CULTURAL COMPETENCY

1
CULTURAL COMPETENCY

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

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DAY ONE

• February 22, 2005
• Wichita, Kansas

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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.

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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

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Setting the Tone

• Expectations
• Training Goals
• Ground Rules
• Introductions

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Trainer Expectations

• Show respect by listening to each other and not
  interrupting.
• 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.

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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

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Your Goals

• What do you hope to learn from this training?

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Icebreaker

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

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Cultural Competency Self-Assessment Checklist

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

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Welcome to a Changing World

• Demographics
• Health disparities
• Culture

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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 www.globalissues.org

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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
  water
• 10 would be lesbian, gay or bisexual
• 1 would have a college education
• from Meadows, D., If the World Were a Village

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Changing Demographics

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

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Changing Demographics

• In the U.S. today, Asian Americans and Pacific
  Islanders are the fastest growing segment of the
  population
• 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
  immigrants
• 2000 US Census Bureau national data

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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
  American

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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
  industries.
• Source Martin, Phillip Taylor, J. Edward Fix,
  Michael, 1996. Immigration and the Changing
  Face of Rural America Focus on the Midwestern
  States

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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.

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Minority Health Statistics

• Hispanics/Latinos
• 83 higher age-adjusted death rate from diabetes
  than general population
• lack of understanding of preventative health
  services
• African Americans
• 34 more likely to die of cancer and twice as
  likely to die from diabetes than Whites
  nationally
• 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.

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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

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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.

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CULTURE

• Define culture.
• What does culture mean?

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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.

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Culture

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

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Cultural Lenses

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

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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
  remember
• What constitutes good and bad parenting

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Active Listening

• What challenges did you experience in this
  exercise?
• Were you surprised by what you learned from
  others?

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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.

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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
  India

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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

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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

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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.

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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.

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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

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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

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Road Signs Leading to Cultural Competence

• Awareness
• Knowledge
• Skills

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Awareness

• 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

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Knowledge

• 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

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Skills

• 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

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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.

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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?

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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
  people

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Cultural Competency Continuum
- New York/New Jersey Public Health
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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.

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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.

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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
  cultures.
• 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.

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Exploring Stereotypes

• Close your eyes and listen.

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Exploring Stereotypes

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

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Cultural Views of the World

• Causes of Illness
• Traditional Healing
• Cultural Norms

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Causes of Illness

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

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Video

• Worlds Apart Justine Chitsenas Story

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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?

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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?

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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?

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Chitsena Story

• Issues to consider with alternative therapies
• Some may have beneficial effects for patients,
  whether proven (true in some cases) or
  subjective.
• 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.

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Causes of Illness - Beliefs in some cultural
communities

• 1. HUMORAL IMBALANCE
• imbalance between hot and cold causes illness
• balance between hot and cold must be restored
• 2. SPIRITUAL CAUSES OF ILLNESS
• unhappy ancestor, bad spirit, gods sending
  illness as a test or punishment
• 3. MAGICAL CAUSES OF ILLNESS
• witchcraft, illness through act of negative
  willpower or ritual performed by other

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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
  births
• Diviners often only diagnose illness

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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

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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

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Refugees / Immigrants Frequently Asked Questions

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

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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
  assigned.

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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.

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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.

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Predominant cultural groups in this region

• Hispanic/Latino
• Southeast Asian
• Pacific Islanders (Micronesian, Filipino, etc.)

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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.

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Hispanic/Latino - General

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

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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.

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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

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Hispanic/Latino Traditional Illnesses and
Treatments

• 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,
  vomiting.
• Cause poorly digested or uncooked food.
• Treatment dietary restrictions, herbal teas,
  abdominal massage with warm oil

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Hispanic/Latino Traditional Illnesses and
Treatments

• 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

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Hispanic/Latino Other Problems and Traditional
Remedies

• 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

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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.

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Video

• World Apart Alicia Mercado Story

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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
  opportunities
• Waves of large-scale immigration from Central
  and South America, driven by war, conflict, and
  asylum-seeking
• 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).

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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?

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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?

77
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.

78
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
  energies.
• Asian patients may deny illness, viewing it as
  personal carelessness or weakness, or as a result
  of external forces over which they have no
  control.
• The basis for most views on health come from
  Buddhist beliefs.

79
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

80
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
  men
• 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

81
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

82
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
  medicines.

83
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
  difficulty.
• 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.

84
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.

85
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
  balance
• Acupressure fingers are pressed at the same
  points as acupuncture to stimulate the energy
  points
• The use of specific jewelry worn around the neck
  are often used as a form of spiritual protection

86
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.

87
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.

88
Dynamics of Difference

• Power
• Ethnocentrism
• Social Class
• Acculturation
• Cultural Bumps

89
Power

• 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

90
Ethnocentrism

• 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
  perspective.
• M Issacs and M Benjamin, Towards a Culturally
  Competent System of Care, Vol II.

91
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.

92
Acculturation

• 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

93
Cultural bumps

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

94
Cultural bumps

• Please discuss the following situations in small
  groups.
• 3 Cases

95
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
  training

96
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

97
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.

98
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
  Cultures.

99
Conclusion. . . . . . . .

• Questions
• Discussion
• Observations
• Evaluations

100
Day Two

• February 23, 2005
• Wichita, Kansas

101
Exercise

• Word Association

102
Creating Cultural Competency

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

103
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.

104
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.

105
Myth Busters!

• 3 Myth Immigrants do not serve their new
  country.
• 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.

106
Creating Cultural Competency

• Title VI - Overview
• Title VI Assessment and Policy

107
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
  assistance.

Source Title VI of 1964 Civil Rights Act and
Office of Civil Rights Policy Guidance on
Language Access to Services
108
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

109
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!

110
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

111
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
  communication
• Limited English Proficient (LEP) individuals
  should receive language assistance free of charge

112
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

113
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
• [phone]
• [phone]

114
Four Keys to Title VI Compliance

• Assessment
• Development of a comprehensive written policy on
  language access
• Training of staff
• Vigilant monitoring

115
Assessment

• 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

116
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
  characteristics
• cultural health beliefs and practices
• current socioeconomic status

117
Development of a Comprehensive Policy

• Oral Language Interpretation
• Translation of written materials
• Methods for providing notice to LEP persons

118
Issues that impact compliance

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

119
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.

120
Case Studies

• In groups discuss the case studies.

121
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

122
Working Effectively with Interpreters

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

123
Video

• Communicating Effectively Through an Interpreter

124
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

125
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
  interpretation
• Anyone who does not have an understanding of
  ethics and interpreting practices

126
Interpreter

• 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

127
Video

• Worlds Apart Mohammad Kochis Story

128
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?

129
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?

130
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
  interpreter?
• What problems can arise when family members or
  others act as interpreters?

131
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.

132
Roles of the Interpreter

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

133
Tips for Effective Communication through an
Interpreter

• 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

134
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

135
Article

• Language Barriers Lead to Medical Mistakes

136
Language and Culture

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

137
The New Americans

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

138
Identifying Barriers and Building Bridges

• Compare the experiences of the two families
• How do we bridge cultural gaps?
• How do we build community power?

139
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.

140
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

141
Building Culturally Competent Community
Partnerships

• What community organizations do you collaborate
  with?
• What are effective strategies for working
  together?
• Identify areas to be improved (on a community
  level, on an institutional level, etc.).

142
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,
  Washington
• - 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
  Competency
• Toolkit Ten Grant Sites Share Lessons
  Learned.

143
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

144
Organizing Culturally Specific Community Forums

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

145
Culturally Specific Community Forums and
Assessments

• 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

146
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
  community
• Benefits
• - increased access to services
• - positive reputation in the community
• - word of mouth makes your organization thrive

147
Unanswered Issues

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

148
Conclusion. . . . . . . .

• Questions
• Discussion
• Observations
• Evaluations

149
References

• Please refer to handout with a list of online
  resources.

150
Resources

• Cross Cultural Health Care Program
  www.xculture.org
• OCR/HHS www.hhs.gov/ocr
• CMS //cms.hhs.gov/states/letters
• Natl Health Law Prog www.healthlaw.org
• National Council on Interpreting in Health Care
  www.ncihc.org
• HHS, Office of Minority Health
  www.omhrc.gov/CLAS

151
THANK YOU!

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

152
Contact us!

• Jewish Vocational Service
• Language and Cultural Services
• 1608 Baltimore
• Kansas City, MO 64108
• (816) 471 - 2808
• www.jvskc.org
• Brandi Miller bmiller_at_jvskc.org
• Cathy Anderson canders_at_jvskc.org