CULTURAL COMPETENCY Presented By Cathy Anderson Brandi Miller

CULTURAL COMPETENCY Presented By: Cathy Anderson Brandi Miller Jewish Vocational Service Wichita, Kansas

DAY ONE February 22, 2005 Wichita, Kansas

Jewish Vocational Service z. History: established in 1949 to resettle holocaust survivors and other refugees z. MISSION: to assist any individual with barriers to become more self-reliant by providing employment, training, personal development, and support services.

Jewish Vocational Service z Refugee/Immigration/Lang. & Cult. Svcs. Dept. includes refugee employment services, refugee resettlement, immigration counseling z Language and Cultural Services Dept. includes Interpreter Development Services, Cultural Competency training, Occupational Spanish classes, Title VI training, Provider training

Setting the Tone z. Expectations z. Training Goals z. Ground Rules z. Introductions

Trainer Expectations z Show respect by listening to each other and not interrupting. z Participate actively in the training. z Maintain strict confidentiality by not identifying specific individuals or clinics or anything else that could identify a client or provider and not sharing outside the classroom any of the personal stories that are told. z Give feedback in appropriate ways by starting feedback with a positive comment; avoid blaming; identify individual opinions as such.

Training Goals v Increase awareness of diversity v Expand definition of cultural competency v Improve service quality for diverse populations v Work more effectively with interpreters v Understand Title VI and Basic Components of Office for Civil Rights policy guidance v Improve cross-cultural communication and decrease potential misunderstandings

Your Goals z. What do you hope to learn from this training?

Icebreaker z Your name and what you do in your organization. z Who is your community?

Cultural Competency Self-Assessment Checklist z. Self-Assessment Checklist – Tamara D. Goode, Georgetown University Center for Child and Human Development

Welcome to a Changing World z. Demographics z. Health disparities z. Culture

Life by the Numbers • 3 billion : People in the world that live on less than $2 per day • 3: How many of the world’s top 10 wealthiest people it would take to exceed the gross domestic product of the world’s 48 poorest nations • 1 billion: billion People who entered the 21 st century unable to read a book or sign their name • 86: 86 Percent of the world’s goods consumed by 20 percent of the population in developed nations • 790 million: million People in the developing world who are chronically undernourished Source: www. globalissues. org

If the world were a village of 100 people. . . z z z 52 female; 48 male; 33 children; 6 over age of 65 58 would be Asian 79 would be persons of color 30 would be Christian 6 would own half of the village’s wealth; all 6 would be U. S. citizens 9 would speak English 50 would suffer from malnutrition 80 would live in sub-standard housing 66 would not have access to clean, safe drinking water 10 would be lesbian, gay or bisexual 1 would have a college education z from Meadows, D. , If the World Were a Village

Changing Demographics z. The U. S. attracts two thirds of the world’s immigration. z. General physicians can expect more than 40% of their patients to be from minority cultures. z American Medical Student Association

Changing Demographics o In the U. S. today, Asian Americans and Pacific Islanders are the fastest growing segment of the population o 15% of U. S. residents over age 5 speak a language other than English at home o As of 2003, Latinos are the largest minority group in the U. S. o In 2005, ethnic minorities will account for 47% of the U. S. population. 85% of those entering the workforce will be women, people of color, and immigrants o 2000 US Census Bureau national data

Demographics - Kansas z According to the 2000 Census. . . z - 5% of Kansans were foreign born z - 9% of Kansans speak a language other than English at home z - 7% of Kansans were Latino, compared with 12. 5% of total U. S. population z The Kansas foreign born population is quite diverse: 55% are Latin American, 28% Asian, 11. 2% European, 2. 7% African, and 2. 7% North American

Changes in rural population z“The demographics of rural America are changing rapidly, as Mexican, Central American, and Asian immigrants take jobs in agriculture and related industries. ” – Source: Martin, Phillip; Taylor, J. Edward; Fix, Michael, 1996. “Immigration and the Changing Face of Rural America: Focus on the Midwestern States”

Minority Health Statistics z Asian/Pacific Islanders ylanguage isolation is a consistent challenge ywomen are 16% less likely than general population to receive a Pap smear test z Native Americans y 72% higher age-adjusted death rate from diabetes than general population yother problems are obesity, mental health, alcohol and substance abuse x Source: “Minority Health Disparities in Kansas”, Kansas Health Institute, January 2003.

Minority Health Statistics z Hispanics/Latinos y 83% higher age-adjusted death rate from diabetes than general population y lack of understanding of preventative health services z African Americans y 34% more likely to die of cancer and twice as likely to die from diabetes than Whites nationally y infant mortality is twice as high when compared to other populations y other concerns include obesity, cardiovascular disease and HIV/AIDS y Source: “Minority Health Disparities in Kansas”, Kansas Health Institute,

Disparities in Health 1. Racial and ethnic minorities tend to receive lower quality health care than whites do, even when insurance status, income, age, and severity of conditions are comparable. 1. - Source: Alan Nelson, M. D. ; Committee Chair, Institute of Medicine 2002 Report on Disparities

Another thought. . . z. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman. – - Dr. Rev. Martin Luther King, Jr.

CULTURE Define culture. What does culture mean?

Culture: One Description z Culture is the set of values, structures and practices held in common by a group of people and passed on to succeeding generations. These groups are usually identified by ancestry, language and/or traditions. Culture is also used to describe those characteristics that we are born with, some of which are permanent and some of which can be changed.

Culture • What are the cultural lenses through which we view the world?

Cultural Lenses • • • Personality Gender Race Age Socio-economic Sexual orientation Life experiences Religious affiliation Point in history in which you were born

Active listening z. Stand in two lines facing each other. z. Discuss the following topics with the person across from you: y. Given names and meaning y. Where your family immigrated from y. Languages spoken in family as far back as you remember y. What constitutes good and bad parenting

Active Listening z. What challenges did you experience in this exercise? z. Were you surprised by what you learned from others?

Impact of Personal Culture on Communication Ø Incorrect assumptions about the other. Ø Language and communication style issues. Ø Biases against the unfamiliar. Ø Personal values in conflict. Ø Expectations that others will conform to established norms. Ø Myers, Selma. Conflict and Culture.

Listening In. . z. Actual Comments Made by Foreign Visitors to the United States: z“Americans seem to be in a perpetual hurry Just watch the way they walk down the street. They never allow themselves the leisure to enjoy life; there are too many things to do. ”--Visitor from India

More comments. . . z“Once in a rural area in the middle of nowhere, we saw an American come to a stop sign. Though he could see in both directions for miles and no traffic was coming, he still stopped!”--Visitor from Turkey

More Comments. . . z“The American seems very explicit; he wants a ‘yes’ or ‘no’. If someone tries to speak figuratively, the American is confused. ” --Visitor from Ethiopia

Another thought. . . . z. All humans are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly. – Dr. Rev. Martin Luther King, Jr. Letter from Birmingham Jail.

Reasons for Cultural Competence o All of these points prove to be good reasons for exploring cultural competency and how it can help us living in this diverse world.

Why is there a need for Cultural Competence? • To respond to current and projected demographic changes in the United States • To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds • To improve the quality of services • To enhance the workplace environment • To meet regulatory and accreditation mandates • To decrease the likelihood of liability/malpractice claims • - Source: National Center for Cultural Competence, Georgetown University

Cultural Competency To be culturally competent doesn’t mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and are willing to accept, that there are many ways of viewing the world. - Okokon O. Udo, BD, Ph. D, CPCC, Ordained Prebysterian Minister --From Cross Cultural Health Care Program

Road Signs Leading to Cultural Competence z. Awareness z. Knowledge z. Skills

Awareness • Increase awareness of other cultural perspectives • Consider diversity in values, beliefs, practices, lifestyles, problem solving strategies • Examine and appreciate your own culture • Reflect on learned biases and prejudices towards other cultures

Knowledge • Learn about historical, societal, political, spiritual influences that impact the world view of others • Distinguish between individual traits of a person and common traits of people of a community • Share information about yourself and your experiences so others can understand you

Skills • Use awareness and knowledge as information base • Integrate awareness and knowledge into a cross-cultural encounter • Conversation instead of confrontation • Develop culture-specific, appropriate individualized interventions

Earliest memory of difference. . . z. Think back as far as possible and reflect on your earliest memory of difference. z. The difference can refer to skin color, age, body size, sexual preference, cultural background, ethnicity, language, etc.

Earliest memory of difference. . . z. In groups, discuss: z. Was it yourself that was different? z. Was it another person that was different? z. What made them different? z. How did others respond?

Self Assessment z Create a large group awareness of existing stereotypes and assumptions z Create awareness of origins of our own cultural values and beliefs z Recognition of how these influence individual attitudes and behaviors z Understand how these attitudes affect “other” people

Cultural Competency Continuum - New York/New Jersey Public Health

Cultural Competency Continuum y. Ethnocentric vs. Ethnorelative y. Ethnocentric z You view your own (or adopted) culture as central to reality. y. Ethnorelative z You experience your culture in relation to, or in context of, other cultures.

Cultural Competency Continuum - Ethnocentric x. Denial z You experience your culture as the only culture that exists. You deny and are disinterested in cultural differences. x. Defense z You experience your culture as the only good culture. You acknowledge cultural differences but see them as threatening. You use mechanisms such as stereotyping to defend yourself. x. Minimization z You experience elements of your culture as universal. You minimize differences between cultures and believe that human similarities outweight any differences.

Cultural Competency Continuum - Ethnorelative x. Acceptance z You recognize and value cultural differences, without judging them. You are curious about different cultures. x. Adaptation z You experience other cultures by yielding to perceptions and behaviors acceptable to that culture. You intentionally change your behavior to communicate more effectively in different cultures. x. Integration z You value a variety of cultures and continuously define your own identity in contrast and in conjunction with a number of cultures. You move easily in and out of varying worldviews.

Exploring Stereotypes z. Close your eyes and listen.

Exploring Stereotypes z. What was your reaction? z. What images were in your mind? z. Did the images change as you heard more information? Why?

Cultural Views of the World z. Causes of Illness z. Traditional Healing z. Cultural Norms

Causes of Illness z. What causes us to become ill? z. What makes us heal or become well?

Video z. Worlds Apart: Justine Chitsena’s Story

Chitsena Story z. What are the grandmother’s beliefs about the illness itself and the surgery? z. How do they differ from the medical perspective? z. What is Bouphet Chitsena’s perspective, and Chitsena how is it different than both of the others?

Chitsena Story z While Justine’s mother is her primary caretaker, and the one interacting with the medical staff, her grandmother clearly plays an important role. y. How does the decision-making happen in this family (vs. most American families)? y. What is Justine’s grandmother’s role? y. What is her mother’s role? y. How would you explore this issue and deal with it in a clinical encounter like this?

Chitsena Story z. What are your views on the use of complementary/alternative medicine in general, and in this case specifically? z. Why is it important to know about these practices?

Chitsena Story z Issues to consider with alternative therapies: z Some may have beneficial effects for patients, whether proven (true in some cases) or subjective. z Trust can be built by being open to patients’ ideas about these. z Some alternative therapies may be dangerous, either due to their direct side effects or interactions with other medications that the patient takes. z Patients may avoid using potentially more effective medical treatment due to their use of alternative practices. z Being judgmental about alternative therapies contributes to patients not revealing their use.

Causes of Illness - Beliefs in some cultural communities y 1. HUMORAL IMBALANCE ximbalance between “hot” and “cold” causes illness xbalance between “hot” and “cold” must be restored y 2. SPIRITUAL CAUSES OF ILLNESS xunhappy ancestor, bad spirit, gods sending illness as a test or punishment y 3. MAGICAL CAUSES OF ILLNESS xwitchcraft, illness through act of negative willpower or ritual performed by other

Common traditional healers z. Herbal healers: use roots and herbs z. Shaman / spiritual healers: address spiritual and magical causes of illness, often through ceremony and ritual z. Bone setters: deal with breaks and sprains z. Midwives: care for pregnant women and attend births z. Diviners: often only diagnose illness

Areas of Difference z Historical Distrust: Past injustices may cause distrust between patient and provider z Interpretations of Disability: Ideas of what is/what causes a disability z Concepts of Family Structure and Family Identity: Family often extends beyond the sphere of the traditional nuclear family z Communication Styles and Views of Professional Roles: Westerners tend to separate professional and personal identity

Areas of Difference (cont. ) z Incompatibility of Explanatory Models: Physical health vs. Spiritual/Moral health z Disease without Illness: “Invisible” diseases (hypertension, high cholesterol, HIV) z Illness without Disease: Folk illnesses that are not defined within western biomedicine z Misunderstandings of terminology, language or body language – American Medical Student Association

Refugees / Immigrants: Frequently Asked Questions z. What is the difference between refugees and immigrants? y. Refugees have fled their country because of a “well founded fear” of persecution, while immigrants have left their home country on their own will.

Refugees / Immigrants: Frequently Asked Questions z Why do refugees leave their country? y. There are many reasons, some main ones being: war, religious or political persecution, reasons of race, etc. z Why do refugees come to the U. S. ? y. Refugees do not choose where they go from the refugee camp; they are assigned by the UN. z Do refugees ever return home? y. Yes, in large numbers, although many others also choose to stay and build a life where they are assigned.

Refugees / Immigrants: Frequently Asked Questions z Why do immigrants leave their country? y. Again, there are many reasons. It may be to find a better job, to reacquaint with family, to build a better life, to gain an education, to simply live in another place, among many other reasons. z Do immigrants help or hurt the United States? y. Immigrants have contributed greatly to the face of the U. S. in the types of food we eat, the music we hear and the many events that take place. They also add to our country intellectually, financially and culturally.

Cultural Norms z. There are some traits that are common to particular ethnic groups and people from a certain region. However, it is extremely important to remember that any information presented cannot be taken as a definitive representation of a community or individual in that community.

Predominant cultural groups in this region z. Hispanic/Latino z. Southeast Asian z. Pacific Islanders (Micronesian, Filipino, etc. )

Hispanic/Latino - General z. Family plays a central role. There is a huge emphasis on family as a support network and also on how decisions made will affect family members. z. Emphasis on interpersonal relationships and friendships. There is an abounding willingness to help others and to extend hospitality to all.

Hispanic/Latino - General z. Hierarchy within groups. Showing respect and seeking advice from elders/respected community members. z“Warmer” in personal interactions (standing closer, touching, kisses) z. Naming system y. Ex. First name, Middle name, Paternal last name, Maternal last name

Hispanic/Latino - Gender Roles z The man generally is “head” of household and makes all important decisions z Historically viewed as the idea of the male who is strong and dominating. However, he can also be seen as one who takes care of his family financially and works hard to provide for loved ones (machismo) z The woman takes responsibility for the children and many times takes on the quiet, but all important, behind-the-scenes role of caring for the family.

Hispanic/Latino - Health z. View providers as the authority figures on health care causing for a reluctance in asking questions z. Traditional/folk healers and forms of healing play an important role

Hispanic/Latino: Traditional Illnesses and Treatments z Mal de ojo (evil eye): vomiting, fever, crying, restlessness; a heating up of the child’s blood. y. Cause: an admiring or covetous look from a person with the evil eye y. Treatment: herbal remedies, ritual cures (folk healer), using egg, lemon, chili pepper on child’s body z Empacho: lack of appetite, stomachache, diarrhea, vomiting. y. Cause: poorly digested or uncooked food. y. Treatment: dietary restrictions, herbal teas, abdominal massage with warm oil

Hispanic/Latino: Traditional Illnesses and Treatments z Nervios: restlessness, insomnia, loss of appetite, headache, aches and pains. y. Cause: chronic, negative life circumstances, especially in interpersonal relationships y. Treatment: traditional/folk healer z Susto: loss of soul or an extreme fright characterized by lethargy, depression, insomnia, hallucinations, irritability y. Cause: a traumatic or frightening experience y. Treatment: herbal teas, spitting a mouthful of water or alcohol into patient’s face unexpectedly, covering face with cloth and sprinkling holy water

Hispanic/Latino: Other Problems and Traditional Remedies z Diarrhea: rice water; increase clear liquids (no milk or food); suedro (solution made of water, sugar, lemon or banana) z Conjunctivitis: breast milk drops in eyes, carrot juice, chamomile drops or wash for eyes z Skin rash: apply cornstarch; alcohol rub or bath; rub with watermelon shell z Minor burns: apply pork lard, cooking oil or butter; raw onions; apply toothpaste, egg white, cooked beans

Hispanic/Latino - Diversity z It is very important to remember that within the heading “Hispanic/Latino” are included people from as many as twenty different countries with as many different histories, governments, customs, traditions, beliefs, etc. z Many times we hear the words Hispanic and Latino/a used interchangeably, however some people have strong feelings toward the use of one over the other. Finally, there also other people who dislike both and would prefer to use a more specific terminology, calling themselves Mexican. American, Cuban-American, etc.

Video z. World Apart: Alicia Mercado Story

Mercado Story z There have been three distinct Hispanic/Latino patterns of immigration: z Continuous flow of both legal and undocumented immigration from Mexico which intensified in 1980, driven by economic forces and opportunities; z “Waves” of large-scale immigration from Central and South America, driven by war, conflict, and asylumseeking; z A Caribbean pattern of frequent back-and-forth migration between the country of origin and the U. S. (typified by the Puerto Rican experience in the Northeast).

Mercado Story z. What are some of the reasons (from Mrs. Mercado’s perspective) for her lack of ideal adherence to medical therapy and follow-up? z. What are some other reasons why patients are non-adherent to medical therapy, especially for chronic diseases?

Mercado Story z. What are your views on the use of complementary/alternative medicine in general, and in this case specifically? z. What home remedies did your family use when you were growing up? z. Why is it important to know about these practices?

Southeast Asians z. There are many similarities between the cultural practices and forms of healing used by Southeast Asians (Vietnamese, Cambodian, Laotians, etc. ). However, it is important to keep in mind that they are all people from different countries, speaking different languages and coming from different histories. Many of the common traits come from Buddhist beliefs, the majority religion of the area.

Southeast Asians - General z The traditional view of health is holistic linking the mind, body and soul. It focuses on establishing and maintaining a balance of life energies. z Asian patients may deny illness, viewing it as personal carelessness or weakness, or as a result of external forces over which they have no control. z The basis for most views on health come from Buddhist beliefs.

Southeast Asians - General z. Respect for education, family and elders z. Sparing one’s feelings is considered more important than factual truth z. Tend to be reserved in most interactions and expression of strong feelings (positive or negative) is not valued. z. Bow heads to superior or elder z. When talking, one should not look steadily at a respected person’s eyes

Southeast Asians - General z Family is held in high regard, often with grandparents and other relatives living in the same house z Women do not shake hands with each other or with men z Disrespectful to touch another person’s head z Naming system y. Ex. Last name, Middle name, First name y. Most names can be used for either gender y. Name reflects some meaning

Southeast Asians Gender Roles z. Men have higher status than women, sons are valued more than daughters z. A traditional woman must submit to her father, then obey her husband, and then if widowed, obey her eldest son z. However, the mother is not docile. She is considered the home minister and is responsible for family harmony, the family budget and the family schedules

Southeast Asians - Health z Mental illness is a shameful thing and often feared or denied z Many times health and health care based on spiritual factors or the hot/cold belief system (you are sick because the hot/cold balance has been altered) z There is a common belief that Western medicines are developed for Americans and Europeans, hence they assume the dosages are too strong for their slight builds and will selfadjust their medicines.

Southeast Asians - Health z Physical and mental wellness are tied to a balance of the “winds” of the body and also to a person’s ability to sleep or eat without difficulty. z Persons who are sick will turn first to traditional means of healing and then seek treatment at a clinic or hospital. Generally, traditional practices are often continued alongside western medicine. z Health histories may be incomplete for a number of reasons, mostly for a reluctance in volunteering such personal information as sexual activity, family history and other illness (vulnerability) issues. Trust or a lack of it is a major issue.

Southeast Asians - Traditional Health Practices z Coining: a coin dipped in oil is rubbed across the skin, causing a mild abrasion. It is believed to release excess “wind” from the body and restore the balance. z Cupping: a series of small, heated glasses are placed on the skin, forming a suction that draws out the bad force. z Pinching: similar to coining and cupping. The abrasion left by the pinch allows the force to leave the body. y. Note: Many of these practices are formed on young children or infants and the temporary abrasions should not be confused with abuse or injury.

Southeast Asians - Traditional Health Practices z Steaming: a mixture of medicinal herbs is boiled and the steam is inhaled z Acupuncture: thin, steel needles inserted in specific locations to help cause an energy balance z Acupressure: fingers are pressed at the same points as acupuncture to stimulate the energy points z The use of specific jewelry worn around the neck are often used as a form of spiritual protection

SE Asians and the Western Medical System z It is common for patients to not report or even to deny symptoms or problems. z It is common to discontinue treatment or medication as soon as symptoms have disappeared. There is an expectance to receive medication for every illness and that it will quickly relieve the problem. z Most are more oriented to illness than to the prevention of illness and only seek help after symptoms arise. There is little value on early detection or disease screening.

SE Asians and the Western Medical System z. Blood draws are thought to be very painful and will make them weaker because the blood is “taken away” and not replaced. z. Genital exams are a foreign concept to them and are preferred to be done by a same-sex provider. z. X-rays are thought to destroy red blood cells and to decrease general life expectancy. z. Surgery is extremely frightening to them and is considered a last resort.

Dynamics of Difference z. Power z. Ethnocentrism z. Social Class z. Acculturation z. Cultural Bumps

Power z. Nearly all men can stand adversity, but if you want to test a man's character, give him power. -Abraham Lincoln z. Power does not corrupt men; but fools, if they get into a position of power, corrupt power. - George Bernard Shaw

Ethnocentrism z All of us, both Euro-Americans and members of ethnic minority groups are ethnocentric. That means that we usually value our own group above all others. The concept of cultural competence applies not just to Euro-Americans but to all of us who have been born, educated, and live on American soil. Very few things in the American institutional structure have prepared us to live harmoniously in a pluralistic and multicultural society. Therefore, every one of us needs to learn and practice from a culturally competent perspective. – M Issacs and M Benjamin, Towards a Culturally Competent System of Care, Vol II.

Social Class / Classism z. Although not readily acknowledged in the United States, in many countries classism exists openly. z. Differences in class, or in the way class is perceived, must be taken into account so as not to lose trust in an interaction.

Acculturation z. Refers to the acquisition of a new cultural identity, but does not imply ridding oneself of the elements of one’s first culture. z Original Culture Bicultural Assimilation z • ---------------------- • z Monolingual Bilingual Abandoned previous cultural values/language

Cultural bumps z. Please pay attention to the following situation and consider what caused a misunderstanding z. Video: Guatemalan woman

Cultural bumps z. Please discuss the following situations in small groups. z 3 Cases

Cultural Relativity Any behavior must be judged first in relation to the culture in which it occurs – behavior may seem strange until placed in appropriate context. - Cross Cultural Health Care Program, Interpreter training

Signs of conflict. . . z. Competence is challenged z. Individual is not appreciated z. Communication in ways that irritate you z. Communication in condescending manner z. Unsolicited advice given z. Quick judgements z. Lack of respect

What can we do to minimize obstacles? • Be knowledgeable about the cultures you work with • Avoid judgement based on your own cultural norms • Be understanding of different traditions, cultures, concepts of sickness, notions of healing, etc.

More conflict resolution across cultures… o o o o Being nonjudgmental Understanding stereotypes Treating people as individuals Looking at whether expectations are real Accepting ambiguity Empathizing Checking assumptions Being open to differences o Myers, Selma. Conflict Resolution Across Cultures.

Conclusion. . . . z. Questions z. Discussion z. Observations z. Evaluations

Day Two February 23, 2005 Wichita, Kansas

Exercise z. Word Association

Creating Cultural Competency z. Mythbusters! z. Title VI - Overview z. Title VI Assessment and Policy z. Working with Interpreters z. Building Community Connections z. Sharing Resources

Myth Busters! z#1 Myth: Immigrants don’t pay taxes. z. Fact: Significant local, state & federal taxes are paid by immigrants each year, an estimated $133 billion. z. Fact: Alan Greenspan has stated that both legal and non-legal immigrants pay $20 billion more in taxes than they receive in benefits.

Myth Busters! z#2 Myth: America is over-run by immigrants. z. Fact: Percentage of foreign-born is higher than in 1970 (11%), but still lower than the all-time high of 14% in 1910. z. Fact: The 2000 Census found that 22% of US counties lost population from 19902000.

Myth Busters! z#3 Myth: Immigrants do not serve their new country. z. Fact: Immigrants make up nearly 5% of all enlisted personnel on active duty in the US Armed Forces. (62, 000) z. Fact: 20% of the recipients of the Congressional Medal of Honor were immigrants.

Creating Cultural Competency z. Title VI - Overview z. Title VI Assessment and Policy

What is Title VI? Ø Title VI of 1964 Civil Rights Act: No person in the United States, shall, on ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. Source: Title VI of 1964 Civil Rights Act and Office of Civil Rights Policy Guidance on Language Access to Services

Who is Protected by Title VI? z. Limited English Proficient (LEP) individuals: “National Origin. ” Ø OCR Policy Guidance: Fall 1998 Title VI Prohibition Against National Origin Discrimination As it Affects Persons with Limited English Proficiency Revised August 2000; published again in February 2002, currently under revision

What organizations are impacted by Title VI? • • • Health care providers Hospitals, doctor’s offices, nursing homes Managed care organizations, home health agencies State Medicaid agencies Municipal and county health departments Social service and non-profit organizations • The list is endless!

Explanation of Title VI Ø Title VI prohibits discriminatory impact - services more limited in scope - lower quality of services - unreasonable delays in service delivery - limiting participation in a program

Title VI – OCR Policy Guidance z Any organization that receives federal funds must provide meaningful access to programs, services, and benefits z Federal financial assistance includes grants, training, donations of surplus property, and other assistance z Meaningful access ensures accurate and effective communication z Limited English Proficient (LEP) individuals should receive language assistance free of charge

OCR Enforcement of Title VI • OCR assists organizations in development of comprehensive written policy • OCR considers these circumstances: • • Size of the covered entity Size of the eligible population Nature of Program or Service Program Objectives Resources Frequency of a given language Frequency of encounters with LEP persons

Office of Civil Rights z. Maria A. Smith, Investigator z. Office of Civil Rights z. Federal Office Building z 601 E. 12 th Street, Room 248 z. Kansas City, MO 64106 z(816) 426 -7238 z(800) 368 -1019

Four Keys to Title VI Compliance o Assessment o Development of a comprehensive written policy on language access o Training of staff o Vigilant monitoring

Assessment • Conduct a thorough assessment of the language needs of population served • Identify the languages likely to be encountered • Identify language needs of every LEP patient/client and note in client files • Identify resources needed to provide effective language assistance

Areas to consider in an assessment z level of ethnic identity z use of informal network and supportive institutions in the ethnic/cultural community values orientation z language and communication process z migration experience z self concept and self esteem z influence of religion/spirituality on the belief system and behavior patterns z views and concerns about discrimination and institutional racism z views about the role that ethnicity plays z educational level and employment experiences z habits, customs, beliefs z importance and impact associated with physical characteristics z cultural health beliefs and practices z current socioeconomic status

Development of a Comprehensive Policy § Oral Language Interpretation § Translation of written materials § Methods for providing notice to LEP persons

Issues that impact compliance q Financial cost of interpreting services q Lack of awareness of the need for interpreter services q Negative impact when untrained, unqualified interpreters are used q Organization does not have a comprehensive written policy on language access

Two Compliance Cases z#1: Sole physician practitioner with 50 LEP Hispanic patients. Staff of two nurses and receptionist. No interpreters on staff. Uses community org. & telephone interp. z#2: County Social Services agency serves 500, 000; 10, 000 are LEP. No policy; clients bring own interpreters. Materials in English.

Case Studies z. In groups discuss the case studies.

CLAS Standards z Health Care providers have a responsibility to provide culturally and linguistically appropriate services (CLAS) to patients y. Interpretation/Translation services y. Ongoing education and training for all staff y. Recruit and retain a diverse and culturally competent staff y. Collect and utilize data about the diverse communities in provider’s service area y. Implement ongoing self-assessments of cultural competence within organization

Working Effectively with Interpreters z Who is an appropriate interpreter? z Roles and responsibilities of interpreter z Effective strategies for communicating through an interpreter

Video z. Communicating Effectively Through an Interpreter

Who is appropriate to act as an Interpreter? • Bilingual staff who are trained and competent in skill of interpreting • Staff interpreters • Contracted Interpreter Service • Community Volunteer Interpreters • Telephone Interpreter Lines

Who is NOT appropriate as an Interpreter? Friends of any LEP individual Family member of LEP patient/client Minor children Anyone who has not demonstrated proficiency in both languages § Anyone who has not received training in interpretation § Anyone who does not have an understanding of ethics and interpreting practices § §

Interpreter z. The basic purpose of the medical/social service interpreter is to facilitate understanding and communication between two or more people who are speaking different languages. – CCHCP, Interpreter training curriculum

Video z. Worlds Apart: Mohammad Kochi’s Story

Kochi Story z The cancer had been there all along, even after the surgery, but the family members serving as interpreters had not translated this to Mr. Kochi nor to the rest of the family at home. z How does culture influence the way patients and families discuss medical information and make medical decisions?

Kochi Story z Why, in this case, does Noorzia (a relatively young daughter—and a woman in a male dominant culture) seem to play a very important role in medical decisions about her father’s care? z How is Noorzia’s perspective on her father’s health, and the medical in general, different than her father’s?

Kochi Story z How important are professional interpreters (as opposed to family members or no interpreter) in medical interactions like this? z Could it have changed the situation in this case? z Are there any laws requiring the use of an interpreter? z What problems can arise when family members or others act as interpreters?

Kochi Story z What do you think about this interaction? : z Mr. Kochi: z “We believe our day has been chosen for us and it cannot be pushed up or forced back. ” z Dr. Fisher: z “Our goal is to help you feel as well as you can feel until that day comes. ”

Roles of the Interpreter § CONDUIT § Interpret exactly what is said: add nothing, change nothing, omit nothing. § CLARIFIER § Adjust register or complexity of language. Check for understanding. § CULTURE BROKER § When cultural differences cause misunderstanding, provide necessary cultural framework for understanding message. § ADVOCATE § Action taken on behalf of someone else.

Tips for Effective Communication through an Interpreter § POSITIONING – interpreter should be seated next to and a little bit behind LEP client § ACCURACY – everything that is said should be interpreted; no side conversations; check for comprehension; speak in short phrases and pause to allow for interpretation § COMPETENCY – assess interpreter qualifications and skills; bilingual individuals should be trained in interpreting and have knowledge of policies at your organization

Medical errors z. According to a study by the Institute of Medicine, “at least 44, 000 people and perhaps as many as 98, 000 people die in hospitals each year as a result of medical errors that could have been prevented. ” – Source: Institute of Medicine, “To Err is Human: Building a Safer Health System”, Nov. 1999

Article z“Language Barriers Lead to Medical Mistakes”

Language and Culture z“People who speak different languages live in different worlds, not the same world with different labels. ” – Edward Sapir, linguist, 1928.

The New Americans z. The Flores Family (Mexico) z. The Nwidor Family (Nigeria) z. Active Voice & Kartemquin Educational Films

Identifying Barriers and Building Bridges z. Compare the experiences of the two families z. How do we bridge cultural gaps? z. How do we build community power?

Successful community partnerships z Informal collaboration among social service agencies: JVS, Catholic Charities, Della Lamb, Don Bosco, El Centro z KC partnership of “safe harbor” health care providers: KC Free Health Clinic, Cabot Westside Clinic, Swope Parkway Medical Center, Truman Hospital and other community clinics.

Kansas City Free Health Clinic z Over 50 staff members z Over 400 volunteers z Safe harbor health care provider for individuals without insurance z Extensive services for individuals without primary health care coverage z Active community involvement and integration with other healthcare providers

Building Culturally Competent Community Partnerships z. What community organizations do you collaborate with? z. What are effective strategies for working together? z. Identify areas to be improved (on a community level, on an institutional level, etc. ).

Strategies for working effectively in communities l Asian American Family Counseling Center - Houston - brown bag lunches for mental health professionals to learn more about working with the area’s Asian American communities l Consumer Voices Are Born - Clark County, Washington - established a “warm-line” where individuals facing mental health challenges could call in and discuss their problems with a peer, now extending services to ethnic communities - National Consumer Supporter Technical Assistance Center, National Mental Health Association. A Cultural Competency Toolkit: Ten Grant Sites Share Lessons Learned.

Strategies for working effectively in communities • Build bridges of trust and dispel misinformation • Recruit staff from within the community • Community members provide insight into cultural beliefs and practices • Identify elders or leaders within the community and seek their support • Initiative must be give and take

Organizing Culturally Specific Community Forums z. Culturally competent community assessments z. Barriers and benefits of community partnerships

Culturally Specific Community Forums and Assessments • MAPP : KCMO Health Department health survey • The Pulse: Survey of Health in the KC gay and lesbian community • Interpreter Training classes: Informal and formal networking among key community members • Social service organizations • Religious organizations • Community partnerships with other organizations

Barriers and benefits of community partnerships z Barriers: Barriers z - mistrust on the part of the community z - results and outcomes not clearly defined z - organization unable to effectively work with community z Benefits: Benefits z - increased access to services z - positive reputation in the community z - word of mouth makes your organization thrive

Unanswered Issues z. What are some topics that we have not mentioned or that we have not covered completely in this training? z. Are there any common cultural issues you face that we have not talked about? What are they? z. What are some possible resolutions or outcomes?

Conclusion. . . . z. Questions z. Discussion z. Observations z. Evaluations

References z. Please refer to handout with a list of online resources.

Resources o Cross Cultural Health Care Program: www. xculture. org o OCR/HHS: www. hhs. gov/ocr o CMS: //cms. hhs. gov/states/letters o Natl Health Law Prog: www. healthlaw. org o National Council on Interpreting in Health Care: www. ncihc. org o HHS, Office of Minority Health: www. omhrc. gov/CLAS

THANK YOU! z Thanks for your participation, time and energy! z Thanks to KDHE for funding the course!

Contact us! Jewish Vocational Service Language and Cultural Services 1608 Baltimore Kansas City, MO 64108 (816) 471 - 2808 www. jvskc. org Brandi Miller Cathy Anderson bmiller@jvskc. org canders@jvskc. org