Culturally competent care: a strategic imperative

ABNF Journal, The, Nov-Dec, 2004 by Jessy G. Devieux

AIDS continues to be an acute, deadly illness for most of the world s populations. It is the leading killer in the Caribbean, in many countries in Africa, and within the African American population in the United States. Regions in transition are increasingly vulnerable, such as Eastern Europe and Asia. The AIDS virus not only exposes and exploits the human body's vulnerabilities, it likewise exposes the vulnerabilities of our social institutions. Whether in the United States or the Caribbean, HIV/AIDS has demonstrated the dangers of neglected health disparities, barriers to health care, and epidemics of chronic illness. HIV/AIDS has only exacerbated health disparities and compounded the problems of access to care and entrenched chronic illnesses in vulnerable communities. Most critically, the AIDS epidemic completes a spectrum of risk and burden for minority communities, and in the case of Haiti, entire countries, such that members of these communities and societies visibly see the epidemic every day in the very young and in parental figures, layered over other epidemics ranging from malnutrition to cancer. In a sense, it becomes the case that there is no respite or retirement from the epidemic for significant portions of civic society or the global population. This can only become more crucial as progress is made in addressing the "hot spots" of HIV/ AIDS-related mortality, for then the epidemic becomes a chronic burden, in which living with HIV, with aliveness, must become sustainable and sustained by the very social institutions that are in doubt. Until there is a cure, living with HIV is the way we-all of us-live now.

Castro and Garfinkle (2003) describe a cultural competence continuum that proceeds from cultural destructiveness on the negative axis to cultural sensitivity, cultural competence, and cultural proficiency on the positive. Reducing health disparities depends on the design of our social institutions, ranging from medical care delivery and physician training to macro issues of economics, policy commitment, and the supply of donor assistance. However, there are intermediate steps that can contribute to this goal. Culturally adapted and competent interventions, which provide increased access to services proven to work in other populations, is a strategic response that the scientific community and public health funding agencies can offer within their own mandates that can significantly alter the futures of those most burdened by the epidemic.

Fundamentally, the epidemic's history and the scientific evidence on effective HIV/AIDS prevention demonstrate that in the absence of culturally relevant activities, interventions will either fail or exhibit high rates of decay in any positive outcomes. Health disparities, long associated with poverty and inadequate education, have been the means by which HIV and other diseases have ravaged populations (Page, 2004). Myths about HIV transmission have contributed to the lack of success of some prevention efforts; these myths have arisen due partially to insufficient efforts to involve local populations and already existing organizations in the formative phases of project design.

The papers in this issue illustrate the importance of cultural competence as explained by Castro & Garfinkle (2003), that is, having the ability to work with complex cultural issues and understand cultural nuances in an effort to reduce disparities. We discuss research activities among Haitian American adolescents, and African American and Caribbean men in the U.S., a homeless drug-using population in Saint Lucia and Trinidad, and among HIV individuals in Haiti.

Haitian American adolescents are at increased risk of HIV infection due to cultural prohibitions against discussion of sex with girls and encouragement of boys to engage in early sex (DeSantis, Thomas, & Sinnett, 1999). These risks are further exacerbated by the disproportionate impact of the disease in their communities in conjunction with barriers to access to care and prevention services. Furthermore, they are embedded in a culture in which minority youth populations are disproportionately affected by HIV (CDC, 2002). Many Haitian American youth experience the same vulnerabilities as African American youth (poverty, poor educational opportunities, etc.), but with the additional challenges of acculturation stressors highlighted by problematic communication styles with parents. Malow and colleagues explore how social influences and acculturation shape the risk behavior of Haitian American adolescents and presents preliminary data from the first phase of the project. Culturally specific adaptation of the BART intervention, effective among African American adolescents, represents a strategic approach to countering the disproportionate burden of the disease in this population. This project represents a unique partnership between university-based researchers and a community-based organization, building on an already existing relationship with the Haitian American community.