Building Bridges to
Cultural Competency
Center for Public Health Education
Stony Brook University
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Who We Are:
A Cultural Perspective
Module I
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Welcome
• Introductions
• CPHE
– RTC
– COE
– HRSA
• Cell Phones and Pagers
• Housekeeping
• Postcards
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Introductions
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Name
Agency
Position
What do you expect to get out of this
training?
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Notes . . . .
• Three basic goals
– To increase knowledge about the impact of
culture on the delivery and accessing of
health and human services
– To increase knowledge about the impact of
power and privilege on the delivery and
accessing of health and human services
– Assist providers in their attempt to
become culturally competent
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Training Objectives
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Define culture
Define power and privilege
Examine the cultural competency continuum
Examine how cultural personal, social and
family experiences influence assumptions
and perceptions
• Review the effects of perceptions,
assumptions and stereotypes on health and
human service delivery
• Examine the relationship between culture
and privilege
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Training Objectives
• Explore the effects of privilege on accessing
healthcare
• Define cultural competency
• Demonstrate the need for cultural
competency in the health and human service
setting
• Review the cultural values of western
medicine in a multi-ethnic and multi-cultural
society
• Describe the impact of culture on accessing
and delivering health and human services
• Review strategies for enhancing cultural
competence
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Ground Rules . . . .
• What are some ground rules we should
establish?
• Does the group agree on the suggestion?
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Ground Rules . . . .
• It’s okay to pass
• Listen actively-respect others while they are
talking
• Respect each others right to have an opinion
other than you own
• Speak from your own experience instead of
generalizing (Use I statements)
• Refrain from personal attacks
• Keep an open mind to explore other ideas,
values and opinions
• Allow yourself to examine personal beliefs and
attitudes
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Definitions . . .
How would you define culture?
Culture – the total way of life of a group of
people, including their beliefs, institutions,
and technology.
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Definitions . . .
• Culture- “ a system of shared values, beliefs,
ideas and learned patterns of behavior, explicit
and implicit, which a people use to interpret the
world. Art, literature and history of a society, but
also less tangible aspects such as language,
attitudes, prejudices and folklore can impact a
persons’ culture. Cultural identity influences
how a person behaves and acts, what they
believe and what they actually know . . .”
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Definitions . . . .
• Historical Underpinnings – Events that
occurred in the past which may affect how
a particular individual or community
perceives events or reacts to specific
issues
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Definitions . . . .
• External Factors – Issues/events
occurring around the world which may
affect an individual.
• Access Barriers – Prevent individuals
from using existing services. These
barriers may be cultural, individual,
physical, financial or structural.
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Points to Consider
• Culture is a very broad concept
• Perceiving, assuming and stereotyping are
part of the “human condition”
• Providers need to be aware so this
“human condition” does not interfere with
the delivery of services
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Cultural Postcard
• Review your list of your own cultures and
subcultures.
• I.- Can you add any other cultures or
subcultures based on the lecture?
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A Look Inward:
Examining Personal Experiences
Module II
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Cultural Competence
• Gaining cultural competence is a process
• In order to achieve higher levels of
competence, it is helpful to engage in self
assessment
• Self assessment provides direction for
improvement
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Cultural Competence Model
Cultural Proficiency
Cultural Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destruction
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Cultural Competence Continuum
• Cultural Destructiveness
– The negative end of the spectrum
– Refers to the blatant attempts to destroy the
culture of a given group
– Assumes that one group is superior over
another
– Acknowledges only one way of being and
purposefully denies or outlaws any other
cultural approach
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Cultural Competence Continuum
• Cultural Incapacity
– The capacity is lacking to be responsive to
different groups, though not intentional
– Ignorance and unfounded fear is often the
underpinning of the problem
– Failure to recognize when mistreatment is due
to cultural differences and there by
perpetuating its occurrence
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Cultural Competence Continuum
• Cultural Blindness
– Blindness or ignorance of cultural differences
– Perceives of themselves as “unbiased”
– The believe that culture makes no difference
in the way a person or group acts or reacts
– Fosters the assumption that we are all
basically alike so what works with members of
one group will work with members of all other
cultures
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Cultural Competence Continuum
• Cultural Pre-Competence
– Movement toward cultural sensitivity
– Actively pursues knowledge about differences
and attempts to integrate this information into
delivery of services
– Recognizes that cultural differences exist but
those differences are acknowledged as
“differences” and nothing more
– Learning and understanding of new ideas is
encouraged along with solutions to improve
performances or services
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Cultural Competence Continuum
• Cultural Competence
– The capacity to function in an effective
manner within the context of the targeted
group
– Acceptance and respect of differences
– Continual expansion of knowledge about the
target group
– Actively seeks advice and consultation
– Committed to incorporating new knowledge
and experiences into a wider range of practice
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Cultural Competence Continuum
• Cultural Proficiency
– The positive end of the spectrum
– Proactively regards cultural differences
– Promotes improved cultural relations among
diverse groups
– Holds culture in very high esteem
– Regarded as a specialist in developing
culturally sensitive practices
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Cultural Postcard
• II-A. Where do you fall on the Cultural
Competence Continuum?
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Cultural Competence Model
Cultural Proficiency
Cultural Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destruction
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Eight Questions: Personal
Memories Activity
• Choose one culture that has had the most
influence on you
• You will have the opportunity to be the
interviewer and the person interviewed
• Obtain the answers to questions 1-7
• You will use the information to formulate an
answer to question 8
• Switch roles
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Eight Questions: Personal
Memories Activity
• Human beings are complex
• Beliefs, values and traditions come from
cultural and life experiences
• Cultures we are born into and cultures we
embrace shape who we have become
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Eight Questions: Personal
Memories Activity
• Individuals may belong to the same culture,
but may not share the same experiences
• There may be greater differences within a
culture than between cultures
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Power and Privilege: Making
Privilege Visible
Module III
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What is Power?
The ability to achieve aims or further the
interests you hold even when opposed by
others; or as the ability to impose one’s
will on others, even if those others resist in
some way.
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What is Privilege?
An unearned right, advantage or immunity
granted to or enjoyed beyond the common
advantages of all others; an exemption in
many certain cases from burdens of
liabilities.
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What is Privilege
Those with privilege rarely understand it’s
full impact on those who do not have
privilege
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The “I” Statements
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The “I” statements reflect privileges enjoyed
by different groups or cultures in our
society.
The lists are not inclusive of all privileges,
but provide a basic overview and help to
identify some unearned privileges.
Privileged groups are usually unaware of
their privilege
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The “I” Statements
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Having privileges is not always a negative
Privileges should not taken away, but
shared with all members of society
When only certain members of society
enjoy privileges, it creates inequities
Once all members of a society enjoy the
same privilege, it no longer is a privilege
but has become an equal right for all
members of society
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White Privilege
1. I can move wherever I want to move
2. I can do well in a challenging situation without
being called a credit to my race
3. I can go into a supermarket and find the staple
foods which fit my cultural traditions
4. I can take a job without my coworkers
suspecting I got it because of my race
5. My medical provider will be aware of cultural
values and traditions related to my healthcare
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Male Privilege
1. When competing against a female for a job, the
odds are probably in my favor
2. My odds of being raped are low
3. I can be assertive without being called a bitch
4. If I have sex with a lot of people, it will not make
me an object of contempt or stereotyping
5. I am not expect to spend my entire life 20-40
pounds underweight
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Heterosexual Privilege
1. When I talk about my intimate relationships I will
not be accused of pushing my sexual orientation
onto others
2. People do not ask me when I decided to be
heterosexual
3. I can marry and enjoy all the legal benefits
associated with marriage
4. I can hold hands in public with my significant other
5. I can count on finding a health and human service
provider willing and able to talk about my sexuality
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Non-Trans Privilege
1. My validity as a man/woman/human is not based
upon how much surgery I’ve had
2. I am not expected to constantly defend my medical
decisions
3. Strangers do not ask me what my “real name” is
4. People do not disrespect me by using incorrect
pronouns
5. I do not have to worry about whether I will be able to
find a bathroom to use or whether I will be safe
changing in a locker room
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Able-bodied Privilege
1. If I need to move, I can be assured of purchasing
a home I can get access to easily
2. I can be assured that my entire neighborhood will
be accessible to me
3. I can be assured that assumptions about my
mental capabilities will not be based on my
physical limitations
4. I can take a job without someone suspecting I got
my job because of my physical status
5. I can turn on the TV or open the newspaper and
see people of my physical ability represented
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The Effect of Privilege on Accessing
Health and Human Services
• Presenting western medicine as superior
to all other medical beliefs
• Having a health and human service
provider that only sees the physical
challenge and not the whole person
• Providers who ignore the need to be
culturally competent
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Effect of Privilege on Accessing
Health and Human Services
• Providers who refuse to provide health and
human services within a neighborhood
• Providers that exclude individuals from
clinical trails based on gender or using
information from clinical trails based on
other races.
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Addressing Privilege
• Inequities and discrimination occur when
power and privilege are not equally shared
by all members of society
• Legislative attempts to level the playing field
have not always been successful
– Inequities that are part of a society’s structure or
system are not always adequately addressed by
laws
– Laws have no power when addressing invisible
privilege
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Addressing Privilege
• Lawmakers have attempted to address
imbalance
• This is often met with resistance
– Women’s suffrage movement was met with great
resistance and required a constitutional amendment
to allow women to vote
– Current debate allowing gays and lesbians the right
to marry has met with opposition, including an
attempt to pass an amendment banning gay marriage
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Making the Connection
• Membership in multiple privilege groups
result in additional invisible privileges.
• Members with the most privileges tend to
have the most power in society.
• White, heterosexual, able-bodied, males
typically have the most privileges in our
society.
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Making the Connection
• When privilege remains invisible it is
difficult to see how it effects the privileged
and the unprivileged.
• Becoming aware of privilege can lead to
feelings of guilt for some
– It is important not to let guilt paralyze
– Guilt can politicize
• Recognizing privilege may help to address
inequity
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Cultural Postcard
• III. List any privileged groups or cultures
you belong to.
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Bowling for Privilege
• Choose ten privileges that are most
desirable
• As a group pick the most important
privilege
• Arrange privileges like bowling pins with
the most desirable as the first bowling
pin.
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Bowling for Privilege
In your groups, answer the following question:
1. What privilege was most important?
2. Which groups commonly have this
privilege?
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Bowling for Privilege
•Two members from each group will have
one chance each at knocking down the pins
•After one member goes, reset the pins
•Each group must keep score of how many
pins were knocked down.
•The group that knocks down the most pins
wins
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When Culture and Health and
Human Services Collide
Module IV
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When Culture and
Healthcare Collide
• By the year 2010, the US minority
population will increase by 32%
• More that 31million Americans are unable
to speak the same language as their
health care providers
• There is a direct correlation between
health care disparities and culturally
incompetent health care
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When Culture and
Healthcare Collide
• Human service providers need to identify
cross-cultural differences between their
clients, themselves and other providers
• It is important to identify potential cultural
obstacles and barriers early in the
provider-client/patient relationship
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When Culture and
Healthcare Collide
• Everyone has a culture and cultural
background that shapes one’s view about
health, illness, mental health and human
services
• It is impractical, if not possible, to learn
every aspect of every culture and
subculture
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When Culture and
Healthcare Collide
• Providers should explore the various types
of challenges that are likely to occur in
cross-cultural encounters
• Misunderstandings often reflects
differences in culturally determined values
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The Spirit Catches You and You
Fall Down
• Read the case study on page 4.
• Given this information, what would your
next course of action be in working with
this family?
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Points to Consider
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Country of Origin
Preferred Language
Communication Style
Views on Health
Family and Community Relationships
Religion
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The Spirit Catches You and You
Fall Down
• In your groups read the full case study on
page 6
• Choose a recorder and a reporter
– Group 1: Questions 1,4,7
– Group 2: Questions 2,5,8
– Group 3: Questions 3,6,9
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The Spirit Catches You and You
Fall Down
1. How do Hmong and Western views of illness
and health differ?
2. What do you think of the Hmong cultural
practices?
3. How do you feel about the Lee’s refusal to give
Lia her medicine? Do you empathize with it?
4. How is this story similar to treatment
recommendation regarding ART for the
prevention and treatment of perinatal
transmission? What issues are similar?
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The Spirit Catches You and You
Fall Down
5. How do providers generally react if a
patient/client declines treatment because of
cultural values and beliefs?
6. It is clear that many of Lia’s doctors tried to
help Lia and that her parents cared for her
deeply, yet this tragedy still occurred. List
three strategies you think might have
prevented it.
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The Spirit Catches You and You
Fall Down
7. What was the rationale for involving Child
Protective Services?
8. What examples of power and privilege can be
gleamed from this case study?
9. What can providers do to increase their
understanding of patient’s/client’s culture?
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Where do you think Lia Lee’s health care
providers fall on the
Cultural Competency Continuum?
Cultural Proficiency
Cultural Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destruction
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The Eight Questions of Cross
Cultural Medicine
• Dr. Arthur Kleinman from Harvard Medical
School developed a set of 8 questions
designed to elicit a patient’s “explanatory
model.”
• An explanatory model is an individual’s
ideas about the origin of illness and
treatment.
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The Eight Questions
1.
2.
3.
4.
What do you call the problem?
What do you think caused the problem?
Why do you think it started when it did?
What do you think the illness does? How
does it work?
5. How severe is the sickness? Will it have
a short or long course?
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The Eight Questions
6. What kind of treatment do you want to
receive? What are the most important
results you hope to receive from this
treatment?
7. What are the chief problems this
sickness has caused?
8. What do you fear most about this
sickness?
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The Spirit Catches You and You
Fall Down Revisited
• How may have Lia’s situation been
different if Dr. Kleinman’s suggestions
been implemented?
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Impact of Historical Events on
Healthcare Delivery
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Tuskegee Syphilis Study
Japanese-American Internment Camps
Sterilization of Puerto Rican Women
Los Angeles Vaccine Study
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Cultural Postcard
• IV. Has your culture ever collided with
accessing healthcare? How?
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Building Bridges to Cultural
Competence
Module V
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Building Bridges to
Cultural Competence
• Culture greatly influences behavior,
attitudes, values and beliefs about health
and human services
• Understanding these influences will help
providers to develop cultural competency
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Building Bridges to
Cultural Competence
• The Culturally Competent person:
– Knows that competency involves a deeper
commitment to the people for whom we
provide services
– Recognizes and learns to work within the
context of different languages, customs,
worldviews, religions, spiritual views, health
beliefs, gender roles, sexuality and family
relationships when interacting with
clients/patients
– Develops specific practice skills
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Building Bridges to
Cultural Competency
– Practice Skills
• Has an awareness and acceptance of
difference whereby diversity is valued
• Understands how one’s own culture
influences how one thinks, acts and
delivers services
• Understands the dynamics of difference
and is conscious of those dynamics
inherent when cultures interact
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Building Bridges to
Cultural Competency
• Becomes familiar with the different
aspects of various cultures in target
areas and institutionalizes cultural
knowledge within an agency,
institution or system
• Has the ability to adapt practice
skills that fit the cultural context of
the patient/client
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THE LEARN MODEL
• Listen with empathy and understanding of the
patient/clients perception of the problem
• Explain your perceptions of the problem
• Acknowledge and discuss the differences and
similarities
• Recommend a course of action or treatment
• Negotiate an agreement
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Role Plays
• Break into dyads
• You will have the opportunity to play both
the client and the provider
• Remember to use the LEARN model
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Wrap Up!
Module VI
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Cultural Competence includes:
•Self-examination
•Understanding the effects of power and
privilege
•Actively engaging clients/patients
•An ongoing process and determined effort
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The achievement of cultural competence
assures that clients/patients are treated with
dignity and that cultural traditions and values
that can impact healthcare are identified and
treated respectfully.
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ACKNOWLEDGMENTS
•
•
•
•
•
This curriculum was originally developed and written by Center for Public
Health Education (CPHE), at Stony Brook University under contract with
the NYSDOH AIDS Institute (AI) Case Management Unit.
This training is intended for health and human service providers. Staff,
supervisors and administrators are encouraged to attend.
Our appreciation and thanks is extended to our consultant, Lisa Skill of
PDP, SUNY at Albany for assistance in the development of this curriculum.
Her creative input was invaluable.
Much thanks to the AIDS Institute (AI) staff who served as an Advisory
Workgroup. The workgroup included: Richard Cotroneo, Rachel
Iverson, Heather Duell, Sally Perryman, Dina M. Williams, Barry D.
Watson, Bethsabet Justiniano and Mary Lou Del Rio.
Lastly, we would like to thank staff from the following agencies for their
helpful suggestions and encouragement: NDRI, Inc., PDP, Latino
Commission on AIDS, Inc., Cicatelli Associates, Inc., and Erie County
Health Department.
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QUESTIONS?
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Evaluations
Letters of Attendance
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