
language, culture or national origin.
Ability to anticipate and recognize misunderstandings
that arise from the differing cultural assumptions and
expectations of providers and patients and to respond to
such issues appropriately.
http://www.cahealthadvocates.org/_docs/cmc/2008/Importance-LanguageServices-2008.ppt#385,8,Cultural Competence
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Developing Cultural Competence:
Fundamental Attitudes
Non-judgmental approach to another’s
culture
Cultural humility about one’s own beliefs
Awareness of one’s own biases and
assumptions
Willing and able to explain and describe
one’s perspectives to others
Desire to understand others’ perspectives
Flexibility to negotiate toward desired
outcomes
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Skills for Cultural Competence (1) —
Document for performance reviews
Questioning skills to learn about a patient’s or
partner’s culture—including how a systematic
set of cultural health beliefs and health practices
makes sense
Observational skills to learn about a patient’s
and group’s access to health care and other
social needs
Communication skills to effectively negotiate
with people of different cultural backgrounds
about their health beliefs, behaviors, and access
needs
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Skills For Cultural Competence (2) —
Document for performance reviews
Awareness of communication styles
types and degrees of politeness
varying amounts of directness in questions
and answers
story telling as answers to questions
focus on the task or focus on the person
importance of eye contact or body language
Provide explanations to clients about why
certain questions are asked or why you are
doing certain things
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Complementary Strategies to build and
document cultural competence
Individual
staff strategies
Understand and explain own culture
Actively acquire cultural knowledge and skills,
including subcultures
Cross-cultural communication, negotiation skills
Programmatic
strategies
Bridging structural factors of health disparities
Language access & support for cultural practices
Organizational partnerships / integration
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Cultural Competence Training Process
Educate staff about culture
Continuity and self-peer review
basic concepts and definitions,
self-awareness
specific knowledge about cultural groups
cultural competence self-assessments
case conferences focusing on cultural issues
critical incident discussions
Include patient/community member
in cultural competence assessment, case
conference for mutual learning
planning interventions & services
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Developing Programmatic Cultural
Competence
Start by providing staff a shared framework for
talking about culture (definition)
Identify primary cultural groups with highest
incidence of STDs and for each group list age, risk
behavior, ethnicity/language, etc.
Plan specific times for learning about these cultures
Identify resources to teach—staff, community
members, trainers
Structure specific activities—workshops, speakers,
staff discussions, community events, critical
incident debriefing
Build in evaluation processes—staff goals, increase
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in partner notification,
Programmatic Strategies to Build
Cultural Competence (1)
Language Access
Find out which are most common languages in
your jurisdiction
Identify interpretation resources and funding
before you need them, including bilingual staff
Train staff to identify and accommodate client
interpretation needs
Develop effective ways of letting patients know
that interpretation is available at no cost to them
Implement interpreter training standards for
language skills and STD-specific training
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Programmatic Strategies to Build
Cultural Competence (2)
Support for Cultural Practices
Acknowledge and respect ethnomedical
explanations and treatments while
negotiating biomedical treatment
Support family decision making while
ensuring legalities of patient consent
Are there cultural healers you can involve?
Are there effective outreach or treatment
practices in clients’ communities or from
home countries that you can adapt?
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Programmatic strategies to build
cultural competence (3)
Resources for Cultural Knowledge
Non-medical specialists
social scientists
members of cultural heritage or identity
groups
“traditional” or “alternative” healers
patients themselves
patients’ families
community members
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Programmatic strategies to build
cultural competence (4)
Community Partnerships
Which local ethnic, cultural or advocacy groups
have community organizations?
Can you partner with them for outreach or to help
plan accessible services?
Do any of these organizations have opinion
leaders, cultural brokers, trained interpreters?
Do these organizations know anything about
STDs, HIV/AIDS?
Do these organizations have formal or informal
support services for patients, partners, families?
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Reaching the goal: culturally
appropriate and effective services
Culturally competent staff and programs can
develop individual patient-centered care that
includes clients’ cultures and biomedical best
practices:
Culture Care Preservation
Culture Care Accommodation
Culture Care Repatterning
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