Communication with Diverse
Population Groups
Chapter 9
Key Terms
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Aphasia
Cultural Competence
Cultural Groups
Culture
Disability
Discrimination
Eating Disorders
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Ethnocentric
Health Disparities
Interpreter
Prejudice
Stereotype
Weight Bias
Cultural Competence
• Cultural competence: a set of knowledge and
interpersonal skills that allows individuals to
increase their understanding and appreciation
of cultural differences and similarities
• Gaining cultural competence in health care
means developing attitudes, skills, and levels
of awareness enabling the development of
culturally appropriate, respectful, and relevant
interventions
Reasons to Focus on Cultural
Competence
• Demographic Trends
– Population changes require health care professionals
to acquire skills in communicating across cultures
• Health Disparities
– Population-specific differences in the presence of
disease, health outcomes, or access to health care
• Quality Care
– Goal is to increase client satisfaction and improve
health outcomes
• Legislative and Accreditation Requirements
– Gov’t and professional services mandate culturally
appropriate services
Reasons to Focus on Cultural
Competence
• Title VI of the Civil Rights Act of 1964:
– “No person in the U.S. shall, on ground of race,
color or national origin, be excluded from
participation in, be denied the benefits of, or be
subjected to discrimination under any program or
activity receiving federal financial assistance”
– Discrimination is a behavior that treats people
unequally because of their group memberships
Cultural Competence Models
1. Cultural Competence Continuum
– Provides a series of stages to assess the act of
gaining cultural competence
– Individuals may be at different levels of
awareness, knowledge, and skills along the
cultural competence continuum
Cultural Competence Models
2. The LEARN Model
– By Berling and Fowlkes
– Developed for health care providers to elicit
cultural, social, and personal information relevant
to a given illness episode
– Helps to reduce communication barriers
– 5 steps to guide an intervention
The LEARN Model
Cultural Competence Models
3. The ETHNIC Model
– By Levin, Like, and Gottleib
– Incorporates the client's explanation and beliefs
and guides intervention to a culturally acceptable
plan of action
The ETHNIC Model
Cultural Competence Models
4. Campinha-Bacote Model:
– Provides a bridge between cultures in order to
achieve mutual understanding and meet unique
needs
– Views cultural competence as a process rather
than an end result
– “The process in which the healthcare provider
continuously strives to achieve the ability to
effectively work within the cultural context of a
client”
– 5 interdependent constructs = ASKED
Campinha-Bacote Model
1. Development of Cultural Self-Awareness
– Nutrition professionals need to approach crosscultural interactions with a nonjudgmental
attitude and a willingness to explore and
understand different values, beliefs, and behaviors
– A basic requirement for cultural awareness is an
in-depth exploration of one’s own cultural
background, including biases and prejudices
Campinha-Bacote Model
2. Development of Cultural Skills
– Takes time and requires technique flexibility
– Skills include ability to use respondent-driven
interview questions to effectively conduct a
culturally sensitive assessment
– Work effectively with an interpreter if needed
• A person who transfers the meaning of one spoken
language to another one
– Involve key decision makers and those that have a
major impact on the success of the intervention
Campinha-Bacote Model
• 3. Development of Cultural Knowledge
– Gaining knowledge helps to avoid stereotypes and
biases as we learn to appreciate the positive
characteristics of various cultures
• Stereotypes: an exaggerated belief, image, or distorted
truth about a person or group
– Without cultural knowledge, there is risk of
intervention conflicting with common beliefs,
values, and customs
Campinha-Bacote Model
• 4. Cultural Encounters
– Providers seek and engage in cross-cultural
encounters
• 5. Cultural Desire
– Providers need a true inner feeling of wanting to
engage in the process of becoming culturally
competent
Campinha-Bacote Model
• "Cultural Competency in Healthcare Delivery: Have I
'ASKED' Myself The Right Questions?“ (Campinha-Bacote,
2002)
 Awareness: Am I aware of my biases and prejudices
towards other cultural groups, as well as racism and other
"isms" in healthcare?
 Skill: Do I have the skill of conducting a cultural
assessment in a sensitive manner?
 Knowledge: Am I knowledgeable about the worldviews of
different cultural and ethnic groups?
 Encounters: Do I seek out face-to-face and other types of
interactions with individuals who are different from
myself?
 Desire: Do I really "want to" become culturally
competent?
Working with Interpreters
• Suppliers of healthcare need to include
“reasonable steps to provide services and
information in appropriate languages other
than English to ensure that persons with
limited English proficiency are effectively
informed and can effectively benefit”
– National Standards for Culturally and Linguistically Appropriate
Services in Health Care Final Report, 2003
Working with Interpreters
• The need for interpreters (spoken) and
translators (written) has grown rapidly
• 20% of population speaks a language other
than English at home (U.S. Census Bureau
2010)
• Healthcare interpreter provides language
services to patients with limited English
proficiency; they have a good understanding
of medical and informal terminology in both
languages
Working with Interpreters
• Best to use a healthcare interpreter vs. a
friend/relative of client, or a nonprofessional
– Client may be embarrassed or reluctant
– Interpreter may decide certain information is not
necessary, or may embellish
– Interpreter may be unfamiliar with medical
terminology
• Sign language interpreters – communicate
between people who are deaf and those who
can hear
Telephone Interpreter Devices
• TDD = Telecommunication Device for Deaf
– Uses telephone line
– A deaf person can communicate
with a hearing person
• Telephone Interpreting
– Service that provides human interpreters for
language interpretation
Lifespan Communication and
Intervention Essentials
• Nutrition intervention approaches should be
tailored to specific segments of the
population:
– Preschool-Aged Children (2-5 years)
– Middle Childhood (6-11 years)
– Adolescence (12-19 years)
– Older adults
Preschool-Aged Children (2-5 years)
• Determinants of Food Behavior:
– Family, media and culture have major impact
– Picky-eaters, food jags, reluctance to try new or
unfamiliar foods
– Parents should encourage child to try new foods
• May need to be exposed to a food 15 or more times
before acceptance occurs
– Children are able to physiologically recognize
fullness
Preschool-Aged Children (2-5 years)
• Developmental Factors:
– Need opportunities to touch, feel, manipulate,
questions, compare, and identify objects
– Capable of classifying foods by color, shape and
function, rather than by nutrient content
– Parents need to be good role models regarding
attitude towards food
– USDA’s Health Eating Index (HEI) for 2001
reported only milk and fruit groups were adequate
• Increased intake of soft drinks and juice displacing milk
consumption leading to calcium deficiency
Preschool-Aged Children (2-5 years)
• Intervention Strategies:
– Involve family and caregivers
– Provide action-oriented behavior change activities
– Creative food records
– Parental advice
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Encourage one bite
Introduce new foods at beginning of meal
Presentation should be attractive/colorful
Uphold regular mealtimes
Maintain a positive atmosphere at mealtime
Minimize using food as a reward
Middle Childhood (6-11 years)
• Determinants of Food Behavior:
– Family, school, and screen media time are major
factors
• “Screen time”: TV, computer games, DVDs, internet
• Screen time associated with high-calorie snacking and
poor food choices
• Marketing tools for candy, cereal, fast-food restaurants,
and snacks
– USDA and state regulatory agencies have
instituted healthier food standards for schools
Middle Childhood (6-11 years)
• Developmental Factors:
– Able to understand the function of food and how
it influences growth and health
– Likely to accept adult viewpoints about food
choices
• Nutritional Risks:
– USDA’s HEI report from 2005 indicated:
• children 6-11 yrs need to increase whole fruit, whole
grains, dk green and orange veggies, and legumes
• Need to decrease intake of sat’d fat, sodium, extra kcals
Middle Childhood (6-11 years)
• Intervention Strategies:
– Differential attention: Give praise for desired
behavior and ignore undesirable behavior
– Family-based interventions including diet, physical
activity, behavior modification, family counseling
– Limit media screen time
• AAP recommends ≤ 2 hours/day
– Use activity-oriented nutrition interventions
• Books, games, apps
Adolescence (12-19 years)
• Determinants of Food Behavior:
– Family influence declines as teens strive for
autonomy and independence
– Greater reliance on school food, snacking, vending
machines, fast food, convenient stores
– Marketing focuses on desserts, snacks and
beverages
– Often skip breakfast
– School food provides 35-40% of a high school
students’ total energy intake per day
Adolescence (12-19 years)
• Developmental Factors:
– Dramatic physical, cognitive, psychosocial changes
occur
– Family values may be rejected
– Best approaches include family involvement and
educational materials with clear messages
– Useful interventions include role-playing, focus on
pros/cons of choices, evaluate “what if”
possibilities
Adolescence (12-19 years)
• Nutritional Risks
– HEI report indicates inadequate consumption of
fruits, vegetables, fiber, calcium and high intakes
of sat’d fat, total fat, sodium, kcals, soft drinks
– Major issues include overweight, obesity,
smoking, disordered body image, low levels of
physical activity and disordered eating
– 80% of adolescents fearful of being “fat”
Adolescence (12-19 years)
• Intervention Strategies
– Motivational interviewing
– Use of behavioral strategies
– Multicomponent, school-based interventions
– Consider multivariable outcomes measures
– Intervention activities and topics
• Role-playing, taste tests, taking pictures w/ cell phone
– Use collaborative approach
Older adults
• Determinants of Food Behavior:
– Physical, social, economic, cultural and
psychological factors involved
– 36% with low income or living below poverty
– 1/3 live alone – loneliness, depression, social
isolation
– Reduced ability to taste or smell, dentures
– Chronic diseases, medications, disabilities,
arthritis
Older Adults
• Developmental Factors:
– Generally concerned about improving their diet,
daily activity, and not smoking
– Shop frugally, know how to prepare and store
food, enjoy eating out frequently
– Not concerned with body image
– Changes in GI function can reduce nutrient
absorption and utilization
• Vit D, calcium, Vit B12
– REE declines w/ age
Older Adults
• Nutritional Risk:
– HEI reports older Americans need to increase
intake of whole grains, dark green and orange
vegetables, legumes, and dairy
– Intake of zinc, iron, folate, and antioxidants often
inadequate
– Dehydration is a concern d/t decreased thirst
mechanism, reduced kidney function, medication
side effects
Older Adults
• Intervention Strategies:
– Referral for food assistance if needed
– Encourage social interactions
– Nutrition Screening Initiative checklist
– Mini Nutritional Assessment (MNA)
– Interventions should address physical, emotional,
social needs; keep message clear, direct, practical
– Materials clearly visible and easy to read
– Respect older adults knowledge and experience
Eating Disorders
• Anorexia Nervosa, Bulimia Nervosa, EDNOS
• AND advocates for RD to collaborate with
other professions during assessment and
treatment across the continuum of care
• Specialized training is needed to understand
the complexities of treatment
• RD to be cognizant of nutrition messages from
parents that emphasize weight rather than
health
Weight Bias
• ~2/3 of Americans are overweight or obese
• Stereotypes in Western culture stigmatize as lazy,
ugly, unattractive, unintelligent, dishonest, and
unsuccessful
• Clinical treatment and health outcomes for
overweight and obese individuals treated by
biased health care professionals have been
compromised
• Individuals stigmatized by weight bias are more
likely to experience depression, lower selfesteem, anxiety, body dissatisfaction, suicide
Weight Bias – Self Assessment
• Do I make assumptions about a person’s
character, intelligence, health status, or lifestyle
behaviors based only on body weight?
• Am I comfortable working with patients of all
sizes?
• What kind of feedback do I give obese patients?
• Am I sensitive to the needs and concerns of
obese patients?
• What are common stereotypes about obese
people? Do I believe these to be true or false?
What are my reasons for my beliefs?
Weight Bias
• Intervention Essentials
– Use sensitive language
– Incorporate motivational interviewing approaches
– Provide bias free care
– Set specific, realistic, and measurable goals
– Discuss benefits of modest weight loss
– Update skills
Individuals with Disabilities
• American Disability Act signed in 1990
– Policies shifting to emphasize inclusion,
independence, and empowerment for people with
disabilities
– 2010 – American Dietetic Association issued a
position statement regarding providing nutritional
services for people with developmental disabilities
and special health care needs
Individuals with Disabilities
• Words have power
• Should use first-person language to put
emphasis on the individual rather than the
condition or disability
• People do not want to be defined by a single
characteristic
– Ex/ diabetic, paraplegic
• See Table 9.11 for “Disability Etiquette 101”
Individuals with Disabilities
• Mobility Impairment
– Treat assistive devices as if they are part of body
– Assist only if person indicates it is OK
• Visual Impairment
– Be sure to identify self
• Deaf or Hard of Hearing (HOH)
– Read lips, sign language, look at client not
interpreter
Individuals with Disabilities
• Speech Disabilities
– Aphasia is a disorder that impairs the expression
and understanding of language, as well as, reading
and writing, but not intelligence
• i.e. – Language function is absent d/t injury
• Stroke, head injury, brain tumor, infection, dementia
– Computer-assisted devices, hand gestures, word
cards, picture cards can be used to assist
communication
Individuals with Disabilities
• Communication tips for aphasia:
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Make sure you have the individual’s attention
Minimize background noise
Speak to the person as an adult, not a child
Permit a reasonable amount of time to respond
Simplify sentence structure and rate of speaking
Focus on one message at a time
Do not attempt to finish patient statements
Do not turn conversation into therapy by correcting the
patient
– Try to involve the patient in decision-making
– Augment your speech with gestures and visual aids
– Consider using yes or no questions or thumbs up or down
Individuals with Disabilities
• Invisible Disabilities
– Some disabilities are not readily apparent, but do
impair normal daily activity
– Ex/ mental health issues, Asperger syndrome,
fibromyalgia, dexterity difficulties, chronic
conditions that cause disabling pain or fatigue,
medications that cause confusion