Cultural Humility and Competency: Understanding Multicultural Health in a Diverse Society

1. Cultural Humility and Competency:Understanding Concepts of Multicultural Health in a Diverse Society Asher Delerme, MS, LADC, CCS, CCDP Executive Director, CASA, Inc. www.casaincct.org adelerme@casaincct.org May 3, 2012

2. What is Cultural Competence? Knowledge Information and Data From and About Self, Individuals and Groups Integrated & Transformed INTO Clinical Standards Skills Service Approaches Techniques Marketing Programs that match the individual’s culture and increase both the quality and appropriateness of health care and health outcomes. (King Davis, 2003)

3. HEALTH Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 2004) NATIONAL PRIORITY: SOCIETY IN WHICH ALL PEOPLE LIVE LONG HEALTHY LIVES (HEALTHY PEOPLE, 2020)

4. Culture Defined • The sum total of ways of living developed by a group of human beings to meet biological and psychological needs. It refers to elements such as values, norms, beliefs, attitudes, folkways, behavior styles and traditions that are linked together to form an integrated whole that functions to preserve the society (Leighton, 1982).

5. Multiculturalism • Multiculturalism is about creating a new world where all people, because of who they are (as differentiated from “regardless who they are”), are welcomed , appreciated, and celebrated. • It means acknowledging our biases, and striving to overcome our limitations. • It focuses on raising our awareness of our cultural assumptions about ourselves and the world. It cannot exist if we are not willing to change our minds, hearts, and our lives. • We must build alliances with those who are different from us and not be tempted to surround ourselves in sameness. • Finally, we must transform our worldview in order to move beyond our very real human and spiritual limitations. Amy L. Reynolds, Ph.D., Staff Psychologist, Buffalo State College Handbook of Multicultural Counseling, Sage Publications

6. How do we become culturally competent?Exploring one’s own cultureExploring one’s own BiasFamily of OriginExploring other cultures

7. THE ICEBERG

8. THE LENS

9. Stereotyping Is. . . • A shortcut version of perception • Not always based on reality • Frozen and static • Not open to exceptions for individual behavior • Very difficult to undo • The first barrier to cultural competence

10. Mental Tapes • Early-learned stereotypes affecting our • Thoughts • Feelings • Beliefs and especially Behaviors

11. Automatic Pilot • The process of using our mental tapes to determine our reactions to people who are “different.” • Being “on automatic” is stereotyping • Most adults operate “on automatic” • Our responses are unconscious

12. Provider Bias • Pregnant Black Females 1.5 X more likely to be tested for illicit drug use than Non-Black females (DPH, 2009)

13. National Behavioral Health Disparities • Quality of Care • Minorities are over-diagnosed and misdiagnosed as having SMI, and underdiagnosed w/ affective disorders • In one study, case vignettes that were identical in terms of symptomatology and varied only by race, AA dx w/ schizophrenia 1.5X more than caucasians

14. Taking Off our “Lenses” or Turning Off “Automatic Pilot” • Stopmaking knee-jerk reactions • Think about YOUR mental filters • Decide NOT TO ACT on existing stereotypes • Seekout new information - read, talk, and observe to identify cultural patterns

15. Where do we begin? • “Tell me someone’s race. Tell me their income. Tell me whether they smoke. The answers to those three questions will tell me more about their longevity and health status than any other questions I could possibly ask. There’s no genetic blood test that would have anything like that for predictive value.” -Donald M. Berwick, Pediatrician and former member of President Bill Clinton’s Commission on Health Care Quality

16. Health Disparities Defined • “…systematic differences in healthcare practices and service utilization patterns related to race, culture or gender and not due to a health condition.” Connecticut Department of Mental Health & Addiction Services

17. Health Disparities Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion (Healthy People, 2020)

18. Race, Ethnicity, and Health •Greater exposure to racism and discrimination, violence, poverty •Disparities in infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infections/AIDS, and immunizations •Increased rates of substance use (+alcohol) and suicide amongst minority groups

19. Health Disparities • Health disparities: 2009 CT Health Disparities Report -Median age at death (2009) for whites -79, African Americans (AA) - 68 and Latinos - 62 years old -Infant mortality- AA triple rate for whites -Cancer-AA cancer death rate 30% higher than whites -Diabetes-Latinos twice as likely to die from Diabetes as whites -Acute Hepatitis B – AA 1.9X higher than Whites -HIV/AIDS – AA 6.6 X higher than Whites, Latinos 7.4X higher than Whites -Hospitalization & ED Visits – AA, Asthma, 3.7X higher than Whites, Latinos – 3.9X higher than Whites

20. Cultural mistrust Payor status Psychological access Socioeconomic differences Differences in help seeking norms Stereotyping Intercultural divide between service systems and people’s community norms Language barriers Oppression, racism, and discrimination Causes of Behavioral Health Disparities?

21. What’s the Connection Between Health Disparities and Culture? Cultural differences affect how people: • Communicate pain or problems • Label symptoms or indicators • Determine the causes of problems • Perceive health care providers • Utilize & respond to treatment or assistance

22. Disparities in Health Care: The Five A’s FIT BETWEEN A PERSON’S NEEDS and SYSTEMS ABILITY TO MEET THOSE NEEDS •Availability –Does it exist? •Accessibility –Ease and convenience to obtain and use the service (including geography) •Accommodation –Ease with which people can use care (hours, waiting time, length of waiting time) •Acceptability/Appropriateness –Correctness, effectiveness, quality –Congruent with cultural beliefs, values, & world view (

23. Disparities in Health Care: The Five A’s (Cont.) •Affordability: Costs to the person, perception of value waiting time, length of waiting time) •Acceptability/Appropriateness –Correctness, effectiveness, quality –Congruent with cultural beliefs, values, & world view

24. Barriers to and Mediators of Equitable Health Care (Cooper et al., 2002)

25. Target Population • Demographics: Changing Needs of Society (Growth of Connecticut’s Populations) • In 1980, minorities represented about 10% of Connecticut’s overall population. (U.S. Bureau of the Census, 1980). • U.S. Census projections indicate that by the year 2025 about 31% of all Connecticut residents will belong to a racial or ethnic minority group (U.S. Bureau of the Census, 2010). • In 2010, Latinos represented about 12% of Connecticut’s overall population. (U.S. Bureau of the Census, 2010).

26. Survey: Immigrants • Asian Population in CT (Fastest Growing, 2000 – 2007 - 38%) • South Asians from India (well trained & highly educated) • Vietnam, Thailand, Cambodia and Laos • 3.4% of CT Population (US census Bureau 2005a, 2008a.) • Latin Americans and Caribbean Immigrants (Highest Growing by Numbers, 2000 – 2007, 25%) • Nationally account for over ½ of all immigrants (52%) • In CT, Mexico and Central America (10%), South America (12%) • Puerto Ricans who are US citizens remain largest Latino subpopulation in CT • 12% of CT Population

27. Immigrants: Special Concerns • Personal histories i.e. war, torture, trauma, etc. • Cut off from Cultural Roots (Isolation and Loss of Family/Community) • Migration Experience • Culture Shock & Political Powerlessness • Linguistic Difficulties • Health Concerns • Refugee Status • Definition of Health and Wellness

28. Why Are You Trying to Reach Them? • Health Disparities: Less access to, & availability of, health services (including behavioral health) • Prevalence of diseases in certain groups • Non-traditional view of illness and health • Less likely to receive needed health services • Less likely to receive high quality health care\ • Reduce number of preventable hospitalizations (Racial and Ethnic minority populations accounted for 100% of growth in preventable hospitalizations between 2000 & 2006, the 2009 CT Health Disparities report)

29. Why Are You Trying to Reach Them (Cont.)? • Underrepresented in health research • Experience a greater burden of disability • Socio-political context impacts access • Language barriers • Insurance coverage (expensive/complicated/unavailable)

30. Non-Western Notions About Sickness and Health • Health interrelated with mind, body and spirit or view from a holistic approach. Human distress is perceived as an indication that people have fallen out of harmony with both their internal and external environments. • Health/healing often involves religious or spiritual rituals that invoke higher powers • Some healers will “journey” to other levels of reality on behalf of the person to find answers to their problems

31. Non-Western Notions About Sickness and Health • Family dynamics can cause sickness • Fate may cause sickness (Predestined) • Possession of malevolent spirits

32. Multicultural Counseling and Therapy (MCT) • MCT help to explain the notion of helping beyond a culture-bound perspective. • Clients are biological, cultural, spiritual and political beings as well. • Medical model was developed in a particular cultural context (Eurocentric) • Different worldviews lead toward different determinations of client concern. • MCT seeks to work with & learn from clients • Helps clients to think, feel and behave within their own cultural framework and respect other worldviews

33. Self care behaviors of Our Identified Groups • Health seeking behaviors • Support networks, folk health practices • Coping with stress and • Access to care: Men vs. Women

34. Target Population Social Identity Factors/Six factors that vary among cultural groups • Race • Ethnicity and Language • Age • SES • Sexual Orientation • Religion

35. Socio-Political Context in Which Treatment Occurs • History of Colonialization • History of Oppression • Marginal Status • Stigmatization • Migration Issues

36. Poor Communication • Poor Communication Occurs When We: - assume similarity - ignore difference in values - do not pay attention to non-verbal communication - disrespect a person’s native language - stereotype groups and individuals

37. Effective Communication • Pronounce names correctly • Be open to patient’s expertise • Ask for clarification or meaning(s) • Increase cultural specific awareness • Tolerate ambiguity • Be aware of non-verbal messages • Avoid language with questionable connotations • Consult with community leaders and family members • Never use children as interpreters • Address the person not the interpreter

38. Conclusions- A starting Place • Acknowledge culture as a predominant force in shaping behaviors, attitudes, values, and institutions • Recognize the challenges and opportunities associated with culturally diverse populations. • Check your own attitude & accept that you don’t know it all and allow yourself to learn from the people you serve • Acknowledge and accept that cultural differences will have an impact on program development, implementation and retention. • Respect the unique, culturally defined needs of your client populations.

39. Morals of the Story • To work effectively with persons from diverse cultures we must be clear on our own cultural identity and find ways to respect, understand and help bring forth the cultural strengths of others as well as ourselves for the benefit of all.

40. To make cultural competence a reality requires a commitment of the heart and a willingness to confront and get beyond cultural baggage.

41. Morals of the Story Cont. • Culture counts as the bridge of communication between clients and staff • Culture facilitates engagement and relationships • Value and understand the diversity within diversity • Language is critical in understanding worldview.

42. Service Recommendations Specific to Cultural Groups Learn the role of Cultural broker, i.e. help individuals and families recognize their cultural values/beliefs and how those may conflict with perceptions that emanate from the larger culture and institutions Culturally Specific Health Practices Culturally Specific Help Seeking Recognize issues of social injustice as well as the legacy of endurance, survival and triumph

43. SUGGESTIONS Service workers of same race background Utilization of religious and spiritual supports Culturally Specific peer/mentoring groups Incorporate Culturally Specific events for Health outreach activities (e.g. Hispanic Heritage, Kwanza, Black Hx)

44. SUGGESTIONS • Review and understand our own personal biases towards other cultural groups • Confront prejudicial behaviors and actions of one group versus another • Involve clients in applying ideals such as fairness, equity and justice to their world • Review institutional policies and practices for fairness, equity and justice as applied to patients (do any of these policies contribute to experiences of alienation or hostility)

45. SUGGESTIONS Utilize talents, skills and culturally based strengths of all patients in the delivery of services Pay attention to the socio-political context in which services are delivered Provide alternative and empowering roles for clients and staff so it creates a sense of hope and purpose

46. SUGGESTIONS Is culture an intrinsic part of the plan to deliver services? Value client’s cultural, linguistic and experiential backgrounds Review the service delivery plan for its relevancy to the cultural experiences and values of the target population

47. Developing a Professional/Personal Learning Agenda

48. Questions and Answers

49. Gracias.