CULTURAL COMPETENCY IN
ADOLESCENT MEDICINE:
DOES IT MATTER?
David Breland MD MPH
Assistant Professor of Pediatrics
Division of Adolescent Medicine
Seattle Children’s Hospital
OBJECTIVES
Historical prospective
 Cultural competency/effectiveness

Definitions
 Value
 Conceptual frameworks


Why important in Adolescent Medicine/Health


Suggestions on how to approach cultural
effectiveness in adolescence
Discussion Videos
2.11 min
HISTORICAL CONTEXT IS IMPORTANT

In the past…..
Separate and unequal administration of health care
 Negative acknowledgement of different races
 Bias of researchers and clinicians unchecked
 African American nurses and doctors not allowed to
join medical societies


Now….
Culture of medicine still seen as key to transmission
of stigma, racial bias and the development of health
disparities across minority groups
 Inequity of health care

HEALTH EQUITY
The absence of systematic disparities in health
AND
in the major social determinants of health
BETWEEN
social groups who have different levels of
underlying social advantage/disadvantage
SEARCH FOR HEALTH EQUITY
Recognized need for health equity
 Medical errors not explained fully by
socioeconomics
 Focus on increasing diversity in workforce
 Need for diversity in research
 Cultural competence

WHAT IS CULTURE?

Anthropologist
Not a single variable but comprises multiple
variables affecting all experiences
 Inseparable from economic, political, religious,
psychological and biological conditions
 Ordinary activities/conditions take on emotional tone
and moral meaning for participants
 Often differ within the same ethnic or social group
because of differences in age cohort, gender, political
association, class, religion, ethnicity and even
personality

CULTURALLY COMPETENT CARE
“Ability of health care providers and institutions to
deliver effective services to racially, ethnically
and culturally diverse populations”
WHY CULTURAL COMPETENCY?

Cultural competency/effectiveness
Fashionable term!
 No one can define the term to operationalize


Clear that it does matter in clinical settings

Cultural factors crucial to
Diagnosis
 Treatment
 Ongoing care


Shapes health-related beliefs, behaviors and
values
CULTURALLY EFFECTIVE CARE

AAP


“the delivery of care within the context of appropriate
physician knowledge, understand, and appreciation
of all cultural distinctions leading optimal health
outcomes”
AMA
Advises clinicians to assess ethnic identity and
acculturation of minority and immigrant youth in
clinical practice
 Delivering Culturally Effective Health Care to
Adolescents by Fleming and Towey 2001


Key is to recognize there are differences
PROBLEMS WITH THE IDEA OF CULTURAL
COMPETENCY

Suggest that culture can be reduced to a
technical skill for which clinicians can be trained
and develop expertise

Problem stems from medical definition of culture


Cultural factors not always central to a case


Often synonymous with ethnicity, nationality and language
May hinder a more practical understanding of the
case
Historically


Culture in health care solely domain of patient and
family
Can also talk about culture of health care
WHAT IS THE VALUE?
Large claims of value for cultural competence not
supported by robust evaluation research showing
improvement in clinical services
 Might be a failure of outcomes research to take it
seriously to evaluate its cost effectiveness


Consumer Assessment of Healthcare Providers and
Systems (CAHPS)
Standardized survey instruments used to collect reliable
information from patients about the care they received
 Assess racial/ethnic and language differences in patient
experiences with care
 CAHPS Cultural Competence (CC)

Weech-Maldonado et al, Medical Care, Vol 50, 9(2): 2012
REVISED CULTURAL FORMULATION
(BASED FROM DSM IV)

Step 1: Ethnic/cultural Identity
Ask about ethnic/cultural identity and see if matters
 Acknowledge and affirm a person’s experience with
illness
 Don’t assume knowledge


Step 2: What is at stake?
What is at stake as patient and family face illness
 Shed light on the moral lives of patients and families


Step 3: The illness narrative
Reconstruct the patient’s illness narrative to acquire
understand of the meaning of illness
 Explanatory model

REVISED CULTURAL FORMULATION
CONTINUED

Step 4: Psychosocial stresses


Consider ongoing stresses and social support that
make up people’s lives (i.e. family tension)
Step 5: Influences of culture on clinical
relationships
Clinician critical self reflection
 Unpack the formative effects that the culture of
biomedicine and institutions has on the most routine
clinical practices


Step 6: The problem of a cultural competency
approach
Efficacy!!
 Does this intervention actually work in a all cases?

GROWING DIVERSITY OF THE ADOLESCENT
POPULATION
Most adolescent minority populations are
growing faster than the white populations
 By 2040 the projected % of non-Hispanic whites
in the adolescent population will drop below 50%
 Hispanics are becoming the second most
populous ethnic group
 Asian/Pacific Islander, though small in number,
are growing at the fastest rate
 The American Indian/Alaska Native population
is projected to remain largely unchanged

Source: National Adolescent Health Information Center. 2000
OTHER KEY FACTORS TO CONSIDER IN
ADOLESCENCE
SES
 Educational attainment
 Population characteristic and access to health
care
 Family structure and dynamics
 Culture of Western medicine
 Culture’s influence on health care
 Health beliefs and practices

ASSESSING CULTURAL FACTORS WITHIN A
HEALTH HISTORY
Integrating adolescent patients’ cultural
backgrounds in health assessments can help
facilitate communication
 Asking about significance of their behavior w/in
the context of their cultural background
 Avoid assessment based on dominant culture
norms
 Critical factors


SES, educational attainment, family structure and
dynamics, cultural beliefs and practices, ethnic
origin/identification and language preference
UNDERSTANDING ADOLESCENTS’ PERSPECTIVES
ON THEIR HEALTH PROBLEMS
1.
2.
3.
4.
5.
6.
7.
8.
9.
How would you describe the problem that brought you to
me?
What name do you give your problem/illness?
Why do you think this problem has happened to you?
What do you think will help treat your health problem?
Are there things that make you feel better that doctors do
not know about?
What do you fear most about your illness?
Apart from me, who else do you think can help you get
better?
Has anyone else helped you with this problem?
What are the chief problems your illness has caused you
or your family?
3.03 min
2.35 min
10 min
REFERENCES




Kleinman A, Benson P, Anthropology in the Clinic:
The Problem of Cultural Competency and How to Fix
it. PLoS Medicine,3(10) 2006: 1673-76.
Vo DX, Park MJ, Racial/Ethnic Disparities and
Culturally Competent Health Care Among Youth and
Young Men. Am Journal of Men’s Health, 2(2) 2008:
192-205.
Weech-Maldonado R, Carle A, et al, The Consumer
Assessment of Healthcare Providers and Systems
(CAHPS) Cultural Competence (CC) Item Set.
Medical Care, 50(9) suppl 2, 2012: S22-S31
Fleming M, Towey K, Delivering Culturally Effective
Health Care to Adolescents. American Medical
Association, 2001.
QUESTIONS?
14 min