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  • Presented By
  • Cathy Anderson
  • Brandi Miller
  • Jewish Vocational Service
  • Wichita, Kansas

  • February 22, 2005
  • Wichita, Kansas

Jewish Vocational Service
  • History established in 1949 to resettle
    holocaust survivors and other refugees
  • MISSION to assist any individual with barriers
    to become more self-reliant by providing
    employment, training, personal development, and
    support services.

Jewish Vocational Service
  • Refugee/Immigration/Lang. Cult.Svcs. Dept.
    includes refugee employment services, refugee
    resettlement, immigration counseling
  • Language and Cultural Services Dept. includes
    Interpreter Development Services, Cultural
    Competency training, Occupational Spanish
    classes, Title VI training, Provider training

Setting the Tone
  • Expectations
  • Training Goals
  • Ground Rules
  • Introductions

Trainer Expectations
  • Show respect by listening to each other and not
  • Participate actively in the training.
  • Maintain strict confidentiality by not
    identifying specific individuals or clinics or
    anything else that could identify a client or
    provider and not sharing outside the classroom
    any of the personal stories that are told.
  • Give feedback in appropriate ways by starting
    feedback with a positive comment avoid blaming
    identify individual opinions as such.

Training Goals
  • Increase awareness of diversity
  • Expand definition of cultural competency
  • Improve service quality for diverse populations
  • Work more effectively with interpreters
  • Understand Title VI and Basic Components of
    Office for Civil Rights policy guidance
  • Improve cross-cultural communication and decrease
    potential misunderstandings

Your Goals
  • What do you hope to learn from this training?

  • Your name and what you do in your organization.
  • Who is your community?

Cultural Competency Self-Assessment Checklist
  • Self-Assessment Checklist
  • Tamara D. Goode, Georgetown University Center for
    Child and Human Development

Welcome to a Changing World
  • Demographics
  • Health disparities
  • Culture

Life by the Numbers
  • 3 billion People in the world that live on
    less than 2 per day
  • 3 How many of the worlds top 10 wealthiest
    people it would take to exceed the gross domestic
    product of the worlds 48 poorest nations
  • 1 billion People who entered the 21st century
    unable to read a book or sign their name
  • 86 Percent of the worlds goods consumed by 20
    percent of the population in developed nations
  • 790 million People in the developing world who
    are chronically undernourished
  • Source

If the world were a village of 100 people...
  • 52 female 48 male 33 children 6 over age of 65
  • 58 would be Asian
  • 79 would be persons of color
  • 30 would be Christian
  • 6 would own half of the villages wealth all 6
    would be U.S. citizens
  • 9 would speak English
  • 50 would suffer from malnutrition
  • 80 would live in sub-standard housing
  • 66 would not have access to clean, safe drinking
  • 10 would be lesbian, gay or bisexual
  • 1 would have a college education
  • from Meadows, D., If the World Were a Village

Changing Demographics
  • The U.S. attracts two thirds of the worlds
  • General physicians can expect more than 40 of
    their patients to be from minority cultures.
  • American Medical Student Association

Changing Demographics
  • In the U.S. today, Asian Americans and Pacific
    Islanders are the fastest growing segment of the
  • 15 of U.S. residents over age 5 speak a language
    other than English at home
  • As of 2003, Latinos are the largest minority
    group in the U.S.
  • In 2005, ethnic minorities will account for 47
    of the U.S. population. 85 of those entering
    the workforce will be women, people of color, and
  • 2000 US Census Bureau national data

Demographics - Kansas
  • According to the 2000 Census . . . . .
  • - 5 of Kansans were foreign born
  • - 9 of Kansans speak a language other than
    English at home
  • - 7 of Kansans were Latino, compared with 12.5
    of total U.S. population
  • The Kansas foreign born population is quite
    diverse 55 are Latin American, 28 Asian,
    11.2 European, 2.7 African, and 2.7 North

Changes in rural population
  • The demographics of rural America are changing
    rapidly, as Mexican, Central American, and Asian
    immigrants take jobs in agriculture and related
  • Source Martin, Phillip Taylor, J. Edward Fix,
    Michael, 1996. Immigration and the Changing
    Face of Rural America Focus on the Midwestern

Minority Health Statistics
  • Asian/Pacific Islanders
  • language isolation is a consistent challenge
  • women are 16 less likely than general population
    to receive a Pap smear test
  • Native Americans
  • 72 higher age-adjusted death rate from diabetes
    than general population
  • other problems are obesity, mental health,
    alcohol and substance abuse
  • Source Minority Health Disparities in Kansas,
    Kansas Health Institute, January 2003.

Minority Health Statistics
  • Hispanics/Latinos
  • 83 higher age-adjusted death rate from diabetes
    than general population
  • lack of understanding of preventative health
  • African Americans
  • 34 more likely to die of cancer and twice as
    likely to die from diabetes than Whites
  • infant mortality is twice as high when compared
    to other populations
  • other concerns include obesity, cardiovascular
    disease and HIV/AIDS
  • Source Minority Health Disparities in Kansas,
    Kansas Health Institute, January 2003.

Disparities in Health
  • Racial and ethnic minorities tend to receive
    lower quality health care than whites do, even
    when insurance status, income, age, and severity
    of conditions are comparable.
  • - Source Alan Nelson, M.D. Committee Chair,
    Institute of Medicine 2002 Report on Disparities

Another thought. . . . . .
  • Of all the forms of inequality, injustice in
    health is the most shocking and the most inhuman.
  • - Dr. Rev. Martin Luther King, Jr.

  • Define culture.
  • What does culture mean?

Culture One Description
  • Culture is the set of values, structures and
    practices held in common by a group of people and
    passed on to succeeding generations. These groups
    are usually identified by ancestry, language
    and/or traditions. Culture is also used to
    describe those characteristics that we are born
    with, some of which are permanent and some of
    which can be changed.

  • What are the cultural lenses through which we
    view the world?

Cultural Lenses
  • Personality
  • Gender
  • Race
  • Age
  • Socio-economic
  • Sexual orientation
  • Life experiences
  • Religious affiliation
  • Point in history in which you were born

Active listening
  • Stand in two lines facing each other.
  • Discuss the following topics with the person
    across from you
  • Given names and meaning
  • Where your family immigrated from
  • Languages spoken in family as far back as you
  • What constitutes good and bad parenting

Active Listening
  • What challenges did you experience in this
  • Were you surprised by what you learned from

Impact of Personal Culture on Communication
  • Incorrect assumptions about the other.
  • Language and communication style issues.
  • Biases against the unfamiliar.
  • Personal values in conflict.
  • Expectations that others will conform to
    established norms.
  • Myers, Selma. Conflict and Culture.

Listening In. . . .
  • Actual Comments Made by Foreign Visitors to the
    United States
  • Americans seem to be in a perpetual hurry Just
    watch the way they walk down the street. They
    never allow themselves the leisure to enjoy life
    there are too many things to do.--Visitor from

More comments. . .
  • Once in a rural area in the middle of nowhere,
    we saw an American come to a stop sign. Though he
    could see in both directions for miles and no
    traffic was coming, he still stopped!--Visitor
    from Turkey

More Comments. . .
  • The American seems very explicit he wants a
    yes or no. If someone tries to speak
    figuratively, the American is confused.
    --Visitor from Ethiopia

Another thought. . . . . . . .
  • All humans are caught in an inescapable network
    of mutuality, tied in a single garment of
    destiny. Whatever affects one directly, affects
    all indirectly.
  • Dr. Rev. Martin Luther King, Jr. Letter from
    Birmingham Jail.

Reasons for Cultural Competence
  • All of these points prove to be good reasons for
    exploring cultural competency and how it can help
    us living in this diverse world.

Why is there a need for Cultural Competence?
  • To respond to current and projected demographic
    changes in the United States
  • To eliminate long-standing disparities in the
    health status of people of diverse racial, ethnic
    and cultural backgrounds
  • To improve the quality of services
  • To enhance the workplace environment
  • To meet regulatory and accreditation mandates
  • To decrease the likelihood of liability/malpractic
    e claims
  • - Source National Center for Cultural
    Competence, Georgetown University

Cultural Competency
  • To be culturally competent doesnt mean you are
    an authority in the values and beliefs of every
    culture. What it means is that you hold a deep
    respect for cultural differences and are eager to
    learn, and are willing to accept, that there are
    many ways of viewing the world.
  • - Okokon O. Udo, BD, PhD, CPCC, Ordained
    Prebysterian Minister
  • --From Cross Cultural Health Care Program

Road Signs Leading to Cultural Competence
  • Awareness
  • Knowledge
  • Skills

  • Increase awareness of other cultural perspectives
  • Consider diversity in values, beliefs, practices,
    lifestyles, problem solving strategies
  • Examine and appreciate your own culture
  • Reflect on learned biases and prejudices towards
    other cultures

  • Learn about historical, societal, political,
    spiritual influences that impact the world view
    of others
  • Distinguish between individual traits of a person
    and common traits of people of a community
  • Share information about yourself and your
    experiences so others can understand you

  • Use awareness and knowledge as information base
  • Integrate awareness and knowledge into a
    cross-cultural encounter
  • Conversation instead of confrontation
  • Develop culture-specific, appropriate
    individualized interventions

Earliest memory of difference. . . . .
  • Think back as far as possible and reflect on your
    earliest memory of difference.
  • The difference can refer to skin color, age, body
    size, sexual preference, cultural background,
    ethnicity, language, etc.

Earliest memory of difference. . . . .
  • In groups, discuss
  • Was it yourself that was different?
  • Was it another person that was different?
  • What made them different?
  • How did others respond?

Self Assessment
  • Create a large group awareness of existing
    stereotypes and assumptions
  • Create awareness of origins of our own cultural
    values and beliefs
  • Recognition of how these influence individual
    attitudes and behaviors
  • Understand how these attitudes affect other

Cultural Competency Continuum
- New York/New Jersey Public Health
Cultural Competency Continuum
  • Ethnocentric vs. Ethnorelative
  • Ethnocentric
  • You view your own (or adopted) culture as central
    to reality.
  • Ethnorelative
  • You experience your culture in relation to, or in
    context of, other cultures.

Cultural Competency Continuum - Ethnocentric
  • Denial
  • You experience your culture as the only culture
    that exists. You deny and are disinterested in
    cultural differences.
  • Defense
  • You experience your culture as the only good
    culture. You acknowledge cultural differences but
    see them as threatening. You use mechanisms such
    as stereotyping to defend yourself.
  • Minimization
  • You experience elements of your culture as
    universal. You minimize differences between
    cultures and believe that human similarities
    outweight any differences.

Cultural Competency Continuum - Ethnorelative
  • Acceptance
  • You recognize and value cultural differences,
    without judging them. You are curious about
    different cultures.
  • Adaptation
  • You experience other cultures by yielding to
    perceptions and behaviors acceptable to that
    culture. You intentionally change your behavior
    to communicate more effectively in different
  • Integration
  • You value a variety of cultures and continuously
    define your own identity in contrast and in
    conjunction with a number of cultures. You move
    easily in and out of varying worldviews.

Exploring Stereotypes
  • Close your eyes and listen.

Exploring Stereotypes
  • What was your reaction?
  • What images were in your mind?
  • Did the images change as you heard more
    information? Why?

Cultural Views of the World
  • Causes of Illness
  • Traditional Healing
  • Cultural Norms

Causes of Illness
  • What causes us to become ill?
  • What makes us heal or become well?

  • Worlds Apart Justine Chitsenas Story

Chitsena Story
  • What are the grandmothers beliefs about the
    illness itself and the surgery?
  • How do they differ from the medical perspective?
  • What is Bouphet Chitsenas perspective, and
    perspective, and Chitsena how is it different
    than both of the others?

Chitsena Story
  • While Justines mother is her primary caretaker,
    and the one interacting with the medical staff,
    her grandmother clearly plays an important role.
  • How does the decision-making happen in this
    family (vs. most American families)?
  • What is Justines grandmothers role?
  • What is her mothers role?
  • How would you explore this issue and deal with it
    in a clinical encounter like this?

Chitsena Story
  • What are your views on the use of
    complementary/alternative medicine in general,
    and in this case specifically?
  • Why is it important to know about these practices?

Chitsena Story
  • Issues to consider with alternative therapies
  • Some may have beneficial effects for patients,
    whether proven (true in some cases) or
  • Trust can be built by being open to patients
    ideas about these.
  • Some alternative therapies may be dangerous,
    either due to their direct side effects or
    interactions with other medications that the
    patient takes.
  • Patients may avoid using potentially more
    effective medical treatment due to their use of
    alternative practices.
  • Being judgmental about alternative therapies
    contributes to patients not revealing their use.

Causes of Illness - Beliefs in some cultural
  • imbalance between hot and cold causes illness
  • balance between hot and cold must be restored
  • unhappy ancestor, bad spirit, gods sending
    illness as a test or punishment
  • witchcraft, illness through act of negative
    willpower or ritual performed by other

Common traditional healers
  • Herbal healers use roots and herbs
  • Shaman / spiritual healers address spiritual and
    magical causes of illness, often through ceremony
    and ritual
  • Bone setters deal with breaks and sprains
  • Midwives care for pregnant women and attend
  • Diviners often only diagnose illness

Areas of Difference
  • Historical Distrust Past injustices may cause
    distrust between patient and provider
  • Interpretations of Disability Ideas of what
    is/what causes a disability
  • Concepts of Family Structure and Family Identity
    Family often extends beyond the sphere of the
    traditional nuclear family
  • Communication Styles and Views of Professional
    Roles Westerners tend to separate professional
    and personal identity

Areas of Difference (cont.)
  • Incompatibility of Explanatory Models Physical
    health vs. Spiritual/Moral health
  • Disease without Illness Invisible diseases
    (hypertension, high cholesterol, HIV)
  • Illness without Disease Folk illnesses that are
    not defined within western biomedicine
  • Misunderstandings of terminology, language or
    body language
  • American Medical Student Association

Refugees / Immigrants Frequently Asked Questions
  • What is the difference between refugees and
  • Refugees have fled their country because of a
    well founded fear of persecution, while
    immigrants have left their home country on their
    own will.

Refugees / Immigrants Frequently Asked Questions
  • Why do refugees leave their country?
  • There are many reasons, some main ones being
    war, religious or political persecution, reasons
    of race, etc.
  • Why do refugees come to the U.S.?
  • Refugees do not choose where they go from the
    refugee camp they are assigned by the UN.
  • Do refugees ever return home?
  • Yes, in large numbers, although many others also
    choose to stay and build a life where they are

Refugees / Immigrants Frequently Asked Questions
  • Why do immigrants leave their country?
  • Again, there are many reasons. It may be to find
    a better job, to reacquaint with family, to build
    a better life, to gain an education, to simply
    live in another place, among many other reasons.
  • Do immigrants help or hurt the United States?
  • Immigrants have contributed greatly to the face
    of the U.S. in the types of food we eat, the
    music we hear and the many events that take
    place. They also add to our country
    intellectually, financially and culturally.

Cultural Norms
  • There are some traits that are common to
    particular ethnic groups and people from a
    certain region. However, it is extremely
    important to remember that any information
    presented cannot be taken as a definitive
    representation of a community or individual in
    that community.

Predominant cultural groups in this region
  • Hispanic/Latino
  • Southeast Asian
  • Pacific Islanders (Micronesian, Filipino, etc.)

Hispanic/Latino - General
  • Family plays a central role. There is a huge
    emphasis on family as a support network and also
    on how decisions made will affect family members.
  • Emphasis on interpersonal relationships and
    friendships. There is an abounding willingness to
    help others and to extend hospitality to all.

Hispanic/Latino - General
  • Hierarchy within groups. Showing respect and
    seeking advice from elders/respected community
  • Warmer in personal interactions (standing
    closer, touching, kisses)
  • Naming system
  • Ex. First name, Middle name, Paternal last name,
    Maternal last name

Hispanic/Latino - Gender Roles
  • The man generally is head of household and
    makes all important decisions
  • Historically viewed as the idea of the male who
    is strong and dominating. However, he can also
    be seen as one who takes care of his family
    financially and works hard to provide for loved
    ones (machismo)
  • The woman takes responsibility for the children
    and many times takes on the quiet, but all
    important, behind-the-scenes role of caring for
    the family.

Hispanic/Latino - Health
  • View providers as the authority figures on health
    care causing for a reluctance in asking questions
  • Traditional/folk healers and forms of healing
    play an important role

Hispanic/Latino Traditional Illnesses and
  • Mal de ojo (evil eye) vomiting, fever, crying,
    restlessness a heating up of the childs blood.
  • Cause an admiring or covetous look from a person
    with the evil eye
  • Treatment herbal remedies, ritual cures (folk
    healer), using egg, lemon, chili pepper on
    childs body
  • Empacho lack of appetite, stomachache, diarrhea,
  • Cause poorly digested or uncooked food.
  • Treatment dietary restrictions, herbal teas,
    abdominal massage with warm oil

Hispanic/Latino Traditional Illnesses and
  • Nervios restlessness, insomnia, loss of
    appetite, headache, aches and pains.
  • Cause chronic, negative life circumstances,
    especially in interpersonal relationships
  • Treatment traditional/folk healer
  • Susto loss of soul or an extreme fright
    characterized by lethargy, depression, insomnia,
    hallucinations, irritability
  • Cause a traumatic or frightening experience
  • Treatment herbal teas, spitting a mouthful of
    water or alcohol into patients face
    unexpectedly, covering face with cloth and
    sprinkling holy water

Hispanic/Latino Other Problems and Traditional
  • Diarrhea rice water increase clear liquids (no
    milk or food) suedro (solution made of water,
    sugar, lemon or banana)
  • Conjunctivitis breast milk drops in eyes, carrot
    juice, chamomile drops or wash for eyes
  • Skin rash apply cornstarch alcohol rub or bath
    rub with watermelon shell
  • Minor burns apply pork lard, cooking oil or
    butter raw onions apply toothpaste, egg white,
    cooked beans

Hispanic/Latino - Diversity
  • It is very important to remember that within the
    heading Hispanic/Latino are included people
    from as many as twenty different countries with
    as many different histories, governments,
    customs, traditions, beliefs, etc.
  • Many times we hear the words Hispanic and
    Latino/a used interchangeably, however some
    people have strong feelings toward the use of one
    over the other. Finally, there are also other
    people who dislike both and would prefer to use a
    more specific terminology, calling themselves
    Mexican-American, Cuban-American, etc.

  • World Apart Alicia Mercado Story

Mercado Story
  • There have been three distinct Hispanic/Latino
    patterns of immigration
  • Continuous flow of both legal and undocumented
    immigration from Mexico which intensified in
    1980, driven by economic forces and
  • Waves of large-scale immigration from Central
    and South America, driven by war, conflict, and
  • A Caribbean pattern of frequent back-and-forth
    migration between the country of origin and the
    U.S. (typified by the Puerto Rican experience in
    the Northeast).

Mercado Story
  • What are some of the reasons (from Mrs. Mercados
    perspective) for her lack of ideal adherence to
    medical therapy and follow-up?
  • What are some other reasons why patients are
    non-adherent to medical therapy, especially for
    chronic diseases?

Mercado Story
  • What are your views on the use of
    complementary/alternative medicine in general,
    and in this case specifically?
  • What home remedies did your family use when you
    were growing up?
  • Why is it important to know about these practices?

Southeast Asians
  • There are many similarities between the cultural
    practices and forms of healing used by Southeast
    Asians (Vietnamese, Cambodian, Laotians, etc.).
    However, it is important to keep in mind that
    they are all people from different countries,
    speaking different languages and coming from
    different histories. Many of the common traits
    come from Buddhist beliefs, the majority religion
    of the area.

Southeast Asians - General
  • The traditional view of health is holistic
    linking the mind, body and soul. It focuses on
    establishing and maintaining a balance of life
  • Asian patients may deny illness, viewing it as
    personal carelessness or weakness, or as a result
    of external forces over which they have no
  • The basis for most views on health come from
    Buddhist beliefs.

Southeast Asians - General
  • Respect for education, family and elders
  • Sparing ones feelings is considered more
    important than factual truth
  • Tend to be reserved in most interactions and
    expression of strong feelings (positive or
    negative) is not valued.
  • Bow heads to superior or elder
  • When talking, one should not look steadily at a
    respected persons eyes

Southeast Asians - General
  • Family is held in high regard, often with
    grandparents and other relatives living in the
    same house
  • Women do not shake hands with each other or with
  • Disrespectful to touch another persons head
  • Naming system
  • Ex. Last name, Middle name, First name
  • Most names can be used for either gender
  • Name reflects some meaning

Southeast Asians - Gender Roles
  • Men have higher status than women, sons are
    valued more than daughters
  • A traditional woman must submit to her father,
    then obey her husband, and then if widowed, obey
    her eldest son
  • However, the mother is not docile. She is
    considered the home minister and is responsible
    for family harmony, the family budget and the
    family schedules

Southeast Asians - Health
  • Mental illness is a shameful thing and often
    feared or denied
  • Many times health and health care are based on
    spiritual factors or the hot/cold belief system
    (you are sick because the hot/cold balance has
    been altered)
  • There is a common belief that Western medicines
    are developed for Americans and Europeans, hence
    they assume the dosages are too strong for their
    slight builds and will self-adjust their

Southeast Asians - Health
  • Physical and mental wellness are tied to a
    balance of the winds of the body and also to a
    persons ability to sleep or eat without
  • Persons who are sick will turn first to
    traditional means of healing and then seek
    treatment at a clinic or hospital. Generally,
    traditional practices are often continued
    alongside western medicine.
  • Health histories may be incomplete for a number
    of reasons, mostly for a reluctance in
    volunteering such personal information as sexual
    activity, family history and other illness
    (vulnerability) issues. Trust or a lack of it is
    a major issue.

Southeast Asians - Traditional Health Practices
  • Coining a coin dipped in oil is rubbed across
    the skin, causing a mild abrasion. It is
    believed to release excess wind from the body
    and restore the balance.
  • Cupping a series of small, heated glasses are
    placed on the skin, forming a suction that draws
    out the bad force.
  • Pinching similar to coining and cupping. The
    abrasion left by the pinch allows the force to
    leave the body.
  • Note Many of these practices are formed on young
    children or infants and the temporary abrasions
    should not be confused with abuse or injury.

Southeast Asians - Traditional Health Practices
  • Steaming a mixture of medicinal herbs is boiled
    and the steam is inhaled
  • Acupuncture thin, steel needles inserted in
    specific locations to help cause an energy
  • Acupressure fingers are pressed at the same
    points as acupuncture to stimulate the energy
  • The use of specific jewelry worn around the neck
    are often used as a form of spiritual protection

SE Asians and the Western Medical System
  • It is common for patients to not report or even
    to deny symptoms or problems.
  • It is common to discontinue treatment or
    medication as soon as symptoms have disappeared.
    There is an expectance to receive medication for
    every illness and that it will quickly relieve
    the problem.
  • Most are more oriented to illness than to the
    prevention of illness and only seek help after
    symptoms arise. There is little value on early
    detection or disease screening.

SE Asians and the Western Medical System
  • Blood draws are thought to be very painful and
    will make them weaker because the blood is taken
    away and not replaced.
  • Genital exams are a foreign concept to them and
    are preferred to be done by a same-sex provider.
  • X-rays are thought to destroy red blood cells and
    to decrease general life expectancy.
  • Surgery is extremely frightening to them and is
    considered a last resort.

Dynamics of Difference
  • Power
  • Ethnocentrism
  • Social Class
  • Acculturation
  • Cultural Bumps

  • Nearly all men can stand adversity, but if you
    want to test a man's character, give him power.
    -Abraham Lincoln
  • Power does not corrupt men but fools, if they
    get into a position of power, corrupt power. -
    George Bernard Shaw

  • All of us, both Euro-Americans and members of
    ethnic minority groups are ethnocentric. That
    means that we usually value our own group above
    all others. The concept of cultural competence
    applies not just to Euro-Americans but to all of
    us who have been born, educated, and live on
    American soil. Very few things in the American
    institutional structure have prepared us to live
    harmoniously in a pluralistic and multicultural
    society. Therefore, every one of us needs to
    learn and practice from a culturally competent
  • M Issacs and M Benjamin, Towards a Culturally
    Competent System of Care, Vol II.

Social Class / Classism
  • Although not readily acknowledged in the United
    States, in many countries classism exists openly.
  • Differences in class, or in the way class is
    perceived, must be taken into account so as not
    to lose trust in an interaction.

  • Refers to the acquisition of a new cultural
    identity, but does not imply ridding oneself of
    the elements of ones first culture.
  • Original Culture Bicultural Assimilation
  • ------------------------------------------------
  • Monolingual Bilingual Abandoned
    previous cultural values/language

Cultural bumps
  • Please pay attention to the following situation
    and consider what caused a misunderstanding
  • Video Guatemalan woman

Cultural bumps
  • Please discuss the following situations in small
  • 3 Cases

Cultural Relativity
  • Any behavior must be judged first in relation to
    the culture in which it occurs behavior may
    seem strange until placed in appropriate context.
  • - Cross Cultural Health Care Program, Interpreter

Signs of conflict...
  • Competence is challenged
  • Individual is not appreciated
  • Communication in ways that irritate you
  • Communication in condescending manner
  • Unsolicited advice given
  • Quick judgements
  • Lack of respect

What can we do to minimize obstacles?
  • Be knowledgeable about the cultures you work with
  • Avoid judgement based on your own cultural norms
  • Be understanding of different traditions,
    cultures, concepts of sickness, notions of
    healing, etc.

More conflict resolution across cultures
  • Being nonjudgmental
  • Understanding stereotypes
  • Treating people as individuals
  • Looking at whether expectations are real
  • Accepting ambiguity
  • Empathizing
  • Checking assumptions
  • Being open to differences
  • Myers, Selma. Conflict Resolution Across

Conclusion. . . . . . . .
  • Questions
  • Discussion
  • Observations
  • Evaluations

Day Two
  • February 23, 2005
  • Wichita, Kansas

  • Word Association

Creating Cultural Competency
  • Mythbusters!
  • Title VI - Overview
  • Title VI Assessment and Policy
  • Working with Interpreters
  • Building Community Connections
  • Sharing Resources

Myth Busters!
  • 1 Myth Immigrants dont pay taxes.
  • Fact Significant local, state federal taxes
    are paid by immigrants each year, an estimated
    133 billion.
  • Fact Alan Greenspan has stated that both legal
    and non-legal immigrants pay 20 billion more in
    taxes than they receive in benefits.

Myth Busters!
  • 2 Myth America is over-run by immigrants.
  • Fact Percentage of foreign-born is higher than
    in 1970 (11), but still lower than the all-time
    high of 14 in 1910.
  • Fact The 2000 Census found that 22 of US
    counties lost population from 1990-2000.

Myth Busters!
  • 3 Myth Immigrants do not serve their new
  • Fact Immigrants make up nearly 5 of all
    enlisted personnel on active duty in the US Armed
    Forces. (62,000)
  • Fact 20 of the recipients of the Congressional
    Medal of Honor were immigrants.

Creating Cultural Competency
  • Title VI - Overview
  • Title VI Assessment and Policy

What is Title VI?
  • Title VI of 1964 Civil Rights Act
  • No person in the United States, shall, on ground
    of race, color, or national origin, be excluded
    from participation in, be denied the benefits of,
    or be subjected to discrimination under any
    program or activity receiving Federal financial

Source Title VI of 1964 Civil Rights Act and
Office of Civil Rights Policy Guidance on
Language Access to Services
Who is Protected by Title VI?
  • Limited English Proficient (LEP) individuals
    National Origin.
  • OCR Policy Guidance Fall 1998
  • Title VI Prohibition Against National Origin
    Discrimination As it Affects Persons with Limited
    English Proficiency
  • Revised August 2000 published again in February
    2002, currently under revision

What organizations are impacted by Title VI?
  • Health care providers
  • Hospitals, doctors offices, nursing homes
  • Managed care organizations, home health agencies
  • State Medicaid agencies
  • Municipal and county health departments
  • Social service and non-profit organizations
  • The list is endless!

Explanation of Title VI
  • Title VI prohibits discriminatory impact
  • - services more limited in scope
  • - lower quality of services
  • - unreasonable delays in service delivery
  • - limiting participation in a program

Title VI OCR Policy Guidance
  • Any organization that receives federal funds must
    provide meaningful access to programs, services,
    and benefits
  • Federal financial assistance includes grants,
    training, donations of surplus property, and
    other assistance
  • Meaningful access ensures accurate and effective
  • Limited English Proficient (LEP) individuals
    should receive language assistance free of charge

OCR Enforcement of Title VI
  • OCR assists organizations in development of
    comprehensive written policy
  • OCR considers these circumstances
  • Size of the covered entity
  • Size of the eligible population
  • Nature of Program or Service
  • Program Objectives
  • Resources
  • Frequency of a given language
  • Frequency of encounters with LEP persons

Office of Civil Rights
  • Maria A. Smith, Investigator
  • Office of Civil Rights
  • Federal Office Building
  • 601 E. 12th Street, Room 248
  • Kansas City, MO 64106
  • (816) 426-7238
  • (800) 368-1019

Four Keys to Title VI Compliance
  • Assessment
  • Development of a comprehensive written policy on
    language access
  • Training of staff
  • Vigilant monitoring

  • Conduct a thorough assessment of the language
    needs of population served
  • Identify the languages likely to be encountered
  • Identify language needs of every LEP
    patient/client and note in client files
  • Identify resources needed to provide effective
    language assistance

Areas to consider in an assessment
  • level of ethnic identity
  • use of informal network and supportive
    institutions in the ethnic/cultural community
    values orientation
  • language and communication process
  • migration experience
  • self concept and self esteem
  • influence of religion/spirituality on the belief
    system and behavior patterns
  • views and concerns about discrimination and
    institutional racism
  • views about the role that ethnicity plays
  • educational level and employment experiences
  • habits, customs, beliefs
  • importance and impact associated with physical
  • cultural health beliefs and practices
  • current socioeconomic status

Development of a Comprehensive Policy
  • Oral Language Interpretation
  • Translation of written materials
  • Methods for providing notice to LEP persons

Issues that impact compliance
  • Financial cost of interpreting services
  • Lack of awareness of the need for interpreter
  • Negative impact when untrained, unqualified
    interpreters are used
  • Organization does not have a comprehensive
    written policy on language access

Two Compliance Cases
  • 1 Sole physician practitioner with 50 LEP
    Hispanic patients. Staff of two nurses and
    receptionist. No interpreters on staff. Uses
    community org. telephone interp.
  • 2 County Social Services agency serves 500,000
    10,000 are LEP. No policy clients bring own
    interpreters. Materials in English.

Case Studies
  • In groups discuss the case studies.

CLAS Standards
  • Health Care providers have a responsibility to
    provide culturally and linguistically appropriate
    services (CLAS) to patients
  • Interpretation/Translation services
  • Ongoing education and training for all staff
  • Recruit and retain a diverse and culturally
    competent staff
  • Collect and utilize data about the diverse
    communities in providers service area
  • Implement ongoing self-assessments of cultural
    competence within organization

Working Effectively with Interpreters
  • Who is an appropriate interpreter?
  • Roles and responsibilities of interpreter
  • Effective strategies for communicating through an

  • Communicating Effectively Through an Interpreter

Who is appropriate to act as an Interpreter?
  • Bilingual staff who are trained and competent in
    skill of interpreting
  • Staff interpreters
  • Contracted Interpreter Service
  • Community Volunteer Interpreters
  • Telephone Interpreter Lines

Who is NOT appropriate as an Interpreter?
  • Friends of any LEP individual
  • Family member of LEP patient/client
  • Minor children
  • Anyone who has not demonstrated proficiency in
    both languages
  • Anyone who has not received training in
  • Anyone who does not have an understanding of
    ethics and interpreting practices

  • The basic purpose of the medical/social service
    interpreter is to facilitate understanding and
    communication between two or more people who are
    speaking different languages.
  • CCHCP, Interpreter training curriculum

  • Worlds Apart Mohammad Kochis Story

Kochi Story
  • The cancer had been there all along, even after
    the surgery, but the family members serving as
    interpreters had not translated this to Mr. Kochi
    nor to the rest of the family at home.
  • How does culture influence the way patients and
    families discuss medical information and make
    medical decisions?

Kochi Story
  • Why, in this case, does Noorzia (a relatively
    young daughterand a woman in a male dominant
    culture) seem to play a very important role in
    medical decisions about her fathers care?
  • How is Noorzias perspective on her fathers
    health, and the medical in general, different
    than her fathers?

Kochi Story
  • How important are professional interpreters (as
    opposed to family members or no interpreter) in
    medical interactions like this?
  • Could it have changed the situation in this case?
  • Are there any laws requiring the use of an
  • What problems can arise when family members or
    others act as interpreters?

Kochi Story
  • What do you think about this interaction?
  • Mr. Kochi
  • We believe our day has been chosen for us and it
    cannot be pushed up or forced back.
  • Dr. Fisher
  • Our goal is to help you feel as well as you can
    feel until that day comes.

Roles of the Interpreter
  • Interpret exactly what is said add nothing,
    change nothing, omit nothing.
  • Adjust register or complexity of language. Check
    for understanding.
  • When cultural differences cause misunderstanding,
    provide necessary cultural framework for
    understanding message.
  • Action taken on behalf of someone else.

Tips for Effective Communication through an
  • POSITIONING interpreter should be seated next
    to and a little bit behind LEP client
  • ACCURACY everything that is said should be
    interpreted no side conversations check for
    comprehension speak in short phrases and pause
    to allow for interpretation
  • COMPETENCY assess interpreter qualifications
    and skills bilingual individuals should be
    trained in interpreting and have knowledge of
    policies at your organization

Medical errors
  • According to a study by the Institute of
    Medicine, at least 44,000 people and perhaps as
    many as 98,000 people die in hospitals each year
    as a result of medical errors that could have
    been prevented.
  • Source Institute of Medicine, To Err is Human
    Building a Safer Health System, Nov. 1999

  • Language Barriers Lead to Medical Mistakes

Language and Culture
  • People who speak different languages live in
    different worlds, not the same world with
    different labels.
  • Edward Sapir, linguist, 1928.

The New Americans
  • The Flores Family (Mexico)
  • The Nwidor Family (Nigeria)
  • Active Voice Kartemquin Educational Films

Identifying Barriers and Building Bridges
  • Compare the experiences of the two families
  • How do we bridge cultural gaps?
  • How do we build community power?

Successful community partnerships
  • Informal collaboration among social service
    agencies JVS, Catholic Charities, Della Lamb,
    Don Bosco, El Centro
  • KC partnership of safe harbor health care
    providers KC Free Health Clinic, Cabot Westside
    Clinic, Swope Parkway Medical Center, Truman
    Hospital and other community clinics.

Kansas City Free Health Clinic
  • Over 50 staff members
  • Over 400 volunteers
  • Safe harbor health care provider for individuals
    without insurance
  • Extensive services for individuals without
    primary health care coverage
  • Active community involvement and integration with
    other healthcare providers

Building Culturally Competent Community
  • What community organizations do you collaborate
  • What are effective strategies for working
  • Identify areas to be improved (on a community
    level, on an institutional level, etc.).

Strategies for working effectively in communities
  • Asian American Family Counseling Center - Houston
  • - brown bag lunches for mental health
    professionals to learn more about working with
    the areas Asian American communities
  • Consumer Voices Are Born - Clark County,
  • - established a warm-line where individuals
    facing mental health challenges could call in and
    discuss their problems with a peer, now extending
    services to ethnic communities
  • - National Consumer Supporter Technical
    Assistance Center,
  • National Mental Health Association. A Cultural
  • Toolkit Ten Grant Sites Share Lessons

Strategies for working effectively in communities
  • Build bridges of trust and dispel misinformation
  • Recruit staff from within the community
  • Community members provide insight into cultural
    beliefs and practices
  • Identify elders or leaders within the community
    and seek their support
  • Initiative must be give and take

Organizing Culturally Specific Community Forums
  • Culturally Specific Community Forums
  • Culturally competent community assessments
  • Barriers and benefits of community partnerships

Culturally Specific Community Forums and
  • MAPP KCMO Health Department health survey
  • The Pulse Survey of Health in the KC gay and
    lesbian community
  • Interpreter Training classes Informal and
    formal networking among key community members
  • Social service organizations
  • Religious organizations
  • Community partnerships with other organizations

Barriers and benefits of community partnerships
  • Barriers
  • - mistrust on the part of the community
  • - results and outcomes not clearly defined
  • - organization unable to effectively work with
  • Benefits
  • - increased access to services
  • - positive reputation in the community
  • - word of mouth makes your organization thrive

Unanswered Issues
  • What are some topics that we have not mentioned
    or that we have not covered completely in this
  • Are there any common cultural issues you face
    that we have not talked about? What are they?
  • What are some possible resolutions or outcomes?

Conclusion. . . . . . . .
  • Questions
  • Discussion
  • Observations
  • Evaluations

  • Please refer to handout with a list of online

  • Cross Cultural Health Care Program
  • CMS //
  • Natl Health Law Prog
  • National Council on Interpreting in Health Care
  • HHS, Office of Minority Health

  • Thanks for your participation, time and energy!
  • Thanks to KDHE for funding the course!

Contact us!
  • Jewish Vocational Service
  • Language and Cultural Services
  • 1608 Baltimore
  • Kansas City, MO 64108
  • (816) 471 - 2808
  • Brandi Miller
  • Cathy Anderson
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