1. Culturally Appropriate Public Health Training Series

2. Josephina Campinha-Bacote Cultural Competency Model Cultural Desire Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounters

3. Cultural Desire You are here! Cultural desire is the motivation of the healthcare professional to want to engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful and seeking cultural encounters; not the have to. Cultural desire is the spiritual and pivotal construct of cultural competence that provides the energy source and foundation for ones journey towards cultural competence. –Source: http://www.transculturalcare.net/

4. Cultural Awareness Cultural awareness is defined as the process of conducting a self-examination of ones own biases towards other cultures and the in-depth exploration of ones cultural and professional background. Cultural awareness also involves being aware of the existence of documented racism and other "isms" in healthcare delivery. –Source: http://www.transculturalcare.net/

5. Cultural Awareness Start class by presenting and discussing some of the feedback from PHNs about their needs – to kick off the class. Here are some of the Challenging Cultural Scenarios presented by your PHN peers: How to deal with misconceptions that others (coworkers) have about different cultures Who is present at the exam (male/female attendants) Male makes decisions for females; do you talk with male only when he speaks for wife Want cultural perspectives on TB Want to know how to give women optimal health care (e.g. birth control) in situations where males are dominant and resist some health promoting intervention (e.g. limiting number of children) KEY POINTS: Everyone has a dominant culture and our actions occur without thought when we are operating in that dominant culture. Increasingly we operate within a multicultural context and need to develop cultural competence to effectively provide nursing care. Barriers to cultural competence include stereotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural conflict and cultural shock. We are frequently unaware (have a blind spot) to our own stereotyping and prejudice. To start wed like you to complete this questionnaire that is a self– assessment of cultural and linguistic competency. This will take about 15 minutes to complete. To Facilitator: Read directions at top of survey. GIVE SURVEY – NOTE: Fatima is obtaining permission to use this survey developed by Tawara Goode, Georgetown U. Post-survey activity: Look your survey over for items you selected a c. Partner with person next to you to discuss these areas; why you answered the way you did and ideas you both have for changing/improving that action.

6. Cultural Awareness Self-Assessment Checklist for Personnel Providing Primary Health Care Services –http://www11.georgetown.edu/research/gucchd/nccc/ documents/Checklist%20PHC.pdfhttp://www11.georgetown.edu/research/gucchd/nccc/ documents/Checklist%20PHC.pdf Self-Assessment Checklist for Personnel Providing Services and Supports In Early Intervention and Early Childhood Settings –http://www11.georgetown.edu/research/gucchd/nccc/ documents/Checklist.EIEC.doc.pdfhttp://www11.georgetown.edu/research/gucchd/nccc/ documents/Checklist.EIEC.doc.pdf Dr. Patty Hale

7. Cultural Knowledge Dr. Charlene Douglas, Dr. Courtney H. Lyder Dr. Bennie Marshall

8. Cultural Knowledge Definition - Health care professionals seeking an informational base regarding the worldviews of different cultural and ethnic groups –Also includes discussions of biological variations, diseases and health conditions found among ethnic groups

9. Areas To Be Covered In This Unit Refugees vs. Immigrants Cultural Attitudes Related To: –Gender Roles/Authority –Child Care/Discipline –Time –Sanitation Communicable Diseases Chronic Illness Nutrition Womens Health and Family Planning Resources

10. Cultural Perspectives Be Very Careful –Human beings are far more similar than different –They love their families, value life and want the best –Life experiences, socioeconomic status, family dynamics, religious influences, and specific cultural influences will impact on matters of health care –For our clients, the culture of poverty is the overwhelming thread of commonality across races and cultures

11. Cultural Attitudes Hispanics FAMILISM or FAMILISMO – Cultural emphasis on maintaining strong intimate, and supportive relationships with both nuclear and extended families. Often a protective factor. – The Hispanic American has a very deep awareness of and pride in his/her membership in the family. - The importance of family membership and belonging cuts across class lines and socioeconomic conditions. – An individuals self-confidence, worth, security and identity are determined by his/her relationship to other family members

12. Cultural Attitudes Hispanics Each feels an inner dignity (dignidad) and expects others to show respect (respeto) for that dignidad. When working with Hispanic families, developing trust and personal relationships will be critical.

13. Cultural Attitudes Hispanic Gender roles/authority Machismo –- to maleness or manliness –- it is expected that a man be physically strong, unafraid, and the authority figure in the family, –Has an obligation to protect and provide for his family. Motherhood is an important goal for women –Mothers are expected to sacrifice for her children and care for elderly relatives.

14. Cultural Attitudes Childcare/discipline Child rearing very important (family event) Often find explanation of consequences less effective compared to other measures of disciplining (time out, withdrawing privileges).

15. Cultural Attitudes Time Second wave of Latino immigration to U.S. in 1990s –More Latino children are suffering from health problems, obesity, learning disorders, panic attacks and a series of other health issues related to stress (i.e. fear of deportation/separation, economic hardship of going underground). –Live in larger cohorts in smaller spaces.

16. Cultural Attitudes Many crimes against undocumented immigrants goes unreported, including robberies, burglaries, rape, violent crimes. They are often victims when trying to purchase cars or rent apartments from unscrupulous vendors

17. Cultural Attitudes Asian Gender Roles/Authority Patriarchy and Gender Inequality –Patriarchal beliefs, values and practices –Unequal Power relationships Status and role of women in society – culturally constructed Norms of male and female behaviour –Example: KIRIBATI - legal recognition of men as official head of household –Honor killings Women not included in decision making process –May experience challenges in Patient centered care. Often passive patients.

18. Cultural Attitudes Child care/discipline Majority of child care is left to mother. Very active in childs achievements Parents, especially the father, have the ultimate authority or power over the children. They act as supporters to assist their children to fit into the social structure. There is always the hierarchy in the family and between the relationship of parents and children. Parents seem somewhat more serious than friendly and always apply a strict discipline to the children, but are always prepared to give encouragement and advice.

19. Cultural Attitudes When they have to use disciplinary means, they do not hesitate to apply harsh punishments. Often physical punishment in Asian tradition is not considered abuse Other members of the family, such as grandparents, aunts, uncles, etc. also can punish naughty children. In turn, the obligation of children is to submit, obey, and respect their parents and other relatives.

20. Cultural Attitudes Time Asian migration began over 100 years ago. Largest group pf Asians are Chinese Health is a balance of Western/Eastern philosophies (Buddhism, Confucianism, Taoism and Shamanism). Wide use of acupuncture, moxibustion and herbal remedies. Time orientation is to the present.

21. Refugees vs. Immigrants May be similar or widely different Refugees –May be fleeing war experience –May have suffered torture, wounds, disabilities –May have lived in refugee camps –Females from the Middle East and Africa may be circumcised –They may have minimal education, and may be illiterate in their own language

22. Refugees Have visas Eastern Europeans –Religious persecution –Infrastructure in place Muslims may have multiple wives –Can declare just one –Financial strain –Resist passing judgment on this situation

23. Muslim Women Wearing Veils

24. Muslim Women Veils are not oppressive, they are a religious expressions –They vary by region and their practice of Islam Wealth and assets are in your children –Some families will have as many children as possible Fully veiled women will always be with a partner; that will not be changed in this generation

25. Immigrants El Savador is the primary country of origin, but Asia, the Middle East and Africa are also places of origin Young population, under 40 years Half of all Central Americans speak little or no English Live primarily in suburbs where service jobs are available

26. Immigrants We see a skewed, and impoverished, sample of the population Almost half of immigrant children from Central America live in homes owned by their parents 77% of immigrant children in Virginia are citizens and 41% are bilingual and are an investment in this economy

27. Domestic Violence A sad reality in many womens lives; middle- class, educated women live with domestic violence The Wheel of Power gives a framework for how it develops –A Muslim Wheel conveys some of the ways religion can be distorted to justify abuse against women and children in the family context The Cycle of Violence shows how it occurs day to day

28. Immigrants and Domestic Violence With immigrants, the above are fueled by: –Culturally endorsed male dominance –Lack of money –Difficult / strenuous working conditions –Undocumented status –High rates of substance abuse Ask Who hurt you? rather than What happened? Have an established referral system in your office

29. Domestic Violence: Wheel of Power

32. Immigrant Women – Why They Stay Fears exposure of immigrant status Sexual abuse of teen girls by stepfathers is a real danger, mothers stay with abusive husbands instead Practicing Catholics seek to preserve marriage for a lifetime Getting help is difficult: –Court papers arrive in English or a Spanish that is not understood –Legal exposure can result in deportation

33. Gender Roles / Authority Muslim women confined to home –May be depressed –Sees opportunities, cannot access them Female Arabic translators can be used and may accompany women without partners –Not widely available –Men with women in the exam room is a cultural practice that will continue

34. Inequalities Between Genders Manifested as dominance by boys and men and acquiescence by girls and women These inequalities make women more vulnerable to: –Lack of control of their reproductive life –Domestic violence –Coerced, unprotected, or unwanted sex

35. Child Care Pagil - Korean tradition Do not prepare for child Celebration only after infants first 100 days of life Before immunizations, 100 days was a good sign that a child would survive Immune system now working, could fight disease

36. Child Care / Discipline Research is contradictory and inadequate due to –Differing client / professional perceptions –Not separating out poverty and culture –Treating all cultures from different countries the same [ethnic clumping] Culture of Poverty –Atmosphere of violence with more corporal punishment than the middle class –Hitting used to encourage respect –Ignorance around positive bonding behaviors

37. Hispanic Issues Very young children not under control in the office –Child care is often a neighbor/friend –No real structure and many children –They see their mothers very little; moms report that they cannot control the children Older children –Latinos are more likely to use an authoritarian style of parenting and demand obedience and respect from their children –This combined with the culture of poverty [in our clients] can result in CPS referrals

38. Teen Issues Teens are caught between cultures –A more permissive dominant society and family rules cause friction –Everyone in the family works hard –Teens are bilingual and are hired quickly in the service industry –Often by-pass higher education for immediate work Teens are left alone when parents work –Girls and boys at risk for gang activity –CPS has no placement for troubled teens –All traditional immigrant families may opt out of even Family Life classes, but the teens are still sexually active –Latinas have babies, Muslims have abortions due to cultural pressures

39. Time Culture of Poverty in U.S. –Present time focus –Limited money, resources Health care, child care, help for troubled children –Will deal with whatever comes Some Spanish speaking countries do not use the future tense in speaking Be leery of Blaming the Victim –Many clients take multiple buses to appointments –A client in a large SUV does not mean all clients are cheating the system –Encourage to call to cancel and to be on time –Remember, your Dr. office and dentist calls to remind you of your appt. – we do not have resources for that

40. Sanitation Rotavirus –Suspect this with recurrent diarrhea / vomiting in infants and young children –Crowded multiple family dwellings can result in lax overall sanitation –Advise moms - Bottles and nipples must be kept clean Food Preparation –Women are used to shopping every day with fresh produce and meats – not in this country –Many single men cook for themselves for the first time in homes where they rent rooms –This can result in kitchens that are unkept

41. Sanitation Issues In children new to this country –If well nourished but remains anemic, with failure to thrive –Test for parasites Tap Water –Clean in this country –In countries of origin, causes illness –They continue to buy bottled water in U.S. Bottled water expensive, no fluoride Unnecesary

42. Immunizations Vaccination Camps –Still in operation –Large # of people –No written record Clients –Know that they have been immunized –You do not need any more shots

43. Strategies Related To Immunizations Prior immunizations? In this country? Outside of this country? Ask for written records Acknowledge that they are telling the truth Explain the need for a written record: –For School –For Work –To make sure they are completely protected against these diseases Encourage them to keep the new record secure

44. Special Issues With Ruebella Our clients can be incredibly shy –Culture –Lack of education Do not start with When was your last period –Vaccine is dangerous to your baby if pregnant –We must make sure you are not pregnant –When was your last menstrual period

45. Tuberculosis This is a child in Nicaragua Fear of TB is pervasive in our clients countries Infection vs. Disease is not clear to our clients Take every opportunity to educate Worldwide, TB is greatest cause of death by a single agent

46. PPD Testing After BCG Results will generally be inconclusive (<10mm) Second PPD and X-ray needed to determine if infection is present Most clients with TB have an infection only 1/3 of the worlds population harbors TB If clients told they have an infection, they believe they the disease

47. Infection vs. Disease If you are not the primary TB nurse, one or two meds means infection –NIH or Rifampin If they have the disease, they will be on multiple medications –INH, Rifampin, Ethamentol, PVA, B 6 The word TB means they cannot touch dishes, touch babies, cook food, family may be afraid of them

48. TB and Patient Education Take every opportunity to educate Infection does not mean infectious Taking medications as scheduled will prevent TB infection from becoming infectious Medications are often not taken correctly Reinforce schedule of medication Reinforce that they cannot pass TB infection on to others while on their medication

49. Family Planning Issues In the traditional Latino culture, discussions of sex reach the level of taboo –Against cultural, social and religious mores Incredible shyness is lack of knowledge –About how the body works –Any information related to sex –How to discuss issues related to sex –Female role is not to ask or lead in any way –Exploring their bodies may be seen as shameful and a source of embarrassment

50. Family Planning Issues Clients will state I need to talk to my husband Often hungry for birth control information –Women learn to silence themselves to avoid conflict Strategy –It is fine to speak with your husband –Why dont you and I beginning talking now –Clients faces light up when they are able to get information

51. Family Planning Issues: Refugees Your wealth and assets rests with your children Acknowledge your respect for family Discuss advantages of fewer children in U.S. –Costs of food, clothes, housing –Opportunities available to children –Cultural values may over-ride birth control

52. STD Women engage in risky sexual behaviors in the name of emotional and physical connections Women equate intimacy and trust with not verifying a potential partners HIV and STD status before having sex, trusting in supposed fidelity, and engaging in condomless sex

53. Sexually Transmitted Diseases Power differences between genders is even greater in traditional societies These inequalities are fueling the HIV epidemic and the rise of STDs in women –Rates of Chlamydia are on a significant rise in women Inequalities undermine the ability of women to cope if they become infected –Increases the possibility they will not seek treatment –Increases their unintentionally infecting others

54. Sexually Transmitted Diseases Successful treatment is a challenge Antibiotics are available over the counter Clients self-prescribe They share antibiotics and birth control pills Clients take meds until they feel better or overt symptoms disappear

55. Intervention Strategies Immigrant women need specific medication counseling –Taking on a regular schedule –Until the medication is gone –Have women repeat the directions back to you Give information to women about sexual health at every opportunity –You speak openly, clearly – role model –Show no embarrassment

56. Strategies Important for their children –Adolescents whose mothers discuss condom use with them are more likely to use a condom at their first intercourse and regularly thereafter –Children are learning about sex in school –They need to talk, and often know more than their mothers –You may break an old cycle and initiate a new, healthy level of communication

57. PAP Tests / HPV Men with multiple partners –An issue in ALL cultures –Including religious cultures –Mores of purity apply to women –These multiple partners put our female clients at risk for STDs and HPVs

58. PAP Tests / HPV If gangs are present –Girls are gang raped to be jumped in Many Hispanic teens are pregnant by adult men, who have multiple partners Young sexually active women need annual PAP tests

59. Female Circumcision This is a social custom, 1,400 years old Supported and refuted with passages from the Quaran Increasingly under fire, banned in some African countries, but still practiced

60. Refugees African and Muslim women If embarrassed about the pelvic exam, ask if they are circumcised –Objective voice and facial expression Inform Midwife/MD –Everyone, maintain control over facial expression, body language –Client may have fissures Screen for Hepatitis B –Secondary to dirty instruments used

61. Mammograms Little resistance in foreign born clients –Frame the discussion as an investment in the family, keeping themselves healthy More resistance in African American clients –Concerned about looking for trouble If your office promotes mammograms, have referrals and access to local programs available

62. Cultural Diversity and Nutrition Denise DiCicco MSN, RNC, IBCLC,RLC

63. Nutrition Science that includes the study of how food, nutrients & other substances interact with the body to foster growth and development, health or contribute to disease. Requires a knowledge and understanding of social, economic, cultural and psychological implications of food and eating behaviors. Adequate nutrition plays a critical role in the maintenance and restoration of good health and well-being.

64. Nutrition (cont) Factors that can affect an individuals nutritional status include: personal preferences & habits cultural, religious & family customs social & environmental setting economic & political circumstances Being aware of social and religious complexities can help professionals working with families to meet nutritional needs within the context of their own cultural and religious beliefs.

65. Role of Health Professional To provide families with information and support to meet their needs, not to change their beliefs or choices whether they are personally or culturally based. Accurately assess the nutritional status of families Determine the familys knowledge of nutrition & provide appropriate resources Identify ways in which food is used and managed Ensure that families are adequately nourished

66. Overview of Normal Patterns of Nutrition Water & electrolytes –Primary component of body tissue –Maintaining fluid balance is essential to good health –No specific recommended daily requirement for water –Infants can be susceptible to rapid variations in water balance Water losses may be due to; –Illness can lead to significant water loss & dehydration. (i.e. vomiting & diarrhea) – Activity level (i.e. strenuous activity in warm, dry environment requires additional water intake –Altitude –Temperature & dryness if ambient air. –If > 10% of body weight is lost without replacement, dehydration may be life threatening

67. Sodium Involved in the regulation of; –Extracellular fluid volume –Osmolarity –acid-base balance –membrane potential of cells –cell membrane transport pump –exchange with K+ in the intracellular fluid Loss occurs with Vomiting, diarrhea, & perspiration Typical North American diet far exceeds the minimum requirements and thus it is not necessary to add sodium to the diet. Most sodium is provided during the processing and manufacture of foods.

68. Potassium Maintains intracellular homeostasis Contributes to muscle contractility & transmission of nerve impulses Hypokalemia (low K+) can lead to cardiac arrhythmias & death Hyperkalemia (high K+) can cause cardiac arrest Urinary & GI systems regulate K+ levels Extreme imbalances usually due to disease process or medication rather than diet. Fruits, vegetables & fresh meat have K+

69. Chloride Functions with Na+ to maintain fluid & electrolyte balance Loss occurs with vomiting, diarrhea & perspiration Major source is salt added to foods during processing No recommended daily allowance Adequate amounts are ingested with a normal diet

70. Protein Fundamental component of all body cells Broken down into amino acids which are important in synthesis of body cell protein Required in some enzyme & hormone activity involved in cell transport, tissue growth & development Essential amino acids are not synthesized by the body & must be included in the diet Protein & amino acid deficiencies usually occur with other dietary deficits (i.e. extreme stress, some disease processes may deplete nitrogen, contributing to tissue wasting & create increased demand for protein)

71. Carbohydrates Bodys major dietary source of energy Recommended that 45%-65% of childrens diet include carbohydrates, and most should be in complex form. Adequate carbohydrate intake is important for protein synthesis Simple carbohydrates found in fruits, vegetables, milk & prepared sweets. Complex carbohydrates found in cereal, grains, potatoes, legumes & other vegetables.

72. Fats (lipids, fats, fatty acids) Used by the body to provide energy Facilitate absorption of fat- soluble vitamins (A,D,E,K) Maintain integrity of cell membranes & myelin Essential fatty acids are not produced by the body & must be included in the diet, & are found in most vegetable oils There should be no fat restriction for children < 2 years of age

73. Fats (lipids, fats, fatty acids) (cont) Children >2years of age should have 20%- 30% of total calories from fats Saturated fats should be <10% No more than 300 mg of cholesterol Excessive restriction of fat or caloric intake may contribute to loss of essential nutrients & result in growth failure

74. Vitamins Fat soluble (A,D,E, K) –can be stored in body tissues for a long time –temporary deficiencies may not affect growth & development –stable when heated & not destroyed in cooking Water soluble –Vitamin C & B complexes stored in small amounts in the body –daily intake is necessary

75. Minerals Major minerals are Calcium, Magnesium, Phosphorus Peak bone density is directly related to Ca+ intake during the years of bone mineralization Most mineralization takes place by the time a person is 20 years old, but calcification can continue for several years Dietary calcium should remain high until about 25 years of age.

76. Foods Eaten Around the World Every country & region of a country has its own typical foods & ways of combining them into meals. Components of meals vary across cultures but generally include grains, meat or meat substitutes such as fish, beans, tofu & vegetables. Each culture has acceptable & unacceptable foods. As an example, alligator, horses, turtles, & dogs may be eaten in some cultures as delicacies but unacceptable in other cultures.

77. Foods Eaten Around the World (cont) Sweetness is a universally acceptable flavor, taste for salty, savory, spicy, tart, bitter, & hot must be acquired When families leave their traditional ways of eating patterns, they may encounter different food choices than they are accustomed to which may lead to obesity, diabetes, & other health related conditions.

78. Food Pyramid The Food Guide Pyramid is a useful teaching tool for families. –Additional Food Guide pyramids have been created as educational resources for various ethnic groups & those eating a Vegetarian diet. –www.oldwayspt.orgwww.oldwayspt.org –www.mypyramid.gov/pyramidwww.mypyramid.gov/pyramid

79. Vegetarians Vegans- eat only foods of plant origin (fruits, vegetables, grains, nuts, seeds, legumes) Lacto-vegetarians-include milk & dietary products as well as plant-based foods in their diets. Lacto-ovo-vegetarians-eat eggs, dairy products & all plant based foods in their diet Sometimes vegetarians-will eat predominantly plant-based foods & occasionally eat fish, chicken & some seafood

80. Vegetarians (cont) Vitamin B 12 supplementation is required because bio-available Vitamin B 12 is found only in animal based foods. Lactose intolerance caused by lack of the enzyme lactase is rare in infants, but common in older children & adults from Asian, Native American, Black & Hispanic ethnic groups.

81. Mexican Food is often used to cure illness Cold vs Hot foods (www.ethnomed.org)www.ethnomed.org Hot & warm foods thought to digest easier than cold foods therefore foods are warmed before eating. Cold FoodsHot Foods BeansAromatic beverages Corn productsChili Dairy productsExpensive meats (beef, water fawl, fish, mutton) CitrusWheat products Tropical fruit Inexpensive meat (goat, chicken, rabbit)

82. Asian Chi is energy present in all living things. Food is transformed into chi & becomes either a cold yin or a hot yang force. Cold foods are needed for hot conditions such as pregnancy Wide range of foods found to be harmful or beneficial between cultural groups Foods thought to play a part in cause & effect of disease. Women of east Asian & Southeast Asian cultures ( Cambodian, Chinese, Vietnamese) may follow a custom of doing the month Women thought to be vulnerable to cold, wind, and magic, and therefore stay home, avoid drafts, and dress warmly in the first 30 days after childbirth.

83. Asian (cont) Those eating traditional Chinese foods consume three times the fiber, eat half the fat, and have lower cholesterol levels than those eating the American way. Total amount of meat, fish, or egg is small with meals centering on a staple starch such as rice. All food is cut into bite-sized pieces before cooking so food cooks quickly with few nutrients destroyed. Deep fried foods are rarely eaten. Heavy use of condiments such as MSG and soy sauce. (Estes, 2006)

84. Mediterranean Diets Limited consumption of dairy products/meats includes abundance of vegetables, fruits, legumes, & whole grains Olive oil is principle source of fat Average daily consumption of meat in U.S. is more than half a pound per person per day. In the Mediterranean region, it is about half a pound per person per week

85. Religious Diets Kosher refers to a set of restrictions that orthodox Jews place on selection & preparation of animal-derived foods. Done as a religious commitment. Jews in different countries may eat different foods, but the kosher rules apply to all. The rules of kosher do not provide any special health benefits. Beef may be eaten, but not pork Fish can be eaten, but not shellfish Milk & meat are prohibited in the same meal. Non-dairy creamer is used as substitute in some meals that also include meat.

86. Religious Diets (cont) Blood is forbidden as food, therefore, kosher rules govern methods of animal slaughter, cuts that may be eaten & preparation rituals. During Lent, many Christians eat only vegetarian meals, giving up meat until Easter. May also have fasting days. The Mormon faith does not allow any alcohol, coffee, or tea. Many Seventh Day Adventists consume no meat, but eat eggs & milk products, no alcohol, coffee, or tea.

87. Childhood Eating Behaviors & Nutrition Important to note regarding childrens nutrition; –Nutritional needs will vary as they grow, and are influenced by their state of health (i.e. chronic illness) –Wide range of food choices & feeding behaviors may be used to meet nutritional needs Proper nutrition affects the childs ability to interact with their environment and is essential for normal growth & development. Recommended dietary allowances (RDA) are guidelines, not absolutes. Children dont need to eat the RDA of all foods.

88. Childhood Eating Behaviors & Nutrition (cont) Appetite fluctuations & preferences are typical of children Parents & caregivers are responsible for establishing healthy eating patterns & providing nutritionally adequate food choices, therefore & must be well informed.

89. Nutritional Recommendations for Children Breastmilk is the best source of nutrition for infants. The AAP recommends whole milk for children 12-24 months of age. Note: 2% milk as part of a varied diet can also contribute to adequate fat intake & has no negative affect on growth or body composition Variety of foods should be incorporated in childs diet. Iron-rich foods are essential especially for infants & teenagers.

90. Nutritional Recommendations for Children (cont) Limit saturated fats, cholesterol, & sugars. Include adequate fiber. Extra Calcium, Iron, & Folic Acid are important for teenage girls. Advice & counseling should be offered within the familys belief system. Resources for intake patterns: –www.mypyramid.gov/professionals/pdf-food- intake.htmlwww.mypyramid.gov/professionals/pdf-food- intake.html

91. Breastfeeding and Culture Mothering through breastfeeding transcends cultural & language differences. Cultural & religious beliefs include ideas about modesty & nursing in front of others or how long a child should nurse.

92. LaLeche League Leaders Handbook The primary goal is to provide each mother with good, sound knowledge and allow her to proceed with the rearing of her child according to her own beliefs, values, and personality - www.lalecheleague.orgwww.lalecheleague.org Breastfeeding problems often are rooted in culture beliefs & practices that do not match the biological needs of the mother & infant If new information challenges a mothers culturally based beliefs, she may mistrust it & have difficulty complying with recommendations offered. Research has demonstrated that exclusive breastfeeding for 6 months or longer is important in maintaining the health of the mother & baby.

93. Benefits to Breastfeeding Benefits include; –reduction in the incidence of acute illness in children such as diarrhea, ear infections, pneumonia, meningitis –lessens the occurrence of chronic disease & conditions such as; –SIDS (sudden infant death syndrome) –obesity –childhood leukemia –asthma –women have reduced rates of breast cancer (Wolf, 2003)

94. Breastfeeding (cont) The AAP recommends Breastfeeding for at least one year and thereafter for as long as mother and infant desire. WHO recommends breastfeeding for at least two years Not only initiation, but exclusivity and duration of breastfeeding is important A common trend is that women immigrating to the U.S. are not continuing to breastfeed (Weibert, 2002)

95. Breastfeeding Around the World Latin American/Mexican –80% of women breastfeed for at least 4 to 6 months –After immigration to the U.S., the rates fall to 48% Colostrum considered dirty or stale milk and therefore infant may not breastfeed for several days after birth Having the mother express a few drops of Colostrum then placing the infant to the breast may help change this practice and get the infant to breastfeed sooner Any stress or emotional upset may change the quality, quantity, and even sour the breast milk, leading the mother to give formula to avoid harming her baby

96. Breastfeeding Around the World (cont) Cold environments are thought to decrease milk flow. Extreme heat makes milk curdle in the infants stomach or mothers breast. Hot and cold food classification is applied to the infant as well. Evaporated milk is considered hot food. Whole milk is considered cold food. Skin rashes are thought to develop from hot foods, (i.e., infant formula.) Mothers may prefer to give infants whole milk.

97. Japanese Having healthy children is highly valued in the Japanese culture Breastfeeding is viewed as necessary for the health of the child. Figurines and plaques may given to the mother to help her prayers for sufficient milk supply

98. South East Asian Excessive hot foods are thought to deplete the milk supply Colostrum is thought to be dirty & stale & is discarded. Infant may be fed by other, lactating women in the first few days. Breastfeeding is considered more expensive than bottlefeeding, because the quality of the mothers milk can only be enriched by eating expensive foods. Traditionally breastfeed until 2-3 years of age Early weaning to cups is not a cultural norm.

99. South East Asian (cont) Solid foods introduced after 1 year. In rural areas of Vietnam, Cambodia or Laos, infants typically breastfeed for 1 year. Breastmilk may be supplemented with pre- chewed rice paste. Women in urban areas are more likely to formula feed. Following immigration to U.S., only 10% of women continue to breastfeed. (www.ethnomed.org)www.ethnomed.org

100. East African Breastfeeding is equated with motherhood. Almost all mothers at least initiate breastfeed & often continue for 2-3 years. Breastmilk is not offered in the first 24 hours and the infant may be given sugar water, fresh cow, goat, or camel milk in the first few days. Colostrum is thought to have little value or be unhealthy & may be pumped & discarded.

101. Islam Teachings require mothers to breastfeed children for 2 years. Even if divorced, father should pay mothers cost of living so her full attention is on nursing the baby. Wet nurses may be used.

102. Summary While it is not possible to know the details about each and every culture that is represented in our community, we need to know the implications that cultural diversity poses for the patient, their families, and the health professionals entrusted with their care. Health care professionals play an important role in the care of families from diverse backgrounds. Achieving an improved level of cultural competence will lead to improved communication with families and reduce disparities in health and heath care utilization.

103. Cultural Competency and Chronic Diseases

104. Chronic Disease Stats approximately 80% of persons over 65 have at least one chronic condition and half have more than one such condition (CDC, 2003). public health achievements have led to a significant decrease in mortality due to infectious disease and other acute illnesses the new challenge in this epidemiologic transition is chronic diseases such as cardiovascular diseases and cancer.

105. Although increased age is associated with chronic diseases, certain broad racial and ethnic groups have much higher rates of incidence and mortality for many chronic conditions, even with a lower life expectancy than non- Hispanic Whites

106. Chronic Diseases Diabetes; Obesity; HIV/AIDS Cancer Heart disease Hypertension Kidney Disease

107. Health Disparities Rates of death from heart disease are 29% higher among African American adults than among White adults, and African American adults are 50% more likely to die from a stroke than White adults (OMH Web site, 2005b). Hispanics have higher incidence rates of cervical and stomach cancer than Whites (OMH Web site, 2005c).

108. Health Disparities (cont.) Mexican Americans, the largest Hispanic subgroup, are more than twice as likely as Whites to have diabetes (OMH Web site, 2005d). Of all the racial and ethnic minority groups in the U.S., American Indian/Alaskan Native populations have the highest rates of depression and suicide (Lipson & Dibble, 2005).

109. Culturally Sensitive Approaches to Chronic Disease Consider the impact of each particular disease on a particular cultural group Consider how disease and illness are defined Review common fears associated with particular terms and diseases, e.g tumor vs cancer; HIV/AIDS

110. Behaviors that contribute to chronic disease Poor eating habits Believe in spells or witchcraft Traditional methods of treating disorders; home remedies; use of herbal products; Smoking Alcohol use/abuse Coping mechanisms

111. Discussion Question What is the most dreaded chronic disease? Explain why. Discuss with assigned small group. Report on areas of consensus.

112. Resources Spanish/English language resources for staff Hire Spanish speaking outreach workers –Clients feel more open and welcomed STD and safe sex negotiation literature The Latino culture is more expressive than western cultures –Greet clients with a smile and a friendly face –Talk to them about their care They need the health education They are grateful for and appreciate the time

113. Cultural Skill Ann Hershberger, PhD, RN Rebecca Greer, MSN, RN

114. Definition of Cultural Skill the effective integration of cultural awareness and cultural knowledge to obtain relevant cultural data and meet need of culturally diverse clients. (Stanhope,M, & Lancaster, J. (2004). Community and Public Health Nursing. St. Louis: Mosby. p.156.)

115. Examples of Cultural Blunders Bilingual Hispanic son translated explanation of hysterectomy inappropriately. Mother threatened to sue hospital. http://www.culturediversity.org/hisp.htm

116. Examples of Cultural Blunders 36-year old Mexican man. Failure to communicate among nurses and wife hinders clients rehabilitation. http://www.culturediversity.org/hisp.htm 27-year old Arab man. Refused to let male lab technician into wifes room to draw blood. http://www.culturediversity.org/mide.htm

117. Components Obtain relevant data --Assessment Meet client needs --cultural preservation --cultural accommodation --cultural repatterning --cultural brokering

118. Skill: Cultural Assessment Cultural identity should be included in all patient assessments. The CONFHER Model can be used as a systematic framework to obtain information necessary to develop a culturally appropriate plan for meeting the clients needs (Fong, 1985).

119. CONFHER Assessment Model CCommunication Style OOrientation NNutrition FFamily Relationships HHealth Beliefs EEducation RReligion

120. Communication Style Language and dialect preference? Meaning of non- vervbal behaviors? Ethnic behaviors such as bowing of head? Is client agreeable to avoid unpleasantness?

121. Orientation Ethnic identity –Allow to identify own ethnicity Acculturation –How long lived in United States? How closely does client follow traditional customs? Value orientation –Human nature; humans and nature; time orientation; purpose in life; peoples relationships to one another

122. Nutrition Meaning of food –i.e. hot and cold Preferences and taboos

123. Family Relationships Clients definition of family Who is head of household Importance of family nearby when client is sick Important social customs or taboos Life-style and living arrangements

124. Health Beliefs Alternative Care Health, crisis, and illness Response to pain and hospitalization Predisposition to certain diseases Ask patient, What do you think caused your illness? (Munoz & Hilgenberg, 2006) Ask patient, What treatment do you think will make you better? (Munoz & Hilgenberg, 2006).

125. Education Learning Style Occupation and socioeconomic level

126. Religion

127. Skill: Meet client needs using Cultural preservation Cultural accommodation Cultural repatterning Cultural brokering

128. Cultural Preservation Encourage and support the incorporation of scientifically supported cultural practices along with the biomedical system. Examples: Acupuncture Acupressure

129. Cultural Accommodation Support and facilitate cultural practices which scientific study has not been found to be harmful. Home burial of placenta Covering the babys head

130. Cultural Repatterning Work with the client to rework or modify cultural practices known to be harmful. Use of fried foods Teas for a strong baby Spouse abuse

131. Cultural Brokering Advocate, mediate, and negotiate between the clients cultural norms and the biomedical system.

132. Summary Ask client to describe health concern from his or her perspective Involve client and family in care Negotiate with client to plan care that is mutually acceptable to nurse and client When in doubt, ask politely.

133. References Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services: A culturally competent model of care. Cincinnati: Transcultural C.A.R.E. Associates. Fong, C. (1985). Ethnicity and nursing practice. Topics in Clinical Nursing 7(3),1-10. Munoz, C. & Hilgenberg, C. Ethnopharmacology: Understanding how ethnicity can affect drug response is essential to providing culturally competent care. Holistic Nursing Practice 20(5), 227- 234. Retrieved July 20, 2007 from Ovid database. Stanhope,M, & Lancaster, J. (2004). Community and Public Health Nursing. St. Louis: Mosby. p.156.) Transcultural Nursing. (1997-2005). The Hispanic American community. Retrieved August 8, 2007 from http://www.culturediversity.org/hisp.htm Transcultural Nursing. (1997-2005). The Middle Eastern community. Retrieved August 8, 2006 from http://www.culturediversity.org/mide.htm

134. Cultural Encounter Erin Cruise Dr. Margaret Bassett Dr. Scheherazade Taylor

135. Cultural Encounter We are proposing that Giger and Davidhizer's cultural assessment be the organizing framework for this section. We think that their model provides a useful tool that can be used with a variety of cultures and lends itself to the more general discussion that we perceive to be intend of the first workshop. Their assessment model has evolved over time to include consideration of the cultural aspects of communication, space, social organization, time, environmental control and biologic variation. Some of the facilitator resources we are suggesting are: Giger, J.N., & Davidhizar, R.E. (2007). Transcultural nursing: Assessment and intervention (5th Ed.). St. Louis: Mosby. http://www.us.elsevierhealth.com/product.jsp?isbn=9780323048118 This new edition is due out in early October.http://www.us.elsevierhealth.com/product.jsp?isbn=9780323048118 Groper, R.C. (1996). Culture and the clinical encounter: An intercultural sensitizer for the health professions. Yarmouth, ME: Intercultural Press. http://interculturalpress.com/store/pc/viewCategories.asp?idCategory=71 http://interculturalpress.com/store/pc/home.asp This is a simple "how to" guide to improving clinical encounters with those from other cultures. This is an extensive website on transcultural communication and health care practice from the Royal College of Nursing, Britain. These sections have information on the Giger and Davidhizer assessment model, with examples and suggested exercises. http://www.rcn.org.uk/resources/transcultural/foundation/sectiontwo.php <https://ruexchange.radford.edu/exchweb/bin/redir.asp?URL=http://www.rcn.org.https://ruexchange.radford.edu/exchweb/bin/redir.asp?URL=http://www.rcn.org uk/resources/transcultural/foundation/sectiontwo.php> http://www.rcn.org.uk/resources/transcultural/foundation/sectionthree.php

136. Miscellaneous Charlenes slides that may work somewhere

137. Just some slides for your use Charlene Douglas, Ph.D., MPH, RN Associate Professor George Mason University

138. DEFINITIONS Culture – a learned set of ideals and values that are widely shared among a group Values – principles and standards that have meaning and worth to individuals, groups or communities Norms – rules by which human behavior is governed and are the result of cultural values

139. QUINCEAÑERA The Latino tradition At 15 years of age, every young girl is given a large party to celebrate her entry into womanhood

140. Conflicts Ethnocentrism –The view that ones cultures way of doing things is the right and natural way –Other ways are inferior, unnatural, perhaps even barbaric Cultural Imposition –The belief in one's own superiority, or ethnocentrism, and imposing those beliefs on another

141. Conflicts Prejudice –An emotional manifestation of deeply held beliefs (stereotypes) about other groups –Usually refers to negative feelings conjured up by as a result of pre-judging, limited knowledge about, or limited contact with an individual or group

142. Conflicts Cultural Conflict - A perceived threat that may arise from a misunderstanding of expectations between clients and nurses when either group is not aware of cultural differences Culture Shock - The feeling of helplessness, discomfort, and disorienttion experienced by an individual attempting to understand or effectively adapt to a different cultural group because of differences in practice, values and beliefs

143. Definitions Enculturation – how patterns of cultural behavior are learned; starts at birth, parents and the community teach children what it means to be a member of that community Acculturation – Adapting to another culture, for example, when one moves to another country or community

144. Values and Health U.S. - Mastery over nature –Battle heart disease –Hospice difficult to institute in 70s Dis-ease, imbalance with nature –Massage, pressure, heat reasserts balance Beliefs regarding causes of illness Folk medicine and folk healers Seeking medical care

145. ETHNICITY VS. RACE Ethnicity – speaks to nationalism related to customs and traits; ethnicity does not mean race Race is a social classification that relies on physical markers such as skin color to identify group membership Latino – persons descended from Spain or from countries colonized by Spain; these persons can have blonde hair or be very dark skinned

146. U.S. Asian and Pacific Islander Population

147. Countries of Origin for Spanish Speaking People in the U.S.

148. Hispanic / Latino / Hispano Name created by U.S. Demographers Latino, Hispano Countries of origin, language & customs can be very different 11th generation Mexican-American [Texas, CA] or new immigrant Argentina, Cuba, Central America 70% are born in the U.S.; do not make immigration assumptions Undocumented immigrant is a more professional and appropriate term than illegal aliens Do not appear hurried; process is as important as the goal [my book]

149. Latino Origins of Disease Hot and Cold Mal De Ojo [Evil Eye] Empacho - poorly digested food, sticking to the stomach wall

150. Arab Americans 22 countries in the Middle East & North Africa Establish rapport and confidence, rather than presenting yourself as an authority Ramadan – important religious month long holiday –Beginning of the calander year –Fasting during the day, medications Most respected: middle-aged & elderly male M.D. Medication expected as part of treatment Try to establish a direct contact with the mother, but do not discount the father Christian population – Lebanon, Syria and Palestine

151. African-American Populations Eye contact Address family members formally, using titles and last names, until given permission to be more informal Recognize that poverty does not equate with dysfunction many impoverished families manage to provide strong, nurturing care for their children More authoritarian child-rearing

152. Roles Of The Interpreter Conduit – exchange one word for another Clarifier – adjust for language complexity Culture Broker – explaining cultural meanings Advocate – providing for clients unmet needs

153. Roles Of The Interpreter The roles proceed from simple to complex Inappropriate choices – Housekeeping, avoid family if possible, other non- professionals Interpreters should be trained and their work must remain confidential Translation Line, Tele-Interpreter The LAW requires interpreters