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What’s Inside
INTERCULTURAL COMPETENCE AND PATIENT-CENTERED CARE (MANDATORY) 1 [4 CE hours] Culture serves as a lens through which patients and practitioners filter their experiences and perceptions. Patients will bring their unique life stories and concerns to the practitioner, and their cultural values and belief systems will inevitably shape how the problem is defined and their beliefs about what is effective in solving the problem. However, the cultural backgrounds and values of patients are not necessarily scripts that define behavior, and when practitioners view culture as a
strength and not a pathology, practitioners will be able to more effectively join with patients to mobilize change. THIS COURSE FULFILLS THE REQUIREMENT FOR CULTURAL COMPETENCY
SETTING ETHICAL LIMITS: FOR CARING AND COMPETENT PROFESSIONALS (MANDATORY) 23 [6 CE hours] Without proper self-care, boundaries, and awareness (transference), therapists become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve. THIS COURSE FULFILLS THE REQUIREMENT FOR PROFESSIONAL ETHICS 47 [10 CE hours] No substance, legal or illegal, has a more paradoxical mythology than alcohol. It is undeniably one of the most widely and safely used intoxicants in the world; however, it is also potent and dangerous, both from a psychologic and physiologic viewpoint. Alcohol is currently responsible for more deaths and personal destruction than any other known substance of abuse, with the exception of tobacco. All of this is known with scientific certainty. Alcohol is legal, easily obtained, and supported by a multi-billion-dollar worldwide industry. Alcohol consumption reduces social inhibitions and produces pleasure and a sense of well-being. It also can have some rather impressive positive medical effects, such as a reduced risk of cardiovascular disease. This course will include core competencies related to alcohol use and abuse as well as knowledge, assessment, and treatment-based competencies. ALCOHOL AND ALCOHOL USE DISORDERS PSYCHEDELIC MEDICINE AND INTERVENTIONAL PSYCHIATRY 87 [10 CE hours] It is apparent that psychedelic medicine is now in a renaissance period, and this time could not have come too soon. Many people in the United States and around the world suffer from severe psychiatric disorders, including depression, PTSD, substance use disorders, anxiety disorders, OCD, anorexia nervosa, and multiple other psychiatric disorders that are not readily responsive to treatment with pharmacotherapy and psychotherapy. In the aftermath of the COVID-19 pandemic, depressive disorders are more prevalent, and people are urgently and actively seeking effective treatments. Exploration of novel interventional and psychedelic therapies may be a path to recovery for patients who have not improved on traditional approaches.
FINAL EXAM ANSWER SHEET
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SOCIAL WORK CONTINUING EDUCATION
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How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions on how to complete and receive your certificate. Are you a Texas board-approved provider? As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. The Texas State Board of Social Worker Examiners accepts NetCE courses. Are my hours reported to the Texas board? No, the Texas Behavioral Health Executive Council requires licensees to certify at the time of renewal that he/she has complied with the continuing education requirement. The board performs audits at which time proof of continuing education must be provided. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third parties. We are also rated A+ by the National Better Business Bureau.
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Setting Ethical Limits: For Caring and Competent Professionals (Mandatory)
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______________________________________________ Intercultural Competence and Patient-Centered Care SWTX04IC — 4 CE HOURS R elease D ate : 10/01/23 E xpiration D ate : 09/30/26
Intercultural Competence and Patient-Centered Care
Audience This course is designed for all members of the interprofessional
Faculty Disclosure Contributing faculty, Alice Yick Flanagan, PhD, MSW, has dis- closed no relevant financial relationship with any product manu- facturer or service provider mentioned. Division Planners John M. Leonard, MD Mary Franks, MSN, APRN, FNP-C Margaret Donohue, PhD Randall L. Allen, PharmD Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Designations of Credit Social workers completing this intermediate-to-advanced course receive 4 Cultural Competency continuing education credits. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfill- ing their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
healthcare team. Course Objective
The purpose of this course is to provide members of the interpro- fessional healthcare team with the knowledge, skills, and strategies necessary to provide culturally competent and responsive care to all patients. Learning Objectives Upon completion of this course, you should be able to: 1. Define cultural competence, implicit bias, and related terminology. 2. Outline social determinants of health and barriers to providing care. 3. Discuss best practices for providing culturally competent care to various patient populations. 4. Discuss key aspects of creating a welcoming and safe envi- ronment, including avoidance of discriminatory language and behaviors. Faculty Alice Yick Flanagan, PhD, MSW , received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conduct- ing qualitative research studies on death and dying in Chinese American families. Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contribut- ing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychol- ogy doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.
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Disclosure Statement It is the policy of NetCE not to accept commercial support. Fur- thermore, commercial interests are prohibited from distributing or providing access to this activity to learners. HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Complete a mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. • Complete the mandatory Course Evaluation.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
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DISCRIMINATION Discrimination has traditionally been viewed as the outcome of prejudice [7]. It encompasses overt or hidden actions, behav- iors, or practices of members in a dominant group against members of a subordinate group [8]. Discrimination has also been further categorized as lifetime, which consists of major discreet discriminatory events, or everyday, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals [9]. DIVERSITY Diversity “encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics” [10]. Diversity is often incorrectly conceptu- alized into singular dimensions as opposed to multiple and intersecting diversity factors [11]. INTERSECTIONALITY Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole [12]. This term also encompasses the ways that different types and systems of oppression intersect and affect individuals. PREJUDICE Prejudice is a generally negative feeling, attitude, or stereotype against members of a group [13]. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that “prejudice plus power equals racism” [13]. Prejudice stems from the process of ascribing every member of a group with the same attributes [14]. RACISM Racism is the “systematic subordination of members of tar- geted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power” [15]. Racism is perpetuated and reinforced by social values, norms, and institutions. There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups [16]. These implicit attributes affect individuals’ thoughts and behaviors without a conscious awareness. Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities, resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities [17; 18].
INTRODUCTION Culturally competent care has been defined as “care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orienta- tion” [1]. A culturally competent person is someone who is aware of how being different from the norm can be marginaliz- ing and how this marginalization may affect seeking or receiving health care [1]. To be effective cross-culturally with any diverse group, healthcare professionals must have awareness, sensitiv- ity, and knowledge about the culture involved, enhanced by the use of cross-cultural communication skills [2; 3]. Healthcare professionals are accustomed to working to pro- mote the healthy physical and psychosocial development and well-being of individuals within the context of the greater community. For years, these same professionals have been identifying at-risk populations and developing programs or making referrals to resources to promote the health and safety of at-risk groups. But, because of general assumptions, persistent stereotypes, and implicit and explicit biases, culture- related healthcare disparities persist [2]. In the increasingly diverse landscape of the United States, assessing and addressing culture-related barriers to care are a necessary part of health care. This includes seeking to improve one’s cultural compe- tence and identifying blind spots and biases.
DEFINITIONS
CULTURAL COMPETENCE In healthcare, cultural competence is broadly defined as prac- titioners’ knowledge of and ability to apply cultural informa- tion and appreciation of a different group’s cultural and belief systems to their work [4]. It is a dynamic process, meaning that there is no endpoint to the journey to becoming cultur- ally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach. CULTURAL HUMILITY Cultural humility refers to an attitude of humbleness, acknowl- edging one’s limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others’ cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [5]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique [6].
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An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvan- taged or produces inequities [20; 28]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages [28]. When the concept of implicit bias was introduced in the 1990s, it was thought that implicit biases could be directly linked to behavior. Despite the decades of empirical research, many questions, controversies, and debates remain about the dynamics and pathways of implicit biases [21]. Specific conditions or environmental risk factors have been associated with an increased risk for certain implicit biases, including [130; 131]: • Stressful emotional states (e.g., anger, frustration) • Uncertainty • Low-effort cognitive processing • Time pressure • Lack of feedback • Feeling behind with work • Lack of guidance • Long hours • Overcrowding • High-crises environments • Mentally taxing tasks • Juggling competing tasks
BIAS: IMPLICIT AND EXPLICIT In a sociocultural context, biases are generally defined as nega- tive evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [19]. For example, an individual may openly endorse a belief that women are weak and men are strong. This bias is fully conscious and is made explicitly known. The individual’s ideas may then be reflected in his/her work as a manager. FitzGerald and Hurst assert that there are cases in which implicit cognitive processes are involved in biases and con- scious availability, controllability, and mental resources are not [20]. The term “implicit bias” refers to the unconscious atti- tudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/ attitudes can negatively affect their behaviors [21; 22; 23; 24]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [24]. Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessar- ily change in accordance to these outward expressions [25]. Because implicit biases occur on the subconscious or uncon- scious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [26]. According to Georgetown University’s National Center on Cultural Competency, social characteristics that can trigger implicit biases include [27]: • Age • Disability • Education • English language proficiency and fluency • Ethnicity • Health status • Disease/diagnosis (e.g., human immunodeficiency virus [HIV]) • Insurance • Obesity • Race • Socioeconomic status • Sexual orientation, gender identity, or gender expres- sion • Skin tone • Substance use
ROLE OF INTERPROFESSIONAL COLLABORATION AND PRACTICE
The study of implicit bias is appropriately interdisciplinary, representing social psychology, medicine, health psychology, neuroscience, counseling, mental health, gerontology, gen- der/sexuality studies, religious studies, and disability studies [28]. Therefore, implicit bias empirical research and curricula training development lends itself well to interprofessional collaboration and practice (ICP). The main characteristics of ICP allow for implicit and explicit biases to be addressed by the interprofessional team. One of the core features of ICP is sharing—professionals from differ- ent disciplines share their philosophies, values, perspectives, data, and strategies for planning of interventions [29]. ICP also involves the sharing of roles, responsibilities, decision making, and power [30]. Everyone on the team employs their expertise, knowledge, and skills, working collectively on a shared, patient- centered goal or outcome [30; 31].
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Another feature of ICP is interdependency. Instead of working in an autonomous manner, each team member’s contributions are valued and maximized, which ultimately leads to synergy [29]. At the heart of this are two other key features: mutual trust/respect and communication [31]. In order to share responsibilities, the differing roles and expertise are respected. Experts have recommended that a structural or critical theoretical perspective be integrated into core competencies in healthcare education to teach students about implicit bias, racism, and health disparities [32]. This includes [32]: • Values/ethics: The ethical duty for health profes- sionals to partner and collaborate to advocate for the elimination of policies that promote the perpetuation of implicit bias, racism, and health disparities among marginalized populations. • Roles/responsibilities: One of the primary roles and responsibilities of health profes-sionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contrib- ute to health disparities. This analysis should extend to include one’s own position in this structure. • Interprofessional communication: Ongoing discussions of implicit bias, perspective taking, and counter- stereotypical dialogues should be woven into day-to-day practice with colleagues from diverse disciplines. • Teams/teamwork: Health professionals should develop meaningful contacts with marginalized communities in order to better understand whom they are serving. Adopting approaches from the fields of education, gender studies, sociology, psychology, and race/ethnic studies can help build curricula that represent a variety of disciplines [33]. Students can learn about and discuss implicit bias and its impact, not simply from a health outcomes perspective but holistically. Skills in problem-solving, communication, leader- ship, and teamwork should be included [33]. SOCIAL DETERMINANTS OF HEALTH Social determinants of health are the conditions in the environ- ments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. Healthy People 2030 groups social determinants of health into five categories [34]: • Economic stability
These factors have a major impact on people’s health, well- being, and quality of life. Examples of social determinants of health include [34]: • Safe housing, transportation, and neighborhoods • Racism, discrimination, and violence • Education, job opportunities, and income • Access to nutritious foods and physical activity oppor- tunities • Polluted air and water • Language and literacy skills Social determinants of health also contribute to wide health disparities and inequities. For example, people who lack access to grocery stores with healthy foods are less likely to have good nutrition, which raises the risk of heart disease, diabetes, and obesity and lowers life expectancy compared with those who have easier access to healthy foods [34]. Promoting healthy choices will not eliminate these and other health disparities. Instead, public health organizations and their partners must take action to improve the conditions in people’s environments. Healthcare providers play a role by identifying factors affecting the health of their patients, providing resources (when appropriate), and advocating for healthy environments. ECONOMIC STABILITY In the United States, 1 in 10 people live in poverty, and many people are unable afford healthy foods, health care, and hous- ing. People with steady employment are less likely to live in poverty and more likely to be healthy, but many people have trouble finding and keeping a job. People with disabilities, injuries, or chronic conditions (e.g., arthritis) may be especially limited in their ability to work. In addition, many people with steady work still do not earn enough to afford the things they need to stay healthy [34]. Employment programs, career counseling, and high-quality childcare opportunities can help more people find and keep jobs. In addition, policies to help people pay for food, housing, health care, and education can reduce poverty and improve health and well-being [34]. HEALTH CARE ACCESS AND QUALITY Many people in the United States are unable to access the healthcare services they need. About 1 in 10 people in the United States lack health insurance, and people without insurance are less likely to have a primary care provider and be able to afford the healthcare services and medications they need. Strategies to increase insurance coverage rates are critical for making sure more people get important healthcare services, including preventive care and treatment for chronic illnesses [34].
• Education access and quality • Health care access and quality • Social and community context • Neighborhood and built environment
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In some cases, patients are not recommended health care services (e.g., cancer screenings) because they do not have a primary care provider or because they live too far away from healthcare providers who offer them. Interventions to increase access to healthcare professionals and improve communica- tion—in person or remotely—can help more people get the care they need [34]. SOCIAL AND COMMUNITY CONTEXT People’s relationships and interactions with family, friends, co-workers, and community members can have a major impact on their health and well-being. Many people face challenges and dangers they are not able to control, including unsafe neighborhoods, discrimination, or trouble affording the things they need. This can have a negative impact on health and safety throughout life. Positive relationships at home, at work, and in the community can help reduce these negative impacts. But some people (e.g., children whose parents are in jail, adolescents who are bullied) often do not get support from loved ones or others. Interven- tions to help people access the social and community support they need are critical for improving health and well-being [34]. Healthy People 2030 objectives in this category focus on increasing the proportion of children and adolescents who have an adult they can talk to about serious problems, improv- ing community health literacy, increasing the likelihood that an individual talks to friends or family about their health, and expanding access to online healthcare services [34].
fact, in 2016, Mississippi and Tennessee passed laws allowing health providers to refuse to provide services if doing so would violate their religious beliefs [35]. However, it is important to remember that providers are obligated to act within their profession’s code of ethics and to ensure patients receive the best possible care. BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE The U.S. Department of Health and Human Services has outlined steps important to incorporate in evaluation and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills [36]. The first step is to engage patients. In nonemergent situations, it is important to establish rapport before asking a series of assessment questions or delving deeply into history taking. Providers should use simple gestures as culturally appropri- ate (e.g., handshakes, facial expressions, greetings) to help establish a first impression. The intent is that all patients feel understood and seen following each interaction. Culturally responsive interview behaviors and paperwork should be used at all times [36]. When engaging in any patient teaching, remember that indi- viduals may be new to the specific language or jargon and expectations of the diagnosis and care process. Patients should be encouraged to collaborate in every step of their care. This consists of seeking the patient’s input and interpretation and establishing ways they can seek clarification. Patient feedback can then be used to help identify cultural issues and specific needs. If appropriate, collaboration should extend to include family and community members. Assessment should incorporate culturally relevant themes in order to more fully understand patients and identify their cultural strengths and challenges. Themes include [36]: • Immigration history • Cultural identity and acculturation • Membership in a subculture • Beliefs about health, healing, and help-seeking • Trauma and loss In some cases, it may be appropriate and beneficial to obtain culturally relevant collateral information, with the patient’s permission, from sources other than the patient (e.g., family or community members) to better understand beliefs and practices that shape the patient’s cultural identity and under- standing of the world. Practitioners should work to identify screening and assess- ment tools that have been translated into or adapted for other languages and have been validated for their particular population group(s). An instrument’s cultural applicability to the population being served should be assessed, keeping in
BARRIERS TO PROVIDING CARE
Culturally diverse patients experience a variety of barriers when seeking health and mental health care, including: • Immigration status • Lower socioeconomic status • Language barriers • Cultural differences • Lack of or poor health insurance coverage • Fear of or experiences with provider discrimination • Mistrust of healthcare systems Such obstacles can interfere with or prevent access to treatment and services, compromise appropriate referrals, affect compli- ance with recommendations, and result in poor outcomes. Culturally competent providers build and maintain rich refer- ral resources to meet patients’ assorted needs. Encountering discrimination when seeking health or mental health services is a barrier to optimal care and contributor to poorer outcomes in under-represented groups. Some providers will not treat patients because of moral objections, which can affect all groups, but particularly those who are gender and/or sexual minorities, religious minorities, and/or immigrants. In
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mind that research is limited on the cross-cultural applicabil- ity of specific test items or questions, diagnostic criteria, and concepts in evaluative and diagnostic processes [36]. Typically, culturally responsive care establishes holistic treat- ment goals that include objectives to improve physical health and spiritual strength; utilizes strengths-based strategies that fortify cultural heritage, identity, and resiliency; and recognizes that treatment planning is a dynamic process that evolves along with an understanding of patient history and treatment needs. In addition to these general approaches, specific considerations may be appropriate for specific populations. While discussion of every possible patient subgroup is outside of the scope of this course, some of the most common factors are outlined in the following sections [36]. RACIAL BACKGROUNDS Race and color impact the ways in which individuals interact with their environments and are perceived and treated by others. Race is defined as groups of humans divided on the basis of inherited physical and behavioral differences. As part of the cultural competence process and as a reflection of cultural humility, practitioners should strive to learn as much as possible about the specific racial/ethnic populations they serve [37]. However, considerable diversity exists within any specific culture, race, or ethnicity [37]. Cultural beliefs, tradi- tions, and practices change over time, both through generations and within an individual’s lifetime. It is also possible for the differences between two members of the same racial/ethnic group to be greater than the differences between two people from different racial/ethnic groups. Within-group variations in how persons interact with their environments and specific social contexts are also often present. As with all patients, it is vital to actively listen and critically evaluate patient relationships. All practitioners should seek to educate themselves regarding the experiences of patients who are members of a community that differs from their own. Resources and opportunities to collaborate may be available from community organizations and leaders. Finally, preferred language and immigration/migration sta- tus should be considered. Interpreters should be used when appropriate, with adherence to best practices for the use of interpretation services. Stressing confidentiality and privacy is particularly important for undocumented workers or recent immigrants, who may be fearful of deportation. Black Patients “Black” or “African American” is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifi- cations. The U.S. Census Bureau defines African Americans or Black Americans as persons “having origins in any of the Black racial groups of Africa” [38].
According to the U.S. Census, African Americans number 46.9 million as of 2020 [39]. By 2060, it is projected they will comprise 17.9% of the U.S. population [40]. This group tends to be young; 30% of the African American population in the United States is younger than 18 years of age. In 2019, the median age for this group was 35 years [41]. In terms of educational attainment, 89.4% of African Americans 25 years of age or older had a high school diploma or completed college in 2020 [39]. Texas has the largest African American popula- tion, at 3.9 million [41]. Historical adversity and institutional racism contribute to health disparities in this group. For the Black population, patient assessment and treatment planning should be framed in a context that recognizes the totality of life experiences faced by patients. In many cases, particularly in the provision of mental health care, equality is sought in the provider- patient relationship, with less distance and more disclosing. Practitioners should assess whether their practices connect with core values of Black culture, such as family, kinship, com- munity, and spirituality. Generalized or Eurocentric treatment approaches may not easily align with these components of the Black community [42]. Providers should also consider the impact of racial discrimination on health and mental health among Black patients. Reports indicate that expressions of emotion by Black patients tend to be negatively misunderstood or dismissed; this reflects implicit or explicit biases.
When providing mental health services for African Americans, the American Psychiatric Association recommends exploring how a patient’s present experiences connect to historical trauma for a particular group or community.
(https://www.psychiatry.org/psychiatrists/diversity/ education/stress-and-trauma/african-americans. Last accessed September 26, 2023.) Level of Evidence : Expert Opinion/Consensus Statement Asian Patients As of 2019, 22.9 million Americans identified as Asian [43]. Between 2000 and 2019, Asians experienced the greatest growth compared with any other racial group at 81% [44; 45]. The Chinese group represents the largest Asian subgroup in the United States, and it is projected that this population will grow to 35.7 million between 2015 and 2040 [46; 47]. In 2019, Chinese Americans (excluding Taiwanese Americans) numbered at 5.2 million [43]. They also have the highest edu- cational attainment; 54.6% of Asians 25 years of age or older had a bachelor’s degree or higher in 2019 [43].
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Intercultural Competence and Patient-Centered Care _ _____________________________________________
“Asian” is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent [48]. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others [48]. There are more than 25 Asian/ Pacific Islander groups, each with a different migration his- tory and widely varying sociopolitical environments in their homelands [49]. Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English- speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [49; 50]. In 2019, California had the largest Asian American population, totaling 5.9 million [44]. Recommended best practices when caring for Asian American patients include: • Create an advisory committee using representatives from the community. • Incorporate cultural knowledge and maintain flexible attitudes. • Provide services in the patients’ primary language. • Develop culturally specific questionnaires for intake to capture information that may be missed by standard questionnaires. • Emphasize traditional values and incorporate tradi- tional practices (e.g., acupuncture) into treatment plans, when appropriate and desired. • Explore patient coping mechanisms that draw upon cultural strengths. Latino/a/x or Hispanic Patients In 2020, the Hispanic population in the United States numbered 60.6 million [51]. The majority of the Hispanic population in the United States (63.3%) identify themselves as being of Mexican descent [53]. Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian [54]. In 2020, the Hispanic population comprised 18.7% of the U.S. population [51]. As such, they are the largest ethnic minority group in the United States. By 2060, Hispanics are expected to represent 31% of the U.S. population [55]. They are also a young group, with a median age of 29.8 years [51]. In 2019, the three states with the largest Hispanic population growth were Texas (2 million), California (1.5 million), and Florida (1.4 million); these three states have the largest Hispanic populations overall [52].
When involved in the care of Latinx/Hispanic individuals, practitioners should strive to employ personalismo (warm, genu- ine communication) and recognize the importance of familismo (the centrality of the family). More flexible scheduling strate- gies may be more successful with this group, if possible, and some patients may benefit from culturally specific treatment and ethnic and gender matching with providers. Aspects of Latino culture can be assets in treatment: strength, persever- ance, flexibility, and an ability to survive. Native American Patients The Native American population is extremely diverse. According to the U.S. Census, the terms “Native American,” “American Indian,” or “Alaskan Native” refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America [56]. In the United States, there are 574 federally recognized tribal governments and 324 federally recognized reservations [57]. In 2020, it was reported that there were 7.1 million Native Americans in the United States, which is approximately 2% of the U.S. population [57]. By 2060, this number is projected to increase to 10.1 million, or 2.5% of the total population [57]. In general, this group is young, with a median age of 31 years, compared with the general median age of 37.9 years [58]. As of 2018, the states with the greatest number of residents identify- ing as Native American are Alaska, Oklahoma, New Mexico, South Dakota, and Montana [59]. In 2016, this group had the highest poverty rate (26.2%) of any racial/ethnic group [58]. Listening is an important aspect of rapport building with Native American patients, and practitioners should use active listening and reflective responses. Assessments and histories may include information regarding patients’ stories, experi- ences, dreams, and rituals and their relevance. Interruptions and excessive questioning should be avoided if at all possible. Extended periods of silence may occur, and time should be allowed for patients to adjust and process information. Practi- tioners should avoid asking about family or personal matters unrelated to presenting issues without first asking permission to inquire about these areas. Native American patients often respond best when they are given suggestions and options rather than directions.
The American Psychological Association recommends that clinicians aim to
understand and encourage Indigenous/ ethnocultural sources of healing within professional practice. (https://www.apa.org/about/policy/ guidelines-race-ethnicity.pdf. Last accessed September 26, 2023.) Level of Evidence : Expert Opinion/Consensus Statement
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______________________________________________ Intercultural Competence and Patient-Centered Care
White American Patients In 2021, 76.3% of the U.S. population identified as White alone [60]. The U.S. Census Bureau defines White race as person having origins in any of the original peoples of Europe, the Middle East, or North Africa [38]. While the proportion of population identifying as White only has decreased between 2010 and 2020, the numbers of persons identifying as White and another race/ethnicity increased significantly. The White population in the United States is diverse in its religious, cultural, and social composition. The greatest proportion of this group reports a German ancestry (17%), followed by Irish (13%), English (10%), and Italian (7%) [61]. Providers can assume that most well-accepted treatment approaches and interventions have been tested and evaluated with White American individuals, particularly men. However, approaches may need modification to suit class, ethnic, reli- gious, and other factors. Providers should establish not only the patient’s ethnic back- ground, but also how strongly the person identifies with that background. It is also important to be sensitive to persons multiracial/multiethnic heritage, if present, and how this might affect their family relationships and social experiences. Assumption of White race should be avoided, as White-passing persons of color have their own unique needs. Multiracial Patients Racial labels do not always have clear meaning in other parts of the world; how one’s race is defined can change according to one’s current environment or society. A person viewed as Black in the United States can possibly be viewed as White in Africa. Racial categories also do not easily account for the complexity of multiracial identities. An estimated 3% of United States residents (9 million individuals) indicated in the 2010 Census that they are of more than one race [149]. The percentage of the total United States population who identify as being of mixed race is expected to grow significantly in com- ing years, and some estimate that it will rise as high as one in five individuals by 2050 [36; 150]. Multiracial individuals often report feeling not fully embraced by any racial or ethnic group, and mistaken identity is a com- mon issue. A small study of multiracial patients assessed their healthcare experiences and noted six commonly encountered microaggressions: mistaken identity, mistaken relationships, fixed forms, entitled examiner, pervasive stereotypes, and intersectionality [144]. It is important to avoid assuming race/ culture based only on appearance and to take into account the patient’s self-reported identity.
advice without understanding how health beliefs and cultural practices influence the way that advice is received. Asking about patients’ religions, cultures, and ethnic customs can help clini- cians engage patients so that, together, they can devise treat- ment plans that are consistent with the patients’ values [37]. Respectfully ask patients about their health beliefs and customs and note their responses in their medical records. Address patients’ cultural values specifically in the context of their health care. For example, one may ask [37]: • “Is there anything I should know about your culture, beliefs, or religious practices that would help me take better care of you?” • “Do you have any dietary restrictions that we should consider as we develop a food plan to help you lose weight?” • “Your condition is very serious. Some people like to know everything that is going on with their illness, whereas others may want to know what is most impor- tant but not necessarily all the details. How much do you want to know? Is there anyone else you would like me to talk to about your condition?” • “What do you call your illness and what do you think caused it?” • “Do any traditional healers advise you about your health?” Practitioners should avoid stereotyping based on religious or cultural background. Each person is an individual and may or may not adhere to certain cultural beliefs or practices com- mon in his or her culture. Asking patients about their beliefs and way of life is the best way to be sure you know how their values may impact their care [37]. The following sections provide a glimpse of the beliefs and practices of the major world religions. This overview is meant only to give a very simple, brief summary of the general ideol- ogy of each religion. By no means are all of the rites or beliefs described practiced by all members of each religion; likewise, not all religious rites or beliefs are discussed for each religion. As always, individualized assessment is encouraged. Judaism Judaism emerged in the Southern Levant (an area in the Middle East) in about 2000 B.C.E. [136]. There are approxi- mately 13 million Jewish people in the world—6 million in North America, 4.3 million in Asia, and 2.5 million in Europe [137]. Jewish descent is traced through the maternal line, but the choice to practice Judaism is made by the individual. In Jewish tradition, the Torah is believed to be the word of God and the ultimate authority. There are three tenets of Judaism. The first tenet is monothe- ism; there is one God who created the universe and continues to rule [138]. The second tenet is that the Jews were chosen to receive the law of God (Yahweh) and to serve as role models
RELIGIOUS, CULTURAL, AND ETHNIC BACKGROUNDS
Religion, culture, beliefs, and ethnic customs can influence how patients understand health concepts, how they take care of their health, and how they make decisions related to their health. Without proper training, clinicians may deliver medical
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