Chapter 15- Cultural Competence

Value- terminology

- Any belief or quality that is important, desired or prized- - Bringing awareness to your own values will help you to appreciate individuals from a culture different from your own

What else could the RD do to ensure culturally appropriate services going forward?

- Clarify with client or substitute decision makers (SDM) whether cultural practices involve other people (ie. spouse, child, friend, spiritual leader ...) - Consider relevant audio/visual materials to assist - Use sensitivity, respect and understanding of the varying age and cross-cultural communication needs and practices among clients/SDMs - Strive to understand client's cultural beliefs and values in relation to the nutrition intervention - open ended questions - Speak in a way that does not presume the other person share's one's own values or experiences - Seek support from RD colleagues who may have access to culturally appropriate resources - Review culturally appropriate non-verbal cues and signs of respect

Introduction

- How receptive would you be to a program featuring heart-healthy ways to prepare dog meat? - How would you like to be treated in a hospital where most of the décor was black and everyone wore black? - How would you like to be spoken to as if you are a child when you are seeking health care support?

Cross-Cultural definition

- interaction between or among individuals representing distinctly different cultures

4) Under-representation of diverse HCPs

- Universal cultural competence skills - Mix of HCPs will never completely match the population it serves

Cultural Values

- principles or standards the members of a cultural group share

EatRight Ontario

- Provincial call center of the registered dieticians of Ontario

Differences between cultures occur on many levels

On levels of... - communication, sense of time, family practices, beliefs about the cause of illness, and healing beliefs - Health professionals need to have strategies to bride cutlural gaps - can be learned through gaining cultural competence

Ethnocentric definition

- To consider the beliefs, values, customs and viewpoints of your group to be superior to other groups - It is a natural tendency to be ethnocentric - Every culture teaches its memebers its beliefs are "the best"... some even teach that their ebliefs are the only acceptable ones How could an extremely level of ethnocentricity cause a problem in society?

Ways to Learn about cultural dietary practices

- Eating at ethnic restaurants - Exploring stories in the media - Focus groups - Read about cultural customs and etiquette - Travel - Take language lessons - Familiarize yourself with diverse neighbourhoods - Attend professional development and trainings

Campinha-Bacote Model of Cultural Competence - ASKED

- *A*wareness: health care providers become appreciative of the influences of culture on development of values, beliefs, life ways, practices, and problem solving strategies. A basic requirement for cultural awareness is an in-depth exploration of ones own cultural background, including biases and prejudices toward other cultural groups - *S*kill- health care providers perform culturally sensitive assessments and interventions - *K*nowledge- health care professionals develop a sound educational foundation concerning various worldivews in order to understand behaviours including food practices, health customs, and attitudes towards seeking help from health care providers. Also acquire knowledge of physical needs such as common health problems and nutrition issues of different cultures - *E*ncounters- providers seek and engage in cross-cultural encounters and reflect on experiences allowing integration of cultural competence constructs - *D*esires- appear genuine and to be effective cross-culturally, the health care provider must have a true inner feeling of wanting to engage in process of becoming culturally competent

LEARN- Communication guidelines for health care professionals

- *Listen* with sympathy and understanding to a client's perception of a problem -- use active listening skills, don't be judgmental - *Explain* your perceptions of the problem to the client -- Paraphrase to client to make sure you understand what their problem is - *Acknowledge* and discuss differences and similarities between your perception and the issue -- Resolve misunderstandings - *Recommend* treatment that is relevant, concise, and practical - *Negotiate* agreement -- Let the client determine which options of possibilities you've discussed and see which one best suits them

Cultural awareness- terminology

- Biases- you might hold different values and thus be bias, but you must remove that in your interactions - Worldview - ones worldview shapes their perception of how we believe the world should function based on opinions, judgments and beliefs biased by culture, values and experiences

1) Demographic diversity and projected population shifts

- Change in cultural makeup - multicultural, ex: language, religion, etc. -- Differences in immigration laws, expansions of global market, tendency of minorities and immigrants to have higher birth rates Population shifts: - 2011 Canada had highest foreign-born population, 20.6% - 200 ethnic origins in 2011 in Canada Ageing population - Increased life expectancy --> larger older adult population - Stress for health care system as they have to think about long term care for elders - Older age impacts work force and people working with elders.

Activity- look at all but learn one

- Commonly consumed food and beverages of one of the following ethnicities. - dietary concerns you think may arise from those typical food consumption patterns. *****Mexican- know this one - Consumed foods: chicken, eggs, beans, flour or corn tortillas, rice, tomatoes, squash, lard, etc.. - Diet issues: high intake of carbonates beverages, limited dental care among migrant workers European Americans - Consumed foods: beef, chicken, pork, pasta, rice, bread, dairy, potatoes, bananas, apples, cirtuis juices lettuce - Diet issues: high intake of fat, salt, sugar and fast foods Puerto Rican - Consumed foods: beans, various meats, rice, cornmeal, yams, sweet potatos, onions, green peppers, etc.. - Diet issues: overweight and obesity, breastfeeding=uncomon, low intake of vegetables, dairy intake is low Middle Eastern American - Consumed foods: fermented fairy products, feta, lamb, legumes, pita bread, rice, olive oil, figs, dates, etc. - Diet issue: high incidence of lactose intolerance Italian - Consumed foods: light foods (easy to digest), wet meals (spinach, cabbage), etc... Chinese Mediterranean

Suggestions for communicating information

- Consider using a less direct approach - Use visual aids, food models, gestures, etc. - If answers are unclear, ask same question differently- rephrase - Consider alternatives to written communications - Write numbers down - Written communication should be made available in the major languages

Cultural Competence in Health Care- Vide notes

- Cultural competency= Being able to provide respective health care to people in different cultures - Culture- a group of people that live in the same place, etc.... - Don't stereotype people- ex: not all Muslims are the same - More than 12 countries in Carribean region identify each with their culture - Becoming culturally competent- It's about being respectful, open minded and willing to learn as you go - Tailor interactions for each patient - When u make sure patients receive high quality care at the start then their health will usually authomatically improve - Being sensitive to other cultures makes your interaction go more smoothly - Being treated with respect and empathy begins the process in a good way

Barriers of Cross-cultural Communication

- Differing languages- -- Verbal communication: the client and professional don't speak the same language. Similar words with different meanings -- Non-verbal cues may be interpreted differently by different cultures, ex: gestures - Stereotyping -- Research shows on *1/3rd* of individuals part of the group actually behave in ways considered atypical of group -- The other 2/3rds act different than what is stereotyped to be...

Different Communication Styles

- Emotional expressiveness= dynamic and expressive of body language of African Americans may be considered excessiveand too intense to European Americans.... - Volume of speech= Asian Americans tend to speak quietly whereas African and European Americans tend to speak loud - Gender roles= different cultures prescribe who will talk during interviews. Even during female diet and medical assessments, husbands may answer all the questions no matter how personal Others: - touching, vocal style, verbal following, eye contact, physical space, silence, question authority, aggression

5) Legislative, regulatory, accreditation mandates

- Professional and government organizations mandate culturally appropriate standards - *Civil Rights Act of 1964*- United States that outlaws discrimination based on race, color, religion, sex, or national origin. - Academy of Nutrition and Dietetics discipline-specific recommendations (CDO) - A culturally competent health care system provides the means to respond to the needs of individuals, families and communities in an acceptable and equitable manner

Culture definition

- Shared history consisting of thoughts, communication, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or societal groups -- Societal groups- ex: gender, sexual orientation, health status, occupation, SES -- Cultural charactersitcis & beliefs are developed through life experiences and education

Culturally Sensitive Communication Skills

- Smile, show warmth and friendliness - Learn keywords, ex: greetings and titles of respect - Thank clients for trying to communicate in English - Suggest clients choose their own seat - Speak clearly, normal volume - Explain you have some questions to ask and there is no intention to offend - Ask if something you are doing or saying is offending the client - Remember *limited ability to speak the dominant language does not reflect level of cognitive functioning

Working with Interpreters

- Use professional interpreters who are familiar with the language and customs - Try to limit use of family members or friends - A translator works with written information, while an interpreter explains spoken words Issues: - Issue on relying on family members of friends: they might also not understand that English as well as what's needed to communicate the problem- as medical terminology is more complex - Information passed onto client is distorted which can be intentional or unintentional by the family member sometimes acting in their own interest or what they think is acceptable

Campinha-Bacote Model of Cultural Competence

- Views cultural competency = a *process* - Health care providers continuously strive to achieve ability to work affectively within culture context of client, individual, or family. - ASKED = a quick construct for health care provider to assess their level of cultural competence

Increased need for health professionals to gain cultural competence- 5 points

1) Demographic diversity and projected population shifts 2) Increased utilization of traditional therapies 3) Disparities in health status of various racial groups 4) Under-representation of health care providers from culturally and linguistically diverse groups 5) Legislative, regulatory and accreditation mandates

College of Dieticians Ontario- 3 components of Cultural Competence

1) Managing *prejudices*: - Registered dietitians can learn to manage prejudice so they do not affect the way they provide service 2) Communicating *across culture*: - A culturally competence RD will ask themselves questions to ensure they're communicating effectively and appropriately - Culturally competent dieticians will ask themselves questions and self-reflect to ensure they are communicating affectively 3) Understanding a *client's culture*: - Asking open- ended questions to learn about the client's cultural values and preferences to understand how they access and respond to health care services

CDO Scenario- Brainstorm activity

A newcomer to Canada speaks English as a second language. A private practice RD speaks with the client over the phone to arrange the appointment for dietetic services. From the phone conversation, the RD suggests that if the client found it helpful, he/she could bring someone along as an interpreter. What else could the RD do to ensure culturally appropriate services going forward? - Manage prejudices- make sure they are not being prejudice so that the service isn't being affected - Communicating across cultures- RD should ask themselves questions on if they are communicating effectively - Understanding client's culture- through asking open ended questions

Cultural knowledge & Cultural encounters- terminology

Cultural knowledge- valuing diversity - Explore unfamiliar cultures - Learn useful generalizations as a starting point-- Make no assumptions about all individuals within a particular culture these are still generalizations (*cultural knowledge starts with generalizations*) Cultural encounters - Direct and indirect experiences with individuals from diverse backgrounds provides a catalyst for revising existing beliefs and reducing stereotyping - Direct: meeting a person from a certain culture - Indirect: through the media, driving through their neighborhoods - Eat in cultural restaurants, read about customs, travel (encountering experiences with people from different backgrounds helps you fix your existing beliefs on that cultural and reduces stereotyping) Notes: - Characteristics of cultures are generalizations so try to avoid these - Different strategies to learn about different culture practices, you can: explore the media, meeting people in different cultures and interact with them, walking or driving through different neighbourhoods or communities - Areas to explore about cultural groups you encounter in work are: socioeconomic environmental factors- language and communication style, common health concerns amongst that group, health care values

Explanatory Models

Explanatory models - culturally sensitive tool for opening conversation to learn the client's viewpoint re: illness - Ethnic identity- asking clients to identify their ethnicity and inquiring about the importance of their ethnicity in self-identity What is at stake? - Weighing pros and cons for them to change their current lifestyle - Looking at if the illness has impacted their daily life currently- if not, they might be less willing to change The illness narrative= - using a respondent driven interview approach to nutrition care. Asking open-ended questions and showing a genuine desire to understand clients story- ask open ended questions and let the client drive the interview by explaining their illness/story Psychosocial stress - Lack of social support and resources that can be used to complete a treatment plan and to make changes in diet patterns. Try to get to know the psychosocial issues - Influence of culture on clinical relationships - The problems of a cultural competence approach-- Don't go above and beyond when assuming culture is part of their lives as one

Cultural competence in health care- video

How does the client feel? - Client felt frustrated, confused, and wanted to be understood btu fearful for client as they are not understood How do the care providers feel? - Health care providers- confused, felt powerless, were unable to provide their usual amount of care and a thorough assessment of issue due to communication barrier What positive strategies did the team use to ensure the client received optimal and adequate medical care? - Uplifting ending: the use of a translator can help provide equal medical care, it can aid with medical assessment and provide a key role in ensring the clients comfort level in the medical process- by telling him what is going to happen in the appointment before it happened which is expected in a medical appointment - Pain scale- used pictures with universally known expressions such as: happy, sad, angry, upset to allow a visual level of exploring the clients pain and discomfort

3) Health disparities

Not all cultural groups have the same health status - why? - *Socioeconmic status*: Lower education, income, unsafe housing and fewer opportunities to engage in health behaviors - *Culture*: Beliefs about health, emphasis on power of god vs. preventative health care -- Acculturation: process of adopting beliefs, values and behaviors of another culture - *Access to and use of health care services* -- Lack of cultural sensitivity of health care system, long lines, lack of translators, unawareness of services, inconvenientely located - *Discrimination/racism/stereotyping* -- Psychological distress, depression, substance use -- Even well meaning HCPs demonstrate unconscious negative racial attitudes and make decisions based on bias and stereotypes - *Environment* -- Pollution, hazardous occupations toxin exposures - *Lack of insurance* -- That they may have moving to a new country for example

Cultural competence continuum

Stages: - *Cultural destructiveness*: attitudes, practices, and policies are destructive to other cultures - *Cultural incapacity*: paternalistic attitude towards "unfortunates". no capacity to help - *Cultural blindness*: belief that culture makes no difference. Everyone is treated the same. Approaches of the dominant culture are applicable for everyone - *Cultural pre competence*: Weaknesses in serving culturally diverse populations are realized, and there are some attempts to make accommodations - *Cultural competence*: differences are accepted and respected, self-evaluating are continuous, cultural skills are acquired, and a variety of adaptations are made to better severe culturally diverse populations. Situations can be evaluated from multiple frames of reference - *Cultural proficiency*: engages in activities that add to the knowledge base, conducts research, develops new approaches, publishes, encourages organizational cultural competence, and works in society to improve cultural relations

Functions of Cultural Values

The functions of cultural values: - Provide a set of *rules* by which to govern lives - Serve as basis for *attitudes, beliefs, behaviours* - Guide *actions* and *decisions* - Give *direction* to lives and help solve problems - Influence how to *perceive and react* to others - Help determine *basic attitudes* rgarding: personal, social and philosphical issues - Reflect a person's *identtiy* and provide a basis for *self-evaluation*

A few points

- cultural competence is a *set of universal skills* that offers the same *respect* and *dignitiy* to people regardless of their social group or culture - Takes time, effort, and self-reflection for a lot of health professionals to do - Make sure you're being professional, non-judgemental, and offering quality and care to any client or group you're working with

Diversity definition

- differences among groups of people -- Visible differences, ex: physical differences, abilities or disabilities, language -- Invisible ex: sexual orientation, SES, age

Cultural desire- terminology

Sincere motivation to engage in cross-cultural encounters stimulates the process of becoming culturally competent (sincerely motivated/desired to know different cultures --> stimulates process of becoming culturally competent)

2) Increased use of traditional therapies

- Combination of convential and complementary approaches - Western medicine vs. holistic approaches -- Ex: acupuncutre, meditation, herbal medicines and other natural remedies- these are all traditional therapies - people are becoming more aware of investigating their own health towards medicine and products people use reguarly