Beyond Diversity:
A Journey to Cultural Proficiency

Facilitator's Guide
ACKNOWLEDGEMENTS
The Heartland National Tuberculosis Center (HNTC) is funded by the Centers for Disease Control and Prevention (CDC) and is a joint project of The University of Texas Health Science Center at Tyler (UTHSCT) and the Texas Center for Infectious Disease (TCID). HNTC's primary goal is to provide tuberculosis training, technical assistance and medical consultation activities to a 13 state region including: Arizona, New Mexico, Texas, Nebraska, Oklahoma, Missouri, Kansas, Iowa, Illinois, North Dakota, South Dakota, Wisconsin and Minnesota; and the cities of Chicago and Houston.

A note of appreciation is extended to the following for their assistance in developing and producing this manual:
Heartland National TB Center Staff
Center for Health Training
Centers for Disease Control and Prevention
Texas Department of State Health Services

A special thank you to all our reviewers
Millie Blackstone, AZ Dept of Health
Mary Long, HNTC
Phil Griffin, KS Dept of Health
Amera Kahn, CDC DTBE
Lynelle Phillips, HNTC
Delphina Sánchez, HNTC

All materials in this document are in the public domain and may be used or printed without special permission (unless otherwise noted in the document); citation of source is appreciated.

Suggested citation:
Heartland National Tuberculosis Center. Beyond Diversity: A Journey to Cultural Proficiency – Facilitator's Guide, 2008 (Rev 4.2010).

This document is available through the:
Heartland National Tuberculosis Center
2303 SE Military Drive
San Antonio, Texas 78223
Phone: 1-800-TEX-LUNG
1-800-(839-5864)
Fax: (210) 531-4590
Website: www.HeartlandNTBC.org

TABLE OF CONTENTS

Introduction 6
Purpose 10
Training and Trainer Requirements and Readiness 11
Recommendations for Best Practice 14
Getting Started 16
Sample 17
Training Agenda At-a-Glance
Exercise
Individual Introduction 18
Identify Course Expectations 19
Summary of How to Get the Most from This Workshop 21
Exercise 22
Setting Group Ground Rules
Exercise
What is Diversity? What is Cultural Proficiency?
Part I: Defining Diversity 24
Part II: What does it mean to be Culturally Proficient? 26
Part III: Cultural Influences on Healthcare 29
Cultural Proficiency: What is it? 35
Cultural Dynamics Influencing the Clinical Encounter 36
My Pen 37
Kleinman's Tool to Elicit Health Benefits in Clinical Encounters 39
Cross Cultural Communication 40
Exercise
Communication Skills for Cultural Proficiency 41
Working with Interpreters: Guide to working with interpreters in health service settings 46
Exercise
Stereotypes and Assumptions 48
The Story of Jack 50
Exercise
Negotiating and Supporting Change 52
Supporting Others through Change 57
Exercise
Collaboration Bead Toss 58
Exercise
Training Transfer: Now What? 61
Wrap-Up 63
Glossary 65
References 66
Additional Resources 67

Page 5

Introduction

We hear a lot about cultural proficiency. It is the quintessential buzz-word which often elicits a round of groans from all those in ear-shot; yet public health professionals must cultivate skills to provide effective care for the multitude of cultures we face in our shrinking world. There is no public health field where this is more critical than in TB. With 50% or more of our TB cases foreign born, we have to gain skills in building rapport with patients from many diverse cultures if we are going to succeed in reducing TB morbidity and mortality and preventing drug resistance.

We chose "Beyond Diversity: A Journey to Cultural Proficiency" as our title because most often culture is defined solely on race or ethnicity; yet a unique culture exists within a multitude of other groups. Cultural groups are often defined by what makes them similar or the same. Here are some examples of what defines some of the other cultural groups that are not ethnically based:

Life situation, e.g., homeless culture
Differently-abled, e.g., hearing impaired culture
Age, e.g., generational culture
Geography, e.g., rural versus urban culture

Although ethnicity does impact our particular culture, becoming culturally proficient is more than knowing about different ethnicities. It is about knowing yourself and your own biases and assumptions that impact interactions with people who you view as being different than yourself – whether they are homeless, have a disability or are of a different ethnic or racial group than you.

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Why is being culturally proficient important for those working in Tuberculosis?

Tuberculosis is the most prevalent infectious disease in the world. The majority of TB cases in the United States are diagnosed in foreign-born individuals, thus increasing the likelihood that our front line staff will be working with patients from a variety of different cultures

(CDC 2007).1
Slide 12. Trends in TB Cases in Foreign-born Persons, United States, 1987–2007.

This slide shows trends in TB cases in foreign-born persons in the United States from 1986, when information on country of birth was first reported by all areas submitting reports to CDC, through 2007. The number of TB cases in foreign-born persons increased from nearly 5,000 in 1986 to 7,000–8,000 each year since 1991. The percentage of TB cases accounted for by foreign-born persons increased from 22% in 1986 to 58% in 2007.

Reference: http://www.cdc.gov/tb/pubs/slidesets/surv/surv2007/Slides/surv12.htm%20%20 Retrieved

Page 7

Promoting Cultural Proficiency in TB Healthcare Workers Helps Foster Patient-Centered Care

"Ensuring that persons who are suspected of having active TB disease are identified as soon as possible, evaluated appropriately, placed on the recommended course of treatment, and complete therapy as prescribed is the prime responsibility of the health department. Mechanisms to accomplish this goal are numerous and varied given the diverse population groups affected by TB today. Ideally, they include patient-centered programs that assess each patient's needs and identify a treatment plan to ensure the completion of therapy. The Institute of Medicine (IOM) report specifically recommends "use of strategies that are specifically designed to overcome the social or cultural obstacles to treatment completion" (IOM 2000). 2

Improve Outcomes

"TB adherence is a complex behavioral issue and improving treatment outcomes for TB (and for other diseases) requires a full understanding of the factors, including cultural factors, that prevent people taking medicine correctly and those that help them complete their treatment" (Munro SA, et al. 2007).3

A high priority objective for State Health Departments that are recipients of CDC's cooperative agreement funds is for active TB patients to complete treatment within 12 months. The attitudes of public health nurses and outreach staff may be the pivotal factor in their patient's ability to successfully initiate and complete treatment. Support from public health staff may help patients overcome the individual and cultural barriers they may have. Providing this support means understanding our own personal beliefs and biases and devising strategies to provide patient-centered care for TB patients no matter how different their cultural backgrounds may be.

Avoid Unequal Treatment

"In its 2002 publication, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine reports that racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when patients' insurance status and income are controlled. The study committee found evidence that stereotyping, biases and uncertainty on the part of healthcare providers all contribute to unequal treatment. The report calls for cross-cultural training for providers." 4

The purpose of this training is to promote cultural proficiency of front-line public health staff so they may recognize cultural barriers to treatment, foster trust and rapport with patients from many different backgrounds and cultures and assure patient-centered care. This workshop is therefore designed to look beyond the cultures of ethnicity and race and to instead build a strong foundation of culturally proficient care among TB healthcare providers. It will encourage providers to explore personal and professional beliefs that impact dynamics between providers and patients and to build skills in providing healthcare with consideration to the cultural context of the patient.

Page 8

Facilitators Should Familiarize Themselves with Cultural Influences on Healthcare

In non-Western cultures, a person's view of him/herself has a great deal to do with how s/he is in relation to others. Some examples of this: in Hispanic cultures, the notion of simpatico: the idea of respecting and sharing others' feelings; in Japan, the word for self is jibun, which refers to "one's share of the shared life space"; a highly valued Chinese virtue is jen, which implies a person's capability to interact with fellow human beings in a sincere, polite and decent fashion. Looking outside of ethnic groups, we can also see this value of interdependence. Psychologist Jean Baker Miller has said "For many women, the threat of disruption of connections is perceived not just as a loss of relationship, but as something closer to a total loss of self."

However, our American society on the whole places a higher value on independence, thus, the notion of "pulling yourself up by the bootstraps" and an appreciation for the "self-made man." Given that many of the clients we see may come from a cultural construct with a higher value on interdependence, coupled with the fact that our clinics and agencies function within a culture which places a higher value on independence, what implications does this have for how we provide services; and for how our services are perceived and accepted by clients?

Some specific areas where we can anticipate conflict are: choice, making changes and making decisions. The American way is to place a very high value on an individual having choices, making changes in one's life and making one's own independent decisions.

A person with a high value on interdependence might see this entirely differently. Everything depends on the situation, the relationships and a sense of accountability to others.

Our focus in healthcare is often on encouraging people to make decisions that are "good for them," which will result in bettering their personal health. For someone from a culture with a high value on interdependence this may mean less to them than making a decision that will result in a closer relationship or will enable them to be more like someone else or will allow them to defer to someone they hold in esteem or a combination of all of these motives.

Page 9

Purpose

GOAL: The purpose of the guide is to build internal capacity within TB programs by assisting trainers to educate their colleagues on issues of cultural proficiency.

"Beyond Diversity: A Journey to Cultural Proficiency" – Facilitator's Guide has been designed to provide trainers with exercises to be used to conduct an interactive, skill-building workshop. It is designed to improve the knowledge and proficiency of both new and experienced staff working in the field of TB and to serve as a resource for preparing trainers to teach. It provides example agendas, activities and guidance for facilitating a cultural proficiency workshop.

TARGET AUDIENCE: It is important to note that this facilitator's guide is targeted to be used by individuals who have experience in facilitating training workshops for TB workers. The course is targeted to individuals in the field of TB that have limited training in cultural proficiency. This guide was designed primarily to provide necessary skill-building training exercises on cultural proficiency rather than serving as a detailed training toolkit; it is assumed that experienced facilitators will already have the knowledge and skills in training. Resources are available to trainers to assist in the logistical preparations for a course. Some of these additional resources are listed on page 69. In addition, a few adult learning tips and techniques are provided in this manual. They are not meant to be comprehensive in nature and it is recommended that all facilitators review material on this subject prior to conducting this course.

Pre-requisite Recommendation: It is also recommended that the self-study manual Cultural Competency and Tuberculosis Care: A Guide for Self-study and Self-assessment be read as a pre-requisite by participants for this course. This manual is available through the New Jersey Medical School Global Tuberculosis Institute at http://www.umdnj.edu/ntbcweb/products/tbculturalcompguide.htm

OBJECTIVES OF THE COURSE: By the end of this workshop the participant should be able to:
Define cultural proficiency and cultural diversity
Outline the impact of health beliefs and experiences on healthcare service delivery
Explain the role of communication in healthcare
Utilize effective cross-cultural communication
Describe effective methods for working with an interpreter
Outline strategies and practices that can increase the healthcare provider's ability to conduct
culturally-sensitive services

"Patients may not adhere to medical advice because they do not understand or do not trust the provider." 5

Page 10

Training and Trainer Requirements and Readiness

What is training?
Training is designed to convey knowledge, develop skills and change attitudes and behaviors. Unlike other types of instructional methods, training places the emphasis on the learner in order to engage them in the learning process. The goal of training is not just to present information, but to provide an opportunity for participants to apply the information.

Who can be a trainer?
A trainer is essentially a facilitator. They are responsible for creating an effective learning environment for each of the participants. They should understand the principals of adult learning theory and be prepared to play multiple roles throughout the workshop. It is important to remember that the role of the facilitator is to create a safe learning environment for each of the participants and to provide opportunities for participants to learn about themselves and from each other. They are also responsible for coordinating a series of activities that involve different learning methods to address the individual learning styles and needs of the participants. The majority of activities should be based on Adult Learning Theory.

Training Adults
Contrary to how we were taught in school, we know that adults learn best when they are actively involved in the learning process. As a trainer, it is important to provide many opportunities for examples, real life stories and questions. Adults are best able to learn when the material being presented can be related to their daily lives. It is important to make sure that the materials being covered within a workshop can be directly linked to the work or life of the participant. Allow opportunities for participants to brainstorm how what they learn during the training will impact their lives.

TECHNIQUES FOR TRAINING ADULTS:
Stephan Lieb in his article "Principles of Adult Learning" 6 outlined the following characteristics of adult learners:

Adults are autonomous and self-directed. They need to be free to direct themselves. Their teachers must actively involve adult participants in the learning process and serve as facilitators for them. Specifically, they must get participants' perspectives about what topics to cover and let them work on projects that reflect their interests. They should allow the participants to assume responsibility for presentations and group leadership. They have to be sure to act as facilitators, guiding participants to their own knowledge rather than supplying them with facts. Finally, they must show participants how the class will help them reach their goals (e.g., via a personal goals sheet).

Adults have accumulated a foundation of life experiences and knowledge that may include work-related activities, family responsibilities and previous education. They need to connect learning to this knowledge/experience base. To help them do so, teachers should draw out participants' experience and knowledge that is relevant to the topic. They must relate theories and concepts to the participants and recognize the value of experience in learning.

Page 11

TRAINING AND TRAINER REQUIREMENTS AND READINESS
Adults are goal-oriented. Upon enrolling in a course, they usually know what goal they want to attain. They, therefore, appreciate an educational program that is organized and has clearly defined elements. Instructors must show participants how this class will help them attain their goals. This classification of goals and course objectives must be done early in the course.

Adults are relevancy-oriented. They must see a reason for learning something. Learning has to be applicable to their work or other responsibilities to be of value to them. Therefore, instructors must identify objectives for adult participants before the course begins. This means, also, that theories and concepts must be related to a setting familiar to participants. This need can be fulfilled by letting participants choose projects that reflect their own interests.

Adults are practical, focusing on the aspects of a lesson most useful to them in their work. They may not be interested in knowledge for its own sake. Instructors must tell participants explicitly how the lesson will be useful to them on the job.

As do all learners, adults need to be shown respect. Instructors must acknowledge the wealth of experiences that adult participants bring to the classroom. These adults should be treated as equals in experience and knowledge and allowed to voice their opinions freely in class."6

Additional resources on adult learning techniques are available online. It is recommended that all facilitators thoroughly review material on this subject matter prior to conducting adult training courses.

KEY POINT TO REMEMBER:
In constructing a course for adults it is important to remember that adults have different learning styles. Participants will learn more effectively if the course incorporates activities that address all learning styles.

Page 12

Training on Cultural Proficiency
It takes an experienced and skilled trainer to facilitate cultural proficiency training. A qualified trainer should have the following competencies and internal characteristics:

Self-awareness of own biases, beliefs, assumptions and stereotypes.
Ability to model making mistakes, owning them and moving on.
Presentation and facilitation skills. Cultural proficiency training is not for beginning or inexperienced trainers.
Training skills necessary for successful cultural proficiency trainers include:
delivery skills to clearly and concisely offer needed information
use of questioning to elicit information from participants
facilitation skills to manage and lead a group through controversial discussions
listening skills to allow participants to safely express their feelings and thoughts
group management skills to handle difficult participants and situations and maintain a safe environment
conflict management skills to summarize, to find consensus and refocus the group on the task

Training knowledge and experience including the use of adult learning theory, knowledge of how multiple intelligences impact learning and the impact of behavior change theory on groups.

Subject matter expertise including: knowledge of the impact of values, beliefs and cultural practices on service delivery; awareness and acceptance that significant differences may exist between people of different cultures and within cultural groups; how his or her own culture influences actions; and awareness of different meanings that behaviors may have within different cultures.

Awareness that every organization has its own culture (which may or may not support the organization's vision, mission, values and goals), and that there may exist different cultures between management and line staff, as a result of professional degrees, expertise, roles and responsibilities.

Page 13

Recommendations for Best Practice

Use open-ended questions
Most of the activities include many open-ended questions for you to ask the participants. Asking open-ended questions in the training is very important for two reasons:

It models for the participants a critical skill in developing cultural proficiency.
It engages the participants and involves them as active learners.

You will need to rehearse the open-ended questions so thoroughly that the asking of them in the training appears spontaneous and natural. The questions indicated in the activities are by no means the only questions you can ask; you should also develop your own list of questions and spontaneously ask others as they occur
to you.

Use co-trainers to present each workshop
Cultural proficiency training should be presented by a minimum of two experienced trainers for these reasons:

Co-training brings diversity to the workshop and expands the range of skills and experiences that can be
used throughout the training.

Different people respond to different personalities and training styles.

While one trainer is leading an activity, the other can observe for potential issues or problems, which can
allow both trainers to address the issue before it develops.

Co-facilitation models powerful allied relationships.

Co-trainers must be able to:

Share with each other expectations, personal limitations and preferences in handling tough situations.

Offer total and unconditional support of each other; when one is leading an activity, the other serves as
support. Do not contradict each other in front of a group.

Debrief each session; provide each other with specific, behavior-based feedback and appreciations. 7

Page 14

Allow a minimum of one and a half days for training of all staff
We recommend that you allow for a minimum of one and a half days for training on cultural proficiency. Less than this does not allow participants to develop the trust and comfort levels needed to engage in the skills-building activities. We strongly encourage additional training for managers, as they have greater opportunities to influence others and instigate needed changes in their organizations. At a minimum, they should attend a one-day training with staff and continue with a minimum of a half-day training designed to help them address issues specific to their positions.

Limit the participant group size
Limit the group size to provide a safe environment for participants to honestly explore their own and others' values and knowledge and skills. Ideally, we recommend small groups of 15-30 participants. If, however, you must have a larger number of participants it is recommended that the course be co-facilitated with 3-4 co-trainers.

Know and plan how to handle difficult participants
In any training the potential exists for conflict or controversy and just opening the door to the particular topic of cultural proficiency prompts strong feelings for many participants. Frequently, when someone presents as "difficult," it is when s/he is experiencing strong feelings; keeping this in mind can help you to keep your cool and not get caught up in the feelings. It is important to remember to treat all participants with respect; if necessary, take a quick break in the agenda to allow participants and yourself to calm down.

KEY POINTS TO REMEMBER:

Instructors need to put their egos aside and not be afraid to have their ideas and instruction challenged.
Don't be afraid to give up control.

Make the environment comfortable and leave time for breaks (include a break or exercise every
60-90 minutes at a minimum).
Page 15

Getting Started

So you have your training location, you have reviewed the material and now are ready to jump in. Before you do, there are just a few things left to do.

Physical Space
Consider the training that you will be conducting. Make sure that the physical space allows the interaction needed for each participant to get the most out of the workshop. This may require you to rearrange a few items, but once you have, the training will go much smoother. Some things to consider:

Is the seating arrangement conducive to group discussion and small group work?

Is there enough open space for exercises and games?

Materials
Make sure that all materials are copied, prepared and set out for you and the participants to use. Always make sure you have extra pens and paper for use by the participants. A good motto is "it's better to be over-prepared than under-prepared." If you are planning on using newsprint or a flipchart, which is done a lot in this curriculum, consider purchasing newsprint that sticks to the wall; you can use the wall to display the group ground rules and other pertinent information that will be referred to throughout the entirety of the course.

What to Expect
Throughout the following workshop, participants will be given opportunities to explore their own culture and will be asked to examine their internal assumptions and biases that impact their interactions with others. It is important to expect that participants will express a wide variety of emotions; they may get angry, upset or withdrawn. As a trainer, it is important to recognize these reactions and acknowledge the difficulties that the group is having.

KEY POINT TO REMEMBER:
Ground rules should be well covered with participants in this workshop. Given the content of this workshop, participants may have a tendency to forget the ground rules if they become emotional. It is recommended that you remind participants of the ground rules throughout the course — remember to do so in a respectful manner!

Page 16

SAMPLE: Training Agenda At-a-Glance
SAMPLE: Training Agenda At-a-Glance
DAY ONE ACTIVITY
8:15-8:30 am Registration
8:30-9:30 am Introductions and Expectations
9:30-9:45 am Group Agreement
9:45-10:45 am What is Diversity?
10:45-11:00 am BREAK
11:00-12:00 pm What is Cultural Proficiency?
12:00-1:15 pm LUNCH
1:15-2:15 pm Communication Skills for Cultural Proficiency
2:15-3:00 pm Cultural Influences on Healthcare
3:00-3:15 pm BREAK
3:15-4:15 pm Stereotyping and Assumptions
4:15-4:30 pm Final Questions, Thoughts, Concerns
4:30 pm End of Day One

DAY TWO ACTIVITY
8:15-8:45 am Welcome Back Icebreaker
8:45-9:45 am Negotiating and Supporting Change
9:45-10:00 am BREAK
10:00-11:00 am Collaboration Bead Toss
11:00-11:45 am Training Transfer
11:45-12:00 pm Questions and Answers/Evaluations/Adjourn

Page 17

EXERCISE: Individual Introduction

Purpose
To promote individual involvement and investment in the training
To introduce participants to each other
To create a sense of belonging and familiarity

Time Required
Varies between 15-45 minutes

Materials
None needed

Process
This exercise is useful for encouraging participants to open up and share early in the training session.
It may be helpful for the facilitator to participate in this activity to begin building a relationship with the
group as well as to provide an example.
Ask everyone to take out (or off) a personal object that represents something about themselves.
Give them a few minutes to think about what they are going to say.
Ask the participants to introduce themselves one by one and explain why they chose what they chose
as a symbol.
Ask participants what they learned about themselves and one another. Point out how creative they were
with their responses.
Ask them how this creativity can be put to work in this training.

EXAMPLE:
"This is my wallet and it's overstuffed with papers, notes, cards and other junk. As a TB program manager, like my wallet, I'm overstuffed. I have a million little details to oversee and lots of staff with lots of problems and I'm feeling a little overwhelmed."

Page 18

EXERCISE: Identify Course Expectations

Purpose
To clearly establish expectations for what will and will not be accomplished in the training session.

Time Required
30 minutes

Materials
Newsprint/Flipchart
Markers
Handout "How to Get the Most from This Workshop"

Preparation
Write the following on newsprint: "What do you hope to gain from this course?"

Process
Identifying participant expectations:
Ask participants to take a moment to think about what they hope to gain from attending this course.
Acknowledge that some participants may have chosen to attend voluntarily and others may have been sent
by a supervisor.
Depending on group size, you may ask all participants to respond or you may just invite input from the
group at large.
Ask participants to respond to the question and write their input on newsprint.
Compare the answers on newsprint to your agenda and objectives for the session.
Point out which topics or areas of interest will be addressed and which will not.
Handout "How to Get the Most from This Workshop" (pg. 22). Give participants a few minutes to review it
and ask any questions they might have.

NOTE:
If you did not have participants wearing nametags you may want them to reintroduce themselves during this exercise. Ask everyone to restate their name and answer the question above.

If you have obtained input from the participants on the pre-registration form and have planned your training based on it, their answers should be similar to your agenda. However, there will undoubtedly be some topics that were not included and should be addressed. Offer appropriate resources for those topics not covered.

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PARTICIPANT TAKE HOME POINTS:
Cultural proficiency is a highly complex and challenging area. There are no simple answers and becoming
culturally proficient is a never-ending journey.

We believe that the best use of our very limited time together is to focus on how to learn about cultural
proficiency, so that we can all be prepared to leave here ready to continue learning.

We will not attempt to cover everything we need to know about every culture; rather we will focus on
learning skills that can be used throughout all facets of TB work and life.

"The only kind of learning which significantly influences behavior is self-discovered or self-appropriated learning—truth that has been assimilated in experience." - Carl Roger 8

Page 20

Summary of How to Get the Most from This Workshop

This is a unique opportunity, so take advantage of every minute. You will have a number of opportunities to really get involved. That may mean taking some risks and doing some things that are new for you. Do yourself a favor, and immerse yourself as much and as often as you can.

Some final suggestions...

If you are typically a person who speaks a lot in a group, count to ten and listen before you speak.

If you are typically a person who does not speak much in a group, speak up. Take responsibility for your own
participation in the group.

Listen to each other.

Practice giving solid, specific appreciations to everyone. This is a real skill to be developed, and takes
constant practice.

Ask for help if you need it. Assume that all of your questions and needs are important to the group.

Speak your mind. Be candid. Don't "save up" concerns or problems until the very end.

Welcome and learn from your mistakes. Forgive others' mistakes quickly and cleanly.

Resolve conflicts when they arise, with whom they arise.

Don't complain about anyone. Don't criticize anyone. Ask yourself: What can I learn from this?
What's going on for me that I have a need to complain? How can I take more effective leadership?
How can I be a better ally to this person?

Distinguish your own feelings from your own clear thinking. Both are important and it's important to know
from which mode you're operating. Take care of yourself. You probably need to pay special attention to
yourself if:
- You have a headache or stomachache;
- You feel like you're holding back tears;
- You feel angry; or
- You want to critique the workshop rather than immerse yourself in it.

Be totally loving to yourself; this means no self-criticism. Remind yourself often that you're a terrific human being.12

Page 21

EXERCISE: Setting Group Ground Rules

Purpose
To clearly establish expectations for participant behavior throughout the course.

Time Required
15 minutes

Materials
None needed

Preparation
Write the following on newsprint: "Group Agreement"

Process
Setting group ground rules

Ask participants to think about what kind of behavior from others will make this the best possible
learning environment.

Invite participants to call out what they can promise for their own behavior throughout the day, as well
as what they would like from others. If the group has trouble getting started, it may help to offer some of
the following:

- Participate at your level of comfort; it's okay to "pass"
- Honor confidentiality
- Be on time after breaks
- Speak one at a time
- Ask questions
- Respect opinions that conflict with my opinions/beliefs, etc.

NOTE:
You should have minimum ground rules in mind and offer them if participants do not, but it's best to have more of the ideas come from the group than you.

List all input.

Ask the group to look over the list and reflect on these expectations.

Ask:
- Do we need to revisit or clarify any?
- Are we all comfortable with these? If not, how can we change this rule so that it's okay?
- Post group agreement in a spot visible to most participants.
Page 22

A note about language usage:
Tell the group that the final and shared expectation to cover is that of language. We all have preferences
about terminology and names and it's helpful to establish up front what we will agree to use.
Ask participants: What are some terms that you have strong feelings about that you'd like to advocate.
Answers may focus on ethnic group names, such as "black" versus "African American" or may be about
medical jargon versus "street" language or "patients" versus "clients." When there is clear consensus about
preferences, agree to use those. When there is not, ask if it would be acceptable to alternate terms.

PARTICIPANT TAKE HOME POINTS:
Cultural proficiency is a very difficult subject that often elicits extreme emotions in people.

It is important that we create an environment where participants are comfortable in sharing personal
experiences and stories as well as their true emotions regarding the activities by setting the expectations
from each of the participants.

According to Stephen Lieb, "there are four critical elements of learning that must be addressed to ensure that participants learn. These elements are: 1.) Motivation 2.) Reinforcement 3.) Retention and 4.) Transference." 9

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EXERCISE: What is Diversity? What is Cultural Proficiency?

Part I: Defining Diversity

Purpose
This activity gives the participants an opportunity to realize the dimensions of diversity by examining their own identity and diversity of the group.

Time Required
20-30 minutes

Materials
Newsprint
Markers

Preparation
Practice the exercise on your own before the training.

Process
Ask participants to think for a moment about how they would describe themselves to a stranger. They can
use characteristics or qualities they were born with, e.g., male/female, Latino/White/African-American or
they could use roles they've chosen or otherwise have, e.g., husband/wife, outreach worker, brother/sister.
They can choose things they like to do or skills they have, e.g., weight lifter, reader, etc. Ask them to write
these descriptors down on a blank sheet of paper.

Give them a few minutes to complete their list. Then ask them to get into groups of 3 - 4 and to share a few
of their characteristics. Give the groups about 5 minutes to share.

Ask: Looking at your descriptors, which ones are the most central to who you are? Choose the top 2, and call
them out. As they call them out, write them on newsprint.

Lead discussion by asking the following questions:
- How did you decide which characteristic is most central to you?
- Was it the same 5, 10, 20 years ago?
- Do you think it will be the same in 5, 10, 20 years?
- What do you feel are the advantages and disadvantages of being who you are in your personal life?
In your professional life?
- How many of you have experienced discrimination, stereotyping, oppression, prejudices based on
your most central characteristic?

What does this tell you? Point out that pride and pain is often experienced around the same characteristic.

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PARTICIPANT TAKE HOME POINTS:
Culture and diversity are not just about race and ethnicity but also gender, age, sexual orientation, ability,
geography, class, religion, etc.

In short, we are all individuals who have many dimensions. When we see somebody and think "oh, she is
a Latina — I know about Latinas," we may be focusing entirely on the wrong thing. That she is Latina may be
less important to her than being a mother or being single or having a health concern or any other dimension
of her that we may not even be able to see.

Point out that cultural difference can be influenced by: sociopolitical factors, poverty, history of oppression,
experience of prejudice and racism, religious practices, family role and structure, and personal values and
attitudes.

All of these aspects of culture affect our healthcare in many ways. It can influence: description of symptoms,
communication about the symptoms, attribution of the source of the illness, attitudes toward helpers, and
expectations of treatment, plus many more.

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Part II: What Does it Mean to be Culturally Proficient?

Purpose
This activity gives the participants an opportunity to explore a model of diversity and cultural proficiency

Time Required
20 minutes

Materials:
Newsprint
Markers
Handout:
Cultural Proficiency: What is it? (pg. 36)

Preparation
Familiarize yourself with the following definitions (as shown on handout Cultural Proficiency: What is it?
pg. 36):

Knowledge comes from deliberately seeking out information regarding the worldviews of different cultures,
keeping in mind our broad definition of "culture." This also means developing and maintaining a solid
knowledge base about biological variations, diseases and health conditions, and variations in
drug metabolism found among ethnic groups (biocultural ecology). Finally, this means being aware of
institutionalized racism and other "isms" within our culture and our profession.

Self-awareness is an ongoing process, of examining our own biases towards other cultures and exploring
our own cultural, personal, social, and professional background. This awareness also involves being aware of
the existence of documented discrimination in our culture, including healthcare delivery.

Skills include effective cross-cultural communication skills as well as the ability to conduct a cultural
assessment to collect relevant cultural data regarding the client's presenting problem as well as accurately
conducting a culturally-based physical assessment.

Note that we'll spend more time on all of these through the rest of the training, but this is a useful model to keep in mind and have as a framework.

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Process
Ask the group to think about a time when they had a positive experience with someone from a culture very
different from their own. This could have been in a health care setting or a personal experience.

Ask: What made this experience so positive? What kinds of knowledge, attitudes, and/or skills did the people
in this experience demonstrate?

Write list on newsprint. The list could include things like:
- Open to learn about each other
- Interested and positive attitudes
- Willing to take risks
- Don't make assumptions
- Listen
- Ask questions
- Had some basic knowledge about the others' culture
- Forgave mistakes

Point out how much on the list has to do with attitudes, not expertise or special skill sets.

Point out that all of us in the room obviously know a great deal already about what it takes to be
culturally proficient.

Give everyone the handout Cultural Proficiency: What is it? (pg. 36).

Provide the following explanation of the handout using the notes below.

Knowledge comes from deliberately seeking out information regarding the worldviews of different cultures,
keeping in mind our broad definition of "culture." This also means developing and maintaining a solid
knowledge base about biological variations, diseases and health conditions, and variations in drug
metabolism found among ethnic groups (biocultural ecology). Finally, this means being aware of
institutionalized racism and other "isms" within our culture and our profession.

Self-awareness is an ongoing process, of examining our own biases towards other cultures and exploring
our own cultural, personal, social, and professional background. This awareness also involves being aware of
the existence of documented discrimination in our culture, including healthcare delivery.

Skills include effective cross-cultural communication skills as well as the ability to conduct a cultural
assessment to collect relevant cultural data regarding the client's presenting problem as well as accurately
conducting a culturally-based physical assessment.

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Note that we'll spend more time on all of these through the rest of the training, but this is a useful model to keep in mind and have as a framework.

Read the following quote (and/or show on PowerPoint slide): Cultural proficiency is when providers and systems seek to do more than provide unbiased care as they value the positive role culture can play in a person's health and well-being. —National Alliance for Hispanic Health, 2001

Ask: What would it take to truly value the positive role culture can play? It may sound easy, but think about
what this really looks like on a busy day! Lead a brief discussion, eliciting or making the following points:

- We can only continue on this ongoing (never-ending) journey involving head, hands and heart by
deliberately seeking out interactions with individuals who are different from us.

- This means sometimes we'll be uncomfortable. Sometimes we'll make mistakes and will cause "rubs."
Sometimes we'll be "rubbed."

- We have to practice forgiveness – of ourselves and others. It also helps to assume good intentions.

- We have to find some part of us - in our hearts - that truly wants to know, to have awareness and to be
skilled in being with people who are different from us.

- No one said this would be easy.

Return to their list of proficiencies on newsprint. Ask the participants to pick three proficiencies that they
want to pay more attention to in their daily work. Invite them to write down their three proficiencies on
the handout.

PARTICIPANT TAKE HOME POINTS:
We have now explored the $10,000 question, "What is Cultural Proficiency?" This does not mean that this question is answered and settled. This means that during this course we will continue to discuss subjects and practice skills related to delivering health and human services in a culturally proficient manner.

Point out that this is not something you can learn overnight.

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Part III: Cultural Influences on Healthcare

Purpose
This activity gives the participants an opportunity to examine some different ways people approach health care and to explore some attributes and skills helpful in cross-cultural experiences

Time Required
45 minutes

Materials
Handouts:
Cultural Dynamics Influencing the Clinical Encounter
My Pen (2)
Kleinman's Tool
Cross-cultural Communication

Preparation
Write the following questions on newsprint:
Is your client's perspective more medical model or traditional? How can you tell?
How might this perspective impact your client's access to and use of healthcare?
How might knowing this about your client impact how you provide services?
How can you approach this client with courage, curiosity and creativity?

Process
Hand out Cultural Dynamics Influencing the Clinical Encounter (pg.37 )

Explain to the group that culture influences beliefs and patterns of behavior, including behavior and beliefs
about health care.

Emphasize that we need to be careful to not stereotype based on these differences, but this may be a useful
way to explain some differences that we see among our clients and their families.

Ask participants to look over the handout. Point out that these are characteristics, and are not meant to
limit anyone. Rather, these may be ways in which we can look at some differences in values and
communication styles.

Discuss by asking the following questions:
- Do you see yourselves here?
- How many of you find yourselves completely in one column?
- What about your organizations?
- Are you in the same column in your professional and private settings?
- How about your clients? Can you think of someone who is completely one or the other?
- Even if we see ourselves and our clients as a little bit of both, what happens if we tend more toward one
side and our client and coworker tends toward the other?
- Which items do you think are particularly likely to cause conflict?

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Provide the following lecturette in your own words:

While this handout focuses on a number of different characteristics, one way to sum up the differences is to
look at them as an appreciation of independence vs. interdependence. What this is really about is people's sense
of self.

In non-Western cultures, a person's view of him/herself has a great deal to do with how s/he is in relation to others. Some examples of this: in Hispanic cultures, the notion of simpatico - the idea of respecting and sharing others' feelings; in Japan, the word for self is jibun, which refers to "one's share of the shared life space"; a highly valued Chinese virtue is jen, which implies a person's capability to interact with fellow human beings in a sincere, polite, and decent fashion. Looking outside of ethnic groups, we can also see this value of interdependence. Psychologist Jean Baker Miller has said, "For many women, the threat of disruption of connections is perceived not just as a loss of relationship, but as something closer to a total loss of self."

Our American society on the whole, however, places a higher value on independence; thus the notions of "pulling yourself up by the bootstraps," and the appreciation for a "self-made man." Given that many of the clients we see may come from a cultural construct with a higher value on interdependence, coupled with the fact that our clinics and agencies function within a culture which places a higher value on independence, what implications does this have for how we provide services, and for how our services are perceived and accepted by clients?

Some specific areas where we can anticipate conflict are: choice, making changes, making decisions. The American way is to place a very high value on an individual having choices, making changes in one's life, and making one's own independent decisions. A person with a high value on interdependence might see this entirely differently.

Everything depends on the situation, the relationships and a sense of accountability to others.

Our focus in health care is often on encouraging people to make decisions that are "good for them," that will result in bettering their personal health. For someone from a culture with a high value on interdependence, this may mean less to them than making a decision that will result in a closer relationship, or will enable them to be more like someone else, or will allow them to defer to someone they hold in esteem, or a combination of all of these motives.

In brief, what this can mean for providers is a very high level of frustration, frustration with clients, with themselves, and with the system. This frequently results in feeling that there must be something wrong with us, or with the client.

Tell the group they're going to get a chance to experience what it can be like to have different perspectives.
Form pairs and tell each to find a pen and place it between them.

Hand out the two different versions of the My Pen handout (pg. 38-39), one for each person.

Instruct the partners to read their handout carefully and learn it (they are not supposed to read while
engaged in the conversation with their partner). They should reflect on the pen between them as they read.

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When they have finished reading tell them to put their paper aside and start communicating about the pen
(based on the handout they were given). They should use their imagination and their own words in a mutual
exchange of thoughts, feelings and concerns. Give them 2-3 minutes.

Ask everyone to stop communicating and to write down on their worksheet what their partners told them
about the pen. What was her perspective on the pen? What was her relationship with the pen? Give them
2 minutes.

Now tell the partners to share their perspectives and their understandings of their partner's perspective.
Give them 5 minutes to talk about what they have just experienced.

Process this activity by asking questions like:
- What did you experience?
- How many of you actually found out what your partner's perspective was?
- Was it easy or difficult?
- What assumptions did you make?
- Did you have any communication breakdowns during the conversation?
- What can you take with you from this activity?

Tell participants that they can share their sheets.

Ask: In our dealings with clients, how can we tell what their perspectives about their health and about
health care are? We can ask questions! Point out the handout Kleinman's Tool (pg. 40) and give
participants a few moments to read this.

Ask: How many of you ask questions like this of your clients? When you do, what do you learn from
and about them? What would it be like to ask such questions?

Give everyone the handout Cross-cultural Communication (pg. 41). Point out that the group has
mentioned and practiced a number of attributes that can help ease cross-cultural communication and
increase cross-cultural understanding. These attributes can be summed up by the three words courage,
curiosity, and creativity.

Ask: How many of you have you ever been in a cross-cultural situation where you were misunderstood
or misunderstood someone else? What was that like? Ask for one or two stories.

Ask: How many of you have ever been in a cross-cultural situation that might have been a real clash, but
instead, really clicked? Ask for one or two stories. Listen for, and point out and affirm any specific
examples of courage, curiosity, and creativity.

Ask the rest of the group: From hearing these stories, and reflecting on your own situations, think

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about: Did you have the courage to engage in further communication? Enough curiosity to ask?
Enough creativity to imagine another way of thinking (even about pens!)?

Break the group into smaller groups of 4-5 people each. Assign half of the groups to one of the clients
from below, and assign the other client to the other half. (Note: you can either write the descriptions of
the clients on newsprint, or copy them on paper, or simply read them aloud.)

Ask the groups to discuss their client and to answer the questions that you wrote on newsprint:
- Is your client's perspective more a medical model or traditional? How can you tell?
- How might this perspective impact your client's access to and use of health care?
- How might knowing this about your client impact how you provide services?
- How can you approach this client with courage, curiosity and creativity?

They should plan to report back to the full group.

Client Descriptions:
You're a field worker making a home visit. Your client greets you at the door, and you explain to her that
she needs DOT. She tells you that she needs to ask her husband first.

You're a field worker making a home visit. The door is answered by a male, who invites you to come in
and be seated. Several women come into the room and sit down. None makes eye contact with you; all
are veiled. You recognize your client among them.

Ask: Who has ever had an experience where there has been a culture clash? This might just be
something you observed, or an interaction you were part of. Invite 2-3 examples. Pick one example and
ask the whole group: How do you suppose most of us would feel in this situation? (People may say
things like: frustrated, inadequate, helpless, hopeless, and angry). List on newsprint.

Tell the group that you are going to ask them to do something that is very difficult, but important.

Ask them to sit quietly, and if they're comfortable, to close their eyes or at least to look down at their
laps. Ask them to imagine that they're with a client, and let themselves feel the feelings we just
described ... frustrated, helpless, and critical. Ask them to be with those feelings for a while. After

seconds, tell them to stop. Tell them to immediately allow themselves to feel the opposite, to imagine
they're with that same client, only this time they're feeling open, accepting, and caring. Stop them after
30 seconds.

Process by asking the following questions:
- How long was the second episode compared to the first?
- What was it like to hold the negative feelings for you?
- How about the more open feelings?

Point out that when we expect others to behave according to our values and they don't, these are the

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kinds of feelings we have, the kind of messages we're sending, whether we're aware of it or not. The
client, or co-worker, who is the recipient of these messages, may not even know that this is how we
feel, although they probably will sense something. However, the impact of these negative thoughts on
us is very strong. When we have negative thoughts or feelings about a client, we experience physical
stress and tension.

To have such thoughts and feelings is human! Our challenge is not to try not to have them, but simply
to notice them. We can think to ourselves, "Hmmm, that's interesting. I'm aware of thinking ______; I
wonder what that's about?" We can be curious about ourselves.

Ask: What would it be like to continually send this second set of messages while we were with clients?
Is that possible? Why or why not?

PARTICIPANT TAKE HOME POINTS:
Some people believe that only two feeling states exist: love and fear. If we're not feeling love, we're feeling fear. (Love is Letting Go of Fear, Gerry Jampolsky)

Even if you don't agree with that theory, it is an interesting perspective. Play with it.

Much of what we've been discussing points out the importance of not making assumptions about what is important to someone, but to ask questions and find out. We can then tailor our messages to that which is important to them, not to what we think should be important. And when we can do all of this with an open, accepting, caring countenance it makes our own lives easier, too!

We can apply courage, curiosity, and creativity to ourselves, as well as to others! Instead of wanting to believe we're "just fine," we can have the courage to look honestly at our own stereotypes and assumptions. Instead of judging ourselves, we can have the curiosity to explore where some of our stereotypes and assumptions may have come from. Instead of giving up on changing, we can creatively seek new ways to think about ourselves as well as others.

"The ultimate test of a man is not where he stands in moments of comfort and moments of convenience, but where he stands in moments of challenge and moments of controversy." Martin Luther King10

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Page 34

Cultural Proficiency: What is it?

(Head) Knowledge
Comes from deliberately seeking out information regarding the worldviews of different cultures; keeping in mind our broad definition of "culture." This also means developing and maintaining a solid knowledge base about biological variations, diseases and health conditions and variations in drug metabolism found among ethnic groups (biocultural ecology). Finally, this means being aware of institutionalized racism and other "isms" within our culture and our profession.

(Hands) Skills
Includes effective cross-cultural communication skills as well as the ability to conduct a cultural assessment to collect relevant cultural data regarding the client's presenting problem as well as accurately conducting a culturally-based physical assessment.

(Heart) Self-Awareness
Is an ongoing process of examining our own biases towards other cultures and exploring our own cultural, personal, social and professional background. This awareness also involves being conscious of the existence of documented discrimination in our culture, including in healthcare delivery.

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Cultural Dynamics Influencing the Clinical Encounter 13

Traditional Cultures

Core Health Beliefs and Practices
Health is a state of harmony within body, mind, and spirit.
Seeks medical system when in acute stage of illness.
Seeks herbalists, midwives, santiguadoras, curanderos, priests, shamans, espiritistas, voodoo priests, etc.
Disease prevention not a recognized concept.
Family is the focus of decision-making.
Food used to restore imbalances (hot/cold; yin/yang).
Belief of origin of disease is possibly inorganic (curse, god, hex, etc.).

Value Placed on Interdependence
Values collectivism: reliance on other and group acceptance.
Values interdependence with family and community.
Individual interests are subordinate to family needs.
Reliance on nuclear and extended family networks.

Communication Styles
Greeting on first-name basis denotes disrespect.
Being direct denotes conflict.
Eye contact is considered disrespectful.
Close personal space builds rapport.
Gestures have taboo meanings depending on cultural subgroups.

Other Cultural Values, Norms, Customs
Values respect for authority and elderly status.
Fate controls environment and destiny.
Present oriented: here and now.
Efficiency; time is flexible.

Medical Model

Core Health Beliefs and Practices
Health is absence of disease.
Seeks medical system to prevent disease and treat illness.
Seeks specialty practitioners (physicians, nurses, psychiatrists, surgeons, etc.).
Prevention is used to avoid disease in future.
Individual is the focus of healthcare decision-making.
Food used to affect biological functioning.
Belief of origin of disease is mostly bio-medical (bacteria, virus, etc)

Value Placed on Independence
Values individualism: focus on self-reliance and autonomy.
Values independence and freedom.
Individual interests are valued and encouraged.
Reliance on nuclear family bonds.

Communication Styles
Greeting on first name basis denotes informality to build rapport.
Being direct avoids miscommunication.
Eye contact signifies respect and attentiveness.
Personal distance denotes professionalism and objectivity.
Gestures have universal meaning.

Other Cultural Values, Norms, Customs
Values youth over elderly status.
Personal control over environment and destiny.
Future oriented.
Efficiency; time is important; tardiness viewed as impolite.

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My Pen

My pen is very dear to me.

I don't want anyone else touching my pen.

My pen has been in our family for generations, it was passed on to me by my mother and to her by her mother.

My pen is a female.

I carry my pen around because it gives me strength.

Sometimes I ask my pen for advice. And I can hear the voice of my mother or grandmother when the pen is answering.

My partner's pen is:

My Pen

My pen is very inexpensive.

I use it for writing or someone else uses it.

In fact I lose my pens all the time. It doesn't upset me because I also take pens from others. Sometimes I buy a whole box of pens, so I have some extras.

The only problem with my pen is that it never seems to be around when I need it. Or it doesn't work any longer.

Another problem is that my child wants my pens all the time and I think they can be dangerous. I don't like it when my child draws all over things, either.

When I think about it this little thing can be very troublesome.

My partner's pen is:

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Kleinman's Tool to Elicit Health Beliefs in Clinical Encounters 15

Eliciting health beliefs is another tool that can be used when working with other cultures. This method is designed to elicit beliefs a patient has about their condition, the cause of their condition and the cure. Eliciting health beliefs provides insight into a patient's perspective.

Questions:
What do you call your problem? What name does it have?
What do you think caused your problem?
Why do you think it started when it did?
What does your sickness do to you? How does it work?
How severe is it? Will it have a short or long course?
What do you fear most about your disorder?
What are the chief problems that your sickness has caused for you?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from the treatment?
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Cross Cultural Communication14

Effective cross cultural communication takes skills such as:

Asking open ended questions:
"How...?" "Who...?" "What...?" "When...?" "Why...?"

Affirming:
"Great question ... Good point ..."

Listening for feelings, restating and using your partner's language:
"Seems like that's pretty scary..."
"I heard you say you need to discuss this with your family first..."

Being present.

But it also takes:

Courage:
The effective cross-cultural communicator ...
is present
takes risks
tries to lower his/her defenses

Curiosity:
The effective cross-cultural communicator ...
has a flexible mind and an open heart
approaches others with a desire to learn
is willing to accept alternative perspectives

Creativity:
The effective cross-cultural communicator...
attempts to understand the world from the others' points of view
tolerates ambiguity well
practices a variety of communication styles

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EXERCISE: Communication Skills for Cultural Proficiency

Purpose
To identify and practice using skills which ease cross-cultural communication and increase cross-cultural understanding.

Time Required
45-60 minutes

Materials
Newsprint
Markers
Handout Working with Interpreters: guide to working with interpreters in health service settings (pg. 47)

Preparation
Familiarize yourself with the handout Working with Interpreters: guide to working with interpreters in health service settings (pg. 47)

Process
The Skills (10-15 minutes)
Tell the group we're going to look at four specific communication skills that we can use in any situation that help us work with clients in a culturally proficient way.

NOTE:
Communication skills may be a review for some participants. Acknowledge their experiences and have them assist you in providing examples of each skill.

The first skill is Affirming

Ask: What does "affirming" mean? The first, most important and simple thing you can do for others is to offer your support. This is unbelievably simple, yet most of us forget to do it!

Demonstrate: What are some examples?
"That's good."
"I'm glad you asked that."
"You've come to the right place."
"That's a good question."
"You're on the right track."
"You really seem to given this a lot of thought."

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The second skill is Open-ended questions.

Ask: What is an open-ended question? Open-ended questions are questions that can't be answered by "yes" or "no." Why are they useful? We get much more information from people when participants "own" the information they're learning; powerful teaching tool.

Demonstrate: Ask for a volunteer to think of their favorite color. Ask a series of closed questions: Is your favorite color pink? Lime green? Black? Red? After several of these, ask the group: What should I ask her? (What's your favorite color?)

Ask: What are some examples of open questions? As participants come up with questions, if they ask a closed question, simply answer "yes" or "no" and move on. When they come up with open questions, write the first word on newsprint, until you have the following list:

When Where How Who Why Tell me more ...

Ask: How would you change each of the following questions into open-ended questions? Do you plan to take your TB medications? (What do you think about your TB medication? When was the last time you took your medication? What would it be like to talk with your family about taking the TB medication?)


The third skill is Listening.

The Chinese character for listen contains the sub characters one heart, eye and ear, all of which we must use to truly listen. So it's not just about hearing; it's also using our eyes to observe their non-verbal behavior and our heart to clue us in on any feelings.

Ask: What are some feelings that clients might have? List on newsprint; the list could include any feeling, including: sad, angry, relieved, grateful, frustrated, etc.

Tell the group: One thing that's really simple and really effective is to just name the feeling, by saying something like, "you seem upset/frustrated/sad, etc."

Ask: Why does this work? We let the person know it's okay to have feelings; we give permission to express them and often to let them go, so he can hear the information he came to get.

Why is it hard to do?! It's too simple. We tend to want to "fix" it if someone is having uncomfortable feelings, and in fact, by simply naming the feeling, it does help that person to let go and move on.

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"Seems like that's pretty scary..."

Another thing that shows we're listening is to simply restate what the client says:
"I heard you say you need to discuss this with your family first ..."

The final skill is Being present.

Ask: What do we mean by this? Being present means several things: we're really paying attention (using our eyes, ears and heart as in listening) to the other person; we're making observations, paying attention to not only what they say, but how they say it, how they're using their body to communicate; and we're paying attention to their environment.

Ask the group: What are some things that you have learned from paying attention to your clients' environment, for example, doing a home visit?

EXAMPLE #1:
A caseworker goes to a new client's home. The client tells the caseworker that she lives alone. The caseworker had already noticed the name on the mailbox is not the same as her clients. She also sees a large pair of men's work boots inside the door, as well as some photos of her client, a man and two children.

EXAMPLE #2:
A caseworker visits a new client and notices a large aloe vera plant outside the front door. When he goes inside the house, he sees an altar in one corner, with Virgin of Guadalupe candles and statues of saints.

Point out that a single item may not tell us much, but taking note of many details may help us to paint a more complete picture. In the examples above, we still don't know that the client lives with a man, but we have some disjointed information (between what she tells us and what we see) and we can follow up on this. Likewise, the aloe vera plant outside the second client's house doesn't prove she practices traditional medicine, but the additional clue of the altar gives us more reason to be curious about her health beliefs and practices, and to try to learn more from her before we charge in with recommendations.

Ask: What else does it mean to "Be Present"? Being present means paying attention to our own thoughts and feelings and if they're not helpful, setting them aside. Being present means really being in the moment, in the present tense, not the future - thinking ahead about what we're going to say next - or the past. Being present means gathering data (information) about the person in front of us, not assuming this person is like anyone else.

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Practice (20-25 minutes)

Tell the group they're going to get to practice using these skills. They'll get to work with 2 other people and everyone gets only one turn being the staff person, being a client and being an observer. The observer will give feedback. (Note: if any participants do not work directly with clients, ask them to think of another staff member they may have a communication challenge with or other situation that is real for them.)

Ask: How do you feel when someone says to you, "I have some feedback for you!" While sometimes we feel nervous getting feedback, it helps to remember it is truly a gift. Feedback that's most helpful is specific and behavioral. Instead of simply saying, "that was great" we can say, "I liked how you ..." and describe what the person said and did. The more specific the feedback the better!

Create groups of three (3) with a variety of professions in each group, e.g. TB nurse, outreach case workers, administrators, etc.

Ask the participants to think about a specific situation or client that they dread the most, or that they're a little nervous or uncomfortable with ... an angry client/co-worker, giving positive test results, a client who denies
any risk ...

Tell the participants that they'll each get a turn describing their situation to the others.

Here's how it will work:
When it's your turn, describe your situation to the others in your group.
You will play yourself; ask another person to play the client (for supervisors it could be a staff person)
The third person will be the observer Act out your situation for a few minutes, then stop and discuss it.
How did it go? What worked? What are some other ways you might have handled it? Share ideas and
problem solve with the group.
Don't worry about getting it all just right, that's why we're all here – to learn from one another.
Each person should take about 5-7 minutes to describe the situation, act it out and discuss it. Then move on
to another person so everyone gets to share their story.

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The trainers can do a brief demonstration to show how the exercise works.

After the groups have finished (about 20 minutes), ask the full group to reconvene and process the experience by asking the following questions:
How was that?
What are some useful tips you learned?
Any ah-has?
What would it be like to do these kinds of practice sessions outside of training?
What would it be like to do these together informally?

Language (5-10 minutes)
Point out that one additional challenge we face in cross-cultural communication is ...language! We might be
the best communicator in the world, but if we simply speak two different languages, that's a barrier. So, it's
crucial that we know how to work effectively with interpreters.

Handout Working with Interpreters: guide to working with interpreters in health service settings (pg. 47) and
give the group a few minutes to look it over. As they read, ask them to see if they can identify at least one
thing on there that they (or their agency) are not already doing. Ask them to imagine what it would be like to
do that thing: who would have to agree to it? How could they make it happen?

Ask for general comments on the handout: what do you think about these recommendations?

PARTICIPANT TAKE HOME POINTS:
Remind the group that communication is important and very challenging, and most of us never had any
formal classes in it!

We're just expected to know how to communicate, from doing it all our lives. However communicating
effectively and cross-culturally takes continual practice and work.

Wrap up by reading the following quote:

"People don't get along because they fear each other. People fear each other because they don't know each other. They don't know each other because they have not properly communicated with each other." Martin Luther King 11

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Working with Interpreters:

Guide to working with interpreters in health service settings16

How can you tell if an interpreter is required, especially if the person can speak some English?
Some people can't communicate in English at all or will have such minimal English proficiency that the decision is obvious. Some will bring an 'I need an interpreter' card. However, if there is any doubt, here are some simple tests to help you make your decision.
Ask a question that requires the person to answer in a sentence. Avoid questions that can be answered with
a 'yes' or a 'no' or a very familiar question such as 'Where do you live?"
Ask the person to repeat a message that you have just given in his/her own words.

If you consider using an interpreter, arrange for one after discussing this with the patient/client. Remember the interpreter is there to enable you to do your job competently, not only for the client.

How do you identify which language the person speaks before requesting an interpreter?
Sometimes the language needed is conveyed to you in advance or the client brings a card naming the language required. However, you may need to seek this information out from the person or via an accompanying relative.

If possible, your agency should have the following statement translated into languages that your clients may speak or read: Please indicate which language you speak and we will try to obtain an interpreter to help us. Print this list and ask the person to point to the appropriate language.

How do you conduct face-to-face interviews with an interpreter present?
Before an interview
Arrange a place where the interview can be conducted in private.
Allow for extra time.
Arrange the seating to allow for easy communication: in a circle or triangle or place the interpreter to the
side and just behind you.
Brief the interpreter prior to the interview where possible.
Ask the interpreter for any cultural factors that may affect the interview, but remember that interpreters do
not consider themselves to be cultural experts.

During the interview
General pointers
Sit facing the patient/client.
Look at the person and maintain awareness of body language. Avoid looking at the interpreter unless you
are directly addressing him/her.
Speak directly to the patient/client as you would with an English speaker.
Always use the first person, e.g., "How are you feeling?" Not (to the interpreter) "Ask her how she is feeling?"
Don't try to save time by asking the interpreter to summarize.

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Be aware that it may take more words than you've spoken to convey the message.
Don't let the interpreter's presence change your role in the interview. It is not the interpreter's role to
conduct the interview.

Introduction and set up
Introduce yourself and the interpreter.
Explain both your and the interpreter's role.
Stress that both you and the interpreter are bound by codes of ethics to maintain the confidentiality of the
interview.
Explain the purpose of the interview and how it will proceed.

Interview style
Speak a little more slowly than usual in your normal speaking tone. Speaking louder doesn't help.
Use plain English where possible.
Pause after 2 or 3 sentences to allow the interpreter to relay the message.
Stop speaking when the interpreter signals by raising a hand or starting to interpret.
Summarize periodically when complex issues are involved.
If the person does not understand, it is your responsibility (not the interpreter's) to explain more simply.
Seek the client's permission if you need to obtain cultural information from the interpreter.
Avoid long discussions with the interpreter. If you need to talk to the interpreter directly tell the client that
you're going to do so, what you're going to discuss and why and have the interpreter translate that to
the client.

Ending the interview
Check that the client has understood the key messages in your interview. Ask for any questions.
Thank both the client and the interpreter. Say good-bye formally.
Debrief the interpreter if the interview was emotionally taxing and clarify any questions you have arising
from the interview. This may need to happen later as it may make the patient/client uncomfortable if you are
seen to be in detailed conversation with the interpreter.

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EXERCISE: Stereotypes and Assumptions

Purpose
Participants have an opportunity to examine what stereotyping is and explore the effects that stereotyping can have on interactions with others.

Time Required
45 minutes

Materials
Handout "The Story of Jack"

Process
Ask the group to get into smaller groups of 3-5 people.

Give each group a copy of the handout "The Story of Jack." Ask them to choose one person in their group
to be the reader. This person will read aloud one part of the story at a time and the group will discuss some
questions after each part of the story before moving on.

Give the groups about 15 minutes to complete the entire story. As they work, circulate through the room to
be sure they're stopping and discussing each part of the story before moving on.

After the groups have all completed the story and discussions, read the following:

Jack had sexual contact with Tasha who is a transgendered person. Jack met Lorena in the Philippines and
married her over 20 years ago. They have only had one child, Giana, who recently befriended a young Nigerian
woman who has undiagnosed active TB.

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EXERCISE: Stereotypes and Assumptions
Process the activity by asking:
- What was the process like?
- How easy/hard is it to make assumptions for each person–the Filipina women, the Nigerian woman, the
transgendered person, the teenager, the corporate executive?
- Why do you suppose this is?
- Are assumptions ever useful?
- How many of you have heard of an assumption used about a group you belong to?
- What was that like?
- What feelings did you have?
- What can we learn from these feelings?

PARTICIPANT TAKE HOME POINTS:
Wrap up the activity by acknowledging that making assumptions is a normal part of being human and is one
way that we make sense out of our world. However, assumptions can also prevent us from getting to know
the human behind the stereotype.

It is a good idea to pay attention to our assumptions and to let ourselves be curious about the assumptions
we make, and why and when we make them.

It is a good idea to pay attention to whether our assumptions are helping us in our interactions with others,
or if they're actually getting in our way.

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The Story of Jack

Background
Jack, a 55 year-old former telephone company executive, has been disabled for over a year due to a work-related back injury. During this time his marriage has become more strained as he spends more time around the house and the frequency of verbal arguments between him and his foreign-born wife, Lorena, has increased. Lorena had LTBI when she first came to the U.S. with Jack. She has also been experiencing health difficulties, but has dismissed them because she believes it is related to her and Jack's arguing. She often berates him saying "he is lazy and meddling" because he is interfering with her and her daughter's lifestyle. Giana, his 15 year-old daughter, is American-born and is close to him emotionally, but lately she seems to have pulled back. Because Giana has recently become sexually active, Lorena and she have visited the local birth control clinic. Since he is home now, he notices more things about them and the home environment. To keep the peace, he has been sleeping in the garage-apartment at night, but finds himself depressed and alone. During the past several months he has been frequenting a late night bar called the "Round-Up" where he met "Tasha." Tasha has been under medical care the past year for an undisclosed medical issue. She likes Jack because he is financially stable and because he is of European descent and she is sure he is "clean."

Discussion questions:
What do you know, think or assume about each of the characters: Jack, Lorena, Giana and Tasha?
What do you know about their healthcare beliefs, practices or access to healthcare?

Presenting Problem
Clinician Interview
Jack came into the city clinic complaining of an infection during urination. The clinician notices he is also having difficulty breathing and Jack acknowledges that he felt weaker than normal and is coughing a lot - probably due to sleeping in the garage apartment. The primary care physician confers that it is probably an allergic reaction to mold in the garage apartment.

During the medical assessment, Jack confides that he has found a "girlfriend" that he likes to hang out with at a bar, but he's pretty certain he got something from Tasha. Also, he was very close to a gay-male friend who recently died after a long bout with AIDS. He visited him every day at the hospital. "Tasha" was a mutual friend of theirs and helps him remember "John." The clinician ordered routine STD screening services and recommended a chest x-ray.

During this initial visit, Jack's chest x-ray shows left lower lobe consolidation and he was diagnosed with drug-susceptible pulmonary TB and was placed on first-line anti-TB drugs. A TB interview and Direct Observation Therapy were assigned to an outreach worker (OW). He was also treated for Chlamydia trachomatis and referred to a Disease Intervention Specialist for additional partner contact tracing.

Discussion questions:
What assumptions might the clinician, the outreach worker or the disease intervention specialist have about Jack's healthcare beliefs, practices or access to healthcare?

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THE STORY OF JACK
TB Outreach Worker (OW)
Within a day the OW conducts the initial home visit and Jack's wife, Lorena, answers the door and aggressively asks why the OW wants to speak to Jack. After some skillful communication, the OW convinces the wife to call for Jack. Jack emerges from the garage apartment looking hesitant and worried. Alone, the OW explains the importance of the therapy, potential side effects and need for adherence. Jack is compliant but expresses concern about where or how he could have been exposed. He is reluctant to discuss his "other life." The OW stresses the importance of contacting additional partners whom may have been exposed to TB.

Discussion questions:
What communication skills would be helpful for the OW to use?
What are some open-ended questions he could ask Jack?
What are some affirming statements he could make?
What feelings might Jack be having and how could the OW elicit them?

 

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EXERCISE: Negotiating and Supporting Change

Purpose
This activity allows participants to identify stages clients go through in the change process and to plan how they can support clients in a culturally sensitive way.

Time Required
45-60 minutes

Materials
Newsprint
Markers
Handout "Supporting Others Through Change"

Preparation
Prior to session, write each of the six stages of change (see "Supporting Others Through Change" handout)
on sheets of newsprint (one per sheet). Post the newsprint around the room or across one wall.

Copy the Scenarios page and cut up so that each client is on a separate slip of paper.

Write on newsprint:
- What stage do you think this client is in? Why?
- What feelings might this client be experiencing? How would you invite the client to name the feeling(s)?
- What questions would you ask?
- What other issues does this raise for you?

 

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Process
Ask: Why do we do what we do? More specifically, why don't our patients take their TB treatment as
prescribed? What are their barriers? Many need to change entrenched behaviors to complete treatment
(perhaps participants can give examples of barriers to treatment completion such as alcohol abuse.) The end
result (we hope) is that our patients will change their behavior and comply with treatment without having to
use legal enforcement. So understanding how people change behavior can help TB healthcare providers be
more effective.

Ask participants: Think about a change you have made at some point in your life – could be anything, losing
weight, quitting smoking, flossing, etc. Think about how you made this change; how long it took; what
helped; what didn't; etc.

Ask: What did it take for you to make this change? Note: they do not have to identify what the change is, just
what helped them make the change. Write list on newsprint.

Point out that it's obvious from this that we all know that making changes is complicated, and is a process, involving several steps or stages, rather than a single, one-time event. Tell the group that what we've just been talking about is a change process. In recent years, lots of research has been done about what it takes for people to make significant changes in their lives and there are many theories about this. One of these theories is called the Trans-Theoretical Model, also known more simply as Stages of Change. In fancy language this theory describes what we've just been talking about ... in making a change, people go through phases or stages.

Handout "Supporting Others through Change." Briefly and in your own words, go over the six stages.
Emphasize that they don't necessarily happen in just that order and people can move back and forth from
stage to stage. There's also no given time for each one; people travel through these at their own pace and in
their own way.

Ask: How understanding that change is a process and that each individual must move through these stages
in their own way, at their own pace, help us in our work with our clients?

As much as we want to "convince" people to move from one stage into another, it's really up to them. However, we can support them in whatever stage they're in.

NOTE:
If no one goes to a stage, be prepared to represent that stage yourself. Pre-contemplation is the most likely stage to not be represented.

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Ask everyone to think about a change that they're now in the process of making. Ask them to think about
what stage they're in: it could be any stage. Tell them they do not have to share with others what this change
is. Point out the signs on the walls with the six stages. Ask them to get up and go to the sign for the stage
they think they're in.

When everyone has chosen a stage, show the newsprint you prepared with these questions:
- How does it feel to be in this stage?
- What can other people say that would be supportive?

Ask them to talk about these questions and to plan to report back briefly. If anyone is at a stage alone, check in with him/her.

Give the groups approximately 5 minutes and then have them (or individual) report back on their stage,
answering both questions. After all have gone, ask: Is there anything that all stages have in common?
Ask: What are some of the differences between stages?

Refer back to the handout, "Supporting Others with Change." Look at the specific examples of things we can
say and do to someone in each stage. How similar are these suggestions to what we came up with?

Point out that some stages are ready for more encouragement than others. Some stages, especially
precontemplation, contemplation and relapse really need gentle treatment and support, because people in
those stages are likely to be hard on themselves and/or not really ready to make changes. The important
thing in those stages is to keep the door open so the person will come back to us when they're ready for
advice or suggestions.

Tell the group they're now going to get to apply this to some real clients. Break the group into six smaller
groups and give each group one of the scenarios (see below). Tell them they have about 10 minutes to
discuss their client and answer the questions you wrote earlier on newsprint:
- What stage do you think this client is in? Why?
- What feelings might this client be experiencing? How would you invite the client to name the feeling(s)?
- What questions would you ask?
- What other issues does this raise for you?

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They should plan to report back to the full group on their answers to these questions.

Key to correct answers for the trainer
Client A = Contemplation
Client B = Relapse
Client C = Precontemplation
Client D = Action
Client E = Preparation
Client F = Maintenance

After 10 minutes, have each group report on their client by sharing their answers to the questions.

After all groups have reported, ask:
- How easy or difficult was it to decide what stage the client was in?
- How did knowing the stage impact how you would respond to them?
- How will you use this with your real-life clients?

PARTICIPANT TAKE HOME POINTS:
Remind participants that what we know about clients also holds true for ourselves. That is, change is
incremental, and we need to acknowledge and reward small steps. We and other staff members need time
and patience and support to implement changes.

This process is also true for organizations! This model can be very helpful in looking at organizational change
and can help us to diagnose where we are, and to move forward.

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SCENARIOS
- COPY THIS PAGE AND CUT IT UP SO THAT EACH CLIENT IS ON A SEPARATE PIECE OF PAPER -

Client A
We had been sharing the same smoking paraphernalia even though I noticed he had been coughing. I just assumed he smoked too much. I know I need to cut back on pot smoking, but he is the only close friend I have and this is something we always first do when we see each other. I just do not know how I would change things without having to give up this way of relating, but I guess I'll have to think about it.

 

Client B
I started taking the medications and I felt so much better that I decided not to take them anymore. The drugs themselves scared me and it's just easier not to take them. I know I should; they told me to keep taking them regardless. I was doing so well too. I'm just a screw-up, I can't do anything right.

 

Client C
What does this have to do with me? I thought TB was an older person's disease? Why should I be concerned? I'm healthy and do not take high risks. I can hardly take vitamin pills much less TB drugs on a daily basis.

Why, if I had TB I'd just kill myself. I'm already HIV positive and going to die sooner than later. I couldn't imagine having two infections.

 

Client D
I talked to Jack about not smoking pot and instead doing activities together that were more outdoors oriented. I know he's shy about being in social places with other people, so this is something we can still do together, but that's a lot healthier. We tried it a couple of times and it seems to be working.

 

Client E
I tried imagining having a conversation with my friend about sharing smoking paraphernalia, but then I could just see him look at me as if I were better than him or judging him. I know I need to choose friends who live healthier lifestyles. Maybe I could cut back on my own smoking habit to weekends only.

 

Client F
I started feeling sick when taking my meds, but remembered the clinician told me that I might get sick before I got better. Even though they make me sick, taking them helps me feel like I have some control, like maybe I am poisoning the bacteria itself. I'm going to keep on taking the meds.

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Supporting Others Through Change

One model we can use to understand better how we deal with change is the Trans-Theoretical Model (TTM), otherwise known as the Stages of Change model.17 This theory proposes that we typically progress through stages as we incorporate a new behavior, attitude or skill into our lives. We can identify at what stage a colleague; client, family member or friend is in and offer support to help them move forward.

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EXERCISE: Collaboration Bead Toss
EXERCISE: Collaboration Bead Toss

Purpose
This activity allows participants to identify and discuss skills needed to build and foster community partnerships.

Time Required
35-45 minutes

Materials
40 Mardi Gras bead necklaces
3 large, heavy cans (e.g., 24-oz tomatoes)
Empty space (i.e., no tables and chairs) in the meeting room: minimum 20 ft by 30 ft.
3-4 prizes

Preparation
Place a 6-foot length of masking tape on the floor in the empty space of the meeting room, leaving enough
room behind it for up to four players to line up. This will be the Starting Line.
Place one can 10 feet from the Starting Line. Place another c

Process
Point out that regardless of what "specialty" of public health we work in, we need to work with other partners
who work in other specialty areas. Tell the group they're going to play a game to explore some skills required
for partnership work.

Ask for 6-8 volunteers. Ask the volunteers to line up in two rows of 3-4 participants per row. Tell them that
each row represents a community or town. Each person within the row (or town) represents a different
human service organization. Ask them to imagine there's a funder who can only provide funds to one of
these towns. The town that gets the most points will get the funding.

Tell the teams that they'll get to win points by tossing Mardi Gras beads over the cans. The cans represent
behavioral outcomes with farthest placed cans representing sustained long-term behavior change (30
points, each successful toss) the middle cans representing intermediate behavior change (20 points, each
successful toss) and the closest cans representing short-term behavior change accomplished (10 points,
each successful toss).

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EXERCISE: Collaboration Bead Toss
Read the rules to the teams:
- Tosser's feet may not cross the Start Line.
- Tosser may collaborate with team members or other class participants for consultation and/or assistance.
- Team may not change their strategy once they have agreed upon it.

Allow each team a practice round, with no points awarded. Each person on the team should practice.
Give them two minutes, then call "Stop!"

Ask each team to designate a "Tosser."

Begin Round One: Give the teams two minutes to toss as many beads as they want to. Call time after two minutes,
and tally up the scores (if any). Tell them they're going to get another chance, but this time you'd like them to
spend one minute conferring in their teams before beginning. You may also want to reread the rules to them.
Give them one minute, and then begin Round Two. Give them two minutes, making sure they follow the rules.

NOTE:
As long as the rules are followed, anything goes. For example, team members besides the "tosser" can walk onto the playing field, or lay down on the floor. The only exception is that the team MUST keep their original plan after seeing what the other teams do.

As the teams are competing, ask the other participants about their observations about preparation, tossing style,
evaluation methods, creative use of resources, teamwork, leadership, etc. (e.g., "what do you notice about how
she's changed her approach?" etc.)

After two minutes, call time and tally up the points.

Lead a round of applause for the winning team. Give them fake money or candy. Ask everyone to return to
their seats.

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Process by asking the following questions:
- What were the winning team's secrets to success?
- How did things change from Round One to Round Two?
- What importance does collaboration have in cultural proficiency?

Example:
Collaboration is a huge piece of cultural proficiency. We can't expect to know everything about all communities, but when we reach out to a community and work with community members and local agencies, we are better able to serve our clients and gain insight into the nuances of each community.

Who are some partners that you could/should partner with to be culturally proficient, but don't at this time?
What are some benefits to partnerships? List on newsprint.
What are some challenges to partnerships? List.

PARTICIPANT TAKE HOME POINTS:
Point out that partnering takes high-level skills, much attention and hard work. However, the potential
richness and benefits of this would seem to make it worthwhile.

Partnering happens on a community level, and can also apply to your relationships within your work teams,
with funders and even with your clients.

Cultural proficiency can be gained by working with community organizations and getting the input of
community members which will help you serve your clients more effectively and with more cultural
sensitivity.

Emphasize the importance of building partnerships, preparation and pre-planning, walking through
program implementation through the eyes of your client and stepping back and evaluating what you learn
and how to better your processes.

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EXERCISE: Training Transfer: Now What?

Purpose
This activity provides an opportunity for participants to:
- Reflect on where we've been and where they'd like to go.
- To practice using some specific skills which ease cross-cultural communication and increase
cross-cultural understanding.

Time Required
30 minutes

Materials
Index cards (1/ participant)
Newsprint / Flipchart
Markers

Often, when we attend a training event, we get wrapped up in the activities and enjoy ourselves and it's only when we get back home that we ask ourselves: "Now what?"

Process
Invite participants to reflect on the training.
Tell them to think about one thing they plan to do differently as a result of this workshop.
While they are thinking, hand out index cards.
Tell participants to write on the card the one thing they plan to do differently.
Let them know that they will be sharing this with one other person.
Have participants form pairs.
Tell participants to take turns sharing their plan with their partner.
When they are the listener, instead of giving advice or just listening, they are to challenge their partner about
the plan. They should do this by asking such questions as (write the questions on newsprint):
- What will you do first?
- When will you start?
- How will that work?
- What if ... ?
- Who will you tell about this?

Let participants know that it's okay to ask other questions, but the questions should be open-ended and
they should not give advice unless it is asked for.

Give 10-15 minutes. Check in after a few minutes to make sure both partners have a turn.

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Processing the activity:
How did it feel to be the listener and ask these kinds of questions? (Participants often report that they felt
nosy, pushy and too challenging. Without comment, ask the next question.)

How did it feel to be the teller? (People usually feel challenged in a very positive way, and really listened to
as the teller.) Point out the difference in experience, if this feels so good to the teller, why don't we overcome
our discomfort as listeners and do this more often anyway?

What would it be like to ask questions like this of our patients? Of our co-workers?

What stops us from asking these questions?

When would you ask these questions?

What do you think would happen?

Are there times and situations when these questions would truly be out of place? When and where?

Point out that cultural proficiency is about listening and finding out where people are instead of making
assumptions. When we don't ask questions because we feel "pushy" or "nosy," this is about our barriers, not
about a person from another culture finding these questions impolite. We can learn to trust others to let
us know, either verbally or non-verbally, if we truly are being too pushy. We can learn to trust our own good
judgment and communication skills to listen to others and respect their boundaries.

PARTICIPANT TAKE HOME POINTS:

Point out that this is a simple way we can show some loving support to others by really listening and gently
challenging, rather than giving advice. Often, when people tell us they're going to do something, we think
we're being supportive by saying, "good for you!" "Good for you" is nice, but not really very helpful.

In the same way, being "culturally proficiency" doesn't have to mean having sophisticated skills or vast
knowledge. It means showing loving support and really listening.

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Wrap-up

End training by thanking everyone for their participation, energy and ideas. Remind the group that this is an ongoing process and that we can all work together.

Ask everyone to complete their evaluations and complete any logistical or other business.

You may want to recommend that the group continue informally in their learning process on this subject through continued interaction with one another. Some suggestions include having the group:

Designate a team leader who will volunteer to arrange monthly or quarterly calls with the group.

Designate a volunteer to read an article, locate a helpful website, etc. and discuss his/her information on
the calls.

Designate volunteers to set up monthly emails that contain website links and other helpful information on
cultural proficiency.

If the group members are co-workers in the same office, recommend that they reconvene monthly during
the lunch hour to discuss new items or issues they have encountered. This is an opportunity to continue to
network and receive helpful advice from colleagues.

Set up a "chat" room on the web for the group to discuss issues.

Distribute a quarterly newsletter.

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Page 64

GLOSSARY

CLAS Standards are the collective set of culturally and linguistically appropriate services (CLAS) mandates, guidelines and recommendations issued by the United States Department of Health and Human Services Office of Minority Health intended to inform, guide and facilitate required and recommended practices related to culturally and linguistically appropriate health services (National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH 2001).

Culture is the thoughts, actions, customs, beliefs and values of any racial, ethnic, religious or social group. Culture can include: dress, language, religion, rituals, norms of behavior and systems of beliefs.

Culturally and linguistically appropriate services healthcare services which are respectful and responsive to cultural and linguistic needs (National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH, 2001).

Cultural Proficiency a continual process in the development of an individual's and an organization's knowledge, skills and self awareness in relation to culturally diverse backgrounds.

Cultural awareness is defined as the process of conducting a self-examination of one's own biases towards other cultures and the in-depth exploration of one's cultural and professional background. Cultural awareness also involves being aware of the existence of documented racism in healthcare delivery.

Cultural knowledge is defined as the process in which the healthcare professional seeks and obtains a sound information base regarding the worldviews of different cultural and ethnic groups as well as biological variations, diseases and health conditions and variations in drug metabolism found among ethnic groups (biocultural ecology).

Cultural skill is the ability to conduct a cultural assessment to collect relevant cultural data regarding the client's presenting problem as well as accurately conducting a culturally-based physical assessment.

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REFERENCES

CDC. Reported tuberculosis in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human
Services, CDC; 2008

Institute of Medicine. Ending Neglect: The Elimination of Tuberculosis in the United States. Washington, DC:
Institute of Medicine, National Academy Press; 2000.

Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, et al. 2007. Patient Adherence to Tuberculosis
Treatment: A Systematic Review of Qualitative Research. PLoS Med 4(7): e238.

Health Disparities, Clinical Outcomes Retrieved November 2007, from http://erc.msh.org

The Providers Guide to Quality & Culture Retrieved November 2007, from http://erc.msh.org

Lieb, S. (Fall 1991). Principles of Adult Learning, Vision Retrieved November 14, 2007 from
http://adulted.about.com

Adapted from Barry Myles and Caroline Haskell, "Training: A Team Approach".

Retrieved November 2007, from http://adulted.about.com/od/icebreakers/a/quotations_2.htm

Lieb, S. (Fall 1991). Principles of Adult Learning, Vision Retrieved November 14, 2007 from
http://adulted.about.com

Retrieved November 2007 from http://quotations.about.com/od/stillmorefamouspeople/a/martinluther1.htm

Retrieved November 2007 from http://quotations.about.com/od/stillmorefamouspeople/a/martinluther1.htm

Adapted from Equity Institute.

PHYSICIAN TOOLKIT AND CURRICULUM, U. S. Department of Health and Human Services, Office of Minority
Health, March 2004.

Adapted from Lynch (1992) Developing Cross Cultural Competence.

Kleinman, A. (1981). Patients and Healers in the Context of Culture. The Regents of the University of California.
Retrieved June 14, 2006 from http://www.diversityrx.org/HTML/MOCPT3.htm

Queensland Health Retrieved February 27, 2006 from http://www.health.qld.gov.au/multicultural/pdf/
guideto.pdf

Dick J., Vander Walt H., Hoogendoorn L., Tobias B. (1996). Development of a health education booklet to enhance adherence to tuberculosis treatment Tuber Lung Dis 77: 173-177.

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ADDITIONAL RESOURCES

An extensive list of cultural proficiency resources is outlined in the "Cultural Proficiency and TB Care: A Manual for Self-Study and Self-Assessment" available through the New Jersey Medical School Global TB Institute. This manual can be obtained online at http://umdnj.edu/globaltb.

Additional related information and educational products can be obtained through the following sites:

Francis J. Curry National Tuberculosis Center
3180 18th Street, Suite 101
San Francisco, CA 94110-2028
(415) 502-4600 Main Phone
(415) 502-4620 Fax Number
Website: http://www.nationaltbcenter.edu
(A Training Toolkit is available through this Center. This is an excellent source of information on the logistical components of putting together a training workshop.)

Heartland National Tuberculosis Center (HNTC)
2303 S.E. Military Drive
San Antonio, TX 78223-3542
(800) 839-5864 Main Phone
(210) 531-4590 (Fax)
Website: http://www.heartlandntbc.org

New Jersey Medical School Global Tuberculosis Institute
225 Warren Street
Newark, NJ 07103
(973) 972-3270 Main Phone
(800) 482-3627 Toll Free
(973) 972-0979 Education and Training Department
Website: http://umdnj.edu/globaltb
(The self-study module "Cultural Proficiency and TB Care; A manual for self-study and self-assessment is available through this Center.)

Southeastern National Tuberculosis Center
1329 SW 16th Street
Room 5187
Gainesville, FL 32608
(352) 265-7682 Main Phone
(352) 265-7683 Fax
Website: http://sntc.medicine.ufl.edu
(Country-specific "snapshots" are available through this Center which provides culture specific information for several countries outside the U.S.)

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Beyond Diversity: A Journey to Cultural Proficiency