diversity & cultural competence in respiratory care

Diversity Diversity & &

Cultural Cultural Competence in Competence in

Respiratory CareRespiratory Care

ObjectivesObjectives

• Identify how the beliefs, attitudes Identify how the beliefs, attitudes and behaviors of major American and behaviors of major American cultural groups impact public health.cultural groups impact public health.

• Create heightened appreciation for Create heightened appreciation for the influence of cultural competency the influence of cultural competency in health care.in health care.

• Identify strategies for enhancing Identify strategies for enhancing cultural competency in respiratory cultural competency in respiratory care.care.

WHAT IS CULTURAL

COMPETENCE?

Basic Diversity Basic Diversity TerminologyTerminology

Culture:Culture: An integrated pattern of An integrated pattern of human behavior that includes human behavior that includes thoughts, communications, thoughts, communications, languages, practices, beliefs, values, languages, practices, beliefs, values, customs, courtesies, rituals, customs, courtesies, rituals, manners of interacting, roles, manners of interacting, roles, relationships and expected relationships and expected behaviors of a racial, ethnic, behaviors of a racial, ethnic, religious or social group.religious or social group.

Culture Defined BroadlyCulture Defined Broadly

• Term culture inclusive of:Term culture inclusive of:– RaceRace– LanguageLanguage– EthnicityEthnicity– GenderGender– Sexual OrientationSexual Orientation– Shared Experiences (i.e. poverty, Shared Experiences (i.e. poverty,

mental illness, addiction, homelessness, mental illness, addiction, homelessness, etc.)etc.)

What Culture is Not:What Culture is Not:

• Culture is not:Culture is not:– RaceRace– Stereotypic generalizations about the behaviors, Stereotypic generalizations about the behaviors,

emotions and values of a group of people.emotions and values of a group of people.– A laundry list of values behaviors and facts related A laundry list of values behaviors and facts related

to a group of people.to a group of people.– Rigid or static categorizations of people without a Rigid or static categorizations of people without a

deep and fundamental awareness of their deep and fundamental awareness of their differences.differences.

– Superficial adoption of customs, language, dress or Superficial adoption of customs, language, dress or behavior in a patronizing manner.behavior in a patronizing manner.

““What is Cultural Competence?”, Family Resource Coalition Report, What is Cultural Competence?”, Family Resource Coalition Report, Fall/Winter 1995-96Fall/Winter 1995-96

Basic TerminologyBasic Terminology

• Cultural awareness:Cultural awareness: Being cognizant, Being cognizant, observant and conscious of similarities observant and conscious of similarities and differences among cultural groups and differences among cultural groups

• Cultural sensitivity:Cultural sensitivity: Understanding Understanding the needs and emotions of your own the needs and emotions of your own culture and the culture of others.culture and the culture of others.

• Cultural CompetenceCultural Competence: : Has many Has many definitionsdefinitions!!

Definitions of Cultural Definitions of Cultural Competence Competence

Cross et al, 1989Cross et al, 1989• Cultural competence is a set of Cultural competence is a set of

congruent behaviors, attitudes, and congruent behaviors, attitudes, and policies that come together in a policies that come together in a system, agency or among system, agency or among professionals and enable that professionals and enable that system, agency or those professions system, agency or those professions to work effectively in cross-cultural to work effectively in cross-cultural situations.situations.

Definitions of Cultural Definitions of Cultural CompetenceCompetence

Denboba, MCHB, 1993Denboba, MCHB, 1993

…… a set of values, behaviors, attitudes, and a set of values, behaviors, attitudes, and practices within a system, organization, practices within a system, organization, program or among individuals and which program or among individuals and which enables them to work effectively cross enables them to work effectively cross culturally. culturally.

… … the ability to honor and respect the the ability to honor and respect the beliefs, language, interpersonal styles and beliefs, language, interpersonal styles and behaviors of individuals and families behaviors of individuals and families receiving services, as well as staff who are receiving services, as well as staff who are providing such services. providing such services.

Definitions of Cultural Definitions of Cultural CompetenceCompetence

Health Resources and Services Administration, Health Resources and Services Administration, Bureau of Primary Health CareBureau of Primary Health Care

• Cultural and linguistic competence is a set of Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that congruent behaviors, attitudes and policies that come together in a system, agency or among come together in a system, agency or among professionals that enables effective work in cross-professionals that enables effective work in cross-cultural situations. "Culture" refers to integrated cultural situations. "Culture" refers to integrated patterns of human behavior that include the patterns of human behavior that include the language, thoughts, communications, actions, language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups. "Competence" ethnic, religious or social groups. "Competence" implies having the capacity to function effectively implies having the capacity to function effectively as an individual and an organization within the as an individual and an organization within the context of the cultural beliefs, behaviors and context of the cultural beliefs, behaviors and needs presented by consumers and their needs presented by consumers and their communitiescommunities

Cultural Competence Cultural Competence Within the Health Care Within the Health Care

System Requires:System Requires:• Culturally Competent Care:Culturally Competent Care: Administered Administered

with sensitivity for a patients culture and with sensitivity for a patients culture and health-related beliefs.health-related beliefs.

• Culturally Competent Staff:Culturally Competent Staff: That reflect the That reflect the ethnic communities they serve with ethnic communities they serve with understanding and respect for the beliefs, understanding and respect for the beliefs, attitudes, interpersonal styles and health-attitudes, interpersonal styles and health-related beliefs of their patients.related beliefs of their patients.

• Organizational Management:Organizational Management: Who develop Who develop policy, procedures and processes the assure policy, procedures and processes the assure uniform patient care.uniform patient care.

Changing National Changing National DemographicsDemographics

Changing demographicsChanging demographics result in an result in an increased need to medical delivery increased need to medical delivery responsive to multicultural populations:responsive to multicultural populations:

Population Size and Composition: 2003Population Size and Composition: 2003

Approximately 33.5 million foreign-born Approximately 33.5 million foreign-born people live in the United States.people live in the United States.

The foreign born represent 11.7 percent The foreign born represent 11.7 percent of the U.S. population.of the U.S. population.

Source: US Census Bureau, Current Population Survey, Annual Social Source: US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2003and Economic Supplement, 2003

Changing National Changing National DemographicsDemographics

• Percent Distribution of Percent Distribution of Foreign Born by World Foreign Born by World Region of Birth: 2003:Region of Birth: 2003:

Latin America (LA)Latin America (LA) 53.3%53.3%

Asia (A)Asia (A) 25% 25%

EuropeEurope (E)(E) 13.7%13.7%

Other Regions (O) Other Regions (O) 8% 8%

Source: US Census Bureau, Current Source: US Census Bureau, Current Population Survey, Annual Social Population Survey, Annual Social and Economic Supplement, 2003and Economic Supplement, 2003

LAA

E

O

Different Customs, Beliefs and Practices

NONWESTERN CULTURES

• Health is a state of harmony within body, mind, spirit

•Seeks alternative medical practitioners (i.e. herbalists, shamans, midwives etc.)

• Seeks medical system when in acute stage of illness

•Values interdependence with family and community

• Present oriented: here and now

• Gestures have taboo meanings, depending on culture

•Individual interests are subordinate to family needs

AMERICAN/WESTERN CULTURES

• Health is absence of Disease

•Seeks traditional health care providers (i.e. physicians, nurses, surgeons, psychiatrists)

•Seeks medical system to prevent and treat illness

•Values independence and freedom

•Future oriented

• Gestures have universal meaning

•Individual interests are valued and encouraged

Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners, March, 2004

Why be Culturally Why be Culturally Competent?Competent?

•Because many cultures Because many cultures populate our country:populate our country:– Culture inclusive of many factorsCulture inclusive of many factors– Changing national demographics.Changing national demographics.– Vast array of customs, beliefs, practicesVast array of customs, beliefs, practices

•Because it’s the law.Because it’s the law.

Why be Culturally Why be Culturally Competent? Competent?

•Because It’s the Law:Because It’s the Law:– The Civil Right’s Act of 1964: Title VIThe Civil Right’s Act of 1964: Title VI

““No person in the United States shall, on No person in the United States shall, on the grounds of race, color or national-the grounds of race, color or national-origin, be excluded from participation in, origin, be excluded from participation in, denied the benefit of, or be subjected to denied the benefit of, or be subjected to discrimination under any program or discrimination under any program or activity receiving federal financial activity receiving federal financial assistance.”assistance.”

It’s the LawIt’s the Law

• Emergency Medical Treatment Emergency Medical Treatment and Active Labor Act :and Active Labor Act :

Also known as the Patient Anti-Also known as the Patient Anti-dumping Act, requires hospitals that dumping Act, requires hospitals that participate in the Medicare program participate in the Medicare program that have emergency departments to that have emergency departments to treat all patients (including women in treat all patients (including women in labor) in an emergency without labor) in an emergency without regard to their ability to pay. regard to their ability to pay.


• Medicaid :Medicaid :

Medicaid regulations require Medicaid regulations require Medicaid providers and participating Medicaid providers and participating agencies, including long-term care agencies, including long-term care facilities, to render culturally and facilities, to render culturally and linguistically appropriate services. linguistically appropriate services.


• MedicareMedicare

Medicare addresses linguistic access in Medicare addresses linguistic access in its reimbursement and outreach its reimbursement and outreach education policies. “Medicare providers education policies. “Medicare providers are encouraged to make bilingual are encouraged to make bilingual services available to patients wherever services available to patients wherever the services are necessary to adequately the services are necessary to adequately serve a multilingual populations.” serve a multilingual populations.”

Importance of Cultural Importance of Cultural CompetenceCompetence

•Cultural Competence is Cultural Competence is necessary to improve the necessary to improve the health care outcomes of a health care outcomes of a culturally diverse population culturally diverse population of patients who utilize the of patients who utilize the health care system.health care system.

Health Care DisparitiesHealth Care Disparities

• Research indicates that clinical Research indicates that clinical encounters between culturally encounters between culturally insensitive health care insensitive health care practitioners and patients from practitioners and patients from different cultural backgrounds different cultural backgrounds can contribute to disparities and can contribute to disparities and barriers to appropriate health barriers to appropriate health care.care.


• Disparities in health care delivery Disparities in health care delivery has been documented among:has been documented among:– African AmericansAfrican Americans– Latino/HispanicsLatino/Hispanics– Native AmericansNative Americans– AsiansAsians– AlaskansAlaskans– Pacific IslandersPacific Islanders


• In the U.S., ethnic minority In the U.S., ethnic minority populations lag behind the European populations lag behind the European population on a number of key population on a number of key health indicators including:health indicators including:– Health care coverageHealth care coverage– Access to health careAccess to health care– Life expectancyLife expectancy– Acute and chronic disease statesAcute and chronic disease states


• Common barriers to providing Common barriers to providing culturally sensitive health care culturally sensitive health care include:include:– Underestimation of need for service Underestimation of need for service – Lack of appreciation for cultural belief Lack of appreciation for cultural belief

differences related to illness, suffering, differences related to illness, suffering, and dying and dying

– Language and other communication Language and other communication barriersbarriers


•Culturally competent Culturally competent health care guidelines health care guidelines will help eliminate these will help eliminate these disparities.disparities.

Key Components of Key Components of Culturally Appropriate Care Culturally Appropriate Care

Include:Include:

AttitudeAttitude

Hiring and TrainingHiring and Training

SkillsSkills

Culturally Diverse Health Culturally Diverse Health SystemSystem

AttitudeAttitudeCulturally Biased Health CareCulturally Biased Health Care

• Patients from other races and socio-economic Patients from other races and socio-economic status tend to be viewed more negatively by status tend to be viewed more negatively by physicians (VanRyn and Burke, 2000)physicians (VanRyn and Burke, 2000)

• Hispanics and Blacks are less likely to receive Hispanics and Blacks are less likely to receive major therapeutic and diagnostic procedures major therapeutic and diagnostic procedures for their conditions ( VanRyn and Burke, 2000)for their conditions ( VanRyn and Burke, 2000)

• Vietnamese, Hispanics and Blacks have higher Vietnamese, Hispanics and Blacks have higher mortality rates for cancer and studies indicate mortality rates for cancer and studies indicate that physicians manage cancer different based that physicians manage cancer different based on race ( Bach et al, 1999: King and Brunetta, on race ( Bach et al, 1999: King and Brunetta, 1999)1999)

AttitudeAttitude

Culturally Biased Health Care:Culturally Biased Health Care:• A patient’s race and gender have been A patient’s race and gender have been

shown to influence a physicians decision shown to influence a physicians decision to refer for cardiac catherization. to refer for cardiac catherization. (Schulman et al, 1999) (Schulman et al, 1999)

• Physicians fail to recognize the presence Physicians fail to recognize the presence of pain in patients who are culturally of pain in patients who are culturally different resulting in under medication. different resulting in under medication. (Todd et al, 1993)(Todd et al, 1993)

AttitudeAttitudeCultural competence requires Cultural competence requires

willingness to adapt to the needs of willingness to adapt to the needs of patients and their family members, and patients and their family members, and to meet those needs in an objective, to meet those needs in an objective, non-judgmental way includingnon-judgmental way including– Ability to demonstrate empathyAbility to demonstrate empathy– Ability to value diversityAbility to value diversity– The capacity for cultural self assessmentThe capacity for cultural self assessment– Awareness of the dynamics that exist Awareness of the dynamics that exist

when cultures interactwhen cultures interact– A clinical demeanor based on an A clinical demeanor based on an

understanding of cultural diversityunderstanding of cultural diversity

Hiring and Training Hiring and Training for Cultural Competencefor Cultural Competence

• Hire a culturally diverse work force.Hire a culturally diverse work force.• Develop a comprehensive training Develop a comprehensive training

curriculum in the elements of cultural curriculum in the elements of cultural competence.competence.

• Mandate training in language, medical Mandate training in language, medical interpretation and cultural competence for interpretation and cultural competence for all employees as required by their position.all employees as required by their position.

• Allocate the budget and time for employee Allocate the budget and time for employee orientation, training and up-dates in the orientation, training and up-dates in the area of cultural competence area of cultural competence

SkillsSkills

• Cultural competence requires Cultural competence requires behaviors that exemplify behaviors that exemplify appropriate interactions between appropriate interactions between health care professionals and their health care professionals and their patients in the areas of:patients in the areas of:– Patient cultural assessmentPatient cultural assessment– Treatment planning and adherenceTreatment planning and adherence– Patient education and communicationPatient education and communication– Clinical decision makingClinical decision making

SKILLSSKILLS

• Patient Cultural Assessment: the need to assess Patient Cultural Assessment: the need to assess cultural, environmental and socioeconomic cultural, environmental and socioeconomic factors as part of diagnostic procedures.factors as part of diagnostic procedures.– Cultural: Race, family structure, gender roles, Cultural: Race, family structure, gender roles,

religion and spirituality, dietary habits and religion and spirituality, dietary habits and time/space orientation.time/space orientation.

– Social: Support networks, socioeconomic status, Social: Support networks, socioeconomic status, community resources, literacy level and lifestyle community resources, literacy level and lifestyle behaviors.behaviors.

– Environment: Aculturalization, knowledge of U.S Environment: Aculturalization, knowledge of U.S health care system, political history, racism and health care system, political history, racism and discrimination and geographic access.discrimination and geographic access.

SKILLSSKILLS

• Models for patient cultural Models for patient cultural assessment:assessment:– LEARN model (Berlin and Fowke’s):LEARN model (Berlin and Fowke’s):

• (L) – Listening to the patients perspective(L) – Listening to the patients perspective• (E) – Explaining and sharing one’s own (E) – Explaining and sharing one’s own

perspectiveperspective• (A) – Acknowledging differences and (A) – Acknowledging differences and

similarities between the two perspectives.similarities between the two perspectives.• (R) – Recommend a treatment plan(R) – Recommend a treatment plan• (N) – Negotiating a mutually agreed-on (N) – Negotiating a mutually agreed-on

treatment plantreatment plan

SKILLSSKILLS

• Models for patient cultural assessment:Models for patient cultural assessment:– Patient Explanatory Model (Klienman et al) Patient Explanatory Model (Klienman et al)

Elicitation techniques for gaining information from Elicitation techniques for gaining information from patient and/or family members about onset, patient and/or family members about onset, treatment and prognosis:treatment and prognosis:• What do you call your problem? What name does it have?What do you call your problem? What name does it have?• What do you think caused your problem?What do you think caused your problem?• What is your sickness doing to you?What is your sickness doing to you?• What problems has it caused you?What problems has it caused you?• Will it last a short or long time?Will it last a short or long time?• What type of treatment do you think you should get?What type of treatment do you think you should get?• What do you hope to get from the treatment?What do you hope to get from the treatment?

TREATMENT PLANNING TREATMENT PLANNING AND ASSESSMENTAND ASSESSMENT

• Factors affecting treatment planning:Factors affecting treatment planning:– Cultural health beliefsCultural health beliefs

• Traditional/folk medicine practicedTraditional/folk medicine practiced• Religious practicesReligious practices• Patients views about health, medications and health Patients views about health, medications and health

care establishmentcare establishment

– Role of familyRole of family• Family member designated as key decision makerFamily member designated as key decision maker• Family members responsible for giving and Family members responsible for giving and

monitoring caremonitoring care• Extended family members to be included in care Extended family members to be included in care

planningplanning


• Factors affecting treatment planning:Factors affecting treatment planning:– Socioeconomic factorsSocioeconomic factors

• Ability to pay for treatment over timeAbility to pay for treatment over time• Limited resources may lead to skipping or sharing Limited resources may lead to skipping or sharing

medications with other family membersmedications with other family members

– Environmental factorsEnvironmental factors• Patients work schedule can result in missed appointmentsPatients work schedule can result in missed appointments• Lack of transportation presents barriers to keeping Lack of transportation presents barriers to keeping

appointmentsappointments• Exposure to environmental toxins ( i.e. pollution, Exposure to environmental toxins ( i.e. pollution,

allergens, roaches, etc.) can decease the effectiveness of allergens, roaches, etc.) can decease the effectiveness of therapytherapy

Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners, March, 2004


• Negotiation of treatment plans:Negotiation of treatment plans:– The patient and the healthcare provider must The patient and the healthcare provider must

acknowledge their differences about the acknowledge their differences about the treatment plan/methods and come to a treatment plan/methods and come to a mutually-agreeable but beneficial alternative.mutually-agreeable but beneficial alternative.

– Process of negotiation involves:Process of negotiation involves:• Relationship buildingRelationship building• Problem clarificationProblem clarification• Agenda settingAgenda setting• AssessmentAssessment• Follow-up care managementFollow-up care management

Patient Patient Communication/EducationCommunication/Education

• Barriers to effective communication:Barriers to effective communication:– Lack of awareness of patient expectationsLack of awareness of patient expectations– Devaluing the patient or the patients’ family Devaluing the patient or the patients’ family

health care viewshealth care views– Language barriersLanguage barriers– Cultural norms/customs for interpersonal Cultural norms/customs for interpersonal

communicationcommunication– Patient feeling rushedPatient feeling rushed– Physician biases Physician biases

Collins et all, 2002; IOM, 2003:Rivadeneyra et al., 2000Collins et all, 2002; IOM, 2003:Rivadeneyra et al., 2000

Promote Effective Promote Effective CommunicationCommunication

• Translation: When written words in one language are Translation: When written words in one language are translated into another. Patient materials must be translated into another. Patient materials must be developed and written in the clients language.developed and written in the clients language.

• Interpretation: Conversation between two speaker is Interpretation: Conversation between two speaker is translated from one language to another including translated from one language to another including sign language. This is usually performed by a third sign language. This is usually performed by a third party.party.

• Medical Interpretation: Goes beyond routine Medical Interpretation: Goes beyond routine interpretation with emphasis placed on the ability to interpretation with emphasis placed on the ability to interpret for the provider and the patient within a interpret for the provider and the patient within a medical context medical context


• Suggested strategies for effective cross-Suggested strategies for effective cross-cultural communication:cultural communication:– Use open ended questionsUse open ended questions– Collect information via conversation rather Collect information via conversation rather

than intensive questioning.than intensive questioning.– Do not interrupt the patientDo not interrupt the patient– Communicate in an unhurried mannerCommunicate in an unhurried manner– Allow the patient time to ask questionsAllow the patient time to ask questions– Speak in a normal toneSpeak in a normal tone– Explain medical terms in simple languageExplain medical terms in simple language– Use validating techniques to assure the Use validating techniques to assure the

patient you are listening.patient you are listening.


Suggestions for non-verbal cross-cultural Suggestions for non-verbal cross-cultural communication:communication:

• Speak directly to the patient.Speak directly to the patient.• Understand that lack of eye contact may not Understand that lack of eye contact may not

imply lack if interest.imply lack if interest.• Limit the use of gestures.Limit the use of gestures.• Be aware of the patients’ cultural norms for Be aware of the patients’ cultural norms for

appropriate distance.appropriate distance.• Social touching of the patient may be Social touching of the patient may be

unacceptable.unacceptable.• Slouching or exposing the sole of the foot can Slouching or exposing the sole of the foot can

be viewed as unacceptable.be viewed as unacceptable.• Use interpreters when needed.Use interpreters when needed.


Patient education to help in understanding Patient education to help in understanding the nature and conditions of their illness the nature and conditions of their illness and changing risky behaviors:and changing risky behaviors:

– Consider literacy and education level of the Consider literacy and education level of the patientpatient

– Overcome language barriers through the use Overcome language barriers through the use of interpretersof interpreters

– Incorporate concepts familiar to patient views Incorporate concepts familiar to patient views related to health values, beliefs and practices.related to health values, beliefs and practices.

Betancourt et al. 1999; Buchwald et al.,1993, Flores, 2000Betancourt et al. 1999; Buchwald et al.,1993, Flores, 2000

Clinical Decision MakingClinical Decision Making

• Culturally sensitive clinical decision making Culturally sensitive clinical decision making must transcend:must transcend:– The clinicians preconceived assumptions about The clinicians preconceived assumptions about

the patient and the cause of their illness.the patient and the cause of their illness.– Professional norms, behaviors and training that Professional norms, behaviors and training that

distance the clinician from the patient and their distance the clinician from the patient and their individual needs.individual needs.

– The complex health care system and The complex health care system and institutional operations that promote cost institutional operations that promote cost control, clinical productivity and workforce control, clinical productivity and workforce competence over patient preferences and competence over patient preferences and individual needs.individual needs.

Goals of a Culturally Goals of a Culturally Diverse Health SystemDiverse Health System

• To value the diverse cultural beliefs of all To value the diverse cultural beliefs of all clients.clients.

• To promote effective communication To promote effective communication between providers and the diverse between providers and the diverse community of interest they serve.community of interest they serve.

• To hire and train for cultural competence To hire and train for cultural competence with the same seriousness as applied to with the same seriousness as applied to other essential clinical skills.other essential clinical skills.

• To institutionalize cultural competenceTo institutionalize cultural competence

Institutionalize Cultural Institutionalize Cultural CompetenceCompetence

• Integrate cultural competence into Integrate cultural competence into the strategic planning at all levelsthe strategic planning at all levels

• Include funding for culturally diverse Include funding for culturally diverse staffing as well as training and other staffing as well as training and other essential activities. essential activities.

• Make cultural competence a criterion Make cultural competence a criterion for employee evaluation.for employee evaluation.

• Involve your community of interest in Involve your community of interest in the process of defining and the process of defining and addressing health service needs. addressing health service needs.

Culturally Competent Culturally Competent Health Care is EffectiveHealth Care is Effective

• More complete and specific information More complete and specific information gathering is provided for the provider gathering is provided for the provider resulting in more accurate diagnosis.resulting in more accurate diagnosis.

• Treatment plans supported by the family Treatment plans supported by the family are developed which increase patient are developed which increase patient compliance.compliance.

• There is a greater use of health services by There is a greater use of health services by ethnic populations and reduced delays in ethnic populations and reduced delays in seeking care.seeking care.

• Communication between healthcare Communication between healthcare provides and patients is enhanced.provides and patients is enhanced.

• The compatibility between Western and The compatibility between Western and traditional health practices is enhanced.traditional health practices is enhanced.

ReferencesReferences• Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Towards A

Culturally Competent System of Care, Volume I. Culturally Competent System of Care, Volume I. Washington, DC: Washington, DC: Georgetown University Child Development Center, CASSP Technical Georgetown University Child Development Center, CASSP Technical Assistance Center.Assistance Center.

• Denboba, D., U.S. Department of Health and Human Services, Health Denboba, D., U.S. Department of Health and Human Services, Health Services and Resources Administration (1993). Services and Resources Administration (1993). MCHB/DSCSHCN MCHB/DSCSHCN Guidance for Competitive Applications, Maternal and Child Health Guidance for Competitive Applications, Maternal and Child Health Improvement Projects for Children with Special Health Care Needs.Improvement Projects for Children with Special Health Care Needs.

• Census Bureau’s Web site: Census Bureau’s Web site: http://www.census.govhttp://www.census.gov, , FForeign-Born oreign-Born Population DataPopulation Data

• Paulson and Dekker,, Paulson and Dekker,, Healthcare Disparities in Pain Healthcare Disparities in Pain Management,Management, J Am Osteopath Assoc 2005;105:S14-S17. J Am Osteopath Assoc 2005;105:S14-S17.

• James et al., James et al., Association of Race/Ethnicity with Emergency Association of Race/Ethnicity with Emergency Department Wait Times, Department Wait Times, PediatricsPediatrics 2005;115:e310-e315 2005;115:e310-e315

• Kagawa-Singer and Blackhall, Kagawa-Singer and Blackhall, Negotiating Cross-Cultural Issues Negotiating Cross-Cultural Issues at the End of Life: "You Got to Go Where He Livesat the End of Life: "You Got to Go Where He Lives, , JAMAJAMA 2001;286:2993-3001 2001;286:2993-3001

ReferencesReferences

• Achieving Cultural Competence: A Achieving Cultural Competence: A Guidebook for Providers of Services to Guidebook for Providers of Services to Older Americans and Their Families: Older Americans and Their Families: www.aoa.gov/prof/adddiv/www.aoa.gov/prof/adddiv/

culture/CC-guidebook.pdfculture/CC-guidebook.pdf

““Health Care RX: Access for ALL”,The Health Care RX: Access for ALL”,The Presidents Initiative on Race, U.S. Presidents Initiative on Race, U.S. Department on Health and Human Department on Health and Human Services, Health Resources and Service Services, Health Resources and Service Administration, 1999, P.17-18.Administration, 1999, P.17-18.

diversity & cultural competence in respiratory care

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