Culturally Appropriate Public Health Training Series

1. Culturally Appropriate Public Health Training Series

2. Josephina Campinha-BacoteCultural 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 one’s 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 one’s own biases towards other cultures and the in-depth exploration of one’s 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 • 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 we’d 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 Dr. Patty Hale • Self-Assessment Checklist for Personnel Providing Primary Health Care Services  • http://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.pdf

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 • Women’s 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. 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 individual’s self-confidence, worth, security and identity are determined by his/her relationship to other family members Cultural AttitudesHispanics

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

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. 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. Cultural Attitudes Asian Gender Roles/Authority

18. Majority of child care is left to mother. Very active in child’s 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. Cultural Attitudes Child care/discipline

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 women’s 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 client’s 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 world’s 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, B6 • 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 theirmedication

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 don’t you and I beginning talking now” • Client’s faces “light up” when they are able to get information