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

Chapter 6: Delivering a Cultural and Linguistic Competence Curriculum

The preceding chapters focused on the essential content of cultural and linguistic competence training for health professionals. This chapter suggests some basic pedagogical strategies for incorporating this content into curricula. It begins with a discussion about the theory of delivering a curriculum, and ends with practical examples from organizations that have put these theories into practice. Included are discussions about:

• developing faculty commitment
  
• providing a rationale for building cultural and linguistic professional competencies
  
• creating a developmental learning path
  
• integrating cultural and linguistic subject matter into basic and elective courses
  
• sample tools for delivering cultural and linguistic curricula

Specific areas of cultural and linguistic subject matter, such as health care disparities and cross-cultural communication skills, require special attention. Suggested methods for enhancing the delivery of a cultural and linguistic curriculum include bringing in outside expertise from other disciplines in the university and from the community. Some of the subject matter inherent in teaching cultural and linguistic competency can create emotional responses in students, requiring excellent facilitation skills on the part of faculty. Methods of dealing with such responses are briefly discussed.

The goal of a comprehensive cultural and linguistic competence focus within the Centers of Excellence is to give health professionals the skills and knowledge to care effectively for a diverse patient caseload and aid them in forming good therapeutic alliances with those patients. More important, however, such a curriculum should move students to embrace lifelong attitudes that allow them to learn from their diverse patients, to continue to seek new and developing information on health care disparities, and to practice their professions in such a way as to promote equity in health care. The students should leave their formal professional educations with a willingness and strong desire to pursue cultural and linguistic competence throughout their professional lives. In order to create this response at both affective and intellectual levels, cultural and linguistic competence curricula need to be lively, intellectually stimulating, and emotionally rewarding. It needs to be inserted in many ways throughout the course of the students’ studies and learning experiences.

Since many medical, nursing, dental, and pharmacy schools have been incorporating cultural and linguistic competency education into their curricula in the last decade, there is extensive literature on the topic (see Chapter 10, Resources). It would be useful for any group charged with integrating cultural and linguistic elements into a curriculum to systematically review these resources, many of which document successful and innovative strategies for incorporating cultural and linguistic materials into curricula. Review of the resources currently available also may help to identify experts willing to serve as consultants on program development or to train clinicians in specific areas.

I. Developing Faculty Commitment

There is probably no more important strategy for implementing cultural and linguistic competency education than having a broad-based, multidisciplinary cadre of committed, knowledgeable, and enthusiastic faculty dedicated to developing and including cultural and linguistic information in the curriculum. Students will grasp the importance of such information readily if faculty clearly and vigorously endorses it as an essential ingredient of professional training. Ideally, such faculty should represent every sub-discipline or specialty and the various ethnic, racial, and professional backgrounds.

The experience of such schools as the Medical College of Wisconsin in Milwaukee and the University of California San Francisco School of Medicine that have implemented cultural and linguistic competence training longitudinally into their curricula suggests that faculty development needs to precede the planning and implementation of the curricula. Faculty acceptance of the evidence-based need for integrating these materials into the coursework frequently requires a well-articulated rationale, a familiarity with the perspectives and content of cultural and linguistic competence training, some specific knowledge development for their specialties, and a good level of comfort with the techniques they can use for such training. Special stipends could be offered to educators who would develop courses in topics related to cultural and linguistic competency or who wish to become master teachers in the subject.

Some aspects of cultural and linguistic competence education, particularly those that deal with attitudes, prejudices, and biases, are sensitive and require more fully developed facilitation skills than are usually needed in lectures and course work. Educators should have initial and ongoing opportunities to develop these skills and deepen their understanding of the content areas of cultural and linguistic competency. Since such skills and understandings generally are not part of a faculty’s background, they should be given every opportunity, through workshops and cross-disciplinary discussions, to develop the necessary expertise. Some of the Web-based training modules listed in Chapter 11, Resources, could serve as the basis for discussion. Most are clinically oriented and are accompanied by materials that guide discussion. Training and workshops in facilitation techniques are widely available through university communications departments.

II. Providing a Rationale for Building Cultural and Linguistic Professional Competencies

Many students in the health care professions do not initially recognize the need for developing competencies in cultural and linguistic issues. Failing to see the relevance of such teaching, they, in fact, may at first resist the content areas and skills involved. Fortunately, there is strong evidence for these understandings as an essential aspect of providing quality patient care and an increasingly sophisticated discourse around the related issues. From the Institute of Medicine’s report, Unequal Treatment (2002), to the DHHS’ Culturally and Linguistically Appropriate Standards for Health care Organizations (Office of Minority Health, 2000) and the DHHS’ Office of Civil Rights Guidance on the Provision of Language Services, there is public and professional endorsement of these essential aspects of quality health care. At every opportunity, when issues relating to cultural and linguistic competence are addressed in the curriculum, educators should take care to link the issues directly to quality patient care and enhanced therapeutic alliances between health care professionals and their patients. Examples of statements in support of this linkage from numerous health care professional organizations are reviewed in Chapter 10, Resources.

There is widespread documentation of disparities in health care status and access across populations. Many professional and practice associations have explicit statements about the importance of addressing cultural differences and health care disparities. The American Association of Medical Colleges, the Accreditation of Graduate Medical Education, the American Medical Association, The American Dentistry Association, and the American Nurses Association, among others, have underscored the importance of this subject matter in the training of professionals. As part of their early training, students in the health care professions should be made aware of the support for such training, both within and outside their potential professions. Such early awareness of the importance of cultural and linguistic competency can form an initial rationale on which ongoing subject matter and experiential learning can consistently build through the students’ educational career. Educators can use the information in Chapter 11, Resources, Section I A and B, to begin a discussion of rationale and build the case. Many of the Websites listed in the Resources chapter, such as that of the Commonwealth Fund and the Kaiser Family Foundation, can provide ongoing and current statistical support for and policy discussions of cultural and linguistic competence issues in health care.

Finally, using census and other demographic data, educators can develop an understanding of the extensive changes in the cultural and linguistic characteristics of the U.S. population that have occurred as a result of alterations in immigration policy, refugee resettlement, and other social and economic factors. Often, examining data on population groups helps educators and students to understand the epidemiological patterns and health risk factors of various populations, information that is useful in developing the rationale for exploring cultural variation in belief and lifestyles. Whenever possible, detailed population characteristics of the immediate locale should be explored, either in lecture or as part of student assignments. These data can then form the basis for further exploration into the epidemiological implications for service delivery, community mapping, and community service.

III. Creating a Developmental Learning Path

Most professional schools that have successfully developed a cultural and linguistic competence focus within their curricula have recognized that multicultural content cannot and should not be taught in just one course or workshop, but needs to be reinforced in many different ways over the course of the students’ education. Integrating a cultural and linguistic competency focus into most aspects of health professional training requires thoughtful planning. It initially requires reviewing the existing curricula and identifying where this focus might be placed most advantageously to enhance the curriculum. The placement will vary in terms of the overall objectives for each level of training from pre-clinical to clinical to graduate education. It will be necessary to develop goals and objectives around cultural and linguistic competence in attitudes, knowledge, and skills in each level and segment of the curriculum.

In the area of patient-provider communication, for example, students should have an opportunity early in their education to explore how their own backgrounds have influenced attitudes toward health care and toward specific groups of patients. Ideally, students will come from varying cultural and linguistic backgrounds and then could express strong and highly divergent views on cross-cultural issues. It is important for students to recognize the effect of their cultures on their own emotional, social, and intellectual development. One of the best tools for increasing their understanding in this area is constructing a personal genogram such as that developed by Hardy and Laszloffy (1995). Students can be encouraged to discuss aspects of these “family trees” and the influences that have shaped their views. Moving forward with an enhanced understanding of the effect of culture in their lives, they can begin to explore and reflect on their own biases toward patients and patient care, and how these attitudes can impede or enhance good communication with patients. Significantly, such approaches help health care professionals understand the affective component of their approaches to their lives and their professions.

A. Attention to Disparities and Bias in Health care

Discussions focused on issues of racism, homophobia, prejudices, and biases of all kinds must be an intrinsic part of the curriculum. Early attention to these issues is important and should not be given cursory treatment. Cultural and linguistic competence experts are unanimous in their insistence that developing attitudes that are open and accepting of diversity and differences are an essential first step toward integrating the knowledge and skills necessary for cultural and linguistic competence. Addressing these subjects in depth always carries some risk, since students may be reluctant to discuss their biases, or even hostile when confronted with them. Skillfully facilitated classroom discussions, videos, and small group work, all in a safe, non-judgmental environment, are necessary in promoting the self-reflection needed to uncover and deal with bias and stereotyping. While careful attention to these issues should receive early attention in the curriculum, the faculty needs to be attentive to bias, prejudice, and stereotyping as they emerge throughout the curriculum or work with patients in the later stages of the students’ education.

Discussions about disparities in health care across racial and ethnic populations frequently produce various types of strong denial among students and health care professionals alike. However, the reality of these disparities is evidence-based. In Chapter 11, Resources, the section titled “Racial and Ethnic Issues in Health care Access and Delivery” provides many references that document this evidence. Additionally, the landmark IOM report, Unequal Treatment and its appendices include a comprehensive discussion of the reasons for inequalities in health care. Taken together, these publications provide rich discussion materials for an objective examination of racial and ethnic bias in health care. It is essential for a cultural and linguistic competence curriculum to include careful attention to these issues. It is also critical for educators to become familiar with this material in order to introduce it to students, integrate it into course work, and to lead reasoned discussions.

The issue of disparities in health status across populations should be given careful attention at several levels, and problems in the types of epidemiological and other currently available statistical data should be addressed. In the early stages of reviewing health statistics across populations, it would be helpful to review the data drawn from National samples, starting with the early data developed in the 1980s that showed a large discrepancy between the health of African-Americans and the rest of the U.S. population. This disparity continues to be problematic. Subsequent research, however, has revealed significant differences between the health status of the larger population and that of Latino, American Indians, and some Asians. Students can be asked to trace the historical patterns of health status within specific groups. An excellent exercise would be to have students create health profiles for different racial and ethnic groups. Reviewing these data will give students a sense of enduring disparities and developing issues relative to the health of different population groups.

When reviewing National data, it will be important to discuss problems in adequately interpreting these large data sets, most of which do not show important variation within groups such as that related to region, class, and specific culture. In most National data sets, for example, ethnic terms such as “Asian” and “Hispanic” are used as group identifiers. These labels include very different populations, such as Chinese, Korean, and Hmong; or Puerto Rican, Cuban-American, and Mexican-American under the same label. Such labeling masks important differences among groups in health status. Several sources of statistical data are available through the National Center for Health Statistics, the Office of Minority Health Resource Center, and MedlinePlus (see the Website section of Chapter 11, Resources). As students become more sophisticated in understanding epidemiological data, their research assignments and analyses can focus on data for discrete populations, such as those for specific Hispanic or American-Indian populations. Data from various regions also can be compared.

Further, faculty should be encouraged to review and discuss ethnic and racial health status data pertinent to the individual courses they teach. Data pertaining to racial and ethnic variation in relative risk, disease incidence, prevalence, severity, and treatment efficacy and modalities now exist in many, if not most, health disciplines and practice specialties. The bibliographies listed in Chapter 10, Resources, will be helpful in directing faculty and student attention to these data sources. Use of key word searches in Medline will unearth data related to specific populations. Students should be encouraged to hone their skills in using the search facilities of various databases to uncover data on specific populations.

B. The Need for Skills in Cross-Cultural Communication

Students should consistently be helped to understand how cultural and linguistic differences between a patient and a provider can influence communication, rapport, and treatment compliance. Such training can be initiated early as part of coursework in the fundamentals of patient care in medicine or nursing. Students can be taught to conduct a respectful, culturally sensitive clinical interview with a patient whose background is different from their own, beginning with role playing and progressing in later years to working a cultural focus into history taking and patient assessment. Instruction in how to conduct an interpreted encounter effectively would be an important aspect of training in patient-provider communication, as would information on how culture is reflected in different languages and communication styles. It will be important to create an understanding of how the students’ own language informs their perceptions, including the language of U.S. health care.

In later clerkships and preceptorships, students can sharpen their language skills and understanding in community settings with actual patients by doing assessments, taking histories, and completing diagnostic work-ups and care plans as they rotate through community clinics that serve diverse populations. Preceptors of diverse backgrounds can be recruited from community clinics in the surrounding locales. Students can develop culturally and linguistically appropriate diagnostic, treatment, and care plans with patients and their families (see the section on patient assessment tools in Chapter 11, Resources). At each step, they should be given an opportunity, through such activities as journal-keeping and small group discussion, to review issues of bias and record successful communication practices. Objective standardized clinical examinations or patient assessments can then include diverse patients and cross-cultural issues.

In the area of understanding disease and disorder processes, electives or required courses focused on special population groups could be offered to explore the epidemiology of diseases across population groups, as well as cultural practices and environmental factors that affect the differential health status of specific groups. These courses could be followed by such activities as cooperative community health projects that profile segments of the community and demonstrate an understanding of historic, cultural, and social factors such as immigration and acculturation that affect the health care of that segment. Students can work with community members, public health agents, and non-profit agencies to develop practical, culturally sensitive outreach, education, and prevention projects.
Integration of cultural and linguistic competencies should follow the movement from knowledge and theory to practical application that characterizes almost all education in the health professions.

IV. Integrating Cultural and Linguistic Subject Matter

Integrating a cultural and linguistic focus into existing coursework often depends on the instructor involved, meaning the whole faculty needs to be involved in the initial stages of curriculum development. Such integration requires subject matter expertise, knowledge of how subject-related information is applied in a clinical setting, and specific information on cultural and social issues as they apply to the subject matter or clinical work. Normally, all health care faculty demonstrate the first two requirements, and the last may require that they develop additional expertise, often through research into how cultural or linguistic factors affect their specialty. As previously mentioned, support for research and development of expert knowledge might be through stipends or funds to attend the several excellent conferences or workshops offered in cultural and linguistic competence in health care.

Fortunately, the literature on cultural factors in all specialties and aspects of health care has grown in the last two decades. There is extensive information on health beliefs and practices in many cultural groups; population epidemiology relative to specific diseases; disparities across groups with respect to diseases, risk, and protective factors; variation in acceptance and practice of illness prevention; ethnic pharmacology; cross-cultural pain management; death and dying issues; and much more. Information relative to specific cultural, ethnic, or racial groups as it applies to the subject matter can be integrated into lectures and grand rounds, diagnostics, and patient assessments. Examples, data, and information from a variety of cultures and cultural situations can be used to illustrate the key concepts and principles being taught in each course or practicum. Culturally or linguistically oriented case study examples, which are plentiful in the literature, can be used as the basis for class discussion or assigned to individual students for analysis. A number of mnemonic tools, such as LEARN, TRANSLATE, and ETHNIC have been developed to aid students in remembering cultural and linguistic competence precepts and concepts. These approaches are described in articles listed in Chapter 11, Resources (particularly Berlin and Fowkes, 1983; Levin, Like, and Gottlieb, 2000; Dobbie et al., 2003) and in Appendix A, The Toolbox.

The bibliographies listed in the final section of Chapter 11, Resources, contain cultural and linguistic competence references broken down into specialty areas. These resources can serve as a beginning point for research that can augment course offerings. Additionally, Medline, PsychInfo, and other databases in the social and behavioral sciences can identify emerging information on culture, ethnicity, race, and language in health care. Such databases can be useful in developing specialized bibliographies, research papers, and class presentations that can form the basis for student research assignments and in-depth class discussion in specific practice areas. Summer research opportunities focused on specific subjects or populations can be offered to students.

Research on cultural and linguistic competence issues can be organized and conducted by faculty members and presented in team-taught seminars or workshops. Some professional schools have hired research associates to organize, coordinate, and support faculty research projects. Others have sought external funding and developed research centers organized around research and specialized health services to specific racial or ethnic groups.

A. Using Experts from the Social, Linguistic, and Behavioral Sciences

Most large universities have anthropology, sociology, psychology, communications, and linguistics departments that can be tapped. Medical anthropologists, in particular, have frequently worked with medical and nursing schools in developing courses on culture and medicine, lecture series, and workshops for pre-clinical and clinical students. Some have done collaborative research in clinical or health care settings. Historically, these linguists have focused on the intersection of culture and disease. Many have studied the people of non-Western cultures who are now immigrating in large numbers to the United States. Medical sociology, a newer social science, is more focused on Western health systems and the social factors that affect those systems. Some linguistics departments may offer courses in translation and interpretation. Communications departments often have experts in cross-cultural communication. Many university public health departments have educators with expertise in specific ethnic and racial communities. Working with established professionals in these fields is useful in faculty development as well as in developing curriculum content and teaching modalities.

Having cross-cultural, cross-disciplinary teaching teams sends a strong, non-verbal message of respect for different cultures and diverse approaches to health problems. Professional schools that have done so have found that partnering with other campus schools and disciplines promotes significant institutional support and respect for their programs, and can facilitate opportunities for cross-disciplinary projects and outside funding for programs.

B. Use of Web-Based and Video Tools

Over the last few years, a number of organizations have developed two highly useful cultural and linguistic competence training modalities: interactive, Web-based modules and video tapes. These tools are almost all case-based, depicting patients in a wide variety of clinical settings. The Web-based, interactive modules are designed for health care professionals and cover specific objectives, require clinical decision making, and test students on their grasp of the material. These modules carry continuing medical education credit and could be used to augment classroom content or as the basis for small-group discussion.

The teaching videos currently available encompass a wide variety of clinically oriented subject matter. Among the topics covered are racism and heart disease, cultural barriers in patient-physician communication, learning to use face-to-face interpreters and telephonic interpretation in medical encounters, caring for gay adolescents, the effect of religious practices on hospital routines, dealing with HIV and sexually transmitted diseases in a cross-cultural context, and the effects of poverty and social factors on response to treatment.

In almost every case, the video materials are broken down into modules with accompanying contextual information and guides to facilitate discussion. This flexible modular approach facilitates the integration of 30- to 40-minute units that can be integrated into lectures in existing courses or used in groups that could comprise half-day workshops or seminars that incorporate other educational modalities. Often, the accompanying facilitator’s guides offer tips on how to conduct discussions about sensitive issues and provide sample questions to guide discussion.

C. Using Community Expertise and Student Community Immersion Strategies

Within most communities there are informal and traditional healer and healing modalities. Effort should be made to find local individuals who fill these roles and provide students with opportunities to hear their views on health care as it is viewed and practiced within the community. “Healers” can vary from grandmothers, herbalists, bone-setters, and traditional midwives to spiritual healers and funeral arrangers, to name just a few possibilities. Often, it is possible to arrange field trips to such places as Latino botanicas or traditional Chinese pharmacies to learn how patients are assessed and provided with medications and treatment regimens. Students can take this information back to the classroom or to clerkship discussions to analyze the similarities and differences in concepts of etiology and treatment as compared with bio-medical concepts.

Students can be assigned research projects that involve immersion in community health settings such as creating and analyzing a set of real life case studies drawn from their experience and observation of health care access, patient interviews, and interviews with health administrators, directors of programs, and case workers. Students can be assigned group projects, such as creating a community-based health resource directory for a specific population group or groups. They can design social marketing strategies for preventive health care activities involving diet, obesity, exercise, mammograms, diabetes, or prenatal care that take into consideration the needs and perspectives of specific local groups. Community “safety net” clinics offer multiple opportunities for clerkships that involve students in diverse communities.

Service learning programs, available at most universities, offer semi-structured opportunities for involvement in local non-profit agencies and clinics that could be particularly useful early in a student’s career. These programs help instructors integrate community work with classroom learning, usually involving limited and structured activities to help students reflect on what they are experiencing and how it relates to coursework.

Many health professional schools have worked with Area Health Education Centers (AHECs) to organize conferences and workshops focused on cultural and linguistic competence. Participation in these community-based events helps faculty and students develop expertise in aspects of cultural and linguistic competence through the eyes of persons working in community health care and local service agencies.

Numerous individuals in health care have developed focused workshops in both general and specific aspects of cultural and linguistic competence. Some of these are referenced in Chapter 11, Resources. Depending on their content and methods of delivery, these workshops can be used to begin self-exploration, become familiar with overall concepts in the field, or focus on a specific subject area, such as how to use interpreters or how to do culturally appropriate patient assessments. They provide a concentration that may be more intense and synergistic than other strategies simply because of the large block of time devoted to the subject matter.

Workshops given by outside experts are useful in presenting varied and fresh perspectives on issues in cultural and linguistic competence. They frequently involve well-paced developmental processes involving didactics, lectures, small-group work, interactive exercises, and video presentations, and can serve as models of strategies to use in addressing cultural information. They may cover a half-day, a whole day, or even several days. In selecting workshops, care must be taken to assess the expertise of the presenters, the content of the workshop, how it fits within the overall curriculum, and the timing of its integration into the curriculum. It is important that the presenter have expertise or knowledge of clinical settings and patient care, and can speak the language of the health care professionals to whom the education is directed.

On the other hand, half or full day workshops developed and presented by students and faculty result in a multifaceted, collaborative learning experience that can involve research, developing activities, accessing the community, and tapping student and faculty expertise. Such collaborative workshops can be integrated easily into ongoing cultural and linguistic approaches in the overall curriculum.

It is important to recognize, however, that no matter how well a workshop is planned and executed, it will not substitute for an overall, comprehensive and integrated developmental curriculum.

D. Elements of Risk and the Need for Strong Facilitation Skills

Addressing issues of personal bias, accountability in the area of health care disparities, and strongly held individual views and attitudes carries a number of risks, but it is essential work at each level of education in cultural and linguistic competence. Some frequent risks involve the expression of negative stereotypes, conflicting personal and political views held by members of classes and discussion groups, and reluctance to participate in, or disdain for, specific learning strategies, such as role playing and interactive exercises. These risks require practiced facilitation skills on the part of group leaders, instructors, and trainers, and it is helpful that training in facilitation skills be available to them.

The following outline of general facilitation skills that encourage student participation and exploration are adapted with permission from Teaching Skills and Cultural Competency: A Guide for Trainers, a manual published by the National MultiCultural Institute, in Washington, D.C., fourth edition, 2000. A review of the skills outlined here is not a substitute for interactive training in their use and application.

Practice active listening skills:

• Check for understanding often
  
• Paraphrase one’s understanding of what has been said and recap periodically
  
• Allow sufficient time to debrief adequately

Be sensitive to subtle cues and body language:

• Watch for glazed, unfocused eyes or a tendency to look away
  
• Notice grins, laughter, nods, or constant nodding
  
• Note facial expressions
  
• Note degree of body tension

Express oneself clearly:

• Organize one’s thoughts
  
• Avoid slang, idioms, and sarcasm
  
• Allow for individual differences and avoid stereotypes
  
• Recap periodically

Pose questions carefully:

• Ask open-ended questions
  
• Be careful about asking direct, private, or confrontational questions until a trusting relationship has developed
  
• Allow time for adequate processing of material and closure
  
• Ask clarifying questions

Consult with colleagues and participants for feedback on one’s facilitation skills. Be open to hearing honest feedback on areas that need improvement.

Creating a safe environment for discussions of discrimination, biases, difficult patient situations, and the emotional reactions to these discussions is not always easy. However, specific attention to group dynamics is useful. One of the most effective approaches is to have the group or class think through and agree on a set of norms to be followed in their large and small group discussions. These norms can be written, referred to when appropriate, and added to as needed.

Another helpful and critical procedure is to develop a glossary of terms and definitions to which all parties can agree. What, for example, is the difference between a stereotype and a generalization? What is a health care disparity? What definition of discrimination can the group agree on? Who are people of color? What is homophobia? What is racism? Who are the aged? What does the term minority mean in terms of the present U.S. population? What is homosexuality? What is feminism? Who are illegal immigrants? What does non-proficient in English mean? Defining such terms helps students and faculty to approach difficult subjects objectively, though the process may yield some emotional reactions and strong opinions. Group-produced definitions are important because they begin to yield common understandings and, at the same time, clarify variation around the meanings of terms as different individuals understand them. Definitions and meanings provide a safe first step in clarifying difficult concepts. Over time, it is useful to create a written group glossary of terms.

Although some pedagogical modalities may seem less risky in terms of potentially eliciting negative affective response or resistance from students, the potential for both reactions is present in many aspects of cultural and linguistic competence education. For example, a lecture and discussion on epidemiological variation in chronic lifestyle disease across ethnic and racial groups may appear to be about objective and clinically relevant data, but some students may respond to such data with a “blame the victim” reaction. While a discussion of cultural beliefs related to somatic disorders or herbal medicines may be meant to aid students in understanding and relating to persons from cultures different from their own, students may express their belief that such ideas are “primitive,” and so should be ignored. Watching videos may seem to be a safer approach to informing about cultural, social, and linguistic differences. However, the utility of videos usually lies in debriefing discussion about their content, and such discussion has the potential for revealing strong opinions and biases. The reality is that cultural and linguistic competence in health care is best promoted and developed through involved, rich, and continuing interactive dialog with educators, other students, and patients. Along with such discourse and dialog lies the potential for strongly held differences in opinion. Preparing educators and leaders for this potential is important and requires the development of good facilitation techniques.

V. Sample Tools for Delivering Cultural and Linguistic Curricula

An extensive number of specific tools developed to teach the attitudes, skills, and knowledge basic to cultural and linguistic competency curricula have been developed over the last decade as health care organizations and professional schools have worked to include this focus in their training. The Resources chapter provides references to many strategies used in these trainings as well as to useful videos and websites.

Appendix A, The Toolbox, also provides examples of pedagogical tools. Here we will give a quick sampling of the kinds of teaching tools that are available.

Among the tools that are useful when developing curriculum content are those specifically designed to help faculty and students increase their own self-awareness. Building awareness of the effects of one’s own culture on one’s behavior and of one’s biases is critically important to the success of a COE’s efforts to develop such curriculum content.

COEs can increase the self-awareness of staff and students about their personal cultural identity and their perspectives on differences through the use of cultural genogram exercises (see Appendix A, The Toolbox). They can increase awareness of their blind spots and comfort zones by exploring their community maps, and can explore similarities and differences that exist within and between ethnic groups by using the context grid (see Appendix A, The Toolbox). The context grid helps to highlight points of connection or similarities that exist among different cultural groups, and can be used with providers or patients to explore similarities and differences between the two. (See Appendix A for samples of the Cultural Genogram Exercise, Exploring One’s Own Community Map, and Context Grid, which are used by the Harvard Medical School in its course on self-awareness and cultural identity course.)

Next, tools that are useful in promoting understanding of how culture influences an individual’s beliefs and behaviors include using the Iceberg Metaphor or model to visually and conceptually describe culture as having both visible and invisible components, requiring the need for clinicians to explore hidden concepts, values, and norms guiding the responses and behaviors of their patients. Likewise, the diversity wheel is a visual tool often used by diversity instructors to help practitioners to understand the personal, cultural, and societal elements that contribute to patients’ diverse perspectives on health, illness, and health care.

• Many professionals are improving communication and helping to improve patient-centered care during cross-cultural clinical encounters by making use of the following mnemonic interviewing tools (see Appendix A, The Toolbox, for more information): LEARN (which stands for Listen, Explain, Acknowledge, Recommend, and Negotiate)
  
• ESFT (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, and Therapeutic contracting)
  
• ETHNIC (which is a framework for culturally competent clinical practice that stands for Explanation, Treatment, Healers, Intervention, and Collaboration
  
• BATHE (which is used for eliciting a patient’s psychosocial context and stands for Background, Affect, Trouble, Handling, and Empathy.
  
• ADHERE (is a mnemonic for improving patient adherence with therapeutic regimens, and stands for Acknowledge, Discuss, Handle, Evaluate, Recommend, and Empower.
  
• RESPECT (which stands for Respect, Explanatory model, Socio-cultural context, Power, Empathy, Concerns, and Therapeutic
  
• BELIEF (stands for health Beliefs, Explanation, Learn, Impact, Empathy, and Feelings)

One patient assessment tool that has been particularly useful to clinicians is often referred to as “Kleinman’s Nine Questions.” These questions were developed by Arthur Kleinman, M.D., M.A., a physician, anthropologist, and the Esther and Sidney Rabb professor and chair of the Department of Anthropology at Harvard University. He and his colleagues L. Eisenberg and B. Good listed the questions in an article, “Culture, Illness and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research,” in the Annals of Internal Medicine in 1978. The nine questions comprise an assessment designed to yield a patient’s cultural perspective on his or her illness. They are:

1. What do you think has caused your problem?
2. Why do you think it started when it did?
3. What does your sickness do to you; how does it work?
4. How severe is your sickness?
5. Will it have a short or long duration?
6. What kind of treatment should you receive?
7. What are the most important results you hope to receive from this treatment?
8. What are the chief problems your sickness has caused you?
9. What you do you fear about your sickness?

At some point, any effort involved in developing the content for a cultural and linguistic competency curriculum will address the need to work effectively with interpreters in providing care to patients with limited English proficiency by using the following tools (see Appendix A, The Toolbox, for more information):

• TRANSLATE is a mnemonic for working with health care interpreters and stands for Trust, Roles, Advocacy, Non-judgmental, Attitude, Setting, Language, Accuracy, Time, and Ethical issues
  
• INTERPRET is used when working with interpreters to obtaining a history from a patient with limited English proficiency. Of particular importance regarding INTERPRET is that this tool was developed by a COE. It stands for Introduction, Negotiation, Trust, Engagement, Room set-up, Patient-centered, Respect of cultural beliefs, Ethical considerations, and Time management. (See Appendix A, The Toolbox, Section III, for more information.).