Fathers Network Working with Diverse Families

Working with Diverse Families

"Being culturally aware, sensitive and competent is a challenge which must be met by all professionals and programs wishing to develop or expand their services for families. Without such careful attention to the context of the planned services, a program’s success is unlikely to be achieved. The espoused values, program curriculum, and service delivery must parallel the values of the families being served."

Working with Diverse Families
James May

"In the history of human thinking, the most fruitful developments frequently occur at those points where different lines of thought meet. These lines may have their roots in different cultures, in different times, in different religious traditions. If these are allowed to meet... a new and interesting way of being will emerge. " 1

The United States has often been described as a "melting pot" of nationalities. This implies that cultures and races will be assimilated into a representative set of values with extensive commonalties. While many nationalities and races are indeed acculturated, the assumption we all share similar heritage and values is specious and potentially destructive in its intent as well as outcome. A more accurate metaphor is that America is a complex tapestry, full of variations, colors and backgrounds. Rather than E Pluribus Unum (from many one), the United States is E Pluribus Pluribus (from many many).

Population demographics clearly demonstrate such diversity. Between 1970 and 1980 there was an 11.5% increase in total United States population, while the population of diverse racial and ethnic groups increased by 36%: American Indians, Alaskan Natives, Asians, Pacific Islanders, African Americans, and Hispanics. In 25 U.S. Cities, in numerous U.S. counties, and in one State, minorities comprise more than 50% of the total population. Thus the term, "minorities," is not accurate or appropriate in these areas. 2

Presently, one in four people in the U.S. is a minority. There are 26 million African Americans, and 17% of the total population is Hispanic. It is estimated by the year 2000 Hispanic population will increase by 21%, Asian population will grow 22%, African Americans will rise 12%, while white population will increase just 2%.

By the year 2020 it is estimated the number of U.S. residents who are Hispanic or nonwhite will have more than doubled to 115 million; the white population will not expand at all. By the year 2056 it is estimated whites will be a minority group. 3

With such a precipitous shift in population, it is vital health practitioners develop skills to work with culturally diverse families. Professionals must create and provide quality health care for all families, particularly those with low income or limited access to health services. The Report of the Secretary’s Task Force on Black and Minority Health (1985) indicated that many "individuals encountered barriers to receiving available, accessible, acceptable, culturally appropriate care." 4 This care must be culturally-competent, family-centered, and community-based, fully attuned to a pluralistic clientele.

Health policy must take into account a new set of "Multicultural imperatives." As defined by Lorraine Cole, they include:

-An increasing number of minorities with special health care needs in the coming decades.

-An increasing number of minority children born at risk for disorders.

-Differences in etiologies, manifestations and prevalence of some disorders among minority groups (i.e., 82% of children with HIV are black or Hispanic).

-Increasing difficulty in establishing behavioral and developmental norms within each minority group (difficult to use standardized criteria).

-Use of different belief systems and values among minority groups about health and disorders (Western medicine is germ based and uses technological intervention; non-Western cultures generally do not).

-Different preferences and values among minority groups regarding health care delivery systems (i.e., Western medicine is based on school degrees; non-Western is often lay, spirit based).

-An increasing linguistic heterogeneity (i.e., non-English) among minority groups with special health care needs.

-An increasing potential for cultural conflict within the clinical setting (i.e., confusion, misunderstanding). 5

I would also add the following imperative:

What are your personal biases towards health care?

Such imperatives provide impetus to create programs "derived from the cultures they seek to serve." 6 Culture is defined here as "a set of beliefs, behaviors, and interactional patterns that identify a person with a larger social or ethnic group," a way of living that any society or group of people develops to meet its fundamental needs. 7

Cultural competence is:

a program’s [and person’s] ability to honor and respect those beliefs, interpersonal styles, attitudes and behaviors both of families who are clients and the Multicultural staff who are providing services. 8

Culturally competent systems of care "acknowledge and incorporate - at all levels - the importance of culture, the assessment of cross cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge and the adaptation of services to meet culturally unique needs." The goals of such programs and services are to maintain and improve "the self-esteem, cultural identification, and goal setting ability of each family, with special attention to assisting the family to achieve and maintain self-sufficiency within the context of the larger family. 9

For the practitioner, developing insight into cultural competence always begins with personal awareness. Professionals will gain understanding by assessing their own personal cultural heritage and messages received through their families of origin and personal experiences. Hutchinson (1986) has suggested the following questions as hallmarks for understanding:

-What ethnic group, socioeconomic class, religion, age group, and community do you belong to?

-What experiences have you had with people from ethnic groups, socioeconomic classes, religions, age groups, or communities different from yours?

-What were those experiences like? How did you feel about them?

-When you were growing up, what did your parents and significant others say about people who were different from your family?

-What about your ethnic group, socioeconomic class, religion, age, or community do you find embarrassing or wish you could change? Why?

-What sociocultural factors in your background might contribute to being rejected by members of other cultures?

-What personal qualities do you have that will help you establish interpersonal relationships with persons from other cultural groups? What personal qualities may be detrimental? 10

A professional cannot look at an individual or family and know to what extent they subscribe to dominant belief systems or how much they comply with the tenets of traditional culture. Cultures themselves are continually changing as they adapt to new realities. Therefore, the best way for a professional to be competent and sensitive is to be honest about one’s own lack of knowledge of the backgrounds, beliefs, and values represented by the clients. This approach offers immediate value and empowerment to the clients; it declares, "I acknowledge you as an individual, as a family, different from myself, and I value you enough that I want you to teach me about who you are." This ability to step into another’s world and to be self-aware -- as well as self-correcting -- is central to understanding the values and beliefs of clients and families different from ourselves.

Cultures bring a heterogeneity of values, many very distinct from mainstream Anglo-Americans. Schilling and Brannon developed a comparison of common values from dominant and non-dominant perspectives: 11

Anglo-American Other Ethnocultural Groups
Mastery over Nature Harmony with nature
Personal control over the environment Fate
Doing/Activity Being
Time Dominates Personal Interaction dominates
Human Equality Hierarchy/Rank/Status
Individualism/Privacy Group Welfare
Youth Elders
Self help Birthright inheritance
Competition Cooperation
Future Orientation Past or Present Orientation
Informality Formality
Directness/Openness/Honesty Indirectness/Ritual/"Face"
Practicality/Efficiency Idealism
Materialism Spiritualism/detachment

The above provides a distinct picture of the complex values families present professionals, who in turn must offer appropriate policy, programs and services. Cross (1987) describes a continuum of cultural competence that ranges from cultural destructiveness at the low end, to cultural blindness as a mid point, to advanced cultural competence at the high end. 12

Cultural competence demands a practitioner understand a client’s perception of his/her health status or the status of a family member. Randall-David developed questions designed to assist professionals in such an appraisal:

1) What do you think caused your problem? Why do you think it started when it did?

2) What do you think your sickness does to your body? How does it work?

3) How severe is your sickness? How long do you think it will last?

4) What are the main problems your sickness has caused for you?

5) Do you know anyone else who had this problem? What did they do to treat it?

6) Did you discuss your problem with any of your relatives or friends? What did they say?

7) What kinds of home remedies, medicines, or other treatments have your tried for your sickness? Quantity/Dosage? Frequency? How prepared? Did it help? Are you still using it/them?

8) What type of treatment do you think you should receive from me? What are the most important results you hope to receive from this treatment?

9) Do you think there is any way to prevent this problem in the future?

10) Is there any other information that would be helpful for designing a workable treatment plan? 13

Randall-David further talks about the five "A’s." To be culturally competent and to be fully utilized, services must be available, affordable, accessible, appropriate and acceptable. Treatment needs to be flexible in treatment hours as well as in the providing of transportation. If possible, evening clinics should be offered as well as regular daytime hours. Comprehensive care for chronic diseases can be very expensive. Suggestions to limit such costs include: "seeking state funds; forming coalitions with other groups and organizations to create legislation for insurance coverage; hiring staff or training existing staff to assist patients in obtaining insurance; developing an information clearinghouse of reimbursement possibilities; and directly subsidizing insurance premiums or care." 14 Appropriate health care must be available to all citizens, independent of socioeconomic, racial, geographical or cultural restraints.

Being culturally aware, sensitive and competent is a challenge which must be met by all professionals and programs wishing to develop or expand their services for families. Without such careful attention to the context of the planned services, a program’s success is unlikely to be achieved. The espoused values, program curriculum, and service delivery must parallel the values of the families being served.

References

1 Heisenberg, W. (1974). Across the frontiers. New York: Harper and Row.

2 Cole, L. (1989). Multicultural health care imperatives: Answers to the Surgeon General’s call for action, Office of Minority Concerns, American Speech-Language Hearing Association, Washington, DC.

3 Time, April 9, 1990, p. 28.

4 From Improving state services for culturally diverse populations: Focus on children with special health needs and their families, Maternal and Child Health Bureau, St. Paul, MN: Pathfinder Resources, Inc.

5 Cole, ibid.

6 Adams, E.V. (1990). Policy planning for culturally comprehensive special health services. Rockville, MD: United States Department of Health and Human Services, Maternal and Child Health Bureau, p. 4.

7 Roberts, R., et al. (1990) Developing culturally competent programs for families of children with special needs. Washington, DC: Georgetown Uni- versity Child Development Center, Maternal and Child Health Bureau, p. 1.

8 Roberts, R., et al, Ibid.

9 Cross, T.L. (1988). Cultural competence continuum. Focal Point, 3(1). Portland, OR: Research and Training Center to Improve Services for Seriously Emotionally Handicapped Children and Their Families, Portland State University, p. 5.

10 Hutchinson (1986). From Randall-David, E. (1989), Strategies for working with culturally diverse communities and clients, Association for the Care of Children’s Health, Maternal and Child health Bureau, p. 5.

11 Schilling and Brannon (1986). From Randall-David, E. (1989), Strategies for working with culturally diverse communities and clients, Association for the Care of Children’s Health, Maternal and Child Health Bureau, p. 4.

12 Cross, ibid.

13 Randall-David, E. (1985). "Mama always said": The transmission of health care beliefs among three generations of rural black women. Doctoral Dissertation, University of Florida, Gainesville. p. 1982.

14 Randall-David, E. (1989). Strategies for working with culturally diverse communities and clients, Association for the Care of Children’sHealth, Maternal and Child Health Bureau, p. 28-29.

Resources

Anderson, P. and Fenichel, E., Serving Culturally Diverse Families of Infants and Toddlers with Disabilities, National Center for Clinical Infant Programs, Washington, DC, 1989.

Cross, T., Bazron, B., Dennis, K., and Isaacs, M., Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who are Severely Emotionally Disturbed, CASSP Technical Assistance Center, Georgetown University Development Center, Washington, DC, 1989.

Harwood, A., Ethnicity and Medical Care, Harvard University Press, Cambridge, MA, 1981.

Henderson, G. and Primeaux, M. (Eds.), Transcultural Health Care, Addison-Wesley Publishing Company, Menlo Park, CA, 1981.

Malach, R., Segel, N, and Thomas, T., Overcoming Obstacles and Improving Outcomes: Early Intervention Services for Indian Children with Special Needs, Southwest Communication Resources, Bernallilo, NM, 1989.

Miranda, M. and Kitano, H., (Eds.), Mental Health Research and Practices in Minority Communities: Development of Culturally Sensitive Training Programs, National Institute of Mental Health, Rockville, MD, 1986.

Nelkin, V. and Hubbell, R., Evaluation of Communication-Based Services for Children with Special Health Care Needs, CSR, Inc. and Bear Enterprises, Ltd., Washington, DC, 1989.

Randall-David, E., Strategies for Working with Culturally Diverse Communities and Clients, Comprehensive Hemophilia Program, Bowman Gray School of Medicine. Published by the Association for the Care of Children Health, Bethesda, MD, 1989.

Roberts, R., et al., Developing Culturally Competent Programs for Children with Special Needs, Georgetown University Child Development Center, Washington, DC, 1990. (Monograph)

Roberts, R., et al., Developing Culturally Competent Programs for Children with Special Needs, Georgetown University Child Development Center, Washington, DC, 1990. (Workbook)

Watkins, E.L. and Johnson, A.E. (Eds.), Removing Cultural and Ethnic Barriers to Health Care, National Maternal and Child Health Clearinghouse, Washington, DC, 1985.