Cultural Competency and Adolescent
Health

Objectives
 Discuss the relationship between culture and health
in the context of adolescent-friendly services
 Describe the intersection of patient-centered care
and cultural competency
 Utilize the framework of cultural humility to minimize
provider bias and optimize health outcomes

The Culture of Adolescence
 Peer dependent
 Egocentric
 Distinct language and dress
 Influenced by popular culture
 Ongoing search for identity

The Growing Diversity of the
Adolescent Population
1990
2050
75.7
52.7
21.1
11.8
15
10
9
3
Non-Hispanic White Non-Hispanic Black

Asians
Hispanics
An Adolescent’s Identity Includes
Race and
Ethnicity
Religion/Spirituality
Genetics
Socioeconomic
Status
Geography
Peer Group
Ability
Stage of
Development
Gender Identity

Sexual
Orientation
Family Structure
“Minority” Status in One or More Aspects
of an Adolescent’s Identity Can Affect
 How and where health care is sought
 Ability to obtain and pay for quality care
 Patient-health care provider interaction
 Societal stereotyping and marginalizing

Lack of Insurance
 Young Adults aged 19-25:
 22.6% uninsured
 2nd-highest uninsured age group under 26- to 34-yearolds (23.5%)
 Teens and children under 19:
 7.6% uninsured
 Teens and children under 18:
 7.3% uninsured

US Census Bureau (2013)
Lack of Insurance = Lack of Care
 Uninsured adolescents are:
 Less likely to receive medical care
 Less likely to have a usual source of care
 More likely to experience long wait times
 More likely to be low income and of color
 Insured adolescents visit a physician’s office twice as
often as uninsured teens.

Barriers to Care: Provider Attitude
 Lambda Legal survey through partner organizations,
4,916 LGB respondents, 2009
 Almost 8% of LGB and 27% of transgender and gender
nonconforming reported being denied care because of
their identity/orientation
 11% reported that providers refused to touch them or
used excessive precautions
 Transgender and gender nonconforming respondents
reported facing discrimination and barriers to care 2-3
times more frequently than LGB respondents

16. Lambda Legal (2010)
Youth of Color Face Barriers to
STI/Pregnancy Prevention
 Cultural barriers to consistent condom use for Latinas
 Machismo
 Catholicism’s opposition to birth control
 Cultural expectation to be submissive
 Memories of medical abuses and mistrust of U.S.
government
 Hampers HIV education in some ethnic communities

http://www.advocatesforyouth.org/storage/
advfy/documents/transitions1503.pdf
Youth of Color Face Barriers to
STI/Pregnancy Prevention
 Higher rates of medical indigence than white youth
 Financial, cultural, institutional barriers in obtaining
health care
 Publicly funded health insurance provides limited
access to comprehensive, adolescent-friendly health
services
 High levels of worry about AIDS among urban
minority adolescents
 Greater concerns: housing, food, transportation, child
care, getting pregnant, street violence

http://www.advocatesforyouth.org/storage/
advfy/documents/transitions1503.pdf
Barriers Lead to Health Disparities
 Higher incidences of sexual risk behaviors
 Higher rates of
 Pregnancy
 STIs
 Delayed medical care


For Example…
LGB Youth Sexual Behaviors

Disparities in Teen Pregnancy Rates
Persist

Birth Rates, Females Aged 15-19,
U.S. 1991-2013

National Vital Statistics System. July 2014.
Teen Birth Rates by State

Pregnancy Rates: U.S. vs. CHOICE

N Engl J Med 2014;371:1316–23
Gonorrhea: Rates by Race/Ethnicity,
United States, 2009-2013

CDC STD Surveillance Report 2013
Chlamydia: Rates by Race/Ethnicity,
United States, 2009-2013

CDC STD Surveillance Report 2013
Chlamydia: Rates by State, United States
and Outlying Areas, 2013

CDC STD Surveillance Report 2013
Primary and Secondary Syphilis: By Sex, Sexual
Behavior, and Race/Ethnicity, United States, 2013

CDC STD Surveillance Report 2013
Herpes Simplex 2: Seroprevalence by Race,
Sex, and Age Group

CDC STD Surveillance Report 2013
Women who Have Sex with Women
(WSW) STI Risk
Nationwide, 6,935 self-identified lesbians
17.2% reported past history STI
Increased Risk
• Trichomonas
• HPV
• Bacterial vaginosis
• HIV

Consequences of Barriers
 1 out of 2 LGBT adults withheld their sexual orientation
from a provider
 1 of 4 withheld information about sexual practices (5
times more than heterosexual peers)

Harris Poll (2002 & 2003). Gran JM et al (2011). Krehely J (2009).

How Can Providers Improve
These Health Outcomes?
Strategies for Providing Optimal Care
 Cultural Competency
 Cultural Humility
 Adolescent-Centered Care

Cultural Competency
 Movement to address health disparities through
provider education
 Trainings often required by many funders,
accreditation bodies, and institutions

Most Common Definition
of Cultural Competency
 Cultural and linguistic competence:
 A set of congruent behaviors, attitudes, and policies
that come together in a system, agency, or among
professionals that enables effective work in crosscultural situations. (Cross, et al. 1989)

Cultural Competence: Strengths
 Brings culture into the discussion about manifestation
of disease and notions of health
 Encourages providers to learn about cultures of
patients served
 Supports respect for cultural differences and diversity

Cultural Competence
Provider Guidelines
 Increase knowledge about how culture influences
behaviors and outcomes
 Develop an awareness of providers’ and patients’
cultural issues and their effect on the medical
encounter
 Understand the importance of appropriate language
and the use of interpreters

Framework
for Cross-Cultural
Care
Cultural Competency
in Practice
 Listen to the patient's perception of the problem
 Explain your perceptions of the problem and your
strategy for treatment
 Acknowledge and discuss the differences and
similarities between these perceptions
 Recommend treatment while remembering the
patient's cultural parameters
 Negotiate agreement. Understand the patient's
explanatory model so medical treatment fits in
cultural framework

Berlin EA, Fowkes WC.1983
Efficacy of Cultural Competence
Programs
 Patient-centered care (PCC) models with a cultural
competence framework have been shown to:
1. Increase provider’s knowledge
2. Increase provider’s awareness
3. Increase provider’s cultural sensitivity
 One 10-week medical Spanish course for pediatric
emergency department physicians showed:
1. Decreased use of interpreter services
2. Increased patient satisfaction with physician concern,
respectfulness, and listening/communication.

A.M.N. Renzaho et al. 2013.
Mazor, et al. 2002.
Weaknesses in “Cultural Competency”
 Not clearly defined
 Denotes attainment of concrete level of knowledge
 Risks cultural stereotyping
 Focus on others instead of reflecting on individual
and organizational biases and prejudices

Cultural Competency and Adolescent
Health
 What does is it mean to provide culturally competent
care to adolescents?
 How does the “culture of adolescence” differ from
commonly held notions of culture?
 How does the culture of adolescence interact and
coexist with racial and ethnic cultures?


Building On Cultural Competency:
Cultural Humility
Cultural Humility
 Puts onus on provider to
self-evaluate how
personal biases may
affect service delivery
 Redresses power
imbalances in patientphysician dynamic

Tervalon and Murray-Garcia, 1998
Health Care Providers’ Identities
Race and
Ethnicity
Profession
Marital Status
Parental
Status
Sexual
Orientation
Training
Background
Gender
Identity

Age
Medical
Specialty
Religion
Issues to Confront Before Seeing
an Adolescent Patient
 How comfortable are you talking to adolescents?
 What are your feelings/beliefs about adolescent
sexuality?
 Are you able to separate your own values in order to
treat your patient?

Self-Evaluation During a Clinical
Encounter
 How do you react when confronted with a patient
situation that does not fit your expectations?
 Does the situation provoke feelings of anxiety and
discomfort?
 Are you able to assess what is going on within
yourself as well as within the patient?

www.diversityRx.org

Cultural Competence and Cultural Humility
Combined: Adolescent-Centered Care
Elements of Adolescent-Centered
Services
 Adolescent-specific
 Multi- and
interdisciplinary
 Accessible
 Financially affordable
 Adolescent-focused
materials on display
 Peer educator component

 Adequate space
 Confidential
 Flexible scheduling
 Comprehensive services
 Continuity of care
 Help transitioning into the
adult medical care
system
Providing Care to Adolescents
 Confront personal biases head-on
 Be prepared to refer patient for appropriate care if
unable to provide it

Adolescent-Centered Care
 Assure confidentiality
 Invite parents to wait in waiting room
 Explain why you will be asking sensitive questions
 Treat each patient as an individual, acknowledging all
the interacting forces that make him/her unique

Ways to Provide Adolescent-Centered
Care
 Ask a question and listen to the response!
 Wait 30 seconds until you speak after each question
 Answers will help identify how culture interacts with
patient’s health decisions
 Utilize HEEADSSS

Comprehensive HEEADSSS
 H: Home
 E: Education/Employment
 E: Eating
 A: Activities
 D: Drugs
 S: Sexuality
 S: Suicide/depression
 S: Safety
 *Additional questions:
 Strengths, Spirituality

Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
SHEEADSSS
 S: Strengths/Spirituality
 H: Home
 E: Education/Employment
 E: Eating
 A: Activities
 D: Drugs
 S: Sexuality
 S: Suicide/depression
 S: Safety

Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014.
Strengths-Based Approach
 Identify strengths early
 Look for examples of past difficulties that your patient has
successfully overcome
 Praise
 Use reflective listening and pause
 Create a comfortable, trusting, nonjudgmental setting
 Share your concerns

Wrap Up
 Emphasize that your approach is nonjudgmental and
that you welcome future visits
 “I’m here for you, and I want you to feel comfortable
confiding in me. If you have something personal to
talk about, I’ll try to give you my best advice and
answer your questions.”

Provider Resources and Organizational
Partners
 www.advocatesforyouth.org—Advocates for Youth
 www.aap.org—American Academy of Pediatricians
 www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
 www.acog.org—American College of Obstetricians and
Gynecologists
 www.arhp.org—Association of Reproductive Health
Professionals
 www.cahl.org—Center for Adolescent Health and the Law
 www.glma.org Gay and Lesbian Medical Association

Provider Resources and Organizational
Partners
 www.guttmacher.org—Guttmacher Institute
 janefondacenter.emory.edu Jane Fonda Center at Emory
University
 www.msm.edu Morehouse School of Medicine
 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
 www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
 www.prh.org—Physicians for Reproductive Health

Provider Resources and Organizational
Partners
 www.siecus.org Sexuality Information and Education Council of
the United States
 www.adolescenthealth.org Society for Adolescent Health and
Medicine
 www.plannedparenthood.org Planned Parenthood Federation of
America
 www.reproductiveaccess.org Reproductive Health Access
Project
 www.spence-chapin.org Spence-Chapin Adoption Services

Please Complete Your Evaluations Now
