Teresa M. Nesman, Ph.D.
November 30, 2012
Department of Child and Family Studies
College of Behavioral and Community Sciences, USF
Culture definitions are developed for
different purposes, emphasizing different
aspects of life.
(Kao, Hsu, & Clark, 2004)
◦ Traits, abilities, and habits that signify membership
in a society
 Volksgeist or the "spirit of the folk” - cultural traits
are shaped by ancestral history & physical
environment; include language, literature, religion, the
arts, customs, & folklore (Herder, 1769)
 “Complex whole”- includes knowledge, belief, art,
morals, law, custom, & any other capabilities & habits
acquired by man as a member of society" (Tylor, 1958
[1871])
◦ Shared behavior, lifestyle, and meanings:
 “Customs, beliefs, values, knowledge, and skills that
guide a people’s behavior along shared paths” (Linton,
1947)
 “Means by which a local population maintains itself in
an ecosystem” (Rappaport, 1968 [1980])
 “Pattern of meanings embodied in symbols…by means
of which men communicate, perpetuate, & develop
their knowledge about and attitudes toward life"
(Geertz 1973)
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Culture
Culture
Culture
Culture
Culture
Culture
Culture
is
is
is
is
is
is
is
general and specific
shared
learned
symbolic
adaptive and mal-adaptive
integrated
dynamic
Everyone “has” culture
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Sense of self
Group membership- individualism vs.
collectivism
Communication & language
Relationships
View of time
Values & norms
Beliefs & attitudes
Mental processes & learning styles
Work styles & practices
Dress & appearance
Food & eating habits
Art & aesthetics
Stately & Clark, 2003
Culture is often invisible to people until they
find themselves in cross-cultural situations
◦ Since one is born into a culture, one experiences
that culture as always already there, part of the
world that one sees, not as a way of seeing the
world (Steeves & Kahn, 1995, p. 183).
Culture influences most, if not all aspects of
human social interactions
Self
Actualization
Esteem and Identity
Love and Belonging
Safety and Security
Physiologic (e.g., Food, Water)
Maslow’s Hierarchy Of Human Needs
(Cross, Bazron, Dennis, & Isaacs, 1989)
Culture influences health behaviors
and expectations.
Typical week’s groceries in Germany : $500.07
Typical week’s groceries in China : $155.06
Typical week’s groceries in Chad : $1.62
Life trajectories and health status are
impacted by culture:
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Lifestyles
Help-seeking behaviors
Values/beliefs/norms of families & individuals
Values/beliefs/norms of service systems
Lack of cultural compatibility between health
care organizations and clients reduces access
to appropriate services and can result in:
◦ Misdiagnoses (Fabrega, Ulrich, & Mezzich, 1993;
Kilgus, Pumariega, & Cuffe, 1995; Malgady &
Constantino, 1998; U.S. DHHS, 2001; Yeh et al.,
2002)
◦ Mistrust and low utilization of services (Snowden,
1998; Takeuchi, Sue, & Yeh, 1995; Theriot, Segal,
& Cowsert, 2003; U.S. DHHS, 2001)
(Hernandez & Nesman, et al., 2006)
Understanding
Cultural Influences in
Yourself and Others
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What was in your “back yard” when you were a
child?
What did your kitchen look like? What was in it?
Who spent most time in it?
What were common foods you ate? When & where
did you eat?
How did you learn to read? Who helped you?
What was a common saying related to health,
hygiene, or well-being?
What did your parent(s)/caregivers do when you
were sick with a cold?
Cultural Competence:
What is it and Why is
It Important?
Culturally Diverse Contexts
Individual
In context of
FAMILY
In context of
CULTURALLY
DIVERSE
ENVIRONMENT
 Process of becoming adapted to a new
culture, either within the natural culture or
among strangers, at home or in a foreign
land.
 Process of learning to adjust.
 Involves re-orientation of thinking, feeling,
and communicating.
The force that moves a culture learner across
a continuum from a state of no
understanding of, or even hostility to, a new
culture to a near total understanding.
Moving from mono-culturism to bi- or multiculturism.
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What seems to be right, logical, sensible, important,
or obvious to a person in one culture may seem
wrong, irrational, silly, unimportant, or confusing to
someone in another culture.
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Differences between cultures are too often perceived
as threatening or bothersome and are described in
negative terms.
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Most people take their own language for granted until
they encounter another language.
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Understanding another culture requires personal
experience and time spent interacting with members of
that cultural group.
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Stereotyping is most likely to occur in the absence of
frequent contact with people from other cultures.
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Understanding another culture is a continuous and not a
discrete process.
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Culture is negotiated whenever two or more groups come
in contact.
“The acquisition of awareness, knowledge and skills needed to
function effectively in a pluralistic democratic society (e.g.,
ability to communicate, interact, negotiate, and intervene on
behalf of clients from diverse backgrounds)” (Stately & Clark,
2003)
“The ability of individuals and systems to respond respectfully
and effectively to people of all cultures, races, ethnic
backgrounds, sexual orientations, and faiths or religions in a
manner that recognizes, affirms, and values the work of the
individuals, families, tribes, and communities and protects the
dignity of each.” (Child Welfare League of America, 2002)
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Individual level- engage in actions or create
conditions that maximize the optimal
development of clients and client systems
Organizational and societal level- develop
theories, practices, policies, and
organizational structures that are responsive
to all groups
(Stately & Clark, 2003)
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Cultural Destructiveness
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Cultural Incapacity
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Cultural Blindness
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Cultural Pre-Competence
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Cultural Competence
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Advanced Cultural Competence
(Cross, Bazron, Dennis, & Isaacs, 1989)
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Cultural destructiveness: assumes one race or culture
is superior to another, e.g. social or medical
experiments without knowledge or consent
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Cultural incapacity: unconscious bias, paternalistic
posture, may support segregation, disproportionately
applies resources
(Cross, Bazron, Dennis, & Isaacs, 1989)
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Cultural blindness: believes ethnicity or race makes
no difference, views self as unbiased yet is
ethnocentric in service delivery, views minorities as
culturally deprived, encourages assimilation
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Cultural pre-competence: commitment to civil rights,
realizes weaknesses and makes attempts to improve,
hires staff that match the service population but may
be only token efforts
(Cross, Bazron, Dennis, & Isaacs, 1989)
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Basic cultural competence: accepts and respects
difference, continuously self-assesses, adapts service
models, seeks advise and input from minority
communities and includes informal supports
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Advanced cultural competence: holds culture in high
esteem, seeks to add to knowledge base, advocates
continuously for cultural competence across service
systems
(Cross, Bazron, Dennis, & Isaacs, 1989)
Accept:
Learn:
ALERT
Model
Explain:
for
Service
Providers
Respect:
Train:
Accept the family’s beliefs, values,
& practices, even if you don’t agree
Learn about the culture of the
community and the individual
families you serve; ask questions
rather than assuming you know
Explain to families why you need
information, why time &
appointments are important, & how
their child will benefit
Respect the family’s cultural ideas,
beliefs, values & practices. Find
culturally appropriate ways to show
respect
Support & elicit the participation of
families in the education & training
of providers
Multi-Cultural Panel
Discussion on HelpSeeking Behavior
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How does the family talk about illness? What questions are
asked of a person who doesn’t feel well?
Who in the family decides what to do for a sick family
member?
Where or who does the family go to for help outside the
home? What kind of help is sought?
What kind of service provider is most often contacted?
What do family members believe about the help they will get
at a medical facility?
Where do they go in emergencies?
How do families talk about insurance, financial, or legal
status?
How do families address any literacy or linguistic challenges?
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What are the most difficult barriers to
accessing medical services for someone from
your background?
What is the worst situation you’ve ever seen
that limited access to services for someone
from your background?
What is the best situation you’ve seen that
facilitated access to services for someone
from your background?
Increasing Access to
Services for Culturally
Diverse Families:
Organizational Cultural
Competence
“A set of congruent behaviors, attitudes, and policies
that come together in an agency that enables
employees to work effectively in cross-cultural
situations.” (Cross, Bazron, Dennis, & Isaacs, 1989)
“A culturally competent program possesses the skills
and abilities to work effectively with diverse
populations. This is demonstrated by serving particular
subgroups of the larger population in a way that
understands, is relevant to and respects the unique
features, cultural beliefs, language and lifestyles within
these populations” (Amherst H. Wilder Foundation,
2002)
Increasing Accessibility of Mental Health Services to
Culturally/Linguistically Diverse Populations
Definition: Within a framework of addressing mental health disparities in a community, the level of a human service organization’s/system’s
cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a
community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate
access, availability and utilization of needed services/supports (Hernandez,& Nesman, 2006).
Degree of compatibility defines level of
organizational/systemic cultural competence
Community
Context
Cultural/Linguistic
characteristics of a
community’s
population(s)
Compatibility
Outcomes:
Reducing mental
health disparities
Organization’s/System’s
Infrastructure
Domain/
Functions
Direct
Service
Domain/
Functions
Hernandez, M., & Nesman, T. (2006).
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Cultural/Linguistic
characteristics of a
community’s
population(s)
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Compatibility
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Cultural View of Health
History
Language Characteristics
Resource Characteristics
Strength Characteristics
Needs Characteristics
An organization’s/system’s
combined policies,
structures and
processes
Hernandez, M., & Nesman, T. (2006).
Compatible Organizational Strategies
Infrastructure
Domain
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
• Communication
Compatibility between the
• Human Resources
infrastructure and direct
Development
service functions of an
• Community &
organization
Consumer
Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/
Supports- language,
technology, etc.
Direct Service
Domain
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports
Utilization
Availability
Appropriate
rates of use of
needed mental
health services
Services and
supports exist in
sufficient range
and capacity to
meet the needs
of the population
Hernandez, M., & Nesman, T. (2006).
Specific behaviors, knowledge, attitudes, policies, and
procedures that demonstrate:
 Acceptance, respect, regard, flexibility, knowledge about
culture and ethnicity
• Working effectively when faced with cultural differences
including:
 Responding effectively, linguistic competence, improving
access to and quality of care for underserved
• Congruence across system components/levels:
 Policies and procedures that enable effective work in
cross/multi-cultural situations at all organizational levels
• Self-assessment and quality assurance
• On-going development of knowledge, resources, and
service models:
 Knowledge and skills to use appropriate assessment and
treatment methods
•
(Cross, Bazron, Dennis, & Isaacs, 1989)
Organizational
Cultural Competence:
Assessment of
Progress
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Awareness of one’s own and others’ culture (beliefs, values,
assumptions), and one’s own prejudices & stereotypes
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Knowledge about and sensitivity to diverse clients being
served (e.g., epidemiology, social context, resources, etc.)
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Developing appropriate service strategies and techniques
(e.g. cross-cultural communication skills, openness, flexibility
& adaptability, knowing when interpretation is needed, etc.)
(Seeleman, Suurmond, & Stronks, 2009;
Stately & Clark, 2003; Suh, 2004; )
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Acknowledgement of culture
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Ongoing assessment
◦ Observable behaviors & attitudes demonstrate
acceptance, respect, regard, flexibility, &
knowledge about communities served.
◦ Policies, procedures, & documents demonstrate
acceptance, respect, regard, flexibility, &
knowledge about communities served.
◦ Ongoing self-assessment of cross-cultural
relations
◦ Ongoing quality assurance
(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, Mowery, Worthington, & Isaacs, 2006)
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Responsiveness to cross-cultural dynamics
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Cultural knowledge development
◦ Organization recognizes and responds effectively
to cross-cultural issues that impact access to
care
◦ Linguistic adaptations meet client needs
◦ Organization facilitates equal access to and
utilization of quality care
◦ Ongoing development of knowledge about
characteristics of communities served
◦ Ongoing assessment of organizational
compatibility with the communities served
(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)
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Adaptation for compatibility
◦ Adaptations are made to policies and procedures to
increase compatibility with community
characteristics
◦ Input and feedback is regularly sought from
community members & clients
◦ Infrastructure supports the delivery of compatible &
effective direct services
◦ Outcomes are meaningful to providers, families, &
community members (quality of life, satisfaction
with services, treatment effectiveness, costs
effectiveness, etc.)
(Cross, Bazron, Dennis, & Isaacs, 1989; Harper, Hernandez, Nesman, et al., 2006)
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Avoid stereotyping- culture is not static, and varies
by individuals and families, it’s not a single variable,
it’s a dynamic process
Attention to culture may be interpreted as intrusive
or singling out as “different” (i.e., not normal, an
outsider)
Cultural assumptions may hinder practical
understanding (e.g., access may be hindered by work
hours rather than cultural beliefs)
Medical terms can stigmatize- use culturally
appropriate explanations & terms, ask “What do you
call this problem?”
Don’t assume that health goals are the same, ask
“What matters most to you?”
(Kleinman & Benson, 2006)
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More effective, holistic care for diverse patients
Improved quality of life of patients
Increased health care satisfaction
Improved perception of health care providers
Better adherence to prescribed treatments
Personal & professional growth of health care
providers
Improved quality of care
Improved provider-patient rapport
Treatment effectiveness
Cost effectiveness (increased adherence, reduced
emergency care)
Reduced disparities in health outcomes for diverse
groups
(Suh, 2004)
Linking Refugee
Children to Services
in the Community
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What cross-cultural issues are identified?
How has the organization developed
knowledge about the population?
How has the organization facilitated access to
services?
How does the organization determine its
effectiveness in serving the population?
Using a Cultural
Competence
Assessment Tool
Cognitive Domain
___ Cultural awareness- appreciation and
sensitivity to values, beliefs, lifeways, practices, &
problem-solving strategies of clients
___ Cultural knowledge- learning about other
cultures’ worldview, languages, & social contexts
through cultural immersion or extensive training
Affective Domain
___ Cultural sensitivity- intentional and affective
perception of cultural diversity and respect for
cultural differences
(Suh, 2004)
Behavioral Domain
___ Ability to conduct cultural and physical
assessments & communicate cross-culturally to
learn patients’ cultural beliefs, values, and
practices & determine proper interventions
Environmental Domain
___ Cultural encounter experience with patients of
different cultural backgrounds, either in cultural
immersion or international programs
(Suh, 2004)
Organizational Values
_____ Cultural competence is incorporated into the
organization’s mission statement
_____ Staff is familiar with and understands cultural
competence in the organization
_____ Organizational leadership and staff say
cultural competence is important
Policies, Procedures, & Governance
_____ Policies and procedures include cultural and
linguistic competence.
_____ Policies and procedures in the principal
language of the client.
_____ Administrators, the board of directors, and
committees support culturally competent
practices.
_____ Proportional representation of diverse group
members at all levels.
Planning, Monitoring, & Evaluation
_____ Baseline information on cultural groups is collected
_____ Ongoing awareness of cultural group characteristics
_____ Cultural competence plan is updated annually.
_____ Cultural competence planning involves staff and
clients.
_____ Systematic collection of information about groups
served
and staff demographics.
_____ Monitoring of access to and quality of services for all
groups served.
_____ Programs fit the cultural and historical aspects of
communities and staff
Communication
_____ Leadership communicates with staff about cultural
competence.
_____ Community feedback is solicited and responded to.
_____ Organization décor and written materials
communicate
a culture-affirming message.
_____ Staff able to communicate effectively in ways that
are easily understood by diverse audiences.
_____Targeted outreach activities to communicate health
care information in appropriate languages & literacy
levels.
Human Resource Development
_____ Diverse staff recruited with knowledge of
community served.
_____ Diverse staff retained and promoted equitably.
_____ Staff knowledgeable about federal and state
statutes and regulations for cultural and linguistic
competence.
_____ Staff evaluated on cultural and linguistic
competence for promotion.
_____ Bilingual interpreters assessed for ability to
accurately translate in health settings.
Community and Consumer Participation
_____ Organizational leadership and staff collaborate with
clients and community members in developing
culturally competent services.
_____ Staff participates in cultural functions and
community education activities.
_____ The organization purchases goods and services
from community-based and minority businesses.
_____The organization values the opinions of clients, &
solicits feedback.
_____Staff involved in community advocacy for social
issues.
Facilitation of a Broad Service Array
_____Services are appropriate for community
culture & incorporate strengths in all aspects of
care.
_____ Services are accessible, facilitate’ use, &
provide for continuity of care.
_____ Facilitates obtaining health education
materials & other resources in appropriate
languages.
Organizational Resources
_____Database systems, set up to support planning,
monitoring, and evaluating services for diverse
clients, including tracking disparities.
_____Financial resources support cultural competence,
such as diversity training or compensation for bilingual
capacity.
_____Communication resources support cultural and
linguistic competence through appropriate
technologies and staffing (e.g., interpreters, etc.).
_____ Culturally/linguistically appropriate educational
media, forms, literature, and service directories.
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Mission statement, other documents
Website & other media
Outreach activities
Attendance records for meetings
Meeting minutes
Participant evaluation/satisfaction surveys
Personnel files
Clinical records; case records
MIS data
Opinion surveys
Participant observation (journal)
Interviews with staff; administrators; community
members
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A developmental process: Cultural competence
is a goal toward which professionals, agencies,
and systems can strive; it can be learned &
improved
A continuum: Responses to cultural difference
move back & forth along the continuum,
varying for individuals, groups, points in time,
& contexts
An ongoing process: It is active, developmental,
iterative, and aspirational rather than achieved
http://rtckids.fmhi.usf.edu/
rtcpubs/CulturalCompetenc
e/porch/default.cfm
http://rtckids.fmhi.usf.edu/
rtcpubs/CulturalCompetenc
e/services/default.cfm
http://rtckids.fmhi.usf.edu
/rtcpubs/CulturalCompete
nce/protocol/default.cfm
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Betancourt, J.R., & Green, A.R. (2010). Linking cultural
competence training to improved health outcomes:
Perspectives from the field. Academic Medicine, 85, 4:
583-585.
Callejas, L.M., Hernandez, M., Nesman, T., and Mowery,
D. (2010). Creating a front porch in systems of care:
Improving access to behavioral health services for
diverse children and families. Evaluation and Program
Planning 33,1:32-35.
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989).
Toward a culturally competent system of care: A
monograph on effective services for minority children
who are severely emotionally disturbed. Washington, DC:
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National Technical Assistance Center for Children’s
Mental Health.
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Harper, M., Hernandez, M., Nesman, T., Mowery, D., and
Worthington, J., Isaacs, M. (Eds.) (2006). Organizational
Cultural Competence Assessment: A Review of
Assessment Protocols (Making Children’s Mental Health
Services Successful series, FMHI pub. No. 240-2).
Tampa, FL: University of South Florida, Louis de la Parte
Florida Mental Health Institute, Research & Training
Center for Children’s Mental Health. Available:
http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence
/protocol/default.cfm
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Hernandez, M., Nesman, T., Isaacs, M., Callejas, L. M., &
Mowery, D. (Eds.). (2006). Examining the research base
supporting culturally competent children’s mental health
services. Tampa, FL: USF, Louis de la Parte Florida Mental
Health Institute, Research & Training Center for
Children’s Mental Health.
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Hernandez, M., Nesman, T., Mowery, D., AcevedoPolakovich, I. D., and Callejas, L. M. (2009). Cultural
competence: A review and conceptual model for
psychiatric and mental health services. Psychiatric
Services, 60, 8:1046-1050.
Kleinman, A., & Benson, P. (2006). Anthropology in the
clinic: The problem of cultural competency and how to
fix it. PLOS Medicine 3, 10: 1673-1676.
Seeleman, C., Suurmond, J., & Stronks, K. (2009).
Cultural competence: A conceptual framework for
teaching and learning. Medical Education 43: 229-237.
Siegel, C., Davis-Chambers, E., Haugland, G., Bank, R.,
Aponte, C., & McCombs, H. (2000). Performance
measures of cultural competency in mental health
organizations. Administration and Policy in Mental
Health 28, 2:91-106.
Stately, A.L., & Clark, R.L. (2003). AIDS Project Los
Angeles & United American Indian Involvement, Inc.
Suh, E.E. (2004). The model of cultural competence
through an evolutionary concept analysis. Journal of
Transcultural Nursing 15: 93-102.
U.S. Department of Health and Human Services [DHHS].
(1999). Mental health: A report of the Surgeon General.
Rockville, MD: Author.
World Health Organization. (2001). The World Health
Report 2001. Mental Health: New Understanding, New
Hope. France.
http://www.who.int/entity/whr/2001/en/whr01_en.pdf