Cultural Competency and Adolescent Health

Cultural Competency and Adolescent
 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
Non-Hispanic White Non-Hispanic Black
An Adolescent’s Identity Includes
Race and
Peer Group
Stage of
Gender Identity
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.
 Hampers HIV education in some ethnic communities
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
 High levels of worry about AIDS among urban
minority adolescents
 Greater concerns: housing, food, transportation, child
care, getting pregnant, street violence
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
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
• Bacterial vaginosis
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
 Understand the importance of appropriate language
and the use of interpreters
for Cross-Cultural
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
 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
 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
Marital Status
Issues to Confront Before Seeing
an Adolescent Patient
 How comfortable are you talking to adolescents?
 What are your feelings/beliefs about adolescent
 Are you able to separate your own values in order to
treat your patient?
Self-Evaluation During a Clinical
 How do you react when confronted with a patient
situation that does not fit your expectations?
 Does the situation provoke feelings of anxiety and
 Are you able to assess what is going on within
yourself as well as within the patient?
Cultural Competence and Cultural Humility
Combined: Adolescent-Centered Care
Elements of Adolescent-Centered
 Adolescent-specific
 Multi- and
 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
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
 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.
 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
—Advocates for Youth
—American Academy of Pediatricians
 American Civil Liberties
Union Reproductive Freedom Project
—American College of Obstetricians and
—Association of Reproductive Health
—Center for Adolescent Health and the Law
 Gay and Lesbian Medical Association
Provider Resources and Organizational
—Guttmacher Institute
 Jane Fonda Center at Emory
 Morehouse School of Medicine
Pro-Choice New York Teen Outreach Reproductive Challenge
 North American Society of Pediatric and
Adolescent Gynecology
—Physicians for Reproductive Health
Provider Resources and Organizational
 Sexuality Information and Education Council of
the United States
 Society for Adolescent Health and
 Planned Parenthood Federation of
 Reproductive Health Access
 Spence-Chapin Adoption Services
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