Health Resources and Services Administration & Social Solutions International, Inc. July 2012

The State & Community Intimate Partner Violence (IPV)

& Perinatal Depression (PD) Resource Development Project: Cultural

CompetencyHealth Resources and Services

Administration&

Social Solutions International, Inc.July 2012

IPV/PD: A Comprehensive Approach

Webinar Speakers and Guests

Moderator: Kristen Stier, MASocial Solutions International, Inc.

Keisher Highsmith, DrPHHRSA/Maternal and Child Health Bureau

Speaker: Suganya Sockalingam, PhDChange Matrix

Speaker: Darby TaylorDes Moines Healthy Start Project


Objectives

• Understand what cultural and linguistic competency is and why it is important for addressing IPV/PD

• Learn how to examine cultural competence in your organization

• Discover tools for staff development related to cultural competence


Toolkit Goals

• Provide a guide that is culturally and linguistically appropriate to support community-based programs with making the case for why its important to address the IPV/PD intersection.

• Assist communities in reducing stigma and provide strategies for building partnerships and increasing support from leadership

• To improve the health and safety of families experiencing IPV and PD


Cultural and Linguistic Competence

Suganya Sockalingam, Ph.D.

Managing Member & Co-Founder

Change Matrix


Cultural and Linguistic Competence

• Explore an Overview of:• Population Demographics• Group Diversity, Culture, and Values• Cultural Influences on health

• Identify a Framework for Approaching Culturally Competent Care


Demographics


Women Impacted by IPV

Source: CDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366 IPV/PD: A Comprehensive Approach

Women Impacted by PPD

• An overview of:• cultural and linguistic

competence, • group diversity, culture, and

values• issues related to health


CDC Data

• Women more likely to report Postpartum Depressive Symptoms:• Younger women • Those with lower educational attainment• Women who received Medicaid benefits for

their delivery• Non-Hispanic white women had a lower

prevalence of PDS compared with women of other racial/ethnic groupsCDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366

(http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm

)IPV/PD: A Comprehensive Approach

http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm


Population by Race/Ethnicity – Women Impacted by PPD

Source: CDC – MMWR Weekly; April 11, 2008/ 57(14); 361-366 IPV/PD: A Comprehensive Approach

IPV in Immigrant and Refugee Communities

• Immigrant & refugee women vulnerable due to:• Poverty• Limited language proficiency• Social isolation• Immigration status• Confusion over their legal rights• Stress of adaptation to new culture• Disparities in economic and social resources

• Effects of IPV on Immigrants/Refugee women:• Mental health -- depression, posttraumatic stress,

anxiety symptoms and disorders, substance abuse• Reproductive/sexual health – miscarriage, unwanted

pregnanciesIntimate Partner Violence in Immigrant and Refugee Communities:

Challenges, Promising Practices and Recommendations. A Report by the Family Violence Prevention Fund for the Robert Wood

Johnson Foundation (March 2009)


IPV, PPD Resources

• Intimate Partner Violence in Immigrant and Refugee Communities: Challenges, Promising Practices & Recommendations (March 2009)• http://www.rwjf.org/files/research/ipvreport20090331.pdf

• Lifetime Prevalence of Rape, Physical Violence, and/or Stalking by an Intimate Partner, by Race/Ethnicity — U .S . Women, NISVS 2010• http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf

• CDC – MMWR Weekly; April 11, 2008/ 57(14)• http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5714a1.htm


http://www.rwjf.org/files/research/ipvreport20090331.pdf

http://www.rwjf.org/files/research/ipvreport20090331.pdf

http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf

http://www.cdc.gov/ViolencePrevention/pdf/NISVS_Report2010-a.pdf



Group Diversity, Culture and Values


Factors That Influence Diversity Among

Individuals and GroupsInternal Factors• Ethnic/Racial/Tribal

Identity• Socioeconomic

Status/Class• Nationality• Language• Family Constellation• Social History• Health Beliefs &

Practices• Perception of Disability• Education• Perception of Health

(including mental health)

Internal Factors• Age & Life Cycle Issues• Spatial & Regional

Patterns• Gender & Sexuality• Sexual Orientation• Religion & Spiritual Views• Political Orientation &

Affiliation• Acculturation/

assimilation level

Source: National Center for Cultural Competence, 2002 - modified from James Mason, Ph.D.IPV/PD: A Comprehensive Approach

Factors That Influence Diversity Among

Individuals and Groups, cont.

External Factors•Institutional Biases•Community Economics•Intergroup Relations•Natural Networks of Support•Community History•Race relations

External Factors• Political Climate• Workforce Diversity• Community

Demographics• Migratory Patterns• Group & Community

resiliency

Source: National Center for Cultural Competence, 2002 - modified from James Mason, Ph.D.


Challenge in Recognizing Diversity


Definitions of Culture

• sum of total of the learned behavior of a group of people generally considered to be tradition and transmitted from generation to generation

• collective programming of the mind that distinguishes one group from another

• culture, including their embodiments in artifactsconsists of the distinctive achievement of human groups

• cultivated behavior through social learning• way of life of a group of people• symbolic communication deliberately perpetuated • in a society through its institutions• culture = communication• systems of knowledge shared by group of people• Cumulative deposit of Knowledge, Experience,

Beliefs and AttitudesIPV/PD: A Comprehensive Approach

Iceberg Metaphor for Culture

• How individuals are perceived by the world and how they are (in actuality) in the world can differ by how much we understand of what is in our consciousness and what is “out-of-awareness”

• Just as nine-tenths of an iceberg is out of sight (below the water line) so is nine-tenths of an individual or organizational culture - out of our conscious awareness.

• The top of the iceberg represents manifestations or surface levels of the organizational culture. They are primarily in our awareness for example - cultural artifacts: such as dress, coffee mugs, physical layout

• The lower levels of the iceberg operate unconsciously, are shared by all members, and define in a basic way the “taken for granted” view of the individual, and organization and its environment.

• To change the individual or organization, you must be aware of all levels.

• Change must take place below the water line.


Iceberg


Continuum of Values

• Fate• Tradition• Human Orientation• Hierarchy/Rank/Status• Group Welfare• Cooperation• Past-Orientation• Time-Linear

Orientation• Formality• Idealism• Spiritualism• “Being” Orientation

• Personal Control Over Life

• Change• Object Orientation• Individual

Equality/Egalitarian• Individualism/Privacy• Competition• Future Orientation• Time-Event Orientation• Informality• Practicality/Efficiency• Materialism• Action/Goal/Work

OrientationIPV/PD: A Comprehensive Approach

Cultural Influences on Health


Cultural Influences on Health Seeking Behaviors & Attitudes

• Diverse beliefs about health, disease, and disease management• Reliance on traditional healers, practices, and medicines• Mistrust of health care professionals and institutions outside of own culture• Experiences of racism, discrimination and bias• Communication/Linguistic barriers• Lack of understanding of western medical systems


Health Seeking Behaviors


What is cultural and linguistic competence?

• A Framework for approaching health care issues in an appropriate and effective way


Definitions

• Cultural Competence– capacity to function effectively in cross-

cultural situations at an individual, organizational and systems level

Cross, Bazron, Dennis, and Isaacs, 1989

• Linguistic Competence– convey information in a way easily

understood by diverse groups (language, literacy and communication formats)

Goode and Jones, 2004


Cultural Competence Continuum

• Cultural Proficiency• Cultural Competence• Cultural Precompetence• Cultural Blindness• Cultural Incapacity• Cultural Destructiveness

Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care Volume I.

Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center


Elements of Cultural Competence – Organizational Level

• value diversity• conduct cultural self-assessment• manage the dynamics of difference• institutionalize cultural knowledge• adapt to diversity

• - policies - structures• - values - services


Elements of Cultural Competence – Individual Level

• acknowledge cultural differences• understand your own culture• engage in self-assessment • acquire cultural knowledge & skills• view behavior within a cultural context

Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care

Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical

Assistance Center


Elements

These five elements must be manifested at every level of an organization including:

policy makingadministrative practice/service delivery consumer/family community

and reflected in its attitudes, structures, policies and services

Adapted from Cross, Bazron, Dennis, & Isaacs, 1989


Contact Us

Suganya Sockalingam, Ph.D.Partner

Change Matrix LLC2721 Breakers Creek Drive

Las Vegas, NV 89134Phone: 702-219-7379

E-mail: [email protected]: www.changematrix.org


Cultural and Linguistic Competency:

A Provider PerspectiveDarby Taylor

Healthy Start Project DirectorDes Moines Healthy Start Project

Des Moines, Iowa


Program Description

• Des Moines Healthy Start: Provides comprehensive home-based services to address perinatal health, child health, social services, parenting, and child development for high-risk families with pregnant women and children under two years of age in a nine zip-code area in Polk County, Iowa (363 families served last year)

• Empowerment (State Funds): Expands geographic area to all of Polk County and age of child to six (308 families served last year)


Numbers ServedJune 1, 2011 – May 31, 2012

• Case Management Services for the Des Moines Healthy Start Project:

• 671 families and 682 children were served during the Fiscal Year 11-12

• 8,000 face-to-face visits were completed by case managers

• 20 Case Managers and 19 full and part time Outreach Workers


Des Moines, IowaCensus Data, 2010

• Population: • Iowa - 3,046,355• Des Moines (capital city) - 203,433• Polk County - 430,640• • Caucasian-only population: • Iowa - 91.3%• Des Moines - 76.4%

• Primary language other than English: • Iowa - 6.8%• Des Moines - 16%


Participant Ethnicity, Des Moines Healthy Start

June 1, 2011 – May 31, 2012

30%

12%

34%

24%


Participant Language, Des Moines Healthy Start

July 1, 2011 – June 30, 2012

SpanishEnglishArabicOther

29%38%

5% 28%IPV/PD: A Comprehensive Approach

Participant Primary LanguageDes Moines Healthy Start

• English is the primary language of only about 1 in every 3 Healthy Start participants

• During FY 11-12, 38% of participants spoke a language other than English, Spanish, or Arabic (a 21% increase from 2010)

• Participants spoke a total of 28 languages including:

Bassa; Karen; Nepali; Burmese; Karenni; Nuba; Chin; Kirundi; Nuer; Thai; Krahn; Pashto; Dinka; Kunama; Somali; Grebo;

Laotian; SwahiliIPV/PD: A Comprehensive Approach

Changes in Population: Des Moines, Iowa

2007 - 2012• Refugee arrivals in Polk County

between 2007 and 2010 (out of 1,829 total arrivals):• 37 Vietnamese• 52 Sudanese• 641 Burmese

• During FY 11-12, 164 families from Burma received services through Des Moines Healthy Start


Des Moines Healthy Start Outreach Services

• 6 Full-Time and 13 Part-Time Outreach Workers/Interpreters (High School Diploma and bilingual):• Speak a total of 20 languages (Arabic, Bendi,

Burmese, Chin Lai, Chin Mizo, Chin Phalam, Chin Zo Mi, Hindi, Kachin, Karen, Laotian, Nepali, Nuer, Nuba, Somali, Spanish, Swahili, Thai, Thai Dom, Vietnamese)

• Challenges• Recruiting/hiring• Small communities and pressure placed on

staff within their own communities


Case Management ServicesDes Moines Healthy Start

• 20 Case Managers (Bachelor’s Degree in Human Services related field and two years’ experience):• 8 Case Managers bilingual in English and

Spanish• 1 Case Manager trilingual in English,

Arabic, and Nuba• 1 Case Manager trilingual in English,

Spanish, and French• 1 Case Manager with VNS maintains a

caseload dedicated to African American families residing in the Healthy Start project area


Staff Recruitment Des Moines Healthy Start

• Project population discussed extensively during interviewing process

• Sample interview question: “How would you respond to behaviors or customs that conflict with your own beliefs or knowledge of best practices (for example, as it relates to child rearing or discipline)?”

• Outreach Specialists are recruited directly from the target communities; they then help identify and recruit other community members and leaders to work for the project

• Case managers and participants receive specific education to work with Interpreters (triadic relationships)


Staff TrainingDes Moines Healthy Start

• Monthly all-staff meetings; most include training related to cultural competence

• Outreach Specialists and participants provide education to case managers, formally and informally

• Program offers ongoing support groups, nutrition groups, and parent/child interaction groups targeting different populations

• Participants hold traditional celebrations as part of these groups; rich education opportunity for staff

• Program staff asked to attend and honored at community celebrations


Depression, Des Moines Healthy StartJune 1, 2011 through May 31, 2012

• 99% of women were screened for depression• Project has two licensed mental

health therapists who can see participants regardless of insurance status

• Contract with community-based psychiatrist


Depression, Des Moines Healthy Start Project Cultural Challenges

• Recognition of depression or mental health as a problem

• Previous experiences in trauma• Stigma associated with depression• Starting support groups for Burmese

women – critical to gain community buy-in


Domestic Violence June 1, 2011 through May 31, 2012

• Only 7% of participants reported domestic violence as an issue

• Believed to be very under-reported in our population

• Limited resources – one shelter, lack of translated materials, lack of interpreters, smaller communities


Domestic Violence, Des Moines Healthy Start Cultural Challenges

• Fear of being alone in a new country without the ability to speak the language

• May be culturally more acceptable• Lack of understanding of the system• Women may become more independent,

which can be threatening to men• Increased availability and lower cost of

alcohol in this country• Some success in presenting information

in group setting vs. individually


Culturally Competent Service Delivery

Challenges• A growing number of referrals due to

increasing client need within the community has resulted in a waiting list for services

• Successfully linking the refugee and immigrant populations to available community resources can be difficult or impossible

• Need to identify better resources for identifying and addressing domestic violence

• Large burden placed on staff by other community providers (lack of interpreters community wide)



Successes• Culturally and linguistically diverse staff

provide case management, parent education, and outreach services

• Project continues to adapt to respond to the changing needs of the community

• Comprehensive depression screening and access to mental health services is a benefit

• Hiring staff directly from the communities; utilizing these staff to provide ongoing education to others



Points to Consider & Where to Start• Barriers to learning English• Keeping traditions and languages alive• Empowering communities reduces

dependency on services• Community members are the best

source of education – ask questions and listen to the responses

• Cultural Considerations Tool – p. 89; a great place to start


Contact Us

Des Moines Healthy Start ProjectVisiting Nurse Services of Iowa1111 9th StreetSuite 320Des Moines, IA 50314Phone: 1-515-288-1516Fax: 1-515-288-0437


Toolkit: A Comprehensive Approach for Community-Based Programs to Address the

Intersection of Intimate Partner Violence and Perinatal Depression

Cultural and Linguistic CompetencyKristen Stier, MA

Social Solutions International, Inc.


Cultural and Linguistic Competency

1. Requires a commitment to organizational change

2. Involves a re-evaluation of one’s health values, beliefs, practices, and behaviors

3. Includes an understanding of how social determinants such as oppression, suppression, bias, and institutional prejudices affect one’s experience of health and healthcare


Cultural and Linguistic Competence, cont.

• Allows us to:• Be respectful of a person’s

experiences• Provide quality services


Cultural and Linguistic Competence: Goals

• Value diversity• Conduct a self-assessment• Manage the dynamics of difference• Acquire and institutionalize cultural

knowledge• Adapt to diversity and the cultural

contexts of the communities they serve


Goals

• Cultural and linguistic competency – Goals for an organization include:– Adapt to Diversity and the cultural contexts of

the communities you serve– Value Diversity– Conduct a self-assessment– Manage the dynamics of difference– Acquire and institutionalize cultural knowledge

• Source: Health Resources and Services Administration. A Comprehensive Approach for Community-Based Programs to Address Intimate Partner Violence and Perinatal Depression.


Resources for Staff Development

• The Office of Minority Health website offers trainings and provides “National Standards for Culturally and Linguistically Appropriate Services in Health Care”• thinkculturalhealth.hhs.gov/Content/

ContinuingEd.asp.• minorityhealth.hhs.gov/assets/pdf/checked/

executive.pdf

• The Community Toolbox (2012) from the University of Kansas offers tips on Cultural Competency• ctb.ku.edu/en/dothework/tools_tk_9.aspx

• HRSA has developed “Cultural Competence Works” for HRSA grantees exploring cultural competency• ftp.hrsa.gov/financeMC/cultural-competence.pdf


Cultural Considerations Tool

• Goals for staff:• All staff, understand the importance of

cultural competency.• An agency-wide process helps staff to

understand how cultural and linguistic differences impact behaviors, and help staff achieve and maintain cultural competency.

• Staff represent and/or appreciate diverse racial, ethnic, and cultural backgrounds.

• Staff understand how to utilize language interpreters


Cultural Considerations Tool, cont.

• What is your organization vision for cultural competence?

• Describe the level of support the organization’s leadership and staff will give in working towards cultural competence?

• What are the primary cultural groups and languages represented in your community? By staff?

• What special services or arrangements does the organization have for diverse participants?


Tool, cont.

• Describe the organization’s process for assessing the need for a translator or “language line.”• What types of training or events have staff been provided in the area of cultural competency?• Describe any issues, policies, or procedures that are barriers to staff providing quality services for diverse participants.• Describe the identified needs of the organization and possible steps to move toward cultural competence


Cultural Considerations Tool - Goals

What is your goal for cultural competence at the:

• Individual level:• Organizational level:

• Program level: • Community level:


Contact Us

Kristen Stier, [email protected] Solutions International,

Inc.8070 Georgia AvenueSuite 201Silver Spring, MD 20910Phone: 1-866-901-6583Fax: 1-866-369-6809


Contact Information

For more information, questions, or comments about The State & Community Intimate Partner Violence

(IPV) & Perinatal Depression (PD) Resource Development Project, please contact:

Keisher Highsmith, Dr.P.H.Project Director

[email protected] of Health and Human Services

Health Resources and Services AdministrationMaternal and Child Health Bureau

Division of Healthy Start and Perinatal Serviceswww.mchb.hrsa.gov


mailto:[email protected]

Documents

Health Resources and Services Administration & Social Solutions International, Inc. July 2012