Presentation--Disparities and Cultural Competence in STD Programs

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Responding to Multicultural Training

Needs and Resource Development

Some Intersections of TB and HIV

Federal Training Centers

Collaboration Meeting

Kansas City

July 14-16, 2010

Stephanie Spencer, MA

California Department of Public Health

TB Control Branch

How does culture shape TB & HIV and identify cross-cultural training needs?

System factors: Culture shapes U.S. economic and political systems; Culture shapes the healthcare system Disparities exist in access to health care

Provider factors: Culture shapes attitudes and beliefs about cultural groups; culture influences clinician / staff attitudes/ beliefs about groups and about health care

Patient factors: Culture shapes patients’ health beliefs and practices, patients’ experiences of health care system, patients’ abilities to deal with health concerns

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Specific Cultural Aspects of HIV/AIDS & TB

(sexual activity; expression, regulation of desire) death and dying cleanliness and contamination guilt or innocence; reward and punishment tradition and culture change gender roles & relationships social class relationships economic and power structures meaning/symbolism of body fluids ideas about personal and social responsibility prevention and treatment/latent vs. active disease personal and affinity-group identity substance use

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Epidemiology Helps Identify Cultural Groups and Cross-cultural Factors

Epidemiologic information on HIV/AIDS and TB…

 When are people being diagnosed?

 Is incidence changing over time?

 Who is affected?

 Where are affected people…

 …living when they are diagnosed?

 …being diagnosed?

 How are people becoming infected?

…points to the groups of people that programs need to target for prevention and treatment

But, epi data doesn’t give enough information about these groups to design specific, effective interventions or disease investigations

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HIV Disparities: Interaction of Environment,

Culture, and Sexual Networks

Environment

Culture

Sexuality-related beliefs, attitudes, values, norms, behaviors, gender roles; internalized

Racism; language; immigration

Experience; etc.

External Racism

Discrimination

Crime/Incarceration

Homicide

Gender Imbalance Ratio

Education/Drop-Outs

Health Care Access

Sexual Networks

Structure

Segregation

Concurrency

Dissortative Mixing

Duration of Infection

STD Prevalence

TB Infection

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TB Risk Factors in U.S. Present

Cross-cultural Training Needs

Birth in a high TB incidence country

Drug/Alcohol abuse

Incarcerated

Homeless

U.S.-born racial/ethnic minority, especially if at least one parent is foreign-born

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TB Risk Factors in California

75% are born in TB high incidence countries

Top five countries of origin of TB cases:

China

India

Mexico

Philippines

Vietnam

10% have these risk factors

Drug/Alcohol abuse

Incarcerated

Homeless

U.S.-born racial/ethnic minority, especially if at least one parent is foreign-born

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All factors present cross-cultural training needs

Beliefs are not mutually exclusive

A Paul Farmer example...

Source: Tracy Kidder. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer,

a Man Who Would Cure the World. Random House, 2003, pp. 33-35.

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Continuum of Cultural Competence

Lacks cultural awareness and thinks there is only one way of doing things

Culturally

Incompetent

Views themselves as culturally superior to other cultures

Recognizes different cultures and seeks to learn about them

Sees all the same people, and thinks everyone should be treated the same

Actively seeks knowledge about other cultures; educates others about cultural differences

Culturally

Competent

Accepts, appreciates and accommodates cultural differences.

Understands the effect his/her own culture has in relating to others

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Developing Cross-Cultural Competence

Understanding the background, cultural values, and beliefs of patients, and applying that understanding in a health context.

Cultural competency is the genuine sensitivity and respect given to people regardless of their ethnicity, race, language, culture or national origin.

Ability to anticipate and recognize misunderstandings that arise from the differing cultural assumptions and expectations of providers and patients and to respond to such issues appropriately.

http://www.cahealthadvocates.org/_docs/cmc/2008/Importance-Language-

Services-2008.ppt#385,8,Cultural Competence

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Developing Cultural Competence:

Fundamental Attitudes

Non-judgmental approach to another’s culture

Cultural humility about one’s own beliefs

Awareness of one’s own biases and assumptions

Willing and able to explain and describe one’s perspectives to others

Desire to understand others’ perspectives

Flexibility to negotiate toward desired outcomes

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Skills for Cultural Competence (1) —

Document for performance reviews

Questioning skills to learn about a patient’s or partner’s culture—including how a systematic set of cultural health beliefs and health practices makes sense

Observational skills to learn about a patient’s and group’s access to health care and other social needs

Communication skills to effectively negotiate with people of different cultural backgrounds about their health beliefs, behaviors, and access needs

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Skills For Cultural Competence (2) —

Document for performance reviews

Awareness of communication styles

 types and degrees of politeness

 varying amounts of directness in questions and answers

 story telling as answers to questions

 focus on the task or focus on the person

 importance of eye contact or body language

Provide explanations to clients about why certain questions are asked or why you are doing certain things

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Complementary Strategies to build and document cultural competence

Individual staff strategies

 Understand and explain own culture

 Actively acquire cultural knowledge and skills, including subcultures

 Cross-cultural communication, negotiation skills

Programmatic strategies

 Bridging structural factors of health disparities

 Language access & support for cultural practices

 Organizational partnerships / integration

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Cultural Competence Training Process

Educate staff about culture

 basic concepts and definitions, self-awareness

 specific knowledge about cultural groups

Continuity and self-peer review

 cultural competence self-assessments

 case conferences focusing on cultural issues

 critical incident discussions

Include patient/community member

 in cultural competence assessment, case conference for mutual learning

 planning interventions & services

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Developing Programmatic Cultural

Competence

Start by providing staff a shared framework for talking about culture (definition)

Identify primary cultural groups with highest incidence of STDs and for each group list age, risk behavior, ethnicity/language, etc.

Plan specific times for learning about these cultures

Identify resources to teach—staff, community members, trainers

Structure specific activities—workshops, speakers, staff discussions, community events, critical incident debriefing

Build in evaluation processes—staff goals, increase in partner notification,

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Programmatic Strategies to Build

Cultural Competence (1)

Language Access

Find out which are most common languages in your jurisdiction

Identify interpretation resources and funding before you need them, including bilingual staff

Train staff to identify and accommodate client interpretation needs

Develop effective ways of letting patients know that interpretation is available at no cost to them

Implement interpreter training standards for language skills and STD-specific training

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Programmatic Strategies to Build

Cultural Competence (2)

Support for Cultural Practices

Acknowledge and respect ethnomedical explanations and treatments while negotiating biomedical treatment

Support family decision making while ensuring legalities of patient consent

Are there cultural healers you can involve?

Are there effective outreach or treatment practices in clients’ communities or from home countries that you can adapt?

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Programmatic strategies to build cultural competence (3)

Resources for Cultural Knowledge

Non-medical specialists

 social scientists

 members of cultural heritage or identity groups

“traditional” or “alternative” healers

 patients themselves

 patients’ families

 community members

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Programmatic strategies to build cultural competence (4)

Community Partnerships

Which local ethnic, cultural or advocacy groups have community organizations?

Can you partner with them for outreach or to help plan accessible services?

Do any of these organizations have opinion leaders, cultural brokers, trained interpreters?

Do these organizations know anything about

STDs, HIV/AIDS?

Do these organizations have formal or informal support services for patients, partners, families?

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Reaching the goal: culturally appropriate and effective services

Culturally competent staff and programs can develop individual patient-centered care that includes clients’ cultures and biomedical best practices:

Culture Care Preservation

Culture Care Accommodation

Culture Care Repatterning

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