Presented By:
Cathy Anderson
Brandi Miller
Jewish Vocational Service
Wichita, Kansas
February 22, 2005
Wichita, Kansas
Jewish Vocational Service
History: established in 1949 to resettle
holocaust survivors and other refugees
MISSION: to assist any individual with
barriers to become more self-reliant by
providing employment, training, personal
development, and support services.
Jewish Vocational Service
Refugee/Immigration/Lang. & Cult.Svcs. Dept.
includes refugee employment services, refugee
resettlement, immigration counseling
Language and Cultural Services Dept. includes
Interpreter Development Services, Cultural Competency
training, Occupational Spanish classes, Title VI training,
Provider training
Setting the Tone
Training Goals
Ground Rules
Trainer Expectations
 Show respect by listening to each other and not
 Participate actively in the training.
 Maintain strict confidentiality by not identifying
specific individuals or clinics or anything else that could
identify a client or provider and not sharing outside the
classroom any of the personal stories that are told.
 Give feedback in appropriate ways by starting feedback
with a positive comment; avoid blaming; identify
individual opinions as such.
Training Goals
Increase awareness of diversity
Expand definition of cultural competency
Improve service quality for diverse populations
Work more effectively with interpreters
Understand Title VI and Basic Components of
Office for Civil Rights policy guidance
Improve cross-cultural communication and
decrease potential misunderstandings
Your Goals
What do you hope to learn from this
 Your name and what you do in your
 Who is your community?
Cultural Competency
Self-Assessment Checklist
Self-Assessment Checklist
– Tamara D. Goode, Georgetown University Center for Child and
Human Development
Welcome to a Changing
Health disparities
Life by the Numbers
3 billion : People in the world that live on less than $2 per day
3: How many of the world’s top 10 wealthiest people it would take to
exceed the gross domestic product of the world’s 48 poorest nations
1 billion: People who entered the 21st century unable to read a book or
sign their name
86: Percent of the world’s goods consumed by 20 percent of the
population in developed nations
790 million: People in the developing world who are chronically
If the world were a village of
100 people...
52 female; 48 male; 33 children; 6 over age of 65
58 would be Asian
79 would be persons of color
30 would be Christian
6 would own half of the village’s wealth; all 6 would be U.S. citizens
9 would speak English
50 would suffer from malnutrition
80 would live in sub-standard housing
66 would not have access to clean, safe drinking water
10 would be lesbian, gay or bisexual
1 would have a college education
 from Meadows, D., If the World Were a Village
Changing Demographics
The U.S. attracts two thirds of the world’s
General physicians can expect more than
40% of their patients to be from minority
 American Medical Student Association
Changing Demographics
o In the U.S. today, Asian Americans and Pacific Islanders are the
fastest growing segment of the population
o 15% of U.S. residents over age 5 speak a language other than
English at home
o As of 2003, Latinos are the largest minority group in the U.S.
o In 2005, ethnic minorities will account for 47% of the U.S.
population. 85% of those entering the workforce will be women,
people of color, and immigrants
o 2000 US Census Bureau national data
Demographics - Kansas
According to the 2000 Census . . . . .
 - 5% of Kansans were foreign born
 - 9% of Kansans speak a language other than English at
 - 7% of Kansans were Latino, compared with 12.5% of
total U.S. population
 The Kansas foreign born population is quite diverse:
55% are Latin American, 28% Asian, 11.2% European,
2.7% African, and 2.7% North American
Changes in rural population
“The demographics of rural America are
changing rapidly, as Mexican, Central
American, and Asian immigrants take jobs
in agriculture and related industries.”
– Source: Martin, Phillip; Taylor, J. Edward; Fix, Michael, 1996.
“Immigration and the Changing Face of Rural America: Focus on
the Midwestern States”
Minority Health Statistics
Asian/Pacific Islanders
language isolation is a consistent challenge
women are 16% less likely than general population
to receive a Pap smear test
Native Americans
72% higher age-adjusted death rate from diabetes
than general population
other problems are obesity, mental health, alcohol
and substance abuse
 Source: “Minority Health Disparities in Kansas”, Kansas Health Institute, January
Minority Health Statistics
 Hispanics/Latinos
83% higher age-adjusted death rate from diabetes than general
lack of understanding of preventative health services
 African Americans
34% more likely to die of cancer and twice as likely to die from
diabetes than Whites nationally
infant mortality is twice as high when compared to other
other concerns include obesity, cardiovascular disease and
 Source: “Minority Health Disparities in Kansas”, Kansas Health Institute,
Disparities in Health
• Racial and ethnic minorities tend to
receive lower quality health care than
whites do, even when insurance status,
income, age, and severity of
conditions are comparable.
• - Source: Alan Nelson, M.D.; Committee Chair, Institute of Medicine 2002
Report on Disparities
Another thought. . . . . .
Of all the forms of inequality, injustice in
health is the most shocking and the most
– - Dr. Rev. Martin Luther King, Jr.
Define culture.
What does culture mean?
Culture: One Description
Culture is the set of values, structures and
practices held in common by a group of
people and passed on to succeeding
generations. These groups are usually
identified by ancestry, language and/or
traditions. Culture is also used to describe
those characteristics that we are born
with, some of which are permanent and
some of which can be changed.
• What are the cultural lenses through
which we view the world?
Cultural Lenses
Sexual orientation
Life experiences
Religious affiliation
Point in history in which you were born
Active listening
Stand in two lines facing each other.
Discuss the following topics with the
person across from you:
Given names and meaning
Where your family immigrated from
Languages spoken in family as far back as
you remember
What constitutes good and bad parenting
Active Listening
What challenges did you experience in
this exercise?
Were you surprised by what you learned
from others?
Impact of Personal Culture
on Communication
 Incorrect assumptions about the other.
 Language and communication style issues.
 Biases against the unfamiliar.
 Personal values in conflict.
 Expectations that others will conform to
established norms.
 Myers, Selma. Conflict and Culture.
Listening In. . . .
Actual Comments Made by Foreign
Visitors to the United States:
“Americans seem to be in a perpetual
hurry Just watch the way they walk down
the street. They never allow themselves
the leisure to enjoy life; there are too
many things to do.”--Visitor from India
More comments. . .
“Once in a rural area in the middle of
nowhere, we saw an American come to a
stop sign. Though he could see in both
directions for miles and no traffic was
coming, he still stopped!”--Visitor from
More Comments. . .
“The American seems very explicit; he
wants a ‘yes’ or ‘no’. If someone tries to
speak figuratively, the American is
confused.” --Visitor from Ethiopia
Another thought. . . . . . . .
All humans are caught in an inescapable
network of mutuality, tied in a single
garment of destiny. Whatever affects one
directly, affects all indirectly.
– Dr. Rev. Martin Luther King, Jr. Letter from Birmingham Jail.
Reasons for Cultural
o All of these points prove to be good
reasons for exploring cultural
competency and how it can help us
living in this diverse world.
Why is there a need for
Cultural Competence?
• To respond to current and projected demographic
changes in the United States
• To eliminate long-standing disparities in the health
status of people of diverse racial, ethnic and cultural
• To improve the quality of services
• To enhance the workplace environment
• To meet regulatory and accreditation mandates
• To decrease the likelihood of liability/malpractice claims
• - Source: National Center for Cultural Competence, Georgetown University
Cultural Competency
To be culturally competent doesn’t mean you are
an authority in the values and beliefs of every
culture. What it means is that you hold a deep
respect for cultural differences and are eager to
learn, and are willing to accept, that there are
many ways of viewing the world.
- Okokon O. Udo, BD, PhD, CPCC, Ordained Prebysterian Minister
--From Cross Cultural Health Care Program
Road Signs Leading to
Cultural Competence
• Increase awareness of other cultural
• Consider diversity in values, beliefs,
practices, lifestyles, problem solving
• Examine and appreciate your own culture
• Reflect on learned biases and prejudices
towards other cultures
• Learn about historical, societal, political,
spiritual influences that impact the world
view of others
• Distinguish between individual traits of a
person and common traits of people of a
• Share information about yourself and your
experiences so others can understand you
• Use awareness and knowledge as
information base
• Integrate awareness and knowledge into
a cross-cultural encounter
• Conversation instead of confrontation
• Develop culture-specific, appropriate
individualized interventions
Earliest memory of
difference. . . . .
Think back as far as possible and reflect
on your earliest memory of difference.
The difference can refer to skin color, age,
body size, sexual preference, cultural
background, ethnicity, language, etc.
Earliest memory of
difference. . . . .
In groups, discuss:
Was it yourself that was different?
Was it another person that was different?
What made them different?
How did others respond?
Self Assessment
 Create a large group awareness of existing stereotypes
and assumptions
 Create awareness of origins of our own cultural values
and beliefs
 Recognition of how these influence individual attitudes
and behaviors
 Understand how these attitudes affect “other” people
Cultural Competency
- New York/New Jersey Public Health
Cultural Competency
Ethnocentric vs. Ethnorelative
You view your own (or adopted) culture as
central to reality.
You experience your culture in relation to, or in
context of, other cultures.
Cultural Competency
Continuum - Ethnocentric
 You experience your culture as the only culture that exists.
You deny and are disinterested in cultural differences.
 You experience your culture as the only good culture. You
acknowledge cultural differences but see them as
threatening. You use mechanisms such as stereotyping to
defend yourself.
 You experience elements of your culture as universal. You
minimize differences between cultures and believe that
human similarities outweight any differences.
Cultural Competency
Continuum - Ethnorelative
 You recognize and value cultural differences, without judging
them. You are curious about different cultures.
 You experience other cultures by yielding to perceptions and
behaviors acceptable to that culture. You intentionally change
your behavior to communicate more effectively in different
 You value a variety of cultures and continuously define your
own identity in contrast and in conjunction with a number of
cultures. You move easily in and out of varying worldviews.
Exploring Stereotypes
Close your eyes and listen.
Exploring Stereotypes
What was your reaction?
What images were in your mind?
Did the images change as you heard more
information? Why?
Cultural Views of the World
Causes of Illness
Traditional Healing
Cultural Norms
Causes of Illness
What causes us to become ill?
What makes us heal or become well?
Worlds Apart: Justine Chitsena’s Story
Chitsena Story
What are the grandmother’s beliefs
about the illness itself and the
How do they differ from the medical
What is Bouphet Chitsena’s perspective,
and perspective, and Chitsena how is it
different than both of the others?
Chitsena Story
While Justine’s mother is her primary caretaker,
and the one interacting with the medical staff,
her grandmother clearly plays an important role.
How does the decision-making happen in
this family (vs. most American families)?
What is Justine’s grandmother’s role?
What is her mother’s role?
How would you explore this issue and deal with
it in a clinical encounter like this?
Chitsena Story
What are your views on the use of
complementary/alternative medicine
in general, and in this case
Why is it important to know about these
Chitsena Story
 Issues to consider with alternative therapies:
 Some may have beneficial effects for patients, whether
proven (true in some cases) or subjective.
 Trust can be built by being open to patients’ ideas about
 Some alternative therapies may be dangerous, either due
to their direct side effects or interactions with other
medications that the patient takes.
 Patients may avoid using potentially more effective medical
treatment due to their use of alternative practices.
 Being judgmental about alternative therapies contributes to
patients not revealing their use.
Causes of Illness - Beliefs in
some cultural communities
imbalance between “hot” and “cold” causes illness
balance between “hot” and “cold” must be restored
unhappy ancestor, bad spirit, gods sending illness as a test or
witchcraft, illness through act of negative willpower or ritual
performed by other
Common traditional healers
Herbal healers: use roots and herbs
Shaman / spiritual healers: address spiritual
and magical causes of illness, often through
ceremony and ritual
Bone setters: deal with breaks and sprains
Midwives: care for pregnant women and
attend births
Diviners: often only diagnose illness
Areas of Difference
Historical Distrust: Past injustices may cause
distrust between patient and provider
Interpretations of Disability: Ideas of what
is/what causes a disability
Concepts of Family Structure and Family
Identity: Family often extends beyond the
sphere of the traditional nuclear family
Communication Styles and Views of Professional
Roles: Westerners tend to separate professional
and personal identity
Areas of Difference (cont.)
Incompatibility of Explanatory Models: Physical
health vs. Spiritual/Moral health
Disease without Illness: “Invisible” diseases
(hypertension, high cholesterol, HIV)
Illness without Disease: Folk illnesses that are
not defined within western biomedicine
Misunderstandings of terminology, language or
body language
– American Medical Student Association
Refugees / Immigrants:
Frequently Asked Questions
What is the difference between
refugees and immigrants?
Refugees have fled their country
because of a “well founded fear” of
persecution, while immigrants have left
their home country on their own will.
Refugees / Immigrants:
Frequently Asked Questions
Why do refugees leave their country?
There are many reasons, some main ones being:
war, religious or political persecution, reasons of race,
Why do refugees come to the U.S.?
Refugees do not choose where they go from the
refugee camp; they are assigned by the UN.
Do refugees ever return home?
Yes, in large numbers, although many others also
choose to stay and build a life where they are
Refugees / Immigrants:
Frequently Asked Questions
Why do immigrants leave their country?
Again, there are many reasons. It may be to find a
better job, to reacquaint with family, to build a better
life, to gain an education, to simply live in another
place, among many other reasons.
Do immigrants help or hurt the United States?
Immigrants have contributed greatly to the face of
the U.S. in the types of food we eat, the music we
hear and the many events that take place. They also
add to our country intellectually, financially and
Cultural Norms
There are some traits that are common to
particular ethnic groups and people from
a certain region. However, it is extremely
important to remember that any
information presented cannot be taken as
a definitive representation of a community
or individual in that community.
Predominant cultural
groups in this region
Southeast Asian
Pacific Islanders (Micronesian, Filipino,
Hispanic/Latino - General
Family plays a central role. There is a
huge emphasis on family as a support
network and also on how decisions made
will affect family members.
Emphasis on interpersonal relationships
and friendships. There is an abounding
willingness to help others and to extend
hospitality to all.
Hispanic/Latino - General
Hierarchy within groups. Showing
respect and seeking advice from
elders/respected community members.
“Warmer” in personal interactions
(standing closer, touching, kisses)
Naming system
Ex. First name, Middle name, Paternal last name,
Maternal last name
Hispanic/Latino - Gender Roles
The man generally is “head” of household and
makes all important decisions
Historically viewed as the idea of the male who
is strong and dominating. However, he can also
be seen as one who takes care of his family
financially and works hard to provide for loved
ones (machismo)
The woman takes responsibility for the children
and many times takes on the quiet, but all
important, behind-the-scenes role of caring for
the family.
Hispanic/Latino - Health
View providers as the authority figures on
health care causing for a reluctance in
asking questions
Traditional/folk healers and forms of
healing play an important role
Hispanic/Latino: Traditional
Illnesses and Treatments
 Mal de ojo (evil eye): vomiting, fever, crying,
restlessness; a heating up of the child’s blood.
Cause: an admiring or covetous look from a person
with the evil eye
Treatment: herbal remedies, ritual cures (folk
healer), using egg, lemon, chili pepper on child’s
 Empacho: lack of appetite, stomachache,
diarrhea, vomiting.
Cause: poorly digested or uncooked food.
Treatment: dietary restrictions, herbal teas,
abdominal massage with warm oil
Hispanic/Latino: Traditional
Illnesses and Treatments
 Nervios: restlessness, insomnia, loss of appetite,
headache, aches and pains.
Cause: chronic, negative life circumstances,
especially in interpersonal relationships
Treatment: traditional/folk healer
 Susto: loss of soul or an extreme fright
characterized by lethargy, depression, insomnia,
hallucinations, irritability
Cause: a traumatic or frightening experience
Treatment: herbal teas, spitting a mouthful of water
or alcohol into patient’s face unexpectedly, covering
face with cloth and sprinkling holy water
Hispanic/Latino: Other Problems
and Traditional Remedies
Diarrhea: rice water; increase clear liquids (no
milk or food); suedro (solution made of water,
sugar, lemon or banana)
Conjunctivitis: breast milk drops in eyes, carrot
juice, chamomile drops or wash for eyes
Skin rash: apply cornstarch; alcohol rub or bath;
rub with watermelon shell
Minor burns: apply pork lard, cooking oil or
butter; raw onions; apply toothpaste, egg white,
cooked beans
Hispanic/Latino - Diversity
 It is very important to remember that within the
heading “Hispanic/Latino” are included people from
as many as twenty different countries with as many
different histories, governments, customs,
traditions, beliefs, etc.
 Many times we hear the words Hispanic and
Latino/a used interchangeably, however some
people have strong feelings toward the use of one
over the other. Finally, there are also other people
who dislike both and would prefer to use a more
specific terminology, calling themselves MexicanAmerican, Cuban-American, etc.
World Apart: Alicia Mercado Story
Mercado Story
 There have been three distinct
Hispanic/Latino patterns of immigration:
 Continuous flow of both legal and undocumented
immigration from Mexico which intensified in 1980,
driven by economic forces and opportunities;
 “Waves” of large-scale immigration from Central and
South America, driven by war, conflict, and asylumseeking;
 A Caribbean pattern of frequent back-and-forth
migration between the country of origin and the
U.S. (typified by the Puerto Rican experience in the
Mercado Story
What are some of the reasons (from
Mrs. Mercado’s perspective) for her
lack of ideal adherence to medical
therapy and follow-up?
What are some other reasons why
patients are non-adherent to medical
therapy, especially for chronic diseases?
Mercado Story
What are your views on the use of
complementary/alternative medicine
in general, and in this case
What home remedies did your family use
when you were growing up?
Why is it important to know about these
Southeast Asians
There are many similarities between the
cultural practices and forms of healing used
by Southeast Asians (Vietnamese,
Cambodian, Laotians, etc.). However, it is
important to keep in mind that they are all
people from different countries, speaking
different languages and coming from
different histories. Many of the common
traits come from Buddhist beliefs, the
majority religion of the area.
Southeast Asians - General
The traditional view of health is holistic linking
the mind, body and soul. It focuses on
establishing and maintaining a balance of life
Asian patients may deny illness, viewing it as
personal carelessness or weakness, or as a
result of external forces over which they have
no control.
The basis for most views on health come from
Buddhist beliefs.
Southeast Asians - General
Respect for education, family and elders
Sparing one’s feelings is considered more
important than factual truth
Tend to be reserved in most interactions and
expression of strong feelings (positive or
negative) is not valued.
Bow heads to superior or elder
When talking, one should not look steadily at
a respected person’s eyes
Southeast Asians - General
Family is held in high regard, often with
grandparents and other relatives living in the
same house
Women do not shake hands with each other or
with men
Disrespectful to touch another person’s head
Naming system
Ex. Last name, Middle name, First name
Most names can be used for either gender
Name reflects some meaning
Southeast Asians Gender Roles
Men have higher status than women, sons
are valued more than daughters
A traditional woman must submit to her
father, then obey her husband, and then if
widowed, obey her eldest son
However, the mother is not docile. She is
considered the home minister and is
responsible for family harmony, the family
budget and the family schedules
Southeast Asians - Health
Mental illness is a shameful thing and often
feared or denied
Many times health and health care are based on
spiritual factors or the hot/cold belief system
(you are sick because the hot/cold balance has
been altered)
There is a common belief that Western
medicines are developed for Americans and
Europeans, hence they assume the dosages are
too strong for their slight builds and will selfadjust their medicines.
Southeast Asians - Health
 Physical and mental wellness are tied to a balance
of the “winds” of the body and also to a person’s
ability to sleep or eat without difficulty.
 Persons who are sick will turn first to traditional
means of healing and then seek treatment at a
clinic or hospital. Generally, traditional practices are
often continued alongside western medicine.
 Health histories may be incomplete for a number of
reasons, mostly for a reluctance in volunteering
such personal information as sexual activity, family
history and other illness (vulnerability) issues. Trust
or a lack of it is a major issue.
Southeast Asians -
Traditional Health Practices
 Coining: a coin dipped in oil is rubbed across the
skin, causing a mild abrasion. It is believed to
release excess “wind” from the body and restore the
 Cupping: a series of small, heated glasses are
placed on the skin, forming a suction that draws out
the bad force.
 Pinching: similar to coining and cupping. The
abrasion left by the pinch allows the force to leave
the body.
Note: Many of these practices are formed on young
children or infants and the temporary abrasions
should not be confused with abuse or injury.
Southeast Asians -
Traditional Health Practices
Steaming: a mixture of medicinal herbs is boiled
and the steam is inhaled
Acupuncture: thin, steel needles inserted in
specific locations to help cause an energy
Acupressure: fingers are pressed at the same
points as acupuncture to stimulate the energy
The use of specific jewelry worn around the
neck are often used as a form of spiritual
SE Asians and the Western
Medical System
It is common for patients to not report or even
to deny symptoms or problems.
It is common to discontinue treatment or
medication as soon as symptoms have
disappeared. There is an expectance to receive
medication for every illness and that it will
quickly relieve the problem.
Most are more oriented to illness than to the
prevention of illness and only seek help after
symptoms arise. There is little value on early
detection or disease screening.
SE Asians and the Western
Medical System
Blood draws are thought to be very painful
and will make them weaker because the
blood is “taken away” and not replaced.
Genital exams are a foreign concept to them
and are preferred to be done by a same-sex
X-rays are thought to destroy red blood cells
and to decrease general life expectancy.
Surgery is extremely frightening to them and
is considered a last resort.
Dynamics of Difference
Social Class
Cultural Bumps
Nearly all men can stand adversity, but if
you want to test a man's character, give
him power. -Abraham Lincoln
Power does not corrupt men; but fools, if
they get into a position of power, corrupt
power. - George Bernard Shaw
 All of us, both Euro-Americans and members of ethnic
minority groups are ethnocentric. That means that we
usually value our own group above all others. The
concept of cultural competence applies not just to
Euro-Americans but to all of us who have been born,
educated, and live on American soil. Very few
things in the American institutional structure have
prepared us to live harmoniously in a pluralistic and
multicultural society. Therefore, every one of us
needs to learn and practice from a culturally
competent perspective.
– M Issacs and M Benjamin, Towards a Culturally Competent
System of Care, Vol II.
Social Class / Classism
Although not readily acknowledged in the
United States, in many countries classism
exists openly.
Differences in class, or in the way class is
perceived, must be taken into account so
as not to lose trust in an interaction.
Refers to the acquisition of a new cultural
identity, but does not imply ridding
oneself of the elements of one’s first
 Original Culture
 •--------------------------------------------•-----------------------------------------•
 Monolingual
cultural values/language
Cultural bumps
Please pay attention to the following
situation and consider what caused a
Video: Guatemalan woman
Cultural bumps
Please discuss the following situations in
small groups.
3 Cases
Cultural Relativity
Any behavior must be judged
first in relation to the culture in
which it occurs – behavior may
seem strange until placed in
appropriate context.
- Cross Cultural Health Care Program, Interpreter training
Signs of conflict...
Competence is challenged
Individual is not appreciated
Communication in ways that irritate you
Communication in condescending manner
Unsolicited advice given
Quick judgements
Lack of respect
What can we do to
minimize obstacles?
• Be knowledgeable about the cultures you
work with
• Avoid judgement based on your own
cultural norms
• Be understanding of different traditions,
cultures, concepts of sickness, notions of
healing, etc.
More conflict resolution
across cultures…
Being nonjudgmental
Understanding stereotypes
Treating people as individuals
Looking at whether expectations are real
Accepting ambiguity
Checking assumptions
Being open to differences
o Myers, Selma. Conflict Resolution Across Cultures.
Conclusion. . . . . . . .
Day Two
February 23, 2005
Wichita, Kansas
Word Association
Creating Cultural
Title VI - Overview
Title VI Assessment and Policy
Working with Interpreters
Building Community Connections
Sharing Resources
Myth Busters!
#1 Myth: Immigrants don’t pay taxes.
Fact: Significant local, state & federal
taxes are paid by immigrants each year,
an estimated $133 billion.
Fact: Alan Greenspan has stated that both
legal and non-legal immigrants pay $20
billion more in taxes than they receive in
Myth Busters!
#2 Myth: America is over-run by
Fact: Percentage of foreign-born is higher
than in 1970 (11%), but still lower than
the all-time high of 14% in 1910.
Fact: The 2000 Census found that 22% of
US counties lost population from 19902000.
Myth Busters!
#3 Myth: Immigrants do not serve their
new country.
Fact: Immigrants make up nearly 5% of
all enlisted personnel on active duty in the
US Armed Forces. (62,000)
Fact: 20% of the recipients of the
Congressional Medal of Honor were
Creating Cultural
Title VI - Overview
Title VI Assessment and Policy
What is Title VI?
Title VI of 1964 Civil Rights Act:
No person in the United States, 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
Source: Title VI of 1964 Civil Rights Act and Office of Civil Rights Policy Guidance
on Language Access to Services
Who is Protected by
Title VI?
Limited English Proficient (LEP)
individuals: “National Origin.”
OCR Policy Guidance: Fall 1998
Title VI Prohibition Against National Origin
Discrimination As it Affects Persons with
Limited English Proficiency
Revised August 2000; published again in February 2002, currently under revision
What organizations are
impacted by Title VI?
Health care providers
Hospitals, doctor’s offices, nursing homes
Managed care organizations, home health agencies
State Medicaid agencies
Municipal and county health departments
Social service and non-profit organizations
• The list is endless!
Explanation of Title VI
Title VI prohibits discriminatory impact
- services more limited in scope
- lower quality of services
- unreasonable delays in service delivery
- limiting participation in a program
Title VI – OCR Policy
 Any organization that receives federal funds must
provide meaningful access to programs, services, and
 Federal financial assistance includes grants, training,
donations of surplus property, and other assistance
 Meaningful access ensures accurate and effective
 Limited English Proficient (LEP) individuals should
receive language assistance free of charge
OCR Enforcement of Title VI
• OCR assists organizations in development of
comprehensive written policy
• OCR considers these circumstances:
Size of the covered entity
Size of the eligible population
Nature of Program or Service
Program Objectives
Frequency of a given language
Frequency of encounters with LEP persons
Office of Civil Rights
Maria A. Smith, Investigator
Office of Civil Rights
Federal Office Building
601 E. 12th Street, Room 248
Kansas City, MO 64106
(816) 426-7238
(800) 368-1019
Four Keys to Title VI
o Assessment
o Development of a comprehensive written policy
on language access
o Training of staff
o Vigilant monitoring
• Conduct a thorough assessment of the language needs
of population served
• Identify the languages likely to be encountered
• Identify language needs of every LEP patient/client and
note in client files
• Identify resources needed to provide effective language
Areas to consider in an assessment
 level of ethnic identity
 use of informal network and supportive institutions in the ethnic/cultural
community values orientation
 language and communication process
 migration experience
 self concept and self esteem
 influence of religion/spirituality on the belief system and behavior patterns
 views and concerns about discrimination and institutional racism
 views about the role that ethnicity plays
 educational level and employment experiences
 habits, customs, beliefs
 importance and impact associated with physical characteristics
 cultural health beliefs and practices
 current socioeconomic status
Development of a
Comprehensive Policy
 Oral Language Interpretation
 Translation of written materials
 Methods for providing notice to LEP
Issues that impact
Financial cost of interpreting services
Lack of awareness of the need for interpreter
Negative impact when untrained, unqualified
interpreters are used
Organization does not have a comprehensive
written policy on language access
Two Compliance Cases
#1: Sole physician practitioner with 50
LEP Hispanic patients. Staff of two nurses
and receptionist. No interpreters on staff.
Uses community org. & telephone interp.
#2: County Social Services agency serves
500,000; 10,000 are LEP. No policy;
clients bring own interpreters. Materials in
Case Studies
In groups discuss the case studies.
CLAS Standards
Health Care providers have a responsibility to
provide culturally and linguistically appropriate
services (CLAS) to patients
Interpretation/Translation services
Ongoing education and training for all staff
Recruit and retain a diverse and culturally competent staff
Collect and utilize data about the diverse communities in
provider’s service area
Implement ongoing self-assessments of cultural
competence within organization
Working Effectively with
Who is an appropriate interpreter?
Roles and responsibilities of interpreter
Effective strategies for communicating through
an interpreter
Communicating Effectively
Through an Interpreter
Who is appropriate to act as
an Interpreter?
• Bilingual staff who are trained and
competent in skill of interpreting
Staff interpreters
Contracted Interpreter Service
Community Volunteer Interpreters
Telephone Interpreter Lines
Who is NOT appropriate as
an Interpreter?
Friends of any LEP individual
Family member of LEP patient/client
Minor children
Anyone who has not demonstrated proficiency in both
 Anyone who has not received training in interpretation
 Anyone who does not have an understanding of ethics
and interpreting practices
The basic purpose of the medical/social
service interpreter is to facilitate
understanding and communication
between two or more people who are
speaking different languages.
– CCHCP, Interpreter training curriculum
Worlds Apart: Mohammad Kochi’s Story
Kochi Story
The cancer had been there all along, even after
the surgery, but the family members serving as
interpreters had not translated this to Mr. Kochi
nor to the rest of the family at home.
How does culture influence the way
patients and families discuss medical
information and make medical decisions?
Kochi Story
Why, in this case, does Noorzia (a relatively
young daughter—and a woman in a male
dominant culture) seem to play a very important
role in medical decisions about her father’s
How is Noorzia’s perspective on her father’s
health, and the medical in general, different
than her father’s?
Kochi Story
How important are professional
interpreters (as opposed to family
members or no interpreter) in medical
interactions like this?
Could it have changed the situation in this case?
Are there any laws requiring the use of an
What problems can arise when family members
or others act as interpreters?
Kochi Story
What do you think about this interaction?:
Mr. Kochi:
 “We believe our day has been chosen for us and
it cannot be pushed up or forced back.”
Dr. Fisher:
 “Our goal is to help you feel as well as you can
feel until that day comes.”
Roles of the Interpreter
 Interpret exactly what is said: add nothing, change nothing,
omit nothing.
 Adjust register or complexity of language. Check for
 When cultural differences cause misunderstanding, provide
necessary cultural framework for understanding message.
 Action taken on behalf of someone else.
Tips for Effective Communication
through an Interpreter
 POSITIONING – interpreter should be seated next to and a little
bit behind LEP client
 ACCURACY – everything that is said should be interpreted; no side
conversations; check for comprehension; speak in short phrases
and pause to allow for interpretation
 COMPETENCY – assess interpreter qualifications and skills;
bilingual individuals should be trained in interpreting and have
knowledge of policies at your organization
Medical errors
According to a study by the Institute of
Medicine, “at least 44,000 people and
perhaps as many as 98,000 people die in
hospitals each year as a result of medical
errors that could have been prevented.”
– Source: Institute of Medicine, “To Err is Human: Building a Safer
Health System”, Nov. 1999
“Language Barriers Lead to Medical
Language and Culture
“People who speak different
languages live in different worlds,
not the same world with different
– Edward Sapir, linguist, 1928.
The New Americans
The Flores Family (Mexico)
The Nwidor Family (Nigeria)
Active Voice & Kartemquin Educational
Identifying Barriers and
Building Bridges
Compare the experiences of the two
How do we bridge cultural gaps?
How do we build community power?
Successful community
Informal collaboration among social service
agencies: JVS, Catholic Charities, Della Lamb,
Don Bosco, El Centro
KC partnership of “safe harbor” health care
providers: KC Free Health Clinic, Cabot
Westside Clinic, Swope Parkway Medical Center,
Truman Hospital and other community clinics.
Kansas City Free Health
Over 50 staff members
Over 400 volunteers
Safe harbor health care provider for individuals
without insurance
Extensive services for individuals without
primary health care coverage
Active community involvement and integration
with other healthcare providers
Building Culturally Competent
Community Partnerships
What community organizations do you
collaborate with?
What are effective strategies for working
Identify areas to be improved (on a
community level, on an institutional level,
Strategies for working
effectively in communities
 Asian American Family Counseling Center - Houston
- brown bag lunches for mental health professionals to learn more
about working with the area’s Asian American communities
 Consumer Voices Are Born - Clark County, Washington
- established a “warm-line” where individuals facing mental health
challenges could call in and discuss their problems with a peer, now
extending services to ethnic communities
National Consumer Supporter Technical Assistance Center,
National Mental Health Association. A Cultural Competency
Toolkit: Ten Grant Sites Share Lessons Learned.
Strategies for working
effectively in communities
• Build bridges of trust and dispel
• Recruit staff from within the community
• Community members provide insight into
cultural beliefs and practices
• Identify elders or leaders within the
community and seek their support
• Initiative must be give and take
Organizing Culturally Specific
Community Forums
Culturally Specific Community Forums
Culturally competent community
Barriers and benefits of community
Culturally Specific Community
Forums and Assessments
• MAPP : KCMO Health Department health survey
• The Pulse: Survey of Health in the KC gay and lesbian
• Interpreter Training classes: Informal and formal
networking among key community members
• Social service organizations
• Religious organizations
• Community partnerships with other organizations
Barriers and benefits of
community partnerships
- mistrust on the part of the community
- results and outcomes not clearly defined
- organization unable to effectively work with
- increased access to services
- positive reputation in the community
- word of mouth makes your organization thrive
Unanswered Issues
What are some topics that we have not
mentioned or that we have not covered
completely in this training?
Are there any common cultural issues you
face that we have not talked about?
What are they?
What are some possible resolutions or
Conclusion. . . . . . . .
Please refer to handout with a list of
online resources.
o Cross Cultural Health Care Program:
o CMS: //
o Natl Health Law Prog:
o National Council on Interpreting in Health Care:
o HHS, Office of Minority Health:
Thanks for your participation, time and energy!
Thanks to KDHE for funding the course!
Contact us!
Jewish Vocational Service
Language and Cultural Services
1608 Baltimore
Kansas City, MO 64108
(816) 471 - 2808
Brandi Miller
Cathy Anderson

CULTURAL COMPETENCY - Healthy Kansans 2010