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…
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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
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Continuity and self-peer review
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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

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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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