Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Appendix A: The Toolbox

I. Building Cultural Awareness

The tools included in this section can be used by a provider to build cultural awareness, particularly for self-awareness. They include: Cultural Genogram Exercise, Exploring One's Community Map, Context Grid, the Iceberg Analogy, the Diversity Wheel, and the Cox Pie Charts.

A. Cultural Genogram Exercise

Cultural Genogram –The cultural genogram is a tool developed by Hardy and Laszloffy (1995) to increase providers’ cultural awareness and sensitivity through the use of the family genogram or family tree. Family genograms are used widely for training and for clinical purposes to explore a variety of family structures, relationships and legacies, e.g. legacies of loss. They also can be used to explore spirituality (Wiggins Frame, 2001). It also can be used to explore socio-cultural variables within the family and the meanings that are attributed to these variables.

The goal of exercises using cultural genogram is to increase awareness of the provider’s cultural background, the significant socio-cultural differences that emerge in the family of origin and the meaning attributed to these differences (valences).

Cultural Genogram Exercise

Sketch your genogram (at least a three-generation family tree) in the traditional manner, using squares for males and circles for females. Honor the diversity in family forms: i.e. single, blended, adopted, same sex, etc. Be as extensive as you can, assured that the genogram is for your use and will be shared with others only as you wish. Note any differences in your family tree that are of significance to you. Refer to the following guidelines.

Preparing the Cultural Genogram:

1. Defining one’s culture of origin: The culture of origin is comprised by our simultaneous membership and participation in a variety of contexts such as language; rural, urban, suburban setting; race, ethnicity and socioeconomic status; age, gender, religion, Nationality; employment, education and occupation, political ideology, stage of acculturation.” (Falicov, 1998)

Use different colors or symbols to identify each influence in your family tree, i.e. color the squares or circles a certain color for a specific ethnic group or more than one color denoting the mixtures.

2. For each family member representing a group or subgroup that is part of your culture consider the following:

3. Note intercultural marriages: Explore how divergent cultural issues were negotiated in these unions and the influence in had on the children. How does this group view outsiders or is viewed by them?

4. Note how group values have shaped your family and its members? How have they shaped you?

5. Meaning of the differences:

• What significant differences emerge in your family of origin?
  
• What was the meaning associated with those differences? i.e. better than, less than; pride and shame issues; where was the power and what was its effect ?
  
• Note and discuss in your small group the emotional and/or behavioral effects of: pride-shame.
  
• What are the rules for talking about differences in your family?

Adapted from Hardy, K.V. and Laszloffy, T.A. (1995) for ECCP course at Harvard Medical School (Contact for ECCP Course: Roxana_llerena-quinn@hms.harvard.edu)

References:

Hardy, K.V. and Laszloffy, T.A. (1995) The Cultural Genogram: Key to Training Culturally Competent Family Therapists. Journal of Marital and Family Therapy. 21(3): 227-37

Wiggins Frame, M. (2001) The Spiritual Genogram in Training and Supervision. The Family Journal- Counseling and Therapy for Couples and Families. 9(2): 109-115

B. Exploring One's Community Map

The goal of this exercise is to increase our awareness of the communities we have been and are a part of and, what they tell us about our preferences and comfort zones. It also aims to raise awareness about the communities we don’t know very well and what they might tell us about our blind spots.

Capturing Our Social Network: then and now

1. How do you define community? What does “community” mean to you?
2. Make a list of the communities of which you are a part.
3. Who makes up those communities? Who is not there? Is it different from the communities in which you grew up? How so?
4. Where did you grow up? Who else lived there? Who wasn’t there? (Pinderhughes, 1989)
5. How did you or your family feel about “them” and how do you think they felt about you?
6. What does your map of communities say about your comfort zone? Others’ comfort zone with you?
7. What is your position or location in the communities you described?

Adapted from Pinderhughes (1989) for ECCP course at Harvard Medical School (Contact for ECCP course: Roxana_llerena-quinn@hms.harvard.edu)

Reference:

Pinderhughes, E. (1989) Understanding Race, Ethnicity, & Power: The Key to Efficacy in Clinical Practice. New York: Free Press; 109-146.

C. Context Grid

This context grid can be use to facilitate understanding of the differences that exist between and within members from different ethnic groups. It addition to differences, it helps highlight points of connection or similarities that exist across different ethnic groups. It can be used by providers or for patients, or to explore similarities and differences between the two.

*Use GRID to map the clinician, family members, provider team or a patient.

CONTEXT GRID

Race: Distinguish race from ethnicity; different ethnic groups include different racial groups. What is the historical and current power dynamics associated to the construction of skin color for this group? If multiracial, what groups?

Country of Origin: Distinguish country of birth, ethnic background/s, country of citizenship. What socio-political issues in the global /local contexts are associated to membership in this group?

SES: Includes education, occupation, income, status, level of power/life control over resources, note SES pre/post migration.

Immigration/Refugee Status/Acculturation: Country of birth, reason for migration, migration history, historical context of immigration, immigration status, length of stay in the U.S., moves within the U.S.; opportunities for involvement with culture of origin, and/or with host culture, ethnic identity, perception of discrimination/racism, note if trauma/violence related to migration or reason for migration. Note if family was left behind, plans to reunite, generation level, intergenerational conflicts, cultural factors and development. How does society mirror this group? Is there a refugee history associated with immigration? Are there any health and mental health issues? Is this a transnational family? Who is the family (here and there)? Note acculturation patterns, stresses.

Language(s): Primary language spoken at home, language of instruction at school, current use of primary language, other languages spoken, level of literacy/fluency of each-[understand, speak, reads, writes].

Sexual Orientation: Experiences of discrimination and disclosure, in family and culture of origin vs. host culture. Are there any significant intersections between sexual orientation and other group dimensions?

Religion: Dominant/marginalized religious affiliation in country of origin, in host culture. Is religion a primary source of identity? How is the individual or family religious affiliation mirrored by society?

Prepared by Roxana Llerena-Quinn, Ph.D and Fabiana Wallis, Ph.D. (Harvard Medical School-reprint permission can be requested to roxana_llerena-quinn@hms.harvard.edu)

D. Iceberg Analogy

This tool can assist in discussing the immediately apparent and not so immediately apparent characteristics of one's culture. Discussion questions follow the diagram.

(d-link)

Discussion Questions for Iceberg Analogy

• Where are the most of the differences between people?
• Are they immediately apparent?
• What does this analogy suggest?
• What attributes do we have most control over?
• What attributes do we react to?

E. Diversity Wheel

This tool can be used to discuss what constitutes "diversity." Diversity can be defined as all the ways in which people are different. It affects how people see the world, how they behave, and what values they hold, among others.

(d-link)

Source: Diverse Team. Lee, Gardenswartz, and Rowe. Burr Ridge, IL: Irwin Professionals, 1994. Used with permission. Note: Internal Dimensions and External Dimensions are adapted from Marilyn Loden and Judy Rosener, Workforce America! Burr Ridge, IL: Irwin Professionals, 1991

Adapted by Kaiser Permanente (2003).

F. Cox Pie Charts

Please see grid in Chapter 7 for description of tool.

Culture is Like Genetics: Group Definition, Individual Expression

Examples of Culture Identity Structure (d-link)

Define Your Cultural Identity Structure (Cox, 1994) (d-link)

A. List Your Cultural Identity Elements 1 . 2. 3. 4. 5. 6. 7. 8. 9. 10. B. Create a pie chart with these elements. Size of slices reflects strength (importance to you) of each element.

4-10 cultural groups with which you personally identify with, e.g. gender, race/ethnicity, occupation, etc.

Source: Cox Self-Identity Exercise (Pie Chart) as it appears in: Cox, Taylor Jr. (1994) Cultural Diversity in Organization: Theory, Research, and Practice. San Francisco, CA: Berrett-Koehler Publishers, Inc., Pg. 49.
Adapted by The Cultural Imperative

II. Mnemonics

Mnemonics are devices, such as a formula or rhyme, used as an aid in remembering. The mnemonics listed here are primarily used in interacting with patients. Refer to the original citation for more detailed explanation for each of the mnemonics.

LEARN

L Listen with sympathy and understanding to the patient's perception of the problem.

E Explain your perceptions of the problem.

A Acknowledge and discuss the differences and similarities.

R Recommend treatment.

N Negotiate agreement.

From: Berlin E.A. and Fowkes, W.C. Jr: A Teaching Framework for Cross-Cultural Health Care, Western Journal of Medicine 1983, 139:934-938

ESFT

E Explanatory Model of Health and Illness

S Social and Environmental Factors

F Fears and Concerns

T Therapeutic Contracting

Adapted from Betancourt J.R., Carrillo J.E., Green A.R. (1999). Hypertension in Multicultural and Minority Populations: Linking Communication to Compliance. Current Hypertension

Adapted from Betancourt J.R., Carrillo J.E., Green A.R. (1999). Hypertension in Multicultural and Minority Populations: Linking Communication to Compliance. Current Hypertension Reports, 1:482-488

ETHNIC: A Framework for Culturally Competent Clinical

Levin, S.J., Like, R.C., and Gottlieb, J.E. (2000) ETHNIC: A framework for culturally competent clinical practice. In Appendix: Useful clinical interviewing mnemonics. Patient Care, 34(9): 188-189

BATHE: A Useful Mnemonic for Eliciting the Psychosocial Context

B: BACKGROUND A simple question. "What is going on in your life?" elicits the context of the patient's visit.

A: AFFECT (The feeling state) Asking "How do you feel about what is going on?" or "What is your mood?" allows the patient to report and label the current feeling state.

T: TROUBLE "What about the situation troubles you the most?" helps the physician and patient focus, and may bring out the symbolic significance of the illness or event.

H: HANDLING "How are you handling that?" gives an assessment of functioning and provides direction for an intervention.

E: EMPATHY "That must be very difficult for you" legitimizes the patient's feelings and provides psychological support.

From: Stuart, M.R. and Lieberman, J.A III. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care, 3rd Edition. Philadelphia, PA: Saunders, 2002

ADHERE: A Mnemonic for Improving Patient Adherence with Therapeutic Regimens

A: Acknowledge the need for treatment with the patient, and ask about previous treatments utilized. Together determine mutual goals and desired outcomes.

D: Discuss potential treatment strategies and options, as well as consequences of non-treatment with the patient (consider issues such as treatment effectiveness, prognosis, use of complementary/ alternative medicine, brand name vs. generics, off-label uses, prescription plans, formularies, etc.).

H: Handle any questions or concerns the patient may have about treatment (e.g., fears or worries, side effects, costs, dosage, frequency, timing, sequence, duration of treatment, drug or food interactions, proper storage techniques).

E: Evaluate the patient’s functional health literacy and understanding of the purpose/rationale for treatment, and assess barriers and facilitators to adherence (e.g., environmental, economic, occupational, and sociocultural factors, family situation and supports)

R: Recommend treatment, and review the therapeutic regimen with the patient.

E: Empower by eliciting the patient’s commitment and willingness to follow-through with the therapeutic regimen.

From: The Provider’s Guide to Quality and Culture (http://erc.msh.org/quality&culture)

Published in Soto-Greene, M., Salas-Lopez, D., Sanchez, J., and Like, R.C. (2004) Antecedents to Effective Treatment of Hypertension in Hispanic Populations. Clinical Cornerstone, 6(3): 30-36

RESPECT

R espect - A demonstrable attitude involving both verbal and nonverbal communications

E xplanatory Model - What is the patient's point of view about his or her illness? How does it relate to the physician's point of view? All points of view must be elicited and reconciled.

S ociocultural context - How class, race, ethnicity, gender, education, sexual orientation, immigrant status, and family and gender roles, for example, affect care

P ower - Acknowledging the power differential between patients and physicians

E mpathy - Putting into words the significance of the patient's concerns so that he or she feels understood by the physician

C oncerns and fears - Eliciting the patient's emotions and concerns

T herapeutic alliance/Trust - A measurable outcome that enhances adherence to, and engagement in, health care

RESPECT model developed by the Boston University Residency Training Program in Internal Medicine, Diversity Curriculum Taskforce

Published in Bigby J.A., ed. Cross-Cultural Medicine, Philadelphia, PA, American College of Physicians, 2003, page 20

BELIEF

The BELIEF™ Instrument for Eliciting Patients' Health Beliefs

Copyright 2002 by Alison Dobbie, MD and Martha A. Medrano, MD, MPH, the University of Texas Health Science Center at San Antonio. All rights reserved. This work may not be translated or copied in whole or part, transmitted in any form or by any means (electronic or mechanical), including photocopying, recording, storage in an information retrieval system or otherwise, without the written permission of the authors.

III. Communication and Language

This section includes tools to be used in aiding with communication and language issues that arise when interacting with patients. Several items relate to interacting with limited English proficient patients, particularly in using interpreters: General Guidelines for Effective Use of Interpreters in a Health Care Settings, Tips for Successful Interpretation, and the mnemonics, TRANSLATE and INTERPRET. The last item in this section describes tools that can be used to measure the health literacy of patients who may be fluent in English, but still lack language skills for full understanding in a health care setting.

A. General Guidelines for Effective Use of Interpreters in a Health care Setting
Developed by M. Jean Gilbert, Ph.D.

Legal Considerations

When do you need to use an interpreter?

• When your patient is a Limited English Speaker (LEP) and you don’t speak his/her language: You can’t understand fully when they speak to you, and they can’t understand when you speak to them
  
• When any part of the patient’s care is funded by a Federal program (e.g. Medicare, MediCaid)
  
• When the quality of care of a patient would be affected if you didn’t understand each other

Unless you are thoroughly fluent in the patient's language, it is strongly recommended that you work with an interpreter. In this way, you know that your patient fully understands your diagnosis, treatment and advice and you know that you understand the patient's description of his/her illness clearly. When you have a limited ability to speak and understand another language, but do not use the correct forms of verbs or the right genders and nouns, your information is unintelligible at worst and confusing at best to your patient. Whether they understand you or not, patients may not risk questioning you or asking you to explain more thoroughly because:

• They do not wish to appear ignorant or uneducated
  
• They fear insulting you by seeming to call into question your expertise
  
• They may be afraid of losing face by showing ignorance of medical terminology or unfamiliarity with the way health care is structured in the U.S.

Make sure that you are using a competent health care interpreter. Just because a person is bilingual doesn’t mean that they have the language or interpretation skills to accurately interpret medical information. Research has shown that untrained interpreters and family or friends used as interpreters results in about 50 percent of the messages being miscommunicated and is a significant source of medical errors. It is better to use a telephonic interpretation service that does train and certify the proficiency of its interpreters than to use a bilingual medical assistant of whose language skills you are uncertain. If you use a telephonic interpreter, it is best to use a speaker phone.

It is required that you note the language and the type of interpreter services used. This is easily done by having adhesive labels printed with space for the interpreter’s name and the date, then just attaching them to the record of the patient’s visit. If you use a telephone interpreter, record the name, time and date of the telephonic interpretation. The company who provides the interpretation also keeps track of this information.

Legally, you must always offer the patient the use of an interpreter first. If a trained interpreter is not used, record who you do use to interpret in the patient’s chart (e.g. patient’s family member or friend). If the patient refuses your offer of an interpreter and insists you use someone they brought with them, record that also.

Techniques for Effectively Using Interpreters

Read over these proven strategies for efficiently getting the most out of an interpreted patient visit. It takes awhile to become truly adept, but you’ll find that these techniques really work, and you’ll soon be able to implement them quickly and automatically.

Have a Quick Pre-Encounter Discussion with Interpreter

Tell the interpreter what you hope to accomplish, what the encounter is about. As you and your interpreters consistently work together and develop a mutually workable style, this “discussion” may simply be a sentence or two.

• Ask interpreter if he/she is familiar with the concepts involved in the visit that is about to occur
  
• Agree with interpreter on interpretation techniques, e.g., how to signal you to pause, signal that they need to explain something the patient has said
  
• When working with non-staff interpreters, point out importance of accuracy, completeness, impartiality and confidentiality
  
• Agree with interpreter on interpretation techniques, e.g., how to signal you to pause, signal that they need to explain something the patient has said
  
• Encourage interpreters to ask questions when they are uncertain
  
• Encourage interpreters to make pertinent comments when they notice there is a conceptual, cultural or linguistic misunderstanding. Frequently either clinician or patient assumes background information, which is actually lacking
  
• In many cases, patients will prefer an interpreter of their same gender, particularly if a physical examination is to take place

In the Encounter

• Be sure to introduce the interpreter to the patient. Emphasize that the interpreter is bound to confidentiality, just as you are
  
• Place the interpreter slightly to one side and behind the patient, so that it is easy to look directly at the patient when the interpreter is speaking
  
• Look at patient just as if you were conversing with an English-speaking person. The interpreter is only a conduit. Observe non-verbal signs that will give you an indication of their emotional effect; this will provide you with important information as to what your response to the individual patient should be
  
• Use the first person when talking to the patient: “Mr. Quesada, I am wondering if...” Encourage the interpreter to use the first person as well instead of “The doctor says she is wondering if…”
  
• Express one concept at a time
  
• Pace your speech so interpreter and patient can understand and follow
  
• Make sure the complexity of the language is not beyond the interpreter's medical knowledge and familiarity with institutional protocols and procedures
  
• When the interpreter finishes explaining a point to the patient, occasionally ask the interpreter to tell you in English exactly what she just told the patient. This "re-telling" will give you the feedback you need to feel confident about the quality of the translation or to identify and catch mistakes
  
• Give complete information on diagnosis, tests and treatment. Then ask for feedback if there is any doubt that the patient understands. For example, if the question "How do you feel about that?" elicits a nervous and bewildered reaction, you will conclude that the patient doesn't entirely understand and needs you to elaborate more fully
  
• Patients of varied ethnic backgrounds will not follow your orders unless they made to feel that you really care enough to provide a full explanation and are therefore trustworthy. They have a need to clearly understand why it is in their best interest to comply
  
• Encourage interpreters to make pertinent comments when they notice there is a conceptual, cultural or linguistic misunderstanding

After The Visit

Ask for feedback from the interpreter. If possible after the interview, speak privately with the interpreter. Be open to comments. Interpreters may perceive cultural and emotional subtleties more clearly than you. Take advantage of their unique bi-cultural perspective.

Non-verbal Communication in the Interpreted Encounter

Body language and non-verbal behavior are important links. They can make an important difference in those situations where you have no language and no cultural background in common with your international patient. Sixty percent of rapport is the result of non-verbal language. It is therefore important to be aware of signs, which may be misunderstood.

For example:

• Eye contact and a calm, intent attitude will take you a long way with Latin American patients
  
• Lack of eye contact while listening by Asian patients can mean respect and concentration and not disrespect, as it does in Western cultures
  
• When Asian patients are preoccupied, they may seem tense and concentrated. The impenetrable features should prompt the clinician to ask the patient for more detail about their concerns
  
• When Limited English Proficiency (LEP) patients repeatedly nod with a subtle nervousness it sometimes means they are listening intently but don’t understand
  
• A warm empathetic smile at the right time creates a link with Asian as well as Latin American patients. However, a smile while a patient is talking or acting out his/her problem is considered sarcastic by both these cultures and is often misunderstood
  
• Warm and polite physical touch is considered a sign of empathy by most international patients. However some Muslim and Orthodox Jews do not want any male/female physical contact, no matter how friendly

Using the Patient’s Family Members and Friends as Interpreters

When using family members as interpreters, proceed cautiously. Family members will often give incomplete and edited translations of what you say! Relatives will sometimes substitute their own opinion rather than tell you the patient's point of view. It is useful to have your own interpreter in the room even when the patient or family insists on providing theirs.

Why would a friend or family member misinterpret? The reasons can be many:

• Sometimes they are reluctant to ask questions when they don’t really understand or are embarrassed. They may lack medical vocabulary in English or their own language. They may be too embarrassed to ask for an interpreter when the conversation gets beyond their linguistic abilities
  
• Relatives will sometimes not give the patient your full and complete explanations. They may be embarrassed to admit they do not understand, or embarrassed by the nature of the conversation
  
• Relatives' emotional involvement often results in a tendency to protect the patient from bad news; therefore they edit or change information. Also, relatives will sometimes not share with you the full explanation the patient has told them, again because they are embarrassed, do not have what they judge to be the proper vocabulary, or because THEY make a decision that you don't need to know "all this extra information."
  
• Finally, confidentiality is also a problem when relatives serve as the interpreters. Often, the patient does not want to disclose upsetting private information or secret issues in front of a relative. A relative may convey information as he/she perceives it and not as the patient does

Child interpreters pose unique problems. Several negative consequences have resulted from the use of children interpreters and this practice is highly discouraged. The Office of Civil Rights expressly discourages the use of minors in health care interpreting. Why is this?

• Role reversal: Child ends up having to process information and provide support to parents
  
• Editing: Child may present information to suit his personal view of what is "convenient" to say to spare parents from suffering. This will isolate the child and create a burden for him or her
  
• Mistakes: There is no guarantee that children understand the intended message, even when they say they do. They may "think" they do
  
• Guilt: If a child does not convey the information correctly; If a child feels he/she is the source of suffering because he/she said something painful. Children may feel they should carry the burden alone
  
  
  Resentment: Parents have shown resentment of providers because they do not feel they can express their adult concerns when their child is interpreting. Parents do not feel they have the benefit of a one to one relationship with provider. Confidentiality is at stake. Parents usually choose to communicate sensitive information to their children in a particular way and they resent losing all control in respect to communication

B. Tips for Successful Interpretations

The following tips were developed by Kaiser Permanente, National Diversity, National Linguistic & Cultural Programs to aid health care providers in utilizing interpreter services.

(Note: Sometimes patients/family may insist on not using an interpreter for variety of reasons. If that is the case, it is recommended that a trained and qualified interpreter is in the room to ensure that the information is conveyed accurately and completely. It helps for the clinician to explain that the interpreter is there to assist himself/herself in case there is misunderstanding. Remember, the best person to interpret is the one who can facilitate understanding and communication in sensitive situations between speakers with different languages and/or from different cultures, while maintaining neutrality and confidentiality. The clinician is ultimately responsible for effective communication.)

• Don’t depend on children or other relatives and friends to interpret
  
• Ensure that the interpreter is appropriate for the encounter, e.g., language/dialect, gender, religion, etc.
  
• Address yourself to the interviewee, not the interpreter
  
• Watch the patient during the interpretation. Observe the patient’s body language for cues
  
• Don’t say anything that you don’t want the other party to hear
  
• Speak in a normal voice, clearly, and not too fast
  
• Avoid jargon and technical terms
  
• Keep your statements short, pausing to permit the interpretation. Ask only one question at a time
  
• Permit the interpreter to interrupt when clarification is necessary
  
• Be prepared to repeat yourself in different words if your message is not understood
  
• Check to see if the message is understood by having the interpreter ask the patient to repeat important instructions or directions
  
• Ask the interpreter to speak to you and the patient, using the first person pronoun to refer to the patient
  
• Instruct the interpreter not to add or delete anything, especially not to add his/her own comments or offer advice, or suggest questions or answers to your questions

Tips To Share with Untrained Interpreters

From the Provider:

• Please let me know if you are familiar with this patient so that the patient’s confidentiality would not be breached if you provided interpreting services
  
• Advise me if there are diversity and/or cultural reasons that would make it inappropriate for you to serve as an interpreter, such as, language, age, gender, and religious beliefs
  
• Please interpret accurately and convey the meaning of what I say and what the patient says. Do not paraphrase or rephrase the patient’s or my words
  
• I will be facing the patient. Please sit or stand next to the patient. When the patient enters the room, I will introduce myself directly to the patient and wait for you to interpret, then I will introduce you
  
• I will speak in short units and ask short questions. Please let me know if I need to slow down or rephrase something in easier-to-understand terms. If you need to ask the patient to clarify, be sure to inform me that you are getting more clarification. Avoid answering for the patient
  
• At the end of the interview I will ask the patient to repeat the instructions to confirm that they have been understood.

© Copyright 2001 Kaiser Foundation Health Plan, Inc.
Created by National Diversity, National Linguistic & Cultural Programs

C. Useful Mnemonics for Working with Interpreters

TRANSLATE

T: TRUST How will trust be developed in the patient-clinician-interpreter triadic relationship? In relationships with the patient's family and other health care professionals?

R: ROLES What role(s) will the interpreter play in the clinical care process (e.g., language translator, culture broker/informant, culture broker/interpreter of biomedical culture, advocate)?

A: ADVOCACY How will advocacy and support for patient- and family-centered care occur? How will power and loyalty issues be handled?

N: NON-JUDGMENTAL How can a non-judgmental attitude be maintained during health care
ATTITUDE encounters? How will personal, beliefs, values, opinions, biases, and stereotypes be dealt with?

S: SETTING Where and how will medical interpretation occur during health care encounters (e.g., use of salaried interpreters, contract interpreters, volunteers, AT&T Language Line)?

L: LANGUAGE What methods of communication will be employed? How will linguistic appropriateness and competence be assessed?

A: ACCURACY How will knowledge and information be exchanged in an accurate, thorough, and complete manner during health care encounters?

T: TIME How will time be appropriately managed during health care encounters?

E: ETHICAL ISSUES How will potential ethical conflicts be handled during health care encounters? How will confidentiality of clinical information be maintained?

Like RC. TRANSLATE: A mnemonic for working with medical interpreters. In "Appendix: Useful clinical interviewing mnemonics," Patient Care 2000; 34(9):188

[Adapted from and based on the work of Kaufert J.M. and Putsch R.W. (1997). Communication through Interpreters in Health care: Ethical Dilemmas Arising from Differences in Class, Culture, Language, and Power, The Journal of Clinical Ethics, 8(1):71-87]

INTERPRET™ Module Observation Form

Student Name:

Date:

Language interpreted:

Use this form to observe record and reflect upon clinicians’ behavior in an interpreted interview. First, with permission, observe and assess an interpreted interview conducted by a resident or Attending. Briefly discuss your observations with them. Second, conduct a bilingual interview yourself and self-rate your own performance.

Copyright 2002 by Martha A. Medrano, MD, MPH, and Alison Dobbie, MD, the University of Texas Health Science Center at San Antonio. All rights reserved. This work may not be translated or copied in whole or part, transmitted in any form or by any means (electronic or mechanical), including photocopying, recording, storage in an information retrieval system or otherwise, without the written permission of the authors.

D. Tools for Measuring Health Literacy in Patients

The following three tools can be used by health care professionals to identify patients with limited or low health literacy skills.

Ask Me 3

Ask Me 3 is a solution-based initiative developed by the Partnership for Clear Health Communication to quickly and effectively improve health communication between patients and providers.

Through patient and provider education materials developed by leading health literacy experts, Ask Me 3 promotes three simple but essential questions that patients should ask their providers in every health care interaction. The program encourages providers to help their patients understand the answers to the following questions:

• What is my main problem?
  
• What do I need to do?
  
• Why is it important for me to do this?

For more information or to download free materials online, please visit www.askme3.org.

Rapid Estimate of Adult Literacy in Medicine (REALM)

The Rapid Estimate of Adult Literacy in Medicine (REALM) is a screening instrument used to determine a patient's literacy, or ability to read and pronounce common medical terminology and lay terms for body parts and illnesses. It does not measure understanding. It is meant to help medical professionals determine a patient's literacy so that the appropriate educational materials and instructions may be used. The REALM was specifically designed to identify patients who read at levels below ninth grade.

The REALM was developed by researchers at the Department of Family Medicine and Comprehensive Care at the Louisiana State University Medical Center. To receive a sample kit (instruction manual, laminated patient word lists, scoring sheets), write to: Terry C. David, Ph.D., LSU Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932. Please contact the developer at tdavis2@lsuhsc.edu for updated price.

Test of Functional Health Literacy in Adults (TOFHLA)

The Test of Functional Health Literacy in Adults (TOFHLA) is used to measure functional health literacy—both numeracy and reading comprehension—using actual health-related materials such as prescription bottle labels and appointment slips. It is designed to assess adult literacy in the health care setting:

• By health care providers, to determine the adequacy of their patients' reading and understanding of health care materials needed for their health care or health education
  
• By researchers, to assess patient health literacy as a variable in their research

TOFHLA was developed at Georgia State University under a grant to Emory University from the Robert Wood Johnson Foundation and was first published in 1995.

A TOFHLA package includes:

• Full versions in English and Spanish, in regular (12 pt.) and large font (14 pt)
  
• A short version in English and Spanish in large font (14 pt)
  
• Directions for administration and scoring and the technical manual for each
  
• A bibliography of published articles concerning the development and validation of the instrument and research studies for using it

For sample pages of the package and/or to purchase the package, please visit www.peppercornbooks.com.

IV. Culturally Sensitive Patient Assessment and Treatment

This section includes tools that can be used for culturally sensitive patient assessment and treatment that can be used to measure student proficiency as well as in clinical settings. They include: Harvard Medical School Objective Structure Clinical Examination (HMS OSCE), the Guide to Clinical and Public Health Practices, and the Patient/Family/Community Assessment Form.

A. Harvard Medical School Objective Structured Clinical Examinations (HMS OSCE): Cultural Competency/Oral Presentation Station

Objective Structured Clinical Examination (OSCE) is a multi-stationed clinical examination using standardized/simulated patients in a focused history and physical clinical task exercise within a limited time period. The following are sample instructions and evaluation forms for the "Cultural Competency/Oral Presentation Station."

Cultural Competency/Oral Presentation Station

[Authors: Margaret M. Hinrichs, M.Ed., Program Coordinator, Program in Medical Education, Office of Educational Development, Harvard Medical School; David A. Hirsh, M.D., Instructor in Medicine, Department of Medicine, Cambridge Hospital, Cambridge, M.A.; Developed by Janet Palmer Hafler, Ed.D., Director Faculty Development, Harvard Medical School. Please contact Dr. Hafler at Janet_Hafler@hms.harvard.edu to obtain permission to use.]

Goals: The goals of the station are to allow participants:

• to become familiar with the process of developing a cross-cultural OSCE ; and
  
• to begin thinking about one they may initiate at their home institutions.

Activities: The activities at this station will include:

• Overview of the process
  
• Observation and evaluation of an HMS student participating in the OSCE
  
• Discussion of the interaction, history checklist and exploration of main challenges in case development

Student Learning Objectives:

• To be able to elicit complete and concise history in a patient presenting for a blood pressure check

• Identify a non-adherence as a central problem which can affect clinical outcomes

• Demonstrate a framework for approaching non-adherence with a particular focus on key cross-cultural issues

• To be able to present orally effectively

• To communicate effectively with the patient

References:
Betancourt, J.R., Carrillo, J.E., and Green, A.R. (1999) Hypertension in Multicultural and Minority Populations: Linking Communicating to Compliance. Current Hypertension Reports, 1: 482-488
Carrillo, J.E., Green, A.R., and Betancourt, J.R. (1999) Cross-Cultural Primary Care: A Patient-Based Approach. Annals of Internal Medicine, 130: 829-834

Student Instructions:

Setting: you are a second year student working in a primary care clinic with your preceptor. Patient is a 58-year-old woman who comes into her primary care clinic for a routine follow-up.

You learn from a quick review of the record that the patient’s blood pressure has been difficult to control despite multiple medications. She’s had a full medical work-up for secondary causes of hypertension and all tests were completely negative. Today she presents without major complaints, and has a blood pressure of 54/96 on right and 150/94 on left with a heart rate of 84.

You will:

• Take a concise but relevant history of all the details important to understanding why the patient’s blood pressure is not controlled (8 minutes)
  
• Prepare oral presentation (2 minutes)
  
• Perform an oral presentation based on your findings from the history (4 minutes). The presentation is as if you were informing your preceptor of a patient you just saw in the clinic
  
• Answer the question on the case (1 minute)
  
• Receive feedback (5 minutes)

© 2004 President and Fellows of Harvard College. All Rights Reserved.

HISTORY CHECKLIST (DO THIS WHILE STUDENT IS TAKING HISTORY)

After 8 minutes or when student completes history, show the student handout #1, in the 3 ring binder.

After the student prepares Oral Presentation for 2 minutes, tell them it’s time to present.

© 2004 President and Fellows of Harvard College. All Rights Reserved.


HMS PDII OSCE Communication Skills Checklist – For Standardized Patient - CULTURAL COMPETENCY

© 2004 President and Fellows of Harvard College. All Rights Reserved.

B. A Guide to Clinical and Public Health Practices1-3

1 Adapted and expanded from Mettee TM. Community Diagnosis - A Concept for Family Practitioners. Paper presented at Plenary Session of North American Primary Care Research Group Meeting (NAPCRG), Lake Tahoe NV, March, 1981
2 Mettee TM. Community Diagnosis: A Tool for COPC. In PA Nutting (ed.), Community-Oriented Primary Care: From Principle to Practice. (DHHS Publication No. HRS-A-PE-86-1). Washington DC: U.S. Government Printing Office, 1987.
3Like RC, Breckenridge MB, Swee DE, Lieberman JA III. Family Health Science and the New Generalist Practitioner. Family Systems Medicine 1993; 11:149-161.

C. Patient/Family/Community Assessment Form

Patient Name: ________________________________ Date: ___________________________

Additional in-depth questions:

1. Identify a problem that this patient faces that is common to other people in the community.
2. Does [clinical care facility] address this problem on a community level? How?
3. What do other health centers or private physicians do to address this issue? Consider contacting other physicians to find out.
4. What other resources/services already exist in the community to address this issue? Contact or visit 2 or 3 of these resources to learn more about them.
5. What other health/social service professionals or “lay health/para-professional/other healers” besides physicians can be helpful with this issue?
6. What creative ideas do you have for addressing this issue on a community level? Consider performing a literature search. Consider using this issue as a starting point for your senior project.

@ 2001 Developed by Steven Levin, MD, Jan Gottlieb, MPH, Center for Healthy Families and Cultural Diversity, Department of Family Medicine, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School (RWJMS), New Brunswick. Please do not reprint or disseminate without authors’ permission. Contact the Center at (732) 235-7662.

V. Developing Culturally and Linguistically Appropriate Skills

This section describes a framework that one can consider when designing cultural and linguistic competence curriculum/training sessions. This framework is based on the notion that developing cultural and linguistic competence is a journey; as we practice more of what we have learned, we will become more fluent in understanding the different cultures and more fluid in our cross-cultural or intercultural interactions.

Cultural fluency is the degree to which we are able to manage a cross-cultural encounter with ease and fluidity. The level of fluency is dependent on one’s experience, knowledge and skills. Most importantly, and ultimately, it is dependent on our attitude. Our attitude can propel or impede us in achieving the highest levels of cultural fluency. Finally, our desire and ability to apply culturally and linguistically appropriate strategies can be supported by a culturally and linguistically competent system of care, or hindered by its absence.
(G. Tang, 1997)

A culturally and linguistically system of care should take into account systems, technology, environment, people, and safety – STEPS model (G. Tang, 2001).

Systems: Design systems to ensure an integrative care process mindful of the patient’s care experience.

Technology: Leverage technologies that facilitate organizational knowledge of patient’s cultural needs and communication requirements.

Environment: Create an environment that is safe and welcoming, allowing ease of navigation through the facilities, and is reflective of diversity.

People: Employ people who are skilled and knowledgeable to provide high quality care and services that are respectful to the diverse communities.

Safety: Employ continuous quality improvement and total quality management processes to ensure patient’s safety.

Cultural Fluency Crosswalk

A 5 x 6 matrix, designed to enhance levels of cultural fluency using Dr. Josepha Campinha-Bacote’s ASKED Model (described more fully in Chapter 4) and creating a Cultural Fluency Crosswalk (CFC) illustrating how attitudes, skills, knowledge, encounter, and desire relate to oneself, one’s patient, their families, one’s work teams, one’s organizations and the community at large. By applying various cultural fluency tools, such as videos, activities and/or workshops, learning outcomes and performance expectations can be plotted within the CFC dimensions creating a logic model to curriculum design.

Application Example

Use the following Cultural Fluency Tools*:

Videos - “Lost in Interpretation,” Kaiser Permanente
Tips on Using Untrained Interpreters (Included in Appendix A)
Brain Teaser – pre-assessment of knowledge and attitude (10 questions or more on acculturation, language acquisition, legal and regulatory requirements).

* For more information on these specific tools, contact Gayle Tang, MSN, RN, Director of Kaiser Permanente’s National Linguistic & Cultural Programs, at Gayle.Tang@kp.org.

Desired Outcomes:

At the end of this session/module, students will be able to:
1. Gain appreciation of the challenges faced by English speakers in seeking health care in a non-English environment
2. Identify the impact on patient’s comfort and trust in the health care system
3. Identify the impact on quality health outcomes
4. Identify the institutional barriers to language access
5. Identify 3-5 strategies to eliminate the access and communication barriers

The following matrix shows how the Cultural Fluency Crosswalk can be used to map out the concepts illustrated in the tools used above.

Following is an additional example of the matrix that has been expanded and adapted to integrate information outlined in Like et al., 1993.