Cultural Competency Learning Objectives

1. Cultural Competency Learning Objectives • What culture and cultural competency is • Evaluating ourselves • Why it is important to our work • Demographics of America • Disparities in Health Status • Access to Health Care • Quality - a key to future success • How to implement cultural services • Closing the Gap/Development of Competency • Burmese, American Indian, Hispanic, Asian Indian • Game/ Post Test

2. Cultural Competency in the Health Care Setting What is Cultural Competence? Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work efficiently in cross-cultural situations. It reflects the ability to acquire and use knowledge of health care related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups. MSH (Management Sciences for Health) Other terms for cultural competence include cultural proficiency and cultural humility . Effective cross-cultural competency equates to tailoring the delivery of health care to meet the patient’s social, cultural and linguistic needs.

3. What is culture? • The learned, shared, transmitted values and beliefs and practices of a particular group that guide the thinking, actions, behaviors, interactions, emotions and view of the world. • Art Beliefs about: • Relationships Family obligations • Customs Gender Roles • Clothing Preventative Health • Environment Illness and death • Economics Sexuality • Religion • Diet

4. Culture is an integrated pattern of human behavior which includes but is not limited to: roles rituals communication values languages relationships courtesies thought beliefs practices manners of interacting customs expected behaviors … of a racial, ethnic, religious, social, or political group; the ability to transmit the above to succeeding generations; dynamic in nature.

5. COMPETENCE values attributes knowledge skill set requires values, attributes, knowledge and a skill set to work effectively cross-culturally.

6. behaviors practices policies attitudes structures Cultural Competence requires that organizations have a clearly defined, congruent set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally (adapted from from Cross, Bazron, Dennis and Isaacs, 1989)

7. 3 H Approach Head- Understand that people think, believe, behave, perceive, understand, react/respond differently than I do. Heart- Sensitivity to the differences and similarities between and among people; especially those who are different from me. Hands- Tools, skills and knowledge to work effectively with those who are different from me

8. Peeling an Onion multi-layered During what decade did you grow-up? What have been your life experiences? What is your religious background? Who have you worked with? Where have you worked? What schools did you attend? What area were trained in? Area of study? Who were family members that influenced you? Where did you grow up ? Where have you lived? Who raised you? Adapted from Suganya Sockalingam, NCCC Senior Consultant

9. Tip of the iceburg gender language  race or ethnicity  eye behavior  facial expressions Adapted by the NCCC  body language sense of self   gender identity  notions of modesty concept of cleanliness • emotional response patterns rules for social interaction child rearing practices  • decision-making processes  • approaches to problem solving  concept of justice value individual vs. group  perceptions of mental health, health, illness, disability  patterns of superior and subordinate roles in relation to status by age, gender, class  sexual identity & orientation 

10. Community Engagement Cultural Competence Linguistic Competence Partnerships between Families & Professionals Family Centered Care Literacy Integration

11. Self Assessment or Reflection What are your attitudes, knowledge and skills in related to cultural and linguistic competence? What are some barriers and opportunities that you have ? How aware are you of the prevalence of significant health care disparities? Do you have an honest desire to not allow biases keep you from treating every individual with respect and optimum care? Are you honestly capable of looking at your negative and positive assumptions about others? Learning to evaluate our own level of cultural competence must be a part of improving the health care system.

12. Culture and Language may Influence: • Health, healing and wellness belief systems • Illness, disease and how causes are perceived • How health care treatment is sought and attitudes toward providers, impacting treatment • Delivery of health care services by providers who may compromise access for patients from other cultures.

13. How well prepared are you to work with patients of diverse populations? • Do you consider the individual’s culture when planning and coordinating care? • Do you ensure that individuals who do not speak English have trained certified medical interpreters? • Do you modify your educational and printed materials to meet the unique needs or learning styles of a diverse population? • Are you knowledgeable of the culturally and racially diverse population in our area? • What is your degree of proficiency in performing culturally competent tasks? • Is the educational support and communication present for you to meet best practice standards?

14. Researchers have found classic negative and racial stereotypes We have a health system that is the pride of the world , but the March 20, 2002 study entitled “Unequal Treatment Confronting Racial and Ethnic Disparity in Health Care” demonstrates that the playing field is clearly not equal. David R. Williams, Professor of Sociology , U of Michigan It found that racial and ethic minorities in the United States receive lower quality health care than whites even when their insurance and income are the same.

15. Demographics of America Our diverse nation is expected to become substantially more so over next several decades. The U.S. Census Bureau projects that by 2050, populations historically termed “minorities” will make up 50% of the population. The Hispanic –origin population will be the fastest growing ethnic group doubling by 2050. The fastest growing racial group will Asian and Pacific Islander population. Asian American elders will increase by 300 %. Marked differences in education, income with a greater number of blacks and Hispanics being considered “near poor” (100-200% of poverty level). This is remarkable in that income significantly influences health status, access to health care and health insurance coverage. One –sixth of the U. S. population speaks a language other than English at home.

16. Disparities in Health Status • Racial and ethnic minorities experience persistent and often increasing disparity across a number of health care variables. • Members of minorities suffer disproportionately from cardiovascular disease, diabetes, asthma, , TB, HIV/AIDS and cancer. • Variations in patient’s ability to recognize symptoms of disease and illness, thresholds for seeking care, barriers related to mistrust, expectations of care, including preferences for or against treatment plans, diagnostic testing and procedures and the ability to comprehend what is prescribed may influence the health care providers decisions. • Causes of disparity are multi-factorial and often are related to social determinants external to the heath care system.

17. Disparity in Access to Health Care • Assessing high quality health care is often influenced by the lack of an ongoing relationship with a provider, thus reducing use of specialty services and preventative care. • Increased use of ED as their regular place of care • Geographic isolation, transportation, child care may be problematic • Non-English speaking patients may be reluctant to seek treatment in a timely manner

18. Disparities in Health Insurance Coverage • One in six Americans is uninsured and those without coverage is growing. • Cost is the major barrier and many low income uninsured families are not eligible for public programs or lack the knowledge and literacy for enrollment. • Confusion and fear inhibit immigrants from obtaining coverage. • More than one/three Hispanics and American Indians/Alaska Natives do not have health insurance-triple that for whites.

19. Disparities in Quality • The Institute of Medicine indicates that health care should exhibit 6 key quality components: safe, timely, effective, efficient, patient-centered and equitable. All six must be present for it to be high quality and in all these areas there are significant disparities in care delivered to racial and ethnic minorities. • Differences may be the result of differential treatment by providers but studies are indicating that physicians who treat blacks primarily have more difficulty in obtaining high quality ancillary services, specialists, diagnostic imaging, etc.

20. Quality Being Addressed • Healthy People 2010 – a national initiative to promote equity and eliminate health disparities among different segments of the population. • United States Department of Health and Human Services is requiring by 2010, that health care facilities provide culturally competent care. • The Joint Commission is also requiring facilities to provide documentation of culturally competent care. • There are clear links between cultural competence and quality improvement and overcoming disparities. • “Cultural Competence is being talked about a lot and it is a beautiful goal, but we need to translate this into quality indicators or outcomes that can be measured, monitored, evaluated, or mandated.” –Administrator, Community Health Center

21. Culture of Improvement • Mission of RHFW/ Enhancing everyone’s capabilities • Value Added Component /rethink the way we provide service • Patient Centered Service/ Communication Priority • Press Ganey Measures Overall Patient Satisfaction • Priority index • Response to Concerns/Complaints • Degree to which hospital staff addressed your emotional needs • Staff effort to include you in decisions about your treatment • Increasingly responsible for coordinating care beyond our walls • Moving toward Pay for Performance /Quality incentive

22. Barriers to be overcome • Institutional • Socioeconomic, The Health Care System, Inadequate Infrastructure, Discrimination • Lack of diversity in leadership and workforce • Community Level Barriers • Philosophical Beliefs, Health Attitudes, Patient Provider Relationship, American Medical Model, Modesty • Provider Level Barriers • Service Delivery Approach, Health Care Provider Attitudes • Inadequate learning and assessment of knowledge, attitudes and skills

23. Promising Communication Strategies • LEARN: Guidelines for Overcoming Obstacles in Cross Cultural Comminication • L isten with empathy for the patient’s perception of the problem • E xplain your perception of the problem • A cknowlege and discuss the similarities and differences • R eccommend the treatment • N egotiate agreement

24. Ethnic: A Framework for Culturally Competent Clinical Practice • E xplanation • What do you think may be the reason you have these symptoms? • What do friends and family say about these symptoms? • Do you anyone else with this problem? • What have you heard on the tv or radio about the condition? • T reatment • Medicines, Home remedies or other treatments have been tried • Is there anything you eat, drink or avoid to stay healthy? • Please tell me about It. What treatment are you seeking? • H ealers • Alternative or folk healers. Tell me about it • N egotiate • Negotiate mutually acceptable options that incorporate your patient’s beliefs • I ntervention • Determine an intervention which may include alternative treatments- spirituality, healers, etc. • C ollaboration … with family, health care team, healers, community resources

25. BATHE: Useful for Eliciting Psychosocial Context • B ackground • What is going on in your life? • A ffect • How do you feel about what is going on? • T rouble • What about the situation troubles you the most? • H andling • How are you handling that? -provides direction for intervention • E mpathy • That must be very difficult for you. -legitimizes patient’s feelings

26. Language Barriers • Use of trained certified medical interpreters • M.D. s who have access to trained interpreters report significantly higher patient-physician communication/adherence • Discharge instructions in a language preferred by the patient. Written materials developed in other languages • Serving patients in their primary language including notices, etc. • Signage and Wayfinding to help reduce stress and facilitate timely care • Develop written language assistance plans • Hispanics with language-discordant M.D. s are more likely to omit medications, miss appointments, visit emergency rooms for care than those with Spanish speaking doctors.

27. Basic Strategies • Speak clearly and slowly without raising your voice, avoiding slang, jargon, humor, idioms • Use Mrs. Miss, Mr. , avoid first names which may be considered discourteous in some cultures • Avoid gestures- they may have a negative connotation • Sign Language is not mutually understandable • Some individuals believe illness is caused by supernatural or by environmental factors like cold air. Do not dismiss as they play an important role in some people’s lives. • Many carry or wear religious symbols- Sacred threads worn by Hindus, native Americans- medicine bundles

28. Limited English Proficiency (LED) • Determine Language needs at the point of contact • A wide variety of language interpreters are available through Language Line Services - In-service will be forthcoming • Using phone interpreters • Confidentiality-private room with a speaker phone • Setting the Stage –summarize the situation • Time Constraints- plan ahead with questions and allow for extra time • On site interpreters • Position Interpreter beside patient facing you • Address patient directly, not interpreter-ask interpreter to speak in first person so he/she can melt into the background • Family members as translators is least desirable option=error, lack of knowledge, biases, selective communication

29. Questions to Explore • Primary and secondary language • Educational level- here or home country • Years in U.S./ degree of assimilation • Needs: interpreter, food, dietary, religious, cultural • Living arrangements • Who will make client’s health care decisions • Family values • Communication style

30. Lessons Learned • Don’t assume sameness. • What you think of as normal behavior may only be cultural. • Familiar behaviors may have different meanings. • Don’t assume that what you meant was what was understood. • Don’t assume that what you understood was what was meant. • You don’t have to like or accept different behavior, but you should try to understand where it comes from. • Most people do behave rationally; you just have to discover the rationale. Adapted from Craig Storti’s Cross Cultural Dialogues

31. Resources • Culture Clues- tip sheets focused on improving the communication between patients and health care professionals, developed by the University of Washington Medical Center http://depts.washington.edu/pfes • Cue Cards- a multilingual resource to help with health information translation http://www.healthtranslations.vic.gov.au/bhcht.nsf/presentDetail?Open&s=Cue_Cards • Find the resources you need to educate yourself/develop a cheat sheet of cultural issues that affect care.

32. Bridging the Gap- Applying Your Knowledge • RHFW Resources • Internet Resources • Community Resources • Learn about communities we serve and their health seeking behaviors and attitudes • Office Environment • Develop training and appropriately tailored care-giving • Perform self audits • Ask staff to assist with designing ways to provide a supporting and encouraging environment • Provide staff with enriching experiences about the role of cultural diversity

33. The Asian American Patient • Diverse population-Chinese, Filipino, Vietnamese, Korean, Japanese • Traditional Asian Definition of Causes of Illness is based on harmony expressed as a balance of hot and cold states or elements • Practices • Coining- coin dipped in metholated oil is rubbed across skin =release excess force from the body • Cupping-heated glasses placed on skin to draw out bad force • Steaming • Herbs • Chinese Medical Practices- acupuncture • Norms about touch… head is highest part of body and should not be touched • Modesty highly valued • Communication based on respect, familiarity is unacceptable

34. Burmese Refugees • As of 2000, most of the estimated 20-30,000 Burmese living in the U.S. were immigrants of religiously, ethnically and linguistically diverse populations(150 separate sub-groups) Buddhists comprise 89% of the population. • Burma is one of 22 countries with a high burden of TB. • Burma has one of the worst health systems in the world. • In the past two years Burmese refugees have settled in Syracuse, Phoenix, Minneapolis, Dallas, and Ft. Wayne- many from rural villages • Challenging population to work with because of history of persecution and mistrust of the government • Burmese culture may be described as a more collectively-oriented, favoring indirect, nuance style communication • Discuss communication with interpreter and involve “cultural bridge” if possible

35. Burmese Refugees • Burmese traditional medicine is based on the classical health care system of India where health is related to interactions between: • The physical body • Spiritual elements • Natural world • Dat system: Wind, Fire, Water, Earth and Ether elements • Illness is considered an psychological imbalance until final stages when it is classified as a disease • Burmese Spiritualism linked with beliefs about cause, progression and treatment of illness. • Treatment may incorporate spiritual healing and exorcism of ghosts, witches, demons and nats • Muslim Burmese may use amulets-a verse based on Muslim Numerology and Burmese Astrology written on paper and tied up tightly with a thread and worn about a part of the body • Karen Practcioners diagnose disease by wrist pulses and examining face and eyes

36. Amish Society • There are four groups of Amish • Swartzentruber and Andy Weave Amish practice strict shunning and are ultra conservative in their use of technology • Old Order Amish is largest group- little or not modern technology • Beachy Amish more relaxed discipline • New Order Amish have liberal views but high moral standards • Life is given and taken by God • Disability is feared more than death • Elderly ration care during end of life to not burden the community or church’s resources • Usually don’t have health insurance as it is considered a worldly product ; the community comes together to pay costs • Speak to both husband and wife- partners in family life

37. Amish Society • Four Basic Rules: • More health professionals will come in contact with Amish population- growing population • Beliefs and behaviors are specific to the particular church district of which they are a member • Amish consider health care preferences from a holistic view- skill as well as their relationship and reputation with Amish patients count • Amish will continue to change, as will their health care needs and preferences

38. Amish Health Beliefs • Powwowing-physical manipulation /therapeutic touch /draws illness from body • Illness endured with faith and patience • Technology in the hospital for treatment is generally accepted • Belief in fate is common/ recognize external locus of control • Three generational family structure/they care for their elderly • Photographs are not permitted; mirrors are not permitted

39. Hispanic Health Beliefs and Practices • Preventative care may not be practiced • Illness is God’s will and recovery is in His hands • Hot and Cold Principles apply • Expressiveness of pain is culturally acceptable • Family may not want terminally ill told as it prevents enjoyment of life left • Being overweight may be seen as a sign of good health and well being • Diet is high in salt, sugar, straches and fat • High respect for authority and the elderly • Provide same sex caregivers if at all possible

40. Asian Indian • Health encompasses three governing principles in the body • Vata energy and creativity • Pitta optimal digestion • Kapha strength, stamina and immunity • Herbal Medicines and treatments may be used • Modesty and personal hygiene are highly valued. • Right hand is believed to be clean (religious books and eating utensils): left hand dirty (handling genitals) • Stoic/value self control; observe non verbal behavior for pain • Husband primary decision maker and spokesman for family

41. Asian Indian • Courtesy and self-control are highly valued • Close family units/ may desire to stay in hospital and be included in personal care of the patient. • Very important to provide privacy after death for religious rites • Generally vegetarians. Beef is forbidden. • Fasting is significant and crucial to consider in diet teaching • Many clients are lactose-intolerant

42. New and Emerging Knowledge • Cultural Competency Development is a Journey – not a goal • Linking Communication to health outcomes • Communication • Patient Satisfaction • Adherence • Health Outcomes

43. Cultural and linguistic competence is a life’s journey … not a destination Safe travels!

44. References • Andrews, Janice Dobbins, Cultural, Ethnic and Religious Reference Manual, Jamarda Resources,Inc., 1999 • The Providers Guide to Quality and Culture, http://erc.msh.org • Cultural Diversity in Health Care, http://www.ggalanti.com • The State of Health Care Diversity and Disparity : A Benchmark Study of U.S. Hospitals, Institute for Diversity in Health Management, October 2008 • Teaching Cultural Competence in Physical Therapy Education, Committee on Cultural Competence , June 2008 • What is Cultural Competency?- The Office of Minority Health, http://omhrc.gov. • Teaching Cultural Competence in Nursing and Health Care: Inquiry, Action, and Innovation by Seebert, Nancy, August 2006 • Amish Society, An Overview Considered, Journal of Multicultural Nursing and Health, by Donnermeyer, Joseph, Fredrich, Lora, Fall 2002 • The Case for Cultural Competence in Health Care Professions Education by Shaya, Fadia & Gbarayor, Confidence, January 2006, • http://www.pubmedcentral.nih.gov • University of Michigan Health System Multicultural Health Program, • http://www.med.umich.edu/multicultural • The Asian American Patient and Diabetes, MMCD Health Education, Diabetes • Self Management • TB and Cultural Competency, Northeastern Regional Training and Medical Consultation Consortium, Spring, 2008

45. References • Defining Cultural Competence :A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care, by Betancourt, Joseph, Green, Alexander, Carrillo, j, Emillo, Firempong, Owusu, Public Health Records, July-August, 2003, Vol. 118 • Communicating Across Boundaries: Beliefs and Barriers by Gardner, Marilyn • http://www.diversityrx.org • Challenges Encountered When Teaching Cultural Competence, http://medscape.com • Getting the Most from Language Interpreters, by Herndon, Emily & Joyce, Linda, June 2004 http://www.aafp.org • Health Care Language Service Implementation Guide, https://hclsig.thinkculturalhealth.org

46. References • Racial and Ethnic Disparities in U.S. Health Care : a Chartbook, March 2008, www.commonwealthfund.org

47. www11.georgetown.edu/research/gucchd/nccc • www.mchb.hrsa.gov • www.championsforprogress.org • www.cshcndata.org • www.familyvoices,inc. Trish Thomas • Diana Denboba, Branch Chief 301-443-9332; DDenboba@hrsa.gov • Wendy Jones, CSHCN Program Director NCCC, 202 687-5531