Cultural competence in the prevention of sexually transmitted diseases.

Abstract: Generally, programs and interventions that integrate culture into the context of their prevention strategies are thought to be very effective in curtailing disease than those designed for the general population. Subsequently, we reviewed the application of cultural competency in preventing sexually transmitted diseases. Essentials of cultural competence were incorporated into the research studies (n=19). Eighty percent of the studies reported success in achieving desired outcomes. However, no single method of cultural competence was found to produce a successful outcome. Therefore, defining the construct measures of cultural competence may improve our understanding of this concept and its effect on health outcome(s).

**********

There is a considerable amount of current interest in cultural competency among academicians, healthcare providers, public health practitioners, community program planners and policy makers. This interest is stimulated, in part, by the growing racial and ethnic diversity of the United States (U.S.) population. Between, 1995 and 2050 the U.S. population will increase by 50%. Ninety percent of this growth is attributed to the projected increase in ethnic minority groups (The Emerging Minority Marketplace, 1999). As a result, many health professionals are attempting to design culturally competent programs that successfully address the health needs of B\blacks, Latinos/Hispanics, Asian/Pacific Islanders, and Native Americans. Despite widespread agreement on the need for culturally competent interventions, currently there are no guidelines that describe how health professionals can effectively and consistently apply cultural competence to prevention efforts to improve health outcomes. The lack of consensus to define cultural competence, and consequently, the difficulties associated with assessing and measuring this concept has stymied progress in this area.

Nevertheless, health promotion strategies and interventions that infuse elements and techniques of cultural competence can potentially accelerate the reduction of well-known health disparities among racial and ethnic Americans (Brach & Fraser, 2000). The Office of Minority Health, for example, has made recommendations for national standards on culturally and linguistically appropriate services in health care (Houkje, 2001). These standards were organized into three themes: (1) culturally competent care, (2) language access services, and (3) organizational supports. The recommendations were put in place to ensure the availability of respectful care that takes into consideration the cultural beliefs, practices, and the preferred language of the individual.

Building on the concept of respect and the provision of culturally compatible services, a literature review on cultural competence and the prevention of sexually transmitted disease (STD) was conducted to assess: (a) the incorporation of cultural competence in prevention strategies, and (b) the potential impact of cultural competence on the outcomes of STD prevention programs among racial and ethnic groups. The research findings were summarized to make the information easily accessible to planners and evaluators of STD prevention programs. General recommendations were also provided for the use of cultural competence in prevention strategies, based on the review of the STD literature. In addition, broader implications were included for planning and implementing programs aimed at reducing health disparities and improving the health of racial and ethnic populations.

WHAT IS CULTURAL COMPETENCE?

There are various definitions of cultural competence (Table 1). According to Brach and Fraser (2000), cultural competence extends beyond cultural awareness or sensitivity to include possession of cultural knowledge and respect for different cultural perspectives including the effective use of knowledge and skills in cross-cultural situations. Cultural competence reflects the ability to acquire and use knowledge of health-related beliefs, attitudes, practices, and communication patterns of individuals and their families to improve services, strengthen programs, increase community participation and close gaps in health status among diverse population groups.

Several implicit domains are helpful in understanding the broader concept of cultural competence. They include multiculturalism, cultural sensitivity, cultural assessment, and diversity awareness (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Mental health professionals in the 1960s and 1970s were among the first to conceptualize "multicultural" care. Multiculturalism is defined as incorporating and appreciating perspectives of varied racial and ethnic groups without assumptions of superiority or inferiority (Resnicow et al.). In the 1980s, "multiculturalism" evolved into "cultural sensitivity" in response to the changing cultural diversity of the population. Cultural sensitivity is defined as "the extent to which ethnic/cultural characteristics, experiences, norms, values, behavioral patterns and beliefs of a target population, as well as relevant historical, environmental, and social forces are incorporated in the design, delivery, and evaluation of particular health promotion materials and programs." (Resnicow et al.).

There was a shift from population health to a focus on the individual in the 1980s. At that time the goals of treatment and prevention became more personalized and addressed the specific concerns of the individual with respect to culture, race or ethnicity, and experiences and provided one with the necessary tools to make informed decisions about health care (Table 2). As an overlay to the shifting paradigm, there was a distinct need in the 1990s for an appropriate response to the growing diversity of the population and the persistence of health disparities between people belonging to racial and ethnic groups and those of European ancestry.

To reflect this paradigm shift, Coggins and Yancey (2000) defined cultural competence as a habit of exhibiting the appropriate behavior with respect to the diverse cultural, ethnic, and racial patient population (Table 2). The Coggins and Yancey definition emphasized that cultural competence should become a habitual exhibit of appropriate behavior with respect to individual cultural backgrounds.

In light of this paradigm shift, some arenas within preventive health care were struggling to meet the needs of specific populations. In particular, researchers and practitioners within the field of sexually transmitted disease routinely express the desire to create programs and services that are informed by empirical evidence. These practitioners understand that the incidence and prevalence of sexually transmitted disease is a consistent public health concern. An estimated 19 million new sexually transmitted infections are contracted a year in the United States (Weinstock, 2004). Clearly, the number of sexually transmitted infections is staggering for the population at large but even more so for racial and ethnic minority groups.

One of the most recognized sexually transmitted diseases is the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS). African Americans have been disproportionately affected by HIV/AIDS since the epidemic's beginning, and that disparity has only deepened over time (CDC, 2006). Among black men, AIDS is not only a medical problem, but also represents a social-cultural dilemma characterized by issues that center on and around racism, poverty, and gender ideologies (Bowleg, 2004). Race and ethnicity are not, by themselves, risk factors for HIV infection. However, African Americans are more likely to face challenges associated with risk for infection, including at risk partners, substance use, and denial (CDC, 2003).

Interventions that can reduce HIV risk behaviors typically target demographically similar persons who are especially vulnerable for contracting HIV. Targeting relatively homogeneous groups allows for tailoring activities to address specific needs and risk behaviors that are common among group members (Braithwaite, Hammett & Mayberry, 1996). The demographically similar groups that have been frequently targeted in behavioral change interventions include men who have sex with men, intravenous drug users (IDUs), young heterosexual women, and adolescents (Kalichman, Carey & Johnson 1996). Although researchers and practitioners desire to create programs and services that are informed by culture, these efforts are rarely guided by theory or informed by empirical evidence. It is useful to acknowledge, however, that the extant literature offers little direction in the way of providing effective HIV prevention interventions to racial and ethnic populations.

Also, the personal and invasive nature of a sexually transmitted disease, including HIV/AIDS and the presumptions regarding disease transmission makes it difficult for individuals to talk to about sexual practices with health care providers and health professionals who may not understand the cultural dynamics of disease transmission, individual practices or the linguistics used to describe symptoms and health behaviors. In fact it has been noted in a survey on health care quality that African Americans, Latinos and Asian Americans often "are more likely than whites to experience difficulty communicating with their physician, to feel that they are treated with disrespect when receiving health care, to experience barriers to access to care such as lack of insurance or not having a regular doctor, and to feel they would receive better car if they were of a different race or ethnicity" (Commonwealth Fund, 2002, Introduction, [paragraph] 1). Therefore, cultural competence begins with the healthcare professional understanding and respecting the influence of culture and realizing that culture will affect the client's perceptions, beliefs, attitudes and behavior (Centers for Disease Control and Prevention [CDC], 1995). That is why the cultural competence may be fundamental to reducing the prevalence and incidence of sexually transmitted disease.

METHOD

An advisory committee consisting of three consultants with expertise in cross-cultural education provided guidance for the framework of this review. The intention of the search method was to identify articles describing STD prevention strategies that incorporated elements and techniques of cultural competency. The research team used MEDLINE, OVID, and ERIC databases, searched relevant bibliographies and references for original research articles written between 1980 and 2006. The year 1980 was determined as the starting point for three reasons: (1) a shift in sensitivity toward other cultures, (2) the beginning of the AIDS epidemic, and (3) the changing demographics the U.S. population. The following keywords were used in the literature search: cultural competence (ies), cultural sensitivity, cultural diversity, cross-cultural interventions, transcultural, culturally diverse, multicultural populations and special populations. The following racial and ethnic groups also were specified in the literature search: African Americans or blacks, Hispanics or Latinos, Native Americans, and Asian/Pacific Islanders. Within the literature review, phrases such as African American or black were often interchangeable. However, for the purposes of this review we referred to each population in the way that it was described within the study. Furthermore, these terms were coupled with words and phrases such as STD or sexually transmitted diseases and/or HIV or AIDS/acquired immuno-deficiency syndrome and prevention strategies.

Studies selected for inclusion in the review were those that: (a) reported original findings in peer reviewed journals (b) were conducted in the United States, and (c) specifically reported prevention strategies for sexually transmitted disease among racial and ethnic groups. These studies included quantitative and qualitative findings and a description of the efforts to incorporate elements and techniques of cultural competence in program planning and implementation, including training models. We identified elements or implied constructs of cultural competence, including cultural values, linguistic compatibility, cross-cultural training, racial and ethnic concordant staff, interpreter or translation services, community workers and training. We also applied the nine techniques of cultural competence (Brach & Fraser, 2000) in order to illustrate the way cultural competency may be promoted within prevention programs. The techniques are as follows:

* Interpreter Services--the provision of sign language or translation services to improve communication between people who speak different languages.

* Recruitment and Retention--the practice of hiring and retaining staff members who are from the community.

* Training--the inclusion of training programs that help to educate practitioners and others regarding effective communication methods that increase cultural awareness and produce changes in attitudes about cross-cultural interactions.

* Coordinating with Traditional Healers--coordination of care with traditional healers to avoid incompatible therapies (producing an atmosphere of cultural awareness and sensitivity to the patient's needs).

* Use of Community Health Workers--liaison(s) to the community who provide ways to overcome barriers associated with prevention messages and who are able to serve as mediators and endorsers of the health care system.

* Culturally Competent Health Promotion--a process that encourages healthy behaviors that decrease risk, increases knowledge and changes attitudes by incorporating culturally specific and sensitive messages into health promotion efforts (i.e., screening tools and health literature).

* Including Family and/or Community Members--the inclusion of family members in health care decisions to encourage compliance and treatment decisions.

* Immersion into Another Culture--a decision to become deeply engaged in the practices of a culture other than one's own.

* Administrative and Organizational Accommodations--the change of physical environments and assessment procedures to enhance sensitivity to the unique languages, cultures and environmental constraints of the population (e.g., directions or procedures written in appropriate languages).

The articles were then organized into tables that followed a structured format that included the above elements and techniques of cultural competence as well a description of the study population, study objectives, and an assessment of key outcome variables (e.g., drug use, self -efficacy, risk perception, sexual behavior, attitude toward HIV/AIDS and AIDS related knowledge). Many of these variables were also evaluation measures for some behavioral theories.

RESULTS

The literature search identified 18 studies specifically addressing cultural competence and the prevention of sexually transmitted diseases. The majority of the studies were published in the mid-to-late 1990s. Ethnic distribution of the populations studied included African Americans-only (n=8), Asian/Pacific Islanders (n=3), Latinos/Hispanics-only (n=2), and multiple race groups (n=5; i.e., African American, Latino/Hispanic and European American; Table 3). Fourteen studies reported quantitative findings, two studies collected qualitative data, and two studies described the incorporation of cultural competence in training models for HIV prevention. HIV/AIDS was the primary focus in all but two studies. Thirteen of the 18 studies were based in community settings and five were located in local heath care clinics.

ELEMENTS OF CULTURAL COMPETENCE

Each study integrated one or more elements of cultural competence, which included employing lay health workers or community health workers, translated materials or interpreters, culturally relevant videotapes, and racial and ethnic concordance to identify with study participants.

The most commonly used element of cultural competence was racial and ethnic concordance. Fourteen studies matched the race or ethnicity of the presenter, videotaped subjects or project staff to the race and/or ethnicity of the target audience (Delamater, Wagstaff & Havens, 2000; Dushay, Singer, Weeks, Rohena, & Gruber, 2001; Flaskerud & Nyamathi, 1988; Herek et al., 1998; Kalichman, Kelly, Hunter, Murphy & Tyler, 1993; Loue, Lloyd & Loh, 1996; McQuiston & Flaskerud, 2000; Nyamathi, Leake, Flaskerud, Lewis & Bennett, 1993; Nyamathi, Flaskerud, Bennett Leake & Lewis, 1994; Nyamathi & Stein, 1997; Nyamathi et al., 1999; Shain et al., 1999; Stevenson, Gay, & Josar, 1995; Weeks, Schensul, Singer & Grier, 1995).

Six studies identified cultural values as a means to engage participants in the intervention (Dushay et al., 2001; Kalichman et al., 1993; Nyamathi et al., 1994; Nyamathi et al., 1999; Weeks et al., 1995; Foster et al., 1993). Cultural values delineate characteristics that are important to a particular culture (e.g., emphasizing ethnic pride or respect within the design and implementation of the prevention program).

An important element described in the literature reviewed was cross-culturally trained staff (n=4). Cross-culturally trained staff members were those qualified to effectively communicate and relate to people of diverse ethnic backgrounds. In a number of studies, staff underwent training to understand cultural differences in order to reduce communication gaps between cultures (Nyamathi & Stein, 1997; Weeks et al., 1995; Harris, Kavanagh, Hetherington, & Scott, 1992; Jemmott, Maula & Bush, 1999).

Six studies used culturally competent videotapes in their interventions. In most instances, the videotapes were filmed in familiar settings, and matched the ethnicity and language of the audience (Delamater et al., 2000; Herek et al, 1998; Kalichman et al., 1993; Nyamathi et al., 1993; Stevenson et al., 1995; O'Donnell et al., 1995).

Two studies used linguistic compatibility as an element of cultural competence (Weeks et al., 1995; Stevenson et al., 1995). Linguistic compatibility refers to the use of idioms or familiar language (e.g., slang) in the planning or implementation of the intervention.

Other elements of cultural competence noted in the literature were interpreter or translation services and the use of community health workers. Eight studies employed interpreters or translators (Dushay et al., 2001; Flaskerud & Nyamathi, 1988; Loue et al., 1996; McQuiston & Flaskerud, 2000; Nyamathi et al., 1993; Nyamathi et al., 1994; Jemmott et al., 1999; O'Donnell et al., 1995). In these studies, speakers or staff members of the same ethnicity provided translation or interpreter services to Asian/ Pacific Islanders and Latino/Hispanic populations in their native language or dialect.

Four studies used community workers throughout the implementation of the project. Community workers were typically lay health workers who were from the community or liaisons to the community (Nyamathi et al., 1993; Nyamathi et al., 1994; Nyamathi & Stein, 1997; Nyamathi et al., 1999). The community workers distributed information, gathered valuable input on how to structure information for the community and mobilized the community to action. The lay health staff helped to facilitate the intervention through recruitment efforts or to helped participants understand the nature of the study.

TECHNIQUES OF CULTURAL COMPETENCE

Four techniques of cultural competence were identified using Brach and Fraser's (2000) model. Those techniques were: (1) culturally competent health promotion, (2) cultural competence training, (3) interpreter services, and (4) employment of community workers. There was some overlap between the elements of cultural competence and the culturally competent techniques. Techniques were used to classify and distinguish pathways of cultural competence, whereas elements represented discrete intervention components or actions.

The most frequently adopted technique was culturally competent health promotion (n=16) which included, but was not limited to, using culturally relevant videotapes or racial and ethnic concordant staff to educate the public or encourage certain practices, such as increased condom use (Delamater et al., 2000; Dushay et al., 2001; Flaskerud & Nyamathi, 1988; Herek et al., 1998; Kalichman et al., 1993; Loue et al., 1996; McQuiston & Flaskerud, 2000; Nyamathi et al., 1993; Nyamathi et al., 1994; Nyamathi & Stein, 1997; Nyamathi et al., 1999; Shain et al., 1999; Stevenson et al., 1995; Weeks et al., 1995; Jemmott et al., 1999; O'Donnell et al., 1995).

The second most common technique was interpreter and translation services (n=8), which were necessary to ensure that there was a two-way communication process. This technique lowered the incidence of misunderstandings and maximized prevention efforts (Dushay et al., 2001; Flaskerud & Nyamathi, 1988; Loue et al., 1996; McQuiston & Flaskerud, 2000; Nyamathi et al., 1993; Nyamathi et al., 1994; Jemmott et al., 1999; O'Donnell et al., 1995).

The third most commonly used technique was employing community workers (n=4), who were often the liaisons between health care agencies and the community they served. Some community workers served as advocates for the community (Nyamathi et al., 1993; Nyamathi et al., 1994; Nyamathi & Stein, 1997; Nyamathi et al., 1999). In this review, community workers were primarily employed in the recruitment and implementation of the intervention or program.

The fourth technique identified in the literature was cultural competence training (n=2). Training activities included practices that increased cultural knowledge and understanding, developed skills in bicultural and bilingual interviewing, taught methods to increase sensitivity and awareness, and provided multicultural health and demographic information to service area populations (Foster et al., 1993; Harris et al., 1992). Two models attempted to develop cultural competence training. The focus of the first model was to train African American women in a drug treatment program to be peer leaders. The second model incorporated Afrocentric principles of Nguzo Saba and NTU (a central African concept translated as "essence of life") into the AIDS education training. Nguzo Saba embodies the seven principles of Kwanzaa (unity, self-determination, collective work and responsibility, cooperative economics, purpose, creativity, and faith). These precepts were paired with the principles of NTU (harmony, interconnectedness, authenticity, and balance) to design and implement a culturally appropriate AIDS education program for black psychologists (Foster et al., 1993).

This review also examined the primary outcomes of interventions that incorporated cultural competence in the design and implementation. Key outcomes were the reduction in drug use, increase in AIDS knowledge and positive attitude, reduction in sexual risk, increase in self-efficacy (primary reliance on self to effect changes in behavior), and increase in perception of risk.

Eight of the 16 interventions focused solely on African American populations (Delamater et al.,2000; Herek et al., 1998; Kalichman et al., 1993; Nyamathi & Stein, 1997; Nyamathi et al., 1999; Stevenson et al., 1995; Foster et al., 1993; Harris et al., 1992). The major findings from three of these eight interventions were that African Americans responded more favorably to an ethnically matched presenter and culturally-specific message, as opposed to a presenter that was not matched to the audience's ethnicity. Participants in these studies retained more AIDS-related knowledge, were more sensitive to their personal risk factor for HIV infection or expressed more intent to use condoms with steady partners (Delamater et al., 2000; Herek et al., 1998; Kalichman et al., 1993).

Interventions with Asian/Pacific Islanders noted expected changes in AIDS-related knowledge and attitude toward intended practices such as condom use or reduction in partners. Few prevention programs reviewed devoted attention to the specific needs of Asian/Pacific Islander populations (Flaskerud & Nyamathi, 1988; Loue et al., 1996; Jemmott et al., 1999). Studies targeting racial or ethnic populations that were homeless or intravenous drug users (IDUs) showed improvement in behavioral (IV drug use and multiple partners), cognitive (knowledge score) or psychological (depression, distress, and coping scores) outcomes, as compared with baseline assessments. Nyamathi et al. (1994) recruited homeless and Latina IDUs for a culturally sensitive intervention. The women were randomized into either a two-hour gender and culturally sensitive program or a traditional program that included a basic AIDS education program and community resources. Participants in this intervention did not experience significant differences in expected behavioral, psychological, or cognitive outcome variables. Women in the specialized group and the traditional group showed a decrease in distress, depression and high-risk behavior, such as multiple sex partners and IV drug use. Both groups also increased their knowledge of AIDS, as well as the optimism in their attitude towards AIDS. In addition, Weeks et al.(1995) reported that out-of-treatment African American and Puerto Ricans in a culturally targeted intervention found the culturally enhanced program to be more "attractive" as indicated by retention rates for the program. However, in second phase of the program, 5-10 months after the intervention, African American and Puerto Rican drug users out-of-treatment did not experience significant outcome differences between the enhanced condition and the standard condition at follow up.

DISCUSSION

Many factors influence sexual behavior. Some of these influences are psychosocial, gender based, or cultural. For some time, researchers have underscored the need for culturally appropriate STD prevention programs because of the influence of culture on sexual customs and practices (Wingood & DiClemente, 1992). Culture has a bearing on how we interact and relate to one another within the dynamics of a sexual relationship. That is why an understanding of the importance of cultural competence is important to successful prevention techniques.

Cultural competence is a broader and more complex concept than is referenced in the current literature on STD prevention. This literature review examined how the concept of cultural competence was operationalized as a part of STD prevention. Not surprisingly, the incorporation of cultural competency varied significantly throughout the literature. The studies that were reviewed all included some element or practice utilizing cultural competence in their prevention strategy. However, the explicit constructs of cultural competence were rarely defined or explained. Readers of the current literature would need to infer meaning and interpret aspects of cultural competence from the context in which related elements and techniques were used. These inferences were usually drawn from the design of the intervention. There are two basic approaches for integrating culture into an intervention; design the intervention to appeal to a specified cultural group, and to design the intervention so that it is embedded with cultural concepts (Wilson & Miller, 2003).

However, without distinct measurements for culture it is unlikely that any single element or technique of cultural competence would improve the outcomes of STD prevention among racial and ethnic populations. Key cultural components of an intervention will vary depending on the defined population, resources, and social context. The few studies which compared purported culturally competent interventions with standard interventions have shown relative improvement in outcomes such as risk perception, decreased high-risk sexual behavior, increased self-efficacy, and an increase in knowledge or an attitude change toward sexually transmitted diseases and/or HIV(Delamater et al., 2000; Flaskerud et al., 1998; Herek et al.,1998; Harris et al.,1992; Kalichman et al., 1993; Nyamathi et al., 1993; Nyamathi et al., 1999; Nyamathi & Stein, 1997; O'Donnell et al., 1995).

Besides the variance in the number and type of elements of cultural competence incorporated into the interventions, studies still showed that individuals were more responsive to positive behavior change in prevention strategies presented by racial and ethnic concordant staff. Prevention strategies were also more readily accepted if they were presented in the native language of the population or incorporated cultural values into the intervention. In this regard, culturally relevant approaches are promising, but the broader concept of cultural competence still warrants considerable attention in the evaluation of program effectiveness, reliable measurements, and replication of potentially promising prevention strategies (Wilson & Miller, 2003).

Cultural competence in STD prevention and other prevention strategies are a prerequisite for engaging participants in effective communication. Effective communication builds trust and conveys respect and understanding between individuals, as well as in group interactions. The expectation of a culturally competent intervention is that there will be an exchange between program planners and participants, including input and recommendations as to how best to affect mutually desirable behavioral changes. It is indeed the identifiable, describable, and measurable exchanges that pose the greatest challenge in achieving cultural competence in the every day practice of health promotion and disease prevention.

Therefore, we propose the following recommendations for the design and implementation of culturally competent interventions for the prevention of sexually transmitted disease. Primarily, the health care arena should continue to provide contextual meaning and operational definitions of the concept "cultural competence" in order to build consensus of the meaning and application. Secondly, cultural competence will not be attained without an ongoing assessment on how to better meet the cultural needs of the population and focus on specific cultural approaches that may work best for the participant group and the culture's view about the genesis of the disease. In addition, program planners should include culturally and linguistically appropriate survey methods and process outcome measures that reflect the needs of multicultural populations when preparing needs assessments and creating interventions for STD reduction. Within clinical settings, providers may choose to incorporate group approaches to health promotion and provision of services to better understand the differences in the ways each cultural group views health and disease. Providers may also choose to assess cultural and religious values and beliefs that influence the participant's perception of disease and care processes.

In some instances, program planners could seek the involvement of a culturally diverse advisory group to assist program planners in meeting the needs of the participants. Advisory groups may help plannersaddress issues of historic, contemporary, personal, and societal prejudices that are directed toward each ethnic, racial, and gender group. These are some suggested recommendations on how to create and sustain a culturally competent prevention program.

Although the evidence base has yet to be fully developed, experts sense that cultural competence is one essential part of a portfolio of activities to reduce the incidence of STD and eliminate racial/ethnic disparities in health status. Our study supports the conclusion that elements and techniques of cultural competence implemented in a standardized fashion have an impact on the receptiveness of STD prevention.

ACKNOWLEDGEMENTS

Effectiveness Research, Clinical Research Center, Morehouse School of Medicine The literature review was support by a grant from CDC to MHPF (see report) with addition support provided by grants number P01 HS10875 and R24 HS11617 from the Agency for Healthcare Research and Quality to the Program for Healthcare.

REFERENCES

Bowleg, L. (2004). Love, sex, and masculinity in sociocultural context: HIV concerns and condom use among African American men in heterosexual relationships. Men & Masculinities. 7, 166-186.

Betancourt, J. R., Green, A. R., Carrillo, J. E. & Ananeh-Firempong, O., II. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293-302.

Brach, C. & Fraser, I. (2000). Can cultural competency reduce racial and health disparities? A review and conceptual model [Supplement]. Medical Care Research and Review, 57, 181-217.

Braithwaite, R., Hammett, T., & Mayberry, R. (1996). Prisons and AIDS: A public health challenge. San Francisco: Jossey-Bass.

Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38, 203-207.

Centers for Disease Control and Prevention. (1995). Glossary of terms used in HIV/AIDS health education and risk reduction activities. Retrieved November 16, 2005, from http://www.cdc.gov/hiv/HERRG/glossary.htm

Centers for Disease and Prevention. (2003). HIV/AIDS Fact Sheet: HIV/AIDS among African Americans. Retrieved November 16, 2005, from http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm

Centers for Disease Control and Prevention. (2004). Chlamydia screening among active young female enrollers of health. Morbidity and Mortality Weekly Report, 53, 983-985.

Centers for Disease Control and Prevention. (2005). Sexually transmitted disease surveillance, 2004. Atlanta, GA: U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention. (2004). Trends in reportable sexually transmitted diseases in the United States, 2004: National surveillance data for chlamydia, gonorrhea, and syphilis. Retrieved November 16, 2005, from http://www.cdc.gov/std/stats/04pdf/trends2004.pdf

Centers for Disease Control and Prevention. (2006). Racial/ethnic disparities in diagnosis of HIV/AIDS--33 States, 2001-2004. Morbidity and Mortality Weekly Report, 55, 121-125. Retrieved June 3, 2006, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5505a1.htm

Coggins, P. C. & Yancey, E. (2000). Focus on cultural competence: A training manual for healthcare professionals. Atlanta, GA: Morehouse School of Medicine, Substance Abuse Prevention Faculty Development Program.

The Commonwealth Fund. (2002). Minority Americans lag behind whites on nearly every measure of health care quality. Retrieved July 6, 2006, from http://www.cmwf.org/newsroom/newsroom_show.htm?doc_id=223608

Cross, T. L., Barzon, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown Child Development Center.

Delamater, J., Wagstaff, D. A., & Havens, K. K. (2000). The impact of a culturally appropriate STD/AIDS education intervention on black male adolescents' sexual and condom use behavior. Health Education & Behavior. 27, 454-470.

Dushay, R. A., Singer, M., Weeks, M. R., Rohena, L., & Gruber, R. (2001). Lowering HIV risk among ethnic minority drug users: Comparing a culturally targeted intervention to a standard intervention. American Journal of Drug and Alcohol Abuse. 27,501-524.

Flaskerud, J. H. & Nyamathi, A. M. (1988). An AIDS education program for vietnamese women. New York State Journal of Medicine, 88, 632-637.

Foster, P. M., Phillips, F., Belgrave, F. Z., Randolph, S. M., & Braithwaite, N. (1993). An Africentric model for AIDS education, prevention, and psychological services within the African American community. Journal of Black Psychology, 19, 123-141.

Harris, R. M., Kavanagh, K. H., Hetherington, S. E. & Scott, D. E. (1992). Strategies for AIDS prevention. Clinical Nursing Research, 1, 9-24.

He, W. & Hobbs, F. (1999, September). The emerging minority marketplace. Retrieved July 6, 2006, from http://permanent.access.gpo.gov/lps70698/mbdacolor.pdf

Herek, G. M., Gillis, J. R., Glunt, E. K., Lewis, J., Welton, D., & Capitanio, J. P. (1998). Culturally sensitive AIDS educational videos for African American audiences: Effects of source, message, receiver, and context. American Journal of Community Psychology, 26, 705-743.

Jemmott, L. S., Maula, E. C., & Bush, E. (1999). Hearing our voices: Assessing HIV prevention needs among Asian and Pacific Islander women. Journal of Transcultural Nursing, 10, 102-111.

Kalichman, S. C., Kelly, J. A., Hunter, T. L., Murphy, D. A., & Tyler, R. (1993). Culturally tailored HIVAIDS risk reduction messages targeted to African-American urban women: Impact on risk sensitization and risk reduction. Journal of Counseling and Clinical Psychology, 61, 291-295.

Loue, S., Lloyd, L., & Loh, L. (1996). HIV prevention in the U.S. Asian Pacific Islander communities: An innovative approach. Journal of Health Care for the Poor and Underserved, 7, 364-375.

McQuiston, C. & Flaskerud, J. H. (2000). Sexual prevention of HIV: A model for Latinos. Journal of the Association of Nurses in AIDS Care, 11, 70-79.

Nyamathi, A. M. & Stein, J. A. (1997). Assessing the impact of HIV risk reduction counseling in impoverished African American women: A structural equations approach. AIDS Education and Prevention, 9, 253-273.

Nyamathi, A. M., et al. (1999). Two-year follow-up of AIDS education programs for impoverished women. Western Journal of Nursing Research, 21, 405-425.

Nyamathi, A. M., Flaskerud, J., Bennett, C., Leake, B., & Lewis C. (1994). Evaluation of two AIDS education programs for impoverished Latina women. AIDS Education and Prevention, 6, 296-309.

Nyamathi, A. M., Leake, B., Flaskerud, J., Lewis, C., & Bennett, C. (1993). Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color. Research in Nursing & Health, 16,11-21.

O'Donnell, L., San Doval, A. Duran, R., & O'Donnell, C. R. (1995). The effectiveness of video-based interventions in promoting condom acquisition among STD clinic patients. Sexually Transmitted Disease 22, 97-103.

Resnicow, K., Baranowski, T., Ahluwalia, J. S., & Braithwaite, R. L. (1999). Cultural sensitivity in public health: Defined and demystified. Ethnicity & Disease, 9,10-21.

Ross, H. (2001, February/March). Office of Minority Health publishes final standards for cultural and linguistic competence. Closing the Gap, (pp.1-3). Retrieved March 10, 2003, from http://www.omhrc.gov/assets/pdf/checked/Final%20Standards%20for% 20Cultural%20and%20Linguistic%20Competence.pdf

Shain, R. N., Piper, J. M., Newton, E. R., Perdue, S. T., Ramos, R., Champion, J. D., et al. (1999). A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. New England Journal of Medicine, 340, 93-100.

Stevenson, H. C., Gay, K. M., & Josar, L. (1995). Culturally sensitive AIDS education and perceived AIDS risk knowledge: Reaching the "Know-It-All" teenager. AIDS Education and Prevention, 7, 134-144.

Health Resources and Services Administrations' Bureau of Primary Health Care. (2001). Cultural competence: A journey. Rockville, MD: Health Resources and Services Administrations' Bureau of Primary Health Care.

Weeks, M. R., Schensul, J. J., Williams, S. S., Singer, M. & Grier, M. (1995). AIDS prevention for African American and Latina women: Building culturally and gender-appropriate intervention. AIDS Education and Prevention, 7, 251-263.

Weinstock, H., Berman, S., & Cates, W. (2004). Sexually transmitted disease among Americans prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health, 36, 6-10.

Wilson, D. M. & Miller, R. (2003). Examining strategies for culturally grounded HIV prevention: A review. AIDS Education and Prevention, 15,184-202.

Wingood, G. M. & DiClemente, R. J. (1992). Cultural, gender, and psychosocial influences on HIV-related behavior of African American female adolescents: Implications for the development of tailored prevention programs. Ethnicity & Disease, 2, 381-388.

Zweifler, J. & Gonzalez, A. M. (1998). Teaching residents to care for culturally diverse populations. Academic Medicine, 73, 1056-1061.

RESPONSIBILITIES AND COMPETENCIES IN HEALTH EDUCATION

Responsibility II--Planning Effective Health Education Programs

Competency A: Recruit community organizations, resource people, and potential participants for support assistance in program planning

Sub-competency 1 (as related to the literature review): Communicate need for the cultural competence in health promotion and health behavior programs

Identify the principles of cultural competence in planning for STD programs

Demonstrate and evaluate how the principles of cultural competence have been incorporated into STD programs

Leslie R. Boone, MPH, is the Administrative Director of Research for Health Equity Research, Center for Health Care Research for the Institute for Health Care Research and Improvement at Baylor Health Care System, Dallas, Texas. Robert M. Mayberry, MPH, PhD, is the Director for Health Equity Research, Center for Health Care Research for the Institute for Health Care Research and Improvement at Baylor Health Care System, Dallas, Texas. Joseph R. Betancourt, MD, MPH, is a Senior Scientist for the Institute for Health Policy and Program Director of Multicultural Education at Harvard Medical School, Boston, Massachusetts. Patrick C. Coggins, PhD, JD, is the Director for the Multicultural Education Institute at Stetson University, Deland, Florida. Elleen M. Yancey, PhD, is the Director for the Prevention Research Center at the Morehouse School of Medicine, Atlanta, Georgia. Please address all correspondence to Leslie R. Boone, MPH, Administrative Director of Research, Center for Health Care Research, Institute for Health Care Research and Improvement, 8080 North Central Expressway, Suite 500, LB 81, Dallas, Texas 75206; PHONE: [phone]; FAX: [phone]; EMAIL: [e-mail].

Table 1. Selected Definitions of Cultural Competence

Cross,Barzon, Dennis & Isaacs,     "... a set of congruent behaviors
1989                               attitudes, and policies that come
                                   together in a system, agency, or
                                   among professionals and enables
                                   that system, agency, or those
                                   professionals to work effectively
                                   in cross-cultural situations."

Zweifler & Gonzalez, 1998          "... capacity of providers to
                                   effectively identify the health
                                   practices and behaviors of diverse
                                   populations and thereby intervene
                                   and educate across cultural and
                                   language barriers."

Campinha-Bacote, 1999              "... an ongoing process of seeking
                                   cultural awareness, cultural
                                   knowledge, cultural skills, and
                                   cultural encounters."

Brach & Fraser, 2000               "... a step beyond cultural
                                   awareness or sensitivity ...
                                   possession and use of cultural
                                   knowledge and respect of different
                                   cultural perspectives in cross-
                                   cultural situations."

Coggins & Yancey, 2000             "... habit of exhibiting the
                                   appropriate behaviors with respect
                                   to the diverse cultural, ethnic,
                                   and racial patient population."

Bureau of Primary Health           "... a set of attitudes, skills,
Care (DHHS), 2001                  behaviors, and policies that
                                   enables organizations and staff to
                                   work effectively in cross-cultural
                                   situations."

Betancourt, Green, Carrillo &      "... the ability of systems to
Ananeh-Firempong, II, 2002         provide care to patients with
                                   diverse values, beliefs, and
                                   behaviors, including tailoring
                                   delivery to meet patients' social,
                                   cultural and linguistic needs."

Table 2. "Paradigm Shift in Treatment and Prevention Efforts"
(Coggins and Yancey, 2000)

             OLD/PAST                  NEW/PRESENT/FUTURE

Expect same patient behavior           Expect client behavior to be
                                       different based on race,
                                       ethnicity, and culture

Expect shared understanding and        Expect difference in cross-
interpretation of patient behavior     cultural meanings and
                                       communication processes
                                       including styles

Treat everyone the same                Focus on divergent/cultural
                                       approaches to the diversity with
                                       clients/individuals

Table 3. Studies on Cultural Competence and Sexually
Transmitted Disease 1988-2006

                     Racial/Ethnic Groups Studied:

Blacks                8                  Asian/Pacific Islanders   3
Latinos/Hispanics     2                  Multiple Groupings        5
                         Study Settings:
Community             13                 Clinic                    5