Transcript Slide 27
Cultural Competency and Adolescent
Health
Objectives
Discuss the relationship between culture and health
in the context of adolescent-friendly services
Describe the intersection of patient-centered care
and cultural competency
Utilize the framework of cultural humility to minimize
provider bias and optimize health outcomes
The Culture of Adolescence
Peer dependent
Egocentric
Distinct language and dress
Influenced by popular culture
Ongoing search for identity
The Growing Diversity of the
Adolescent Population
1990
2050
75.7
52.7
21.1
11.8
15
10
9
3
Non-Hispanic White Non-Hispanic Black
Asians
Hispanics
An Adolescent’s Identity Includes
Race and
Ethnicity
Religion/Spirituality
Genetics
Socioeconomic
Status
Geography
Peer Group
Ability
Stage of
Development
Gender Identity
Sexual
Orientation
Family Structure
“Minority” Status in One or More Aspects
of an Adolescent’s Identity Can Affect
How and where health care is sought
Ability to obtain and pay for quality care
Patient-health care provider interaction
Societal stereotyping and marginalizing
Lack of Insurance
Young Adults aged 19-25:
22.6% uninsured
2nd-highest uninsured age group under 26- to 34-yearolds (23.5%)
Teens and children under 19:
7.6% uninsured
Teens and children under 18:
7.3% uninsured
US Census Bureau (2013)
Lack of Insurance = Lack of Care
Uninsured adolescents are:
Less likely to receive medical care
Less likely to have a usual source of care
More likely to experience long wait times
More likely to be low income and of color
Insured adolescents visit a physician’s office twice as
often as uninsured teens.
Barriers to Care: Provider Attitude
Lambda Legal survey through partner organizations,
4,916 LGB respondents, 2009
Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of
their identity/orientation
11% reported that providers refused to touch them or
used excessive precautions
Transgender and gender nonconforming respondents
reported facing discrimination and barriers to care 2-3
times more frequently than LGB respondents
16. Lambda Legal (2010)
Youth of Color Face Barriers to
STI/Pregnancy Prevention
Cultural barriers to consistent condom use for Latinas
Machismo
Catholicism’s opposition to birth control
Cultural expectation to be submissive
Memories of medical abuses and mistrust of U.S.
government
Hampers HIV education in some ethnic communities
http://www.advocatesforyouth.org/storage/
advfy/documents/transitions1503.pdf
Youth of Color Face Barriers to
STI/Pregnancy Prevention
Higher rates of medical indigence than white youth
Financial, cultural, institutional barriers in obtaining
health care
Publicly funded health insurance provides limited
access to comprehensive, adolescent-friendly health
services
High levels of worry about AIDS among urban
minority adolescents
Greater concerns: housing, food, transportation, child
care, getting pregnant, street violence
http://www.advocatesforyouth.org/storage/
advfy/documents/transitions1503.pdf
Barriers Lead to Health Disparities
Higher incidences of sexual risk behaviors
Higher rates of
Pregnancy
STIs
Delayed medical care
For Example…
LGB Youth Sexual Behaviors
Disparities in Teen Pregnancy Rates
Persist
Birth Rates, Females Aged 15-19,
U.S. 1991-2013
National Vital Statistics System. July 2014.
Teen Birth Rates by State
Pregnancy Rates: U.S. vs. CHOICE
N Engl J Med 2014;371:1316–23
Gonorrhea: Rates by Race/Ethnicity,
United States, 2009-2013
CDC STD Surveillance Report 2013
Chlamydia: Rates by Race/Ethnicity,
United States, 2009-2013
CDC STD Surveillance Report 2013
Chlamydia: Rates by State, United States
and Outlying Areas, 2013
CDC STD Surveillance Report 2013
Primary and Secondary Syphilis: By Sex, Sexual
Behavior, and Race/Ethnicity, United States, 2013
CDC STD Surveillance Report 2013
Herpes Simplex 2: Seroprevalence by Race,
Sex, and Age Group
CDC STD Surveillance Report 2013
Women who Have Sex with Women
(WSW) STI Risk
Nationwide, 6,935 self-identified lesbians
17.2% reported past history STI
Increased Risk
• Trichomonas
• HPV
• Bacterial vaginosis
• HIV
Consequences of Barriers
1 out of 2 LGBT adults withheld their sexual orientation
from a provider
1 of 4 withheld information about sexual practices (5
times more than heterosexual peers)
Harris Poll (2002 & 2003). Gran JM et al (2011). Krehely J (2009).
How Can Providers Improve
These Health Outcomes?
Strategies for Providing Optimal Care
Cultural Competency
Cultural Humility
Adolescent-Centered Care
Cultural Competency
Movement to address health disparities through
provider education
Trainings often required by many funders,
accreditation bodies, and institutions
Most Common Definition
of Cultural Competency
Cultural and linguistic competence:
A set of congruent behaviors, attitudes, and policies
that come together in a system, agency, or among
professionals that enables effective work in crosscultural situations. (Cross, et al. 1989)
Cultural Competence: Strengths
Brings culture into the discussion about manifestation
of disease and notions of health
Encourages providers to learn about cultures of
patients served
Supports respect for cultural differences and diversity
Cultural Competence
Provider Guidelines
Increase knowledge about how culture influences
behaviors and outcomes
Develop an awareness of providers’ and patients’
cultural issues and their effect on the medical
encounter
Understand the importance of appropriate language
and the use of interpreters
Framework
for Cross-Cultural
Care
Cultural Competency
in Practice
Listen to the patient's perception of the problem
Explain your perceptions of the problem and your
strategy for treatment
Acknowledge and discuss the differences and
similarities between these perceptions
Recommend treatment while remembering the
patient's cultural parameters
Negotiate agreement. Understand the patient's
explanatory model so medical treatment fits in
cultural framework
Berlin EA, Fowkes WC.1983
Efficacy of Cultural Competence
Programs
Patient-centered care (PCC) models with a cultural
competence framework have been shown to:
1. Increase provider’s knowledge
2. Increase provider’s awareness
3. Increase provider’s cultural sensitivity
One 10-week medical Spanish course for pediatric
emergency department physicians showed:
1. Decreased use of interpreter services
2. Increased patient satisfaction with physician concern,
respectfulness, and listening/communication.
A.M.N. Renzaho et al. 2013.
Mazor, et al. 2002.
Weaknesses in “Cultural Competency”
Not clearly defined
Denotes attainment of concrete level of knowledge
Risks cultural stereotyping
Focus on others instead of reflecting on individual
and organizational biases and prejudices
Cultural Competency and Adolescent
Health
What does is it mean to provide culturally competent
care to adolescents?
How does the “culture of adolescence” differ from
commonly held notions of culture?
How does the culture of adolescence interact and
coexist with racial and ethnic cultures?
Building On Cultural Competency:
Cultural Humility
Cultural Humility
Puts onus on provider to
self-evaluate how
personal biases may
affect service delivery
Redresses power
imbalances in patientphysician dynamic
Tervalon and Murray-Garcia, 1998
Health Care Providers’ Identities
Race and
Ethnicity
Profession
Marital Status
Parental
Status
Sexual
Orientation
Training
Background
Gender
Identity
Age
Medical
Specialty
Religion
Issues to Confront Before Seeing
an Adolescent Patient
How comfortable are you talking to adolescents?
What are your feelings/beliefs about adolescent
sexuality?
Are you able to separate your own values in order to
treat your patient?
Self-Evaluation During a Clinical
Encounter
How do you react when confronted with a patient
situation that does not fit your expectations?
Does the situation provoke feelings of anxiety and
discomfort?
Are you able to assess what is going on within
yourself as well as within the patient?
www.diversityRx.org
Cultural Competence and Cultural Humility
Combined: Adolescent-Centered Care
Elements of Adolescent-Centered
Services
Adolescent-specific
Multi- and
interdisciplinary
Accessible
Financially affordable
Adolescent-focused
materials on display
Peer educator component
Adequate space
Confidential
Flexible scheduling
Comprehensive services
Continuity of care
Help transitioning into the
adult medical care
system
Providing Care to Adolescents
Confront personal biases head-on
Be prepared to refer patient for appropriate care if
unable to provide it
Adolescent-Centered Care
Assure confidentiality
Invite parents to wait in waiting room
Explain why you will be asking sensitive questions
Treat each patient as an individual, acknowledging all
the interacting forces that make him/her unique
Ways to Provide Adolescent-Centered
Care
Ask a question and listen to the response!
Wait 30 seconds until you speak after each question
Answers will help identify how culture interacts with
patient’s health decisions
Utilize HEEADSSS
Comprehensive HEEADSSS
H: Home
E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
*Additional questions:
Strengths, Spirituality
Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
SHEEADSSS
S: Strengths/Spirituality
H: Home
E: Education/Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide/depression
S: Safety
Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
Strengths-Based Approach
Identify strengths early
Look for examples of past difficulties that your patient has
successfully overcome
Praise
Use reflective listening and pause
Create a comfortable, trusting, nonjudgmental setting
Share your concerns
Wrap Up
Emphasize that your approach is nonjudgmental and
that you welcome future visits
“I’m here for you, and I want you to feel comfortable
confiding in me. If you have something personal to
talk about, I’ll try to give you my best advice and
answer your questions.”
Provider Resources and Organizational
Partners
www.advocatesforyouth.org—Advocates for Youth
www.aap.org—American Academy of Pediatricians
www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
www.acog.org—American College of Obstetricians and
Gynecologists
www.arhp.org—Association of Reproductive Health
Professionals
www.cahl.org—Center for Adolescent Health and the Law
www.glma.org Gay and Lesbian Medical Association
Provider Resources and Organizational
Partners
www.guttmacher.org—Guttmacher Institute
janefondacenter.emory.edu Jane Fonda Center at Emory
University
www.msm.edu Morehouse School of Medicine
www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
www.prh.org—Physicians for Reproductive Health
Provider Resources and Organizational
Partners
www.siecus.org Sexuality Information and Education Council of
the United States
www.adolescenthealth.org Society for Adolescent Health and
Medicine
www.plannedparenthood.org Planned Parenthood Federation of
America
www.reproductiveaccess.org Reproductive Health Access
Project
www.spence-chapin.org Spence-Chapin Adoption Services
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