To promote the development of culturally competent practice in outreach

The learning activities in this section are designed to engage participants with the subject material using informative and interactive approaches. Instructors will need to determine which, if not all, of these activities to carry out depending on a) participants’ learning needs and interests, b) the focus of the training, and c) time available.

Instructors are encouraged to prepare for each activity by reviewing the handouts to be given to participants and by reading the recommended resource papers and materials that are listed. These papers and materials, along with other relevant resources, will provide useful background information to assist in fulfilling the purpose of this section. The amount of time suggested for each activity should be adjusted as needed.

Below are some useful websites about cultural competency. You are encouraged to browse these sites for your own benefit and as preparation for the activities that follow in this section.

Purpose: To help participants connect issues of diversity and cultural competency with their own experience

Time: 20-25 minutes

Materials: None

Preparation:

Review the activity as described below. This is a relatively "safe" eye-opener for participants to help connect issues of diversity and cultural competency with their own experiences.

Procedure:

1. Ask participants to form pairs or small groups to identify and discuss the following questions:

1. Where did you grow up?

2. What other cultural groups and practices did you encounter – ethnic, race, class, sexual orientation, religious, etc.?

3. What messages were you given about people who were different – messages from family, from peers, from the media, and others?

4. How have your background experiences influenced your perceptions of other "cultures" that you encounter in your outreach work?

2. Reconvene as a large group and ask participants to think about a time when they experienced being or feeling "different" in a group of people – for example, from an ethnic, gender, class, political, religious, or other perspective. Then ask them to identify and share with the group what others did that helped or hindered them to feel more welcomed.

3. Summarize the helpful and the less than helpful strategies one might use when interacting with someone who is "different" in a given situation.

(Thanks to Jackie Green, diversity consultant from St. Louis, for the ideas from which this exercise is adapted.)

Purpose: To gain a clearer understanding of the cultural issue that cuts across every encounter with homeless people – what it means to live in extreme poverty

Time: 20 minutes

Materials: Flipchart and markers

Preparation:

There are myriad cultural differences workers will encounter in outreach. Perhaps the most fundamental of these is what it means to live in a "culture" of extreme poverty, of which homelessness is a manifestation. Many of us are culturally ignorant about living in poverty of any kind. Workers need to understand that the needs, the preoccupations, the barriers, the "rules of living" are often different when one has little or no money, resources, or social support.

This activity attempts to have participants walk in the shoes, if only for a few moments, of people living under the conditions of extreme poverty and thus increase our cultural understanding. This activity has commonality with activities in Module I "The Realities and Experience of Homelessness." It is suggested that you review that section in the curriculum as preparation for this particular activity.

Procedure:

1. Ask participants to take a few moments in silence to put themselves in the place of living under the following circumstances – wandering the streets in a bustling city, with no money, begging for food, seeking a place to urinate, inadequately dressed for the weather, in ill health, belonging to the poorest class/caste of society, etc. Acknowledge that this can be very difficult to do. Many of us need to keep a safe distance in our minds from even imagining ourselves in this situation.

2. After a brief period of silence, ask the group to think about and discuss the cultural differences between living in impoverishment and their own day-to-day existence. What "cultural" characteristics might result from living in extreme poverty that are different from your own (assuming you have adequate resources?) Urge participants to give specific examples in order to make it as real as possible.

Some possible concepts to explore: the experience and use of time, being "scheduled", personal vs. public space, weighing priorities between survival needs and other personal needs, identity, reputation, friendship, sexual and other intimacy needs, sense of belonging, the concept of leisure/play, concept of stability, trust, hope, notion of personal growth, planning for the future, loss, etc.

ACTIVITY 3 Becoming Culturally Competent Outreach Workers

Purpose: To define cultural competence and describe its key elements

Time: 25-30 minutes

Materials:

Handout: "Seven Domains of Cultural Competence"

Handout: "Becoming Culturally Competent Outreach Workers"

Preparation:

Every outreach encounter is cross-cultural, if for no other reason than the extreme poverty under which homeless people live. Often times the cross-cultural nature of these encounters cuts across many other axes in addition to economic and social class. In order to provide appropriate, compassionate, and effective outreach services, workers need to be attuned to the cultural differences and similarities that exist between they and their clients. It is hoped that the worker will celebrate the gifts that both difference and likeness brings, and will likewise work to overcome barriers to relationship and care that these cultural differences may sometimes represent.

In preparation for this activity, review the various definitions of cultural competence provided at the beginning of this section and read the statements below. In addition, read and reflect on the two handouts for this activity.

"Cultural competence begins with an honest desire not to allow biases to keep us from treating every individual with respect. It requires an honest assessment of our positive and negative assumptions about others. This is not easy - no one wants to admit that they suffer from cultural ignorance, or in the worst case, harbor negative stereotypes and prejudices. Learning to evaluate our own level of cultural competency must be part of our ongoing effort to provide better health care." Provider's Guide to Quality and Culture.

"One of the dangers in writing a guide to culture is that in trying to describe an  entire cultural group, a guide may create or reinforce stereotypes. It is important to  remember that diversity exists in every group of humans. In addition, people change  through acculturation and assimilation. We also must avoid jumping to conclusions. If a person wears traditional ethnic dress this may not mean that they lack English  language skills; or if a woman wears traditional clothing, one cannot assume that she  does not work outside the home. And the converse may be true of someone wearing  typical western clothing. We have to evaluate each person using a number of cultural  clues, and when in doubt, learn to ask questions in a culturally sensitive fashion. We  also have to be ready to reevaluate each individual as they undergo change."  (Hassoun, Rosina "Preface on Medical Anthropology: Anthropological Medicine" Guide  to Arab Culture: Health Care Delivery to the Arab American Community Authors: 1999).

Procedure:

1. Read aloud and discuss the definitions of cultural competence at the beginning of this section.

2. Go over the material in the handouts beginning with the "Seven Domains of Cultural Competence" followed by "Becoming Culturally Competent Outreach Workers." As you review various topics, raise questions that invite discussion. Below are several suggested questions to pursue:

• What are the seven domains of culturally competent practice? Can you give some specific illustrations for each domain from your perspective as an outreach worker?

• What are some of your "personal attitudes, beliefs, biases, and behaviors" that are likely to have a positive influence on your outreach?

• What are some possible "barriers to care" that you sometimes see in yourself, i.e. your own attitudes and actions, in addition to client, community and systems barriers?

• How would you define "cultural humility"?

• What is it about a "client-centered" approach that makes your outreach more likely to be culturally competent?

• What are some ways you can challenge various forms of prejudice and discrimination in your workplace? In your outreach work?

3. To conclude the activity, invite participants to consider taking a concrete "next step" on their journeys towards cultural competence. Suggest that they do this by choosing one of the seven domains on which they want to focus and then identifying a specific activity relevant to that domain to implement in the very near future. Have participants share some of their ideas. Below are a few suggestions as examples:

   • Carefully read your agency's policies about cultural competence (assuming they exist)

   • Read and learn more about the history and culture of a specific ethnic group to which one of your clients belongs

   • Scrutinize your office, workspace, or your agency's public space for its "cultural and linguistic friendliness" (e.g. signage, posters, brochures, artwork, etc.) and/or bring up the topic in a staff meeting

   • Have a frank conversation with a trusted colleague or friend for the purpose of doing a "self-check" about your own cultural sensitivity. Ask them to give you specific feedback and suggestions.

4. Other

Purpose: 1) To test your own personal knowledge about quality health care and culture via a self-quiz, and 2) To explore issues relevant to cultural competence for health care providers through an interactive web-based medium

Time: 10 minutes to complete the on-line quiz – considerably more time can be spent reading related materials on this site and its links

Materials: Personal computer with Internet access

Procedure:

1. Introduce participants to this web site. Ask them to take the quiz as "homework" or onsite during the class if you have computers available with Internet access. Below is the introduction section from the website.

"Health care professionals looking for a way to provide culturally and linguistically appropriate services to multicultural populations can now use a new Web-based tool supported by The Health Resources and Services Administration (HRSA).

The Provider's Guide to Quality and Culture features an interactive quiz that helps users enhance their knowledge and skills. The guide also has 11 modules on topics such as common health problems in selected minority, ethnic and cultural groups, and understanding immigrant, refugee and minority populations. Each module contains readings, mnemonics, exercises, references and annotated links to other relevant Web resources.

The Provider's Guide was developed by Management Sciences for Health, a nonprofit organization dedicated to the improvement of global health. In the near future, MSH intends to expand the interactivity of this site to include computer-assisted approaches to build a virtual learning community of experts and practitioners of culturally and linguistically competent health care.

The Provider's Guide is a ‘work in progress’ that will be periodically updated. Comments and suggestions are encouraged. Contact information is listed on the first page of the Web site."

2. If possible, discuss with participants what questions and insights arose for them as a result of visiting this interactive site.

Purpose: To learn about cultural competence in the provision of health care for underserved and unserved populations. This is a self-guided exercise for individual participants.

Time: 30 minutes

Materials: Personal computer with Internet access

Preparation: Go to http://bphc.hrsa.gov/culturalcompetence/Default.htm on the Internet and do the self-guided exercise, Cultural Competence: A Journey. As you do so, reflect on your own place on the "journey."

Procedure:

1. Request that participants go to the Cultural Competence: A Journey website and do the self-guided exercise there.

2. Encourage them to take time to carefully read through the materials presented. This is a web site produced for the Bureau of Primary Health Care that provides an excellent overview of the main themes of cultural competence and is sprinkled with numerous case examples of the provision of culturally competent health care to underserved or unserved populations. It also has some very nice graphics. The themes presented in this site are directly relevant to the work of HCH outreach workers.

3. After participants have visited the site, invite them to discuss what insights they have discovered on this "self-guided cultural competence journey."

Purpose: To experience the "collision of two cultures" in health care in a widely acclaimed book by Anne Fadiman published in 1997

Time: Variable, depending on reading pace

Materials: 

A copy of The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. By Anne Fadiman. New York, NY: Farrar, Straus, and Giroux, 1997. Winner of the National Book Critics Circle Award.

Preparation:

Read the book for yourself if possible, or read various reviews about it on the Internet. Also, go to http://www.fsbassociates.com/fsg/spiritrg.html for an excellent reader’s guide that poses twenty-one questions and subjects for discussion. An example question: "When polled, Hmong refugees in America stated that difficulty with American agencies was a more serious problem than either war memories or separation from family. Why do you think they felt this way? Could this have been prevented? If so, how? What does the author believe?"

Procedure:

1. Introduce the book The Spirit Catches You and You Fall Down. Inquire if anyone has read it who might want to share his or her impressions. This book speaks very directly to issues related to cultural competence in a health care context. Encourage participants to read the book individually or perhaps in study groups. Refer them to the study guide at http://www.fsbassociates.com/fsg/spiritrg.html. Read the book jacket description below to the group.

"This moving chronicle of a very sick girl, her refugee parents, and the doctors who struggled desperately to treat her, becomes, in Anne Fadiman's deft narrative, at once a cautionary study of the limits of Western medicine and a parable for the modern immigrant experience.