Increasing the cultural CULTURE competence of health care providers serving culturally CARE diverse populations CONNECTION Winter 2011/2012

www.culturecareconnection.org Funded by

Culture Care Connection II Clinic Initiative Launches in January Stratis Health is excited to announce • Open Door Health Center, Mankato the launching of a new UCare-funded • Partners in Pediatrics - Brooklyn initiative that focuses on advancing Park cultural knowledge and skills for clinical and non-clinical staff working • Partners in Pediatrics - Calhoun, with multicultural patient populations. We are proud to announce the • Partners in Pediatrics - Maple Grove following participant clinics and • Partners in Pediatrics - Plymouth public health agencies taking on this THIS ISSUE important challenge. • Partners in Pediatrics - Rogers • Culture Care Focus: • Appleton Area Health Services, • Phalen Village Clinic, St. Paul Liberians in 2 Appleton • St. Paul-Ramsey County Public • Hepatitis B Virus (HBV) Status • Community University Health Care Health, St. Paul in Immigrant Populations 4 Center, Minneapolis • Teach-Back: What Does Your • Sleepy Eye Medical Center, Patient Really Understand? 4 • Eagan Child and Family Care, Eagan Sleepy Eye • Resources 5 • HealthEast Rice Street Clinic, St. • Women’s Health Center of Duluth • Events 6 Paul During 2012, Stratis Health will work • Multicare Associates - Fridley with Minnesota clinics and public Eating Contaminated Fish Medical Center health agencies to promote cultural competence and the national Cultur- Mercury and PCBs have been found in • Multicare Associates - Blaine ally and Linguistically Appropriate fish from Minnesota lakes and rivers, Medical Center Services (CLAS) Standards. according to the Minnesota Depart- • Multicare Associates - Roseville ment of Health. This is a concern As part of the initiative, participants Medical Center for many Minnesota immigrants, will receive cultural assessments, including Hispanics, Hmong, and • Neighborhood Health Source, including gap analysis with recom- Vietnamese, who regularly consume Minneapolis mendations, online curriculum, large quantities of fish. Encourage demographic reports, community • Northpoint Health and Wellness your patients to replace some fish with profiles, educational training, and Center, Minneapolis alternative protein sources. links to current cultural research and More> information. STRATIS HEALTH CULTURE CAREQUALITY CONNECTION UPDATE

Culture Care Focus: Liberians in Minnesota Although there is no accurate, publicradio.org/display/web/2007/09/13/ are similar to those of , official record of the number of liberianstatus/; MPR, Liberian President in general, and more specifically to Liberians living in Minnesota today, visits Minnesota, April 10, 2009; http://blog. . Liberians also lib.umn.edu/hhhevent/news/04.11.09%20 according to the Minnesota-based AP-%20Sirleaf.pdf; Star Tribune, March 2, celebrate many of the same holidays Liberian Journal, Minnesota has one 2009, Allie Shah 612-673-4488; http://www. including Christmas, Easter, New of the largest Liberian populations startribune.com/local/north/40516512.html Year’s Day, and Thanksgiving, often in the country, with the highest Located in , with Liberian traditions incorporated. is bordered by , A custom unique to Liberians and , and the Ivory Coast. American Liberians is the “snapshake” Liberia has a unique historical greeting, a greeting which originated in relationship with the U.S., the 1800s as a sign of freedom among initially connected through former slaves. The custom was derived the slave trade. In 1820, from the practice of slave owners who the American Colonization would break the middle finger of a Society, a private organization slave’s hand to indicate bondage. When that included U.S. President shaking hands, you grasp the middle concentration living in the Brooklyn Monroe, sent nearly 300 freed finger of the other person’s right hand Park area. In a March 2, 2009, Star American slaves to Liberia to colonize between your thumb and ring (third) Tribune article, Kerper Dwanyen, the country. In 1847, the colonists, finger, and bring it up quickly with a then president of the Organization identified as Americo-Liberians, snap. of Liberians in Minnesota, said established the Republic of Liberia more than 250,000 Liberians live in based on the U.S. government model. Liberia is known as the home of the the U.S., with an estimated 35,000 In 1980, the Americo-Liberians were carved wooden classical African mask. residing in Minnesota. People of overthrown, initiating two civil The artistic ability of its wood carvers Liberian ancestry make up the third wars that devastated the national largest group of African immigrants economy and left nearly 250,000 to Minnesota. Large populations of people dead. Agricultural Liberians also reside in Philadelphia, production was completely Pennsylvania, and Providence, Rhode disrupted and the entire popula- Island. Liberians Count! Participate in the tion was dependent on donated 2010 Census, March 18, 2010, http://www. theliberianjournal.com/index.php?st=opinion food. s&sbst=details&rid=77 Culture As a result of 14 years of civil war in Unique to African immigrants Liberia that began in 1989 and ended in the U.S., Liberians speak in 2003, the U.S. granted temporary English, a reflection of their protective status to thousands of history as slaves in the American Liberians and has extended that status South. Although English is the several times. Although peace was official language of Liberia, over declared with democratic elections 30 indigenous languages also are first held in 2005, Liberians say the spoken. The social customs and political and economic situation in culture of the Americo-Liberians Liberia continues to be fragile, and were modeled after the slaveowners is widely recognized. Many ceremonial those who have put down roots in of the American South, including the masks are commissioned by the secret Minnesota do not want to return to establishment of the Masonic Order Poro and Sande men’s societies for use a difficult life in Liberia.MPR, Bush of Liberia. Social gatherings, such as in initiation rituals. The Dan group is extends stays of thousands of Liberians in weddings, birthdays, and funerals, noted for masks representing spirits of U.S., September 13, 2007. http://minnesota. 2 2 STRATIS HEALTH CULTURE CAREQUALITY CONNECTION UPDATE

Culture Care Focus: Liberians in Minnesota the forest, and for large spoons carved Religion tion of rice and platto leaves or okra with the features of humans and According to a 2008 national census, called check rice. Favorite desserts animals. Liberians also create musical 85.5 percent of the population include coconut, peanut cookies, and instruments and drums made from in Liberia practices Christianity. sweet potato wood, animal skins, raffia, and gourds. The remainder of the population or pumpkin pie, and a Liberians have a long, rich history are Muslim or practice traditional sweet bread in textile indigenous religions. Practitioners of made from arts and many indigenous religions rice and quilting. Since may recognize the practice bananas. nearly all of of polygamy and witchcraft. Preferred drinks are homemade ginger the ethnic Many people combine beer, palm wine, and Liberian coffee. languages of elements from Christianity, Liberia are Islam, and indigenous Medical Care religions. oral rather Liberian Americans often combine than written, Diet both Western and indigenous health there is Traditionally, Liberians eat a care practices and treatments in their very little healthy diet mainly consisting daily lives. In Liberia, a widespread traditional of rice, fish or meat, greens, belief held by many is that illness and Liberian and other vegetables. Rather death are caused by the evil intentions literature. than being the main part of other people. This belief has lead Both of the meal, meat or fish to many court hearings of witchcraft Americo- is usually a supplement to cases. Major health concerns for Liberians and indigenous peoples of the meal. Rice is often served with Liberian Americans who have lived in Liberia are highly patriarchal, with breakfast, lunch, and dinner. Typical this country for ten or twenty years women serving as homemakers and Liberian dishes may incorporate are related to hypertension, diabetes mothers. In Liberia, a high value eggplant, okra, cassava, and plantains, mellitus Type 2, high cholesterol levels, is placed on women as agricultural as well as coconut, peanuts, bananas, stroke, and heart disease. Physicians workers and childbearers. This is mangoes, citrus fruits, and sugarcane. suggest the increased risk is due to a evident in the institution of bride- Stews and soups are spiced with less healthy diet with less fiber and wealth, payment made by a groom cayenne and more fat and less exercise than they to the kin of the bride. Marriage is other hot received in Liberia. viewed as an ongoing process, with peppers. A secondary health concern is the bridewealth payments made over Goat soup is risk of infections for Liberians who many years. In Liberia, formal Western considered travel regularly to and from Liberia. educational institutions originated the national According to the World Health with mission schools whose primary soup. Meals Organization, infectious diseases aim was conversion to Christianity. are often in Liberia, including yellow fever, Access to education at the University accompanied by fufu, a thick paste lassa fever, malaria, typhoid, polio, of Liberia was limited, especially for made with fermented cassava. Cassava tuberculosis, and diarrhea, are indigenous people, until the 1960s leaves or potato greens are mashed or widespread. In 2009, life expectancy when many children received foreign chopped (to a consistency of cooked in Liberia was estimated at 58 years scholarships to attend school in spinach) with pepper and onion and and the maternal mortality rate was Europe and the U.S. In Minnesota, are often boiled with beef or chicken nearly 1 out of 100 births. In 2007, nearly 40 percent of Liberians are and served with rice. Favorite meals 20.4 percent of children under the age employed in nursing homes, as regis- include pigs’ feet with bacon and of five were malnourished. The civil tered nurses, licensed practical nurses, cabbage, fish with sweet potato leaves, wars destroyed nearly 95 percent of the and certified nursing assistants. shrimp and palm nuts, and a combina- 3 STRATIS HEALTH CULTURE CARE CONNECTION Liberians in Minnesota country’s health care facilities, medical Sources those who are negative regardless of infrastructure, as well as the country’s • Centers for Diseases Control and Prevention, age because they are likely to return to electrical and sanitation facilities, Emerging Infectious Diseases, http://wwwnc. their native countries for visits and will cdc.gov/eid/article/16/6/10-0040_article.htm creating a void for medical services. In be exposed to the HBV virus. 2008, Liberia had only one doctor and • Countries and Their Culture, Liberian Americans, Liberian Americans - History, Morbidity and Mortality Report 27 nurses per 100,000 people. World Modern era, The first liberians in america recommends screening for the Health Organization, http://www.who.int/gho/ http://www.everyculture.com/multi/Le-Pa/ following people for HBV status: countries/lbr.pdf Liberian-Americans.html#ixzz1gS9JLWv6; Liberian Americans - History, Modern era, The Also of great concern for thousands • Persons born in Asia, Africa, Eastern first liberians in america,http://www.everyc - Europe, the Middle East, and Pacific of Liberians living in the U.S. and ulture.com/multi/Le-Pa/Liberian-Americans. in Liberia is undiagnosed post html#ixzz1gSGvYOm4 basin traumatic stress disorder. Civil war • Ethnic Capital and Minnesota’s Future, People • U.S. born children of immigrants victims and aggressors both suffer of Liberian Origin in Minnesota, http://www. from these high-risk areas ethnictrends.info/pdfs/EthnicCapitalLiberians. from PTSD. War experiences have pdf created an unrelenting mental health • Household and sexual contacts of • Minnesota Department of Health, http://www. persons with HBV crisis for victims who still come into health.state.mn.us/macros/search/index.html?q daily contact with some of the same =liberians&cx=001025453661958716519%3Aj • Persons who are immunosuppressed people who tortured and raped them 2323tveixc&cof=FORID%3A10&ie=UTF-8 • Past and current intravenous drug or tortured and killed their family members in Liberia. users End of Life • Inmates of correctional facilities At end of life, individuals may be Hepatitis B Virus (HBV) • Men who have sex with men visited by clergy and prayed for by Status in Immigrant Johns Hopkins Advanced Studies in members of a religious congregation. Populations Medicine, Vol. 9, No. 3. December 2009. Funerals are very important, are often Chronic HBV infection is prevalent elaborate, and may go on for days or in Asia, Africa, Eastern Europe, the weeks. A Liberian funeral is a time for Middle East, and the Pacific basin. In Teach-Back: What Does Your both grief, since the departed will be these areas, HBV is transmitted at Patient Really Understand? missed by loved ones, and a time for childbirth or in early childhood, and is Improving health through clear joy, since it is believed the deceased distinct from adult-acquired infections. communication has gone on to a better life among his Adult-acquired infections are more The teach-back method of patient or her ancestors. On the night before commonly transmitted via sexual and the funeral, a wake is held in the family education validates patients’ under- injection-drug use and occur more standing of the information they home where the extended family and often in the U.S. and Western Europe. friends of the deceased gather for a receive from a health care provider, and feast, with drinking, singing of spiritual Although nearly all immigrants in allows providers to evaluate how well songs, and often a Liberian drummer. Minnesota are tested for HBV, they do they communicated the information. The purpose of the wake is to be jovial, not receive their test results and have Using this method, patients re-state to to console the immediate family, and to no documentation to show physicians. the provider in their own words what wipe away the grief. Alexander Levitan, MD, with the the provider has told them. Minnesota Medical Association, Research shows that only 50 percent of recommends providing information what we teach patients is retained. The cards for all who are tested and Minnesota Health Literacy Partner- explaining its importance as a lifelong ship (MHLP), www.healthliteracymn. health record. He also urges physicians org, has developed free training and to determine the hepatitis status of all presentation materials to help educate new immigrant patients and vaccinate health care professionals about the 4 STRATIS HEALTH CULTURE CARE CONNECTION

Resources teach-back method and about the Refugee Childcare Resources from Culturally importance of health literacy in MicroEnterprise and Linguistically every-day contact with patients. Lack Appropriate Services (CLAS) of patients’ understanding about their Development Project health and health care treatment For Iraqi, Bhutanese, Karen, and Revised CLAS Standards to Be is directly related to extra hospital Somali Refugee Women Released stays, longer hospital stays, increased Funded by the Federal Office of In early 2012, the U.S. Office of -Mi emergency Refugee Resettlement, Resources for nority Health will release the revised department Child Caring, CAPI, and the Hmong National Standards for Culturally visits, American Partnership, this develop- and Linguistically Appropriate Ser- medication ment project offers refugee women the vices (CLAS). The National CLAS errors, opportunity to receive training and Standards will be accompanied by a missed learn skills needed to start their own practical guidance document that will appoint- child care business. provide a blueprint for individuals ments, and a and organizations to implement the higher level Iraqi, Bhutanese, Karen, and Somali Standards. of illness, resulting in increased health refugee women receive health, safety, care costs. and child development training, as Cultural Competence Education well as on-going in-home support Teach-Back can work in any area and technical assistance. They also The following accreditedcontinu - where clarification is needed, such learn the small business skills that ing education programs based on as explaining new medications and can enable them to work toward the CLAS Standards’ three themes self-care techniques, obtaining obtaining a family child care license, are available on the Office of Minor- informed consent, in care planning and receive $3,000 in grant support ity Health’s Think Cultural Health and procedure preparations, and in to help establish a start-up child care website. explaining discharge instructions. The business. For more information about • A Physician’s Practical Guide to MHLP Teach-Back Program includes this opportunity, contact Simran Culturally Competent Care a video, PowerPoint presentation, Aryal, [email protected], • Culturally Competent Nursing Care: program guide, discussion ideas, and 612-767-3695. A Cornerstone of Caring activities to enhance program effective- • Cultural Competency Curriculum ness. The program provides a defini- for Disaster Preparedness and Crisis tion for teach-back and its purpose, Culture Care Connection Response the key elements for using teach-back Online Resource Center correctly in a clinical setting, as well Implementing Language Access as tips for measuring outcomes and Produced by Stratis Health and Services Guide program effectiveness, presenting to funded by UCare, the Minnesota A Patient-Centered Guide to Imple- adult learners, and securing leadership online learning and resource center menting Language Access Services in endorsement of the program. supports health care providers and Healthcare Organizations is available staff in their efforts to provide cultur- from the Office of Minority Health. See the Teach-Back video for examples ally competent care to their patients. Thisguide provides instruction on of how this strategy can be used in the It offers resources to help providers implementing language access services clinic setting. enhance culturally sensitive services within a health care organization. Also available on the MHLP website and implement national Culturally and E-learning programs for oral health is HeLP MN Seniors, a new health Linguistically Appropriate Services providers and community health literacy program to empower and (CLAS) Standards. Look for informa- workers are under development. educate older adults. tion sheets on many of Minnesota’s More about CLAS offerings> More > diverse populations. Visit www.CultureCareConnection. org> 5 STRATIS HEALTH CULTURE CARE CONNECTION

Events Patient Safety Awareness National Council on Ongoing Programs Week: Be Aware for Safe Interpreting in Health Care Hmong Elder Program. Every Care (NCIHC) Annual Membership Monday, 9:30 a.m.-noon, First March 4-10, 2012 Meeting Lutheran Church, St. Paul. Email May 31-June 1, 2012 the Southeast Asian Ministry, seam- Patient Safety Awareness Week is [email protected]. an annual, National Patient Safety “Interpreting for the Whole Person: Minnesota Community Health Foundation (NPSF) education and Mental Health Interpreting across Worker Peer Network. Fourth awareness campaign. Each year, the Spectrum” is the theme for Tuesday of every month, 1:00 - 3:00 health care organizations take part the NCIHC meeting in Madison, p.m., North Point Health and in the event by displaying the NPSF Wisconsin. The NCIHC is a multi- Wellness Center. http://www.wellsha- campaign logo and promotional disciplinary organization based in the reinternational.org/chwpeernetwork materials within their organizations, U.S. whose mission is to promote and and providing educational resources to enhance language access in health care. Cambodian Elder Program. Every hospital staff. Prior to the meeting, there will be a Thursday, 10:00 a.m.-noon, Christ Lutheran Church, St. Paul. Email This year’s theme, Be Aware for Safe hosted visit to the interpreter depart- the Southeast Asian Ministry, seam- Care, stresses how important it is for ment at the University of Wisconsin [email protected]. every member of a health care team, Hospital on May 30 at 1:00 p.m. including patients, to be aware of More> Chinese Senior Program. Last health care safety, and to participate in Saturday of every month, 11:00 efforts to keep patients everywhere safe a.m.-2:00 p.m., China Place Bldg., from medical harm. More> St. Paul. Email the Chinese Social Services Center, [email protected].

Contacts Stratis Health is a nonprofit organization that leads collaboration and innovation Mary Beth Dahl, RN, CPC, CPHQ, in health care quality and safety, and President and CEO Program Manager Jennifer P. Lundblad, PhD, MBA serves as a trusted expert in facilitating [email protected] improvement for people and communities. Director, Medical Affairs 952-853-8546 Stratis Health works toward its mission Jane Pederson, MD, MS Mary Montury through initiatives funded by federal Program Coordinator and state government contracts, and Board of Directors [email protected] community and foundation grants, Kathleen D. Brooks, MD, MBA 952-853-8541 including serving as Minnesota’s Medicare Connie Delaney, PhD, RN Huda Farah, MSc Margaret LeDuc Quality Improvement Organization. William E. Jacott, MD Editor Stratis Health Lucinda Jesson, JD [email protected] 2901 Metro Drive, Suite 400 Dee H. Kemnitz 952-853-8578 Bloomington, MN 55425-1525 Michele Kimball 952-854-3306 •952-853-8503 (fax) Clint MacKinney, MD, MS Email: [email protected] Beth Monsrud, CPA Culture Care Connection is produced with support from www.stratishealth.org Alison H. Page, MHA Michael Spilane, MD Ruth Stryker-Gordon, MA, RN Stephen Swensen, MD, FACR Dale Thompson, board chair Gary Wingrove

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