Delivering Culturally Effective Care Florence S' Coleman, M'D', M'P'A Chief Special Mental Health Pr

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Delivering Culturally Effective CareFlorence S.
Coleman, M.D., M.P.AChief Special Mental Health
Programs Dayton VA Medical Center

• 2007 Healthy Start Grantee Meeting
• Crystal Gateway Marriott
• Arlington, Virginia
• August 6, 2007

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Delivering Culturally Effective CareThis
presentation will help you

• Formulate a plan to practice the delivery of
• culturally effective care in the clinical
  setting.
• Describe ETHNIC, a tool used to elicit a
  clients history in a cultural context .
• Explain the effects of mental health
• disparities.
• Explore the epidemiology of depression across
  cultures

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CULTURE

• Definition
• Culture is a pattern of beliefs, customs, and
  behaviors which a people acquire socially and
  transmit from one Generation to another through
  symbols and shared meanings.
• It provides the tools by which people of a given
  society adapt to their physical environment,
  social environment, and to one another.

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Self Assessment Worlds
Major Religions

• 1. Judaism ---- Attempts to deal
  with problems of human existence such as
• suffering
  and death the end of suffering is in the
  extinction of
• desire and
  emotion, and ultimately, the unreal self
  
• 2. Taoism ---- Considered a
  philosophy or a system of ethics for living,
• rather
  than a religion that teaches how people should
  act toward
• one
  another. People are born good.
• 3. Shintoism ---- All people are
  assigned to castes cows are sacred
• 4. Confucianism ---- Reverence for ancestors
  and the traditional Japanese way
• of life is
  emphasized
• 5. Buddhism ---- Obeying Gods law
  through ethical behavior and ritual
• obedience
  earns the mercy and justice of God
• 6. Islam ---- Most popular
  religion in the world. Brotherly love is
• emphasized
  in the world, Brotherly love is emphasized in
  acts of
• charity,
  kindness and forgiveness.
• 7. Hinduism ----Means the way and
  promotes a doctrine and code of
• behavior
• 8. Christianity ----God rewards the
  good and punishes the sinful Peace is
• gained
  through submission to Allah (the only God)

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What is cultural competence?

• Cultural competence is defined as a set of
  congruent behaviors, attitudes, and policies that
  come together in a system, agency, or among
  professionals and enables that system, agency, or
  those professionals to work effectively in
  cross-cultural situations (Cross et al., 1989)

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Competence

• Competence is used because it implies having the
  capacity to function in a particular way The
  capacity to function within the context of
  culturally integrated patterns of human behavior
  defined by a group.

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Cultural Competence Continuum

• I------------I------------I------------I----------
  --I------------I
• Cultural Cultural
  Cultural
• Destructiveness Blindness
  Competence
• Cultural Cultural
  Cultural
• Incapacity Pre-Competence
  Proficiency

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Diversity

• The mosaic of people who bring a variety of
  backgrounds, styles, perspectives, values, and
  beliefs as assets to groups and organizations
  with which they interact.

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Keys to REACH for DIVERSITY!

• R - Respect
• E - Educate
• A - Awareness
• C - Collaborate
• H Honesty

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R E S P E C T

• Realize Equality
• Share
• Experience and
• Create Trust.

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Race

• A concept under which human beings traditionally
  chose to group themselves. Physical, biological,
  genetic connotation are fully integrated in the
  definition.

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A DISPARITY IS AN INEQUALITY
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US POPULATION (2000)

• Hispanic 35.3 million 12.5
• African American 33.9 million 12.1
• Asian or Pacific 10.5 million
  3.7
• Islander
• Native American 2.1 million
  0.7

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US Population 2000
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RACIAL DISPARITIES

• Disparities White Women AA Women
• Infertility 6.4
  10.5
• Maternal
• Mortality 2.6
  6.3
• (ratio)
• Preterm births 83.7/1000
  160.9/1000
• Prenatal care 85
  73
• (1st trimester)

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Conceptualizing Disparities

• Prevalence Rehabilitation
• Incidence Participation
• Services Outcomes
• Treatment Access
• Prevention Quality
• Recovery Use of Medication

King Davis, 2003
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DISPARITIES IN MENTAL HEALTH CARE
FOR RACIAL AND ETHNIC MINORITIES

• Minorities have less access to, and availability
  of, mental health services
• Minorities are less likely to receive needed
  mental health services
• Minorities in treatment often receive a poorer
  quality of mental health care
• Minorities are underrepresented in mental health
  research
• Mental Health Culture, Race, and Ethnicity,
  a Supplement to the Surgeon Generals Report on
  Mental Health

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An Expanded View of Disparities
Crime Victims
Maternal/ Infant Deaths
Sickle Cell
Criminal Justice
Nutrition
Literacy
Uninsured
Low Birth Weight Babies
Diabetes
Sentencing
Housing Homelessness
Cardiovascular Disease
Periodontal Disease
Political Office
Voting
HIV
Asset Accumulation
Alcohol Abuse
Environmental Pollution
Cancer
Obesity
Low Income
Graduation Rates
Cocaine Use/Sale
Mental Retardation
Schizophrenia
Depression
Bipolar
Domestic Violence
Homicides
Personality Disorder
Dementia
Capital Punishment
Unemployment
King Davis, 2003
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Prospective Frequency Of Illness
Source Davis, King., Johnson, Toni,
McClendon,A. (2002). Guidebook. Baltimore Casey
Foundation Mental Health A Report of the Surgeon
General, DHHS, 1999.
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Need for Behavioral Health Care

• Latinos/Hispanic Americans
• Overall rates of MI similar to non-Hispanic
  whites
• Higher rates of some disorders
• Anxiety-related and delinquency behaviors,
  depression and drug use, more common among Latino
  youth
• Higher rates of depression among elderly Latinos
• Culture-bound syndromes
• Susto (fright), nervios (nerves), mal de ojo
  (evil eye), and ataque de nervios
• Access to behavioral health services is limited

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Need for Behavioral Health Care

• Asian Americans/Pacific Islanders
• Limited data on prevalence of MI
• Existing data suggests overall rates similar to
  whites
• Higher rates of depression, PTSD
• Somatic complaints of depression
• Culture-bound syndromes
• Lower suicide rates - except elderly women who
  have the highest suicide rates in U.S.
• Refugees with PTSD
• Language barrier limits access to services

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Need for Behavioral Health Care

• African Americans
• Overall rates of mental illness similar to
  non-Hispanic whites
• Differences in prevalence of specific illnesses
• Suicide rates lower but on the rise
• Environmental, economic and social factors
• Exposure to violence, homelessness,
  incarceration, social welfare involvement
• Less access to behavioral health services

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Need for Behavioral Health Care

• American Indians and Alaska Natives
• Limited data on prevalence of MI
• One small study with 20 year follow-up found 70
  lifetime prevalence of MI
• Increase rise of depression among older adults
• Suicide rate 1.5xs national average with young
  males accounting for 2/3 of suicides
• 2nd decade of life has highest mortality rate
• Alcohol dependence, alcohol related deaths
• Little information on service utilization
  patterns

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Racial Disparities
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Racial Disparities

• REPRODUCTIVE HEALTH
• White women AA women
• Infertility 6.4
  10.5
• Maternal 2.6
  6.3 mortality (ratio)
• Preterm births 83.7/10000 160.9/10000
• Pre natal care 85 73
• (1st trimester)

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Racial Disparities

• Endometrial Cancer
• AA women with endometrial cancer sere
  significantly less likely to undergo primary
  surgery.

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Racial Disparities

• Ovarian Cancer
• The incidence of ovarian cancer is lower among AA
  women compared with white women, the relative
  survival of AA women is poorer. The national
  Cancer data base study revealed that AA women
  with advanced epithelial ovarian cancer were
  treated less aggressively than white women were
  twice as likely not to receive appropriate
  medical therapy.

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Definitions

• Discrimination, Stereo typing, Ethnicity, Sexual
  Orientation, Religion, Discrimination, Racism,
  Culture, Ethnicity
• 1.________ a population or group distinguished by
  customs, characteristics, language, common
  history, and national origin.
• 2.________a set of beliefs that often involve a
  code of ethics and a philosophy.
• 3.________the sum total of shared behavior
  patterns, arts, beliefs, institutions thought,
  feeling characteristics of a group, community or
  a society.
• 4._______an action or behavior, which favors some
  people/groups and disadvantaged others.
• 5._______ partiality or prejudice

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Background heterogeneous

• 11 Million Asian Americans
• 43 Ethnic subgroups
• 60 Born outside of the US

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Screening for depression

• Have you been able to enjoy the things you
  usually do?
• Have you been feeling down, sad, or blue most of
  the day?

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Strategies to facilitate the Asian-American
Interview
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Clients Culture

• Communication styles
• Symptoms
• Coping strategies
• Family
• Community Support
• Willing to seek treatment

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Clinicians Culture

• Perceptions
• Understandings
• Diagnosis
• Treatment
• Service delivery

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Symptoms of Depression

• Sad Mood
• Loss of interest
• Hopelessness
• Guilt, worthlessness
• Appetite or weight change
• Low energy
• Thoughts of death or suicide
• Poor concentration
• Persistent Physical Symptoms
• May include psychotic Sx

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Suicidality

• Asian American Women
• 2nd highest suicide rate between ages 15 and 24
• Highest suicide rate among women 65 and older

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Communication
Basic Values Class
Non-confrontation and social harmony vs. Open
expression of interpersonal conflict
Psychosomatic vs. Sociosomatic
Reticence and Restraint vs. Gregarious and
Assertive
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Judaism

• Obeying Gods law through ethical behavior and
  ritual obedience earns the mercy and justice of
  God.

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Taoism

• Tao means the way and promotes a doctrine and
  code of behavior.

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Shintoism

• Reverence for ancestors and the traditional
  Japanese way of life is emphasized.

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Confucianism

• Considered a philosophy or a system of ethics for
  living, rather than a religion that teaches how
  people should act toward one another. People are
  born good

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Buddhism

• Attempts to deal with problems of human existence
  such as suffering and death.
• The end of suffering is in the extinction of
  desire and emotion, and ultimately, the unreal
  self.

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Islam

• God rewards the good and punishes the sinful.
• Peace is gained through submission to Allah (the
  only God)

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Hinduism

• All people are assigned to castes
• Cows are sacred

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Christianity

• The most popular religion in the world.
• Brotherly love is emphasized in acts of charity,
  kindness, and forgiveness.

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CROSS-CULTURALCOMMUNICATION

• L Listen with sympathy and understanding to the
  patients perception of the problem.
• E Explain your perceptions of the problem.
• A Acknowledge and discuss differences and
  similarities.
• R Recommend treatment.
• N Negotiate an agreement.

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RECOMMENDATIONS

• 5 Steps to becoming culturally competent
• Awareness and acceptance of differences
• Self-awareness
• Dynamics of Differences
• Knowledge of an Individuals Culture
• Adaptation of Skills

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