1. Cultural Competency

2. Learning Objectives Participants will:
Define culture & cultural competency.
Discuss 6 levels of cultural competency.
Identify 4 communication variations within/across cultures.
List 2 reasons why providing culturally competent healthcare improves client/member treatment.

3. Rule: We all will be respectful of everyone’s views.
Disclaimer & Rules
Disclaimer:
Culture may be a sensitive topic.
Everyone is an expert on their own culture.
We are all responsible for establishing a learning environment where everyone feels safe to share.
Rule: We all will be respectful of everyone’s views.
TRAINER NOTES:
-Before starting the training, discuss with the group how culture can be a sensitive topic.
-Point out that everyone is an expert in their own culture and that no one is an expert in all cultures.
-Tell attendees this is an educational opportunity for EVERYONE, point out some people genuinely do not realize when they are being culturally insensitive (use real life examples if possible - i.e. someone referring to Native Americans by calling them Indians, this term is offensive, however, the person using the word Indians may not have known this).
-Establish rules for the training: respect others’ opinions if they are different than your own, process emotions as they are being experienced, if you don’t knowing something please ask and do not judge others for asking about something they don’t know, refrain from using slang terminology, etc.

4. Defining & Understanding Culture
TRAINER NOTES
-This is a transition slide.
-Next few slides will define what culture is.
-Feel free to ask attendees what the word “culture” means to them (this is optional) before you show them the definition on the next slide.

5. Culture...
Is defined as behaviors, values, and beliefs shared by a group of people.
Affects every aspect of an individual’s life:
i.e., how individuals experience, understand, express, and address emotional and mental distress.
-”Culture can be defined as the behaviors, values and beliefs shared by a group of people, such as an ethnic, racial, geographical, religious, gender, class or age group. Everyone belongs to multiple cultural groups, so that each individual is a blend of many influences.”
-”Culture has many dimensions and includes: how we dress, the language we speak, our customs, the food we eat, the laws we follow, our code of manners, our beliefs, and the behavioral standards we follow.”
SOURCE: - Contains a 6 page resource on Cultural Competence in Mental Health)

6. Culture & Self Perception
An individual’s cultural background affects how they view/ perceive themselves.
Individualistic cultures vs. collectivistic cultures:
Those from an individualistic culture may see themselves:
As separate from others
Based on their personal traits
With characteristics that are relatively stable/ unchanging
Those from a collectivistic culture may see themselves as:
Connected to others
In terms of relationships with others
As having characteristics more likely to change across different contexts
-”An individual’s cultural background affects how they view themselves.”
-”People from individualistic cultures are more likely to have an independent view of themselves (they see themselves as separate from others, define themselves based on their personal traits, and see their characteristics as relatively stable and unchanging).”
-”On the other hand, people from collectivistic cultures are more likely to have an interdependent view of themselves (they see themselves as connected to others, define themselves in terms of relationships with others, and see their characteristics as more likely to change across different contexts).”
TRAINER NOTES/ MORE INFORMATION
-While individualism/collectivism can be measured in any culture, much of the research so far has been conducted on East Asian and Western cultures. Researchers have found that Western cultures tend to be more individualistic while East Asian cultures tend to be more collectivistic.
However, it’s important to remember that many factors can influence individualism/collectivism, so individuals within a culture can also differ in their levels of independence/interdependence. Individualism and collectivism can even be affected by the situational context.
SOURCE: Healthy Psych. Com- Elizabeth Hopper-

7. Acculturation vs. Assimilation
Residents of the US who have not been citizens since birth will fall into one of the following categories:
Legal, permanent residents
Temporary migrants (students)
Humanitarian migrants (refugees)
Naturalized US citizens
Person illegally in the US
Foreign born immigrants will have different levels of acculturation or assimilation.
- Point out that when getting to know our members, we need to take into account their level of acculturation or assimilation. Each individual is unique and has retained varied aspects of the beliefs, traditions, and values of his or her culture(s) of origin, although an individual may or may not accept those beliefs, traditions, and values. In addition, any individual may have assimilated or acculturated to the dominant culture to a greater or lesser degree. Here is the definition of these terms in case trainees want more clarification:
- Acculturation: can be described as the point at which individuals have found value and meaning in both cultures (the majority culture and their culture) and can identify with both.
- Assimilation: on the other hand, is when an individual’s home cultural values and beliefs are replaced by the new culture (leaving behind their native culture). Depending on whether or not the individual has acculturated or assimilated, or where he or she is in the process, is going to influence how the individual responds to treatment.
(Adapted from “Cultural Competence in Health Promotion” PPT from Centene Corporate Headquarters)

8. Culture & Self Expression
Culture plays an important role in how individuals of different backgrounds:
Express themselves
Seek help
Cope with stress
Develop social supports
Access and view treatment
-“It is important to point out the SEEK HELP bullet. When individuals are under stress, our cultural background may impact the type of social support we seek out and benefit from most.”
“For example, research has found that East Asians and Asian Americans are less likely than European Americans to talk about an event that they are stressed by (although this difference was smaller for Asian Americans who were born in the United States).”
“Psychologists have suggested that East Asians are less likely to talk about a stressful event because doing so can present a challenge to relationships in collectivistic cultures. Instead, individuals from East Asian cultures are more likely to seek out implicit social support, which involves spending time with people they are close to, without actually talking about a stressor.”
SOURCE:

9. Components of Culture TRAINER NOTES -This is a transition slide.
-The next few slides will go over some of the different components of culture.

10. Components of Culture Race Ethnicity Language Sexual orientation
Gender
Age
Disability
Class/socioeconomic status
Education
Religious/spiritual orientation
Family orientation
“This slide lists some of the different components of culture. These various components are important because they may influence the decisions we make on a daily basis (i.e. your gender or age may influence how you dress).”
“Because there are so many different components and aspects of culture, we will only be covering a few of them in detail during this presentation.”
Trainer Notes:
- The purpose of this slide is to list some of the various aspects of culture and to get the audience thinking about how some of these aspects may influence their daily decisions. It also gives the trainer the opportunity to tell the audience that we will only be covering a few of these aspects in detail, since there are so many. The following slides will cover the components of race, ethnicity, worldview, religion, and age.

11. Race Is a culturally constructed category of identity.
Divides humanity into groups based on physical traits that individuals have at birth.
-”Another component of culture is race.”
-”Race is a culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits attributed to some hypothetical intrinsic, biological characteristics.”

12. The Role of Race in Society
Racial categories & constructs have varied widely over history & across societies.
The construct of race has no consistent biological definition.
Race plays a role in:
Racial ideologies
Racism
Discrimination
Social exclusion
-”Racial categories and constructs have varied widely over history and across societies.”
-”The construct of race has no consistent biological definition.”
-”Race has been deemed socially important because it supports racial ideologies, racism, discrimination, and social exclusion, which can have strong negative effects on physical and mental health. There is evidence that racism can exacerbate many psychiatric disorders, contributing to poor outcome, and that racial biases can affect diagnostic assessment.
SOURCE: (American Psychiatric Association, 2013).

13. Ethnicity
A culturally constructed group identity used to define people and communities.
May be rooted in a common history, geography, language, religion, or other shared characteristic of a group, which distinguishes that group from others.
Race depends on the biological or physical traits of your ancestry.
Ethnicity depends more on the non-physical aspects of your ancestry. VS
- “Ethnicity may be self-assigned or attributed by outsiders.”
- “The racial categories included in the census questionnaire (noted on the previous slide) reflect a social definition of race recognized in this country and are not meant to indeterminately define race. An individual’s response to the race question is based upon self-identification. Everyone experiences their race and ethnicity differently, so it is imperative that we maintain a client-centered / patient-centered approach when working with our members.”
- TRAINER NOTE: If group members are comfortable, have them share some aspects of their ethnicity OR share some aspects of your ethnicity.
( - Reference)
(American Psychiatric Association, 2013)
(Reference: DSM 5)

14. Worldview World view determines an individual’s:
Perceptions
Spirituality
Understanding of humans, nature, and the universe
Components of worldview include:
Values
Beliefs
Communication style
Individual and group identities
Culture is a predominant force within worldview, shaping behaviors, values, and institutions.
- One of the components of culture is our worldview.
(Reference:

15. Our Role as Healthcare Professionals
We are responsible for understanding & appreciating that:
Individuals’ strengths can be rooted in their worldview.
Differences between individuals are a source of enrichment that can expand the options available to solve problems.
We are also responsible for being aware of our own worldviews/ culture and how these affect our approaches to providing treatment.
- “As healthcare professionals we are responsible for understanding and appreciating that a person’s strengths can be rooted in their worldview and that differences between people are to be appreciated as sources of enrichment that can expand the options available to solve problems.”
- “We are also responsible for respecting the unique, culturally defined needs of all individuals and believe that diversity within cultures is as important as diversity between cultures.”
- “As healthcare professionals we are also responsible for being aware of our own worldviews and cultures and how these affect our approaches to providing treatment.”
SOURCE:

16. Religion 5 of the world’s major religions include: Buddhism
Christianity
Hinduism
Islam
Judaism
(70.6%)
(22.8%)
(1.9%)
(0.9%)
(3.4%)
- “Religion is another important component of culture. This graph serves as a visual aid to demonstrate religious diversity in the United States. Just like we discussed when talking about race, health professionals should increase their awareness and knowledge and develop the skills necessary for appropriate and effective cross cultural interventions (which includes working with individuals from different religious affiliations.)”
-”The goals of widening your knowledge base about religious diversity are to reduce the incidence of poor patient outcomes, boost overall patient satisfaction, and improve overall quality of care.”
(Reference: "America’s Changing Religious Landscape". The Pew Forum ).
(Reference:
(0.6%)

17. Religion in Healthcare Treatment
Studies have shown that:
Many groups dealing with major life stressors state that religion and spirituality are helpful to people in coping.
Individuals would like to be able to talk about matters of faith in their treatment.
TRAINER NOTES/MORE INFO:
Here is more information on how religion can affect people’s healthcare choices:
-Buddhist patients: are typically modest and may have aversions to animal meat products, including those used to make certain medications. Ask patients if they have specific dietary or treatment needs to ensure that you’re providing culturally sensitive care. Buddhist patients may also refuse analgesics because clarity of mind is very important to practicing Buddhists. Nonpharmacologic pain management interventions, such as meditation and relaxation techniques, are often preferred. Buddhism emphasizes mindfulness and peaceful meditation during sickness and times of crisis (so try to provide a quiet and tranquil setting for the patient and family when possible to facilitate meditation).
-Christian patients: may want to keep a crucifix, bible, or rosary beads near them during surgeries, medical procedures, or hospital stays. Most Christianity denominations believe that life starts at conception and many are prolife. A pastor or church elder may visit to pray with the patient or read from the Bible during times of sickness; family members may also choose to pray or organize prayer groups.
-Hindu patients: typically have strong concerns about modesty and may prefer same sex caregivers. Many are strict vegetarians who refuse medications containing animal byproducts, while others may just refuse pork and beef. Fasting is a common practice in times of crisis.
-Jehovah’s Witnesses: many are strictly against personally receiving any type of blood in a transfusion, medication, blood byproduct, or food. This prohibition even applies to the transfusion of the patients' own stored blood. The Patient Self-Determination Act was signed into law in It gives any well-informed, competent person, including expectant mothers, the right to accept or decline any form of medical treatment. Jehovah's Witnesses don't believe in an afterlife immediately after death. Healthcare providers should refrain from saying things such as "He's in a better place now" in an attempt to comfort the family.
-Jewish patients: Observant Jewish patients will follow the strict rule of no work on the Sabbath, which is from sundown on Friday to sundown on Saturday, so they may want to refrain from scheduling medical procedures on the Sabbath. Observant Jewish patients will request a Kosher diet. Families may want to speak with a Rabbi about end-of-life care when death is anticipated.
-Muslim patients: Muslim patients are typically very modest, and complete nudity is a concern for observant Muslims. Women may cover their entire body with clothing and veils. They may prefer receiving treatment from a same sex caregiver. Muslim patients may refuse medications containing gelatin, pork products, or alcohol.
-An agnostic is a person who doesn't have a definite belief about whether God exists. An atheist is a person who believes that God doesn't exist. You're likely to care for patients who don't have a definite belief about God or a belief in God at all. You're also likely to encounter patients who refer to themselves as spiritual, but who don't identify themselves as belonging to a specific religious group
(Reference:
(Reference: "America’s Changing Religious Landscape". The Pew Forum ).
By increasing our knowledge of different religions and views regarding healthcare we can better meet the client’s needs

18. Age Patient care varies depending on the patient’s age group.
Healthcare professionals use different approaches to keep age specific needs in mind.
Differences in communication of information depend on age (i.e., child versus adult)
“Age is another important component of culture.”
“Healthcare professionals use different approaches depending upon the age of the patient. They may use different assessment tools or equipment depending on whether the patient is a child, adolescent, adult, or elder.”
“There may be differences in how we communicate with our clients depending on their age (i.e. we would communicate information differently to a 6 year old versus a 16 year old versus a 60 year old).”
(Reference:

19. What is Cultural Competency?
“Now that we have defined culture and its related terms, let’s talk about being coming culturally competent.”
“What does it mean to be culturally competent?”

20. Cultural Competency An ongoing process.
When individuals & systems respond respectfully & effectively to people of all cultures.
Recognizing & affirming the value/ worth of individuals, families, and communities.
Protecting & preserving the dignity of each individual.
-”Now that we have talked about some of the different components of culture, let’s discuss what it means to be “culturally competent” professionals.”
- “There are many developmental models of cultural competency, however, the most commonly used and referenced mode is the “Cross Model of Cultural Competency” by Terry Cross (1988). It describes cultural competency as a movement along a continuum that is based on the premise of respect and appreciation of individuals and cultural differences.”
-TRAINER NOTE: Emphasize that cultural competency is an ongoing process; this means we will never be experts because we will continue learning and expanding our knowledge.
SOURCE: (Reference:

21. Cultural Competency Involves
Obtaining cultural knowledge.
Developing cultural awareness.
Demonstrating cultural sensitivity.
-”Cultural Competency involves:”
-Obtaining Cultural Knowledge: Familiarization with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group.
-Developing Cultural Awareness: Developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others. Cultural awareness must be supplemented with cultural knowledge.
-Demonstrating Cultural Sensitivity: Knowing that cultural differences as well as similarities exist, without assigning values (i.e. better or worse, right or wrong) to those cultural differences.
(Reference:

22. 6 Levels of Cultural Competency
1. Destructiveness: Assumption of cultural superiority and exploitation by dominant groups.
2. Incapacity: Ignorance or fear of other groups and cultures.
3. Blindness: The philosophy of being “color-blind”; belief that culture, color, or class makes no difference.
4. Pre-Competence: The realization of weaknesses in working with other cultures.
5. Basic Competence: Acceptance and respect for differences; expansion of knowledge.
6. Advanced Competence: Cultures are held in high esteem; constant development of new approaches.
“These are the 6 levels or stages of cultural competency as identified in the Cross Model. Think of these stages as a continuum. Institutions and individuals can be at different stages of development simultaneously on the Cross continuum. For example, an institution or an individual may be at the Basic Stage with reference to race, but may be at the Incapacity Stage with regard to sexual orientation.”
TRAINER NOTE- More in depth info below
1) Destructiveness – this is the most negative end of the continuum. Individuals at this level view culture as a problem; believe that culture can be suppressed or destroyed; believe that people should be more like the “mainstream”; and assume that one culture is superior.
2) Incapacity – can be described as unintentional cultural destructiveness. Individuals in this phase lack cultural awareness and skills; they may have been brought up in a homogeneous society or been taught to behave in certain ways and they never questioned what they were taught. Individuals in this stage also maintain stereotypes.
3) Blindness – the philosophy of being unbiased; the belief that culture, class, or color makes no difference, and that traditionally used approaches are universally applicable. Individuals at this level believe that all people should be treated the same way regardless of race, religion, etc.
4) Pre-Competence – the realization of weaknesses in working with other cultures. An individual in this stage recognizes that there are cultural differences and start to educate themselves and others concerning these difference.
5) Basic Competence – acceptance and respect for differences. Individuals in this stage value diversity, understand and manage the dynamics of differences when cultures intersect, and are willing to examine components of cross-cultural interactions.
6) Advanced Competence – individuals in this phase move beyond accepting, appreciating, and accommodating cultural difference and begin to actively educate less informed individuals about cultural differences. They seek out knowledge about diverse cultures, develop skills to interact in diverse environments, and become allies with and feel comfortable with interacting with others in multicultural settings.
(Reference:
(Reference:

23. What is Diversity?
“The condition of having/ being composed of differing qualities.”
Includes many variables like: race, religion, color, gender, national origin, age, disability, sexual orientation, education, geographic origin, etc.
Why does diversity matter?
Why is diversity relevant to Cultural Competency?
- “In order to be culturally competent professionals, we also need to understand the concept of diversity and how it affects treatment.”
- “Merriam Webster defines diversity as “the condition of having or being composed of differing elements or qualities.”
- “Why does diversity matter and why is it relevant to Cultural Competency?”
Answer: Once we understand that diversity is the condition of being different we can extend that concept to treatment. Different people will respond to various treatment modalities differently. Healthcare professionals should be aware of the many dimensions of diversity and how these factors can be used to motivate and assist clients in treatment – or how they can be barriers to engagement, treatment, and recovery.
SOURCE:

24. Cultural Competency Standards for Professionals
TRAINER NOTES: This slide is a transition into talking about Cultural Competency Standards and what we need to implement in order to provide culturally competent services.
“So far we have talked about the different concepts of culture and why understanding diversity matters.”
“Now we are going to talk about some of the things we can do to practice being culturally competent professionals.”
“This is important because recovery and rehabilitation are more likely to occur where managed care systems, services, and providers utilize knowledge and skills that are culturally competent and compatible with the backgrounds of consumers, their families, and communities.”

25. Communication Variations
“One important component of being a culturally competent professional is to understand the differences or variations in communication styles. This slide shows a visual of the differences between Western culture’s communication style versus how South American and Eastern cultures communicate. As you can see, Americans tend to communicate more with words. Whereas, the other flags (representing Brazil, Russia, India, China, and South Africa) tend to communicate more with non-verbals.”
“Communication and language are intertwined with and are inseparable from culture. The ability to communicate effectively, therefore, is an exceptionally important variable when working cross-culturally or seeking to understand a patient’s cultural value system and “explanatory model” (ie, how a patient makes sense of an illness and how they choose treatments).”

26. Touch
While physical touch is an important form of non-verbal communication, the etiquette of touch is highly variable across and within cultures.
Touch can provide reassurance and kindness, or it can be a discomfort and annoyance.
TRAINER NOTES:
Read bullets to the participants and have them chime in by asking “Can you give some examples of how touch is viewed in your culture, family, and in your workplace?”
“Here is an example of differences in touch across some cultures:”
While patting a child’s head is considered to be a friendly or affectionate gesture in our culture, it is considered inappropriate by many Asians to touch someone on the head, which is believed to be a sacred part of the body. In the Middle East, the left hand is reserved for bodily hygiene and should not be used to touch another or transfer objects. In Muslim cultures, touch between opposite gendered individuals is generally inappropriate.
“Because the meaning of physical touch varies across and within cultures we need to be careful not to assume that touch (like a hug) will be comforting to our clients. We also cannot assume that it wouldn’t be. We want to keep in mind to ask before touching a client or their property (i.e. a person’s cane or wheelchair).”
References:

27. Eye Contact (Nonverbal Communication)
In mainstream Western culture, eye contact is interpreted as attentiveness and honesty; we are taught that we should “look people in the eye” when talking.
However in many cultures including Hispanic, Asian, Middle Eastern, and Native American, eye contact may be thought of as disrespectful or rude, and lack of eye contact may not mean that a person is not paying attention.
“Different cultural groups also may have many nonverbal, observable differences in communication style.”
Example: The physical therapist may believe a patient is acting disinterested if eye contact is not direct, when in reality, the patient may believe it is impolite to look directly at someone who is perceived as the authority figure.
TRAINER NOTES:
Studies suggest that as much as 93% of the total meaning of an encounter is communicated by nonverbal factors such as body language (55%) and tone of voice (38%).
The word “may” is bolded on the slide in the second bullet because we want to point out that within cultures there can also be differences so we want to refrain from generalizing.

28. Time People use time differently in various parts of the world.
There are two different ways of using time:
Monochronic Cultures: one thing at a time.
Polychronic Cultures: many things at the same time.
Why is this knowledge important if you are working with people from different cultures?
If you have done a little traveling or if you have encountered a lot of people from different cultures, you have probably created your own theories about cultural differences and time.
Your theory might sound something like this: "People from __x__ culture are always late and people from _y_ culture are usually on time". However, we need to be careful with a theory like this because it can lead to generalizations and stereotypes. To avoid mistaking a cultural difference for a personality or character issue, try to see time from your colleague’s point of view or from the client’s point of view. You will save yourself a lot of stress and you will have an easier time maintaining your important relationships.
There are 2 different ways of using time:
1) Monochronic Cultures | One Thing at a Time:  In a monochronic culture like the United States or countries in northern Europe, time is a commodity. We have expressions like "waste time" or "lose time" or "time is money". As you have probably already figured out, because time is such a commodity, showing up late, especially for a meeting or a dinner, usually comes across as very disrespectful. A monochronic culture functions on clock time. People like to focus on one thing at a time and are usually concerned with completing objectives in a systematic way. In a meeting, it's often important to stick to the plan or agenda and not to get "off track" by talking about unrelated topics.
2) Polychronic Cultures | Many Things at the Same Time:  Polychronic cultures like southern Europe, Latin American countries and the Middle East, take a very different view towards time. People from these cultures often believe that time cannot be controlled and it is flexible. Days are planned based on events rather than the clock. For many people in these cultures, when one event is finished, it is time to start the next, regardless of what the clock says. In a business exchange in a polychronic culture, sticking to an agenda might not be very important. Instead, many tasks like building relationships, negotiating or problem solving, can be accomplished at the same time.
Why is this knowledge important if you are working with people from different cultures?
- For example, in the US, business decisions are usually made during a meeting, at the workplace. In contrast, in some polychronic cultures, like Japan, the real business takes place over dinner and drinks, hours after the workday ends. Not knowing this and declining an offer from your Japanese colleagues to join them for dinner could cause you to lose a valuable opportunity to strengthen business relationships and get important things done.
- Deadlines: can be considered a promise that work will be done by a certain time OR an estimate. Issues can arise if people view deadlines differently. The same can be said regarding appointment times. If want to communicate your expectations regarding time to your clients from the beginning (i.e. they cannot be later than 5 minutes to appointments or 15 minutes, etc).
(Reference:

29. Communication Zones
What is the patient’s preferred requirement for personal space?
How close does the patient like to stand when speaking with health care providers?
Does a person of the opposite sex seem more uncomfortable than might be expected?
The questions on this slide are questions we can ourselves when interacting with people from different cultures.
A consideration of these questions, an understanding of a range of communication styles (both verbal and nonverbal) and learning styles, and the ability to properly interpret an interaction will undoubtedly minimize barriers that may otherwise exist.
Differences in interpretation occur with regard to eye contact, facial expression, body movement, personal space, and overall formality .
Gender and age are important variables influencing personal space. Why do you think this is? What could be some differences?
For example, people from Hispanic/Latino and Middle Eastern subcultures tend to prefer standing close and are comfortable with physical contact between members of the same sex. People who are members of the orthodox branches of Islam or Judaism, meanwhile, might not be comfortable being touched by someone of the opposite sex.
We all have varying definitions of what our “personal space” is, and these definitions are contextual and depend on the situation and the relationship.
Although our bubbles are invisible, people are socialized into the norms of personal space within their cultural group.
Scholars have identified four zones for US Americans, which are public, social, personal, and intimate distance (these are represented on the graphic on the slide).
(Reference: Edward T. Hall, “Proxemics,” Current Anthropology 9, no. 2 (1968): 83–95.)
(Reference:

30. Person First Language
Use “person first language” when talking about disabilities.
Person first language puts the person before the disability and describes what the person has, not who the person is.
Using appropriate language helps shape attitudes and perceptions.
Person first language avoids perpetuating old stereotypes.
“This slide focuses on guidelines we can use to make sure we are implementing and modeling cultural competency and sensitivity in regards to the language we are using, especially if we are working with individuals with disabilities.”
“Cultural competency also includes being able to incorporate and accommodate individuals with disabilities. Culture does not just represent race or ethnicity, it also encompasses age, gender, religion, as well as disabilities.”
TRAINER NOTES:
Disabilities in the United States are very prevalent; therefore it is important that we practice cultural competency among individuals with disabilities. Some facts:
- 8 percent of children under 15 had a disability.
- 21 percent of people 15 and older had a disability.
- 17 percent of people 21 to 64 had a disability.
- 50 percent of adults 65 and older had a disability.
(Reference: Americans with Disabilities:
(Reference:

31. Cultural Sensitivity Guidelines
He’s demented
She’s confined to a wheelchair
He has dementia
She uses a wheelchair
The disabled
He’s autistic
Persons with disabilities
He has autism
“This slide gives examples of statements that are offensive versus examples of person first language.”
(Reference -

32. Cultural Concepts of Distress
Refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions.
The DSM-5 includes information on cultural concepts in order to improve the accuracy of diagnosis and the comprehensiveness of clinical assessments.
“In addition to using person first language, we want to be mindful of the different cultural concepts of distress. Cultural concepts of distress (found on pg 833 of the DSM-5) refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions.”
“The DSM-5 includes information on cultural concepts in order to improve the accuracy of diagnosis and the comprehensiveness of clinical assessments. Clinical assessment of individuals presenting with these cultural concepts should determine whether they meeting DSM-5 criteria for a specified disorder or an “other specified or unspecified” diagnosis. Once the disorder is diagnosed, the cultural terms and explanations should be included in case formulations; they may help clarify symptoms and etiological attributions that could otherwise be confusing.”

33. Cultural Concepts of Distress
Some cultural concepts of distress:
Ataque de nervios
Dhat syndrome
Khyâl cap
Kufungisisa
Maladi moun
Nervios
Shenjing shuairuo
Susto
Taijin kyofusho
TRAINER NOTES:
Here are the definitions of the concepts of distress identified on the slide. If your audience is non-clinical, point out that the purpose of this slide is to bring awareness to these concepts. They don’t need to know the meaning of each, but they may hear their patients complain of some of these symptoms.
- Ataque de nervious: a syndrome among individuals of Latino descent characterized by symptoms of intense emotional upset including acute anxiety, anger, grief, screaming & shouting uncontrollably, attacks of crying, trembling, and becoming verbally and physically aggressive.
- Dhat syndrome: term coined in South Asia a little more than half a century ago to account for common clinical presentations for young male patients who attributed their various symptoms (i.e. anxiety, fatigue, weakness, weight loss, impotence, etc) to semen loss.
- Khyâl cap: syndrome found among Cambodians in the United States and Cambodia. Also known as “wind attacks” because symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities.
- Kufungisisa: “thinking too much” in Shona, is an idiom of distress and a cultural explanation among the Shona of Zimbabwe. It is considered to be causative of anxiety, depression, and somatic problems (i.e. “my heart is painful because I think too much”).
- Maladi moun: literal translation is “humanly caused illness,” also referred to as “sent sickness.” It is a cultural explanation in Haitian communities for diverse medical and psychiatric disorders. Interpersonal malice and envy cause people to harm their enemies by sending illnesses such as psychosis, depression, social or academic failure, and inability to perform activities of daily living.
- Nervios: literal translation is “nerves.” It is a common idiom of distress among Latinos in the United States and Latin America. It refers to a general state of vulnerability to stressful life experiences and to difficult circumstances. It includes a wide range of symptoms (i.e. headaches, irritability, sleep disturbances, nervousness, etc).
- Shenjing shuairuo: literal translation is “weakness of the nervous system” in Mandarin Chinese. It is a cultural syndrome composed of the following cluster of symptoms: weakness (i.e. mental fatigue), emotions (i.e. feeling annoyed or frustrated), and sleep (i.e insomnia).
- Susto: is a cultural explanation for distress and misfortune prevalent among some Latinos in the United States and among people in Mexico, Central America, and South America. It is not recognized as an illness category among Latinos from the Caribbean. It is attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness, as well as difficulties functioning in key social roles.
- Taijin kyofusho: “interpersonal fear disorder” in Japanese. It is a cultural syndrome characterized by anxiety about and avoidance of interpersonal situations due to the thought, feeling, or conviction that one’s appearance and actions in social interactions are inadequate or offensive to others (i.e. body odor, facial blushing, having a body deformity).

34. Conversation As professionals, we must be:
Open to initiating conversation about issues related to their culture and being honest about issues related to our own.
Having conversations oriented toward people and focusing on human relations.
Assuring information is conveyed and received as intended.
-“Because everyone’s culture is so different, we need to be open to having conversations with others in order to learn more about them and their culture.”
-”Miscommunication occurs frequently between health care professionals and patients, a problem that is intensified by language barriers. About 14% of the USA population does not speak English at home. Of the people who speak a language other than English at home, 47% say they have difficulty speaking English. What methods does your agency have in place to overcome language barriers? (i.e. translation services; bilingual staff; etc).”
-”Like the first bullet on this slide points out, we want to be open to initiating conversation with our clients regarding their culture. The next slide talks about a tool that health professionals can use to start a conversation with clients/patients regarding their culture.”
SOURCE: and

35. Cultural Formulation Interview (CFI)
A set of 16 questions for health professionals.
May use to obtain information about impact of culture on client’s presentation and care.
It focuses on the individual’s experience and the social contexts of the person’s problem.
It assesses the following categories:
Cultural identity of the individual.
Cultural conceptualization of distress.
Psychosocial stressors & cultural features of vulnerability & resilience.
Cultural features of the relationship between the individual & the professional.
Overall cultural assessment
“The Cultural Formulation Interview (CFI) consists of 16 questions which can be found in the back of the DSM-5. They are meant to be used as a tool or a guideline for health professionals in order to aid them with finding out cultural information about their clients or patients. It sets the tone for a conversation between the client and the professional. It is not an interrogation and instead helps build rapport between the professional and the client.”
TRAINER NOTES/MORE INFORMATION:
The DSM-5 has a section on Cultural Formulation that recognizes the importance of understanding the cultural context of illness experience (each individual experiences illness differently depending on their culture) in order to effectively diagnose and treat illnesses.
The Outline for Cultural Formulation provides a framework for assessing information about cultural features of an individual’s problems and how they relate to a social and cultural context. It assesses the following categories:
- Cultural identity of the individual: describes the individual’s racial, ethnic, or cultural reference groups that may influence his or her relationships with others, access to resources, and development & current challenges, conflicts, or predicaments. Language abilities, preferences, and patterns of use are relevant for identifying difficulties with access to care, social integration, and the need for an interpreter. Other clinically relevant aspects of identity may include religions affiliation, socioeconomic background, personal, and family places of birth and growing up, migrant status, and sexual orientation.
- Cultural conceptualization of distress: describes the cultural constructs that influence how the individual experiences, understands, and communicates his or her symptoms or problems to others.
- Psychosocial stressors & cultural features of vulnerability & resilience: identifies key stressors and supports the individual’s social environment and the role of religion, family, and other social networks have in providing emotional, instrumental, and informational support.
- Cultural features of the relationship between the individual and the clinician: identifies the differences in culture, language, and social status between an individual and the clinician/healthcare professional that may cause difficulties in communication and my influence diagnosis and treatment.
- Overall cultural assessment: summarizes the implications of the components of the cultural formulation identified in earlier sections of the outline for diagnosis and other relevant issues or problems, as well as appropriate management and treatment intervention.

36. Positive Impacts of Cultural Competency
More successful patient education.
Increases in patient’s health care seeking behavior.
More appropriate testing and screening.
Fewer diagnostic errors.
Avoidance of drug complications.
Greater adherence to medical advice.
Expanded choices and access to high-quality clinicians.
This slide wraps up the training by identifying the positive aspects of cultural competency. It answers the question “Why is cultural competency important?”
Brach & Fraser, (2000). More successful patient education, because culturally competent clinicians can target, tailor, and communicate health-related messages more effectively.
Increases in patients’ health-care-seeking behavior, by improving trust and understanding between clinician and patient.
More appropriate testing and screening, because clinicians will have more knowledge about the genetic background, risk exposure, and common health-related behavior in various cultural groups.
Fewer diagnostic errors, as a result of more comprehensive and more accurate medical histories.
Avoidance of drug complications, by discovering home or folk remedies used by patients.
Greater adherence to medical advice, because clinicians establish a treatment plan that is most consistent with the patient cultural beliefs and lifestyle. Thus, patients better understand how to follow the treatment plan.
Expanded choices and access to high-quality clinicians, because patients are no longer restricted to a small pool of clinicians who share their language and culture.

37. Select Communication Methods
What Can Providers Do?
Differentiate
Avoid
Ascertain
Be Cognizant
Be Clear
Family Dynamics
Strong Coalitions
Develop Trust
Select Communication Methods
Incorporate
There is no need for the healthcare professional to adopt another’s racial, ethnic, or cultural practices; but there is an expectation that the health care professional should participate in activities that bring about awareness, knowledge, experience, skills, and be willing to commit to a life-long process of change.
Trainer Notes: Read each box as it correlates with the statement.
Differentiate - Don’t assume someone is from a particular culture based on skin color: Muslims are often thought of to be brown-skinned, however, a Bosnian Muslim is typically very fair-skinned
Avoid - Do not assume that every member of a particular group will espouse to the things we talk about here or that you may know or learn about on your own. For example, not everyone over the age of 65 will need to use a walker, but may lead very active social and sexual lives.
Ascertain - Acculturation is the degree in which an immigrant adopts the cultures and behaviors of the host country. While not providing a complete picture, education, income, and language preference may have some influence.
Be Cognizant - People may tell you what they think you want to hear, you will need to push to better understand the sociocultural world of others.
Be Clear - Part of the empowerment process is to have your goals and objectives well defined and well articulated, and developed with your target population in mind.
Family Dynamics- Health educators from the US tend to focus on the individual and not the individual’s social support system. Family members are a powerful and strong source of support in many cultures and ethnic groups. Be sure to keep them included in any patient activities if the patient allows.
Strong Coalitions - In order to develop strong, effective programs involve members of the target group into planning and implementation. The group’s strengths are incorporated into the program and weaknesses are explored as opportunities
Select Communication Methods- Your target population may show admiration and respect due to your title and educational background, but do not assume that these individuals trust you. You need to become more familiar with the group and individuals with whom you are working and be accepted into their community; yours needs to be a familiar face or voice and one that is trusted.
Be sure to develop materials that are not just linguistically appropriate but educationally appropriate as well. Discover the many forms of media that may be preferred by your population; typically this would be a mix of media.
Incorporate - All programs need to have a cultural assessment to ensure the program will meet the needs of the intended audience
(Adapted from “Cultural Competence in Health Promotion” PPT from Centene Corporate Headquarters)

38. What Can Providers Do? Involve members in their own healthcare.
Learn more about culture, starting with your own.
Speak the language or use a trained interpreter.
Ask the right questions and look for answers (use the Cultural Formulation Interview as a guide).
Pay attention to financial issues.
Find resources and form partnerships.
TRAINER NOTES:
These are steps providers can take to become more culturally competent. Here is more information about each bullet:
Involve members in their own healthcare (i.e. ask them if they are satisfied with the care they are receiving from their doctors, nurses, therapist, etc).
Learn more about culture, starting with your own (i.e. read about other cultures, have personal contact with communities from which your patients are from, attend community events).
Speak the language or use a trained interpreter (i.e. arrange for an interpreter when you have a patient whose English proficiency is limited. Do not rely on family members or friends).
Ask the right questions and look for answers. The Cultural Formulation Interview can be used as a helpful tool. Use open-ended questions whenever possible.
Pay attention to financial issues. Learn about health care referral options for patients (i.e. low cost clinics, sliding fee scales, government assistance programs, etc).
Find resources and form partnerships. Network with other providers in your area and get to know healthcare professionals in your area.

39. What Is Your Role? Think about your role in the healthcare field.
How can you apply what you learned/discussed
in this training to your daily operations?
What is the culture of your office/work
environment?
Discussion: Ask the group how they can incorporate what they have learned in this training in their every day lives.
Is the culture in their work environment one of understanding and being tolerable of differences?

40. Learning Objectives Revisited
Participants will:
Defined culture & cultural competency.
Discussed 6 levels of cultural competency.
Identified 4 communication variations within/ across cultures.
Identified 2 reasons why providing culturally competent health care will improve client/member treatment.

41. What questions do you have?
If they feel a facility needs training they can contact you directly.

42. A Parting Thought…
“We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.” 
– Jimmy Carter

43. References
Age Specific Considerations in Patient Care. (2004). Retrieved September 11, 2015, from
America’s Changing Religious Landscape. (2015, May 11). Retrieved September 11, 2015, from
Behind the Numbers: Race, Ethnicity, and Ancestry. (n.d.). Retrieved September 11, 2015.
Brault, M. (2012, July 1). Current Population Reports. Retrieved September 14, 2015, from
Caring for Patients of Different Religions. (2014). Retrieved September 11, 2015, from
Cultural Competence. (n.d.). Retrieved September 14, 2015, from
Cultural Competence in Mental Health. (n.d.). Retrieved September 10, 2015, from

44. References
Definitions for New Race and Ethnicity Categories. (n.d.). Retrieved September 11, 2015, from
Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
Disability Etiquette & People First Language. (n.d.). Retrieved September 14, 2015, from
Disparities in Health and Health Care: Five Key Questions and Answers. (2012, November 30). Retrieved September 14, 2015, from
Edward T. Hall, “Proxemics,” Current Anthropology 9, no. 2 (1968): 83–95.
Eliminating Racial/Ethnic Disparities in Health Care: What are the Options? (2008, October 20). Retrieved September 14, 2015, from

45. References
Factors That Contribute to Health Disparities in Cancer. (2014, July 21). Retrieved September 14, 2015, from
Geriatric Nursing Resources for Care of Older Adults. (2012). Retrieved September 14, 2015, from
Hall, E. (1968). Proxemics (Vol. 9). Chicago, Ill.: Current Anthropology.
Leavitt, R. (n.d.). Developing Cultural Competence in a Multicultural World, Parts 1 & 2. Retrieved September 14, 2015, from
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46. References
McMahon, L. (2012, February 20). Cultural Differences and Time: Looking Beyond "Late" or "On Time" Retrieved September 14, 2015, from
Principles of Multicultural Psychiatric Rehabilitation Services. (n.d.). Retrieved September 11, 2015, from
PSYCH 485 blog. (2012). Retrieved September 14, 2015, from
Race. (2010). Retrieved September 11, 2015, from
Rachel Dolezal and Race as a Social Construct. (n.d.). Retrieved September 11, 2015, from
Racial and Ethnic Disparities in Alzheimer's Disease: A Literature Review. (2015, June 13). Retrieved September 14, 2015, from

47. References
Seibert, P., Stridh-lgo, P., & Zimmerman, C. (2001, November 5). A checklist to facilitate cultural awareness and sensitivity. Retrieved September 14, 2015, from
Section 2. Building Relationships with People from Different Cultures. (n.d.). Retrieved September 11, 2015, from
Stereotyping, Negative Assumptions and Paternalism Towards Older Adults. (2009). Retrieved September 14, 2015, from
Stages and Levels of Cultural Competency Development. (n.d.). Retrieved September 14, 2015, from
The Mission and Structure of the Office of Management and Budget. (n.d.). Retrieved September 11, 2015, from

48. References
Treatment, C. (n.d.). Preparing a Program To Treat Diverse Clients. Retrieved September 14, 2015, from
UCareMinnesota (2000). Six Steps Toward Cultural Competence. Retrieved September 22, 2015 from
Understanding How Culture Influences Behavior - HealthyPsych.com. (2015, January 30). Retrieved September 10, 2015, from
Vermont Department of Health. (n.d.). Cultural Differences in Nonverbal Communication. Retrieved September 14, 2015, from
What Role Do Religion and Spirituality Play In Mental Health? (2013). Retrieved September 11, 2015, from