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A system of shared beliefs, values, customs, behaviors, and artifacts that members of society use to cope with their worlds and with one another. It is passed down from generation to generation through learning.
Fratkin Bates, Cultural Anthropology, 2002.

Provides us with:
A sense of belonging. A sense of identity. A feeling of cohesiveness. A sense of connectedness to those who came before and to those who will come after.
M.K. Moos, Cultural Competence in the Care of Childbearing Families, March of Dimes Birth Defects Foundation, 2003.

Race = A tribe, people, or nation belonging to the same stock; a division of humankind possessing traits that are transmissible by descent.
National Center for Cultural Competence

Ethnic = Large groups of people classed according to common ancestry and national, religious, tribal, linguistic, or cultural origins. Ethnicity = A sense of identity an individual has. How one sees oneself and how one is seen by others as part of a group on the basis of presumed ancestry and sharing a common destiny.
Institute of Medicine (IOM) 1999 Report

Cultural Diversity
According to the 2000 U.S. Census Data:

16.7% of Florida residents were foreign born (up from 12.9% in 1990)
Region of birth of foreign born: 72.8% Latin America 13.3% Europe 8.7% Asia 3.8% Northern America 1.3% Africa 0.2% Oceania

Cultural Diversity
2000 U.S. Census Florida Data: 78% 14.6% 1.7% 0.3% 0.1% 3.0% 2.4% 16.8% White Black or African American Asian American Indian Native Hawaiian/ Pacific Islander Other Multi-racial Hispanic or Latino origin

Cultural Diversity
According to the 2000 U.S. Census Florida Data: 23.1% of total Florida respondents stated a language other than English spoken at home. (Up from 17.9% in 1990.) 10.3% of the total respondents from Florida answered that they speak English “less than very well.” (Up from 7.9% in 1990.)

Changes or adaptations in cultural beliefs, values, and traditions resulting from contact with other cultures over time. Borrowing of certain traits by one culture from another. Can have negative or positive effects.

What is Cultural Competence?

Cultural Competence
Requires that organizations have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively crossculturally
Developmental Disabilities and Bill of Rights Act of 2000

Elements of Cultural Competence
Value diversity. Conduct cultural assessment of self and system. Manage the dynamics of difference. Acquire and institutionalize cultural knowledge. Adapt to diversity and cultural contexts of the communities served.
The National Center for Cultural Competence, 2004.

Cultural Competence
Extends beyond addressing language barriers and providing translation services. Extends beyond simply hiring staff of diverse racial backgrounds.

Culturally Competent Services
Services provided in a manner that demonstrates respect for individual dignity, personal preference, and cultural differences.

Developmental Disabilities and Bill of Rights Act of 2000

Cultural competency is:
A process not an event;
A journey, not a destination;

Dynamic, not static;
And involves the paradox of knowing.
Dr. Josepha Campinha-Bacote, Ph.D., A.P.R.N., B.C., C.N.S., C.T.N., F.A.A.N., President and Founder of C.A.R.E. Associates of Cincinatti, Ohio.

Why do we Need to Be Culturally Competent?
1) Improve the quality of services. 2) Meet legislative and accreditation mandates. 3) Gain a competitive edge in the marketplace. 4) Decrease the likelihood of liability and malpractice claims.
Georgetown University Center for Cultural Competence

Public Health Providers
Our main focus is to improve health outcomes.
Health Promotion = The process of enabling people to increase control over the detriments of health and thereby improve their health.
World Health Organization 1998

Health Promotion Involves:
Actions directed at strengthening skills and capabilities of individuals. Actions directed toward changing social, environmental, and economic conditions so as to alleviate their impact on public and individual health.
World Health Organization 1998

To accomplish the goal of improving health outcomes we must first understand:
Barriers to health improvement. Motivators to health improvement. The relevance of our methods. Effective ways to empower individuals.

Partnership for Clear Health Communication

Literacy = An individual’s ability to read, write, speak in English, compute, and solve problems at levels of proficiency necessary to function on the job, in the family, and in the society.
Workforce Investment Act of 1998

Health Literacy = The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Healthy People 2010

Agency for Health Care Research and Quality (AHRQ) found a positive, significant relationship between literacy level and a participant’s knowledge of health issues.
People with low health literacy are more likely to report poor health, have an incomplete understanding of their health problems and treatment, and be at a greater risk of hospitalization.
AHRQ Evidenced Based Practice Program

Magnitude of Health Literacy
A national adult literacy study, done in 1993, found that 48% of adults do not have the literacy skills necessary to function adequately in society.

Cost of Low Health Literacy
The direct medical costs of low, functional literacy are financed through additional hospital and office visits, longer hospital stays, extra tests, procedures, and prescriptions.
Center For Health Care Strategies, Inc.

Cost of Low Health Literacy

Center For Health Care Strategies, Inc. Source: Estimates from 1998 Medical Expenditure Survey by the Center on an Aging Society

“Often, the people with the greatest health burdens, have the least access to information.” “Even with access to information and services, disparities still exist because many people lack health literacy.”
Healthy People 2010

“Ask Me 3”
An initiative developed by the Partnership for Clear Health Communication. Identifies the three (3) most important questions a patient can ask to help understand their health status.

Limited English Proficient (LEP) = An individual who is unable to speak, read, write, or understand the English language at a level that permits him or her to interact effectively with health and social services agencies and providers.

Linguistic Competence = The capacity of an organization and its personnel to effectively communicate with persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities.

Title VI
Title VI of the Civil Rights Act of 1964 prohibits discrimination by Federallyfunded entities based on: – Race – Color – National Origin
DOH Policy Related to Limited English Proficiency – DOHP 220-3-00

In December 2000, The Federal Office of Minority Health developed standards for what is now known as, “culturally and linguistically appropriate services (CLAS).”

CLAS Standards
The 14 Standards are divided into three (3) categories of varying stringency:

CLAS Mandates CLAS Guidelines CLAS Recommendations

CLAS Mandates
Standard 4: Health care organizations, receiving Federal financial assistance, must offer and provide language assistance services, including bilingual staff or interpreter services, at no cost to each patient/consumer with limited English proficiency, at all points of contact, in a timely manner, during all hours of operation.

CLAS Mandates
Standard 5: Health care organizations must provide to patients/consumers, in their preferred language, both verbal offers and written notices informing them of their right to receive language assistance services.

CLAS Mandates
Standard 6: Health care organizations must assure the competence of language assistance provided to limited, English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used (except upon request by the patient/consumer).

CLAS Mandates
Standard 7: Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonlyencountered groups and groups represented in the service area.

Potential risks/losses when language services are not provided:
Client unable to access eligible services or programs. Client unable to exercise important rights, including informed consent. Client unable to comply with provider requirements and requests. Lost opportunities to decrease disparities/outreach on important health issues affecting LEP communities.
FL DOH Bureau of TB and Refugee Health

Longer “contact” times equal ineffective time management; productivity is affected. Frustration on both sides impairs relationship building with clients and their community, decreases credibility of programs/staff. Incurring “hidden” costs due to unnecessary testing and diagnostics, over-prescribing, and repeat visits, etc.

FL DOH Bureau of TB and Refugee Health

Who Can You Use As An Interpreter?
Individuals who have had their language skills assessed, who are trained and successfully evaluated in the skills, modes, and ethics of interpreting.
FL DOH Bureau of TB and Refugee Health

Language Assistance Options
Trained bi-lingual staff (other primary tasks with interpreter duties as adjunct). On-staff interpreters (employees of the organization with specific interpreter duties only).

Contract interpreters (contractors paid by the encounter, not employees, on an on-call basis).
Telephone interpreters (contracted agency specializing in the provision of interpreter services via phone).
FL DOH Bureau of TB and Refugee Health

Least Preferred Options For Providing Language Services
Family or friends
Minor Children Volunteers Patients/clients waiting in the office
FL DOH Bureau of TB and Refugee Health

This Is Why!
Because – Using Family, Friends, Minor Children, Volunteers, Strangers, and Other Patients: Exposes the agency to liability under Title VI. May result in a breech of confidentiality. May result in the client being reluctant to fully disclose critical information. Increases agency liability due to them not being competent. May result in additions, omissions, and changes in content. May destroy the “power base” within the family.
FL DOH Bureau of TB and Refugee Health

For more information:
CLAS Mandates: The Office of Minority Health website at: Interpretation and Translation Services (ITS): Contact Wilma Jackson, ITS Program Manager, Florida Department of Health, Bureau of TB and Refugee Health at: (850)245-4444, extension 2314.

The Journey

To learn every aspect of each culture that could influence a medical encounter would be impractical if not impossible. Simply relying on knowledge about particular aspects of specific groups may in fact lead to stereotyping and categorization of a culture.

What should we do?

Step One: Self-Assessment
Cultural knowledge Biases Stereotyping Health care beliefs

“Who we are determines how we see others.” “It is not what is around us but rather what is within us that determines what we see”

John Maxwell – The Lens Principle

Step Two: System Assessment
Collect, analyze, and report on the diversity in your patient population. Use a standardized tool to annually assess the understanding and effectiveness of the care delivery system.

System Assessment
“Evidence suggests that a lack of diversity in the leadership and workforce of health care organizations results in structural policies and procedures, and delivery systems inappropriately designed or poorly suited to serve diverse patient populations.”
Health Forum Journal 1999; 42:22.

System Assessment
Individuals will encounter the “front desk staff” prior to seeing a health care provider.

The encounter of a patient with the “front desk staff” can have a greater affect on the patient and their family than the encounter they experience by the health care provider.

System Assessment
It is vital to have all staff who encounter clients to participate in the organizations cultural competency training.

“Cultural Competence: It All Starts at the Front Desk,” National Center for Cultural Competence.

Step Three: Cultural Desire
Having a commitment and passion for caring. Motivation of the health care provider to “want” to engage in the process of cultural competence.
Dr. Campinha-Bacote The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care. Journal of Transcultural Nursing. 2002; 13:181-184.

Step Four: Cultural Attitude
Remain open to learning. Respect differences. Get involved with your community. Attend periodic, cultural training programs. Remain flexible and be willing to adapt.

Cultural Attitude
Attitudes important in effectively engaging in cross-cultural care are:
Humility Empathy Curiosity Respect Sensitivity Compassion Authenticity Openness Availability.
Academic Medicine (2003) 78: 560-569.

Step Five: Communication Skills
Communication is the foundation of all relationships. Research has shown that how patients perceive their connection with their health care provider significantly influences their sense of satisfaction and level of concern about their health.
Communication Behaviors and Being in Relation. Family Medicine. 2002; 34:319-324.

Health Communication = The study and use of communication strategies to inform and influence individual and community decisions that enhance health.

Communication Skills
Social and cultural factors determine differences in expectations, agendas, concerns, meanings, and values between patients and provider.
Surveys show that minority patients feel they are judged unfairly based upon race and how well they speak English.
Racial & Ethnic Differences in patient perceptions of bias and cultural competence in health care. Journal Gen Intern Med. 2004; 19-101-110.

Communication Skills
Providers need to assess what is the patient’s perspective on their disease or illness.
Does the patient believe they have a problem? Do they perceive a need to make a change? Do they understand and “buy into” the treatment plan?

Communication Skills
Folk Illness: Culturally-constructed disease or illness commonly recognized by an ethnic group, often in conflict with biomedical paradigms.
Sometimes the treatments for folk illnesses may cause harm.
Annals of Internal Medicine 1999; Volume 130;10:829-834.

Empacho = A condition in which it is believed that a substance gets stuck to the walls of the stomach.
Symptoms include: diarrhea, vomiting, stomach cramps, and bloating. Patients will frequently consult a folk healer who performs special massage, prayers, and dietary modification. Multiple cases of lead toxicity have been documented among children whose empacho was treated with a folk remedy called greta, azarcon, or albayalde containing high levels of lead oxide.
Arch Pediatric Adolescent Medicine 1995; 149:978-981

Communication Skills
Providers must learn to communicate in an open, sensitive, and nonjudgmental manner.
How we say something is equally, if not more important, than what we are saying.

Communication Skills
Involves using a variety of tools and techniques to convey the message. Recognize that culture, environment, poverty, and education all influence how a message is perceived. Involves both verbal and non-verbal communication methods.

Non-Verbal Communication
Facial Expressions Gestures Personal Distance Sense of Time Seating Arrangements

Non-Verbal Communication
Facial Expressions

Some elements of non-verbal communication may be consistent across cultures such as the emotions of fear, anger, sadness, and surprise. In some cultures, a nod or smile simply means that they heard you – it may not signify an understanding or agreement.

Non-Verbal Communication
Eye Contact In Western culture, direct eye contact is viewed as a positive communication skill. Eye contact in certain Asian and Hispanic cultures is not appropriate.


Personal Space
How close is too close?

Touch – When is it appropriate?

Sense of Time
Is time considered precise or relevant?
Be mindful of clinic hours in relation to cultural beliefs and occupations.

Seating Arrangements
The position the provider takes when speaking with a patient can influence the effectiveness of the communication.
Do you face the patient? Are you standing over or sitting higher than the patient? In a group setting – sitting in a circle is more conducive to sharing than sitting classroom style.

Communication Styles
Cultures may vary in standards for:
Gender Loudness of speech Speed of delivery Silence Attentiveness Timing of when to enter a conversation Decision making

Invite, Listen, and Summarize
An innovative method for teaching communication skills to medical residents at the University of Colorado School of Medicine. Emphasizes the techniques of: Asking open-ended questions. Showing empathy. Using engagement to gather data.

Communication Skills
Open-Ended Questions:
Ask the patient to explain, in their own words, what their illness or problem is. Ask them in what ways their illness or problem is affecting their life. Give careful explanations and rationale for your treatment plans. After giving instructions or a treatment plan, have them explain it back to you.

Communication Skills
Empathetic Listening
Active listening with the intention and commitment of truly understanding the other person before seeking to be understood.

Communication Skills
Utilize members of the community and local partnerships to serve as teachers and experts of their particular cultures.

Patient Education
All materials must be culturally and linguistically competent. Our goal should be to consider the patient a partner in care. Rather than “telling” the patient the best action to take - empower them to learn about their health and encourage them to take steps to improve.

Patient Education
Two (2) main principles:
Simplicity Reinforcement

Patient Education

Verbal patient education should be given in a language the patient understands.
Information should be written at appropriate readability levels. (Average adult in the U.S. reads at a 6th-8th grade reading level.) Avoid medical terminology whenever possible.

Patient Education

Teach the most important concept first and repeat it at the end. Ask clients to re-state what you have taught them. Use a variety of media in the educational process. Always supply written information for the patient to take home.

Points to Remember
All communication is cultural – it draws on ways we have learned to speak and give nonverbal messages. Culture is central to what we see, how we perceive, and how we express ourselves. Learn from generalizations but do not use them to stereotype. Do not assume all English speaking clients have the same belief system concerning health care. Do not assume there is a right way to communicate (yours)!

Thank you!

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