# Presentation: 029181

## Achieving Cultural Competence

**A Guidebook for Providers of Services to Older Americans and Their Families**

## Achieving Cultural Competence

**Overview of the Aging Network**

## Slide 3

## Information and Assistance Programs

- <date/time>

**DHHS**

**Information and Assistance Programs**

**Eldercare Locator**
**AoA Website**
**Nat’l Aging Info Center**

**HCBS Case**
**Management**

**Aging Information**
**and Assistance**

**Senior Center**
**Info Programs**

**Pension**
**Counseling**

**Health Insurance**
**Counseling**

**Nutrition**
**Counseling**

**Legal**
**Hotlines**

**Medicare Anti-Fraud**
**Advocacy**

**Long-Term Care**
**Ombudsman**

##        Information and Counseling

**Home & Community-based**
**               ****Services**
-  Medicaid Home and
-   Community-based Waivers
-  State Funded Programs
-  Older Americans Act
-   Programs

-       **Healthy Aging       **
-  Health Promotion
-  Nutrition
-  Transportation
-  Employment
-  Volunteerism

-        **Information and Counseling**
-  General I&R Services
-  Specialized Counseling Services
-  State Health Information Programs
-  Medicare+Choice
-  Life Course Planning

-      **Elder Rights & Services     **
** **
-  Elder Abuse Prevention
-  Adult Protective Services
-  Long-Term Care Ombudsman
-  Legal Services
-  Senior Medicare Patrol

- AoA’s Service Delivery
-  Systems

## 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?

**What is Culture?**

- The shared values, traditions, norms,
- customs, arts, history, folklore, and institutions of a group of people.

## Why Consider Culture?

**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

**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

- 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.

**In Millions**

**Growth in 65+ Population****1900 - 2020**

## Persons 65+ as a Percentage of Total Population, 1999

## Percentage Increase in 65+: 1990 to 1999

## Growth in 85+ Population 1900 - 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.

**In Millions**

**Growth in 85+ Population ****1900 - 2020**

## Minority groups

- as a proportion of the U.S. population

-     1970	16 percent
-     1998	27 percent
-     2050	50 percent

## Slide 24

## Slide 25

## 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**

## Living Arrangements – Older Men

## Living Arrangements – Older Women

## Poverty

## Life Expectancy

**Life Expectancy**

**Life Expectancy by Age Group and Race, in Years, 1997**

## 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 

**No Pneumococcal Vaccination Persons 65+ by Ethnicity**** **

**Unknown**

- Source:  Centers for Disease Control and Prevention.  (1995).  Healthy People 2000:  Statistical Notes, 1995 Midcourse Review (updated).

- (Non-institutionalized population)

## Prevalence of Hypertension

- Source:  Vital & Health Statistics: Current Estimates from the NHIS, 1994, Page 86

## Source: Health, United States, 1999 with Health and Aging Chartbook, p. 141 - 143.

## 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**

## 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**

## 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.”

## Cultural Competence

- Appreciation and Respect for Cultural Differences

- Core Fundamental Beliefs: Warmth, Empathy and Genuineness

**Cultural Competence**

## Principles of Cultural Competence

**Values and Attitudes**
- Be knowledgeable about cultural differences and their impact on attitudes and behaviors.
- Be sensitive, understanding, non-judgemental, 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

- Value diversity.
- Develop capacity for cultural self-assessment.
- Understand the dynamics of the interaction between cultures.
- Institutionalize cultural knowledge.
- Adapt service delivery based on an understanding of cultural diversity.

## The 3 M’s

**Macro**:  Policies, laws, and regulations (Title VI of the Civil Rights Act, Executive Orders, Healthy People 2010, Older Americans Act, accrediting organizations)
**Mezzo**: Community-based involvement in the design, delivery of programs, services.
**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

## 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**