Cultural Competency PDF

Cultural Competency Abstract: Cultural competency in the healthcare system is a set of behaviors, attitudes, and policies that come together that enable caregivers to work effectively in cross-cultural situations. The word culture is used because it implies the integrated pattern of human behavior...

Cultural Competency Abstract: Cultural competency in the healthcare system is a set of behaviors, attitudes, and policies that come together that enable caregivers to work effectively in cross-cultural situations. The word culture is used because it implies the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, and values. The word competence is used because it implies having the capacity to function effectively. Caregivers need to value diversity, have the capacity to self-assess cultural issues through the use of cultural knowledge, and recognize the dynamics when cultures interact. These are essential elements when caring for clients of different cultures. Cultural competence in healthcare describes the ability of medical systems to provide care to clients with diverse values, beliefs, and behaviors, including specializing delivery to meet the client’s social, cultural, and linguistic needs. Learning Objectives: 1. Describe the meaning of cultural competency and how culture is formed. 2. Identify one’s personal biases. 3. Explain cultural dynamics that enable the caregiver to provide tailored care to their clients. cnaZone.com 1 Introduction Cultural Competency has been a key aspect of psychological thinking and practice for over 50 years. It has become such a fundamental part of the field that it is listed as one of psychology's core competencies. The federal government views it as an important means of helping to eliminate racial, ethnic, and socioeconomic disparities in health and mental health care. Cultural competence is a process that takes an extended length of time to develop and learn. Caregivers and the facilities they work for are at various levels of awareness, knowledge, and skills when it comes to being competent. As we continue to learn more about the actions, customs, beliefs, and values of other cultures we create an environment that produces trusting relationships with clients which leads to better client outcomes. Formation of Culture Culture is formed through the learning processes of enculturation and socialization. Enculturation is a process where individuals learn the dynamics of their surrounding culture and acquire values and norms that are appropriate or necessary to be a part of that specific culture. This shapes the individual to fit in or be accepted by this certain culture. Enculturation is considered successful if it results in the competence of the language, values, and rituals of that specific culture. Enculturation helps form an individual into an acceptable citizen of that society. Everything that an individual does consciously or not impacts culture and can lead to strong ties between others. Even as culture changes core values remain close to the same and those emerging from the culture remain very similar. Enculturation is sometimes referred to as acculturation but enculturation describes the process of learning one's own culture, acculturation denotes the process of learning a different culture than your own. Enculturation can happen in different ways. Direct education suggests those individuals who are closest to you like your parents, teachers, or other individuals teach you certain beliefs, values, or expected standards of conduct. Enculturation is learned through participatory and observational learning. This type of learning is through watching and then doing. cnaZone.com 2 Socialization is the process of learning one’s culture and learning how to appropriately live within it. There are three types of socialization processes listed below. 1. Group socialization a. The theory is that an individual’s peer groups, rather than parental figures, influence his or her personality and behavior rather than parental figures. 2. Gender socialization a. The learning of behavior and attitudes considered appropriate for a given sex. 3. Cultural socialization a. Refers to parenting practices that teach children about their racial history or heritage and, sometimes, is referred to as pride development. Cultural Identity Cultural identity describes an individual’s association or identification with a particular group or groups. Cultural identity develops through the interaction of individuals within a culture over the life cycle. Cultural identities change across stages of the life cycle and do not remain the same. It is common for people to assess their cultural identities and sometimes, reformulate them over time. Cultural identity is not consistent even among individuals who identify with the same culture. Two individuals of the same culture could both identify strongly with their culture, but life experiences could cause certain aspects of that culture to be rejected or pushed away. Cultural groups may also place more importance on various aspects of cultural identities and less on other aspects. Additionally, individuals can hold two or more cultural identities simultaneously. Factors that are likely to vary among members of the same culture include socioeconomic status, geographic location, gender, education level, occupational status, sexuality, and political and religious associations. cnaZone.com 3 Cultural Differences in Communication Language is a key element of culture but just speaking the same language does not mean that people share the same cultural beliefs. English is spoken in many areas of the world such as Australia, Canada, Jamaica, India, Belize, Nigeria, and many other countries. The United States is a great example of many people speaking the same language but having very different diverse cultural identities. Conversely, those who share a certain ethnicity do not automatically share the same language. Families who immigrated to the United States many generations earlier may continue to identify with their culture of origin but are no longer able to speak their native language. English is the most common language in the United States, but 18 percent of the total population report speaking a language other than English when at home. Different styles of communication and nonverbal methods of communication such as gestures or body language are also important aspects of cultural groups. Issues surrounding the communication of certain cultures like the use of direct versus indirect communication, appropriate personal space, and socially acceptable displays of physical contact, such as holding hands could all be barriers if not understood. Additionally, the use of silence, preferred ways of moving, the meaning of gestures, the degree to which arguments and verbal confrontations are displayed, and the amount of eye contact expected are all culturally defined and reflect very basic ethnic and cultural differences. More specifically, the relative importance of nonverbal messages varies greatly from culture to culture; high-context cultural groups place greater importance on nonverbal cues and the context of verbal messages than do low-context cultural groups. Asian Americans come from high-context cultural groups in which sensitive messages are encoded carefully to avoid giving offense. A caregiver who only listens to the literal meaning of words could actually miss the client’s actual message. What is left unsaid, or the way in which something is said can be more important than the words used to convey the message. African Americans have a relatively high-context culture compared with White Americans, but a somewhat lower-context culture compared with Asian Americans. Thus, African Americans typically rely to a greater degree than cnaZone.com 4 White Americans on nonverbal cues in communicating. White American culture is low context, as are some European cultural groups, such as German and British. Within these cultures, communication is expected to be explicit and formal information is conveyed primarily through the literal content of spoken or written messages. High-context vs Low-context Communication: High-context cultures are cultures in which subtlety and collective understanding are the norms. Many Asian and Arabic countries like China, Korea, and Saudi Arabia, fall into this category. In a high-context culture, you might say more through how you make eye contact than you would through verbally expressing your innermost thoughts and feelings. High-context communication requires a great deal of commonality to be effective. High-context communication relies on a high degree of commonality between individuals. Keep these four metrics in mind as you learn more about high-context cultures: 1. Collectivistic: High-context cultures are generally collectivist cultures; they place a higher value on the good of an entire group of people than on any one individual. This sort of collective understanding strengthens the ability to communicate so much about a thought, opinion, or feeling you might have without ever directly stating it. 2. Homogenous: For a culture to be high context, it’s helpful for there to be a great degree of homogeneity among its population. For instance, in Japan, more than ninety-eight percent of the population is Japanese. This leads to a shared language, regional upbringing, and other significant commonalities for the vast majority of the citizens. It becomes easier to rely on subtlety in communication given the high level of shared understanding. 3. Implicit: High-context cultures rely on shared cultural dimensions and more intimate personal relationships to communicate far more subtly than their low-context counterparts. For example, there’s less of a need to be direct when you can assume people will invariably get the gist of cnaZone.com 5 what you’re saying even if you sugarcoat or dance around it for the sake of politeness. 4. Reliant on nonverbal cues: People rely more on nonverbal communication and body language in a high-context culture. Things like eye movement and facial expressions carry far more weight, as they subtly convey the more direct meaning of what one individual wants to get across to another. Low-context cultures are cultures in which directness and individual expression make the most sense. Countries like the United States and Germany operate off a lower level of cultural context, especially as their populations become more diverse demographically. Lower-context cultures can enable a greater degree of cross-cultural communication in certain scenarios, given their emphasis on conveying information more explicitly. Low-context cultures communicate in ways that are direct and to the point. Consider these four characteristics of low-context communication: 1. Diverse: Low-context cultures tend to be more diverse demographically. Take the United States, where the country is a melting pot of cultures. As a result, intercultural communication relies less on subtlety and more on direct communication. 2. Explicit: People from high-context cultures might feel surprised at lowcontext cultures’ directness. Still, representatives from low-context cultures likely do not intend to be caustic or rude in expressing themselves more explicitly. Since low-context cultures rely less on cultural context, it’s only natural they would be more to the point when it comes to problem-solving and decision-making. 3. Individualistic: Low-context cultures often prize individual achievement and expression over collectivism. While interpersonal relationships are still important, there’s a greater level of emphasis on cultivating a unique personality and pursuing a distinct set of desires for each person than there would be in a high-context culture. 4. Reliant on verbal cues: Explicit verbal messages can carry a much higher degree of importance in low-context cultures. In these sorts of societies, cnaZone.com 6 people expect their conversation partners to say exactly what they mean rather than hint at it through nonverbal communication. Direct vs Indirect Communication: Direct communication occurs when the person speaking expresses exactly what the need or desire is. In direct communication the person speaking will state what they want or need and will come directly out and say it. Direct communicators will not analyze what is being said or try to find an underlying meaning. They value direct conversations and respect honesty and being frank when speaking. Indirect communication occurs when the person speaking hides the true intention. Indirect communicators will not make direct statements or directly answer a question. Indirect communicators avoid uncomfortable situations and will answer maybe or possibly to avoid saying no and creating tension. Indirect communicators take pride in being polite rather than being truthful and direct. They prefer to avoid hurting another person’s feelings or selfesteem rather than answering truthfully. Geographical Location Geographical factors can also have a significant effect on a client’s culture. Clients living in rural areas even if they come from different ethnicities can have a great deal in common, whereas individuals from the same ethnical background who were raised in different geographic locations can have very different experiences and attitudes. Geography has also been shown to strongly affect substance use, mental health, or personal well-being, and it can greatly affect access to and use of health services. Also, illicit drug use is less common in very remote geographical locations. Likewise, individuals born or living in urban areas may be at greater risk for serious mental illness. Interestingly, one study demonstrated higher rates of schizophrenia in urban areas, particularly among people who were born in metropolitan areas. Behaviors, Beliefs, and Values cnaZone.com 7 Presentation of medical or emotional symptoms from clients can be very different depending on the culture. Ethnic variations such as somatization which is a physical expression of some form of distress the client is experiencing. Clients of Asian descent are more likely to report somatic symptoms, like pain or discomfort and not the emotional symptoms they are experiencing. This supports that different cultures tend to choose or present symptoms in culturally acceptable ways. Cultures can also relate to an illness with a certain meaning. The meaning of an illness that a certain culture is relating to comes from deepseated beliefs about whether an illness is "real" or just "imagined," or whether it is coming from the mind or the physical body. It is also looked at whether it warrants any sympathy or attention, the stigma surrounding it, what may have caused it, and what type of person might die from it. Cultural meanings of illness can have substantial consequences. The meaning of an illness might determine whether a client seeks treatment, how or if they cope with their symptoms, how supportive their families and communities are, and how well they may respond to treatment if they even agree to it. The consequences can be tumulus when clients with severe mental illness do not seek or receive appropriate treatment. Some Asian American groups utilize avoidance rather than any kind of outward expression. They choose not to dwell on upsetting or disturbing thoughts. They place a higher emphasis on suppression of their reaction or feelings towards the illness and tend to rely on themselves to cope with the distress. African Americans are more likely to take an active approach to face their personal problems, and handle distress on their own. African American culture appears to trust their faith or spirituality to help them cope with adversity. For many African Americans, mental health support is rarely sought out. Seeking therapy is frowned upon within African American culture. They suffer from more serious psychological distress than whites by 20 percent. African Americans are inclined to rely on their faith and go to church rather than seek help. A study from the American Psychological Association found that young adult African Americans, especially those with higher levels of education, are less likely than whites to seek mental health services. cnaZone.com 8 Gender Roles Cultural groups have different understandings of the perceived proper roles, behaviors, and attitudes of men and women. Many things have changed over the years but within modern American society, cultural communities have many variations in how they respond to gender role norms. The Latino culture may simplify these responsibilities and what is expected of men and women. Latino men are expected to be strong, protect their families, and provide for them. Latino women are to care for the family and are expected to be selfsacrificing while being obedient to their husbands. A study based on gathered survey data from 1977 until 2016 suggests that women have advanced in work and education but gender roles in the home have remained primarily unchanged. 25 percent of Americans believe that women should have the same opportunities as men at work but should continue to be responsible for the majority of responsibilities in the household. There continues to be a small portion of the population that believes women should play the role of raising the children and doing household chores. Most Americans born before 1946 are traditional and only 48 percent believe that women should have equal roles in private and public life. Muslim culture has taught men to provide for their wife and in exchange, they will be obedient and serve him. Muslim women in return will keep their virginity and after marriage, loyalty, chastity, and complete dedication to their husbands are prerequisites for being provided for. Women are seen as weak and easily overpowered by men. Men believe they are created to worship God and are warned against attachment to any woman. They are taught that “emotional attachment to a woman divides the heart and Allah has not created man with two hearts within his body.” Gender roles in relationships can be restrictive. Studies have shown that girls are influenced at a young age to believe they need protection, and their education is often placed on hold due to social expectations. The language used every day reinforces traditional gender roles for females. Women are constantly reminded to be calm and to be passive. If women speak up for what they believe is right they are labeled as being aggressive while the same behavior in men is preserved as confidence. cnaZone.com 9 Traditional relationship rules can damage a person’s self-esteem. Many women may try to conform to these rules by suppressing certain traits and emotions. Men may also prioritize work, be away from home the majority of the time, and miss out on having a close relationship with their wife or children. When there are fixed or rigid traditional gender roles, both genders may suffer. Having diverse skill sets in the workforce by having women and men in non-traditional work roles creates new possibilities and ideas. s Socioeconomic Status & Education Socioeconomic Status (SES) in the United States is related to several factors, which include occupational prestige and education, but is primarily associated with income level. Education is usually associated with increased income but can vary among diverse racial/ethnic groups. 49 percent of the workforce believe they’ll make more money just by switching jobs. African American workers, however, were more inclined to completely change their type of employment as a result of no career advancement. In 2021, approximately 8 million African Americans left their jobs primarily due to a lack of advancement. 65 percent of African Americans call themselves ambitious compared to only 53 percent of white professionals, but they still face large promotional gaps in comparison to white professionals. A study completed by McKinsey stated African Americans left their initial careers related to advancement barriers. Low (SES) and the lack of opportunity create desperation. This environment can lead to increased exposure to illicit drugs which can also increase the likelihood of drug use. Lower SES and the associated lack of either money or insurance to pay for treatment are associated with less access to substance abuse treatment and mental health services. Lower (SES) can have a dramatic link to treatment and recovery because private insurance coverage increases the odds twofold that someone will seek and receive treatment compared with Medicare coverage alone. Heritage and History cnaZone.com 10 A culture’s development is created through the culture’s community members, but it is also molded by the actions of others towards that specific culture. Caregivers should be knowledgeable and focused on the positive aspects of each client’s culture, history, and heritage. By understanding and utilizing this knowledge, caregivers will be able to incorporate it into the way they care for and communicate with their clients. It is important to know and understand that nearly all immigrant groups have experienced some degree of trauma in leaving behind family members, friends, and/or familiar places. Additionally, some immigrants are refugees from war, famine, natural disasters, and/or persecution. The degree of suffering that some clients have endured and lived through can result in triggers and symptoms they may not completely understand. For example, a traumatized client could be having auditory hallucinations, it could be unclear whether these voices are suggestive of a mental health disorder or a traumatic stress reaction. Some clients may have witnessed the violent death of a family member and suffer from “survivor guilt” as well as tormenting memories. Somatic complaints can be common for these clients and the most common reported by refugees are: 1. trouble sleeping 2. loss of appetite 3. stomach pains 4. body pains 5. headaches 6. fatigue-lack of energy 7. memory problems 8. mood swings 9. social withdrawal When caregivers work with clients experiencing these symptoms it is important to be supportive while having the understanding that these could be somatic responses to underlying pain or sadness especially if there is no cnaZone.com 11 medical reason for the symptoms. Cultural competency will enable the caregiver to build rapport leading to a relationship that is based on trust and understanding, ultimately placing the client as the center of care. Sexuality Attitudes surrounding sexuality, sexual identity, or orientation are culturally defined. Each culture determines how specific sexual behavior are accepted. Culture also determines the degree to which same-sex relationships are accepted and the types of sexual behaviors that are taboo or admissible. There can be a wide range of what is acceptable behavior in any cultural group. Some Latino cultural groups view homosexual behavior, especially among men as a curable illness and an immoral behavior. Self-identifying as other than heterosexual in the Latino culture could arouse an extremely negative response possibly even more so than actually engaging in homosexual behavior. When individuals from various ethnic/racial groups in the United States identify as different from the normal sexual identity, increased stress from external factors as well as the individual’s belief system could result in the use or increased use of illicit drugs. Sexuality becomes more complicated when looking at lesbian, bisexual, gay, and transgender clients. Disciplines, such as social psychology, philosophy, and behavioral economics tend to define social norms and their beliefs about what others expect of them. Behavioral economics states norms are learned and therefore exist primarily inside our thoughts. The table below captures the different approaches to sexuality. These approaches are blending and are inspired by behavioral science. People have the freedom and the right to adopt new norms and behaviors and these choices should be accepted by others. cnaZone.com 12 Religion and Spirituality Religious traditions or spiritual beliefs are often very important details for defining an individual’s cultural background. Culturally competent services place attention on religion and spirituality during the treatment of the individual. Christians, Muslims, Jews, and Buddhists can be members of any racial or ethnic group. Those individuals having the same religion, even if they come from a different ethnicity may have more in common than someone of the same ethnicity and practicing a different religion. Religious affiliation is an especially important factor in defining a person’s culture. The American Religious Identification Survey (ARIS) reported that 47 percent of those that cnaZone.com 13 responded and who identified culturally as Jewish were not practicing Jews. Secondly, according to the ARIS those Americans not identifying with having a religion was only 15 percent, and of those less than 2 percent identified as atheist or agnostic. Identification of Biases Cultural biases are the assumptions others form about other cultures or groups based upon their own cultural beliefs. It is important to understand that cultural bias is different from racism because bias focuses on cultural differences rather than physical characteristics, and stereotyping focuses on beliefs that don’t align with one’s preconceived ideas. Cultural biases are everywhere, and the study of neuroscience has found that many of these biases were formed throughout the individual’s life, primarily through society and parental conditioning. Most of these biases are stored in the brain at a subconscious level. Subconscious means existing in the mind but not immediately available to the consciousness. These subconscious biases affect thoughts, feelings, and behaviors without entering the individual’s awareness. When individuals react to these biases whether physically or cognitively it presents like an automatic reflex. There are two types of biases, explicit and implicit. Explicit biases are within an individual’s conscious awareness and the individual understands they are choosing their thoughts, feelings, and behaviors associated with that bias. Individuals can reflect on and monitor these easily if they choose to do so. Implicit biases are the automatically activated unconscious counterpart of explicit biases. Implicit biases are harder to identify within ourselves, they lie deep in our subconscious, and could have been formed at a very young age. There is increasing evidence that both implicit (unconscious) and explicit (conscious) biases can have detrimental effects. Cultural bias could be explained by placing individuals into groups with the same traits or expected traits to help with information overload, feeling overwhelmed, or due to lack of knowledge that leads to fear. What this creates is a high potential for prejudice and stereotyping. Identifying and understanding personal biases will enable individuals the opportunity to appreciate and respect others’ differences. This is especially important for cnaZone.com 14 caregivers who are caring for others. Caregivers need to be open to the clients they are caring for, not by understanding everything about the client’s culture but by respecting what is important to them as a person. Caregivers need to care for clients with an open mind and not let the lack of cultural knowledge cause fear which breaks down rapport. To help understand your thought processes challenge your own cultural biases by looking at their origin and if it is true. Here is how to address it. 1. Build awareness Notice your thoughts and don’t jump to conclusions 2. Educate Seek out information that goes against your own cultural beliefs 3. Remain open Stay open to curiosity and compassion and learn to respect other’s customs 4. Communicate Attempt to get to know others from different cultures 5. Avoid generalization No matter what the culture, there will be individuals that behave badly and those that are honorable Self-Assessments when working with different cultures Culturally competent caregivers are aware of their own culture, their values, and they acknowledge their own biases and assumptions surrounding other cultures. Culturally competent caregivers strive to understand how these self-created biases and assumptions affect their work and the ability to provide culturally responsive services to clients from similar or diverse cultures. Caregivers should become culturally competent by identifying and exploring their cultural heritage and worldview along with how these views shape their perceptions of and during the care of clients. By understanding themselves cnaZone.com 15 and how their culture can affect the therapeutic process, culturally competent caregivers hold a general understanding of improving cultural competence in the cultures of the specific clients for whom they care. Culturally competent caregivers: 1. Look at issues in culturally relevant ways 2. Allow for the complexity of issues based on cultural context 3. Make allowances for variations in the use of personal space 4. Are respectful of culturally specific meanings of touch 5. Explore culturally based experiences of power and powerlessness 6. Adjust communication styles to the client’s culture 7. Interpret emotional expressions considering the client’s culture 8. Expand roles and practices as needed Caregivers have a responsibility to those clients they care for and having a good understanding of cultural competency will allow them to build a partnership enabling the client to be the center of all decision-making. Selfassessment can help caregivers consider their skills, knowledge, and awareness in their interactions with others, and recognize what they can do to become more effective working and living in diverse environments. Self-assessment begins with awareness, knowledge, and those personal skills each caregiver possesses. Below are ways caregivers can evaluate their own level of competence and identify those areas that could use personal improvement. Awareness 1. Value diversity, view human differences as positive, and a cause for celebration. 2. Know yourself and have a clear sense of your own ethnic, cultural, and racial identity, and how that is viewed by others that are different. cnaZone.com 16 3. Share your own personal culture. Be aware that in order to learn more about others it is important to understand and be prepared to share your own culture. 4. Be aware of areas of discomfort when encountering differences in race, religion, sexual orientation, language, and/or ethnicity. 5. Check assumptions. Are you aware of the assumptions that you hold about people of cultures different from your own? 6. Challenge your own stereotypes. Are you aware of the stereotypes you hold as they arise and have developed personal strategies for reducing the harm they cause? 7. Reflect on how your culture informs your judgment. Are you aware of how your cultural perspectives influence your judgment about what you deem to be appropriate, normal, or superior behaviors, values, and communication styles? 8. Accept ambiguity. Do you accept that in cross-cultural situations there can be uncertainty and that you might feel uncomfortable as a result. Do you accept that discomfort is part of your growth process? 9. Be curious. Do you intentionally make opportunities to put yourself in places where you can learn about differences and establish diverse connections? 10. Be aware of your privilege and be aware of social justice issues. Are you aware of the impact of social context on the lives of culturally diverse populations, and how power, privilege, and social oppression influence their lives? Knowledge 1. Gain from your own mistakes. When making mistakes do you choose to learn from them? 2. Assess the limits of your knowledge. Do you recognize that your knowledge of certain cultural groups is limited. Make an ongoing cnaZone.com 17 commitment to learning more about others through the lens of cultural groups that differ from my own? 3. Ask questions. Do you listen fully to answers and make the time to advance your knowledge from a variety of existing culturally diverse resources before asking additional questions? Do this so that you don’t unduly burden members of marginalized communities with addressing gaps in my cultural knowledge. 4. Acknowledge the importance of difference. Know that differences in race, culture, ethnicity, etc. are important and are valued parts of an individual’s identity. Do not hide behind the claim of “color blindness?” 5. Know the historical and current experiences of those you have labeled as others. Are you knowledgeable about historical incidents and currentday practices that demonstrate racism and exclusion towards those you label as others? 6. Understand the influence culture can have. Do you recognize that cultures change over time and can vary from person to person, as does attachment to culture? 7. Commit to life-long learning. Recognize that achieving cultural competence and cultural humility involves a commitment to learning over a lifetime. Do you consistently demonstrate your commitment to this process? 8. Understand the impact of racism, sexism, homophobia, and other prejudices. Do you recognize that stereotypical attitudes and discriminatory actions can dehumanize, and even encourage violence against individuals because of their membership in groups that are different from your own? 9. Know my family history. Do you know your family’s story of immigration and assimilation? 10. Know my limitations. Do you continue to develop your capacity for assessing areas where there are gaps in your knowledge? cnaZone.com 18 11. Be aware of multiple social identities. Do you recognize that people have intersecting multiple identities drawn from the race, gender identity, sexual orientation, religion, ethnicity, etc., and the potential influence of each of these identities varies from person to person? 12. Acknowledge acknowledge intercultural both and intracultural intercultural and differences. intracultural Do you differences? Intracultural is between members of the same dominant culture, but with slightly different values, as opposed to intercultural which is between two or more distinct cultures. 13. Understand a point of reference to assess appropriate behavior. Are you aware that everyone has a culture, and your own culture is not to be regarded as the singular or best point of reference to assess which behaviors are appropriate or inappropriate? Skills 1. Adapt to different situations. Have you developed ways to interact respectfully and effectively with individuals and groups that may differ from you? 2. Challenge discriminatory and/or racist behavior. Do you effectively and consistently intervene when observing others behaving in a racist and/or discriminatory manner? 3. Communicate across cultures. Do you adapt your communication style to effectively interact with people who communicate in ways that are different from your own? 4. Seek out situations to expand your skills. Do you consistently seek out people who help change you to increase your cross-cultural skills? 5. Become engaged. Are you actively involved in initiatives, small or big, that promote interaction and understanding among members of diverse groups? 6. Act respectfully in cross-cultural situations. Do you consistently act in ways that demonstrate respect for the culture and beliefs of others? cnaZone.com 19 7. Practice cultural protocols. Do you learn about and put into practice the specific cultural protocols and practices that make you more effective in your work with diverse individuals and groups? 8. Act as an ally. Do your colleagues who are African American, Asian, Latinx, and Indigenous consider you an ally and know that you will support them in culturally appropriate ways? 9. Be flexible. Do you work hard to understand the perspectives of others and consult with diverse colleagues and diverse resources about culturally respectful and appropriate courses of action? 10. Be adaptive. Do you know and use a variety of relationship-building skills to create connections with people from whom you differ? 11. Recognize your own cultural biases. Do you recognize your own cultural biases in each situation and are you aware not to act out based on those biases? 12. Be aware of within-group differences. Are you aware of within-group differences and you do not generalize a specific behavior presented by an individual to the entire cultural community? Providing care for individuals of different cultures Culturally competent skills can greatly improve client engagement in services, therapeutic relationships between clients and caregivers, and treatment retention and outcomes. Cultural competence is an essential element in decreasing disparities in physical and emotional health. Cultural competence cannot be obtained by attending training once or by learning a set of facts about a specific population. Cultures are diverse and continuously changing over time. Developing cultural competence will be an ongoing process that begins with cultural awareness and a commitment to understanding the role that culture plays in an individual’s life. Culture has many subgroups and individual variations. This is important because it illustrates that clients as well as caregivers may communicate differently. It can also account for the variations in how clients communicate their symptoms to their caregivers or others. Many times, culture determines whether clients even seek help in the first place, what kind of help they may cnaZone.com 20 seek, what types of coping styles they possess, and the social support they have in place. Social Determinants of Health (SDoH) Social Determinants of Health are defined by the World Health Organization (WHO), “SDoH is the conditions in which people are born, grow, live, work, and age.” These factors are determined by money distribution, and resources at both a national and local level. SDoH can also determine if someone has quality access to healthcare. SDoH is highly controlled and influenced by policies, systems, and environments. When looking at health and its relationship to smoking the decreased use of tobacco products is influenced more by the price of the product and the control of where individuals can smoke than assisting with cessation. When addressing SDoH, better health outcomes results when health care organizations and communities are rewarded for assisting with lower tobacco use through treatment programs, support call lines, and products to assist with cessation. Primary care is beginning to utilize a framework to integrate SDoH assistance. Screening tools have been developed to capture these vulnerable populations and new models are emerging to create follow-up screening with these identified individuals and populations. Some of these areas may include food insecurities within the household or financial insecurities increasing vulnerabilities to these populations. Innovative models at the local and state levels are exploring those connections with health care, social services, and many SDoH. Attention to transportation, housing, and food are being assessed and how these factors play a vital role in health. Having accountable health communities with evaluation plans could provide better health outcomes and lower medical costs. Recently, a peer-reviewed article on investments in social services, or integrated models of healthcare and social services, was reviewed; most studies were done in the United States. More than 70 percent of the studies were in low-income populations, and the interventions with the most positive health outcomes respectively were housing support, nutritional support, cnaZone.com 21 income support, and care coordination and community outreach. Of the 39 studies reviewed, 20 showed improved health outcomes, 5 showed decreased costs, and 7 showed both. Summary Recognizing and respecting the cultural differences of others improves trust and increases connection. When there is trust and connection between caregivers and clients the client becomes the center of care and they are more likely to engage. When caregivers recognize their own biases and have a good understanding of their own culture, they can correct or intercede before making assumptions about the client they are caring for. Cultural competence is a developmental process that evolves over an extended period. Comments such as, “I see it is important to you”, signals respect to the client. Caregivers should communicate with the client that they don’t completely understand their culture, but they do understand how important it is to the client. Caregivers’ knowledge of different cultures is an ongoing learning curve because cultures change or evolve over time. cnaZone.com 22 Resources: CDC. Cultural Competence | National Prevention Information Network. Cdc.gov. Published 2019. https://npin.cdc.gov/pages/cultural-competence Chapter 2 Culture Counts: The Influence of Culture and Society on Mental Health. Nih.gov. Published August 2001. https://www.ncbi.nlm.nih.gov/books/NBK44249/ Center for Substance Abuse Treatment (US. Tools for Assessing Cultural Competence. Nih.gov. Published 2014. https://www.ncbi.nlm.nih.gov/books/NBK248429/ CULTURAL COMPETENCE CHECK-IN: SELF-REFLECTION. Accessed March 1, 2022. https://www.asha.org/siteassets/uploadedfiles/multicultural/selfreflection-checklist.pdf Kopstein A, Karl H D White, D E, Currier C. This Publication Is Part of the Substance Abuse Prevention and Treatment Block Grant Technical Assistance Program.; 2014. https://www.ncbi.nlm.nih.gov/books/NBK248428/pdf/Bookshelf_NBK248428 .pdf WHO (World Health Organization). 2012. What are the social determinants of health? http://www.who. int/social_determinants/sdh_definition/en/ (accessed June 8, 2017). Agency for Healthcare Research and Quality (AHRQ). 2017. About the National Quality Strategy. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq. gov/workingforquality/about/index.html (accessed June 11, 2017). cnaZone.com 23