What do I need to cover? Introduction Slides AACAP Cultural Competency Curriculum Overarching Goals LEVELS OF COMPETENCY Basic: The minimum level of cultural competency that a fellow should have upon completion of child and adolescent psychiatry training. Intermediate: The recommended level of cultural competency for a practitioner who is working in a community with a diverse patient population.
Advanced: The level of cultural proficiency to which a practitioner can aspire as a result of experience and scholarship 2001 2005 2010 2002 Health Differences Patient Centered care Integration of Psychiatry/Behavioral Health in
Primary Care Each patient has an ongoing relationship with a personal physician The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Is responsible for providing all of the patients health care needs or appropriately arranging care with other qualified professionals Care is coordinated and/or integrated across all elements of the healthcare system Quality and safety are hallmarks Enhanced access to care is available Patient Centered Care Understanding Cultural Differences in each patient/
family is important At the biological level: People of Mediterranean heritage and Glucose-6-phosphate dehydrogenase deficiency (G6PD) At the psychological level: Importance of co-sleeping vs. independent sleeping for infants and children in different families At the community level: Awareness of Historical & Geographic differences in people of Irish Heritage residing in Irish enclaves IOM Findings Racial and ethnic disparities in healthcare exist, and because they are associated with worse outcomes in many cases, are unacceptable
Racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality and evidence of persistent racial and ethnic discrimination in many sectors of American life. Many sources, including health systems, healthcare providers, patients, and utilization managers, may contribute to racial and ethnic disparities in healthcare Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare. Patient Centered Care Includes recognition of the individual patients unique heritage within understanding health and illness issues across populations
Includes recognition of the impact of health differences in individuals Includes recognition of the impact of health disparities on individuals Race: a sociological construct that is used to identify groupings that are presumably biologically and genetically determined. The concept of race has typically defined by anthropologists or sociologists, not by the individual. -Mental Health, Race & Ethnicity Ethnicity: a common heritage shared by a particular group. Heritage includes similar history, language, rituals and preferences for music and foods. Historical experiences are pivotal to understanding ethnic identity and current health status -Mental Health, Race & Ethnicity
Ethnic or Cultural Identity: That part of the individuals selfconcept which derives from knowledge of membership in a social group or groups combined with the value and emotional significance attached to that membership. Ethnocentrism: the tendency to judge all other cultural groups by the standards of ones own, with the assumption that ones own standards are correct and others are not. Minority group: a group who because of their ethnicity, nationality, religion, class, physical or cultural characteristics are singled out from others for differential and unequal treatment
Acculturation: the process by which people from an ethnocultural minority adjust to and adopt the behavior of the dominant norm. Assimilation: the process by which a minority ethnic group loses its distinctiveness. Multiculturalism: the preservation of different cultures or cultural identities within a unified society, such as a state or nation. Dictionary.com First generation: refers to immigrants who arrived in their new country during their adulthood Second generation: refers to the children of
immigrants that were born in the new country Generation 1.5: refers to children who were born in the country of origin and are now being raised in the new country Official racial and ethnic groups
One race Two or more races American Indian or Alaska Native Asian Black or AfricanAmerican Native Hawaiian or Other Pacific Islander White Office of Management and Budget, 2001 Hispanic or Latino
Not Hispanic or Latino U.S. Population by Race/Ethnicity Projections Importance of Diverse Children and Youth to the Future of the U.S. Future citizens Meeting developmental, educational health, and MH needs reduces marginalization, improves overall social/ community climate Future family environments Meeting developmental and MH needs minimizes future health, MH, and social welfare expenditures
Future workforce Meeting health and educational needs maximizes potential for productivity and success Critical to U.S. economy in global competition (both education and bicultural and bilingual skills) Immigration and Refugees U.S. accepts highest percentage of immigrants and refugees 1.2 million legal immigrants and refugees enter annually 800,000 to 1.2 million undocumented immigrants enter annually, net increase of 400,000 to 700,000; total of 8 million estimated currently Total number of immigrants (2000 to 2006): 7.6 million; 2.5 million in West,
2.4 million in South, 1.6 million in NE, 1.0 million Midwest Continents of Origin: Africa- 881,000, Asia- 8.2 million, Latin America- 16.1 million, Europe- 4.9 million, North America- 830,000, 3.3 million under 18 years Total number of immigrants in U.S.: 40 million 3/4 of children of immigrants are US born Immigrant Children and Children of Immigrants Immigrant children 2.2 Million children in the U.S. are recent immigrants By the year 2010 they will comprise 22% of school age children in the U.S. Children of Immigrants
80 percent of children of immigrants are born in the U.S. and are US citizens First and second generation immigrant children are the most rapidly growing segment of the U.S. child population (>30% of the U.S. school population)- Landale & Oropesa (1995) U.S. Immigrants by Place of Birth 60% Latin America 53% Asia 25% Europe 13.7%
Africa 2.8% Canada 2.7% 50% 40% 30% 20% 10% 0% Latin America
U.S. Census 2003 Asia Europe 13 groups experience health disparities Racial/ethnic groups
African-Americans Asian-Americans Native Americans Latinos Immigrants Gender and Sexual Women Gay, lesbian, bisexual and transgender
Special populations The Appalachian poor Those living with disabilities The obese The elderly Prisoners Certain religious groups
Causes of Health Disparities Biological variables PsychosocialCultural variables Genetically mediated susceptibility Socioeconomic status Awareness Preferences Beliefs about
health Beliefs about health care system Social support Self-efficacy Access-Related variables Insurance Geographic proximity to care Temporal access (wait times)
Transportation Physician-health system variables Treatment disparities Cultural incompetence and insensitivity Figure 22 Perceptions of Disparities in Health Care Generally speaking, how often do you think our health care system treats people unfairly based on Percent Saying Very/Somewhat Often Doctors
72% 70% Whether or not they have insurance 43% How well they speak English 58% 29% What their race or ethnic background is Whether they are male or female
The Public 47% 15% 27% Source: Kaiser Family Foundation, National Survey of Physicians, March 2002 (conducted March-October 2001); Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, October 1999 (Conducted July Sept., 1999) Return to KaiserEDU.org Perceptions of Disparities in Health Care When going to a doctor or health clinic for health care services, do you think most African Americans receive the same quality of health care as
whites, higher quality of care or lower quality of health care as most whites? Same Whites Blacks Hispanics Higher Lower 62% 36%
When going to a doctor or health clinic for health care services, do you think most Latinos receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites? Same Whites Blacks Hispanics 29% 38% Higher
8% SOURCE: Kaiser Family Foundation, March/April 2006 Kaiser Health Poll Report Survey, April 2006 (Conducted April 2006) Healthcare Disparities Differences in quality of healthcare not due to patient preferences or clinical characteristics. i.e., not related to Access-related factors Clinical needs Preferences Appropriateness of interventions Diagnostic and treatment decisions are influenced by patients race/ethnicity Persist despite controlling of income and access to insurance
= Potential Sources of Disparities in Care Health systems-level factors financing, structure of care; cultural and linguistic barriers Patient-level factors including patient preferences, refusal of treatment, poor adherence, biological differences Disparities arising from the clinical encounter IOM Recommendations, 2002 Promote consistency and equity of care through the use of "evidence-based" guidelines Produce more minority health care providers
These individuals are more likely to serve in minority and medically underserved communities Make more interpreters available in clinics and hospitals to overcome language barriers that may affect quality Increase awareness about disparities among the general public, health care providers, insurance companies, and policy-makers. Cross Cultural Education of health care providers Knowledge (learning about various cultures) Skills (learning to work with people from different cultures) Attitudes (cultural sensitivity awareness approach to the practice of medicine) Culture The integrated pattern of human behavior that includes thought, speech and action....the
customary beliefs, social norms and material traits of a racial, religious, or social group; the shared values, norms tradition, customs, arts, history, folklore, and institutions of a group of people. Websters Collegiate; Kim What does Culture do? Shapes behavior Categorizes perceptions
Gives names to selected aspects of experience Is widely shared by members of a particular society or social group Is an orientational framework to coordinate and sanction behavior The Basis of Cross-Cultural Immigrant to U.S./Descendant Raised in U.S. as member of a devalued group Regional differences Intra-group differences Gender
Sexual orientation Hearing Occupation (i.e. medical v. mental health) Components of Culture
Objective: easily seen, understood and accepted by other cultures clothing food artifacts Subjective: less easily understood; provide bases for misunderstanding
values ideals attitudes roles norms Cultural competence A set of congruent behaviors, attitudes, practices and policies that come together in a system or agency, or among professionals, and enable that system or agency, or those professionals, to work effectively in crosscultural situations Cross, et al (1989)
The Cultural Competence Continuum Cultural proficiency differences are valued and seen as strengths. Continual efforts to augment knowledge and improve practices. The most advanced stage. Cultural competence acceptance and respect for differences. Commitment to incorporate new knowledge to better meet the changing needs of minority populations. An advanced stage. Cultural pre-competence recognition of limitations of services and staffing with effort to improve. There may be tokenism. Cultural blindness intended philosophy of being unbiased; embracing idea of we are all the same. Race and culture are not considered, and there is no truly individual approach to treatment and treatment planning.
Cultural incapacity a lack of capacity to help children and families of color. No conscious intent to be culturally destructive, but practices may be discriminatory or paternalistic Cultural Competence in Healthcare Cultural awareness is defined as the process of conducting a self-examination of ones own biases towards other cultures and the in-depth exploration of ones cultural and professional background. Cultural awareness also involves being aware of the existence of documented racism and other "isms" in healthcare delivery. Cultural knowledge is defined as the process in which the healthcare professional seeks and
obtains a sound educational base about culturally diverse groups. In acquiring this knowledge, healthcare professionals must focus on the integration of three specific issues: health-related beliefs practices and cultural values; disease incidence and prevalence (Lavizzo-Mourey, 1996). Cultural skill is the ability to conduct a cultural assessment to collect relevant cultural data regarding the clients presenting problem as well as accurately conducting a culturally-based physical assessment. Cultural encounters is the process which encourages the healthcare professional to directly engage in face-to-face cultural interactions and other types of encounters with clients from culturally diverse backgrounds in order to modify existing beliefs about a cultural group and to
prevent possible stereotyping. Cultural desire is the motivation of the healthcare professional to want to engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful and seeking cultural encounters; not the have to. Cultural encounters is the pivotal construct of cultural competence that provides the energy source and foundation for ones journey towards cultural competence. (Josepha Campinha-Bacote 1991) Conceptual Models of Cultural Competence CRASH- based on core principles of cultural competency LEARN- underlies more specific interview
techniques CLEFS perspectives from which to gather information from the patient CRASH Consider Culture Show Respect Assess/Affirm Differences Show Sensitivity and Self-Awareness
Do it all with Humility LEARN Listen with sympathy and understanding Explain your perception of the problem Acknowledge and discuss the differences and similarities Recommend treatment Negotiate treatment CLEFS
Cultural Linguistic Environmental/educational Follow-up care Strengths Culture Bound Syndrome Culture bound syndromes
Amok Ataque de nervios Bilis and colera (aka muina) Boufee delirante Brain fag
Dhat Falling- out or blacking out Ghost sickness Hwa-byung Koro Latah Locura Mal de ojo
Spell Susto Taijin kyofusho Zar The Cultural Formulation Cultural identity of the individual Cultural explanations of the individuals illness cultural factors related to psychosocial environment and levels of functioning Cultural elements of the relationship between the individual and the clinician Overall cultural assessment for diagnosis and care Cultural identity of the individual
What are the individuals ethnic or cultural reference groups? For immigrants and ethnic minorities note separately the degree of involvement with both the culture of origin and the host culture, where applicable. Note language abilities, use and preference, including multilingualism Cultural explanations of the individuals illness Predominant idioms of distress through which need for social support are communicated nerves, spirits, somatic complaints, inexplicable misfortunes Meaning and perceived severity of the symptoms in relation to norms of the cultural reference group
Any local illness category used by the family and community to identify the condition Perceived causes or explanatory models used to explain the illness Current preferences for and past experiences with professional and popular sources of care Cultural factors related to psychosocial environment and levels of functioning
Culturally relevant interpretations of social stressors Available social supports Levels of functioning Level of disability Stresses in the local social environment Role of religion and kin networks in providing instrumental and informational support Cultural elements of the relationship between the individual and the clinician Differences in culture and social status between the individual and the clinician and problems that these may cause
Difficulty in communicating in the individuals first language Difficulty eliciting symptoms or understanding their cultural significance Difficulty in negotiating an appropriate relationship or level of intimacy Difficulty in determining if a behavior is normative or pathological Overall cultural assessment for diagnosis and care How cultural considerations specifically influence comprehensive diagnosis and care The AACAP Cultural Competency
Curriculum LEVELS OF COMPETENCY Basic: The minimum level of cultural competency that a fellow should have upon completion of child and adolescent psychiatry training. Intermediate: The recommended level of cultural competency for a
practitioner who is working in a community with a diverse patient population. Advanced: The level of cultural proficiency to which a practitioner can aspire as a result of experience and scholarship. Purnells Model Of Cultural Competence in Healtcare Meyers : Challenges in Providing a culturally competent healthcare system Meyers analysis: 1.Clinical differences amongst people of different racial and ethnic
background 2.Communication differences in style, method and meaning in communications even where the dominant language is being used well 3.Ethics different belief systems will challenge firmly held western beliefs inculcated through years of professional development 4.Trust/respect different levels of trust in where individuals have come from countries where authority figures have misused their positions. Respect in that some cultures will so respect a clinical authority figures that they will agree with the clinician and seek to provide acceptable answers. 5. Meyer CR. Medicine's melting pot. Minn Med 1996;79(5):5
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