Health Resources and Services Administration & Social Solutions International, Inc. July 2012

1. The State & Community Intimate Partner Violence (IPV) & Perinatal Depression (PD) Resource Development Project: Cultural Competency Health Resources and Services Administration & Social Solutions International, Inc. July 2012 IPV/PD: A Comprehensive Approach

2. Webinar Speakers and Guests Moderator: Kristen Stier, MASocial Solutions International, Inc. KeisherHighsmith, DrPHHRSA/Maternal and Child Health Bureau Speaker: SuganyaSockalingam, PhD Change Matrix Speaker: Darby Taylor Des Moines Healthy Start Project IPV/PD: A Comprehensive Approach

3. Objectives Understand what cultural and linguistic competency is and why it is important for addressing IPV/PD Learn how to examine cultural competence in your organization Discover tools for staff development related to cultural competence IPV/PD: A Comprehensive Approach

4. Toolkit Goals Provide a guide that is culturally and linguistically appropriate to support community-based programs with making the case for why its important to address the IPV/PD intersection. Assist communities in reducing stigma and provide strategies for building partnerships and increasing support from leadership To improve the health and safety of families experiencing IPV and PD IPV/PD: A Comprehensive Approach

5. Cultural and Linguistic Competence SuganyaSockalingam, Ph.D. Managing Member & Co-Founder Change Matrix IPV/PD: A Comprehensive Approach

6. Cultural and Linguistic Competence • Explore an Overview of: • Population Demographics • Group Diversity, Culture, and Values • Cultural Influences on health • Identify a Framework for Approaching Culturally Competent Care IPV/PD: A Comprehensive Approach

7. Demographics IPV/PD: A Comprehensive Approach

8. Women Impacted by IPV Source: CDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366 IPV/PD: A Comprehensive Approach

9. Women Impacted by PPD • An overview of: • cultural and linguistic competence, • group diversity, culture, and values • issues related to health IPV/PD: A Comprehensive Approach

10. CDC Data • Women more likely to report Postpartum Depressive Symptoms: • Younger women • Those with lower educational attainment • Women who received Medicaid benefits for their delivery • Non-Hispanic white women had a lower prevalence of PDS compared with women of other racial/ethnic groups CDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366 (http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm) IPV/PD: A Comprehensive Approach

11. Population by Race/Ethnicity – Women Impacted by PPD Source: CDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366 IPV/PD: A Comprehensive Approach

12. IPV in Immigrant and Refugee Communities • Immigrant & refugee women vulnerable due to: • Poverty • Limited language proficiency • Social isolation • Immigration status • Confusion over their legal rights • Stress of adaptation to new culture • Disparities in economic and social resources • Effects of IPV on Immigrants/Refugee women: • Mental health -- depression, posttraumatic stress, anxiety symptoms and disorders, substance abuse • Reproductive/sexual health – miscarriage, unwanted pregnancies Intimate Partner Violence in Immigrant and Refugee Communities: Challenges, Promising Practices and Recommendations. A Report by the Family Violence Prevention Fund for the Robert Wood Johnson Foundation (March 2009) IPV/PD: A Comprehensive Approach

13. IPV, PPD Resources • Intimate Partner Violence in Immigrant and Refugee Communities: Challenges, Promising Practices & Recommendations (March 2009) • http://www.rwjf.org/files/research/ipvreport20090331.pdf • Lifetime Prevalence of Rape, Physical Violence, and/or Stalking by an Intimate Partner, by Race/Ethnicity — U .S . Women, NISVS 2010 • http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf • CDC – MMWR Weekly; April 11, 2008/ 57(14) • http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm IPV/PD: A Comprehensive Approach

14. Group Diversity, Culture and Values IPV/PD: A Comprehensive Approach

15. Factors That Influence Diversity Among Individuals and Groups Internal Factors • Ethnic/Racial/Tribal Identity • Socioeconomic Status/Class • Nationality • Language • Family Constellation • Social History • Health Beliefs & Practices • Perception of Disability • Education • Perception of Health (including mental health) Internal Factors • Age & Life Cycle Issues • Spatial & Regional Patterns • Gender & Sexuality • Sexual Orientation • Religion & Spiritual Views • Political Orientation & Affiliation • Acculturation/assimilation level Source: National Center for Cultural Competence, 2002 - modified from James Mason, Ph.D. IPV/PD: A Comprehensive Approach

16. Factors That Influence Diversity Among Individuals and Groups, cont. External Factors • Institutional Biases • Community Economics • Intergroup Relations • Natural Networks of Support • Community History • Race relations External Factors • Political Climate • Workforce Diversity • Community Demographics • Migratory Patterns • Group & Community resiliency Source: National Center for Cultural Competence, 2002 - modified from James Mason, Ph.D. IPV/PD: A Comprehensive Approach

17. Challenge in Recognizing Diversity IPV/PD: A Comprehensive Approach

18. Definitions of Culture sum of total of the learned behavior of a group of people generally considered to be tradition and transmitted from generation to generation collective programming of the mind that distinguishes one group from another culture, including their embodiments in artifactsconsists of the distinctive achievement of human groups cultivated behavior through social learning way of life of a group of people symbolic communication deliberately perpetuated in a society through its institutions culture = communication systems of knowledge shared by group of people Cumulative deposit of Knowledge, Experience, Beliefs and Attitudes IPV/PD: A Comprehensive Approach

19. Iceberg Metaphor for Culture How individuals are perceived by the world and how they are (in actuality) in the world can differ by how much we understand of what is in our consciousness and what is “out-of-awareness” Just as nine-tenths of an iceberg is out of sight (below the water line) so is nine-tenths of an individual or organizational culture - out of our conscious awareness. The top of the iceberg represents manifestations or surface levels of the organizational culture. They are primarily in our awareness for example - cultural artifacts: such as dress, coffee mugs, physical layout The lower levels of the iceberg operate unconsciously, are shared by all members, and define in a basic way the “taken for granted” view of the individual, and organization and its environment. To change the individual or organization, you must be aware of all levels. Change must take place below the water line. IPV/PD: A Comprehensive Approach

20. Iceberg IPV/PD: A Comprehensive Approach

21. Continuum of Values • Fate • Tradition • Human Orientation • Hierarchy/Rank/Status • Group Welfare • Cooperation • Past-Orientation • Time-Linear Orientation • Formality • Idealism • Spiritualism • “Being” Orientation • Personal Control Over Life • Change • Object Orientation • Individual Equality/Egalitarian • Individualism/Privacy • Competition • Future Orientation • Time-Event Orientation • Informality • Practicality/Efficiency • Materialism • Action/Goal/Work Orientation IPV/PD: A Comprehensive Approach

22. Cultural Influences on Health IPV/PD: A Comprehensive Approach

23. Cultural Influences on Health Seeking Behaviors & Attitudes Diverse beliefs about health, disease, and disease management Reliance on traditional healers, practices, and medicines Mistrust of health care professionals and institutions outside of own culture Experiences of racism, discrimination and bias Communication/Linguistic barriers Lack of understanding of western medical systems IPV/PD: A Comprehensive Approach

24. Health Seeking Behaviors IPV/PD: A Comprehensive Approach

25. What is cultural and linguistic competence? A Framework for approaching health care issues in an appropriate and effective way IPV/PD: A Comprehensive Approach

26. Definitions • Cultural Competence • capacity to function effectively in cross-cultural situations at an individual, organizational and systems level Cross, Bazron, Dennis, and Isaacs, 1989 • Linguistic Competence • convey information in a way easily understood by diverse groups (language, literacy and communication formats) Goode and Jones, 2004 IPV/PD: A Comprehensive Approach

27. Cultural Competence Continuum Cultural Proficiency Cultural Competence Cultural Precompetence Cultural Blindness Cultural Incapacity Cultural Destructiveness Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center IPV/PD: A Comprehensive Approach

28. Elements of Cultural Competence – Organizational Level • value diversity • conduct cultural self-assessment • manage the dynamics of difference • institutionalize cultural knowledge • adapt to diversity • - policies - structures • - values - services IPV/PD: A Comprehensive Approach

29. Elements of Cultural Competence – Individual Level acknowledge cultural differences understand your own culture engage in self-assessment acquire cultural knowledge & skills view behavior within a cultural context Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center IPV/PD: A Comprehensive Approach

30. Elements These five elements must be manifested at every level of an organization including: • policy making • administrative • practice/service delivery • consumer/family • community and reflected in its attitudes, structures, policies and services Adapted from Cross, Bazron, Dennis, & Isaacs, 1989 IPV/PD: A Comprehensive Approach

31. Contact Us SuganyaSockalingam, Ph.D. Partner Change Matrix LLC 2721 Breakers Creek Drive Las Vegas, NV 89134 Phone: 702-219-7379 E-mail: ssockalingam@changematrix.org Website: www.changematrix.org IPV/PD: A Comprehensive Approach

32. Cultural and Linguistic Competency:A Provider Perspective Darby Taylor Healthy Start Project Director Des Moines Healthy Start Project Des Moines, Iowa IPV/PD: A Comprehensive Approach

33. Program Description Des Moines Healthy Start: Provides comprehensive home-based services to address perinatal health, child health, social services, parenting, and child development for high-risk families with pregnant women and children under two years of age in a nine zip-code area in Polk County, Iowa (363 families served last year) Empowerment (State Funds): Expands geographic area to all of Polk County and age of child to six (308 families served last year) IPV/PD: A Comprehensive Approach

34. Numbers ServedJune 1, 2011 – May 31, 2012 • Case Management Services for the Des Moines Healthy Start Project: • 671 families and 682 children were served during the Fiscal Year 11-12 • 8,000 face-to-face visits were completed by case managers • 20 Case Managers and 19 full and part time Outreach Workers IPV/PD: A Comprehensive Approach

35. Des Moines, IowaCensus Data, 2010 • Population: • Iowa - 3,046,355 • Des Moines (capital city) - 203,433 • Polk County - 430,640 • Caucasian-only population: • Iowa - 91.3% • Des Moines - 76.4% • Primary language other than English: • Iowa - 6.8% • Des Moines - 16% IPV/PD: A Comprehensive Approach

36. Participant Ethnicity, Des Moines Healthy Start June 1, 2011 – May 31, 2012 12% 30% 34% 24% IPV/PD: A Comprehensive Approach

37. Participant Language, Des Moines Healthy StartJuly 1, 2011 – June 30, 2012 29% 38% 5% 28% IPV/PD: A Comprehensive Approach

38. Participant Primary LanguageDes Moines Healthy Start • English is the primary language of only about 1 in every 3 Healthy Start participants • During FY 11-12, 38% of participants spoke a language other than English, Spanish, or Arabic (a 21% increase from 2010) • Participants spoke a total of 28 languages including: Bassa; Karen; Nepali; Burmese; Karenni; Nuba; Chin; Kirundi; Nuer; Thai; Krahn; Pashto; Dinka; Kunama; Somali; Grebo; Laotian; Swahili IPV/PD: A Comprehensive Approach

39. Changes in Population: Des Moines, Iowa2007 - 2012 • Refugee arrivals in Polk County between 2007 and 2010 (out of 1,829 total arrivals): • 37 Vietnamese • 52 Sudanese • 641 Burmese • During FY 11-12, 164 families from Burma received services through Des Moines Healthy Start IPV/PD: A Comprehensive Approach

40. Des Moines Healthy Start Outreach Services • 6 Full-Time and 13 Part-Time Outreach Workers/Interpreters (High School Diploma and bilingual): • Speak a total of 20 languages (Arabic, Bendi, Burmese, Chin Lai, Chin Mizo, Chin Phalam, Chin Zo Mi, Hindi, Kachin, Karen, Laotian, Nepali, Nuer, Nuba, Somali, Spanish, Swahili, Thai, Thai Dom, Vietnamese) • Challenges • Recruiting/hiring • Small communities and pressure placed on staff within their own communities IPV/PD: A Comprehensive Approach

41. Case Management ServicesDes Moines Healthy Start • 20 Case Managers (Bachelor’s Degree in Human Services related field and two years’ experience): • 8 Case Managers bilingual in English and Spanish • 1 Case Manager trilingual in English, Arabic, and Nuba • 1 Case Manager trilingual in English, Spanish, and French • 1 Case Manager with VNS maintains a caseload dedicated to African American families residing in the Healthy Start project area IPV/PD: A Comprehensive Approach

42. Staff Recruitment Des Moines Healthy Start • Project population discussed extensively during interviewing process • Sample interview question: “How would you respond to behaviors or customs that conflict with your own beliefs or knowledge of best practices (for example, as it relates to child rearing or discipline)?” • Outreach Specialists are recruited directly from the target communities; they then help identify and recruit other community members and leaders to work for the project • Case managers and participants receive specific education to work with Interpreters (triadic relationships) IPV/PD: A Comprehensive Approach

43. Staff TrainingDes Moines Healthy Start • Monthly all-staff meetings; most include training related to cultural competence • Outreach Specialists and participants provide education to case managers, formally and informally • Program offers ongoing support groups, nutrition groups, and parent/child interaction groups targeting different populations • Participants hold traditional celebrations as part of these groups; rich education opportunity for staff • Program staff asked to attend and honored at community celebrations IPV/PD: A Comprehensive Approach

44. Depression, Des Moines Healthy StartJune 1, 2011 through May 31, 2012 • 99% of women were screened for depression • Project has two licensed mental health therapists who can see participants regardless of insurance status • Contract with community-based psychiatrist IPV/PD: A Comprehensive Approach

45. Depression, Des Moines Healthy Start Project Cultural Challenges • Recognition of depression or mental health as a problem • Previous experiences in trauma • Stigma associated with depression • Starting support groups for Burmese women – critical to gain community buy-in IPV/PD: A Comprehensive Approach

46. Domestic Violence June 1, 2011 through May 31, 2012 • Only 7% of participants reported domestic violence as an issue • Believed to be very under-reported in our population • Limited resources – one shelter, lack of translated materials, lack of interpreters, smaller communities IPV/PD: A Comprehensive Approach

47. Domestic Violence, Des Moines Healthy Start Cultural Challenges • Fear of being alone in a new country without the ability to speak the language • May be culturally more acceptable • Lack of understanding of the system • Women may become more independent, which can be threatening to men • Increased availability and lower cost of alcohol in this country • Some success in presenting information in group setting vs. individually IPV/PD: A Comprehensive Approach

48. Culturally Competent Service DeliveryChallenges • A growing number of referrals due to increasing client need within the community has resulted in a waiting list for services • Successfully linking the refugee and immigrant populations to available community resources can be difficult or impossible • Need to identify better resources for identifying and addressing domestic violence • Large burden placed on staff by other community providers (lack of interpreters community wide) IPV/PD: A Comprehensive Approach

49. Culturally Competent Service DeliverySuccesses • Culturally and linguistically diverse staff provide case management, parent education, and outreach services • Project continues to adapt to respond to the changing needs of the community • Comprehensive depression screening and access to mental health services is a benefit • Hiring staff directly from the communities; utilizing these staff to provide ongoing education to others IPV/PD: A Comprehensive Approach

50. Culturally Competent Service DeliveryPoints to Consider & Where to Start • Barriers to learning English • Keeping traditions and languages alive • Empowering communities reduces dependency on services • Community members are the best source of education – ask questions and listen to the responses • Cultural Considerations Tool – p. 89; a great place to start IPV/PD: A Comprehensive Approach