School Based Health Centers

CONNECTICUT ASSOCIATION

SCHOOL BASED HEALTH CENTERS

REACHING FOR CULTURAL COMPETENCY

Michele Stewart-Copes M.S., M.S.W., SEET Consultants LLC

REACHING FOR CULTURAL COMPETENCY

SEMINAR OBJECTIVES

Participants will build sensitivity, understanding of others and an appreciation for diversity.

Participants will develop a knowledge base about how cultural values and assumptions influence relationships and interactions.

Participants will develop self-awareness of cultural values and assumptions as well as communication strengths and challenges.

Participants will become more aware of their own stereotypes and attitudes.

Participants will develop communication skills to engage in meaningful dialogue about cultural influences.

Participants will apply domains of knowledge with diverse populations in clinical, educational and social settings.

WHAT IS CULTURE?

Culture is the total system of values, beliefs, attitudes, traditions and standards of behavior that regulates life in a group of people.

Culture is comprised of:

Ethnicity, Knowledge, Shared ideas and Meanings......

Rules, Customs, Law, Traditions, Rituals, Beliefs

Diet, Dress, Body Image, Concept of Space and Time, Family Structure, Communication......

Lifestyles, Behaviors, Perceptions, Emotions, Attitudes toward Health, Illness, Life Experiences

Sub cultures- social groupings with sufficient distinguished behaviors

All of the above are learned as we are born into or live in a society. Culture is not genetic/racial.

References:

Office of Minority Health

NationalCenter for Cultural Competence

www11.georgetown.edu/research/gucchd/nccc/links/index.html.

Frame of Reference

CULTURAL & LINGUISTIC COMPETENCE

Cultural and linguistic competence is a set of congruent behaviors, attitudes

and policies that come together in a system, agency, or among professionals

that enables effective work in cross-cultural situations. “Culture” refers to

integrated patterns of human behavior that include the language, thoughts

communications, actions, customs, beliefs, values and institutions of racial,

ethnic, religious, or social groups. “Competence” implies having the

capacity to function effectively as an individual and an organization within

the context of the cultural beliefs, behaviors, and needs presented by

consumers and their communities.

(Based on Cross, Bazron, Dennis, & Issacs, 1989)

HEALTH DISPARITIES

Health disparities refer to gaps in the quality of health and exist when conditions and risk factors disproportionately affect certain racial and ethnic groups. There is a disproportionate incidence of disease, disability and death among specific racial and ethnic groups. Health inequality is differences in health, closely linked with socio economic or environmental disadvantages and other social determinants.

“A disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative stereotypes, the panel concludes, may be misleading doctors and other health professionals.”

(New York Times, March 22, “Subtle Racism in Medicine”)

CULTURAL HUMILITY

“Cultural Humility” is best defined not by a discrete endpoint but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues and with themselves. It is the willingness to respectively learn from others who are different.

Starting point:

Would not be an examination of the patient’s belief systems.

Would be careful consideration by healthcare providers of assumptions and beliefs embedded in their own understandings and goals in the clinical encounter.

(Hunt,L., Up Front, Beyond Cultural Competence, Applying humility to clinical settings, The Park Ridge Center for Health, Faith and Ethics Bulletin, December, 2001 Issue 24)

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Martin Luther King, Jr.

WHITE PRIVILEGE

“I have come to see white privilege as an invisible package of unearned assets which I can count on cashing in each day, but about which I was “meant” to remain oblivious. White privilege is like an invisible weightless knapsack of special provisions, assurances, tools, maps, guides, codebooks, passports, visas, clothes, compass, emergency gear and blank checks”.

Peggy McIntosh, Center for Research on Women, Wellesley College, MA 1988.

I can, if I wish, arrange to be in the company of people of my race most of the time.
If I should need to move, I can be pretty sure of renting or purchasing housing in an area that I can afford and in which I would want to live.
I can be pretty sure that my neighbors in such a location will be neutral or pleasant to me.
I can go shopping alone most of the time, pretty well assured that I will not be followed or harassed.
I can turn on the television or open to the front page of the paper and see people of my race widely represented.
When I am told about our national heritage or about “civilization,” I am shown that people of my color made it what it is.
I can be sure that my children will be given curricular materials that testify to the existence of their race.
I can go into a music shop and count on finding the music of my race represented, into a supermarket and find the staple foods that fit with my cultural traditions, into a hairdresser’s shop and find someone who can deal with my hair.
Whether if use checks, credit cards, or cash, I can count on my skin color not to work against the appearance of financial reliability.
I can arrange to protect my children most of the time from people who might not like them.
I can swear, or dress in second-hand clothes, or not answer letters without having people attribute these choices to the bad morals, the poverty, or the illiteracy of my race.
I can speak in public to a powerful male group without putting my race on trial.
I am never asked to speak for all the people of my racial group.
I can criticize our government and talk about how much I fear its policies and behavior without being seen as a cultural outsider.
I can be pretty sure that if I ask to talk to “the person in charge” I will be facing a person of my race.
If a traffic cop pulls me over, or if the IRS audits my tax return, I can be sure that I haven’t been singled out because of my race.
I can easily buy posters, postcards, picture books, greeting cards, dolls, toys and children’s magazines featuring people of my race.
I can go home from most meetings of organizations I belong to feeling somewhat tied in rather than isolated, out of place, outnumbered, unheard, held at a distance, or feared.
I can take a job with an affirmative action employer without having coworkers on the job suspect that I got it because of my race. I can enroll at a highly competitive university without having students or professors assume that I got in through affirmative action.
I can choose public accommodation without fearing that people of my race cannot get in or will be mistreated in the places I have chosen.
I can be sure that if I need legal or medical help my race will not work against me.
If my day, week, year is going badly, I need not ask of each negative episode or situation whether it has racial overtones.
I can choose blemish cover or bandages in “flesh” or “nude” color that more or less matches my skin.

HOW DO YOU UNDERSTAND & PURSUE

SOCIAL JUSTICE?

Social justice is the view that everyone deserves equal economic, political and social rights and opportunities.

Examples of social justice can be discussed within the following topics and issues:

Education; Access to Services; Racism; Shelter/Housing; Religion; Discrimination; Homelessness; Medicine; Disability; Poverty.

If you believe in social justice, how do you pursue it or teach it to others?

Every citizen has equal rights to health, safety, freedom and wellbeing.

What are other thoughts or strategies in your work and living that could impact social justice?

Know Your Cultural Style

An important aspect of learning about other cultures is understanding your own. You will be better prepared to see your commonalities and differences with other as you increase your own self-awareness. And when others

ask about your culture, you will be better able to respond

The following pairs of words and phrases indicate opposite ends of a cultural continuum. Review the pairs and put an X on the continuum to indicate your cultural style.
Individualism ------Collectivism
Emotion should be expressed ------Emotion should not be expressed
Competition ------Cooperation
Task oriented ------Relationship oriented
Written communication emphasized ------Oral communication emphasized
Resolve conflict by confrontation ------Resolve conflict by diplomacy
Talking loudly and with much ------Talking softly and with limited
Animation, hand and body movement animation
Few pauses in conversation. ------Silence, pauses in conversation. Pace is fast. Pace can be slow.
Value promptness. “Time is money.” ------Spend time as needed by situation
“Time is free”
Focus on nuclear family, self ------Focus on extended family

Adapted in part from Gardenswartz & Rowe (1994 and Hofstede (1980)

Questions for reflection

Think of situations when you style was different than the prevailing norms of a group you were in. How did you feel? What did you do?

What, if anything, would have made the situation smoother for you?

How do you react to people who exhibit behaviors that are toward the opposite end of a cultural style continuum from yours?

How might someone with different cultural habits experience the culture of your organization?

What could you do to ease the way for them and help them feel accepted?

COMMUNICATING WITH DIVERSE CONSUMERS

Non-verbal communication is a subtle form of communication that takes place in the initial 3 seconds after meeting someone for the first time and can continue through the entire interaction. Non-verbal communication can impact the success of communication more acutely than the spoken word. Our culturally informed unconscious framework evaluates gestures, appearance, body language, the face, and how space is used. Yet, we are rarely aware of how persons from other cultures perceive our non-verbal communication or the subtle cues we have used to assess others.

Styles of Speech

People vary greatly in the length of time between comment and response, the speed of their speech and their willingness to interrupt.

Tolerate gaps between questions and answers, impatience can be seen as a sign of disrespect.
Listen to the volume and speed of the patient’s speech as well as the content. Modify your own speech to more closely match that of the consumer to make them more comfortable.
Rapid exchanges, and even interruptions, are a part of some conversational styles. Don’t be offended if no offense is intended when a consumer interrupts you.
Stay aware of your own pattern of interruptions, especially if the patient is older than you are.

Eye Contact

The way people interpret various types of eye contact is tied to cultural background and life experience.

Most Euro-Americans expect to look people directly in the eyes and interpret failure to do so as a sign of dishonesty or disrespect.
For many other cultures direct gazing is considered rude or disrespectful. Never force a consumer to make eye contact with you.
If a consumer seems uncomfortable with direct gazes, try sitting next to them instead of across from them.

Body Language

Sociologists say that 80% of communication is non-verbal. The meaning of body language varies greatly by culture, social status, gender and age.

Follow the consumer’s lead on physical distance and touching. If the consumer moves closer to you or touches you, you may do the same. However, stay sensitive to those who do not feel comfortable, and ask permission to touch them.
Gestures can mean very different things to different people. Be very conservative in your own use of gestures and body language. Ask consumers about unknown gestures or reactions.
Do not interpret a consumer’s feelings or level of pain just from facial expressions. The way that pain or fear is expressed is closely tied to a person’s cultural and personal background.

Guiding Conversations

English predisposes us to a direct communication style, however other languages and cultures differ.

Initial greetings can set the tone for a visit. Many older people from traditional societies expect to be addressed more formally, no matter how long they have known you. If the consumer’s preference is not clear, ask how they would like to be addressed.
Consumers from other language or cultural backgrounds may be less likely to ask questions and more likely to answer questions through narrative than direct responses. Facilitate consumer centered communication by asking open-ended questions whenever possible.
Avoid questions that can be answered with “yes” or “no”. Research indicates that when consumers, regardless of cultural background, are asked, “Do you understand,” many will answer, “yes” even when they really do not understand. This tends to be more common in teens and older consumers.
Steer the consumer back to the topic by asking a question that clearly demonstrates that you are listening. Some consumers can tell you more about themselves through story telling than by answering direct questions.

Galanti,G. (1997). Caring for Patients from Different Cultures. University of Pennsylvania Press. Hall, E.T.

National Standards for Culturally and Linguistically

Appropriate Services (CLAS) in Health and Health Care

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care

disparities by establishing a blueprint for health and health care organizations to:

Principal Standard:

1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse

cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce:

2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy,

practices, and allocated resources.

3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are

responsive to the population in the service area.

4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and

practices on an ongoing basis.

Communication and Language Assistance:

5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at

no cost to them, to facilitate timely access to all health care and services.

6. Inform all individuals of the availability of language assistance services clearly and in their preferred language,

verbally and in writing.

7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals

and/or minors as interpreters should be avoided.

8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the

populations in the service area.

Engagement, Continuous Improvement, and Accountability:

9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them

throughout the organization's planning and operations.

10. Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into

measurement and continuous quality improvement activities.

11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health

equity and outcomes and to inform service delivery.

12. Conduct regular assessments of community health assets and needs and use the results to plan and implement

services that respond to the cultural and linguistic diversity of populations in the service area.

13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural

and linguistic appropriateness.

14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent,

and resolve conflicts or complaints.

15. Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and

the general public.

Cultural Competence Web sites and References

Web sites

Health care resource for multicultural populations

Office of Minority Health:

The Cross Cultural Health Care Program

National Center for Cultural Competence:

American Academy of Family Physicians:

National Prevention Information Network:

Department of Health and Human Resources:

National Alliance on Mental Illness:

National Education Association:

American Speech-Language-Hearing Association:

Book

Salimbene, S “What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Patient Care, 2nd Edition”. Diversity Resources Publications, 2005.

To order this book or get information, log onto To order an electronic copy at a discount call (800)865-5549

This book is a good desktop reference for providers who treat patients from a variety of cultural backgrounds (African Americans, American Indians, Asians, Hispanics, Middle Eastern and immigrants from former Soviet Bloc countries).

Anthem Blue Cross and Blue Shield Resources

Language line service (Anthem providers may refer their patients whose primary spoken language is other than English)

Connecticut – Language line available to members by contacting the customer service number on the back of their member ID card.

New Hampshire - Language line available to members by contacting the customer service number on the back of their member ID card.

Maine - Language line available to members by contacting the customer service at (800) 482-0966 or (209) 822-7272. Language line is available to providers by contacting the provider service at (800) 832-6011 or (207) 822-8181