EXPLORING CULTURAL COMPETENCE;

CURRENT REALITIES AND HISTORICAL CONTEXTS

CLARISSA WILLIAMS, PHDDIRECTOR, URBAN HEALTH PROGRAM UIUCAPRIL 18, 2006UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE

CONCEPTUAL ASSUMPTIONSWorking Definitions:

1. Race: n. As a relatively modern concept, “race” is a socio-political construct that attempts to separate humankind into distinct groupings based on genotype (genetic heritage), phenotype (physicality) and geography (locality). This is a European/Euro-American socio-political construct, which holds at the center that there are pure and impure “races” of people.

2. Racism: n. Racism is the doctrine or ideology that advances the inherent genetic superiority of an entire “race” and conversely, the inherent inferiority of another. As an ideology, racism is a euphemism for “White Racial Supremacy.”

Working Definitions…….

3. Culture: n. Culture can be operationally defined as the totality of all systematized human social activities, ranging from birth, puberty, marriage, divorce and death rites to the foodstuffs, music, clothing and institutions a society produces. Culture is socially transmitted and it is the binding and perpetuating force of a society. Without this binding force, a society is rendered directionless, malleable, susceptible and vulnerable.

Odom

An integrated pattern of human behavior which includes but is not limited to – thought, communication, languages, beliefs, values, practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected behaviors of a racial, ethnic, religious, social or political group, the ability to transmit the above to succeeding generations, dynamic in nature.

NCCC

Working Definitions…….

4. Discrimination: Differential treatment that selects and favors one individual, group or object over another.

5. Stereotype: An over-simplified and standardized conception or image.

6. Cognitive Dissonance: n. A psychological mechanism (avoidance, opinionating, emotionalism and/or obfuscation) used to prohibit the understanding and resolution of an issue.

7. White Privilege: n A de facto policy whereby Europeans and their descendants are automatically afforded civility, accommodations, advantages, entitlements and rights solely as a result of their perceived “Whiteness.”

Working Definitions…….8. Cultural Competence: Having the capacity to function

effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities

A journey by which an agency must commit itself to a process of continuous improvement. It is a set of behaviors, attributes and policies enabling an agency (or individual) to work effectively in cross cultural situations. It is further defined in terms of commitment, accessibility and relevance.

9. Diversity: The valuing and respect of differences that is demonstrated in an organization through: commitment to inclusive teams at all levels (a leadership issue) cultural change within the organization (incorporation etc.)

Working Definitions…….Conceptual Differences:Diversity and Cultural Competence

Cultural Competence•Skill

Diversity:•Leadership Practice

THE COMPELLING INTERESTS FOR CULTURAL COMPETENCE:

1) TO RESPOND TO CURRENT AND PROJECTED DEMOGRAPHIC CHANGES IN THE UNITED STATES

2) TO ELIMINATE LONG STANDING DISPARITIES IN THE HEALTH STATUS OF PEOPLE OF DIVERSE RACIAL AND ETHNIC BACKGROUNDS

Compelling Interests….. Health Disparities

•Health disparity trends for African Americans, Latinos, Native Americans and some Asian Pacific Islanders subpopulations are widening.

• Concurrently, these groups are underrepresented in the healthcare workforce.

•Major demographic shifts in the US population will likely increase clinical encounters with these populations.

Compelling Interests……..Health Disparities

•Vietnamese women 5x more likely & Mexican & Puerto Rican women 2-3x more likely to have cervical cancer than White women•African Americans are more likely to develop end stage renal disorder due to diabetes but Whites receive 92% of all transplants•American Indians & Alaska natives 2.6x as likely and Mexican Americans and African Americans 2x as likely as non Hispanic whites to have undiagnosed diabetes AND to have higher rates of diabetes related complications•Infants with downs syndrome overall have a survival rate of 90% & median age of death of 49, for African American median age of death is 25•Physicians are les likely to refer African American women for catheterization than White men

THE COMPELLING INTERESTS FOR CULTURAL COMPETENCE:

3) TO IMPROVE THE QUALITY OF SERVICES AND PRIMARY CARE OUTCOMES

4) TO MEET LEGISLATIVE, REGULATORY AND ACCREDITATION MANDATE

Compelling Interests……..Legal/Regulatory Mandates

•Title VI of the Civil Rights Act of 1964•The Hill-Burton Act 1946•Medicaid•Medicare•Emergency Medical Treatment and Active Labor Act•DHHS, national standards on culturally and linguistically appropriate services (CLAS)•The Health Fairness Act of 1999 – PL 106-525 “Minority Health and Health Disparities Research and Education Act of 200•Various Healthcare Accreditation Organizations support standards that require cultural and linguistic competence in healthcare

THE COMPELLING INTERESTS FOR CULTURAL COMPETENCE:

5) TO GAIN A COMPETITIVE EDGE IN THE MARKETPLACE

6) TO DECREASE THE LIKELIHOOD OF LIABIITY/MALPRACTICE CLAIMS

•Integration of Cultural Competence into the Medical School curriculum

•Increase the numbers of physician of color providers from underrepresented groups in medicine

•Comply with CLAS standards in health service organizations

Strategies for Intervention

EXPLORING SOCIAL ENCOUNTERS; A HISTORICAL

PERSPECTIVE

What in the Healthcare Process Produces Less than Optimal Health Outcomes?

Determinants of Health Disparities:•Socio Economic Factors•Racism Factors•Cultural Factors•Medical Care Factors•Biological Factors

The Social Nature of the Clinical Encounter

“The clinical encounter is a science based practice that occurs in a social setting…science skill can be frustrated (or enhanced) by a lack of social skills.”

Louis W. SullivanSecretary of Health and Human Services 1989-1993President Emeritus, Morehouse School of Medicine

IDENTITY, HISTORY AND SOCIAL INTERACTION•Race

•Gender

•Occupation

•Family

•Culture

•Experiences

•Education

•Religion

•Class

•Country/state we live in

1) WITH EXCEPTION OF NATIVE AMERICANS, NATION OF IMMIGRANTS

• VOLUNTARY

• FORCED

SOCIOHISTORICAL FRAMEWORK COMPOSITION OF US

Varied Nature of the Cross Cultural Encounter

The cross cultural encounter may be :

InternationalInterracial

Across GendersAcross Sexual OrientationAcross Religious AffiliationsAcross Class

RACE IN THE US

•Is unique in its rigidity

•France collects no data on race

•Brazil has several intermediate categories in addition to white and black

• In US race is used to justify power, privilege and authority of one group over another

•Fluid/changing

Race and Racism•Historically related activities

•Carolus Linnaeaus 1701-1787

•Americanus rubiscus/American Red

-reddish, obstinate and regulated by custom

•European albus/European White

-white gentle and governed by law

•Asiatic luridus/Asian Yellow

-sallow severe and ruled by opinion

•Afer niger/African Black

-black, crafty and governed by caprice

American Anthropological AssociationStatement on Race

“Racial beliefs constitute myths about the diversity in the humanspecies and about the abilities and behavior of people homogenized into “racial” categories. The myths fused behavior and physical features together in the public mind, impeding our comprehension of both biological variations and cultural behavior, implying that both are genetically determined. Racial myths bear no

relationship to the reality of human capabilities of behavior.”

May 17, 1998

Racism and the Academy

1. Anthropology

2. Philosophy

3. Linguistics

4. Medicine

5. Psychology

Philosophy“I am apt to suspect the Negroes and in general all other species of men, to be naturally inferior to the whites. There never was any civilized nation of any other complexion than white, nor ever any individual eminent in action or speculation.”

(David Hume - National Characters, Essays Moral and Political 1748)

“The Negroes of Africa have received no intelligence that rises above the foolish. The difference between the two races is thus a substantial one: it appears to be just as great in respect of the faculties of the mind as in color.”

(Immanuel Kant - Observations on the Feeling of the Beautiful and the Sublime 1764)

Racism and the African Slave Trade

• European Catholic Church sanctions enslavement of Africans and non-Christians

• Racism and Colonialism

• Racism justifies African enslavement

The One Drop Rule

Every State had legal definitions of how much negro blood makes one black:

Georgia 1935 – no ascertainable Negro, West Indian or African Blood

Virginia 1950 – any ascertainable type of Negro blood

Louisiana up to 1970 – define Negro as anyone w/a trace of black ancestry

DEFINITIONS:

Who Is White?

•.NATURALIZATION ACT OF 1790

•IN RESPONSE TO INCOMING IMMIGRANTS

Negotiating Historical Legacy with the Present

HISTORICAL MYTHS:Media

•African American and Latino women – reproductive rights•African American Males

THE POWER OF STORY

“ The ability to tell one’s story is the power to affirm and interpret ones existence.”

Williams

Accessing HealthcareThe African American Experience

First encounter – Pre Middle Passage

Accessing Healthcare The AA Exp

Subsequent Encounters – As Needed andEncounters as Specimen –Standard Practice

Accessing Healthcare The AA Exp

Jim Crow – Separate and Unequal Access

Accessing Healthcare The AA Exp

Jim Crow – Separate and Unequal Access

1) Banned from nation’s health profession schools2) Banned from state and national medical societies

formed NMA1) Dentists 1965 2) Nursing 1949, 1960

Accessing Healthcare The AA Exp

Pre and Post Civil Rights Era

1950 - Hospitals in Los Angeles County, discriminatory Hospital practices

1956 – 7out of 10 hospital administrators opposed to integrating hospitals1959 – Discrimination in minority patient access to hospital care and

minority appointments to medical staffs widespread throughoutUS

1963US Commission on Civil Rights1964 Medicare Bill signed into law, mandated anti-discrimination

protections of Title VI of the Civil Rights Act of 1964 apply to hospitals receiving public funds.

TODAY……In comparison to Whites, racial and ethnic minoritiescontinue to have low representation in the healthprofessions

Receive second rate health care

Die younger from treatable disease

Where does it occur?

1. Institutional Level• Normative • Intentional or Unintentional

Institutional Level…Examples

• Health Professions - schools recruit and maintain inadequate number of minority faculty and staff who might serve as mentors or in positions of institutional leadership (Sullivan Report)

• Patient Care – Clear systemic patterns of racial and ethnic bias by providers (IOM 2003)

2. Personally Mediated Level

Can operate in the personalized form of prejudice,stereotype, or bias

Can be intentional or unintentional

Personally Mediated Level…Examples

1) Harsh, unsupportive and/or unwelcoming institutional climates (Sullivan)

3. Internalized Level

Psychological Phenomenon

Additional Examples of Bias and Racism in the Healthcare System:

1) One race or ethnic group neglects to share system of governance orinstitutional power with certain other groups

2)Opportunities and resources for health professions education, training, or practice unduly favor a certain racial or ethnic group

3)Opportunities and resources for faculty appointment, leadership and research unduly favor a certain racial or ethnic group

4)Health care providers unduly deliver diagnostic and treatment services disparately to certain racial and ethnic groups

5)Healthcare institutions or health professions schools maintain unresponsive and inflexible policies, procedures, and practices that perpetuate the exclusion of certain racial and ethnic groups from healthcare education or practice

6)Healthcare institutions or health professions school impose ethnocentric culture on any other race or ethnic group to that group’s detriment.

Cultural Competence: PRIME Model

Promoting, Reinforcing and Improving Medical Education Culture and DiversityCurriculum