Cultural Competency and Adolescent Health

1. Cultural Competency and Adolescent Health

2. Outline • Cultural Competency and Adolescent Healthcare: What Does It Mean? • Adolescent stages of development • Identities and disparate health outcomes • Movements to decrease bias and optimize health service delivery

3. Objectives • By the end of this presentation, participants will be able to: • 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

4. 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?

5. Adolescence • Developmental stage separating childhood and adulthood • Occurs between ages 11-22 • Needs vary by development and personal circumstances • Shaped by race, ethnicity, religion, socioeconomic status, family/peers

6. Stages of Adolescence • Early • Middle • Late

7. Early Adolescence • A spurt of growth • Beginning of sexual maturation • Concrete thinking

8. Mid-Adolescence • Develop a stronger sense of identity • Relate more strongly to peer group • Thinking becomes more reflective

9. Late Adolescence • The body fills out and takes its adult form • Distinct identity and more settled ideas and opinions

10. The Culture of Adolescence • Peer dependent • Egocentric • Distinct language and dress • Influenced by popular culture • Ongoing search for identity

11. An Adolescent’s Identity Includes: Religion/ Spirituality Race and Ethnicity Genetics Socioeconomic Status Geography Peer Group Ability Stage of Development Gender Identity Sexual Orientation Family Structure

12. “Minority” Status in One or More Aspects of an Adolescent’s Identity Can Affect: • How and where healthcare is sought • Ability to obtain and pay for quality care • Patient-healthcare provider interaction • Societal stereotyping and marginalizing

13. Living in Poverty Increases the Likelihood of Being Uninsured • 3.3 million (1 in 8) adolescents ages 12-17 lack health insurance • 8 million (1 in 4) youths ages 18-24 are uninsured

14. Lack of Insurance Can = Lack of Care • Insured teens receive care twice as often as uninsured adolescents • In a survey of adolescent girls: • 50% of uninsured reported foregoing needed care • More than 2xs the rate of insured girls

15. This Can Lead to Health Disparities, Including: • Higher incidences of sexual risk behaviors • Higher rates of: • Pregnancy • STIs • Depression • Drug and alcohol use

16. For Example…

17. Teen Pregnancy Has Continued to Declined

18. Disparities in Teen Pregnancy Rates Persist

19. Lesbian, Gay, and Bi Teens Report Sexual Risk Behaviors

20. How Can Providers Improve These Health Outcomes?

21. Strategies for Providing Optimal Care • Cultural Competency • Cultural Humility • Adolescent-Centered Care

22. Cultural Competency • Movement to address health disparities through provider education • Trainings often required by many funders, accreditation bodies, and institutions

23. 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 cross-cultural situations. (Cross, et al. 1989)

24. 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

25. Cultural CompetenceProvider 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 translators

26. 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

27. 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

28. Building Upon Cultural Competency: Cultural Humility

29. Cultural Humility • Puts onus on provider to self-evaluate how personal biases may affect service delivery • Redresses power imbalances in patient-physician dynamic Tervalon and Murray-Garcia, 1998

30. Healthcare Providers’ Identities Profession Race and Ethnicity Medical Specialty Marital Status Parental Status Sexual Orientation Training Background Gender Identity Age Religion

31. 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?

32. 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

33. Cultural Competence and Cultural Humility Combined: Adolescent-Centered Care

34. 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

35. Providing Care to Adolescents • Confront personal biases head on • Be prepared to refer patient for appropriate care if unable to provide it

36. 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

37. 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

38. The HEEADSSS Model • H: Home • E: Education/Employment • E: Exercise/Eating • A: Activities • D: Drugs • S: Suicide/Depression • S: Sexuality • S: Safety • S: Spirituality (Optional)

39. Please Complete Your Evaluations Now

40. Provider Resources • www.prch.org- Physicians for Reproductive Choice and Health • www.aap.org - The American Academy of Pediatrics • www.acog.org - The American College of Obstetricians and Gynecologists • www.adolescenthealth.org- The Society for Adolescent Health and Medicine • http://www.aclu.org/reproductiverights/- The Reproductive Freedom Project of the American Civil Liberties Union • www.advocatesforyouth.org – Advocates for Youth • www.guttmacher.org – Guttmacher Institute • www.cahl.org/ - Center for Adolescent Health and the Law • http://janefondacenter.emory.edu—The - The Jane Fonda Center of Emory University • www.siecus.org - The Sexuality Information and Education Council of the United States • www.arhp.org - The Association of Reproductive Health Professionals

41. Provider Resources • PRCH’s Minors’ Access to Confidential Reproductive Healthcare Cards and Emergency Contraception: A Practitioner’s Guide • ARHP Reproductive Health Model Curriculum • AMA Guidelines for Adolescent Preventive Services (GAPS) • The American College of Obstetricians and Gynecologists: • Confidentiality in Adolescent Health Care • Primary and Preventive Health Care for Female Adolescents • Tool Kit for Teen Care—available at: • http://www.acog.org/bookstore/Tool_Kit_for_Teen_Care_P348C84.cfm • For emergency contraception, call 1-888-NOT-2-LATE

42. Provider Resources • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002: www.cdc.gov/std/treatment/rr5106.pdf • Building Emergency Contraception Awareness Among Adolescents, A ToolKit, Academy for Educational Development: http://www.aed.org/Publications/upload/ECtoolkit3283.pdf • Henry J. Kaiser Family Foundation: public health policy, broken down by area (e.g., reproductive, state-specific, Medicaid, HIV/AIDS): www.kff.org. • The Young Men’s Clinic of Columbia University: http://www.cumc.columbia.edu/dept/sph/popfam/ • Mount Sinai Adolescent Health Center: http://www.mountsinai.org/msh/msh_program.jsp?url=clinical_services/ahc.htm