CULTURAL COMPETENCE IN PUBLIC HEALTH
(OR ANYWHERE ELSE)
Robert Lucio, Ph.D., MSW
College of Public Health
Department of Community and Family Health
College of Behavioral & Community Sciences
Department of Child and Family Studies
2010 Cultural Competence Seminar
Tampa, FL – December 03, 2010
Purpose

What is culture?

Why is culture important to health?

What is cultural competence?

What is meant by the concept of “health disparities?”

To share a framework for building organizational
cultural competence
Assumption Underlying The Training



Culture and society play pivotal roles in health, illness,
and health services
Understanding the wide-ranging roles of culture and
society enables the health field to design and deliver
services that are more responsive to the needs of
culturally and linguistically diverse people
Cultural Competence Starts with the recognition &
awareness of one’s own Biases/Prejudices
Culture Exercise

Know your potato
What Is Culture?


Culture has been defined in various ways by different
disciplines and for numerous purposes (Kao, Hsu, &
Clark, 2004)
Culture represents the histories, attitudes, behaviors,
languages, values, beliefs and uniqueness, which
distinguished each racial or sub-cultural group in a
society. Each of us has a historical heritage and a
contemporary heritage that comprise our present
culture (Coggins, 2004)
What Is Culture?



Culture is the customs, beliefs, values, knowledge, and skills that
guide people along shared paths (Linton, 1947)
Culture is reflected in the social norms, mores, sanctions, and in
the art, history, folklore, and institutions of a group of people
The term culture refers to the way of life of people and includes
the tools or methods by which they extract a livelihood from their
environment (Corsini, 1987)
Maslow’s Hierarchy Of Needs:
Humanistic Theory
Self
Actualization
Esteem and Identity
Love and Belonging
Safety and Security
Physiologic (e.g., Food, Water)
(Cross, Bazron, Dennis, & Isaacs, 1989)
Why is culture important?
Background

Culture has been conceptualized as either a static trait
characteristic of a group of people or a dynamic process.

Static – People are subjected to cultural structures and
are seen as passive carriers of culture inter-generationally.

Dynamic process – People are seen as more active
learners of their cultures.
(Kao, Hsu, & Clark, 2004)
Seeing Culture


Culture is omnipresent and frequently invisible, especially
to those enmeshed within a particular culture
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)
Underlying Assumptions

Everyone in the room has a culture

Understanding your own culture is key


Culture influences most, if not all aspects of human social
interactions
Although culture is omnipresent, it is frequently invisible,
especially to those enmeshed within a particular culture.
What is culture?

Material Culture

What we see

Immaterial Culture

Hidden Culture

Artifacts

Myths

Language

Folklore

Dress

Stories

Behaviors

Feelings

Color

Values

Food

Oral Culture

Songs

Spiritualism
(Coggins, 2010)
Why Culture is Important



The dramatic change in our nation’s ethnic composition is
altering the way we think about ourselves
The deeper significance of America’s becoming a majority
nonwhite society is what it means to the national psyche, to
individuals’ sense of themselves and their nation – their (our)
idea of what it is to be American (Takaki, 1993)
American society is increasingly diversified. The federal funding
agencies require participation of multicultural populations for
health research
Why Culture is Important




Hispanic and Latino Americans accounted for almost half (1.4
million) of the national population growth of 2.9 million
between July 1, 2005, and July 1, 2006
Immigrants and their U.S.-born descendants are expected to
provide most of the U.S. population gains in the decades
There are 45.5 million Hispanics living in the United States,
accounting for 15 percent of the U.S. population
Blacks comprise the second-largest minority group, with 40.7
million (13.5 percent), followed by Asians, with 15.2 million (5
percent).
(The Office of Minority Health, 2010)
Why is culture important

Colors


Perhaps explaining why some native English-speaking children, familiar
with the rainbow of colors in the Crayola 64-pack, actually can tell
“rust” from “brick” or “moss” from “sage,” while children who grow
up speaking languages with fewer color names lump such hues together
(Namibia)
Math Skills

The lack of number-words seems to preclude the ability to
entertain concepts of exact number in certain cultures (Pirahã)
Dingfinger, S. F. (2005). Fuzzy Math. Monitor on Psychology, 36(2), 30-31.
Adelson, R. (2005). Hues and Views. Monitor on Psychology, 36(2), 26-29
Why is culture important?

Intelligence
 Intelligence
cannot be fully or even meaningfully
understood outside its cultural context.
 Research
that seeks to study intelligence without
considering the context risks the imposition of an
investigator’s world-view on the rest of the world.
 Moreover,
research on intelligence within a single culture
may fail to do justice to the range of skills and knowledge
that may constitute intelligence broadly defined and risks
drawing false and hasty generalizations.
Sternberg, R. (2004). Culture and Intelligence. American Psychologist, 59, 325-338.
Why is culture important?

Intelligence and Development
 Some
things are constant across cultures (mental
representations and processes), whereas others are not
(the contents to which they are applied and how their
application is judged)
 African
infants sit and walk earlier than do their
counterparts in the United States and Europe
Sternberg, R. (2004). Culture and Intelligence. American Psychologist, 59, 325-338.
Why is culture important?

Behavior
 Behavior
that in one cultural context is smart may be, in
another cultural context, stupid (Cole, Gay, Glick, &
Sharp, 1971)
 Stating
one’s political views honestly and openly, for
example, may win one the top political job, such as the
presidency, in one culture and the death penalty in
another
Sternberg, R. (2004). Culture and Intelligence.
American Psychologist, 59, 325-338.
Why is culture important?




health, healing, and wellness belief systems;
how illness, disease, and their causes are perceived; both by
the patient/consumer
the behaviors of patients/consumers who are seeking
health care and their attitudes toward health care providers
as well as the delivery of services by the provider who
looks at the world through his or her own limited set of
values, which can compromise access for patients from
other cultures
Why is culture important?


The increasing population growth of racial and ethnic
communities and linguistic groups, each with its own
cultural traits and health profiles, presents a challenge to
the health care delivery service industry in this country
The provider and the patient each bring their individual
learned patterns of language and culture to the health care
experience which must be transcended to achieve equal
access and quality health care
Some Points to Remember About
Cross-Cultural Relationships



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
When people talk about cultures, they tend to
emphasize the importance of differences and tend to
neglect explaining human commonalities
Differences between cultures are too often perceived as
threatening or bothersome and are described in
negative terms
Cultural Competence
A class divided
A class divided part I
A class divided part II
Definition Of Cultural Competence


The ability to work effectively across cultures in a way
that acknowledges and respects the culture of the
person or organization being served
“Cultural Competence” is a set of congruent
behaviors, attitudes, and policies that come together in
an agency that enables employees to work effectively in
cross-cultural situations
J. H. Hanley (1999) - Beyond the tip of the Iceberg: Five Stages toward cultural competence
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.
Online at: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf
Cultural Competence Continuum
Cultural Proficiency (Level 6)
Culture Competence (Level 5)
Cultural Pre-Competence (Level 4)
Cultural Blindness (Level 3)
Cultural Incapacity (Level 2)
Cultural Destructiveness (Level 1)
(Coggins, 2010)
Cultural Destructiveness
“See the difference; stomp it out.”
Using one’s power to eliminate the culture of another.
Represented by attitudes, policies, and practices that are destructive to cultures and
the individuals within the culture.
Examples
 Genocide or Ethnocide
 Exclusion Laws
 English only Speaking laws
 Forms not available in another language
 Denying clients access to their natural healers.
 Shun/Avoid certain curriculum topics
 Dress policies that single out specific ethnic groups
Cecil County Public Schools
Cultural Destructiveness
“See the difference; stomp it out.”
What you might hear
“When we redistrict we can get rid of THAT neighborhood!”
“Why are those kids speaking Chinese here?”
“There are so many problems coming from Southside.”
“If we could get rid of the special needs students, our scores
would improve.”
Cecil County Public Schools
Cultural Incapacity
“See the difference; make it wrong.”
Believing in the superiority of one’s own culture and behaving in ways that
disempower another’s culture
Examples
 Lacks the capacity or will to help minority clients and employees
 Disproportionate allocation of resources to certain groups
 Lowered expectations
 Expecting “others” to change: My way or the highway
 Practices of discrimination in hiring and promotion;
 Subtle messages that some cultural groups are neither valued nor welcomed
 Sending away domestic violence victims in Albuquerque from a hospital to
Indian health clinic
 Lack of an equal representation of staff/administrators that reflect diversity
Cecil County Public Schools
Cultural Incapacity
“See the difference; make it wrong.”
What you might hear
“Another generation to never leave the trailer park.”
“His mom admitted he was special education when she went to
school, so we can’t expect him to do well”
“The apple doesn’t fall far from the tree.”
Cecil County Public Schools
Cultural Blindness
“See the difference; act like you don’t.”
Acting as if cultural differences do not matter or as if there are not differences among or between
cultures
Examples

Beliefs/actions that assume world is fair and achievement is based on merit

Color or culture make no difference and that all people are the same.

Ignores cultural strengths

Believes that the helping approaches by dominant culture are universally acceptable
and applicable

Encourages assimilation; thus, those who don’t are isolated

Blames victim for their problems

Views ethnic minorities as culturally deprived

Using light colored band aids in hospitals that are marked as flesh colored (but only
Cecil County Public Schools
to fair skinned people)
Cultural Blindness
“See the difference; act like you don’t.”
What you might hear
“Our organization does not need to focus on multicultural educationwe have no diversity”
“We treat everyone the same”
“That isn’t a problem in our organization”
“Just don’t recognize their religion. We don’t want to offend”
“I’m not prejudiced. I don’t see color ”
Cecil County Public Schools
Cecil County Public Schools
Cultural Pre-Competence
“See the difference; respond to it inappropriately.”
Recognizing the limitations of one’s skills or an organization's practices when interacting with other
cultural groups.
Examples

Delegate diversity work to others, to a committee

Quick fix, packaged short-term programs

What can we do?” Desire to deliver quality services; commitment to civil rights.

Realizes its weaknesses and attempts to improve some aspect of their services.

Explores how to better serve minority communities.

Agency may believe that their accomplishment of one goal or activity fulfills their
obligation to minority communities; may engage in token hiring practices.

Often only lacks information on possibilities and how to proceed

May feel a false sense of accomplishment that prevents further movement.
Cultural Pre-Competence
“See the difference; respond to it inappropriately.”
What you might hear
“I’ll do my best to make the Special Education student feel
part of the Honors course.”
“Make sure you do an activity for Black History month.”
Cecil County Public Schools
Cultural Competence
“See the difference; understand the difference that difference makes.”
Interacting with others using the five essential elements of cultural proficiency as the standard for behavior
and practice.
Examples

Acceptance and respect for difference.

Expands cultural knowledge and resources.

Continuous self-assessment.

Pays attention to dynamics of difference to better meet client needs.

Variety of adaptations of service models.

Seeks advice and consultation from the minority community.

Commits to policies that enhance services to diverse clientele.

Advocacy

On-going education of self and others

Adapts evidence based promising practices that are culturally and linguistically
competent.
Cecil County Public Schools
Cultural Competence
“See the difference; understand the difference that difference makes.”
What you might hear
“I think it is interesting to look at another’s perspective through
another lens.”
Cultural Proficiency
“See the difference; respond positively. Engage and adapt.”
Esteem culture; knowing how to learn about organizational culture; interacting effectively in a
variety of cultural groups.
Examples

Holds cultures in high esteem.

Agency seeks to add to its knowledge base.



Agency advocates continuously for cultural competence throughout the
system.
Differentiate to the needs of all patients.
Cultural Empowerment is reflected in a philosophy that the client/staff are
co-equal partners in the treatment and learning process
Cecil County Public Schools
Cultural Proficiency
“See the difference; respond positively. Engage and adapt.”
What you might hear
“With the addition of _____, our staff experience has become richer.
The other employees are learning from him also.”
“Thank you for talking to the patients and explaining in Spanish about
our services.”
Cecil County Public Schools
Essential Elements of
Cultural Competence
The culturally competent system of care is made up of culturally competent
institutions, agencies, and professionals.
Five essential elements contribute to a system’s, institution’s, or agency’s ability
to become more culturally competent. The culturally competent system would:
Cross, Bazron,
Dennis, & Isaacs,
(1989).
Towards a culturally
competent system of
care: A Monograph
on Effective Services
for Minority Children
Who Are Severely
Emotionally
Disturbed: Volume I
Washington, DC:
Georgetown
University Child
Development Center.
Value diversity;
 Have the capacity for cultural self-assessment;
 Be conscious of the dynamics inherent when cultures
interact;
 Institutionalize cultural knowledge; and
 Develop adaptations to diversity

Organizational Cultural Competence
A Value Base for
Cultural Competence







Respects the unique, culturally-defined needs of various client populations.
Acknowledges culture as a predominant force in shaping behaviors, values, and
institutions.
Views natural systems (family, community, church, healers, etc.) as primary mechanisms
of support for minority populations and are different for various subgroups
Starts with the “family,” as defined by each culture, as the primary and preferred point
of intervention.
Believes that diversity within cultures is as important as diversity between cultures.
Acknowledges and accepts that cultural differences exist and have an impact on service
delivery.
Acknowledges that when working with minority clients process is as important as
product.
Cross, Bazron, Dennis, & Isaacs, (1989).
Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely
Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.
A Value Base for
Organizational Cultural Competence






Culturally competent agencies are characterized by acceptance of and respect for
difference
continuing self-assessment regarding culture, careful attention to the dynamics of
differences
continuous expansion of cultural knowledge and resources, and adaptations of service
models.
Culturally competent agencies work to hire unbiased employees and seek advice and
consultation from their clients;
They seek staff who represent the racial and ethnic communities being served and
whose self-analysis of their role has left them committed to their community and
capable of negotiating a diverse and multicultural world.
Culturally competent agencies understand the interplay between policy and practice,
and are committed to policies that enhance services to diverse clientele.
Cross, Bazron, Dennis, & Isaacs, (1989).
Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely
Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.
Background



A foundational definition for cultural competence states that it includes
behaviors, attitudes, and policies within a system, agency, or among professionals
that enable them to work effectively in cross-cultural situations (Cross, Bazron,
Dennis, & Isaacs, 1989)
Underlying the definition by Cross et al. (1989): Children’s health services must
acknowledge and incorporate the importance of culture, race, and ethnicity at all
levels of functioning and treatment to provide optimal access to quality services
The recognition that culture, race, and ethnicity have significant influence on the
behavior and thinking of providers and service recipients is an important feature
of cultural competence.
Defining Organizational Cultural
Competence


Operationalizing cultural competence is an important step toward
being able to test its effectiveness in improving health service delivery.
A definition of organizational cultural competence and conceptual
model were developed by Hernandez and Nesman (2006) based on a
thematic analysis conducted for a literature review and protocol
assessment.
Implementation-focused Definition
of Cultural Competence
Within a framework of addressing health disparities, 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)
Conceptual Model for Accessibility of Health Services to
Culturally/Linguistically Diverse Populations
Definition: Within a framework of addressing health disparities within 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 (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997).
Degree of compatibility defines level of
organizational/systemic cultural competence
Community Context
Cultural/Linguistic
characteristics of a
community’s population
Compatibility
Outcomes:
Reducing health
disparities
Organization’s/System’s
Infrastructure
Domain/
Functions
Direct Service
Domain/
Functions
(Hernandez & Nesman, 2006)
Conceptual Model for Accessibility of Health Services to
Culturally/Linguistically Diverse Populations
Degree of compatibility defines level of
organizational/systemic cultural competence
Community Context
Cultural/Linguistic
characteristics of a
community’s
population
Compatibility
Organization’s/System’s
combined policies,
structures, and processes

The compatibility between
the organization’s/system’s
Outcomes:
Reducing
health
disparities
structures and processes and
the community’s populations
determines the level of
organizational cultural
competence.

The model shows the need to adapt an organization’s structures and processes
to the characteristics of the community being served.

Compatibility between the community’s populations and organizational
structures and processes are determined by the level of access and utilization of
appropriate services.
(Hernandez & Nesman, 2006)
Community Context



Important in the development of compatibility between
organizations and populations served.
Based on the recognition that children/adolescents and their
families respond to health problems and concerns within a context
of the larger social environment that guides or pushes them toward
or away from various types of services.
Also recognizes that organizations and systems function within
larger community, state, and national contexts that impact their
attempts to serve their local community.
(Hernandez & Nesman, 2006)
Characteristics of the
Community Population

Assessing compatibility (cultural competence) is
dependent on having information about the
community’s populations, context, and the
organization’s policies, structures, and processes.
Cultural/Linguistic
characteristics of a
community’s population

This includes awareness of the influences of culture,
ethnicity, race, socioeconomic status, and related social
factors on the provision of services and help-seeking.
Compatibility

Important to link interventions the factors that
contribute to a lack of engagement and to recognize
that these factors will vary across groups and service
types (Staudt, 2003). Development of compatible
strategies will not be possible without this information.
An organization’s/system’s
combined policies,
structures and
processes
(Hernandez & Nesman, 2006)
Characteristics of the
Community Population

Cultural/Linguistic
characteristics of a
community’s population
Facilitators

Cultural View of Health: The common perception of
health that is related to the culture and facilitates service
use

History: History of the community or population and the
effects of that history

Language Characteristics: Primary language of the
population

Resource Characteristics: Resources of the population

Strength Characteristics: Strengths of the population
Compatibility
An organization’s/system’s
combined policies,
structures and
processes
(Hernandez & Nesman, 2006)
Characteristics of the
Community Population

Inhibitors

Cultural/Linguistic
characteristics of a
community’s population

Cultural View of Health: Common cultural perceptions
of health that present barriers to service use
Need Characteristics: Needs of the population
Compatibility
An organization’s/system’s
combined policies,
structures and
processes
(Hernandez & Nesman, 2006)
Domains of Organizational Cultural Competence
Infrastructure
Domain/Function
Direct Service
Domain/Function
Cultural/Linguistic
characteristics of a
community’s
population
Compatibility
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community & Consumer
Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/ Supports
Access
Infra- Direct
structure Service
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Utilization
Availability
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence
Infrastructure
Domain/Function
Direct Service
Domain/Function
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community & Consumer
Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/ Supports

Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Utilization
The rate of use or
usability of
appropriate health
services
Availability
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
To better illustrate the conceptual model, a more detailed
diagram (pictured here) was developed to show the direct
link between the organizational infrastructure level and the
direct service level.
(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence
Direct Service
Domain/Function
Infrastructure
Domain/Function
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community &
Consumer Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/
Supports
The
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Availability
Utilization
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
left triangle highlights the infrastructure
component, which includes organizational functions that
are based on the domains identified in through an analysis
of cultural competence protocols.
Organizational/System Implementation Domains for Improving Cultural Competence

•
•
•
•
•
•
•
•
Infrastructure
Domain/Function
Organizational Values
Policies/Procedures/
Governance
Planning/Monitoring/
Evaluation
Communication
Human Resources
Development
Community &
Consumer
Participation
Facilitation of a Broad
Service Array
Organizational
Infrastructure/
Supports
(Hernandez & Nesman, 2006)
The Infrastructure domain is made up of multiple
functions that are typical of organizations, each of which
must be adapted for cultural competence.
Organizational values, policies, procedures and governance
contribute to cultural competence when they promote
compatibility with the community served and provide
support for staff to carry out needed culturally competent
service practices.

Likewise, planning and evaluation processes contribute to
cultural competence when they include communities of
color as fully contributing partners with shared
responsibilities, and when they collect data that reflects
the diversity of the community.

Organizational/System Implementation Domains for Improving Cultural Competence
Communication that supports cultural competence
includes two-way communication and learning within the
organization and between the organization and the
community.

•
•
•
•
•
•
•
•
Infrastructure
Domain/Function
Organizational Values
Policies/Procedures/
Governance
Planning/Monitoring/
Evaluation
Communication
Human Resources
Development
Community &
Consumer
Participation
Facilitation of a Broad
Service Array
Organizational
Infrastructure/
Supports
Human resources and service array domains include
strategies to increase bilingual/bicultural capacity,
recruitment, and retention, and availability of services that
are appropriate and of high quality for the target
population.

Methods of outreach to communities and
opportunities for community/consumer participation are
important mechanisms that can lead to greater
compatibility.

Organizational infrastructure can promote cultural
competence by bringing in financial, technological and
other needed resources.

(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence
Infrastructure
Domain/Function
The
• Organizational Values
• Policies/Procedures/
Governance
• Planning/Monitoring/
Evaluation
Compatibility between the
• Communication
infrastructure and direct
• Human Resources
service functions of an
Development
organization
• Community &
Consumer Participation
• Facilitation of a Broad
Service Array
• Organizational
Infrastructure/
Supports
right triangle highlights the direct service domain,
which includes aspects of access, availability, and use of
services. Findings are based an analysis of literature
related to services for racially/ethnically diverse children
and families.
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Availability
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
Utilization
The rate of use or
usability of
appropriate health
services
Organizational/System Implementation Domains for Improving Cultural Competence
Access
is defined as mechanisms that facilitate
entering, navigating, and exiting appropriate
services and supports as needed.
Availability
is defined as having services and
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
supports in sufficient range and capacity to meet
the needs of the populations they serve. This may
include availability of bilingual personnel and/or
trained translators.
Utilization
Availability
Utilization
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
is defined as the rate of use of
services or their usability for populations served.
Utilization may include issues such as length of
time in service, retention, or dropout rates.
(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence

This model shows that there is a need for
compatibility between the organizational
infrastructure and direct service. It also
highlights the need for compatibility between
Direct Service
Domain/Function
Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
each of the direct service domains.
Availability

Dynamic relationships are shown by two-way
arrows between infrastructure supports, access
mechanisms, and availability of needed/
Utilization
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
appropriate services.
(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence
Direct Service
Domain/Function
An example of this relationship might be as follows:
Access is increased through a one-stop family services
center, but there is a lack of availability of bilingual
services and lack of trust in the organization because it
is not connected with the community. This lack of
trust or bilingual capacity results in low levels of
utilization of services and little improvement in outcomes.

Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Availability
Utilization
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
(Hernandez & Nesman, 2006)
Organizational/System Implementation Domains for Improving Cultural Competence
Direct Service
Domain/Function
This relationship is especially important to
recognize as organizations change. Changes in one area
may affect other areas. Lack of change in one area may
cancel out efforts in other areas. Incorporating cultural
competence into every aspect of the organization or
system requires careful consideration of compatibility
of policies and strategies with the population served as
well as with the other organizational functions. .

Access
The ability to
enter, navigate,
and exit
appropriate
services and
supports as
needed
Availability
Utilization
The rate of use or
usability of
appropriate health
services
Having services and
supports in
sufficient range and
capacity to meet the
needs of the
populations they
serve
(Hernandez & Nesman, 2006)
Achieving Outcomes

Statement of overall mission or desired change
related to reducing disparities, or increasing access,
availability, or utilization for specific racial/ethnic
communities.
Degree of compatibility
Community Context
(Hernandez & Nesman, 2006)
Cultural/Linguistic
characteristics of a
community’s population
Compatibility
Organization’s/System’s
Infrastructure
Domain/
Functions
Direct Service
Domain/
Functions
Outcomes
Defining Disparities
Health Disparities:
Main Assumptions


It is generally recognized that an individual’s helpseeking behavior style for health and mental health
problems is linked to cultural and ethnic factors.
The process of seeking help by various people of
color, and the interactions that result with both formal
and informal sources of help, serves as a filter that
often discourages contact with health and mental
health professionals.
(Leong, et al. 1995)
Mental Health Disparities:
Main Assumptions


Parents from various cultural backgrounds have been
found to differ in the degree to which they identify
child behavior and emotional problems as serious.
Differences have also been found across cultural
groups in their beliefs about whether these child
problems are likely to improve in the absence of
professional support.
(Wiesz & Weiss, 1991)
Maslow’s Hierarchy Of Needs: Humanistic
Theory and Health Disparities
Self
Actualization
Esteem and Identity
Love and Belonging
Safety and Security
Physiologic (e.g., Food, Water)
(Cross, Bazron, Dennis, & Isaacs, 1989)
Examples of Disparities in Mental Health


Children with mental health problems have lower
educational achievement, greater involvement with the
criminal justice system, and fewer stable and longer-term
placements in the child welfare system than children
with other disabilities.
Striking disparities for people of color in mental health
services despite having similar community rates of mental
disorders.

People of color have less access to mental health care than do
whites.

People of color are less likely to receive needed care

When they receive it, it is more likely to be poor in quality.
Children’s Mental Health Facts for Policymakers. By: Rachel Masi and Janice Cooper.
Publication Date: November 2006. Online at: http://nccp.org/publications/pub_687.html#10.
Examples of Disparities in Health


African Americans
In 2005, the death rate for African Americans was
higher than Whites for heart diseases, stroke, cancer,
asthma, influenza and pneumonia, diabetes,
HIV/AIDS, and homicide.
The infant mortality rate for African American mothers
with over 13 years of education was almost three times
that of Non-Hispanic White mothers in 2005.
(The Office of Minority Health, 2010)
Examples of Disparities in Mental Health



Latinos/Hispanic Americans
Hispanics have the highest uninsured rates of any racial
or ethnic group within the United States.
Hispanics have higher rates of obesity than nonHispanic Caucasians.
Puerto Rican infants were twice as likely to die from
causes related to low birthweight, as compared to nonHispanic white infants.
(The Office of Minority Health, 2010)
Examples of Disparities in Mental Health


Asian American/Pacific Islanders
Asian American women have the highest life expectancy
(85.8 years) of any other ethnic group in the U.S. Life
expectancy varies among Asian subgroups: Filipino
(81.5 years), Japanese (84.5 years), and Chinese women
(86.1 years).
Asian/Pacific Islander men are twice as likely to die
from stomach cancer as compared to the non-Hispanic
white population, and Asian/Pacific Islander women are
2.6 times as likely to die from the same disease.
(The Office of Minority Health, 2010)
Examples of Disparities in Health



American Indians/Alaska Natives
American Indians and Alaska Natives have an infant
death rate 40 percent higher than the rate for Caucasians
American Indian/Alaska Native babies are twice as
likely as non-Hispanic white babies to die from sudden
infant death syndrome (SIDS)
American Indian/Alaska Native babies are 30% more
likely to die from complications related to low birth
weight or congenital malformations compared to nonHispanic whites babies.
(The Office of Minority Health, 2010)
Barriers Associated with Disparities Across
Ethnic, Racial, and Cultural Groups

Income, Geographic Location, Language

Managed Care, Medicare/Medicaid

Stigma

Lack of trust

Insurance and related policies

System bias and institutional racism
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.
Online at: http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/services/CultCompServices.pdf
What is Meant by the Term “Disparity”?

Gamble and Stone (2006) label the term disparity as
descriptive:



Used to explain differences in health status or access across
population groups.
In this sense, the term carries no moral nuance, implying
neither rightness nor injustice.
They use the term inequity to describe injustice/bias:
 What ought to be rather than what actually is.
See: Gamble, V. N., & Stone, D. (2006). U.S. Policy on health inequities: The interplay of politics and
research. Journal of Health Politics, Policy and Law, 31(1), 93-126.
Definitions of Health Disparity

Healthy People 2010 (2000):
“…differences that occur by gender, race, or ethnicity,
education, or income, disability, living in rural localities,
or sexual orientation.”

Institute of medicine (2002):
“…racial or ethnic differences in the quality of health
care that are not due to access-related factors or clinical
needs, preferences and appropriateness of
intervention.”
See: Carter-Pokras, O., & Baquet, C. (2002).
What is a "Health Disparity"? Public Health Reports, 117(5), 426-434.
Health Focused Approach
To Defining Disparities


Eliminating Health
Disparities
Leads to focus on health

Access

Quality
Problem is that social inequities
exist and that there is a relationship
between social inequities and
health
(Hernandez, 2009; Office of Minority Health , 2010)
Aligned Approach:
What are the implications for solutions to reducing health disparities?

Problem with the single sector definition approach. For
example, the presence of over-representation in other
sectors

Eliminating Health
Disparities
Over-representation in:


Question then
becomes how
do these two
areas come
together?

Child Welfare
Education
Negative Health and Birth
Outcomes
(Hernandez, 2009; Office of Minority Health , 2010)
Aligned Approach:
What are the implications for solutions to reducing health disparities?
Eliminating
Health
Disparities

How do
these
areas
come
together?
Over-representation in
Child Welfare:


35% of the children in foster care are
African American, but they make up
only 15% of the child population
39% of the children in foster care are
Caucasian, while they represent 59% of
the child population
On September 30, 2003 over fifty percent (59% or 304,910) of the 523,085
children living in foster care placements were children of color, although they
represented only 41% of the child population in the United States
(Hernandez, 2009; Office of Minority Health , 2010)
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Health
Disparities
How do
these
areas
come
together?
Over- and Under-representation in
Education:


Among all students, African-American
students are more likely to be
suspended or expelled than their white
peers (40% vs. 15%)
African-American preschoolers were
about twice as likely to be expelled as
White and Latino preschoolers and over
five times as likely as Asian-American
preschoolers
(Hernandez, 2009; Office of Minority Health , 2010)
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Health
Disparities
How do
these
areas
come
together?
Over- Representation in Poor
Birth Outcomes:



African American are 3 times more
likely to have a baby die than white nonHispanic mothers
American Indians and Alaska Natives
have an infant death rate 40 percent
higher than the rate for Caucasians.
American Indian/Alaska Native babies
are twice as likely as non-Hispanic white
babies to die from sudden infant death
syndrome (SIDS)
(Hernandez, 2009; Office of Minority Health , 2010)
Aligned Approach:
What are the implications for solutions to
reducing mental health disparities?
Eliminating
Health
Disparities
How do
these
areas
come
together?
Over- Representation in Poor
Health Outcomes:

Hispanics have higher rates of obesity
than non-Hispanic Caucasians.
(Hernandez, 2009; Office of Minority Health , 2010)
Why Is The Conversation
So Confusing?


When we talk about disparity issues, we often confuse
sectors, their solutions, and their goals

Holistic solutions are few since each sector focuses on it’s
particular goals and solutions

Solutions are elusive because the concerns and issues facing
different populations are inter-connected
What is the inter-relationship between sectors and the
social concerns they are focused upon?
(Hernandez, 2009)
Why Is The Conversation
So Confusing?
Unrelated Solutions, Sectors, and Their Goals
Health
OverRepresentation
Disparity

Quality

Appropriate

Access

Social control
sectors, poor
health
outcomes
Social Inequities
UnderRepresentation

EducationDrop-Out
(Hernandez, 2009)

Racism

Economics

Housing

Transportation
Aligned Approach
Linked Goals
Eliminating
Health
Disparities
and Beyond
Reducing
OverRepresentation
in Other
Sectors
This leads to planning and “solution making” that:
 Focuses on a community as a whole
 Focuses on the linkages across sectors
(Hernandez, 2009)
Aligned Approach
Social Inequities: Economic, Job, Neighborhood Conditions, Chronic
Stress, Housing, Education, Food Security, Social Policies, and
Racism/Discrimination
Reducing
Over-Representation in
Poor Health Outcomes
Eliminating
Health
Disparities
Linked Goals
Reducing
Over-Representation in
Child Welfare
Reducing
Over- and UnderRepresentation in Education
(Hernandez, 2009)
Example Of A New Definition



Lack of insurance coverage. Without health insurance, patients are more
likely to postpone medical care, more likely to go without needed medical
care, and more likely to go without prescription medicines. Minority groups
in the United States lack insurance coverage at higher rates than whites.
Lack of a regular source of care. Without access to a regular source of
care, patients have greater difficulty obtaining care, fewer doctor visits, and
more difficulty obtaining prescription drugs. Compared to whites, minority
groups in the United States are less likely to have a doctor they go to on a
regular basis and are more likely to use emergency rooms and clinics as their
regular source of care.
Lack of financial resources. Although the lack of financial resources is a
barrier to health care access for many Americans, the impact on access
appears to be greater for minority populations.
(The Medical News, ND)
Example Of A New Definition



The health care financing system. The Institute of Medicine in the United
States says fragmentation of the U.S. health care delivery and financing
system is a barrier to accessing care. Racial and ethnic minorities are more
likely to be enrolled in health insurance plans which place limits on covered
services and offer a limited number of health care providers.
Legal barriers. Access to medical care by low-income immigrant minorities
can be hindered by legal barriers to public insurance programs. For example,
in the United States federal law bars states from providing Medicaid coverage
to immigrants who have been in the country fewer than five years.
Structural barriers. These barriers include poor transportation, an inability
to schedule appointments quickly or during convenient hours, and excessive
time spent in the waiting room, all of which affect a person's ability and
willingness to obtain needed care.
(The Medical News, ND)
Example Of A New Definition



Scarcity of providers. In inner cities, rural areas, and communities with high
concentrations of minority populations, access to medical care can be limited
due to the scarcity of primary care practitioners, specialists, and diagnostic
facilities.
Linguistic barriers. Language differences restrict access to medical care for
minorities in the United States who are not English-proficient.
Health literacy. This is where patients have problems obtaining, processing,
and understanding basic health information. For example, patients with a
poor understanding of good health may not know when it is necessary to
seek care for certain symptoms. While problems with health literacy are not
limited to minority groups, the problem can be more pronounced in these
groups than in whites due to socioeconomic and educational factors.
(The Medical News, ND)
Example Of A New Definition


Lack of diversity in the health care workforce. A major reason for
disparities in access to care are the cultural differences between
predominantly white health care providers and minority patients. Only 4% of
physicians in the United States are African American, and Hispanics
represent just 5%, even though these percentages are much less than their
groups' proportion of the United States population.
Age. Age can also be a factor in health disparities for a number of reasons.
As many older Americans exist on fixed incomes which may make paying for
health care expenses difficult. Additionally, they may face other barriers such
as impaired mobility or lack of transportation which make accessing health
care services challenging for them physically. Also, they may not have the
opportunity to access health information via the internet as less than 15% of
Americans over the age of 65 have access to the internet. This could put
older individuals at a disadvantage in terms of accessing valuable information
about their health and how to protect it.
(The Medical News, ND)
Example Of A New Definition

Within a community-context, the goal of eliminating
health disparities and beyond, must be linked to the
elimination of the over-representation of children
and youth in all sectors (education, child welfare, health
and mental health outcomes) in order to support the
wellbeing of children and their families
A class divided
A class divided part I
A class divided part II
Unnatural Causes
Wealth equals health
How Racism Impacts Pregnancy Outcomes
Unraveling the mystery of white and black differences in infant
mortality (8:53)
Arriving Healthy