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

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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
  patients social, cultural and linguistic needs.

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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.
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COMPETENCE
values
attributes
knowledge
skill set
requires values, attributes, knowledge and a
skill set to work effectively cross-culturally.
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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)
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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
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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?
Where did you grow up ? Where have you lived?
Who were family members that influenced you?
Who raised you?
Adapted from Suganya Sockalingam, NCCC Senior
Consultant
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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 ?
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Integration
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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.

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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.

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How well prepared are you to work with patients
of diverse populations?

• Do you consider the individuals 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?

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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.

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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 patients 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.

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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

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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.

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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.

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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

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Culture of Improvement

• Mission of RHFW/ Enhancing everyones
  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

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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

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Promising Communication Strategies

• LEARN Guidelines for Overcoming Obstacles in
  Cross Cultural Comminication
• L isten with empathy for the patients 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

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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 patients beliefs
• I ntervention
• Determine an intervention which may include
  alternative treatments- spirituality, healers,
  etc.
• C ollaboration with family, health care team,
  healers, community resources

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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 patients feelings

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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.

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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 peoples lives.
• Many carry or wear religious symbols- Sacred
  threads worn by Hindus, native Americans-
  medicine bundles

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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
  optionerror, lack of knowledge, biases,
  selective communication

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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 clients health care decisions
• Family values
• Communication style

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Lessons Learned

• Dont assume sameness.
• What you think of as normal behavior may only be
  cultural.
• Familiar behaviors may have different meanings.
• Dont assume that what you meant was what was
  understood.
• Dont assume that what you understood was what
  was meant.
• You dont 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 Stortis Cross Cultural
  Dialogues

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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?OpensCue_Cards
• Find the resources you need to educate
  yourself/develop a cheat sheet of cultural issues
  that affect care.

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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

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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

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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

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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 churchs resources
• Usually dont 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

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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

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Hispanic Health Beliefs and Practices

• Preventative care may not be practiced
• Illness is Gods 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

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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

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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

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New and Emerging Knowledge

• Cultural Competency Development is a Journey
  not a goal
• Linking Communication to health outcomes
• Communication
• Patient Satisfaction
• Adherence
• Health Outcomes

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Cultural and linguistic competence is a lifes
journey not a destination Safe travels!
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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

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References

• Racial and Ethnic Disparities in U.S. Health Care
  a Chartbook, March 2008, www.commonwealthfund.or
  g

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_at_hrsa.gov
• Wendy Jones, CSHCN Program Director
• NCCC, 202 687-5531