Communication with Diverse Population Groups

1. Communication with Diverse Population Groups Chapter 9

2. Key Terms • Aphasia • Cultural Competence • Cultural Groups • Culture • Disability • Discrimination • Eating Disorders • Ethnocentric • Health Disparities • Interpreter • Prejudice • Stereotype • Weight Bias

3. Cultural Competence • Cultural competence: a set of knowledge and interpersonal skills that allows individuals to increase their understanding and appreciation of cultural differences and similarities • Gaining cultural competence in health care means developing attitudes, skills, and levels of awareness enabling the development of culturally appropriate, respectful, and relevant interventions

4. Reasons to Focus on Cultural Competence • Demographic Trends • Population changes require health care professionals to acquire skills in communicating across cultures • Health Disparities • Population-specific differences in the presence of disease, health outcomes, or access to health care • Quality Care • Goal is to increase client satisfaction and improve health outcomes • Legislative and Accreditation Requirements • Gov’t and professional services mandate culturally appropriate services

5. Reasons to Focus on Cultural Competence • Title VI of the Civil Rights Act of 1964: • “No person in the U.S. shall, on ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance” • Discrimination is a behavior that treats people unequally because of their group memberships

6. Cultural Competence Models 1. Cultural Competence Continuum • Provides a series of stages to assess the act of gaining cultural competence • Individuals may be at different levels of awareness, knowledge, and skills along the cultural competence continuum

8. Cultural Competence Models 2. The LEARN Model • By Berling and Fowlkes • Developed for health care providers to elicit cultural, social, and personal information relevant to a given illness episode • Helps to reduce communication barriers • 5 steps to guide an intervention

9. The LEARN Model

10. Cultural Competence Models 3. The ETHNIC Model • By Levin, Like, and Gottleib • Incorporates the client's explanation and beliefs and guides intervention to a culturally acceptable plan of action

11. The ETHNIC Model

13. Cultural Competence Models 4. Campinha-BacoteModel: • Provides a bridge between cultures in order to achieve mutual understanding and meet unique needs • Views cultural competence as a process rather than an end result • “The process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client” • 5 interdependent constructs = ASKED

15. Campinha-BacoteModel 1. Development of Cultural Self-Awareness • Nutrition professionals need to approach cross-cultural interactions with a nonjudgmental attitude and a willingness to explore and understand different values, beliefs, and behaviors • A basic requirement for cultural awareness is an in-depth exploration of one’s own cultural background, including biases and prejudices

16. Campinha-BacoteModel 2. Development of Cultural Skills • Takes time and requires technique flexibility • Skills include ability to use respondent-driven interview questions to effectively conduct a culturally sensitive assessment • Work effectively with an interpreter if needed • A person who transfers the meaning of one spoken language to another one • Involve key decision makers and those that have a major impact on the success of the intervention

19. Campinha-BacoteModel • 3. Development of Cultural Knowledge • Gaining knowledge helps to avoid stereotypes and biases as we learn to appreciate the positive characteristics of various cultures • Stereotypes: an exaggerated belief, image, or distorted truth about a person or group • Without cultural knowledge, there is risk of intervention conflicting with common beliefs, values, and customs

21. Campinha-BacoteModel • 4. Cultural Encounters • Providers seek and engage in cross-cultural encounters • 5. Cultural Desire • Providers need a true inner feeling of wanting to engage in the process of becoming culturally competent

23. Campinha-BacoteModel • "Cultural Competency in Healthcare Delivery:Have I 'ASKED' Myself The Right Questions?“ (Campinha-Bacote, 2002) • Awareness:  Am I aware of my biases and prejudices towards other cultural groups, as well as racism and other "isms" in healthcare? • Skill:  Do I have the skill of conducting a cultural assessment in a sensitive manner? • Knowledge:  Am I knowledgeable about the worldviews of different cultural and ethnic groups? • Encounters:  Do I seek out face-to-face and other types of interactions with individuals who are different  from myself? • Desire:  Do I really "want to" become culturally competent?  

24. Working with Interpreters • Suppliers of healthcare need to include “reasonable steps to provide services and information in appropriate languages other than English to ensure that persons with limited English proficiency are effectively informed and can effectively benefit” • National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, 2003

25. Working with Interpreters • The need for interpreters (spoken) and translators (written) has grown rapidly • 20% of population speaks a language other than English at home (U.S. Census Bureau 2010) • Healthcare interpreter provides language services to patients with limited English proficiency; they have a good understanding of medical and informal terminology in both languages

26. Working with Interpreters • Best to use a healthcare interpreter vs. a friend/relative of client, or a nonprofessional • Client may be embarrassed or reluctant • Interpreter may decide certain information is not necessary, or may embellish • Interpreter may be unfamiliar with medical terminology • Sign language interpreters – communicate between people who are deaf and those who can hear

27. Telephone Interpreter Devices • TDD = Telecommunication Device for Deaf • Uses telephone line • A deaf person can communicate with a hearing person • Telephone Interpreting • Service that provides human interpreters for language interpretation

29. Lifespan Communication and Intervention Essentials • Nutrition intervention approaches should be tailored to specific segments of the population: • Preschool-Aged Children (2-5 years) • Middle Childhood (6-11 years) • Adolescence (12-19 years) • Older adults

30. Preschool-Aged Children (2-5 years) • Determinants of Food Behavior: • Family, media and culture have major impact • Picky-eaters, food jags, reluctance to try new or unfamiliar foods • Parents should encourage child to try new foods • May need to be exposed to a food 15 or more times before acceptance occurs • Children are able to physiologically recognize fullness

31. Preschool-Aged Children (2-5 years) • Developmental Factors: • Need opportunities to touch, feel, manipulate, questions, compare, and identify objects • Capable of classifying foods by color, shape and function, rather than by nutrient content • Parents need to be good role models regarding attitude towards food • USDA’s Health Eating Index (HEI) for 2001 reported only milk and fruit groups were adequate • Increased intake of soft drinks and juice displacing milk consumption leading to calcium deficiency

32. Preschool-Aged Children (2-5 years) • Intervention Strategies: • Involve family and caregivers • Provide action-oriented behavior change activities • Creative food records • Parental advice • Encourage one bite • Introduce new foods at beginning of meal • Presentation should be attractive/colorful • Uphold regular mealtimes • Maintain a positive atmosphere at mealtime • Minimize using food as a reward

34. Middle Childhood (6-11 years) • Determinants of Food Behavior: • Family, school, and screen media time are major factors • “Screen time”: TV, computer games, DVDs, internet • Screen time associated with high-calorie snacking and poor food choices • Marketing tools for candy, cereal, fast-food restaurants, and snacks • USDA and state regulatory agencies have instituted healthier food standards for schools

35. Middle Childhood (6-11 years) • Developmental Factors: • Able to understand the function of food and how it influences growth and health • Likely to accept adult viewpoints about food choices • Nutritional Risks: • USDA’s HEI report from 2005 indicated: • children 6-11 yrs need to increase whole fruit, whole grains, dk green and orange veggies, and legumes • Need to decrease intake of sat’d fat, sodium, extra kcals

36. Middle Childhood (6-11 years) • Intervention Strategies: • Differential attention: Give praise for desired behavior and ignore undesirable behavior • Family-based interventions including diet, physical activity, behavior modification, family counseling • Limit media screen time • AAP recommends ≤ 2 hours/day • Use activity-oriented nutrition interventions • Books, games, apps

37. Adolescence (12-19 years) • Determinants of Food Behavior: • Family influence declines as teens strive for autonomy and independence • Greater reliance on school food, snacking, vending machines, fast food, convenient stores • Marketing focuses on desserts, snacks and beverages • Often skip breakfast • School food provides 35-40% of a high school students’ total energy intake per day

39. Adolescence (12-19 years) • Developmental Factors: • Dramatic physical, cognitive, psychosocial changes occur • Family values may be rejected • Best approaches include family involvement and educational materials with clear messages • Useful interventions include role-playing, focus on pros/cons of choices, evaluate “what if” possibilities

40. Adolescence (12-19 years) • Nutritional Risks • HEI report indicates inadequate consumption of fruits, vegetables, fiber, calcium and high intakes of sat’d fat, total fat, sodium, kcals, soft drinks • Major issues include overweight, obesity, smoking, disordered body image, low levels of physical activity and disordered eating • 80% of adolescents fearful of being “fat”

41. Adolescence (12-19 years) • Intervention Strategies • Motivational interviewing • Use of behavioral strategies • Multicomponent, school-based interventions • Consider multivariable outcomes measures • Intervention activities and topics • Role-playing, taste tests, taking pictures w/ cell phone • Use collaborative approach

42. Older adults • Determinants of Food Behavior: • Physical, social, economic, cultural and psychological factors involved • 36% with low income or living below poverty • 1/3 live alone – loneliness, depression, social isolation • Reduced ability to taste or smell, dentures • Chronic diseases, medications, disabilities, arthritis

43. Older Adults • Developmental Factors: • Generally concerned about improving their diet, daily activity, and not smoking • Shop frugally, know how to prepare and store food, enjoy eating out frequently • Not concerned with body image • Changes in GI function can reduce nutrient absorption and utilization • Vit D, calcium, Vit B12 • REE declines w/ age

44. Older Adults • Nutritional Risk: • HEI reports older Americans need to increase intake of whole grains, dark green and orange vegetables, legumes, and dairy • Intake of zinc, iron, folate, and antioxidants often inadequate • Dehydration is a concern d/t decreased thirst mechanism, reduced kidney function, medication side effects

45. Older Adults • Intervention Strategies: • Referral for food assistance if needed • Encourage social interactions • Nutrition Screening Initiative checklist • Mini Nutritional Assessment (MNA) • Interventions should address physical, emotional, social needs; keep message clear, direct, practical • Materials clearly visible and easy to read • Respect older adults knowledge and experience

48. Eating Disorders • Anorexia Nervosa, Bulimia Nervosa, EDNOS • AND advocates for RD to collaborate with other professions during assessment and treatment across the continuum of care • Specialized training is needed to understand the complexities of treatment • RD to be cognizant of nutrition messages from parents that emphasize weight rather than health

49. Weight Bias • ~2/3 of Americans are overweight or obese • Stereotypes in Western culture stigmatize as lazy, ugly, unattractive, unintelligent, dishonest, and unsuccessful • Clinical treatment and health outcomes for overweight and obese individuals treated by biased health care professionals have been compromised • Individuals stigmatized by weight bias are more likely to experience depression, lower self-esteem, anxiety, body dissatisfaction, suicide

50. Weight Bias – Self Assessment • Do I make assumptions about a person’s character, intelligence, health status, or lifestyle behaviors based only on body weight? • Am I comfortable working with patients of all sizes? • What kind of feedback do I give obese patients? • Am I sensitive to the needs and concerns of obese patients? • What are common stereotypes about obese people? Do I believe these to be true or false? What are my reasons for my beliefs?