Achieving Cultural Competence
A Guidebook for Providers of Services to Older Americans and Their Families
Achieving Cultural Competence
Overview of the Aging Network
DHHS AoA State Units on Aging Area Agencies on Aging
Eldercare Locator AoA Website Nat’l Aging Info Center
Information and Assistance Programs
HCBS Case Management Pension Counseling Legal Hotlines Aging Information and Assistance Health Insurance Counseling Medicare Anti-Fraud Advocacy Senior Center Info Programs Nutrition Counseling Long-Term Care Ombudsman
Information and Counseling • • • • • General I&R Services Specialized Counseling Services State Health Information Programs Medicare+Choice Life Course Planning
Long Term Care Home & Community-based Services • Medicaid Home and Community-based Waivers • State Funded Programs • Older Americans Act Programs
Healthy Aging
AoA’s Service Delivery Systems
• • • • •
Health Promotion Nutrition Transportation Employment Volunteerism
Elder Rights & Services • • • • • Elder Abuse Prevention Adult Protective Services Long-Term Care Ombudsman Legal Services Senior Medicare Patrol
Achieving Cultural Competence
What is Culture?
Challenges
How do we as professionals work with individuals from diverse cultures and with perspectives different from our own?
What is Culture?
The shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people.
Why Consider Culture?
•
•
Helps us to understand the values, attitudes and behaviors of others Helps us to avoid stereotypes and biases that can undermine our efforts
•
Plays a critical role in the development and delivery of services that are responsive to the needs of the recipient
Factors that Influence Culture
• • • • • • • •
Age Gender Geography Socio-economic status Educational attainment Individual experiences Place of birth Length of residency in the U.S.
Cultural competence can help to better meet the needs of diverse aging populations.
Definition of Cultural Competence
Cultural competence is a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations.
Two Dimensions of Cultural Competence
Surface Structure: Use people, places,
language, music, food, and clothing familiar to and preferred by the target audience.
Deep Structure: Involves sociodemographic
and racial/ethnic population differences and the influence of ethnic, cultural, social, environmental and historical factors on behaviors.
Cultural Competence
Checklist for Success
Makes the environment more welcoming and attractive based on clients cultural mores
Avoid stereotyping and misapplication of scientific knowledge Include community input at the planning and development stage Use educational approaches and materials that will capture the attention of your intended audience Find ways for the community to take the lead
Adapted from material developed by the National Center for Cultural Competence, Georgetown University Child Development Center
Cultural Competence
Checklist for Success.
Be an advocate - strike a balance between community priorities and agency mission
Understand there is no recipe Hire staff that reflect client population Understand cultural competency is continually evolving
Be creative in finding ways to communicate with population groups that have limited English-speaking proficiency
Adapted from material developed by the National Center for Cultural Competence, Georgetown University Child Development Center
Barriers to Service Access
Structural Barriers: lack of health
care insurance, high out-of-pocket expenses, lack of transportation, language difficulties.
Cultural Barriers: Characteristics of
minority groups, such as styles of interaction and expectations.
Research on Cultural Competence
Existing Research: health care service
utilization, Census data, National Center for Health Statistics, new survey and data collection.
Research Needs: utilization data for other
services, interaction between socioeconomic status of minority groups and service utilization
Achieving Cultural Competence
Why is Cultural Competence Important? Demographics
Growth in 65+ Population 1900 - 2020
53.2 60 50
In Millions
34.7 25.7 16.7 3.9 4.9 9
40 30 20 10 0 1900 1920 1940 1960
1980
2000
2020
Source: U.S. Bureau of the Census. (1993). Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1993 to 2050, Current Population Reports, P25-1104.
Persons 65+ as a Percentage of Total Population, 1999
Percentage Increase in 65+: 1990 to 1999
Growth in 85+ Population 1900 - 2020
7 6
In Millions
7 4.3 2.2 0.1
1900
5 4 3 2 1 0 1920 1940 1960 1980
0.2
0.4
0.9
2000
2020
Source: U.S. Bureau of the Census. (1993). Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1993 to 2050, Current Population Reports, P25-1104.
Minority groups
as a proportion of the U.S. population
• 1970 16 percent • 1998 27 percent
• 2050 50 percent
Percent Increase in Population 65+, 1990 - 2030
350% 300% 250% 200% 150% 100% 50% 0% African American American Asians and Indians, Eskimos, Pacific Islanders and Aleuts Hispanics White 131% 147% 81% 285%
328%
Projected Distribution of 65+ Population, by Race and Hispanic Origin 2000 and 2050
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Non-Hispanic White Non-Hispanic Black Non-Hispanic American, Indian and Alaska Native Non-Hispanic Asian and Pacific Islander Hispanic 8.1% 16.4% 12.2% 2.4% 6.5% 5.6% 40.0% 64.2% 60.0%
83.5% 2000 2050
Achieving Cultural Competence
Why is Cultural Competence Important? Racial and Ethnic Disparities
Education Level
Percentage of the 65+ Population with a High School Diploma or Higher or a Bachelor’s Degree or Higher, by Race and Hispanic Origin, 1998
High School Diploma Bachelor's Degree or Higher or Higher Total 67.0 14.8 Non-Hispanic White 71.6 16.0 Non-Hispanic Black 43.7 7.0 Non-Hispanic Asian and Pacific Islander 65.1 22.2 Hispanic 29.4 5.4
Living Arrangements – Older Men
80 70 60
Percentage
50 40 30 20 10 0 Total White Black As ian and Pacific Is lander His panic
With Spous e With Other Relatives With Non-Relatives Alone
Living Arrangements – Older Women
45 40 35 30
Percentage
With Spous e With Other Relatives With Non-Relatives Alone
25 20 15 10 5 0 Total White Black As ian and Pacific Is lander His panic
Poverty
Percentage of 65+ Population Living in Poverty, by Selected Characteristics, 1998
Non-Hispanic Black 26.4 Hispanic Non-Hispanic Asian and Pacific Islander Non-Hispanic White Total 0.0 5.0 8.2 10.5 10.0 15.0 20.0 25.0 30.0 16.0 21.0
Life Expectancy
Life Expectancy by Age Group and Race, in Years, 1997
White
Life Expectancy at Birth Life Expectancy at Age 65 Life Expectancy at Age 85
77.1 17.8 6.2
Black
71.1 16.1 6.4
Health Disparities: Examples
• Native Hawaiians have one of the poorest health profiles of any ethnic group in the United States. (Mokuau et al., 1995) • The death rate for all cancers is 30 % higher for African Americans than for Whites. (Healthy People 2010) • Hispanics living in the United States are almost twice as likely to die from diabetes than are non-Hispanic Whites. (Healthy People 2010) • The rate of diabetes for this population group is more than twice that for Whites. (Healthy People 2010)
No Pneumococcal Vaccination Persons 65+ by Ethnicity
Total 65+ population Hispanic Black Asian and Pacific Islander American Indian
70% 85% 86% 73%
Unknown
(Non-institutionalized population)
Source: Centers for Disease Control and Prevention. (1995). Healthy People 2000: Statistical Notes, 1995 Midcourse Review (updated).
Prevalence of Hypertension
600 500
per 1000
543.8 439.2 337.9 208.1 338.7 376.9 White Black
400 300 200 100 0
45-64
65-74 Age
75+
Source: Vital & Health Statistics: Current Estimates from the NHIS, 1994, Page 86
Death Rate for Heart Disease by Sex, Race, and Age, US, 1996
Age Adjusted Deaths per 100,000 population using Whites as Index
3.00 2.50 2.00 1.00 1.00 2.42 1.63
0.00
Race
White Black Hispanic Native Americans
Source: Health, United States, 1999 with Health and Aging Chartbook, p. 141 - 143.
Ratio of Diabetes Related Deaths by Race, US, 1996
Age Adjusted Deaths per 100,000 population using Whites as Index
3.00 2.50 2.00 1.00 1.00 2.42 1.63
0.00 Race
White Black Hispanic Native Americans
Source: Health, United States, 1999 with Health and Aging Chartbook, p. 141 - 143.
Self-Rated Health Status
Percentage of Persons Who Reported Good to Excellent Health by Age, Sex, Race and Hispanic Origin, 1994-1996
All Persons Non-Hispanic Non-Hispanic Hispanic White Black Total
65 or older 72.2 72.0 74.6 68.3 65.0 72.4 75.2 69.8 65.1 74.0 73.5 76.3 69.4 67.3 74.3 77.5 71.7 66.4 58.4 59.3 61.6 56.4 45.0 57.8 59.3 55.3 56.0 64.9 65.4 68.7 59.7 50.9 64.6 68.5 59.3 55.1
Men
65 or older 65 to 74 75 to 84 85 or older
Women
65 or older 65 to 74 75 to 84 85 or older
Access to and Satisfaction with Health Care
Percentage of 65+ Medicare Beneficiaries Reporting Access to and Satisfaction with Health Care, by Race and Hispanic Origin, 1998
Total
Percent Reporting Difficulty Obtaining Care Percent Reporting They Delayed Getting Care Due to Cost Percent Reporting They Were Unsatisfied or Very Unsatisfied with Health Care 2.3 5.5
Non-Hispanic Non-Hispanic Hispanic White Black
2.1 5.0 3.8 9.6 2.9 7.3
3.0
2.9
2.5
3.7
Achieving Cultural Competence
What are Culturally Appropriate Programs and Services?
Warmth, Empathy, and Genuineness
• Warmth: acceptance, liking, commitment,
and unconditional regard.
• Empathy: the professional’s ability to
perceive and communicate, accurately and with sensitivity, the feelings of the client and the meaning of those feelings.
• Genuineness: openness, spontaneity,
congruence, the opposite of “phoniness.”
Culturally Congruent Behaviors
Appreciation and Respect for Cultural Differences
Cultural Competence
Core Fundamental Beliefs: Warmth, Empathy and Genuineness
Principles of Cultural Competence
Values and Attitudes
• Be knowledgeable about cultural differences and their impact on attitudes and behaviors. • Be sensitive, understanding, nonjudgemental, respectful. • Be flexible and skillful in responding and adapting to different cultural contexts and circumstances.
Principles of Cultural Competence
Communication Styles
• Spend time listening to needs, views and concerns of the community. • Use the language and dialect of the people you serve. • Use communication vehicles that have value and use by your target audience.
Principles of Cultural Competence
Community/Consumer Participation • Get to know the community, its people, its resources to identify strategies for service delivery. • Establish partnerships and relationships with key community resource people. • Report back the results of your initiatives to groups, individuals that help you in the process.
Principles of Cultural Competence
Physical Environment • Create culturally, linguistically friendly interior design, pictures, posters, and art work to make facilities more welcoming. • Display material and information with recognizable props that hold significance, value, and interest for your target audience. • Put props in the hands of people that will maximize their distribution, circulation.
Principles of Cultural Competence
Policies and Procedures • Mission statement must articulate principles and rationale for culturally competent service delivery. • Develop structures to assure community participation in planning, delivery, and evaluation of services. • Institute procedures to recruit, retain, and train a diverse and culturally competent workforce.
Principles of Cultural Competence
Population-Based Service Delivery
• Appreciate the importance of culture while avoiding stereotypes. • Understand the socio-political influences that shaped your consumers’ attitudes, beliefs and values.
Principles of Cultural Competence
Training and Professional Development
• Provide informal opportunities like “brown bag lunches” for staff to explore their attitudes, beliefs and values. • Recognize that cultural sensitivity occurs on a continuum. • Provide specialized training for interpreters.
5 Essential Organizational Components for Cultural Competence
1. Value diversity. 2. Develop capacity for cultural selfassessment. 3. Understand the dynamics of the interaction between cultures. 4. Institutionalize cultural knowledge. 5. Adapt service delivery based on an understanding of cultural diversity.
The 3 M’s
1. Macro: Policies, laws, and regulations (Title VI of
the Civil Rights Act, Executive Orders, Healthy People 2010, Older Americans Act, accrediting organizations)
2. Mezzo: Community-based involvement in the
design, delivery of programs, services.
3. Micro: Prepare service professionals to interact
effectively, appropriately with individuals from diverse cultures.
Characteristics of Culturally Competent Service Delivery
• Available: Availability of services refers to
the existence of health services and bicultural/ bilingual personnel. • Accessible: Accessibility is contingent on factors such as cost of services, the hours of service provision, and the geographic location of a program. • Acceptable: Acceptability is the degree to which services are compatible with the cultural values and traditions of the clientele.
The Cultural Sensitivity Continuum
! ! ! !
Fear: Others are v iewed with trepidation and contact is avoided. Denial: The existence of the other group is denied. Superiority: The other group exists but is considered inferior. Minimization: The group is acknowledged, but the
importance of cultural differences is minimized (e.g., “we’re all human after all”).
! !
Relativism: Differences are appreciated, noted and valued. Empathy: A more full understanding of hoow others perceiv e
the world and how they are treated is achieved.
!
Integration: Assessment of situations involving members of
other cultures can be accomplished and appropriate actions undertaken.
Principles of Interpreter Services
• Use qualified interpreters who have passed qualification standards and completed interpreter education programs. • Do not use family members, friends, young children or youth to interpret. • Do not rely on untrained workers or employees to interpret. • Minimize the use of telephone language lines to times when it is absolutely necessary.
“Culturally competent practice is a long-term developmental process. Proficiency is not achieved after a brief workshop.”
(Tripp-Reimer, 1999)
Achieving Cultural Competence
People Profiles
People Profiles - Age
• Chieko, a 70 year old foreign-born elder recently brought to the U.S. by her family. • Lisa, a fourth generation Asian American elder was has lived in the U.S. her whole life. • Unique personal histories that shape their interaction with service providers. • Chieko delays seeking care for heart trouble due to confusion over health care system, language difficulties, transportation difficulties, and fear. • Lisa is more savvy about the U.S. health care system and navigates it more successfully.
People Profiles - Education
• Joe, an 85 year old African American, was diagnosed with hypertension 15 years ago. • Joe exhibits dramatic fluctuations with his blood pressure due to noncompliance with prescribed treatment regimens. • Joe’s physician is unaware of the effects of using the word “hypertension” versus “high blood pressure” among African American elders. • Using the term “high blood pressure” will more likely lead to better compliance.
People Profiles - Gender
• Husan, a 60 year old Asian American, with limited command of the English language. • During a routine clinical exam, Husan reverts to a passive stereotypical Asian female personality in order to avoid embarrassment from asking questions about her condition.
People Profiles Geographic Location
• Juanita, a 68 year old Latina, who lives in San Diego County. Juanita has lived in a predominantly Latino neighborhood since coming to the U.S. in her thirties. • Juanita consults with “curanderos” about her health concerns and crosses the border back to Mexico to purchase pharmaceutical products. • Because of her geographic location, Juanita is able to live in the U.S. without having to acculturate into American culture and learn English.
Program Profile – Ethnic Dietician
A county-based Area Agency on Aging provides funds for an ethnic dietician. The dietician conducted focus groups with several minority elder groups. The result is a program that offers culturally appropriate meals that may be adaptations of some traditional production techniques. In addition, the dietician is preserving and adapting traditions plus including new knowledge to improve the lives of older county residents.
Program Profile – Bilingual/Bicultural Program
An Area Agency on Aging developed a successful bilingual, bicultural program for Hispanic elders. The AAA trained Hispanic elders to serve as community ambassadors. The elders teach the staff about the Hispanic culture. The result is culturally acceptable and accessible services such as long term care and caregiver support.
Laws
• Title VI of the Civil Rights Act of 1964 • The Older Americans Act
Executive Orders
• Improving Access to Services for Persons with Limited English Proficiency • Historically Black Colleges and Universities • Hispanic Serving Institutions • Tribal Colleges and Universities • Increasing Participations of Asian American and Pacific Islanders in Federal Programs
Healthy People 2010
• The nation’s disease prevention agenda. • Identifies significant opportunities to improve health and focuses on special populations. • AoA’s targeted efforts to address minority elder health disparities in three areas:
• Diabetes • Cardiovascular disease • Adult immunization