Thanksgiving is a fitting day to talk about cultural and linguistic competence. Thanksgiving, for many, is perceived as an observance of the celebration of peace and the setting aside of disputes to be thankful, much as the Pilgrims and Native Americans at Plymouth are said to have done in the original harvest festival. At the same time, it is important to remember that perceptions are individualized and that some of our fellow Americans may view it as more of a “national day of mourning” because of the losses that occurred for Native Americans in the establishment of the U.S. as an independent country (Parvini, 2015). The PBS production of The True Story of the First Thanksgiving provides some interesting insights. And while some of the inequities of our American culture may have a long history, we all have the ability to make changes. This blog post will focus on resources that will help behavioral health providers and others to improve outcomes and access to services in mental health and substance misuse, which some populations in our country experience, that prevent them from being healthy to the full extent of their potential.
What is Health Equity and Why is it Important?
Health equity is based on the premise that all people have a right to health. According to the Centers for Disease Control (CDC), “Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.” Health Disparities are “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations” (Center for Disease Control and Prevention). Behavioral Health Disparities refer to differences in outcomes and access to services related to mental health and substance misuse which are experienced by groups based on their social, ethnic, and economic status. (Substance Abuse and Mental Health Services Administration). Achieving health equity is important to fill in the gaps in healthcare and behavioral healthcare that are created by inequalities.
“Inequalities in health status in the U.S. are large, persistent, and increasing. Research documents that poverty, income and wealth inequality, poor quality of life, racism, sex discrimination, and low socioeconomic conditions are the major risk factors for ill health and health inequalities… conditions such as polluted environments, inadequate housing, absence of mass transportation, lack of educational and employment opportunities, and unsafe working conditions are implicated in producing inequitable health outcomes. These systematic, avoidable disadvantages are interconnected, cumulative, intergenerational, and associated with lower capacity for full participation in society….Great social costs arise from these inequities, including threats to economic development, democracy, and the social health of the nation” (National Association of County and City Health Officials Health and Social Justice Committee, 2018).
Creating equity is not the same as creating equality because equality is treating everyone the same, which is not necessarily fair. Equity means treating all people in ways that are supportive of equal outcomes, because barriers to health are reduced or eliminated. This concept is very well described in the Pacific Southwest Prevention Technology Transfer Center (PTTC) Network archived webinar: Cultural Competence and Health Disparities in Substance Misuse Prevention. In the webinar and related materials are many additional ways people can address health disparities, no matter what their role in doing so.
Cultural competence is “having the capacity to function effectively, both individually and as an organization, within the context of the cultural beliefs, behaviors, and needs of a community or population group” (U.S. Department of Health and Human Services, Office of Minority Health). Program effectiveness is increased with cultural and linguistic competence. Culturally and linguistically appropriate services are respectful, responsive to the health beliefs, practices and needs of diverse patients. Tailoring services to an individual’s culture and language preference enables behavioral health professionals to bring about positive health outcomes for diverse populations. The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards) aim to improve health care quality and advance health equity through the establishment of a framework for organizations to serve increasingly diverse communities.
Some additional barriers to addressing the inequities of behavioral health include:
- Bias: explicit, implicit, and collective integrated bias
These barriers can be reduced or eliminated with cultural and linguistic competency training such as Improving Cultural Competency for Behavioral Health Professionals available on the Think Cultural Health website. an interesting and useful tool is the Harvard University Project Implicit Implicit Association Test (IAT). Project Implicit is a “non-profit organization and international collaboration between researchers who are interested in implicit social cognition – thoughts and feelings outside of conscious awareness and control. The goal of the organization is to educate the public about hidden biases and to provide a “virtual laboratory” for collecting data on the Internet.” As described on the Education page of the Project Implicit website, “People don’t always say what’s on their minds. One reason is that they are unwilling. For example, someone might report smoking a pack of cigarettes per day because they are embarrassed to admit that they smoke two. Another reason is that they are unable. A smoker might truly believe that she smokes a pack a day, or might not keep track at all. The difference between being unwilling and unable is the difference between purposely hiding something from someone and unknowingly hiding something from yourself.
The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report. The IAT may be especially interesting if it shows that you have an implicit attitude that you did not know about. For example, you may believe that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science.”
Training For Cultural Competence
CASAT Learning has recently launched a self-paced, online course for those seeking professional development, Cultural Competency for Counselors & Professional Helpers. According to the description “This workshop will invite helpers to explore current best practices related to cultural competency and multicultural counseling. Workshop topics will focus on helping providers promote self-awareness, adhere to ethical standards of care, and enhance relationships and professional work with clients, supervisors, and supervisees.
- To identify terms of multicultural care and levels of cultural competency including cultural knowledge, cultural awareness, and cultural sensitivity.
- To explore conceptual frameworks for multicultural counseling.
- To identify multi-cultural activities/interventions that can be implemented in personal and professional practice (including online services).” The presenter will be Roberta Miranda, M.S., LCADC, CPC, ACS, NCC.”
Visit CASAT Learning for additional training opportunities.
- The PTTC Network has created a comprehensive list of prevention resources on Building Health Equity and Inclusion, as well as a variety of guides, trainings, and webinars on Cultural Competency.
- The USDHHS Office of Minority Health (OMH) launched of a new, free and accredited e-learning program: Improving Cultural Competency for Behavioral Health Professionals. The program, available via OMH’s Think Cultural Health website, is designed to develop behavioral health providers’ knowledge and skills related to culturally and linguistically appropriate services (CLAS).
- OMH developed a framework and toolkit to guide health care organizations’ efforts in evaluating their implementation of the National CLAS Standards. The full report can be accessed below along with the toolkit which distills the elements of the framework and can help guide evaluations across four settings (ambulatory care, behavioral health, hospitals and public health):
- Substance Abuse and Mental Health Services Administration (SAMHSA) provides many resources applicable to achieving cultural competence. A few of these are:
Additional resources are also available on the CASAT OnDemand Resources and Downloads page.
No matter how you choose to spend this Thanksgiving, please have a safe and meaningful day.
Please join the conversation in our comments section:
What is most meaningful about Thanksgiving to you? What helps you to make this day special?
Braveman, P. (2006). Health disparities and health equity: Concepts and measurement. Annual Review of Public Health, 27(1), 167-194. doi:10.1146/annurev.publhealth.27.021405.102103
National Association of County and City Health Officials Health and Social Justice Committee. Creating Health Equity Through Social Justice. National Association of County and City Health Officials. Available at http://archive. naccho.org/documents/healthsocialjusticepaper5.pdf.
Parvini, S. (2015, ). Giving thanks, with mixed feelings; native americans mark the day’s complicated legacy with a meal on skid row. Los Angeles Times
Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429-445. doi:10.2190/986L-LHQ6-2VTE-YRRN