EXPLORING CULTURAL COMPETENCE;

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EXPLORING CULTURAL COMPETENCE CURRENT
REALITIES AND HISTORICAL CONTEXTS CLARISSA
WILLIAMS, PHD DIRECTOR, URBAN HEALTH PROGRAM
UIUC APRIL 18, 2006 UNIVERSITY OF ILLINOIS
COLLEGE OF MEDICINE
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CONCEPTUAL ASSUMPTIONS
Working 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.
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Working Definitions.

• 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
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Working Definitions.

• Discrimination Differential treatment that
  selects and favors one individual, group or
  object over another.
• Stereotype An over-simplified and standardized
  conception or image.
• 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.

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Working Definitions.

• 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.)

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Working Definitions.
Conceptual Differences Diversity and Cultural
Competence

• Cultural Competence
• Skill

• Diversity
• Leadership Practice

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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

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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.

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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

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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
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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

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THE COMPELLING INTERESTS FOR CULTURAL COMPETENCE
5) TO GAIN A COMPETITIVE EDGE IN THE
MARKETPLACE 6) TO DECREASE THE LIKELIHOOD OF
LIABIITY/MALPRACTICE CLAIMS
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Strategies for Intervention

• 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

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EXPLORING SOCIAL ENCOUNTERS A HISTORICAL
PERSPECTIVE
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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

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The Social Nature of the Clinical Encounter
The clinical encounter is a science based
practice that occurs in a social settingscience
skill can be frustrated (or enhanced) by a lack
of social skills. Louis W. Sullivan Secretar
y of Health and Human Services 1989-1993 Preside
nt Emeritus, Morehouse School of Medicine
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• IDENTITY, HISTORY AND SOCIAL INTERACTION
• Race
• Gender
• Occupation
• Family
• Culture
• Experiences
• Education
• Religion
• Class
• Country/state we live in

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SOCIOHISTORICAL FRAMEWORK COMPOSITION OF US

• WITH EXCEPTION OF NATIVE AMERICANS, NATION OF
  IMMIGRANTS
• VOLUNTARY
• FORCED

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Varied Nature of the Cross Cultural Encounter
The cross cultural encounter may be
International Interracial Across
Genders Across Sexual Orientation Across
Religious Affiliations Across Class
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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

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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

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American Anthropological Association Statement on
Race Racial beliefs constitute myths about the
diversity in the human species 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
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Racism and the Academy

1. Anthropology
2. Philosophy
3. Linguistics
4. Medicine
5. Psychology

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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)
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Racism and the African Slave Trade

• European Catholic Church sanctions enslavement of
  Africans and non-Christians
• Racism and Colonialism
• Racism justifies African enslavement

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• 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

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DEFINITIONS Who Is White?

• .NATURALIZATION ACT OF 1790
• IN RESPONSE TO INCOMING IMMIGRANTS

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Negotiating Historical Legacy with the Present

• HISTORICAL MYTHS
• Media
• African American and Latino women reproductive
  rights
• African American Males

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THE POWER OF STORY
The ability to tell ones story is the power to
affirm and interpret ones existence. Williams
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Accessing Healthcare The African American
Experience
First encounter Pre Middle Passage
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Accessing Healthcare The AA Exp
Subsequent Encounters As Needed
and Encounters as Specimen
Standard Practice
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Accessing Healthcare The AA Exp
Jim Crow Separate and Unequal Access
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Accessing Healthcare The AA Exp

• Jim Crow Separate and Unequal Access
• Banned from nations health profession schools
• Banned from state and national medical societies
  formed NMA
• Dentists 1965
• Nursing 1949, 1960

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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 hospitals
• 1959 Discrimination in minority patient access
  to hospital care and
• minority appointments to medical staffs
  widespread throughout
• US
• US Commission on Civil Rights
• 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.

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TODAY
In comparison to Whites, racial and ethnic
minorities continue to have low representation in
the health professions Receive second rate
health care Die younger from treatable disease
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Where does it occur?

• Institutional Level
• Normative
• Intentional or Unintentional

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• Institutional LevelExamples
• 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)

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2. Personally Mediated Level Can operate in the
personalized form of prejudice, stereotype, or
bias Can be intentional or unintentional
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Personally Mediated LevelExamples 1) Harsh,
unsupportive and/or unwelcoming institutional
climates (Sullivan)
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3. Internalized Level Psychological Phenomenon
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Additional Examples of Bias and Racism in the
Healthcare System

• One race or ethnic group neglects to share system
  of governance or
• institutional 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 groups detriment.

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Cultural Competence PRIME Model Promoting,
Reinforcing and Improving Medical Education
Culture and Diversity Curriculum