Welcome to the AIDS Education Training Center-

National Multicultural Center

To reduce HIV/AIDS disparity by: a) providing quality standardized training in Cultural Competency and HIV/AIDS care; b) to strengthen quality Cultural Competency 1 . (knowledge and practice) capacity of HIV providers and systems nationwide; and 2. to be a resource for the improvement of multicultural health care aimed at building sustainable individual, local, regional and national capacity in HIV care.

WEBINAR PRESENTER:

Rani Srivastava RN, PhDChief of Nursing & Professional Practice (CAMH)Toronto, Ontario

A. Interact with a health care system B. Participate in programs of

prevention and health promotion C. Access financial resources

available to support healthcare (correct response)

D. Implement health seeking behavior and adherence to treatment

E. Access health information and services

A. Expecting and acknowledging differences

B. Reliance on your professional judgment – (correct response)

C. Looking for own biases, assumptions of normalcy and universality

D. Looking for systemic barriers E. Appreciation of the unique

strengths of others

A. InclusivelyB. RespectC. Valuing changeD. Time– (correct response)E. Commitment

A. Effects of migration, racism, and discrimination

B. Concerns relative to disclosure of HIV status

C. Perceptions of the trustworthiness of healthcare providers

D. The incidence/ prevalence of HIV/AIDS in the population

E. All of the above (correct response)

A. Consensus Building, Information Exchange, and Constructive

CritiqueB. Validation, Negotiation and

Reframing (correct response)C. Fact Checking, Open

Communication, and Collaboration

Examine the Culture Care Framework as a guide for practice and service  in the delivery of quality HIV care.

Describe the core knowledge and skill necessary to understanding and addressing health disparities in HIV/AIDS care.

Discuss strategies to bridge the gap across cultures in providing quality health care.

Discuss how to apply the strategies of cultural care validation, accommodation and reframing in providing quality clinical care.

• Respond to current and projected demographic changes in the United States.

• Reduce long-standing disparities in the health status of people of diverse racial, ethnic, & cultural backgrounds.

• Improve the quality of services & outcomes.• Meet legislative, regulatory, & accreditation

mandates. National Center for Cultural Competence,

1999

North America1.5 million1.5 million

Caribbean240,000240,000

Latin America1.4 million1.4 million

Sub-Saharan Africa22.5 million22.5 million

North Africa & Middle East460,000460,000

Western &Central Europe820,000820,000

Eastern Europe & Central Asia1.4 million1.4 million

East Asia770,000770,000

South &South-East Asia4.1 million4.1 million

Oceania57,00057,000

Total: 33.3 million

UNAIDS, 2010

• New HIV infection rate steady.• Increased cases in women, esp. in SE.• Heterosexual transmission are increasing.• Minority populations are disproportionately

affected.• Substance use and/or abuse is an

important co-factor.

Culture and ethnicity are products of both personal history and wider situational, social, political, geographic and economic factors.

Factors related to culture and ethnicity shape: the way people interact with a health care system; their participation in programs of prevention and health

promotion; their access to health information and services; their health-related choices and decisions; their understanding of and priorities re: health and

illness; help seeking behavior and adherence to treatment.

44% of new cases of HIV are seen in African-Americans.

Ethnic minorities have a cancer death rate about 33% higher than that of European Americans.

Ethnic minorities are least likely to receive early prenatal care.

African-Americans are 1.7 times more likely to have diabetes than are European Americans.

Coronary heart disease continues to decline at a much slower rate for African-Americans than any other ethnic group.

Health inequity concerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable – and thus inherently unjust and unfair.

Health equity recognizes differences in health outcomes for members of marginalized communities– poverty, race, age, gender, sexual orientation, immigration or refugee status, etc, and aims to provide service in a manner that mitigates these health impacts.

Access Services in general Specific interventions Appropriate interventions

Engagement & Adherence

But whose culture do we need to understand? Patients? Care providers? Health care systems?

Non

-Min

ori

ty

Min

ori

tyDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases & Prejudice, Stereotyping, &Uncertainty

Disparity

Qual it

y o

f H

eal t

h C

ar e

Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Populations with Equal Access to Health Care

From: IOM Report (2002): Unequal Access

A congruent set of workforce behaviors, management practices and institutional policies within a practice setting resulting in an organizational environment that is respectful and inclusive of cultural and other forms of diversity and that leads to reducing inequities in health care

Adapted from Cross et al.

Culturally competent care is about the creation of an environment in which the best medical practices can be safely accessed and implemented affirming all individuals, alienating none due to various differences, assisting clients to be comfortable with the skin they are in.

1. Inclusivity2. Respect3. Valuing differences4. Equity5. Commitment

RNAO, 2007

To care for someone I must know who I am

To care for someone I must know who the other is

To care for someone I must be able to bridge the gap between myself and the other

Watson cited by Anderson

Culture Sensitivit

y

Culture Resourc

es

Culture Knowled

ge

Health Equity through Culturally

Congruent Care

AFFECTIVE

BEHAVIOURAL COGNITIVE

AFFECTIVE

BEHAVIOURAL COGNITIVE

Dynamics of difference

Environment

Equity

Understanding of issues re:• Power

• Trust

• Equity

•RESPECT

Understanding of OWN

• Biases/Prejudices

• Values / Beliefs

•CULTURE

Understanding of Professional / Organizational CULTURE

Culture Sensitivity

Culture Resources

Culture knowledge

Culture Sensitivity

Culture Resources

Culture knowledge

GENERIC knowledge

CUTLURE SPECIFIC knowledge

Application of Culture Specific Knowledge •Patterns vs. Stereotypes•Holding Knowledge

Basic knowledge about the impact of culture on health that applies across a wide variety of groups

E.g. Cross cultural communication strategies; difference between individualistic cultures and collectivist cultures; Explanatory models of illness

Impact of migration, settlement, racism, and discrimination

Trust re: health system and care providers Selective disclosure

Identify the languages spoken in the community and determine availability of interpreter for non-English speakers and those with disabilities.

Achieve effective encounters with all patients• Send and receive both verbal and nonverbal messages

accurately and appropriately in each culturally different context.

• Communicate respect and inquire about greeting preferences: “How would you like me to refer to you? Mr.? Mrs.? First Name? Nickname? Title?”

• Maintain a non-judgmental attitude.

Elevated Stakes

Power Differences

Time Pressures

CompetitionFeelings and Emotions

Value Differences

Anticipationof Conflict

Differing Needs

Cultural Differences

Ambiguity

Adapted from Mutha, S. (UCSF), 2002

Identify the conflict and define the problem before escalation

Develop a range of acceptable solutions

Analyze the other party’s likely goals and objectives

Analyze the risks inherent in the conflict situation

Review prevalence of HIV in the community/neighborhood served by your practice.

Obtaining knowledge regarding biologic variations based on ethnicity, age, generation, country of origin, language, worldviews, and cultural specific behavioral patterns.

Black gentleman in his mid 30’s from the Carribean

Worked in the community health sector Acute Renal Failure HIV + Requested the advanced practice nurse to

“not have the West Indian nurses caring for me”

What are the key factors to consider behind this request?

Culture ResourcesInternal / External

Client/ Colleagues

Organizational Systems Policies, ToolsPartnershipsCommitmentResourcesInterpreters

/Brokers

Access to information

Culture Sensitivity

Culture Knowledge

Practice Expectations

Maria  a 42 year old Latina reported for the results of her HIV test a month after being tested. She is not fluent in English so she brought her two teenage sons, Miguel and Javier to help translate for her. The clinic does not have bilingual staff or hired interpreters. The counselor feels uncomfortable about sharing the results of Maria’s HIV test with her two sons but has no other way to communicate the results to Maria. As the counselor begins to inform the sons that their mother has tested positive for HIV, Miguel begins to cry. Javier, translates the results to his mother and accuses her of sexual promiscuity.

• Provided for persons with challenges in English as a Second Language (ESL)

• Readily available• Culturally appropriate oral and written

language service through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators

U.S. Department of Health and Human Services, 2000

Culture care preservation / Validation Respect & Honor what we may not know Look for strengths & not just deficits

Culture care Accommodation / Negotiation Does not need to be either / or Ask – what would it take to….

Culture care Re-patterning / Reframing Learn new ways of caring / healing/ meaning of

behaviors Applies to providers & recipients of care

Expect and acknowledge differences Look for systemic barriers Remember Your culture is personal, professional, reflective

of your organization Avoid judgements... Alter your perspective Apply knowledge of cultural factors – barriers & strengths Learn the art of apology and humility Be open to new ideas, new ways of approaching something Use your power and privilege to empower others EARN trust Create SAFE spaces for SENSITIVE conversations

The HIV epidemic will not be over unless and until we develop the capacity, infrastructure and commitment to deliver cultural congruent care. The time to reduce health disparities and inequities is now .

Robert Kerr

A. Interact with a health care system B. Participate in programs of

prevention and health promotion C. Access financial resources

available to support healthcare (correct response)

D. Implement health seeking behavior and adherence to treatment

E. Access health information and services

A. Expecting and acknowledging differences

Reliance on your professional judgment – (correct response)

Looking for own biases, assumptions of normalcy and universality

Looking for systemic barriers Appreciation of the unique strengths

of others

A. InclusivelyB. RespectC. Valuing changeD. Time– (correct response)E. Commitment

Effects of migration, racism, and discrimination

Concerns relative to disclosure of HIV status

Perceptions of the trustworthiness of healthcare providers

The incidence/ prevalence of HIV/AIDS in the population

All of the above (correct response)

Consensus Building, Information Exchange, and Constructive Critique

Validation, Negotiation and Reframing (correct response)

Fact Checking, Open Communication, and Collaboration

1840 7th Street NW, 2nd FloorWashington, DC 20001202-865-8146 (Office)202-667-1382 (Fax)www. AETCNMC.org