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Cultural Competency - Slide 1


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									                    Cultural Competency Learning
• 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
                    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
                    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
 Culture is an integrated pattern of human behavior which includes
 but is not limited to:

communication          values
                 manners of                           practices
customs          interacting
… of a racial, ethnic, religious, social, or political group; the ability
to transmit the above to succeeding generations; dynamic in nature.

             values                attributes

           knowledge               skill set

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

behaviors                   practices                           policies

            attitudes                   structures

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)
                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
                                   Peeling an Onion


                                                                                               During what decade
                                                                                               did you grow-up?

                                                                                                              What have been
                                                                                                              your life

             What is your
             religious                                                                                      Who have you worked
             background?                                                                                    with? Where have you

                            What schools
                            did you                                                                What area
                                           Who were family                     Where did you
                            attend?                          Who raised you?                       were trained
                                           members that                        grow up ?
                                                                                                   in? Area of
                                           influenced you?                     Where have
                                                                               you lived?

Adapted from Suganya Sockalingam, NCCC Senior Consultant
                  Tip of the iceburg
                         gender  language
                          race or ethnicity 

                          eye behavior                  Adapted by the NCCC
                       facial expressions 
                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 

                                              Community Engagement
Cultural Competence

                      Linguistic Competence

                                               Partnerships between
  Family Centered
                            Literacy                Families &
                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
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.
               Culture and Language may
• 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.
                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
• 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?
                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.
                    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.
                   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.
                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
• Non-English speaking patients may be reluctant to seek
  treatment in a timely manner
                Disparities in Health Insurance
• 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
• More than one/three Hispanics and American
  Indians/Alaska Natives do not have health insurance-triple
  that for whites.
                 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,
                 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
                   Culture of Improvement

• Mission of RHFW/ Enhancing everyone’s capabilities
• Value Added Component /rethink the way we provide
• 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
• Moving toward Pay for Performance /Quality incentive
                  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
                  Promising Communication
• 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
                         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
                   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
                  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.
                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
                      Limited English Proficiency
• 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
                  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
                        Lessons Learned

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

• 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

• Find the resources you need to educate yourself/develop a
  cheat sheet of cultural issues that affect care.
                  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
                    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
• Modesty highly valued
• Communication based on respect, familiarity is unacceptable
                     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
                      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
                  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
• Speak to both husband and wife- partners in family life
                   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
   • Amish will continue to change, as will their health care needs and
                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
• Belief in fate is common/ recognize external locus of
• Three generational family structure/they care for their
• Photographs are not permitted; mirrors are not permitted
                 Hispanic Health Beliefs and

•   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
                 Asian Indian

• Health encompasses three governing principles in the
   • 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
• Husband primary decision maker and spokesman for
                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
• Generally vegetarians. Beef is forbidden.
• Fasting is significant and crucial to consider in diet
• Many clients are lactose-intolerant
               New and Emerging Knowledge

• Cultural Competency Development is a Journey – not a
• Linking Communication to health outcomes
                   • Communication

                  • Patient Satisfaction

                      • Adherence

                   • Health Outcomes
    Cultural and linguistic
competence is a life’s journey …
        not a destination

         Safe travels!
•   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

• 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,

• Racial and Ethnic Disparities in U.S. Health Care : a
  Chartbook, March 2008, www.commonwealthfund.org
•   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;
• Wendy Jones, CSHCN Program Director
  NCCC, 202 687-5531

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