Week 6 M1L6.

1-3 Cross- Cultural Competence: A Developmental Approach

From Winkelman CASC Ch 5 Supplemental Reading Culture and Health Chapter 3

Overview
Describe bases for developing cultural competence in health care Present anthropological approaches and personal and interpersonal strategies for intercultural adaptation Present cultural frameworks for adapting to effects of culture on health behavior

Introduction: Cultural Competence in Health Care

Basic Issues
Clinical Relations & Effectiveness Communication and Relations Personal Development Cultural Competence

Cross- Cultural Competence

General Orientation: Major Dimensions
Knowledge of the general dynamics of culture, psychology and cross-cultural relations General Skills in intercultural relations Awareness of ones own cultural influences

Specific cultural competencies

Culture specific knowledge of behaviors and beliefs of group(s) Personal and social abilities in relating to particular cultural groups

General cultural competency

knowledge of culture impacts intergroup interactions ability to apply cultural knowledge, cultural resources (translators, interpreters) and intercultural skills to resolve the difficulties presented by cultural differences. Includes: an awareness of the dynamics of cross-cultural interactions-- ethnocentrism, prejudice, cultural shock, projection and attribution the ability to adopt perspectives to facilitate intercultural interactions-- cultural relativism, conflict resolution and cross-cultural negotiation.

Factors in Cultural Competence

Castro (1998) Three-factor model
capacity level
Gross ethnocentrism thru proficiency

specific cultures, subcultures and segments specialty area

E.g, clinical, community, research, teaching

Developmental Approaches
Ethnocentrism/Denial
Develop cultural awareness of others

Defense
Learn value of cross-cultural relations

Minimization/Universalism
Limits of biological explanations

Acceptance
Acquiring another cultures perspectives

Adaptation
Developing cultural competency

Integration
Shifting cultural perspectives

General Levels of Cross-Cultural Competence

Awareness Sensitivity (Acceptance) Responsiveness (Adaptation) Competence (Everyday life) Proficiency (Teach Others) Organizational Cultural Competence

M1 L6.2 Tools for Cross-cultural Adaptation

Anthropological Perspectives on Cultural Adaptation Personal Skills &Attitudes for Cross-cultural Adaptations Interpersonal Skills for Intercultural Relations Adapting to General Dynamics of Intercultural Attribution Interview as Relationship Building and Negotiation*

Anthropological Perspectives
Culture and Emic Perspectives Cultural Relativism Cross-cultural or Etic Perspectives. Intracultural Variation: Cultural Characterizations versus Stereotypes Racial Concepts vs. Ethnicity and Culture Social versus Cultural Effects

Personal Skills & Attitudes

Cognitive-Behavioral Approach Emotional Maintenance:
Culture Shock Adaptation

Personal Change and Transformation Cultural Self-Awareness Cognitive Re-organization:

Cultural Attribution

Interpersonal Skills for Intercultural Relations

Achieving communication competence Adjusting to the other culture's behavioral expectations Developing and maintaining interpersonal relationships. Interpersonal skills for expressing empathy and cultural understanding Language Skills
use of Translators and Interpreters

Social Interaction Rules & Communication Styles

Hmong Social Interaction Rules

Deserve services Respect & compassion, esp. for elders Allowing & Respecting their decisions Eye contact and touch Yes as acknowledgement not acquiescence Emotional meanings Passive sick role behaviors Family involvement in care planning Indirect questioning styles and communication

Adapting to General Dynamics of Cross-Cultural Relations

Managing Conflict Managing Cultural Differences Personal Reactions to Cultural Shock Personal Projections: Attributions Prejudice and discrimination Managing Defense Mechanisms

Personal Reactions
Culture Shock
Phases/Stages of Cultural Shock
Honeymoon, Crises, Adjustment & Adaptation

Causes of Cultural Shock

Cultural Differences Stress, Fatigue, Personal and Role Shock

Multiple dimensions of shock Cognitive adaptations

Meaning: Attribution and Interpretation

Reality as Meaning making Attribution

Ethnocentrism as most basic

Types of Causal Social Attributions Personal vs Situational Dynamics of Attribution: Ingroup vs Outgroup Interaction of Causes and Group Dynamics

Im Good, Youre Bad

Cultural Attribution Development: Managing Projections

Ingroup vs Outgroup Dynamics

US vs THEM
Xenophobia

Ethnocentrism
The Naturalness of Ethnocentrism
Culture-centeredness The Real People/Gods People

The Ethnocentric Syndrome

Dual-standards for the other

Classic and Modern Views of Prejudice and Discrimination

Prejudice negative stereotyped attitudes about a group. Discrimination negative and damaging behaviors. Modern View Prejudice and Discrimination as Universals Normative (culturally expected) behaviors

PREJUDICE
Prejudice-- tendency to prejudge normal part of relating to world through our prior expectations Reduce through suspending judgmental approach
Normative Perspectives
People develop prejudices & discriminate as a normal part of cultural learning and values

Social and Psychological Causes

Cultural, social & situational targets

Addressing institutional discrimination

norms, structures and organizations that perpetuate discrimination

M1L6.3 Anthropological Medicine: Applying Culture in Medical Care

Overview Managing Projections Bridging Maladies with Explanatory Model Guidelines for Assessing Culture Influences Negotiation Approaches to Compliance Summary: Enhancing Clinical Relations

Psychodynamic Process in Intercultural Relations

Projection
Attribution to others: prejudice, discrimination, stereotypes Ethnocentric and Stereotypes vs. Cultural/Contextual-- Emic and Situational Perspectives

Managing Transference and Counter-transference

Transferred effects of previous experiences

Defense Mechanisms
reactions to maintain psychological stability in the face of stress

Minority Defense Mechanisms

Self-Hatred Denial Acceptance Obsessive Sensitivity Ego Enhancement Aggression

Majority Defense Mechanisms

Stereotyping Prejudice Denial and Displacement Minimization
Everybodys the same

Historicizing
Not learning about cultural and social influences

Considerations of client culture

Salience of cultural identity & background; Idioms of illness and illness and treatment beliefs; Explanatory models for conditions, symptoms, significance of condition and proposed treatments; Clients level of functioning within the culturalpsychosocial environment; Cultural effects on presentation and clientphysician relationships and communication; and Overall assessment of significance of culture in diagnosis, care preferences and treatment adherence

Guidelines for addressing the potential role of culture in pathology and care
Self-assessment by providers of own cultural biases; Consultation with family members to determine cultural significance (culture-bound syndromes) and psychosocial functioning of client; Ask questions using culturally sensitive and appropriate styles; Determine expectations regarding adherence using explanatory model; Identify and resolve conflicts

Kleinmans (1982) Negotiated Problem/Conflict Resolution

Provider elicits explanatory model and illness problems from patient's perspective Provider presents own explanatory model and proposed treatments in lay terms Patient or provider (may) shift models Discrepancies are acknowledged and clarified Changes are negotiated to a mutually agreeable treatment plan

Negotiation (cont)
Provider offers compromises to conflicts and attempts to implement them Provider as expert advice, patient as final arbiter Providers ongoing monitoring of agreement and participation

OConnors (1995) strategies to support the negotiation of treatment plan

Providers expression of an attitude of openness and willingness to cooperated Giving explanation in everyday language of the providers recommendations explication of the reasons for disagreement with the patients beliefs or preferences Providers acceptance of patients preferred treatments not in conflict with patients interest an ability to engage in shared decision making

Strategies (cont)
an ability to compromise on issues regarding religious beliefs an ability to adopt cultural behaviors communicating trust and respect an understanding of the patients goals in treatment

Summary: Cultural Responsiveness as Enhancing Clinical Relations

Enriching the Provider-Patient Relationship with Patient Perspectives
Reduce conflict and non-compliance Enhanced comfort and well-being for both

Using culture to care for providers

Help with coping with culture Managing communication styles Enhancing emotional support