Cultural Competency
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Acknowledgements.............................................................................................................................iv GoalsofThisManual............................................................................................................................1 UnderstandingCulturalCompetency.............................................................................................2 Whatisculturalcompetencyinhealthcare?...........................................................................................2 Whyisculturalcompetencyimportant?...................................................................................................2 WhyisculturallycompetenthealthcareimportantinVermont?..................................................3 BestPracticesforCulturalCompetency........................................................................................5 OfficeofMinorityHealth:CLASStandards...............................................................................................5 Effectivecommunication..................................................................................................................................8 BuildingaCulturallyCompetentPractice–NEW!..................................................................12 Planning,implementing,andevaluatingculturalcompetenceinprimaryhealthcare
settings..................................................................................................................................................................13 NationalCenterforCulturalCompetence:GuidelinesfortheFrontDesk..............................17 Toolsforself‐assessmentandimprovement.......................................................................................19 AdditionalResources......................................................................................................................................19 Vermont’sSpecialPopulations.......................................................................................................20 Populationsincludedinthismanual........................................................................................................21 Healthissuescommontopopulationsincludedinthismanual...................................................21 Bhutanese–NEW!...........................................................................................................................................24 BosnianandHerzegovinian.........................................................................................................................34 Burmese–NEW!..............................................................................................................................................43 Burundian............................................................................................................................................................55 Chinese–NEW!................................................................................................................................................63 Congolese.............................................................................................................................................................75 MeskhetianTurks.............................................................................................................................................83 Somali....................................................................................................................................................................87 Sudanese...............................................................................................................................................................93 Vietnamese..........................................................................................................................................................99 AfricanAmericans..........................................................................................................................................105 DeafandHardofHearing............................................................................................................................110 Elderly.................................................................................................................................................................116 LGBTQI(Lesbian,Gay,Bisexual,Transgender,Queer/Questioning,Intersex)..................122 Homeless............................................................................................................................................................130 ii
LatinoMigrantFarmWorkers..................................................................................................................143 NativeAmericans............................................................................................................................................147 Women................................................................................................................................................................152 AppendixA.........................................................................................................................................158 iii
Acknowledgements
ThismanualwasmadepossiblethroughcollaborationbetweenChamplainValleyArea
HealthEducationCenter(AHEC),theUniversityofVermont’sCollegeofMedicineAHEC’s
SEARCHProgram,andtheFreemanMedicalScholarsProgram.
ChamplainValleyAHECgratefullyacknowledgestheVermontCommunityFoundation
www.vermontcf.orgforitssupportofourworktoexpandthecontentsofthemanualto
includepopulationsnewtoVermontandtorestructurethemanualintoafriendlierand
moreaccessibleformat.
WethankRobinOrrforhereditorialservicesandoversightoftheserevisions.Wealso
wanttothankJudyWechslerofChamplainValleyAHECforherroleincoordinatingthe
revisionprocessforthiseditionofthemanual.
NumerousSEARCHScholarsandFreemanMedicalStudentshaveconductedresearchand
writtensectionsofthismanual;wethankthemfortheircontributions.
FreemanMedicalStudents:
AlexFolkl,UniversityofVermontCollegeofMedicine,Classof2012
DerekHuang,UniversityofVermontCollegeofMedicine,Classof2012
LauraPiper,UniversityofVermontCollegeofMedicine,Classof2012
LindsayNadeauDuy,UniversityofVermontCollegeofMedicine,Classof2012
SEARCHScholars:
PeterB.Cooch,UniversityofVermontCollegeofMedicine,Classof2014
NicoleA.Fossiano,UVM,MastersofSocialWorkcandidate,Classof2013
ChelseaA.Harris,UniversityofVermontCollegeofMedicine,Classof2014
LaurenM.Kreiger,UniversityofVermontCollegeofMedicine,Classof2015
DavidJ.Larsen,UniversityofVermontCollegeofMedicine,Classof2014
Inaddition,wethankthefollowingindividualswhohavegenerouslysharedtheir
knowledgeandexpertise:
MariaMercedesAvila,MEd,VermontInterdisciplinaryLeadershipEducationfor
HealthProfessionals(VT‐ILEHP),UniversityofVermontCollegeofMedicine
JonBourgo,TheCommunityHealthCentersofBurlington
JacquelineRose,MPH,VermontRefugeeResettlementProgram
ThispublicationwasmadepossiblebyGrantNumberU77HP03624fromtheHealth
ResourcesandServicesAdministration(HRSA).Itscontentsaresolelytheresponsibilityof
theauthorsanddonotnecessarilyrepresenttheofficialviewsoftheUSDepartmentof
HealthandHumanServices,HRSA,AreaHealthEducationCenters(AHEC)Program.
iv
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v
GoalsofThisManual
 Toprovideacomprehensive,easilyunderstooddefinitionofculturalcompetency.
 ToraiseawarenessoftheincreasingdiversityinVermontandthenewpopulations
joiningourcommunities.
 Toofferresourcestohelpprovidersbecomebetteracquaintedwithdifferent
populations.
 Tohelpprovidersusetheinformationinthismanualtocomfortablyassesspatients
andprovidethebestcarepossible.
 Toassistproviderswiththeirownsenseofunderstandingbyofferinglinkstoself‐
assessmenttoolsandcontinuingeducationopportunities.
Thisresourcewasdesignedforhealthcareproviderstosupportthepromotionofcultural
competencyintheirpractice.Itisbynomeansmeanttobecomprehensive,butratherto
provideageneraloverviewandtoofferselectresourcesforfurtherstudy.
ChamplainValleyAHECrecognizesthatnewpopulationscontinuetosettleinVermontand
thatnewdata,resources,andtechnologiestoimproveourunderstandingofhowtobest
meetthehealthneedsofadiversepopulationcontinuetobedeveloped.Therefore,our
effortstoupdateandrevisetheinformationinthismanualtokeepitcurrentandhelpful
forVermontprovidersarealsocontinuous.Asresourcespermit,weintendtoaddsections
onnewrefugee,immigrant,andotherspecialpopulationsinVermont.Wealsointendto
begintheprocessofsystematicallyupdatingthecontentsofallofthespecificpopulation
sections.Wewelcomeyourcommentsandquestionsaswellasanyassistanceorexpertise
youcanprovidetoassistusinthisprocess.
ThismanualiscopyrightedandprotectedbytheChamplainValleyAreaHealth
EducationCenter.
Permissionisgrantedtousethismanualfornon‐commercialpurposesifthematerialis
notalteredandpropercreditisgiventotheChamplainValleyAreaHealthEducation
Center.
Permissionisrequiredifthematerialistobemodifiedinanyway,broadlydistributed,or
usedinconnectionwithanycommercialactivity.
Pleaseusethefollowingcitation:
CulturalCompetencyforHealthCareProviders.ChamplainValleyAreaHealthEducation
Centerwebsite.http://www.cvahec.org/app/wp‐
content/uploads/2013/10/CulturalCompetencyforHealthcareProviders13.pdf.Revised
January,2013.Accessed[insertdate].
Pleasedirectcommentsandquestionsto: JudyWechsler
ChamplainValleyAreaHealthEducationCenter
92FairfieldStreet
1
St.Albans,VT05478
T:(802)527‐1474
www.cvahec.org
F:(802)527‐1632
UnderstandingCulturalCompetency
Whatisculturalcompetencyinhealthcare?
Thereisnouniversallyaccepteddefinitionofculturalcompetency.Ingeneral,itisasetof
skillsthatallowssomeonetoincreasetheirunderstandingandappreciationofcultural
differencesbetweengroups.Therearemanydifferentthingsthatmakeupaperson’s
culturalidentity,includingcountryoforigin,language,race,ethnicity,education,family,
spiritualtraditions,traditionalmedicalanddietarypractices,andmuchmore.
Insimpleterms,culturalcompetencyinhealthcareistheabilitytointeractsuccessfully
withpatientsfromvariousethnicand/orculturalgroups.Inpractice,thisinvolves:
 understandingandrespectingeachpatient’sculturalidentity;
 effectivecross‐culturalcommunicationbetweenthepatientandthehealthcare
provider,includingtheavailabilityofhealth‐relatedlanguageresourcessuchas
translatorsandtranslatededucationalmaterial;and
 theabilityofboththehealthcareproviderandthepatienttoaccessadditional
culturalsupportserviceswhenneeded.
Thismanualisaresourcedesignedtohelphealthcareprovidersbecomemoreculturally
competent.AstheAmericanCollegeHealthAssociationnotes,“culturalcompetencyisan
engaging,life‐longjourneyofexpandingyourhorizons,thinkingcriticallyaboutpowerand
oppression,andbehavingappropriately.”Inotherwords,culturalcompetencyisnot
somethingtobelearnedonceandputonadustyshelfattheoffice.Rather,itisadynamic
skillthatmustbecontinuallydevelopedoveralifetime.
Whyisculturalcompetencyimportant?
TheUnitedStatesisacountryofmanyracesandcultures.Witheachpassingyear,more
andmorehealthcareprovidersarerecognizingthechallengeofcaringforpatientswho
speakdifferentlanguagesorwhohavedifferentculturalbackgrounds,includingdiverse
perspectivesonhealthandwellness.Researchhasshownthateffectivecommunication
betweenpatientsandhealthcareprovidersleadstoimprovedtreatmentadherence,higher
patientsatisfaction,andbetteroutcomes.
Disparitiesinhealthindicatorsandoutcomes
In2002,theInstitutesofMedicinepublishedUnequalTreatment,astarkreportthat
unmaskedextensivedisparitiesnotonlyintheoverallhealthofminoritypopulationsinthe
UnitedStates,butalsointhetypeandqualityofhealthservicesthesegroupsreceived.The
resultsofthisreport,thoughhardlyunexpected,nonethelessservedasacatalystforhealth
careprovidersandpolicymakersnationwidetoreexaminecaredeliverymodels.1
Interestingly,theauthorsfoundthatneitherdisparitiesinaccesstocare,nordisparitiesin
socioeconomicstatuscompletelyaccountedforthedifferenceinhealthoutcomes,so
researchersbegantolookforalternativeexplanations.Manyconcludedthatalackof
culturalcompetencyonthepartofproviderscouldaccountforatleastpartofthegapin
2
outcomesbetweenminoritypopulationsandnon‐Hispanicwhites,2whichprecipitateda
nationalpushtoimprovetheskillset.Currently,mostprofessionalorganizations,fromthe
AmericanMedicalAssociationtotheNationalAssociationofSocialWorkers,have
publishedstatementsinsupportofculturalcompetency.3
Doesincreasedculturalcompetencyimprovepatienthealth?
Formalizedstudyofculturalcompetenceisjustbeginningtoemergefromitsinfancy,so
muchoftheexistingscholarlyworkcentersondefiningissuesandidentifyingfuture
researchquestions.Intheabsenceofconclusiveresearch,healthprovidersareprobably
bestservedbyapproachingtheissuefromBetancourt’sperspective,whoobservedthat
“[c]ulturalcompetenceisnotapanaceathatwillsingle‐handedlyimprovehealthoutcomes
andeliminatedisparities,butanecessarysetofskillsforphysicianswhowishtodeliver
high‐qualitycaretoallpatients.”4
WhyisculturallycompetenthealthcareimportantinVermont?
ThemostrecentU.S.Censusdatafrom2010showsthatVermont’spopulationisbecoming
increasinglydiverse.Thosewhoidentifythemselvesassomethingotherthannon‐Hispanic
whitenowmakeup6%ofourpopulation;amongthoseundertheageof18,thepercentage
isnow9%.Inaddition,Vermontregularlywelcomesrefugeesfromtroubledregionsall
aroundtheworld:morethan6,000refugeeshavebeenresettledintoVermont
communitiessince1989.
TheVermontDepartmentofHealth,inits2010reportTheHealthDisparitiesofVermonters,
concludesthat“[w]hilethesenumbersarestillproportionatelysmallcomparedtotherest
oftheUnitedStates,Vermont’sracialandethnic[minority]populationsaregrowingatafar
greaterratethanthepopulationoverall”.Theentirereportcanbefoundat
http://healthvermont.gov/research/documents/VTDisparitiesRpt2010.pdf
ThesectiononRace,Ethnicity,andCulturalIdentityisattachedasAppendixA.
AsVermontbecomesamorediversestate,providerswilltreatpatientsfrommany
differentethnicities,cultures,beliefsystems,countries,andbackgrounds.Duetohealth
carebarriersresultingfromeducationallevel,language,economicstatus,healthinsurance,
culturalbeliefs,andmore,manyhealthissuesarenotaddressedasoftenastheyshouldbe.
Often,providersfocusontheirspecialtycareandmaymisswarningsignsofother
problemstheyarelessfamiliarwith.
3
ReproducedfromHealth
DisparitiesofVermonters2010,
publishedbytheVermont
DepartmentofHealth.
4
BestPracticesforCulturalCompetency
OfficeofMinorityHealth:CLASStandardsa
TheOfficeofMinorityHealth,adivisionoftheUnitedStatesDepartmentofHealthand
HumanServices,haspublishedasetofnationalstandardsforCulturallyandLinguistically
AppropriateServices(CLASstandards).Thesestandardsareprimarilydirectedathealth
careorganizations,butcanbeadaptedforusebyindividualhealthcareproviders.
Mostofthestandardsarerecommendations,howeverallrecipientsoffederalfunds
(includingpaymentsfromMedicaidandMedicare)arerequiredtocomplywithstandards
4through7.Thestandardsarereproducedbelowintheirentirety,withtherequireditems
highlightedinyellow.
1. Healthcareorganizationsshouldensurethatpatients/consumersreceivefromall
staffeffective,understandable,andrespectfulcarethatisprovidedinamanner
compatiblewiththeirculturalhealthbeliefs,practices,andpreferredlanguage.
2. Healthcareorganizationsshouldimplementstrategiestorecruit,retain,andpromote
atalllevelsoftheorganizationadiversestaffandleadershipthatarerepresentative
ofthedemographiccharacteristicsoftheservicearea.
3. Healthcareorganizationsshouldensurethatstaffatalllevelsandacrossall
disciplinesreceiveongoingeducationandtraininginculturallyandlinguistically
appropriateservicedelivery.
4. Healthcareorganizationsmustofferandprovidelanguageassistanceservices,
includingbilingualstaffandinterpreterservices,atnocosttoeachpatient/consumer
withlimitedEnglishproficiency.Theseservicesshouldbeprovidedatallpointsof
contactandinatimelymannerduringallhoursofoperation.
5. Healthcareorganizationsmustprovidetopatients/consumersintheirpreferred
languagebothverbaloffersandwrittennoticesinformingthemoftheirrightto
receivelanguageassistanceservices.
6. Healthcareorganizationsmustassurethecompetenceoflanguageassistance
providedtolimitedEnglishproficientpatients/consumersbyinterpretersand
bilingualstaff.Familyandfriendsshouldnotbeusedtoprovideinterpretationservices
(exceptonrequestbythepatient/consumer).
7. Healthcareorganizationsmustmakeavailableeasilyunderstoodpatient‐related
materialsandpostsignageinthelanguagesofthecommonlyencounteredgroups
and/orgroupsrepresentedintheservicearea.
a
Thesearethestandardsineffectasofthismanual’spublicationdate.Themostcurrentversioncanbefound
attheOfficeofMinorityHealthwebsite:
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 5
8. Healthcareorganizationsshoulddevelop,implement,andpromoteawrittenstrategic
planthatoutlinescleargoals,policies,operationalplans,andmanagement
accountability/oversightmechanismstoprovideculturallyandlinguistically
appropriateservices.
9. Healthcareorganizationsshouldconductinitialandongoingorganizationalself‐
assessmentsofCLAS‐relatedactivitiesandareencouragedtointegrateculturaland
linguisticcompetence‐relatedmeasuresintotheirinternalaudits,performance
improvementprograms,patientsatisfactionassessments,andoutcomes‐based
evaluations.
10. Healthcareorganizationsshouldensurethatdataontheindividual
patient's/consumer'srace,ethnicity,andspokenandwrittenlanguagearecollectedin
healthrecords,integratedintotheorganization'smanagementinformationsystems,
andperiodicallyupdated.
11. Healthcareorganizationsshouldmaintainacurrentdemographic,cultural,and
epidemiologicalprofileofthecommunityaswellasaneedsassessmenttoaccurately
planforandimplementservicesthatrespondtotheculturalandlinguistic
characteristicsoftheservicearea.
12. Healthcareorganizationsshoulddevelopparticipatory,collaborativepartnerships
withcommunitiesandutilizeavarietyofformalandinformalmechanismstofacilitate
communityandpatient/consumerinvolvementindesigningandimplementingCLAS‐
relatedactivities.
13. Healthcareorganizationsshouldensurethatconflictandgrievanceresolution
processesareculturallyandlinguisticallysensitiveandcapableofidentifying,
preventing,andresolvingcross‐culturalconflictsorcomplaintsby
patients/consumers.
14. Healthcareorganizationsareencouragedtomakeavailableregularlytothepublic
informationabouttheirprogressandinnovationsinimplementingtheCLAS
standards.
Legalrequirementsforculturallycompetenthealthcare
TheLiaisonCommitteeonMedicalEducationRequirements,whichoversees
accreditationforallmedicalschoolsintheUnitedStatesandCanada,requiresthatmedical
studentsandfacultymusthaveanunderstandingofthemannerinwhichpeopleofdiverse
culturesandbeliefsystemsperceivehealthandillnessandrespondtovarioussymptoms,
diseases,andtreatments(StandardED21).
TheEmergencyMedicalTreatmentandActiveLaborAct,alsoknownasthePatient
Anti‐dumpingAct,requireshospitalsthatparticipateintheMedicareprogramandthat
haveemergencydepartmentstotreatallpatients(includingwomeninlabor)inan
emergencywithoutregardtotheirabilitytopay.Hospitalsthatfailtoprovidelanguage
6
assistancetopersonsoflimitedEnglishproficiencyarepotentiallyliabletofederal
authoritiesforcivilpenalties,aswellasrelieftotheextentdeemedappropriatebyacourt.
TheHill‐BurtonAct,enactedbyCongressin1946,encouragedtheconstructionand
modernizationofpublicandnonprofitcommunityhospitalsandhealthcenters.Inreturn
forreceivingfunds,recipientsagreedtocomplywith"communityserviceobligations,"one
ofwhichisageneralprincipleofnon‐discriminationinthedeliveryofservices.TheOffice
ofCivilRightshasconsistentlyinterpretedthisasanobligationtoprovidelanguage
assistancetothoseinneedofsuchservices.
MedicaidregulationsrequireMedicaidprovidersandparticipatingagencies,including
long‐termcarefacilities,torenderculturallyandlinguisticallyappropriateservices.The
HealthCareFinancingAdministration,thefederalagencythatoverseesMedicaid,requires
thatstatescommunicatebothorallyandinwriting"inalanguageunderstoodbythe
beneficiary"andprovideinterpretationservicesatMedicaidhearings.
Medicareaddresseslinguisticaccessinitsreimbursementandoutreacheducation
policies.Medicareprovidersareencouragedtomakebilingualservicesavailableto
patientswherevertheservicesarenecessarytoadequatelyserveamultilingualpopulation.
Medicarereimburseshospitalsforthecostoftheprovisionofbilingualservicestopatients.
TheOfficeofMinorityHealth,adivisionoftheUnitedStatesDepartmentofHealthand
HumanServices,haspublishedasetofstandardsforCulturallyandLinguistically
AppropriateServices(CLASStandards).Thesestandardsappearinfullunder“Best
PracticesforCulturalCompetency”(seepage5).Asnotedabove,allrecipientsoffederal
funds(includingpaymentsfromMedicaidandMedicare)arerequiredtocomplywith
standards4‐7.
TitleVIoftheCivilRightsActof1964providesthat"[n]opersonintheUnitedStates
shall,ongroundofrace,colorornationalorigin,beexcludedfromparticipationin,be
deniedthebenefitsof,orbesubjectedtodiscriminationunderanyprogramoractivity
receivingFederalfinancialassistance."
VTStatutesAnnotatedTitle18§1852(a)(15)providesthatpatientswhodonot
understandEnglishandpatientswhoarehearingimpairedhavearighttoaninterpreterif
thelanguagebarrierorhearingimpairmentpreventsthepatientfromunderstandingthe
careandtreatmentprovided.
VTStatutesAnnotatedTitle18§8728(a)(5)and(b)(3)providethatpatientswith
developmentaldisabilities,andtheirfamilies,havetherighttocommunicateintheir
primarylanguageandprimarymodeofcommunication.
7
Effectivecommunication
Thebestmedicalcarecomesfromhighqualitycommunicationbetweenthehealthcare
teamandpatients.Poorcommunicationcanleadtodelayedcare,inappropriatetreatment,
andfrustration.Researchshowsthateffectivecommunicationbuildslastingrelationships
betweenprovidersandpatients,whichensuresthatpatientsaremorelikelytodisclose
information,returnforfuturevisits,andcomplywithmedicaladvice.
Gettoknoweachpatient’ssocialandculturalperspective
Todoso,youmaywanttoaskthefollowingquestions.
 Whatlanguagedoyouspeak?
 Doyouhavefriendsorrelativeswhomyoucancallforhelp?
 Areyouinvolvedinareligiousorsocialgroup?
 Howaremedicaldecisionsmadeinyourfamily?
 Doyoueverhavetroubleunderstandingyourmedicationbottlesorappointment
slips?
 Ismoneyaproblemforyou?Areyouevershortoffoodorclothing?
Takea“cultural”history
Thefollowingsimplevariationsonquestionsaskedduringatypicalhistorymayhelpyou
gainabetterunderstandingofthepatient’sculturaloutlookondisease.
 Whatdoyoucallthisillness?
 Whatdoyouthinkcausedthisproblem?
 Whydoyouthinkitstartedwhenitdid?
 Whatdoesyoursicknessdotoyou?Howdoesitwork?
 Howsevereisyoursickness?Howlongdoyouexpectittolast?
 Whatproblemshasyoursicknesscausedyou?
 Whatdoyoufearaboutyoursickness?
 Whatkindoftreatmentdoyouthinkyoushouldget?
 Whatarethemostimportantresultsyouhopetogetfromthistreatment?
Makeanefforttohireadiversestaff
 Membersofyourhealthcareteamwhocanspeakmorethanonelanguagecanbe
valuableinhelpingthepatientcommunicate,especiallywhenpatientscometoyour
officeandinterpreterarrangementshavenotyetbeenmade.
 Seekingmedicaladviceinanewcountrycanbeintimidating.Havingsomeoneinthe
officewhospeaksyourlanguagecanbecomfortingandmaymakethetransitiongo
moresmoothly.
Havebrochuresandhealthcareinformationavailableinmultiplelanguages
Manypamphletshavebeenwrittenindifferentlanguagesforthosewhodonotspeak
English.Havingtheseavailablecanensurethatyourpatientsleavetheofficewithwritten
informationthattheycanrefertointhefuture.
8
Wheretogetpamphletsinotherlanguages:
The24LanguagesProject
Electronicaccesstoover200healtheducationbrochuresin24different
languages.ThisisaprojectoftheSpencerS.EcclesHealthSciencesLibrary,in
partnershipwiththeUtahDepartmentofHealth,theImmunizationAction
Coalition,theAssociationofAsianPacificCommunityHealthOrganizations,
andmanyothers.http://medlib.med.utah.edu/24languages/
HealthyRoadsMedia
Thissitecontainsfreeaudio,writtenandmultimediahealtheducation
materialsinanumberoflanguages.ProducedbyaconsortiumofMidwestern
organizations.http://www.healthyroadsmedia.org
FoundationforHealthyCommunities
ANewHampshire‐basedorganizationthathasmedicalformsandhealth
informationavailableinseverallanguages.
www.healthynh.com/fhc/resources/translateddocuments.php
VermontDepartmentofHealthRefugeeHealthProgram
http://healthvermont.gov/local/rhealth/rh_fact.aspx
Useinterpreterservices
 Interpretersaretrainedtomakecommunicationeasierandtohelpprovidersrelay
importantmedicaladvicetopatients.
 FamilyandfriendsshouldNOTbeusedtoprovideinterpretationservices(unless
requestedbythepatient).
 Interpretersareavailableinalmosteverylanguageyoumightencounter,bothin
Vermontandnationwide.Ifpossible,makearrangementsinadvancesoan
interpretercanbeinplaceatthetimeofthevisit.
 Keepinmindthatyoumayalsoneedinterpretersandhealthcareinformationfor
patientswithvisualorhearingimpairments.AmericanSignLanguageinterpreters
andhealthinformationinBraillearealsoaccessiblethroughinterpreterservices.
 FollowtherecommendationsintheVermontRefugeeResettlementProgram’s
publicationAQuickGuidetoWorkingWithInterpreters,reproducedonthenext
page.
9
AQuickGuidetoWorkingwithInterpretersb
 Hireatrainedinterpreter;donotasktheclient’s
childrentointerpretunlessitisanemergencyandyou
havenoimmediatealternative.
 Ifyouhaveanewinterpreteroradifficultorhighly
technicalsituation,scheduleapre‐session.Taketime
toexplaintheinformationyouneedtohave
communicated.
 Scheduleenoughtime;workingwithaninterpretertakeslongerthananappointment
withoutone.
 Speakdirectlytotheclient:“Howareyoutoday?”ratherthan,“Askherhowsheis
today.”
 Avoidprofessionaljargon;usetermsalaypersonwouldunderstand.
 Bepreciseandtrynottostringquestionstogether.Forexample,“Doyousmoke,drink
ortakedrugs?”shouldbethreeseparatequestions.
 Giveyourinterpretertimetoprocessbothyourinformationandtheclient’s.
 Bepreparedtohavetheinterpreterinterruptwhensomethingneedsclarification.
 Looktoyourinterpretersasaculturalresource;treatthemwithrespectand
consideration.
ATipforLocalHealthCareProviders:
WhenhiringaninterpreterforaMedicaidpatient,theproviderisexpectedto
paytheinterpreter.Thebillingcodeforinterpreterservicesis“T1013”.Aunit
ofserviceis15minutesofinterpreting.Providersreceive$15.00foreach15‐
minuteunit.
LocalInterpreterServicesandResources
TheCommunityHealthCentersofBurlington.TheCommunityHealthCentersof
Burlington(CHCB)hasgainedgreatknowledgeaboutinterpreterservicesinitsyears
workingwithrefugeeandimmigrantpopulations.ContacttheCHCBforinformationabout
whatservicestheyworkwithandrecommend,andtodiscusswhatissueshavecomeupin
thepastandhowtheywereabletosolvethem.(802)864‐6309www.chcb.org/
bCourtesyoftheVermontRefugeeResettlementProgram,462HegemanAvenue,Colchester,VT05446;802‐
654‐1706
10
VermontInterpreterReferralService.TheVermontInterpreterReferralService(VIRS)
providesinterpreterservicesfordeafandhardofhearingpatientsinavarietyofsettings,
includingmedical.TheyalsoofferComputerAidedRealtimeTranslationservices(CART),
whichallowsdeafandhardofhearingpatientstoreaddialoguefromacomputerscreenas
theconversationtakesplace.(802)254‐3920ortollfree(800)639‐1519www.virs.org
VermontInterpretingandTranslatingServices.TheVermontInterpretingand
TranslatingService,locatedinColchester,Vermont,ispartoftheVermontRefugee
ResettlementProgram(VRRP)andprovidesprofessionalinterpretationandtranslation.
(802)654‐1706or(802)655‐1963http://www.vrrp.org/translation.html
AssociationofAfricansLivinginVermont.TheAssociationofAfricansLivinginVermont
(AALV),locatedinBurlington,Vermont,providesprofessionalinterpretationand
translationaspartofitsAALVInterpretProgram.(802)355‐0795or(802)985‐3106
http://www.africansinvermont.org/interpret/
Otherinterpreterservicesandresources
CertifiedLanguagesInternational
http://www.certifiedlanguages.com
800‐225‐5254
CyraCom
http://www.cyracom.com
520‐745‐9447
NewWorldLanguageServices
http://newworldlanguages.com
800‐873‐9865
SpectraCorp
CrossCulturalCommunicationServices,Inc.
www.embracingculture.com
781‐729‐3736
LanguageLineServices
http://languageline.com
800‐752‐6096
PacificInterpreters
http://www.pacificinterpreters.com
800‐311‐1232
Telelanguage
http://spectracorp.com/services/n_language_services.aspx
877‐695‐7945
http://www.telelanguage.com/interpretation.cfm
888‐983‐5352
Inaddition,TheNationalCouncilonInterpretinginHealthCareoffersavarietyof
usefulresourcesontheirwebsite:http://www.ncihc.org.Weparticularlyrecommend
theirNationalStandardsofPracticeforInterpretersinHealthCare,whichcanbefoundat
http://data.memberclicks.com/site/ncihc/NCIHC%20National%20Standards%20of%20Pr
actice.pdf
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BuildingaCulturallyCompetentPractice–NEW!
Fundamentally,acceptingtheimportanceofculturalcompetenceinclinicalpracticeis
mucheasierthanactuallyestablishingapracticethatincorporatessuchmandates.
Howevertherearestepsthatinstitutionsandpracticescantaketofosteranatmosphereof
inclusionandtofacilitatethebestoutcomespossiblefortheirpatients.Thefollowing
guidelinesandbestpracticesareadaptedfromtheNationalCenterforCultural
Competenceandrelatedsources.5‐9_ENREF_5
Planning,implementing,andevaluatingculturalcompetenceinprimary
healthcaresettings
Createasharedvision
Toshapeinitialculturalcompetenceimprovementeffortsandtoevaluatetheeffectofsuch
effortsinthefuture,anorganizationmustfirstdefinetheconceptofculturalandlinguistic
competenceanditsachievementgoals.Itmaybebeneficialforpracticestotakeaproactive
roleindevelopingtheirgoalsbyinvitinglocalfamilies,advocacygroups,orothervested
partiestoparticipateinthesediscussions.Thegoalsforsmallorruralpracticesmaybe
narrowerthanthoseoflargerpractices;organizersshouldadaptthesuggestionsbelowto
meettheiruniquecapabilities.
 Beinformed.Asahealthcareprofessional,youshoulddevelopasolid
understandingoftheculturalgroupsthatyouarelikelytoserve.Understanding
eachpatient’sculturalidentityasfullyaspossiblecansignificantlyimprovethe
clinicalencounter.Forexample,itmaybeimpossibletoaddresscertainissues,such
assexualhistoryordrugandalcoholuse,withoutagooddegreeofcultural
sensitivity.
 Bewareofstereotyping.Whileinformationaboutaspecificculturecanaid
understandingofapatient,itisalsoimportanttoremembernoteverypatientfrom
aparticularculturewillsharetheexperiencesorholdthebeliefsthatare
traditionallyassociatedwiththatculture.Eachpatientisunique,andtherearemany
factorsthatalteraperson’sculturalidentity,includingsocioeconomicstatus,
education,age,religion,gender,andlifestyle.
 Respectyourpatients.Strivetoshowrespectforthedignityofeverypatient,
regardlessoftheirage,gender,religion,class,sexualorientation,orethnicor
culturalbackground.Bewillingtoincorporatetraditionalpracticesreflectingthe
healthbeliefsofdifferentculturesintotreatmentplans.It’salsoimportantforyouto
accepttherightofpatientstorefusecare.
 Enlistcommunitysupport.Maintainalistofcommunityresourcestoaddress
communicationneeds.
13
Conductaninitialassessment
Topinpointareasinneedofimprovement,practicesneedtobewell‐versedintheir
strengthsandweaknesses,atboththeadministrativeandcare‐directedlevel.Such
assessmentshouldincludemetricsdetailingattitudesandbeliefsandcompliancelevelwith
CLASandTitleVIstandards.Pleaseseepage18,“Toolsforself‐assessmentand
improvement”,foralistofresourcestohelpevaluateculturalcompetence.
 Assessthedifferentethnic,cultural,linguistic,andreligiousgroupsthatmaycome
incontactwithagivenpracticeinordertodeterminethescopeofthenecessary
competencemeasures.Suchassessmentsshouldbeconductedonaregularbasisas
demographicsarechangingatanincreasinglyrapidpace.
 Collectpatientinformationtodeterminecommunicationneeds.
 Involvepatientsintheprocessofdevisingcommunicationsstrategies.
 Beawarethatpatientswillhavedifferentlevelsofhealthliteracy,andprovide
languageassistancewhenneeded.
 Assesspatientsatisfactionwiththequalityofculturalservicesrendered.
 Evaluatecommunicationperformanceovertime.
Evaluatecapacity,definegoals
Likesomuchelseinmedicine,effortstoimproveculturalcompetencyaresubjectto
financialandtemporalconstraints.Assuch,leadersintheseprojectsneedtobehonest
aboutthelevelofeffort,amountofresources,andnumberofpartnershipstheirgoalswill
requireandusetheseparameterstoinformtheirpriorities.Resourcesdevotedto
maintainingordevelopingculturalcompetenceshouldbeidentifiedeachfiscalyearand
analyzedovertime.Similarly,prioritiesshouldbeclearlydefined.Thesecouldinclude:
 raisingawarenessofculturalandlinguisticcompetence;
 increasingunderstandingandknowledgeofculturalandlinguisticcompetence
relatedtothedeliveryofhealthcareservices;and
 developingskillsetsthatapplyknowledgeofculturalandlinguisticcompetenceto
healthdisparities,healthcareaccessandutilization,patientandprovider
satisfaction,andparticipatoryresearchmethodologies.
Implementchanges
Services
 Offerservicesatflexibletimes,andifpossibleinlocationsthatareeasilyaccessible.
 Bemindfulofreligiousholidaysandscheduleaccordingly.
 Makesuremedicalintakeformsareinclusive,withgender‐neutrallanguage
(especiallywithregardtogenderidentification).
 Haveawell‐definedprocedureforidentifyingandaddressingculturally
incompetentbehaviorbystaffmembers.
 Includepolicies,procedures,andfiscalplanningtoensuretheprovisionof
translationandinterpretationservices.
14
‐
‐
‐
‐
‐
‐
‐
Assembleandmaintainalistofinterpretersforbothmanuallycodedand
spokencommunication.
Includepoliciesandproceduresregardingthetranslationofpatientconsent
forms,educationalmaterials,andotherinformationintoformatsthatmeet
theliteracyneedsofpatients.
Attempttolearnafewcommonphrasesinthedifferentlanguagesspokenby
patients.
Providesimplevisualaidsandusegesturesorphysicalpromptsforpatients
withlimitedEnglishproficiencyorwithlimitedhealthliteracy.
Ensurethatprintedinformationdisseminatedbythecliniciswrittenata
levelconsistentwiththeaverageliteracylevelofthetargetpopulation.
Offerwrittennotificationsinpatients’language(s)oforigin.
Somepatientsmayprefertobenotifiedverbally;accountforthis.
Humanresourcesandstaffdevelopment
 Totheextentpossible,hireadiverseandlinguisticallycompetentstaff.
 Providepre‐serviceandin‐servicetrainingandprofessionaldevelopmentactivities
forallstaffandgoverningboardmemberstoensureunderstandingandacceptance
ofvalues,principles,andpracticesgoverningculturalandlinguisticcompetence
(includingfamilies,youth,peerprofessionals,etc.).
 Advertisepositionsinpublicationswithdiversereadershipsorinlocationsthat
haverobustminoritypopulations.
 Dedicateresourcestoprovidelanguageaccessservicesfortheorganization.
Physicalenvironment
 Displaypictures,posters,andothermaterialsthatreflecttheculturesandethnic
backgroundsofchildren,youth,andfamiliesservedbytheclinic.
 Ensurethatmagazines,brochures,andotherprintedmaterialsinreceptionareas
areofinteresttoandreflectdifferentcultures.
 Incorporatetoysthatarerepresentativeofdifferentculturalandethnicgroupsinto
thereceptionareaandduringanyassessments.
 Offergender‐neutralbathroomsandotherfacilities.
 Providesignsthatareinlargeprint,clear,anduseatleasta70%colorcontrastto
ensurevisibility.
Data
 Useself‐identificationasanapproachtocollect,report,andevaluatedatafor
individualsfromdiverseculturalandlinguisticgroups.
 Incorporatestrategiestostayinformedaboutmajorhealthandmentalhealth
concernsandissuesforethnically/culturallydiverseclientpopulationsresidingin
thegeographicregionoftheclinic.
‐ beattunedtodiseaseprevalenceindifferentcommunities
15
‐
‐
beawareofandsensitivetodisparitiesamongthesecommunities
beawareoftheenvironmentalandsocio‐economicriskfactorsthat
contributetohealthdisparitiesamongdifferentcommunities
Thefrontdesk
 Therearemanyaspectsofcarethatextendbeyondpatientinteractionwithagiven
provider.Infact,familiesmayhavemorecontactwithsupportstaff—particularly
thefrontdesk—thantheydowithhealthcareprofessionals.Giventhisreality,
cliniciansmustmakesurethattheymeettheneedsoftheirpatientsinaculturally
sensitivemanneratbothaninstitutionalandpersonnel‐basedlevel.
 SeetheNationalCenterforCulturalCompetence’sGuidelinesfortheFrontDesk,
reproducedonthenextpage,foradditionalinformationonthistopic.
Elicitregularfeedback
 Offeropportunitiesforpatientsandfamiliestolodgeanonymouscomplaints
regardingtheirexperiencewithclinic,linguistic,oradministrativestaff.
 Encourageemployeestoregularlycompleteself‐assessmentsandassessmentsof
theclinic’sfunctioningasawhole.
 Identifyandfollowculturalcompetenceparameterstotrackprogressovertime.
 Supportconcretemechanismstotranslateresultsofqualitysurveysinto
improvements.
16
NationalCenterforCulturalCompetence:GuidelinesfortheFrontDesk
TheNationalCenterforCulturalCompetence(http://nccc.georgetown.edu/)hasanumber
ofusefulresourcesonitswebsite,includingthefollowingrecommendedguidelinesfor
addressingculturalandlinguisticcompetenceatthefrontdesk.
ThisisanexcerptfromapublicationentitledCulturalCompetence:ItAllStartsattheFront
Desk,bySuzanneBronheim,PhD.Theentiredocumentisavailableat:
http://nccc.georgetown.edu/documents/FrontDeskArticle.pdf
OrganizationalPolicies&Procedures
 PoliciesandproceduresonhowtoserveindividualswhospeaklittleornoEnglishare
writtenandwellknowntostaff.Ataminimum,proceduresshouldaddresswhat
resourcesareavailabletostaff,howtheyshoulddetermineafamily’sneedfor
languageaccessservices,andhowtheyshouldhandlesituationsinwhich
communicationsareproblematic.
 Policiesandproceduresonhowtoserveindividualswithothercommunicationneeds
(e.g.,hearingimpairmentandlimitedliteracylevels)arewrittenandwellknownto
staff.Ataminimum,proceduresshouldaddresswhatresourcesareavailabletostaff,
howtheyshoulddetermineafamily’sneedforlanguageaccessservices,andhowto
handlesituationsinwhichcommunicationsareproblematic.
 Dedicatedresourcesareallocatedtoprovidelanguageaccessservicesforthe
organization.
 Organizationstaffarewellversedinthepolicies,andknowledgeableofthe
procedures,usedtoprovideinformationtofamilies.Suchinformationenablesfamilies
toadvocateontheirownbehalfwhentheyexperiencebiasordiscriminationinany
aspectofthehealthcareorganization.
 Organizationalpolicyrequiresperiodicreviewsofthedemographicmakeupofthe
communitiesservedtodeterminewhether:
‐ additionalornewlanguageaccessservicesareneeded,or
‐ modificationstopoliciesandpracticesareneededtoaddressnewand
emergingpopulations.
WorkforceDevelopment
 Organizationalpoliciesandproceduresincludeeffortstorecruitandretainfrontdesk
staffwhoreflecttheculturalandlinguisticdiversityofthecommunitiesserved.
 Jobdescriptionsandrecruitingnoticesincludeskillsetsandareasofknowledge
relatedtoculturalandlinguisticcompetence.
17
 Performanceevaluationstandardsincludebehaviors,attitudes,knowledge,andskill
setsrelatedtoculturalandlinguisticcompetenceandfamily‐centeredcare.
 Frontdeskstaffareincludedin
professionaldevelopmentandtraining
effortsthroughouttheorganizationon
culturalandlinguisticcompetenceand
family‐centeredcare.Additionally,front
deskstaffareprovidedwithnewemployee
orientationandongoingprofessional
developmentthatincludestraining
activitiestailoredtohowculturaland
linguisticcompetenceisincorporatedinto
theirspecificrolesandfunctionswithinthe
organization.Ataminimum,thecontent
ofsuchtrainingactivitiesshouldsupport
frontdeskstaffin:
‐
‐
‐
‐
Negativeinteractionswith
thefrontdeskcanresultin:
 decreasedormissed
appointments
 reticencetocalltheclinic
withquestions
 lossofreferralsand/or
income
 thefilingofagrievanceor
discriminationcomplaint
interactingeffectivelywithindividualsfromdifferentculturalandlinguistic
groups;
workingwellwithtrained/certifiedinterpreters;
communicatingsuccessfullyacomplexarrayofinformationtoindividualswho
possesslowliteracyskillsorwhoarenotliterate;and
confrontingbias,discrimination,andracisminhealth,mentalhealth,and
socialservicesystems.
QualityImprovement
 Supervisorsareknowledgeableaboutthebehaviors,attitudes,andskillsetsrequired
bythefrontdesktoworkeffectivelywithpatientpopulationsthatareculturallyand
linguisticallydiverse.Additionally,supervisorsaretrainedtoconducteffective
evaluationsoftheseperformancerequirementsandtosupportstaffinenhancingtheir
performance.
 Informalandformalmechanismsareusedtosolicitinputfromindividualconsumers
abouttheirfrontdeskencounters,withspecificqueriesabouttheirexperiencesrelated
tothedeliveryofculturallyandlinguisticallycompetentcare.Resultsareusedto
informqualityimprovementefforts,includingthemodificationofpoliciesand
proceduresand/ortheprovisionoftraining.
 Mechanismsexistforfamiliestolodgecomplaintsanonymouslysothattheywillnot
fearreprisalsforraisingconcerns.
 Anadvisorycommittee,madeupofdiversefamiliesservedbythepractice,clinic,or
hospital,providesinputonoverallorganizationfunctions.Thisinformationshouldbe
usedaspartofcontinuousqualityimprovementeffortsoftheorganization.
18
Toolsforself‐assessmentandimprovement
InVermont,traininginculturalandlinguisticcompetenceformentalhealthandhealth
providersisofferedthroughtheVermontChildMentalHealthInitiativebycontacting
MariaMercedesAvilaat(802)999‐4985.
TheNationalCenterforCulturalCompetence(NCCC)atGeorgetownUniversityprovides
linkstomorethanadozenassessmenttoolsatthefollowingURL:
http://nccc.georgetown.edu/resources/assessments.html.
TheNCCChasalsodevelopeditsownassessment,theCulturalCompetenceHealth
PractitionerAssessment,copyrightedbyGeorgetownUniversity,whichisavailableat:
http://nccc.georgetown.edu/features/CCHPA.html.
TheCaliforniaAcademyofFamilyPhysicianshasproducedAddressingLanguageAccess
IssuesinYourPractice:AToolkitforPhysicians,whichisavailableat:
http://www.familydocs.org/assets/Multicultural_Health/Addressing%20Language%20Ac
cessToolkit.pdf.
AdditionalResources
TheEthnoMEDwebsitehttp://ethnomed.org/contains“informationaboutculturalbeliefs,
medicalissues,andrelatedtopicspertinenttothehealthcareofimmigrants[…].”
TheRefugeeHealthInformationNetworkhttp://rhin.org/“providesmultilingualhealth
informationforrefugeesandtheirhealthproviders.”
19
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blank.
20
Vermont’sSpecialPopulations
Populationsincludedinthismanual
ThismanualincludesinformationonmajorrefugeeandimmigrantpopulationsinVermont
aswellasonthefollowingpopulationsthathaveuniquehealthneeds:AfricanAmerican;
NativeAmerican;deafandhard‐of‐hearing;elderly;lesbian,gay,bisexual,transgender,
queer/questioningandintersex(LGBTQI);homeless;Latinomigrantfarmworkers;and
women.
Healthissuescommontopopulationsincludedinthismanual
Thefollowingsectionsofthismanualwillhelpyoubecomefamiliarwithhealthcare
disparitiesthatarecommonwithincertainspecificpopulations.Inaddition,itshouldbe
notedthattherearetwoareasofhealthcaredisparitiesthatarecommontoallofthese
groups:mentalhealthandoralhealth.
Mentalhealth
Mentalhealthisofparticularconcerninrefugeepopulations.Highlevelsofstress,feelings
ofdespairandisolation,historiesofviolenceandpersecution,andothercontributing
factorscanleadtosevereemotionalproblems.Post‐traumaticstressdisorder(PTSD)and
depressionareamongthetwomostcommonmentalillnessesseeninrefugeepopulations.
Approachingarefugeepatientaboutmentalillnesscanbecomplicated.Providerswho
suspectmentalillnessshouldspeakwiththepatientabouttheirculturalbeliefsregarding
mentalillness,asthestigmaisgreaterinsomepopulationsthaninothers.Workingwith
thepatienttofindtherightcarefortheirillnessandtounderstandtreatmentoptionscan
alsobechallenging.Beingpreparedwiththerightresources,knowingaboutspecific
cultures,andbeingsensitivetothewishesofthepatientwillhelpincommunicating
concern.
MinoritypopulationsintheUnitedStatesarealsoatgreatriskformentalillness.Consider
thefollowingfactsfromtheOfficeofMinorityHealth:
 OneintwoAmericanshasadiagnosablementaldisordereachyear.Thisincludes44
millionadultsand13.7millionchildren.
 Fewerthanhalfofadultsandonlyone‐thirdofchildrenwithdiagnosablemental
disordersseekhelp.
 Mostmentaldisorders(80‐90%)aretreatableusingmedicationandbehavioral
therapies.
 AfricanAmericansaremorelikelytoexperienceamentaldisorderthanCaucasians.
Theyarealsolesslikelytoseektreatment.
 NativeAmericansandAlaskanNativessufferdisproportionatelyfromdepression
andsubstanceabuse.
21
 Homelesspeoplehaveoneofthehighestratesofmentalillness.
 AsianAmericanandPacificIslandersaremorelikelytobemisdiagnosedwhenit
comestomentalillness.
Oralhealth
Therearemanyreasonswhydentalhealthhasbecomeasignificantprobleminhealthcare,
particularlyforminoritypopulations.Lackofdentalcareisperhapsthelargest
contributingfactortopoororalhealth.Dentalservicesarerarelycoveredundermedical
insuranceandwithmorethan40millionuninsuredintheUnitedStates,itiseasytosee
whydentalhealthisnotapriorityformany.Dentalworkandmaintenancecanbe
expensiveandmanypeoplearemoreconcernedwithday‐to‐daylivingthanwithcavities
andtoothdecay.
Poororalhealthisextremelycommonamongrefugeepopulations.Manydidnothave
accesstocleanwater,toothpaste,toothbrushes,floss,fluoride,oranyothernecessary
componentsforhealthyteethandgums.Manyrefugeeshaveneverbeentoadentistorare
notawareofthebenefitsoforalhealth.
Dentalhealthisextremelybeneficialtothosewhocanaccessitasitcanpreventserious
healthcomplications.Poororalhealthcanleadtogumdisease,whichcanresultinlost
teethandanincreasedriskforheartdiseaseandstroke.Whenplaquebuildsupand
hardensonteethandgums,itcantravelfromthemouthtothebloodstreamwhereitcan
clogarteries,damageheartvalves,andcauselungconditions.ResearchattheNational
InstitutesofHealth(NIH)hasshownalinkbetweengumdiseaseanddiabetesaswell.
Complicationsofdiabetescanbecomemoreseverewithgumdiseaseandconversely,
diabetescancausegumdisease,makinggoodoralhygieneparticularlyimportantto
diabeticpatients.Finally,oralhealthisextremelyimportantforpregnantwomen.TheCDC
statesthatgumdiseaseinpregnantwomenmayputwomenathigherriskofdelivering
premature,lowbirthweightbabiesthanwomenwithoutgumdisease.
Oralhealthisbestaddressedearly,whenchildrenarefirstbeginningtocareforteethand
gums.AccordingtotheVermontDepartmentofHealth,dentaldecayisthesinglemost
commonchronicdiseaseofchildhoodandisfivetoeighttimesasprevalentasasthma.
Nationally,morethanhalfofallchildrenhavecavitiesbysecondgradeand80%ofchildren
havehadcavitiesbythetimetheygraduatehighschool.
Providersshouldparticipateinoralhealtheducationasmuchaspossible,andrefer
patientstodentalorganizationsthatcanhelp.
22
References
1.
FormicolaAJ,StaviskyJ,LewyR.Culturalcompetency:dentistryandmedicine
learningfromoneanother.JDentEduc.Aug2003;67(8):869‐875.
2.
WhitleyR.Culturalcompetence,evidence‐basedmedicine,andevidence‐based
practices.PsychiatrServ.Dec2007;58(12):1588‐1590.
3.
EngebretsonJ,MahoneyJ,CarlsonED.Culturalcompetenceintheeraofevidence‐
basedpractice.JProfNurs.May‐Jun2008;24(3):172‐178.
4.
BetancourtJ.Culturalcompetency:providingqualitycaretodiversepopulations.
TheConsultantpharmacist:thejournaloftheAmericanSocietyofConsultant
Pharmacists.2006;21(12):988‐995.
5.
GoodeTD.Planning,ImplementingandEvaluatingCulturallyCompetentService
DeliverySystemsinPrimaryHealthCareSettings:ImplicationsforPolicyMakers
andAdministrators.http://nccc.georgetown.edu/documents/Getting_Started.html.
6.
GoodeTD.GettingStarted:Planning,ImplementingandEvaluatingCulturallyand
LinguisticallyCompetentServiceDeliverySystemsforChildrenwithSpecialHealth
NeedsandtheirFamilies.Washington,DC:NationalCenterforCultural
Competence;2003.
7.
GoodeTD,JacksonVH.GettingStarted...andMovingOn:Planning,Implementingand
EvaluatingCulturalandLinguisticCompetencyforComprehensiveCommunityMental
HealthServicesforChildrenandFamilies.Washington,DC:NationalCenterfor
CulturalCompetence;2003.
8.
GoodeTD,SockalingamS,BronheimS,BrownM,JonesW.APlanner'sGuide:Infusing
Principles,ContentandThemesRelatedtoCulturalandLinguisticCompetenceinto
MeetingsandConferences.Washington,DC:NationalCenterforCultural
Competence;2000.
9.
BronheimS.CulturalCompetence:ItAllStartsattheFrontDesk.
http://nccc.georgetown.edu/documents/FrontDeskArticle.pdf.AccessedApril,
2012.
23
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24
Bhutanese–NEW!
CountryInformationa
Name:
Bhutan(translatesto“LandoftheThunderDragon”inreference
totheviolentstormsintheHimalayas)
Location: SouthernAsiabetweenChinaandIndia;Southerneastern
HimalayaMountains
Capital: Thimphu
Area:
38,394sq.km.(OnehalfthesizeoftheStateofIndiana)
Climate: Variable;tropicalinsouthernplains;coolwintersandhot
summersincentralvalley;severewintersandcoolsummersin
Himalayas
Terrain: Mostlymountainouswithsomefertilevalleysandsavanna;Arable
land2.3%
Language(s):Sharchhopka28%,Dzongkha(official)24%,Lhotshamkha
(Nepalese),other26%
EthnicGroups:Bhote50%,ethnicNepalese35%(includingLhotsampas),
indigenousormigranttribes15%
Population:
InBhutan:716,896
RefugeesinNepal:56,710asofJanuary2012b
InVT:950c
aUnlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.https://www.cia.gov/library/publications/the‐world‐
factbook/geos/so.html
bTheUNRefugeeAgency,2012UNHCRCountryoperationsprolfile‐Nepal.AccessedJune27,2012.
http://www.unhcr.org/pages/49e487856.html#
cVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
25
26
27
BackgroundandCulture
TheNepali‐speakingBhutanese,alsoknownasLhotsampa,areBhutanesecitizensofNepali
origin.PeoplefromNepalwereinvitedtopopulatethelowlandsofsouthernBhutaninthe
mid‐tolate‐nineteenthandearlytwentiethcenturies.Contactbetweenthenorthern
Bhutanese,knownasDruks,andtheNepali‐speakingBhutaneseinthesouthwaslimited.
DespitelivinginBhutanforuptofivegenerations,theNepali‐speakingBhutaneseretained
theirdistinctiveNepalilanguage,culture,traditions,andreligion.TheNepali‐speaking
BhutanesecoexistedpeacefullywithotherethnicgroupsinBhutanuntilthemid1980s,
whenBhutan’skingandtherulingDrukmajoritybecameworriedthatthegrowingNepali‐
speakingBhutanesepopulationcouldthreatenthemajoritypositionandthetraditional
BuddhistcultureoftheDrukBhutanese.Thegovernmentthereforeinitiatedacampaign,
knownas“Onecountry,onepeople,”or“Bhutanization”tostrengthenBhutanesenational
identity.ThepoliciesenforcedtheDrukdresscode,religiouspractices,andlanguageuse
onallBhutaneseregardlessofpriorpractices.Thesepoliciesnegativelyimpactedthe
Nepali‐speakingBhutanesepeople,becausetheydidnotwearthesametraditionaldress,
practicethesamereligion,orspeakthesamelanguageasthenorthernBhutanese.
Whentheyrefusedtoconformtotherequests,theNepali‐speakingBhutanesewere
tortured,raped,andbeaten.Theirhomeswereburnedandtheyweredrivenoutoftheir
countrytoNepal.However,Nepalwasunwillingtoacceptthemascitizens,andover
100,000peoplebecamerefugees.TwentyyearslatertheUnitedStateshasagreedto
resettle60,000refugeesandasofsummer2012,40,000havebeenresettled.
Therearefourmajorcastesystems:Brahmins,Chhetris,Vaishyas,andSudras.The
Brahminsaretypicallypriests,scholars,andeducators.Chhetrisarethewarriorsand
governors.Vaishyasaremerchantsandfarmers,andtheSudrasarethelaborers.Thecaste
systemsarenotasprevalentamongtheyoungergenerationsbutfortheoldergenerations
theymaystillholdstrongbeliefsaroundthis.
Language.AmongtheNepali‐speakingBhutanese,Nepaliisspokenathome.Themajority
oftheyoungergenerationsaremulti‐lingual,speakingNepali,theBhutaneselanguage,
DzongkhaandsomeEnglish.EducationinBhutan,aswellastherefugeecampswas
instructedinEnglish,withastrongeremphasisplacedonreadingandwritingratherthan
thespokenlanguage.TheBritishEnglishdialectwasusedintheschoolssotheNepali‐
speakingBhutanesemayhaveadifficulttimewithAmericanEnglish,especiallywhenit’s
spokenfast.TheoldergenerationsofNepali‐speakingBhutanesemaynotbefamiliarwith
EnglishandthereforemayfeelisolatedandfeartheywillnotlearnEnglish.
Religion.ThemajorityoftheNepali‐speakingBhutaneseareHindu;howeversizable
minoritiesalsopracticeBuddhismorChristianity.IntheChittendencountyareathereis
notaHinduTemple,whichinhibitstheirabilitytopracticetheirreligion.
Family.Historically,membersoftheextendedfamilylivetogether.Grandparentsandthe
communityplayamajorroleinchildrearing.Theyoungestsonistypicallyresponsiblefor
caringforhisparentsastheyage.Thecommunityisverycloselyknitandeldersarehighly
28
respected.Polygamymaybepracticedbysomebutisnotdiscussedwithinthecommunity.
Arrangedmarriagesand“lovematches”arebothcommon.“Lovematches”takeplacewhen
ayoungmanisfondofayoungwoman.Theparentsandeldersofthecommunitymust
grantpermissionbeforecourtshipcanbegin.
Education.In1966Bhutanestablishedapublic
schoolsystemwherechildrenbecameeligibleto
Itisimportanttocounselpatients,
receiveeducationuntilgrade10.Priorto1966
especiallyelders,ongoodoral
manyhadlimitededucation,whichiswhymany
hygieneincludinghowtobrushand
eldersinthecommunityarenotasproficientin
floss.
English.Nepali‐speakingBhutaneseplaceahigh
valueoneducationforbothmalesandfemales,andschoolingcontinuedtobeavailablein
therefugeecamps.SomeNepali‐speakingBhutanesecontinuedtheirhighschoolorcollege
educationinBhutanandIndia,butthoseawardeddegreeswerenotequivalenttothosein
theUnitedStates.ThemajorityofNepali‐speakingBhutaneseintheChittendencountyarea
workinfactories,ashousekeepers,andstoreclerks.
Theextentofparentalinvolvementintheirchildren’seducationintheUnitedStatesisa
newconceptfortheNepali‐speakingBhutanese.Manystudentsstrugglewithtechnologyas
theyhavenothadpreviousexposure.Somestudentsalsostrugglewithfriendshipsand
feelingsofloneliness.
Diet.Riceandlentilsareconsideredstaples.SomeNepali‐speakingBhutanesemaybe
vegetarian,manyHinduswhomayeatmeatdonotconsumebeeforpork.
Theideaofconsentpriorto
HealthCare
receivingamedicalprocedure
Inthecamps,inpatient,outpatientandhealtheducation
andbeinginvolvedinhealth
isprovidedbytheAssociationofMedicalDoctorsofAsia
caredecisionsmaybeanew
(AMDA)‐Nepal.Childhoodvaccinesareroutinely
conceptandshouldbe
availableandhavehighacceptancerates(measles98%,
explained.
Diphtheria,Pertussis,TetanusDPT,95%,Polio,94%and
BCG94%).However,adolescentboostersarenot
routinelygiven.1MostNepali‐speakingBhutanesewillhaveseenpeoplesufferordiefrom
preventablecauses,soonceintheUnitedStatesmanyarewillingtoreceiverecommended
vaccines(althoughthereisahigherrateofdeclinationoftheHPVvaccine).
Historically,theNepali‐speakingBhutanesehaveplacedagreateremphasisonacute
healthcare,onlyvisitingadoctoriftheyweresickorhadcomplicationswithpregnancy.
Somemaynotbefamiliarwithprimarycare,soprovidersmayhavetoprovideadditional
counselingonthebenefitsofpreventivecare.Itisespeciallyimportanttoexplainthat
medicationstopreventchronicdiseasessuchasheartdiseaseanddiabetesmayhavetobe
takenforyears.
Specifichealthconcerns.CommonhealthconcernsamongNepali‐speakingBhutanese
refugeesincludemalnutrition,mentalillnesses(includingdepressionandPTSD),poororal
29
health,andlimitedfemalereproductive/gynecologiccare.Intherefugeecamps,food
rationsincludedriceandlentils.However,theeffectsofmalnutritionforthispopulation,
includingvitaminAdeficiencycausingnightblindness,andvitaminB12deficiencyleading
tomacrocyticanemia,arestillprevalent.23
Dentalhealthwaslimitedinthecamps;manyrefugeesmaynothavereceiveddental
services.
Infectiousdisease.Inthecampsmanyrefugeeswereexposedtotuberculosis.Chronic
malnutritionweakenstheimmunesystemsotherearehighratesofrespiratoryillnesses.
Poorsanitationinthecampshasincreasedtheratesofdysentery.4
Lifestyleriskfactors.Althoughsmokingratesinthecampswerehigh,newlyresettled
refugeesarelesslikelytosmoke,possiblyduetothehighercostofcigarettes.Once
resettledintheUnitedStatesthereisahighprevalenceofobesityanddiabetes.
Chewingbetelnutwascommonintherefugeecampsanditmaycontinuetobeusedbythe
olderBhutaneserefugeepopulation. Betelnutisaseedfromthefruitofapalmfruitthat
producesamildlyeuphoricandstimulatingeffect.Itisbelievedtohelpreducetension.
However,estimatesofitsuseinVermontarenotavailable.Longtermeffectsofchewing
betelnutincludeincreasedriskoforalcancers,pepticulcersandincreasedriskofheart
disease.
Familyplanningandchildbirth.Moderncontraceptioniswidelyacceptedandused,
exceptbyhighlytraditionalindividuals.Mostrefugeesundertheageof35receivedbasic
sexeducationintherefugeecamps.Sexualpractices,sexuality,andgynecological
conditionsmaybeuncomfortableforNepali‐speakingBhutanesewomentodiscuss,
particularlythoseintheoldergenerations.Afemaleprovidermaymakethemmoreatease.
Manywomenmayneverhavehadamammogramorpapsmearandcounselingmaybe
neededtounderstandtheimportanceofpreventativecare.
Childbirth/PostpartumPractices
InBhutanwomengavebirthathomewhilebeingoverseenbyadoula,unlesstherewere
complications.Whileintherefugeecampswomenreceivedroutineprenatalcareandmany
gavebirthinclinics.Anewmothertraditionallyrestsforelevendayspostpartum,only
caringforandnursingthebaby,andhasarespitefromcookingandhousework.Onthe
eleventhday,thechildisnamedduringapurificationritual,performedbyareligious
leader.Infantsaretypicallybreastfedexclusivelyforsixmonths.InBhutanifamotherhad
troublebreastfeeding,thebabywouldbefedcow’smilk,howeverformulabecame
availableintherefugeecamps.IntheUnitedStates,eldersmayincreasinglytakeon
responsibilitiesofchildcarewhilethemotherandfatherworkoutsidethehome.
Mentalhealth.ThereisahighprevalenceofmentalillnessincludingPTSD,anxietyand
depressionfromforceddisplacement,andhavingwitnessedmurders,torture,physicaland
sexualviolence.5,6However,thereisastigmaamongBhutaneserefugeesaboutdiscussing
30
theseexperiencesthatmakeitdifficultforthemtoseekhelpuntilsymptomsbecome
severe.
Traditionalmedicine.Traditionalhealersmaybeconsultedtosupplementtheuseof
modernmedicine.OftenfamiliestryseveralhomeremediesbeforeseekingWestern
medicine.Someexamplesoftraditionalmedicineincludeusingbasiltotreatcoughsand
thecommoncold;usinggarlic,turmeric,gingerandcardamomforstomachailmentsand
massagingwithwarmmustardoiltoreducedmuscleaches.
SomeBhutanesemayfollowfoodrestrictionswhentheyaresickorpregnant,asthey
believecertainfoodsshouldbeavoided.Thesepracticesmayhavetobeexplicitlyaskedof
patientswithadisclaimerofunderstandingandacceptancebeforetheymaybewillingto
sharethisinformationtoaprovider.
SocialEtiquette
 PermissionshouldbegrantedbeforecomingtoorenteringBhutanesehomesand
prayerareas,whichmaybeinthekitchen.
 SomeBhutanesecustoms,suchasarrangedmarriage,marryingyoung,andthe
occasionalpracticeofpolygamymayconflictwiththeAmericanway,legalsystem
andculture.
 Genderrolesaretraditionallydefined,withfemalesperformingthemajorityofthe
householdworkwhilemenaretheprimarydecisionmakersinthefamilyand
community.
 DuetopastexperienceswiththeBhutanesegovernment,Bhutaneserefugeesmay
beafraidandfearfulaboutcallingthepoliceforassistance.
 “Headwiggle”meansyesormaybe.
 Especiallyforelders,handshakingandeyecontactmaymakethemuncomfortable
atfirst.Notmaintainingeyecontactisasignofrespect.
 Whenfirstofferedfood/drinkitispolitetosayno,willacceptonsecondoffer.
 Huggingisonlydonebetweenromanticcouples.
 Traditionally,Nepali‐speakingBhutaneseeatwiththeirhands.
31
Commonlyusedphrases7
English
Hello/Goodbye/Iblessthedivinein
you
Pleasedtomeetyou
Thankyou
Yes
No
Idon’tunderstand
ExcuseMe/Sorry
Getwellsoon
Nepali
Namaste
tapaaiilaaiibhetterakhushii
laagyo
Dhanyabad
Huncha/Ho
Hudaina/Haina
mailebujhina
maaphaganus
chadainikohunuhos
AdditionalResources
 TheVermontBhutaneseAssociation:http://vermontbhutaneseassociation.org/
 CulturalOrientationResearchCenter.BhutaneserefugeesinNepal.October2007No4.
RetrievedJune28,2012from
http://www.cal.org/co/pdffiles/backgrounder_bhutanese.pdf
 Dunkle,S.etal2011.VitaminB12deficiencyinBhutaneserefugees—Nepal.Abstract,
EpidemicIntelligenceService.
 Ellis,H.Suicidesamongresettledrefugees.RetrievedJune20,2012from
http://www.refugeehealthta.org
 InternationalRescueCommittee.ThehealthofrefugeesfromBhutan:February2009.
RetrievedJune29,2012from
http://www.cal.org/co/email_discussion/Attachments/IRC‐
Bhutanese_Health_FactSheet.pdf
 MaxymM,etal.Nepali‐speakingBhutanese(Lhotsampa)culturalprofile.2010.Retrieved
July1,2012fromhttp//www.ethnomed.org.
 UnitedNationsHighCommissiononRefugees(UNHCR),HealthInformationSystem
(HIS).RetrievedJuly2,2012http://www.unhcr.org/pages/4a30c06f6.html
 VTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐
FY11.Colchester,VT:2012.
 TheWorldFactbook.AccessedJune28,2012.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/so.html
References
1. UnitedNationsHighCommissiononRefugees(UNHCR),HealthInformationSystem
(HIS).RetrievedJuly2,2012http://www.unhcr.org/pages/4a30c06f6.html
2. InternationalRescueCommittee.ThehealthofrefugeesfromBhutan:February2009.
RetrievedJune29,2012from
http://www.cal.org/co/email_discussion/Attachments/IRC‐
Bhutanese_Health_FactSheet.pdf
32
3. Dunkle,S.etal2011.VitaminB12deficiencyinBhutaneserefugees—Nepal.Abstract,
EpidemicIntelligenceService
4. InternationalRescueCommittee.ThehealthofrefugeesfromBhutan:February2009.
RetrievedJune29,2012from
http://www.cal.org/co/email_discussion/Attachments/IRC‐
Bhutanese_Health_FactSheet.pdf
5. Ellis,H.Suicidesamongresettledrefugees.RetrievedJune20,2012from
http://www.refugeehealthta.org
6. MaxymM,etal.Nepali‐speakingBhutanese(Lhotsampa)culturalprofile.2010.Retrieved
July1,2012fromhttp//www.ethnomed.org.
7. Fromhttp://www.omniglot.com/language/phrases/nepali.php
33
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blank.
34
BosnianandHerzegovinian
CountryInformationa
Location: SoutheasternEurope,alongtheAdriaticSea;borderingCroatia,
Serbia,andMontenegro
Capital: Sarajevo
Area:
51,197sq.km.(slightlysmallerthanWestVirginia)
Climate: Hotsummersandcoldwinters.Areasofhighelevationhaveshort,
coolsummersandlong,severewinters.Mild,rainywintersalong
coast.
Language: Official:Bosnian,Croatian.Other:Serbian
Note:somesourceslistSerbianasanofficiallanguage.Inthis
chapterweincludeallthreelanguagestobeasinclusiveas
possible.
People: Threeethnicgroupspredominate:Bosniak(48%),Serbian(37%),
Croat(14%).MostBosniaksself‐identifyasMuslims,Serbsas
EasternOrthodox,andCroatsasRomanCatholic.
Population:InBosnia‐Herzegovina:4.6million
InVT:1710b
a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/bk.html
b
VTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
35
36
37
Backgroundandculture
BosniawasonceapartoftheSocialistFederalRepublicofYugoslavia.However,inthe
early1990s,amovementforanindependentBosnianstatetookshape,culminatinginthe
declarationofBosnianindependencein1992andformalrecognitionbytheUnitedNations
onMay22,1992.1Subsequently,civilwarbrokeoutbetweentheBosniaks,BosnianSerbs,
andBosnianCroatsinathree‐waystruggleforpoliticalpower.Asaresultofthewar,more
than2millionBosniansfledthecountry.Althoughthewarofficiallyendedin1995withthe
signingoftheDaytonPeaceAccords,asof2009anestimated1millionrefugeesremaineda
partoftheBosniandiaspora.2
Language.BosniaandHerzegovinahasatleasttwoofficiallanguages—Bosnianand
Croation—andsomesourceslistSerbianasathirdofficiallanguage.Themostcommonly
spokenlanguageisBosnian.AminorityoftheBosnianpopulationmayalsospeakRomany,
Hungarian,Albanian,orSlovene.1
Religion.Religiousaffiliationfallspredominantlyalongethniclines:Bosniakstypically
self‐identifyasMuslim,SerbsasEasternOrthodox,andCroatsasCatholic.TheJewishand
Protestantfaithsarealsorepresentedinasmallminorityofthepopulation.1
Family.TheBosnianfamilystructurediffersbetweenruralandurbanBosnia.Rural
familiesaretypicallypatriarchal,withwomenbearingresponsibilityforthemajorityof
domestictasks,andhouseholdsmayincludeseveralmembersoftheextendedfamily(e.g.
grandparents.)Inurbansettings,housingdoesnotgenerallyincludeextendedfamily,and
responsibilitiesaresharedbetweenhusbandandwife.Inbothruralandurbansettings,
childrenareexpectedtocareforelderlyparents.Becauseofthewar,manyrefugeefamilies
maybeheadedbywidows.3
Education.Primaryeducationlastsfornineyears,startingatagefiveorsix,andis
compulsory.Secondaryeducationmaytakeplaceatathree‐yearvocationalschool,afour‐
yeartechnicalschool,oratafour‐yearuniversity‐preparatoryschoolcalledagimnazia.
Post‐secondaryeducationisavailableateightuniversities.
Diet.AllthreemealsarerepresentedinaBosniandiet,althoughlunchisthemainmealof
theday.Thereisaparticularemphasisonmeatanddairy,especiallybeef,lamb,andpork,
althoughstrictMuslimsdonoteatpork.Brandyisapopulardrink,althoughwine,beer,
coffee,andsoftdrinksarealsoconsumed.3
HealthCare
PrimarycareisfreetothecitizensofBosnia,butpaymentisrequiredforsomemedications
andprocedures.Primarycareoccursmainlyincommunity‐basedclinicscalledambulantas;
theirprimaryfunctionistriage,withpatientssenttolargersecondary‐carefacilitiesfor
diagnosisandtreatmentbyspecialists.Complicatedcasesmaybereferredtotertiarycare
facilitiesatuniversityorteachinghospitals.4Ingeneral,hospitalsareunder‐equippedand
privatepracticesaretooexpensiveformostcitizens.Overallhealthcareisholistic,with
emphasisonvitamins,teas,andotherhomeremedies—oftenduetoalackofaffordable
38
medications.3Thelargestburdenofdiseaseisfromcardiovasculardisease,followedby
neuropsychiatricdisease,thenneoplasia.5Depression,anxiety,andPTSDarecommonasa
resultofthewar.6HIV/AIDSprevalenceis<.1%.7
 UniversalfreehealthcareisavailableinBosnia;asaresult,patientsmaybe
concernedabouttheirabilitytopayforcareintheUnitedStates.
 PrimaryhealthcareplaysasmallerroleinBosniathanitdoesintheUnitedStates,
andinpatienthospitalstaysareoftenlonger;asaresult,patientsmaybeconcerned
aboutthequalityofprimarycare,andofshort‐durationhospitalstays.
 SpecialistsplayalargerroleinroutinecareinBosniathanintheUnitedStates,with
primarypractitionersservingalargelytriage‐orientedfunction;asaresult,patients
maybeconcernedaboutthebroaderscopeofprimarycareintheU.S.
 ManypatientsmaybeintimidatedbythebureaucracyoftheUShealthcaresystem.
 Treatmentisoftennotconsideredcompletewithoutmedication,andmanypatients
willexpectadetailedexplanationoftheirillnessandcourseofdisease.
 MentalillnessandphysicaldisabilitycarryastigmaformanyBosnians.
 DentalcaremaybeavoidedbecauseofinadequatedentalservicesinBosnia.
 Smokingisverycommon,whileanunderstandingofsecondhandsmokeisnot;in
particular,childrenmaybeatriskofexposuretosecondhandsmoke.
 Althoughspecificexamplesoftheprocessofmedicaldecision‐makinginBosniaare
scarce,severalresourcessuggestthatdecision‐makinginvolvestheentirefamily,
especiallywhendecisionsconcernend‐of‐lifecare.8,9
SocialEtiquette
Whileitisimportanttorealizethatwhatconstitutesacceptablesocialconductinone
contextmaybeinappropriateinanother,thefollowinggeneralizationsmaybemadeabout
Bosniansocialetiquette10:
 Eyecontactisconsideredacceptable;lookingstraightintosomeone’seyesisasign
ofhonesty.
 Ahandshakeisthepreferredgreetingbetweenmembersofthesamesexand
membersoftheoppositesex.
 Viewsonpunctualityvary;whileexpectedinbusinesssettings,ininformalmeetings
itislessimportant.
 Itisconsideredgoodmannerstogreettheoldestpersonpresentfirst.
39
CommonlyUsedPhrases
English
Bosnian
Serbian
Croatian
Hello
Dobardan
Zdravo
Bok
Goodbye
Dovidjenja
Cao
Dobidjenja
Please
Molim
Molim
Molim
Thankyou
Hvala
Hvala
Hvala
Goodmorning
Dobrojutro
Dobrojutro
Dobrojutro
Goodevening
Dobrovec̆ er
Dobrovec̆ er
Dobrovec̆ er
Yes
Da
Da
Da
No
Ne
Ne
Ne
Tohearsomeofthesephrases(andothers)pronounced,visithttp://www.bbc.co.uk/
languages/european_languages/languages/index.shtmlandselectalanguagefromthe
menuontheleft‐handsideofthescreen.
AdditionalLanguageResources
Bosnian/English,Croatian/English,andSerbian/Englishdictionariesareavailableonlineat
http://ba.rjecnik.com/,http://www.rjecnik.com/logindict.cgi,and
http://www.recnik.com/,respectively.
GoogleTranslatesupportsCroatian/English,Serbian/English,Hungarian/English,
Slovene/English,andRomany/Englishtranslations,availableat
http://translate.google.com/#.
Additionaltranslatedhealthinformationisavailableat:
 http://healthinfotranslations.com/bosnian.php (Bosnian)
 http://www.mhcs.health.nsw.gov.au/mhcs/languages/Serbian.html(Serbian)
 http://www.mhcs.health.nsw.gov.au/mhcs/languages/croatian.html(Croatian)
40
References
1.
UnitedStatesDepartmentofState.BackgroundNote:BosniaandHerzegovina.
2012;http://www.state.gov/r/pa/ei/bgn/2868.htm.AccessedApril,2012.
2.
BosnianInstitute.AboutBosnia:Diaspora.
http://www.bosnia.org.uk/bosnia/viewMetatype.cfm?metatypeID=35.Accessed
April,2012.
3.
SPIRASI.Bosnia‐Herzegovina.SPIRASICulturalProfilesProject2006;
http://cultural.profiles.spirasi.ie/countries/bosnia%20‐h.shtml.AccessedApril,
2012.
4.
SearightHR.Bosnianimmigrants'perceptionsoftheUnitedStateshealthcare
system:aqualitativeinterviewstudy.JImmigrHealth.Apr2003;5(2):87‐93.
5.
WorldHealthOrganization.HighlightsonHealthinBosniaandHerzegovina2005.
2006;http://www.euro.who.int/__data/assets/pdf_file/0014/103208/e88283.pdf.
AccessedApril,2012.
6.
IowaCenteronHealthDisparities.BosniansandOtherRefugeesFromtheFormer
Yugoslavia.
http://www.iowahealthdisparities.org/documents/bosniansrefugees.pdf.Accessed
April,2012.
7.
CentralIntelligenceAgency.TheWorldFactbook:BosniaandHerzegovina.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/bk.html.
AccessedApril,2012.
8.
SearightHR,GaffordJ."It'slikeplayingwithyourdestiny":Bosnianimmigrants'
viewsofadvancedirectivesandend‐of‐lifedecision‐making.JImmigrHealth.Jul
2005;7(3):195‐203.
9.
WeineSM,WareN,KlebicA.Convertingculturalcapitalamongteenrefugeesand
theirfamiliesfromBosnia‐Herzegovina.PsychiatrServ.Aug2004;55(8):923‐927.
10. CultureCrossing.BosniaandHerzegowina.
http://www.culturecrossing.net/basics_business_student.php?id=27.Accessed
April,2012.
41
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42
Burmese–NEW!
CountryInformationa
Name:
UnionofBurma
[sometimescalledMyanmar,thename
adoptedbytherulingjunta;not
recognizedbytheUnitedStates]
Location: SoutheasternAsia,betweenBangladesh
andThailand;borderstheAndamanSea
andtheBayofBengal
Capital: Rangoon[junta’sunrecognized
administrativecapitalisNayPyiTaw]
Area:
676,578sq.km.(slightlysmallerthanTexas)
Climate: Tropical.June‐Sept(southwestmonsoon)cloudy,rainy,hot,
humid.Dec‐April(northeastmonsoon)lesscloudy,scantrainfall,
mildtemperatures,lowerhumidity.
Language: Official:Burmese.Other:Karen,Chin
People: EthnicitiesincludeBurman(68%),Shan(9%),Karen(7%)
Population:
InBurma:54million
RefugeesinThailand:350,000b
InVT:119c
a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/bm.html
bUnitedNationsHighCommissioneronRefugees,ComprehensivePlanAddressingtheNeedsofDisplaced
PersonsontheThailand/Myanmar(Burma)Border.AccessedApril,2012.http://www.unhcr.org/cgi‐
bin/texis/vtx/search?page=search&docid=4691eaa82&query=A%20comprehensive%20plan%20addressing
%20the%20needs%20of%20displaced%20persons%20on%20the%20Thailand/Myanmar%20%2528Burm
a%2529%20border%20in%202007/8 cVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
43
44
45
Backgroundandculture
PositionedasamajorcrossroadsinSoutheastAsia,Burmaisoneofthemostdiverse
countriesintheworld,witheightmajorethnicpopulationsand130individualsubgroups.
Suchdiversitycreatesarichculturallandscape,butitalsosetsthestageforinternal
conflict,leavingBurmawiththedubiousdistinctionashomeofoneoftheworld’slongest‐
runningcivilwars.1Until1948,whenBurmeseforcesgainedtheirindependence,Burma
wasgovernedbytheBritish:firstasanadministrativeprovinceofIndiaandlaterasaself‐
governingcolony.2Followingindependence,Burmaestablishedaparliamentary
government,butpoliticalandethnicconflictcontinued.In1962GeneralNeWinstageda
militarycoup,installedaxenophobicauthoritariangovernment,andlaunchedthe
“BurmeseWaytoSocialism.”3
ToovercomeresistancefromtheKaren(pronouncedkah‐REN)ethnicgroupthatbeganin
1949andcontinuestoday,NeWinestablishedthe“fourcuts”policytargetingthe
insurgents’food,funds,recruits,andinformation.Thestrategyessentiallyamountedto
destroyingvillages,whichspawnedamajorrefugeemovementtocampsontheBurmese‐
Thaiborder.4In1988,politicaloppressionandaflaggingeconomyprecipitatedanother
rebellion,promptingNeWintostepdown.Theuprisingwasquicklyquashedbysecurity
forcesandanewmilitaryjuntaassumedcontrolofthecountry,whichcausedanotherflood
ofrefugeestoThailand,andproducedscoresofinternallydisplacedpersons.Themilitary
regimeheldfreeelectionsin1990,butitrefusedtostepdownaftertheopposingNational
LeagueforDemocracyswept80%oftheseats.Forthenext20years,oppositiongroups
continuedtochallengethemilitaryrulewithviolentandnon‐violentprotests;themilitary
respondedwithviolentcrackdowns,widespreadarrests,andthekillingofdissidents.This
conflictexacerbatedtherefugeecrisis.3
Today,the“StatePeaceandDevelopmentCouncil,”amilitaryjunta,continuestorulethe
UnionofBurma.Theregimechangedthecountry’sofficialnametoMyanmarin1989,but
manycountriesandinternationalregimes,includingtheUnitedStates,donotrecognizethe
namechange.
Language.AlthoughBurmeseistheofficiallanguage
andisunderstoodbymuchofthepopulation,many
Membersofethnic
ethnicgroupsspeaktheirowndialect.TheKaren
minoritiesmayview
dialectfallsintotwomainsubgroupsthatlargelyfollow
Burmeseasthe
ethniclines:Sgaw‐KarenandPwo‐Karen.Seventy
languageof
percentofBurmeserefugeesinThaicamps—andthusa
oppressionandmay
majorityofBurmesenowintheUnitedStates—speak
prefertouseastrictly
Sgaw‐Karen.Thesedialectsaresimilarinstructure,but
Burmesetranslator
theirdifferentpronunciationscangreatlyimpede
5
onlyasalastresort.
understandingbetweennativespeakers. Religion.ThemajorreligionsinBurmaareBuddhism,
Christianity,Animism,andIslam.Asisthecaseinmanycountries,eachfaithdraws
membersfrommanydifferentsub‐populationsbuttheretendstobeadominantreligious
46
affiliationamongeachethnicgroup.ThemajorityofBurmansareBuddhistwhiletheChin
aremorelikelytobeChristian,particularlyBaptist.6TheKarenalsohaveasizeable
Christianpopulation,buttheyaremorecommonlyBuddhist;manypracticingKaren
Buddhistsincorporateanimistbeliefs.
Animism,whichwasprevalentinBurmabeforemissionariesintroducedChristianity,
centersonthebeliefthatalllivingthingshaveaspirit,calledK’la,whichcanbeattackedby
dangerousspirits.Manypeoplemayengageinhealingritualsorwearcharmstoprotect
theirK’la;additionally,duringsleep,theK’lacandepartthebodysooneshouldtakecare
nottowakeapersonbeforetheK’lahasreturned.Someanimistswilltiearedstring
aroundtheirwristtohelpretaintheirk’lawhichprovidersshouldremoveonlyif
absolutelynecessary.
Peopleofallreligionsmayincorporateprinciplesfromayurvedicsystems,alchemyand
Chinesemedicine.4
Family.AsinmanyAsiancultures,familyistremendouslyimportantinBurmaandthe
broadfeatureshighlightedhereareconsistentacrossthemajorethnicgroups.Historically,
membersoftheextendedfamilylivedtogether,andrecentpooreconomicconditions
reinforcethistendencybothinBurmaandamongresettledrefugeepopulationsinthe
UnitedStates.Itisparticularlycommonfornewly
marriedcouplestomoveinwiththeirparents,
especiallythewife’s.Withinthefamilystructure,
Communalchildrearingin
eldersandmenhavethemostauthority,but
BurmaandThaiRefugee
women’sopinionsarerespectedandwomen
campsfacilitateda
maintaininheritanceandpropertyrightsupon
tendencyforBurmese
divorce(exceptChinwhereinheritancefalls
parenttoallowtheir
exclusivelytomaleheirs).5Pregnantwomen
7
childrentowanderwidely.
commandrespectaswell. Careprovidersmayneed
towarnparentsaboutthe
TheBurmesegenerallyviewchildrearingasa
dangersofthispractice,
communalresponsibilityandlargefamiliesare
4
especiallyinareaswith
common. OnceinAmerica,traditionalBurmese
heavytraffic.
familystructurecanbecomemorefluid:familiesare
oftensmaller,couplesmayoptforengagementsand
bigceremoniesratherthansmall,officialweddings,
andmenandwomenmaysharehouseholdchores.
Education.Burmesesocietyplacesahighvalueoneducationforbothmalesandfemales,
howeverconflictoreconomicdemandsoftentruncatethelengthofstudents’schooling.In
Burma,governmentalexpenditureoneducationisquitelow(1‐2%ofGDP)butthesystem
includesfouryearsofprimaryschool,fouryearsofmiddleschool,andthreeyearsofhigh
school.DuetoprotestsamongUniversitystudentsandretaliatorygovernmentaction,the
Burmesehighereducationsystemlacksastrongfoundation,particularlyinruralareas
wherestudentsareincreasinglylikelytoenrollincorrespondenceorvocationalcourses.5
47
ThereisnoformalaccesstoeducationintheThairefugeecamps.TheRoyalThai
Governmentviewstherefugeecampsastemporary,thereforetheydonotallowBurmese
refugeesintoThaischools.Withinthecamps,however,thegovernmenthasadopteda
laissez‐faireattitude,soeducationisadministeredbytherefugeesthemselves.Withthe
assistanceofsomeinternationalnon‐governmentalorganizations(NGOs),schools
operatingwithinthecampsprovideeducationfromnurserythroughadultlevels.Since
Thailawbarsrefugeesfromholdingjobsoutsidethecamps,thepaucityofjobprospects
underminesanyincentiveforstudentstostayinschool.8
Diet.RiceissuchanintegralpartoftheBurmesedietthattheliteraltranslationfor‘how
areyou?’is‘haveyoueatenricetoday?’Peopletypicallyeatricewithvegetablecurriesand
addmeatorafishpasteasavailable;mostmealsareheavilyspiced.OlderBurmesemay
enjoybetelnut,aspiceddishcombiningnuts,lime,andspicesthatismildlysedatingand
stainstheteethred.5
Formanyethnicgroups,andespeciallytheKaren,foodisintimatelylinkedtoillness.
Burmesetendtocharacterizebothfoodanddiseaseaseither‘hot’or‘cold’andprescribea
diettocounteracttheeffectsofsickness—thusifapatienthasahotillness,acareprovider
willrecommendacolddiet.Importantly,theclassificationoffoodashotorcolddoesnot
necessarilycorrelatetoitsphysicaltemperature.Hotfoodsincludedishesthataresalty,
sour,orhighinanimalproteinwhereascolddishesfeaturesweetorbitterflavors.7
Distinctmedicalconditionscanfurtherprecipitatespecificdiets,forexamplepeople
diagnosedwithhepatitisareencouragedtoavoidyellowfoods.4
Healthcare
Infectiousdisease.IntestinalparasitesareverycommonamongnewlyarrivedBurmese
refugees:15%ofthepopulationtestedpositiveforatleastonepathogenicinfectionduring
theirdomestichealthexamination,mostcommonlyforgiardiaorstrongyloides.9
MalariaisalsoaseriousconcernforBurmeserefugees,bothbecauseBurmaishometoone
ofthemostdrugresistantstrainsandbecausemanyrefugeesspenttimeinthejungle
duringperiodsofinternaldisplacement.Malariaissocommonthatrefugeesarelikelyto
attributenearlyallfeverstomalaria.Itisimportantforcareproviderstodifferentiate
betweenmalariaanddenguefeverwhichisalsoveryprevalent.4
Hepatitisiscommon,butalthoughpeopleareawareofthediseasetheymaynot
understandtheimplications.TheKarencommunityinMinnesotareportedthatthey
preferredwhendoctorsgavespecificadviceregardingtreatmentandtoldthemexactly
whattodo.Diagnosinghepatitiswillalsolikelyinvitequestionsaboutfood,asmany
Burmesebelievethatpeoplewithhepatitisshouldn’teatyellowfoodsorfishpaste.Evenin
theabsenceofquestions,physiciansshouldexplainthatfoodwillnotalterthecourseofthe
disease.4
Burmaranksasoneofthe22high‐burdencountriesfortuberculosis(TB),accordingtothe
WHO.TBisstigmatizedinBurmatosuchanextentthatinterpretersmaybereluctantto
48
translateforpatientsduringhomevisitsforfearthattheywillbeassociatedwiththe
illness.Alongsimilarlines,patientswithTBoftenexpressgreaterconcernaboutthe
disease’simpactontheirplaceinthecommunitythanontheirpersonalhealth.Healthcare
providersandBurmesecommunitymembersmayalsohavedifferentdefinitionsof
“contacts”,wherepeoplewhocomeandgofrequentlycanbeconsiderednormaland
thereforenotconstituteareportableevent.10TBratesarehigheramongtheShan
ethnicity.11
Lifestyleriskfactors.Forrecentlyresettledrefugees,malnutritionisamajorhealth
concern.Inaddition,thechewingofBetelnutandlimitedaccesstodentalcarecan
negativelyimpactoralhealth,leadingtotoothdecayandoralcancers.12Approximately
19%oftheKarenrefugeepopulationsmokes,and80%ofthesmokersaremen.9Ratesof
cigaretteandalcoholconsumptionareoftenhigherwithintheChinsubpopulation,where
bothpracticesareconsideredtobeastatussymbol.6
AswithmanypopulationsunfamiliarwiththeWesternmodelofcare,Burmeserefugees
mayhavetroublewithchronicdiseasemanagement,especiallyiftheirtreatmentplan
includestakingmedicineintheabsenceofsymptoms.9
Finally,manyBurmesepeopleareatincreasedriskforleadpoisoning.Althoughsuch
contaminationcancomefromfamiliarsourcessuchasoldhomes,theremayalsobe
culturalfactorstoconsider.Chiefamongthesearetwofolkdigestiveaids,DawTwayand
DawKyin,whichcancontainveryhighlevelsoflead.Inaddition,prolongedexposuretocar
batteries—amajorenergysourceforhomesinThaicamps—hasbeenimplicatedinlead
poisoning,13andincreasingevidencesuggestsalinkbetweenleadpoisoningandthe
practiceofwearingthanaka¸apastemadefromgroundthanakatreeandappliedtothe
cheekstoactasacosmetic/sunscreen.14
Familyplanningandchildbirth.Historically,sexeducationinBurmahasbeen
nonexistent,buttherehasbeensomemovementtowardHIVeducationinschools.
NumerousstudiesconductedinThairefugeecampsindicatethatresidentshavelimited
knowledgeaboutreproductivehealth.ThoughsomeBurmesedousecontraception,the
socialcapitalofchildrenandabeliefthatcondomsencouragepromiscuitylimitits
widespreadadoption.15ProvidersintheUnitedStatesshouldfocusoneducation,andmay
findgreatersuccessbycouchingdiscussionsaboutcontraceptionintermsofchildspacing
ratherthanpreventingpregnancyaltogether.
Asnotedpreviously,pregnantwomenholdaplaceofhonorinBurmeseculture,however
pregnancyoutsideofmarriageisasocialtaboo.Duringpregnancy,womenobserveastrict
dietaryandbehavioralregimeduetothebeliefthateverysound,touch,taste,smellor
actionofthemotherhasaneffectonthefetus.7Womeninrefugeecampsandthose
relocatedtoWesternnationsreportpreferringhomebirthstohospitaldeliveries,citing
shame(vaginalexams,exposedlegs,thepresenceofmalehospitalstaff)astheirbiggest
deterrent.
49
Postpartum,womenaretreatedverydelicately:inthefirstthreedaysthemotherdoesn’t
move,relyinginsteadonherhusbandtofeedandbathehertwiceaday,andtotendafire
nexttoherbedmeanttoensurewarmth(heatersorhotwaterbottlesmaybeacceptable
substitutesinhospitalsettings7).Restrictionscontinueduringthemonthafterdeliveryasa
precautionagainst“sickfever.”Althoughmovementisincreasinglyallowed,womenstilldo
notgooutside,theymaintainalimiteddietofsoupandrice,andavoidcoldwater
completely.AlthoughmanyfamiliesadaptsuchtraditionalpracticesinaWesternsetting,
careprovidersshouldstillengagepatientsinconversationsregardingthelengthoftheir
hospitalstayandtransportationhome.
Mostmothersbreastfeedtheirinfantsforapproximatelyoneandahalfyears,althoughthis
periodcanextendtothreeyears.Giventheimportanceofrice,Karenpeopletraditionally
feedinfantsafewgrainsbeforecommencingbreastfeeding;accordingly,caregiversshould
educatepatientsabouttherisksassociatedwithprelactealfeeds.7
Mentalhealth.Burma’slongstandingcivilwarhasmeantsubjectiontoforcedlabor,rape,
violence,andlong‐termfamilialseparationformanyrefugees,withmeasurable
consequencesformentalhealth.A2004studybyCardozoetal.foundelevatedlevelsof
anxietyanddepressionamongrefugeeslivinginThai‐Burmesebordercampsandlevelsof
post‐traumaticstressdisorderwerecomparabletothoseofotherpopulationsthathad
experiencedwarandupheaval.16
Treatingmentalillnessinthispopulationcanbeproblematic.Asinmanycultures,the
stigmatizationofmentalhealthproblemscanmakepatientsreluctanttoreport
symptoms.17Furthermore,manyBuddhistsbelievethattheircurrentcircumstanceisa
reflectionoftheiractionsinpastlives,soanydepressedoranxiousfeelingstheymaybe
experiencingarejustpunishmentforpriormisdeeds,andthusshouldnotbetreated.Care
providersshouldaskquestionstoelicitpatientbeliefsregardingtheoriginoftheir
symptoms.18
Traditionalmedicine.TraditionalmedicineinBurmamaydrawonpracticesfrom
neighboringAsiancountries,particularlyIndiaandChina.Cupping(seechapteron
Vietnam)isnotuncommon.Traditionalbelieftendstoholdthatmalevolentspiritscause
illnesssopatientsmaycalluponshamanswhenseekingtreatment.19Mostremediescenter
onbalancinghotorcoldillnesswiththeoppositefood(seesectionondiet)oronplant‐
basedmedicines.
SocialEtiquette
Burma’svastethnicdiversityunderminesanymonolithicnotionofculture.SincetheKaren
representthelargestethnicgroupintheU.S.,theyaretheprimaryfocusofthissection,
howevertheChinandBurmanpeoplesarealsodiscussed.
Aswithanygroup,theapplicabilityoracceptabilityofthesenormsmaydifferbetween
ethnicgroupsandindividuals.Itisimportantforproviderstocommunicatewiththeir
patientstoachievethehighestlevelofcomfortinthecareprocess.
50
 Crossedarmsduringconversationisasignofrespect.
 Burmeseconsidertheheadtobeboththeliteralandfigurativehighestpartofbody,
therefore:
‐ theheadshouldnotbetouchedbyanotherperson,and
‐ objectsshouldneverbepassedoveraperson’shead.19
 Thefeetarethelowestpartofthebodyandshouldneverpointdirectlyatsomeone;
whenseated,theyshouldbetuckedunderthebody.19
 Whenshakinghandsorpassingobjects,oneshouldextendtherighthandwhile
supportingtherightelbowwiththelefthand.
 Nothingshouldbepassedwiththelefthand,whichisusedforpersonalhygiene
behaviors.19
 Usebothhandstoacceptagift,especiallyfromanelder.
 Walkingbehindsomeoneismorerespectfulthanwalkinginfront,especiallyifthe
bystanderisseated;ifonemustwalkinfrontitiscustomarytoexcuseoneself.
 Pickingone’snoseiscommonplace,howeverblowingone’snoseintoatissueis
considereddisgusting.19
 Traditionally,KarenandChinareonlygivenonename,althoughtheymayadopta
familynameaftermovingtoWesterncountries;nameordercanleadtocharting
confusion.
 Peopleareaddressedbytheirgivennameandatitle,oftensignifyingthe
relationshiptothespeaker(aunt,elder,teacher,etc.).9
 AmongtheChinethnicgroup,directeyecontactcanbeinterpretedasachallenge
ratherthanasignofcompassion.6
 Medicaldecisionsarefrequentlymadebyconsensus.4
 Patientsmayanswer“no”toaquestiontobemodest,whenthemoreaccurate
answeris“yes.7”
 Menandwomendon’tusuallytouchinpublic,butaffectionategesturesamong
membersofthesamesexarecommon.
 Patientsreportapreferenceforsamegenderproviders.4
51
References
1.
ThorntonP.RestlessSouls:AsiaBooks;2006.
2.
CentralIntelligenceAgency.TheWorldFactbook:Burma.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/bm.html.
AccessedApril,2012.
3.
UnitedStatesDepartmentofState.BackgroundNote:Burma.2011;
http://www.state.gov/r/pa/ei/bgn/35910.htm#history.AccessedApril,2012.
4.
NeimanA,SohE,SutanP.KarenCulturalProfile.2008;
http://ethnomed.org/culture/karen/karen‐cultural‐profile.AccessedJuly,2011.
5.
BarronS,OkellJ,YinSM,etal.RefugeesfromBurma:TheirBackgroundsandRefugee
Experiences.Washington,DC:CenterforAppliedLinguistics;2007.
6.
ScarlisCA.ChinCulturalProfile.2010;http://ethnomed.org/culture/chin/chin‐
cultural‐profile.AccessedJuly,2011.
7.
StateofQueensland.Burma:Karen,Chin,andRohingyaEthnicities.
http://www.health.qld.gov.au/multicultural/health_workers/Burmese‐preg‐
prof.pdf.AccessedJuly,2011.
8.
OhS‐A.EducationinRefugeeCampsinThailand:Policy,PracticeandPaucity:
CommissionedfortheEFAGlobalMonitoringReport2011:TheHiddenCrisis:
ArmedConflictandEducation;2010.
9.
PowerDV,MoodyE,TrussellK,etal.CaringfortheKaren.Anewlyarrivedrefugee
group.MinnMed.Apr2010;93(4):49‐53.
10. NewJerseyMedicalSchoolGlobalTuberculosisInstitute.ReachingOutToBurmese
Refugees.TB&CulturalCompetency:NotesfromtheField,Spring2008.Vol7.
Newark,NJ:NewJerseyMedicalSchoolGlobalTuberculosisInstitute;2008.
11. SuwanvanichkijV.Displacementanddisease:TheShanexodusandinfectious
diseaseimplicationsforThailand.ConflHealth.2008;2:4.
12. LeeKW,KuoWR,TsaiSM,etal.Differentimpactfrombetelquid,alcoholand
cigarette:riskfactorsforpharyngealandlaryngealcancer.IntJCancer.Dec10
2005;117(5):831‐836.
13. NewYorkStateDepartmentofHealth.WorkingWithRefugeesfromBurmato
PreventChildhoodLeadPoisoning.2010;
http://www.health.ny.gov/environmental/lead/health_care_providers/working_wi
th_refugees_from_burma.htm.AccessedApril,2012.
14. RitcheyMD,ScaliaSucoskyM,JefferiesT,etal.LeadpoisoningamongBurmese
refugeechildren‐‐Indiana,2009.ClinPediatr(Phila).Jul2011;50(7):648‐656.
15. CentersforDiseaseControlandPreventionDivisionofReproductiveHealth,
AmericanRefugeeCommittee.AnAssessmentofReproductiveHealthIssuesAmong
KarenandBurmeseRefugeesLivinginThailand.Atlanta,GA2002.
16. LopesCardozoB,TalleyL,BurtonA,CrawfordD.KarenniRefugeesLivinginThai‐
BurmeseBorderCamps:TraumaticExperiences,MentalHealthOutcomes,and
SocialFunctioning.SocialScienceandMedicine.2004;58(12):2637‐2644.
17. KniftonL,GervaisM,NewbiggingK,etal.Communityconversation:addressing
mentalhealthstigmawithethnicminoritycommunities.SocPsychiatryPsychiatr
Epidemiol.Apr2010;45(4):497‐504.
18. LinKM,CheungF.MentalhealthissuesforAsianAmericans.PsychiatrServ.Jun
1999;50(6):774‐780.
52
19.
UKCO.BurmeseCulturalProfile:AToolforSettlementWorkers:International
OrganizationforMigration;2005.
53
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54
Burundian
Country
Informationa
Location: CentralAfrica,Eastofthe
DemocraticRepublicofCongo;bordersTanzania,
Rwanda,andtheDemocraticRepublicofCongo
Capital: Bujumbura
Area:
27,830sq.km.(slightlysmallerthanMaryland)
Terrain: Hillyandmountainous,droppingtoaplateauintheeast,some
plains;considerablealtitudevariation;averagealtitudeis1700m
(5600ft)
Climate: Equatorial;averageannualtemperaturevarieswithaltitudefrom
17°Cto23°C(63°Fto73°F)butisgenerallymoderate.Twowet
seasons(February‐MayandSeptember‐November)andtwodry
seasons(June‐AugustandDecember‐January)annually.Average
rainfallis150cm(60”).
Languages:Kirundi(official)andFrench(official);SwahilispokenalongLake
TanganykikaandnearBujumbura.
People: Twomajorethnicities:Hutu(85%)andTutsi(14%).
Population:
InBurundi:10.2million
InVT:105b
aUnlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/by.html bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
55
56
57
Backgroundandculture
BurundigainedindependencefromBelgiumin1962.Thecountry’sindependencebrought
ethnictensionsbetweenthemajorityHutuandminorityTutsitotheforefront.In1966,a
TutsimilitaryleaderoverthrewtherulinggovernmentandestablishedaTutsijuntaasthe
rulingbody.AHutuuprisingwasputdownin1972andalargeportionofthepopulation
wasforcedtofleetonearbycountries,withmostsettlinginrefugeecampsinTanzaniaand
Rwanda.Instabilityandethnicviolencemarkedthenextseveraldecades,withthedeath
tollestimatedbetween90,000and250,000.Apoliticalassassinationin1993ledtothe
outbreakofacivilwar.In1994theinterimBurundianpresidentandthepresidentof
neighboringRwandawerekilled,whichonlydeepenedtheethnicconflictbetweenthe
HutusandTutsis.1
In2005PierreNkurunzizawonpresidentialelectionsandthisendedthe12yearsofcivil
war.Infallof2006thegovernmentsignedacease‐firewiththeForcesforNational
Liberation,whichwasthelastremainingrebelgroupthathadnotengagedinpeacetalks.
Thecease‐firewasnotimplementedfullyandtheFNLhascontinuedtowreakhavoconthe
stabilityofthecountry.Todatehowever,conflictbetweentheHutuandTutsiremains
problematicandU.S.citizensareencouragednottotraveltoBurundibecauseofthe
violence.Thecountryisoneofthetenpoorestcountriesintheworldandtheeconomyis
notstableduetothelackofresourcesandyearsofwarthathaveravagedthecountry.1
TheBurundianrefugeeswhohavebeenresettledinVermontareprimarilyfromthegroup
ofpeoplewhofledtoTanzaniain1972.PriortobeingresettledintheUnitedStates,many
ofthispopulationweredisplacedmultipletimesandspentyearsinexile.
ThemajorityofBurundianrefugeesinVermontarrivedherebetween2007and2008,2
howeverinterviewswiththerefugeesrevealthatsomehavebeeninthestatesinceasearly
as2004.3Currently113BurundianrefugeeshavebeenresettledinVermont.4Mostofthe
VermontBurundianshavecomefromrefugeecampsinTanzania,howeversomearrived
fromZambiaandMozambique.3
Language.MostBurundiansspeakKirundiandSwahili.SomeeducatedBurundiansmay
alsospeakFrench.Seetheendofthissectionforatranslatedlistofcommonly‐used
phrases.
Religion.ThemajorityoftheBurundiansareChristian:62%areRomanCatholicand
another5%areaffiliatedwithvariousProtestantdenominations.Inaddition,roughly10%
ofBurundiansareMuslimand23%followindigenousreligiousbeliefs.1InVermont,about
one‐thirdoftheBurundiansareProtestantandtwo‐thirdsareCatholic.3Religionplayeda
centralroleintherefugeecampswheretheBurundipeopleweredisplacedandalsoplays
animportantroleintheirlifeintheUnitedStates.2,3
Family.Burundiansvaluetheirfamiliesaboveeverything.Assistingandcaringforfamily
membersinneedisofutmostimportance.Individualismandplacingone’sownneeds
abovethoseoffamilyislookeddownupon.ThefamilysysteminBurundiispatriarchal.
58
Thefatheristheheadofthefamilyandmakesthemajorityofthedecisionsforthefamily.
Womenarevaluedfortheirroleinchildbearingbuthavelittledecision‐makingpowerin
thesociety.Eldersholdahighroleofrespectinsociety.1,2Achallengeformanyofthe
refugeesisthatmanyoftheirfamilymembersremaininrefugeecampsinAfrica.3
Education.TheBurundiangovernmentdidnotpassfreepubliceducationforallchildren
until2005.Schoolingisnowrequiredforchildrenagesevento12.Becauseattending
schoolrequirespurchasingschoolsuppliesanduniformsmanyfamilieschoosetosend
onlytheirsonstoschool.1Intherefugeecampsmostchildrenreceivedfreeprimary
education,howeverthecampschoolswereoftenovercrowdedandattendancewas
sporadic.Ithasbeenestimatedthat20%oftheadultpopulationisliterate.2
Diet.AtypicalBurundiandietincludesrice,beans,cornmeal,potatoes,fish,meat,and
greens.MostBurundiansareopentolearningabouthealthyeating.Mosthavegained
weightsincearrivingintheUnitedStates.Typicaldrinksincludewater,milk,tea,juice,and
occasionallybeerandsoda.3
Healthcare
Mentalhealthissuesarecommonduetothestressfullifeofarefugee.Somerefugeeshave
witnessedtraumaticevents,increasingtheirriskforpost‐traumaticstressdisorder(PTSD).
ManyBurundiansareanxiousbecausesomeoftheirfamilymemberswereleftbehindat
therefugeecamps.Notalltherefugeesknowhowtohandlethesestresses.Highratesof
malariaarepresentintherefugeecamps.HIVincidenceislowintherefugeecamps,but
highinthecountryofBurundiitself.2WhenBurundiansvisittheirphysician,theyexpectto
receivesomesortofmedicationorshot,inadditiontohavingtheirvitalsignstobetakenat
everyappointment.Burundianwomenprefer“privatebirths,”meaningnomenintheroom
andasfewfemalesaspossible.
Languagebarriersareaproblematthedoctor’soffice.SomeBurundiansdonotwantto
disclosetheirhealthissuestoatranslator.Thetranslatorisoftenarelativeorfrienddueto
thesmallpopulationofBurundianslivinginVermont.Theyonlyvisittheirphysicianwhen
theyaresick,andnotforpreventativecareunlessthedoctor’sofficemakesafollow‐up
appointmentforthem.InAfricatherewerewalk‐inhealthcarecentersrequiringno
appointments.Makinganappointmentatthedoctor’sofficeisoftendifficultduetocultural
andlanguagebarriers.Burundiansaresomewhatoffendedwhentheofficeasksfortheir
chiefcomplaint.Theyfindthisquestioningrudebecausetheybelievetheirhealthissues
aresolelybetweenthemandtheirdoctor.Personalhealthinformationissomethingthey
prefernottosharewiththereceptionist.Thesechiefcomplaintquestionsarefrustrating
fortheBurundiansbecausetheyinterpretitasaskingthemforadiagnosis,ratherthanthe
doctordeterminingthediagnosis.3
Specifichealthconcerns
 Burundianwomengenerallypreferfemalephysicians,butanygenderisacceptable
inanemergency.
59
 Burundianwomendonotwantanymenintheroomwhentheygivebirth,even
theirhusband.Theyalsoprefertohaveasfewpeopleintheroomaspossible.
 Whenpossible,avoidusingatranslatorthatisarelativeorfriendofthepatient.
Burundiansalsofeeltheirmedicalissuesarenotconfidentialbecausetheyhaveto
speakthroughatranslator.
 InBurundi,peopleonlygotothedoctorwhentheyaresick.Thereisno
preventativemedicine.Burundianswillkeepanyappointmentsthedoctor’soffice
makesforthem,buttheywillnotmakeanappointmentforthemselvesunless
they’resick.Annualphysicalsshouldbescheduledbythedoctor’soffice.
 MakinganappointmentisstressfulforBurundians.
 Medicineisexpectedtobeprescribedafteradoctor’svisit.
Socialetiquette
Burundiansgreateachotherbyshakinghands.Theymayholdhandsforafewminutes
afterahandshake.2Theyoftensaymwaramutse,whichmeansgoodmorning.Toshow
respect,Burundianswillnotmakeeyecontactandwillbowslightlywithpeopletheyview
asabovethem.1Communicationisalsooftenindirectandhighlycontextbased.Thesociety
ispatriarchal,sothemanoftenhasthefinalsayonhouseholddecisions.2
CommonlyUsedPhrases
English
Hello
Goodbye
Please
Thankyou
Goodmorning
Goodevening
Yes
No
Kirundi
Bwakeye
N’agasaga
Akira
Urakoze
Mwaramutse
Ijororyiza
Ego
Oya
Swahili
Hujambo
Kwaheri
Tafadhali
Asante
Habariyaasubuhi
Habariyajioni
Ndiyo
Hapanala
AdditionalResources
AssociationofAfricansLivinginVermont:http://www.africansinvermont.org
60
References
1.
RepublicofBurundi.CultureGrams;2008.
http://www.culturegrams.com/products/onlineedition.htm.
2.
CulturalOrientationResourceCenter.RefugeeBackgrounderNo.2:The1972
Burundians.March2007ed.
3.
PiperLE,NadeauLA.BurundianWomenRefugeeNeedsAssessment.St.Albans,VT:
ChamplainValleyAHEC;2009.
4.
MacQuerrieB.StressesAnewforRefugeesResettledinVT.BostonGlobe.April27,
2009.
61
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blank.
62
Chinese–NEW!
CountryInformationa
Location: EasternAsia,betweenNorthKoreaand
Vietnam;borderstheEastChinaSea,Korea
Bay,YellowSea,andSouthChinaSea
Capital: Beijing
Area:
9,596,961sq.km.(slightlysmallerthanthe
UnitedStates)
Climate: extremelydiverse;tropicalinsouthtosubarcticinnorth
Languages:S tandardChineseorMandarin(Putonghua,basedonthe
Beijingdialect),Yue(Cantonese),Wu(Shanghainese),
Minbei(Fuzhou),Minnan(Hokkien‐Taiwanese),Xiang,
Gan,Hakkadialects
Population:
InChina:1.34billion
InVermont:1217Chinese(includingTaiwanese)asof2009b
a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.
https://www.cia.gov/library/publications/the‐world‐factbook/geos/ch.html bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
63
64
65
Backgroundandculture
Althoughover90%ofMainlandChineseareethnicallyHan,thecountry’simmensesize,a
longhistoryofmigrationtotheUnitedStates,andasizeableexpatriatecommunityof
ChineseinneighboringAsiancountriesmeanthattheChineseimmigrantscurrentlyliving
intheUnitedStatescanbeverydissimilartooneanother.Itcanbemoreusefulfor
providerstoexaminethedegreeormannerofacculturation—aconstructdevelopedto
describehowindividualsnegotiatetwoculturesusingparameterslikelanguageand
practiceofculturalnorms—thantouseethnicidentifiers.Althoughthischapterwillgivea
broadoverviewofculturalpracticesandbeliefscommonamongmanyChinesepeoples,it
isimportantforhealthcarepractitionerstoseetheirpatientsasindividuals.Factorslike
socioeconomicstatus,educationalbackground,orlengthoftimeinAmericamaybemuch
biggerforcesinshapingapatient’sculturethantheirethnicheritage.
Language.MandarinistheofficiallanguageofthePeople’sRepublicofChinaandTaiwan,
buttherearemanydialects,includingShanghainese,Minbei,andMinnan(Hokkien‐
Taiwanese).InHongKong,whichisofficiallyaSpecialAdministrativeRegionofChina,the
officiallanguagesareCantoneseandEnglish.
LanguageisofparticularconcernfortheelderlyChinese–80%
Immigrant
ofwhomareforeignborn1–becauseolderfirstgeneration
Chinesein
immigrantsaremuchlesslikelytounderstandEnglishthan
2
Vermonthave
youngerorsecondgenerationimmigrants. Despitetheuseof
astrong
translatorservices,theliteraturerepeatedlydemonstrates
relationship
thatlowEnglishproficiencycorrelateswithpoorerhealth
withtheir
outcomesanddecreasedpatientsatisfaction.
translators,
oftenviewing
TheuseoftranslatorscanbeathornyissueforChinese
themassocial
immigrants.Somestudiessuggestthatpatientspreferusing
advocatesas
trainedinterpretersratherthanfamilymembers,citing
wellas
patientconcernoverdisruptingfamilialpowerdifferentials
interpreters.
whenusingchildrentotranslate.3However,otherresearch
describestheopposite,withpatientschoosingfamily‐based
translationbecauseofconcernsoverconfidentialityanda
strongculturalpreferencetoshieldtheillfromanydistressing
knowledgeregardingtheseverityoftheirdisease.4AccordingtoJonBourgo,Community
OutreachManagerattheBurlingtonCommunityHealthCenter,manyoftheChinese
ImmigrantsinVermontfeelaverystrongconnectiontotheirtranslators,oftenviewing
themasvaluableresourcesandadvocatesbeyondinterpretation.
Religion.In2002,ThePeople’sRepublicofChinaofficiallybecameasecularcountry.Yet
despiteitsatheiststatus,theregion’slonghistoryofTaoism(Daoism),Buddhism,and
Confucianisminformsmanymoderncitizens’philosophical,cultural,andhealthnorms.
Taoismemphasizesharmonywithnatureandteachesthatfollowersshouldexercise
outside,breathefreshair,andalignthemselveswiththerhythmsoftheuniverse.Taoism
furtherincorporatesandexpandsupontheChineseideaofChi(alsocalledQi).5Chicanbe
66
roughlydefinedasthelifeforceanditisabalanceofyinandyang,whereyiniscool,
nourishingenergyandyangiswarm,activatingenergy.Food,medicine,andactionsallplay
acentralroleinregulatingyinandyang,keepingthebodyinharmonywiththe
environment.6Importantlyforhealth,Taoismemphasizespassivity,encouragingfollowers
tolookinwardtohealthemselves—aconceptthatcanbefrustratingforWesternhealth
professionalswhomaywanttoadoptmoreaggressiveapproachestoagivenillness.7
BuddhismcentersaroundtheprinciplesofInnandKo—causeandeffect—that,coupled
withKarma(Fate),arethemaindeterminantsofhealth.5Asmentionedinthechapteron
Burma,Buddhistbeliefscanimpacthealthbeliefs,especiallyattitudesregardingmental
health,asfollowersmayinterprettheircurrentpoor
conditionasjustretributionforthesinsofapastlife,
andthusfeellittlecompulsiontotakeactiontoalter
Taoism
theirlot.8
emphasizes
passivity,
Finally,Confucianism—abeliefsystemarguably
encouraging
closertoaphilosophythanareligion9—holdsfive
followerstolook
tenetsatitscore:benevolence,righteousness,loyalty,
inwardtoheal
filialpiety,andvirtue.5Thesevaluesgreatlyinform
themselves:a
familystructure,butalsohaverelevanceincare
conceptthatcan
provisionastheypredisposepatientstoprefer
befrustratingfor
familial‐baseddecisionstrategiesandtoputthe
Westernhealth
welfareofthefamilyunitbeforetheirown.
professionalswho
Additionally,undercurrentsofstrengthtacitly
maywantto
runningthrough“righteousness”and“virtue”canlead
adoptmore
todecreasedhealthseekingbehavior,especially
aggressive
amongmenwhodon’twanttoappearweak.10Like
approachestoa
manyotherChinesereligions,Confucianism
givenillness.
emphasizesharmonywithothersaswellasharmony
betweenselfandtheenvironment.
Family.FormostChinesepeople,familyisthecornerstoneoftheirlivesandamajor
determinantofculture.11AccordingtoConfucianteachings,therearefivemajor
relationshipsinalloflife:ruler‐ruled,father‐son,husband‐wife,brother‐brother,and
friend‐friend,butallareessentiallymodeledonfamilialrelationships.12Traditionally,
powerinthefamilyispredicatedonage,gender,andgeneration,witheldermalesbeing
themostrevered,butthefamilyasaunitretainsgreaterimportancethananyindividual
member.
Theconceptof“face”or“savingface”ishighlyintegratedintofamilydynamics.Filial
devotionishugelyimportantinChinesecultureandfailuretodemonstrateabsolute
submissionordevotiontoone’sparentscanresultintheentirefamilylosingface,ascan
anyotheractsofpoorbehavior,sincefaceisacollectivequalityoftheentirefamily.Fearof
bringingshametothefamilycanbeapowerfulmotivatortoconformtosocialandcultural
norms.13
67
Intermsofgenderdynamics,traditionalChinesefamiliesvalueandrespectmenmorethan
women.Uponmarriage,societyexpectswivestojointheirhusband’shousehold
whereupontheyarechargedwithassumingallthechoresofdailylivingandtheprimary
caregiverroleforanychildren,elderlyparents,orillmembersofthefamily.Thatbeing
said,acrossalldimensionsoffamilyrolesanddynamics,asimmigrantsincreasetheir
lengthofstayintheU.S.,theirfamiliesincreasinglycometoresemblethoseofthe
dominantculture14—thoughitcanbedifficultforallmemberstonavigatethechanging
socialnorms.
Education.MostChinesepeople,immigrantorotherwise,valueeducationquitehighly.In
theUnitedStates,Chineseteenagersenrollincollegeatmuchhigherlevelsthantheir
percentageofthetotalpopulationwouldsuggest,and,evenmorestrikingly,hailfromall
pointsonthesocio‐economicspectrum.Inotherwords,itisnotjustthechildrenof
educatedimmigrantswhoareenjoyingacademicsuccess,butthosefromworking‐class
backgroundsaswell.Differentexplanationsofsuch
achievementexist;somecitetheprinciplesofConfucianism,
particularlyrespectforauthorityandhardwork,while
Valuingstoicism,
otherspointtohighparentalinvolvement,andstillothers
overtdisplaysof
creditethnicsocialstructures.15
affectionare
uncommonin
Yetdespitesuchwidespreadacademicattainment,health
traditional
providersmusttakecarenottobeblindedbythe“model
Chinesefamilies.
minority”paradigmandassumethatallAsianorChinese
Membersshow
youtharedoingwellinschool,especiallyaseconomic
theirlovebythe
resourcescanstillplayabigroleineducation,andmany
efforttheydevote
recentimmigrantsarenotaffluent.16Moreover,although
totheirrolesas
immigrantyouthmaybequitesuccessful,over50%ofthe
providersor
ChinesepopulationintheUnitedStatesstillself‐identifiesas
caregivers.
havinglimitedEnglishproficiency17andliteracyratescan
vary.Cliniciansshouldevaluatetheeducationallevelofeach
patientindividually.
Diet.RiceandnoodlesarethemajorstaplesoftheChinesedietandareusually
supplementedwithcookedvegetablesandoccasionallymeat—oftenwelldonebeef.Most
Chineseeatthreemealsaday,withdinnerasthelargest,andlistchopsticksastheir
preferredutensil.Duetohighlevelsoflactoseintolerance,manyChinesepeoplewillavoid
dairy.LikemanySouthAsiancultures(seechapteronBurma),Chinesepeopleclassify
foodsashotorcoldaccordingtotheiryinandyangproperties,whichmaynotcorrelateto
physicaltemperature.Yin,orcoldfoods,includefruits,vegetables,coldliquidsandbeer,
whereasmeat,eggs,hotsoup,andanyfrieditemsconstitutethehot,oryangfoods.Itis
importanttomaintainayin‐yangbalanceateverymeal.Additionally,certainillnesslike
nosebleedsareconsidered‘hot’illnessessoChinesepeoplemaywanttoincorporate‘cold’
foodstorestorebalanceaspartoftheirtreatmentplan.14
68
Healthcare
InfectiousDisease.HepatitisBisendemicinmanyAsiancountries;withinfectionrates10
timesthatofthegeneralpublicintheU.S.,itsdetectionandtreatmentshouldbeamajor
concernforcareprovidersseeingChineseImmigrants.Moreover,accordingtoTayloretal.,
manypatientsmaybeverymisinformedaboutroutesoftransmission,believingthat
sharingfoodorutensilswithaninfectedpersonwillleadtoinfection,socliniciansmay
needtospendtimeeducatingtheirpatientsregardingpreventivecare.18
AlthoughTuberculosis(TB)testsareaconsistentelementofimmigrants’domestichealth
screening,longlatencyperiodsandincreasedundocumentedimmigrationmaymeanthat
patientsareharboringundiagnosedTB.Importantly,TBratesamongAsiansandPacific
Islandersarealmost10timeshigherthanthatofthegeneralpopulation,1andChinastands
asthebiggestsourceofforeign‐bornTBcases.19DensehousinginChinatowns,with
extendedfamilieslivingunderthesameroof,canexacerbatetransmission.
Cliniciansshouldalsoscreenforparasites,whicharecommoninSouthEastAsia.
LifestyleRiskfactors.Consistentwiththe“modelminority”paradigm,smokingand
alcoholconsumptionratesareloweramongChineseAmericansthanthegeneralpublic,but
increasedacculturationcorrelateswithincreaseduseofbothsubstancesandproviders
shouldapproachpatientsonanindividualbasis.
Similarly,traditionalChinesedietandanemphasisonoutdoorexercisestemmingfrom
TaoismhavelongbeenprotectiveagainstdevelopingcommonWesternlifestyle
pathologieslikediabetesandcardiovasculardisease,butuponmovingtotheUnitedStates
andadoptingthedominantculture,Chinese‐Americansmaybemoreatrisk.1
Cancerrates,ontheotherhand,remainmuchhigheramongtheChinese.Followinghigh
ratesofHepatitisBinfection,hepatocellularcarcinomaisquitecommon.20Prevalenceof
nasopharyngealcarcinoma,prostate,andbreastcancersarealsoclimbing,withratesfor
bothbreastandprostatecancershigheramongChineseAmericansthanChineselivingin
Asia.1Troublingly,evenafteradjustingforaccesstocareandeducationlevel,Chinese
immigrantshavemuchlowerratesofcancerscreeningthanNon‐Hispanicwhites.Current
reasoningforthisdisparityimplicatesshameandface‐savingasmajorimpedimentsto
screeningsincepatientsconsiderthescreeninginvasive.21Otherpatientsmaybefearfulof
blooddrawssincetraditionalbelieflinksbloodverycloselywithlifeforce,sopatients
worrythatbloodremovalwillweakenthem.14Finally,someChineseAmericans,especially
thosewhoareforeign‐born,maynotunderstandthepurposeofscreeningtestsinthe
absenceofsymptoms.21
FamilyPlanning/Childbirth.Chineseemphasisonmodestycanclashwitheffortsto
discusssexorcontraception,particularlyinthecontextofpremaritalsex,whichmany
Chineseconsidertobeshameful.Adolescentsrarelytalktotheirparentsaboutsexual
issuesandrelyinsteadonmediasourcesandfriendsforinformation.Sexeducation
programsexistinChina,butareoflimitedscope.WhilethemajorityofChineseparents
reportcognizanceofchangingsexualnorms(includingpremaritalsex)manystillfeel
69
uncomfortablespeakingwiththeirchildrendirectly.22Chinesecultureremainsstrongly
heteronormative:same‐sexrelationshipsoftengounacknowledgedbythefamilyand
masculinegirlsorfeminineboysfacepressuretochange.14
Theparamountimportanceoffamilyplacespressureonwomenduringchildbirth.
Pregnancyisa“cold”conditionsoexpectantmotherseatyangfoodstomaintainbalance.In
asimilarvein,theChinesebelieveparticularactions—whereawomangoesorwhatshe
does—hasadirecteffectonthefetus;forexamplevisitingazoowillcausethechildtolook
likeananimal.Inthecaseofgeneticdefects,societyblamesthemother’sdietorbehavior.
Chinesewomenarelargelyreceptivetoprenatalcare,withuseincreasingbydegreeof
acculturationandlengthoftimeintheUnitedStatesanddecreasingwiththeusualbarriers
toaccesslikelackofinsurance,loweconomicstandards,andpoorEnglishproficiency.14
Duringchildbirth,malerelativesmaychoosetonotbeintheroom,sincemenstruationand
birtharedeemedunclean.ThoughmostChinesepeoplevaluestoicisminthefaceofpain,
childbirthisfrequentlyconsideredanexceptionand
cliniciansshouldofferpainmedicine,especiallyas
manyChinesewomenareafraidofgivingbirth.23
MostChinese
Postnatally,mothershaveopenporesandarethusly
Immigrantsuseboth
vulnerableto“wind”whichcanenterthebodyand
Westernand
precipitateillness.Womenmaystayindoorsandavoid
TraditionalChinese
bathingaspreventativemeasures.
Medicine,believing
WesternMedicineto
MentalHealth.ChineseAmericanshavesomeofthe
beeffectiveattreating
lowestmentalhealthutilizationratesofany
acuteillnessand
demographicgroupintheU.S.,andalsodemonstrate
relyingonChinese
highdropoutratesafterseekingtreatment.Many
medicineforrecovery
barriersexisttohealthseekingbehavior.First,
andprevention.
religiousandphilosophicaltraditionsinChinafavora
holisticviewofthehumanbodyanddon’tmakethe
mindbodydistinctionthatissocommonintheWest.
Asaresult,Chinesepeoplemaynotthinkofmentalhealthasseparatefromphysicalhealth,
whichcanimpedetreatment,ortheymaysomaticizementalsymptomstobodilyones.6
Furthermore,alongingrainedbeliefthatoneshouldlookinsidethefamilyforsupportand
dealwithproblemsprivatelymaystigmatizeformalizedphysicianvisits.17
Buddhismcanalsohaveanimpactonmentalhealth.First,becauseBuddhistsmayconsider
theircurrentconditionasjustpunishmentforpreviousmisdeedsandconsequentlynot
seekcareatall;second,becausetheymaybelievethatiftheyspeakabouttheirconcerns
karmawillmakethemreal.1
Traditionalmedicine
Chineseuseoftraditionalmedicinecanbeoneofthemoreintimidatingaspectsfor
WesternphysicianswhencaringforChinesepatients.Providersmayfeeluncomfortable
duetotheirlackoffamiliaritywithtraditionalremedies.Agrowingbodyofliterature
indicatesthatmostChineseAmericanswhousetraditionalmedicinesdon’tdosoinplace
70
ofWesterncarebutasacomplement.Ingeneral,Chinesesocietyconsidersmodern
biomedicaltreatmenteffectiveforacuteoracute/chronicdiseaseslikefracture,hepatitis,
orcancer.TraditionalChineseMedicine(TCM)focusesonalleviatingsymptomsby
restoringharmony,takingaholisticapproach.Forthisreason,TCMsplayabiggerrolein
preventativecareforChineseAmericans.
Practicalconcernsalsoshapepatients’useofTCM.ChineseAmericansfrequently“doctor
shop”,soiftheirsymptomsdon’tresolveuponavisittoaWesternprovidertheymay
switchtoatraditionalChinesedoctorandviceversa.Alternatively,insurancemayshape
careutilizationspatterns:ifcoverageplansdon’treimbursepatientsforTCM,theymay
relymoreheavilyontheWesternmedicalsystem,whereasuninsuredpatientswhocan’t
affordtoseeabiomedicaldoctormayturntoalternativemedicineinstead.24Finally,
ChinesepeoplemayfindWesternmedicinetobetoostrong,withmanyunwantedside
effects,andmayuseTCMtoalleviatesucheffects.
Cliniciansshouldbeawareofafewcommontraditional
medicalpractices.Acupuncture,whichstimulatestheflowof
chi,isusedtoalleviatepainandanxiety.Coiningand
cupping—theapplicationorhotcoinsorbamboocups—
treatscongestionandcoldsbylettingbadenergyoutofthe
body.1Thephotoattherightshowsthemarksleftby
cuppingapproximatelyonedayfollowingtreatment.24
Ingeneral,Chinesemedicineisnon‐invasiveanddoctors
willmakeadiagnosisbytakingthepatient’spulseand
askingdetailedquestionsaboutthecontextoftheillness.24
SocialEtiquette
 Handshakingisanacceptedgreeting,asarenoddingorbowing(slightly).
 Uponmeetinganewperson,Chinesepeoplelowertheireyesasasignofrespect.
 Eyecontactbetweenmembersoftheoppositegendermaybeseenasflirtatious.
 Duringintroductions,oneshouldintroducethejuniorpersontothesenior,orthe
familiartotheunfamiliar.
 Personsshouldbeaddressedbytheirtitle(Mr.orMrs.)orprofessionalqualification
(Dr.orEngineer).
 Personalspaceisimportant,andprovidersshouldavoidphysicalcontactuntilthey
haveestablishedarelationshipwiththepatient,andshouldexplainwhytheexamis
important.
 Arespectfuldistanceduringconversationisfour‐fivefeet.
71
 Someindividualsmayprefertositsidebysideratherthanfacetoface.
 Touchinganelder’sheadcanbedisrespectful.
 Carelesstouchingofachild’sheadisbelievedtoreducedevelopment.
 Headnoddingcansignaldeferencetoauthorityratherthan“yes”.
 Chinesepeoplemayavoidsaying“no”tobepolite.
 Exaggeratedhandgesturesordramaticfacialexpressionarenotcommonamong
Chineseandcanbeseenasaggressive.
 Privacyislinkedto“face”andisveryimportant;practitionersshouldbevery
mindfulofconfidentiality.
 InChina,familynameislistedbeforethegivenname,socareshouldbetakento
makesurethatfullnamesarerecordedcorrectlyinhealthrecords.
 SomeChinesepeoplemayvalueprotectingafamilymemberfromaharshtruth
ratherthantellingtheirlovedonetheextentofagivenillnesssoWesterncaregivers
shouldbepreparedtonegotiatethissituation.
 TherearemixedreportsastoChineseattitudestowardstime:someprofilesassert
thatpunctualityisveryimportant,whileotherssaythattraditionalChinesepeople
placegreaterimportanceonfinishingthetaskathandthanontime.9,14,25
 Uponaguest’sdeparture(orpossiblyadoctor’svisit)thehostshouldescortthe
guesttoatleastthedoor.Thefartheroneaccompaniesaguestout,thegreaterthe
signofrespect.
 CliniciansshouldaskChinesepatientsforpermissionbeforeaddingicetowater,
sincemanybelievecoldbeveragesshockthesystem.Manypreferhotteawhenill.
 Duringthe10daysofChineseNewYear,oneshouldnotusenegativewordsor
phrases;duringthisperiodoneissupposedtoencourageluckandprosperity.
CommonlyUsedPhrases
Duetothedifficultyexperiencedbynon‐nativespeakersinmasteringpronunciationand
tonality,wehavenotincludedaphrase‐list.TheNewYorkUniversitySchoolofMedicine,
hasproducedtwoguidesthattranslatecommonly‐usedmedicalphrasesintoMandarinand
Cantonese,respectively.
http://edinfo.med.nyu.edu/mc/extras/mandarin‐trifold.pdf
http://edinfo.med.nyu.edu/mc/extras/cantonese‐trifold.pdf
72
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Ethnogeriatrics:JohnABurnsSchoolofMedicine,UniversityofHawaii;2001.
2.
DegniF,KoivusiltaL,OjanlatvaA.Attitudestowardsandperceptionsabout
contraceptiveuseamongmarriedrefugeewomenofSomalidescentlivingin
Finland.EurJContraceptReprodHealthCare.Sep2006;11(3):190‐196.
3.
Ngo‐MetzgerQ,MassagliMP,ClarridgeBR,etal.Linguisticandculturalbarriersto
care.JGenInternMed.Jan2003;18(1):44‐52.
4.
VoDX,PateOL,ZhaoH,SiuP,GinsburgKR.VoicesofAsianAmericanyouth:
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2007;120(6):e1481‐1493.
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ChenYC.Chinesevalues,healthandnursing.JAdvNurs.Oct2001;36(2):270‐273.
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GreenG,BradbyH,ChanA,LeeM."WearenotcompletelyWesternised":dual
medicalsystemsandpathwaystohealthcareamongChinesemigrantwomenin
England.SocSciMed.Mar2006;62(6):1498‐1509.
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ChenX,SwatzmanLC.HealthBeliefsandExperiencesinAsianCultures.In:Kazarian
SS,EvansD,eds.HandbookofCulturalHealthPsychology:AcademicPress;2001.
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LinKM,CheungF.MentalhealthissuesforAsianAmericans.PsychiatrServ.Jun
1999;50(6):774‐780.
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QueenslandPartnersinCulturallyAppropriateCare.ChineseCultureProfile:
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10. Wei‐ChenT.AsianAmerican'sConfucianism‐basedHealthSeekingBehaviorand
Decision‐makingProcess.HomeHealthCareManagement&Practice.
2010;22(7):536‐538.
11. XieX,XiaY,ZhouZ.StrengthsandChallengesinChineseImmigrantFamilies.Great
PlainsResearch.2004;14(Fall2004):203‐218.
12. LawP‐l.AnIntroductiontoChineseCultureThroughtheFamily[BookReview].
AsianFolkloreStudies.2005;64(2):327‐329.
13. FangS‐RS,WarkL.DevelopingCross‐CulturalCompetencewithTraditionalChinese
AmericansinFamilyTherapy:BackgroundInformationandtheInitialTherapeutic
Contact.ContemporaryFamilyTherapy.1998;20(1):59‐77.
14. ChinP.Chinese.In:LipsonJG,DibbleSL,eds.CultureandClinicalCare.San
Francisco,CA:UCSFNursingPress;2005.
15. ZhouM,KimSS.CommunityForces,SocialCapital,andEducationalAchievement:
TheCaseofSupplementaryEducationintheChineseandKoreanImmigrant
Communities.HarvardEducationalReview.2008;76(1):1‐29.
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Supplement.(May2004).
17. Muse.CulturalCompetencyandChineseMedicine:ImmigrantChineseBeliefsof
UtilizationandPluralityinHealthSeekingBehaviorsandHealthCareCoverage.
InternationalJournalofTransdisciplinaryResearch.2006;2(1):1‐16.
18. TaylorVM,TuSP,WoodallE,etal.HepatitisBknowledgeandpracticesamong
ChineseimmigrantstotheUnitedStates.AsianPacJCancerPrev.Apr‐Jun
2006;7(2):313‐317.
19. HoM‐J.SocioculturalAspectsofTuberculosis:aLiteratureReviewandaCaseStudy
ofImmigrantTuberculosis.SocialScienceandMedicine.2004;59:753‐762.
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74
Congolesea
RepublicoftheCongo
DemocraticRepublicoftheCongo
Note:Congoleserefugeescomefromageographicareathatisnowtwocountries:The
RepublicoftheCongo(atleft)andtheDemocraticRepublicoftheCongo(atright).
WesternAfrica;borderstheSouth
AtlanticOcean,Angola,Cameroon,
Location
CentralAfricanRepublic,Democratic
RepublicoftheCongo,andGabon
Brazzaville
Capital
342,000sq.km.(slightlysmallerthan
Area
Montana)
Tropical;persistenthightemperatures
andhumidity;rainyseasonMarch‐
June;dryseasonJune‐October.Coastal
Climate/Terrain
plain,centralplateau,northernand
southernbasins.
French(official);54locallanguages,of
whichMonokutubaandLingalaarethe
mostcommon.
4.2million
41
Language(s)
Population
Populationin
VTb
CentralAfrica;bordersAngola,
Burundi,CentralAfricanRepublic,
RepublicoftheCongo,Rwanda,South
Sudan,Tanzania,Uganda,andZambia.
Kinshasa
2,344,858sq.km.(slightlylessthan¼
thesizeoftheUnitedStates)
Tropical;hotandhumidinequatorial
riverbasin,coolerinhighlands;North
ofequator,wetseasonApr‐Oct,dry
seasonDec‐Feb;southofequator,wet
seasonNov‐Mar,dryseasonApr‐Oct.
Vastcentralbasinisalow‐lying
plateau;mountainsineast.
French(official);4mainlocal
languages:Lingala,Kingwana,
Kikongo,Tshiluba.
71.7million
144
aUnlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.https://www.cia.gov/library/publications/the‐world‐
factbook/geos/cg.html;https://www.cia.gov/library/publications/the‐world‐factbook/geos/cf.html
bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
75
76
77
78
79
Backgroundandculture
Currently,whatmanyrefertoastheCongoconsistsoftwoseparatecountries:theRepublic
oftheCongo,withitscapitalinBrazzaville,andtheDemocraticRepublicoftheCongo,with
itscapitalinKinshasa.
From1970until1997,theDemocraticRepublicoftheCongowasnamedZaire,underthe
leadershipofMobutuSeseSeko.WarcametoZairein1994whenthecivilwarinRwanda
forcedonemillionrefugeesintoZaire.Someoftheserefugeeswerearmedandbegantokill
thepeopleofZaire,leadingtotheformationofmilitiasandinvasionbyforcesfrom
Rwanda.ThistensionresultedinthedevelopmentofrebelgroupsintheCongoand
eventuallythecountrysawitsowncivilwar.Apeacetreatydrawnupin2002washonored
bymostparticipatingparties,buttherewerestillrivalingmilitiasfightingineasternCongo.
TheRepublicoftheCongosawitsowncivilwarin1993,whenpoliticalandreligious
differencesledtoviolentaltercations.Thefirstcivilwarresultedinthedisplacementof
10,000citizens.In1997theRepublicoftheCongowasfacedwithasecondcivilwar
betweenmilitiagroupsandsupportersofthecountry’spresident,PascalLissouba.Apeace
agreementwasinstitutedin1999andmanyrefugeesthathadfledreturned.
Language.TheofficiallanguageofbothTheRepublicoftheCongo(Brazzaville)andThe
DemocraticRepublicoftheCongo(Kinshasa)isFrench,althougheachregionalsohas
indigenouslanguages.InTheRepublicoftheCongo(Brazzaville),therearemorethan54
differentlanguages,butMonokutubainthesouthandLingalainthenortharethemost
common.InTheDemocraticRepublicoftheCongo(Kinshasa),therearefourmainBantu
languages:Lingalainthewest,Kikongointhewestandsouthwest,Tshilubaincentraland
southernregions,andSwahiliintheeast.
Religion.Inbothcountries,themajorityofcitizensareChristian,mostofwhomareRoman
Catholic.AsmallerpercentageisMuslim.InTheRepublicofCongo(Brazzaville),about
50%ofthepopulationholdsindigenousbeliefs.
Family.Thereismuchvariationinfamilystructure,dependingontheethnicbackgroundof
thefamily.InboththeRepublicofCongo(Brazzaville)andtheDemocraticRepublicof
Congo(Kinshasa)thereareextendedfamilieslivingunderonerooforinseveral
neighboringhomes.Extendedfamiliestypicallyincludeparents,children,grandparents,
cousins,aunts,anduncles.InbothwesternDemocraticRepublicofCongo(Kinshasa)and
mostoftheRepublicofCongo(Brazzaville),themother’sbrotherisconsideredthe
dominantmale,althoughfamilyitselfismatriarchal.OtherareasoftheCongohavemore
patriarchalandpolygamousfamilies.
Education.IntheDemocraticRepublicofCongo(Kinshasa),civilwarhasdrastically
affectedtheeconomyandeducation.Thereareveryfeweducationalinstitutionsand
enrollmentisverylow.Therearethreepublicuniversitiesstillinoperationandseveral
privateinstitutions.TheRepublicofCongo(Brazzaville)hasalsobeenseriouslyaffectedby
war.Supplyshortageshaveledtothedevelopmentofprivateinstitutions,butmostcannot
80
affordtoutilizethem.Generally,schoolattendanceisrequiredbeginningatagesixand
continuinguntil16.Abachelor’sdegreeisgrantedtothosewhocompletesixyearsof
primaryschoolingandsevenyearsofsecondaryschooling.MarienNgouabiUniversityis
thecountry’sonlypublicuniversity;itoffersdegreesinmedicine,law,andotherfields.
Althoughbothcountrieshaveseendamagetotheeducationalinfrastructure,adultliteracy
ratesarerelativelygood.IntheRepublicofCongo(Brazzaville)over90%ofmalesand
80%offemalesareliterate.TheDemocraticRepublicofCongo’s(Kinshasa)literacyrateis
lower,with81%ofmalesand54%offemaleadultsconsideredliterate.
Diet.CongoleseintheDemocraticRepublicofCongo(Kinshasa)experiencehighratesof
malnutritionbecausefoodsuppliesaredifficulttoobtain.Staplefoodsarecassava,rice,
potatoes,bananas,yams,beans,corn,fish,nuts,fruits,andvegetables.Foodsaresimilarin
theRepublicofCongo(Brazzaville),butfishandmeatoftenaccompanystarchierfoods.
Healthcare
Thetwocountriesfacesimilarhealthaccessproblemsandendemicdiseases.Hospitals,
whenavailable,areinpoorconditionandlacknecessaryequipmentandmedications.
Underthesecircumstances,mostpeople,especiallythoseinruralareas,turntotraditional
healing.Peopleofalllevelsofeducation,socialstatus,andeconomicstatusconsult
traditionalhealers,andoftenconsultbothphysiciansandtraditionalhealersconcerning
thesameailment.Traditionaltreatmentsincludeherbs,plants,andprayer.Itiscommon
forsickpeoplewithoutaccesstohealthfacilitiestositinchurcheswaitingtobecuredby
God.Manybelievethatillness,particularlymentalillness,isbroughtonbycursesorby
punishmentfromGod.Mentalillnessisofparticularconcernbecausepeoplebelievethat
evenwithtreatment,mentalillnesswillneverdisappear.
Congolesepeoplehavegreattrustinphysiciansandnurses.Manyareasarestaffedonlyby
nurses,whooftenearnhighersalariesthandoctors.Publichealtheducationhasmade
greatstridesasamissionoftheMinistryofHealth.
Specifichealthconcerns.TheRepublicofCongo(Brazzaville)andtheDemocratic
RepublicofCongo(Kinshasa)facesimilarendemicdiseases.Themostcommoninfectious
diseasesincludemalaria,tuberculosis,diarrhealdiseases,leprosy,HIV/AIDS,andparasitic
infectionslikeschistosomiasis,onchocerciasis,andtrypanosomiasis.Tuberculosisinthe
DemocraticRepublicofCongo(Kinshasa)hasahighdetectionrateof70%andatreatment
rateof75%.HIV/AIDSratesaresignificantlyhigh,withabout7.5%prevalenceforadults
betweenages15and49.Unfortunately,theseriousnessofHIV/AIDSwasdoubtedwhen
firstdiscoveredandmostinhabitantsdidnotchangebehavioruntilfamousactorsand
musiciansdiedfromcomplicationsofthedisease.Therearenogovernment‐runHIV/AIDS
programs,butprivateattemptshavebeenmadetoeducatethepublic.Still,agreatdealof
workisneededinthisarea.
SocialEtiquette
IntheDemocraticRepublicofCongo(Kinshasa),shakinghandsiscommoninurbanareas,
whereitisconsideredappropriatetoshakehandswithmembersofoppositeandsamesex,
81
Outsideurbanareas,menandwomendonotshakehands.Verbally,urbanareapopulations
greetbysaying,Mbote,whichmeans“hello.”Ineasternandsomesouthernareaswhere
Swahiliisspoken,Jambo,meaning“hello”isoftenthegreetingofchoice.Allactivitywhich
involveshands(passingobjectstooneanother,shakinghands)isdonewiththerighthand,
astheleftisusedforpersonalhygiene.
HandshakesarealsousedtogreetoneanotherintheRepublicofCongo(Brazzaville)
althoughmanyalsokisseachotheronthecheekwhenmeeting.Verbally,thegreetingis
dependentonwhatlanguageisbeingspoken.“Hello”ismostcommonlyMboteorMbotena
yo.Inbothcountries,handgesturesandbodylanguagecanbothemphasizeorreplace
verballanguage.
Eyecontactisacceptedinmostregionsofbothcountries.
Planningandconceptionoftimearenotespeciallyvaluedandsomeetingsmaybemissed
orpatientsmaybelate.
Althoughthetwocountriesaresimilaringeographiclocation,history,andmanycultural
practices,itisimportanttoinquireaboutinformationdirectlyrelevanttothepatientbeing
seen.
WorksConsulted
TalleyL,SpiegelPB,GirgisM.AnInvestigationofIncreasingMortalityAmongCongolese
RefugeesinLugufuCamp,Tanzania,May‐June1999.JournalofRefugeeStudies.
2001;14(4):412‐427.
VanHerpM,ParqueV,RackleyE,FordN.Mortality,ViolenceandLackofAccessto
HealthcareintheDemocraticRepublicofCongo.Disasters.2003;27:141‐153.
82
MeskhetianTurks
Georgia
NOTE:TheMeskhetianTurkshavetheirrootsintheMeskhetianregionofGeorgia.Asa
resultofdeportationsanddiscrimination,thepopulationisnowdispersedthroughoutthe
region.a DiasporaInformation
Location: MeskhetianTurksareknowntoliveinAzerbaijan,Georgia,
Kazakhstan,Kyrgizstan,theRussianFederation,Turkey,Ukraine,
Uzbekistan
Capital: N/A
Area:
N/A;AncestralregioninsouthernGeorgiais9656sq.km.
Climate: AncestralregioninsouthernGeorgiaisdryandrelativelycold;the
westernareaiswarmerandhaslushforest.
Terrain: AncestralregioninsouthernGeorgiaisinthevalleyoftheMtkvari
River,surroundedbymountainsthatare1,000‐2,000mhigh.
Language(s):Turkish,Russian
Population:
Indiaspora:300,000‐400,000livinginninedifferentcountries
InVT:difficulttodeterminebecauseimmigrationstatisticsare
basedonthecountryofresidenceimmediatelypriorto
resettlement,notethnicity;ourbestguessisthat~200
movedtoVTandfewerthan20arestillhere
aUnlessotherwisecited,allinformationinthischaptercomesfromapublicationentitledMeskhetianTurks:
AnintroductiontoTheirHistory,CultureandResettlementExperiences,byAyşegülAydıngün,ÇigğdemBalım
Harding,MatthewHoover,IgorKuznetsov,andSteveSwerdlow.Publishedin2006bytheCenterforApplied
Linguistics,itisavailableathttp://www.cal.org/co/pdffiles/mturks.pdf(accessed1/9/11)
83
Backgroundandculture
TheMeskhetianTurksareanomadicgroupthathashadarecentincreaseinimmigration
totheUnitedStatesandtoVermont.Originally,MeskhetianTurkslivedinMeskhetia,a
southernregioninthecountryofGeorgia.Overtime,however,thepopulationwas
discriminatedagainstinvariouswaysandforcedintosurroundingcountries.Becauseof
thishistory,itisdifficulttoknowhowmanyMeskhetianTurksthereare,butmost
estimatesputthepopulationbetween350,000and400,000in2005.TheMeskhetianTurks
resideinninedifferentcountries,includingAzerbaijan,Georgia,Kazakhstan,Kyrgyzstan,
theRussianFederation,Turkey,Ukraine,Uzbekistan,andtheUnitedStates.
TheMeskhetianTurkshaveexperienceddecadesofpersecution,especiallyinregionsof
Russia.Becauseoftheirnomadicways,MeskhetianTurkswerenotpermittedtogain
permanentresidenceinareasofRussiaandthereforewereunabletoworklegally,own
property,haveaccesstohealthandsocialsecuritybenefits,attendhighereducation
institutions,registerformarriageandbirthcertificates,orobtaindocumentsof
identification.Withoutthesebasicrights,MeskhetianTurksweresubjecttopoverty,
deportation,andpersecution,whichledtounbearablelivingconditions.Whereverthey
triedtosettle,MeskhetianTurksweresubjecttofurtherdiscriminationanddeportation.
Bytheendof2007theUnitedStateshadprovidedrefugeforanestimated12,000
MeskhetianTurks.
Language.MostMeskhetianTurksaremultilingual.AnEasternAnatoliandialectof
Turkishisspokenbythemajorityofpeople,buttherearecertainwordsinthemain
languagethathavebeenadoptedfromseveralothers.MostoftheMeskhetianTurks
residingintheUnitedStatesspeakTurkish,Russian,andthelanguageofwhichever
countrytheylivedinpriortotheUnitedStates.
Religion.MostMeskhetianTurksareSunniMuslim,butmanyofthosewhosettledin
RussiaarenotstrictlyobservantduetotheSovietgovernment’sdiscouragementof
religion.ThosewhoidentifywithethnicityoriginatinginGeorgiaaregenerallyChristian.
Family.MeskhetianTurkfamiliesareextended,includinggrandparents,aunts,uncles,and
cousins.Eldersarethemostrespectedandmakealloftheimportantfamilydecisions.Itis
commonforMeskhetianTurkstowanttoliveinverycloseproximitytotheirfamily
memberswhenresettlingintheUnitedStates.
Education.EducationishighlyvaluedbyMeskhetianTurks,howeverdiscriminationwhile
livingintheformerSovietUnionmadeeducatingchildrenextremelydifficult.Classrooms
wereoftensegregatedandadvancementwasmadepurposefullyunattainableformany.
Childrenwerealsotoldthattheywouldneverqualifytofurthertheireducationatthe
universitylevelortowork,whichsignificantlydecreasedtheirmotivationtostudy.Itis
difficulttoestimateliteracyratesforthispopulationbecausetheyresideinsomany
differentcountries.
84
Diet.Dailydietincludespotatoes,rice,vegetables,meat,eggs,cheese,sourcream,and
honey.ObservantSunniMuslimsrefrainfromeatingpork.
Healthcare
BecauseMeskhetianTurkswereunabletoobtainRussiancitizenship,theywerenot
qualifiedtoreceivefreehealthcarefromthegovernment.Inaddition,manylivedinrural
areasandaccesstohealthcarefromsuchadistancewasextremelylimited.Manyolder
MeskhetianTurksareresistanttohealthcareintheUnitedStatesandaskfamilyand
friendstosendmedicationsfromRussia.TheCenterforAppliedLinguistics(CAL)points
outthatmanyofthesystemsforobtaininghealthcareintheUnitedStatesareunfamiliarto
MeskhetianTurks,whichcanbeachallenge.Forexample,
makingappointmentsinadvanceandpracticing
preventativeratherthancurativemedicinearefrequent
obstacles.
Special
Considerations
Commonmedicalproblemsincludedentalproblemsand
mentalillness,astheMeskhetianTurkshaveexperienced
Thehistoryofthe
difficultpastsandhighlevelsofstress.Itisimpossibleto
MeskhetianTurks
listendemicdiseasesbecausetheMeskhetianTurkscome
complicatesthe
fromseveraldifferentcountries.Forexample,WHO
abilitytopinpoint
estimatestheprevalenceofHIV/AIDSinGeorgiatobe
acceptedcustoms.It
lessthan2%asof2005,butintheFederationofRussia,
isrecommendedthat
wheremostMeskhetianTurksreside,theprevalenceis
providersfamiliarize
between0.8%and1.7%.Knowingthecountryoforiginof
themselveswiththe
thepatientmakesthisknowledgeeasiertoaccess.
basichistory,but
mostrelevantdetails
Socialetiquette
shouldcomefromthe
“Hello”inTurkishisMerhaba,althoughtheMeskhetian
patientsthemselves.
TurksspeakaparticulardialectoftheTurkishlanguage
andtheremaybevariationsofthisword.Studiesin
Georgiahaveshownthathandshakesaregenerally
acceptableandeyecontactisvalued.However,SunniMuslimsdonotmakeeyecontact
withmembersoftheoppositesex.Checkingwiththepatienttoseewhattheyaremost
comfortablewithcanmakefuturegreetingsgomoresmoothly.
Worksconsulted
AydıngünA,HardingÇB,HooverM,KuznetsovI,SwerdlowS.MeskhetianTurks:An
IntroductiontotheirHistory,CultureandResettlementExperiences.CenterforApplied
Linguistics,CulturalProfile2006;http://www.cal.org/co/pdffiles/mturks.pdf.Accessed
April,2102.
MirkhanaovaM.PeopleinExile:TheOralHistoryofMeskhetianTurks.JournalofMuslim
MinorityAffairs.2006;26:33‐44.
WisconsinDepartmentofHealthandHumanServices.CulturalProfile:MeskhetianTurks
2005.http://dcf.wisconsin.gov/refugee/pdf/mturks_profile.pdf
85
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86
Somali
CountryInformationa
Name:
Somalia
Location: EasternAfrica,eastofEthiopia;bordersthe
IndianOcean,theGulfofAden,Djibouti,Ethiopia,
andKenya
Capital: Mogadishu
Area:
637,657sq.km.(slightlysmallerthanTexas)
Climate: principallydesert;duringnortheastmonsoon(Dec‐Feb)
temperaturesmoderateinnorth,hotinsouth;duringsouthwest
monsoon(May‐Oct)torridinnorth,hotinsouth;irregularrainfall
Terrain: primarilyflat,risingtoundulatinghillsinthenorth
Language(s):Somali(official),alsoArabic,Italian,English
Population:
InSomalia:9.9million
InVT:573b
a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.https://www.cia.gov/library/publications/the‐world‐
factbook/geos/so.html bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
87
88
89
BackgroundandCulture
Somalia’sestimatedpopulationis9.9millionpeople;theactualpopulation,however,is
difficulttoobtainduetothenomadiclifestyleofsomeandthefactthatmorethanone
millionhavefledthecountryseekingrefuge.Infact,mostofthechildrenfromSomalia
livingintheUnitedStateswereborninKenyainarefugeecampcalledKakuma.Somalia’s
locationhasprovenhistoricallyproblematic,asconflictoverbordersandboundarieshas
ledtofrequentperiodsofviolence,famine,anddisease.Inaddition,warbetween
neighboringEthiopiaandEritrealedtotheformationofmilitiasandtheinvasionof
SomaliaastherivalingEthiopiaandEritreafoughtoverSomalia’sallegianceandalliance.
EthiopiawithdrewfromSomaliainJanuaryof2007.
Ethnically,Somaliais85%Somali,5%Bantu,and10%Arabandsmallerminorities.Inthe
pastfiveyears,VermonthasprovidedrefugeforhundredsofcitizensofSomalia,withthe
majorityofBantuethnicity.
Language.MajorlanguagesincludeSomali,Arabic,English,andItalian.TheSomali
languagehasthreedifferentdialectsanduntilrecentlywasunwritten.MostoftheSomalis
thathavebeenresettledinVermontareBantuSomalis,whospeakMaiMaiwhichisnota
writtenlanguage.VermontisnowalsohometoanincreasingnumberofSomaliSomalis
(notofBantuethnicity)whoareliterateinSomali.
Religion.Morethan97%ofSomalisareSunniMuslim.AverysmallnumberareChristian.
Family.ThepeopleofSomaliaareaffiliatedwithclans.Whilechildrentaketheirfather’s
nameandbecomepartofhisclan,motherskeeptheirmaidennamesandtheirpositionin
theirownclan.
Education.Theformaleducationsystemhasbeensignificantlyimpactedbywar,infact
muchofithasbeendestroyed.Literacyandlanguageskillsareofgreatconcernforthis
population;roughly50%ofadultmalesand26%ofadultfemalesareliterate.
Diet.NomadicandfarminglifestylespredominateinSomalia,leadingtoadietdictatedby
locationandavailability.NorthernSomaliaishometomanynomadicpopulations,whoeat
plentyofmeatandmilk.SouthernSomaliaandfarmingareaseatlotsofvegetables,millet,
andsesame.Dietisalsoinfluencedbyreligionandeconomicstatus.Forexample,strict
SomaliMuslimseatgrains,fish,fruit,andvegetablesbutcannoteatanythingfromanimals
thathaveeatenotheranimals.
HealthCare
Healthcareprofessionals,includingnursesandphysicians,arewellrespectedinSomalia,
whichdoesnothaveastructuredhealthcaresystemsincemanyhospitalsandclinicswere
damagedinwar.
AstheUnitedNationsandotherorganizationsworktoprovideaidandsupporttoSomalia,
itsresidentsarebeingexposedmoretoprimarycareandWesternmedicine.
90
Infectiousdisease.Waranditsresultingpoverty,lackofeducation,andinsufficienthealth
carehaveledtomanyhealthcomplicationsinSomalia.Thoseofmajorconcerninclude
tuberculosisandcholera,whichisendemicinmostofthecountry.Respiratoryinfections,
malaria,anddiarrhea‐relatedcomplicationscausemostchildhooddeathsandmeasles
outbreaksareresponsibleforhighinfantmortality.TheincidenceofHIV/AIDSis
significantlylowerthaninotherAfricancountries,howeverthismaynotbereliable
becausedatahavebeendifficulttocollect.SincetheWorldHealthOrganizationpredictsa
significantincreaseintheincidenceofHIV/AIDS,educationandpreventionprogramsare
beingimplemented.
Mentalhealth.Mentalhealthispoorlyunderstoodandusuallynotacknowledged.
However,post‐traumaticstressdisorder(PTSD)anddepressionareinevitableinacountry
withsuchaviolentbackground.PTSDhasalsobeenattributedtochewingkhat,whichisa
hallucinogenicleaf.
Traditionalmedicine.Traditionalmedicineiswidelypracticed.Illnessesareoftenblamed
onangryspiritswithinanillperson.Tohealthepatientinvolvessettlingthesespirits,often
byhavinghealingceremonies,eatingspecialfoods,readingtheKoran,andburningincense.
Commonhealingpracticesinclude“fireburning”(applyingheatedstickstotheskin),
herbalremedies,prayer,andbloodletting.Fireburningisacommontreatmentfor
hepatitis,malnutrition,andpneumonia.Bloodletting,similartoextremephlebotomy,
consistsoftakingcopiousamountsofbloodfromthepatientinattempttoremovetheir
illnesswiththeblood.
SocialEtiquette
 GreetingsvaryinSomalia,dependingontheregion.A
Physical
commongreetingacceptedinmostregions,however,is
contact
Nabad,whichmeans“peace.”
between
membersof
 Generally,peopleofthesamesexshakehands,butthose
theopposite
whoareofoppositesexandnotofthesamefamilydonot
sex,except
touchwhenmeeting.
family
members,is
 Directeyecontactisconsideredrudeandistherefore
prohibited.
unacceptable.
 Bodylanguageisincorporatedwithspeakinglanguagetomeancertainthingsorto
placeemphasisonspeech,makingitmoredramatic.
91
Worksconsulted
ComerasamyH,ReadB,FrancisC,CullingsS,GordonH.Theacceptabilityanduseof
contraception:aprospectivestudyofSomalianwomen'sattitude.JObstetGynaecol.Jul
2003;23(4):412‐415.
DaviesMM,BathPA.ThematernityinformationconcernsofSomaliwomenintheUnited
Kingdom.JAdvNurs.Oct2001;36(2):237‐245
DegniF,KoivusiltaL,OjanlatvaA.Attitudestowardsandperceptionsaboutcontraceptive
useamongmarriedrefugeewomenofSomalidescentlivinginFinland.EurJContracept
ReprodHealthCare.Sep2006;11(3):190‐196.
RobertsonCL,HalconL,SavikK,etal.SomaliandOromorefugeewomen:traumaand
associatedfactors.JAdvNurs.Dec2006;56(6):577‐587
WissinkL,Jones‐WebbR,DuBoisD,KrinkeB,IbrahimQ.Improvinghealthcareprovision
toSomalirefugeewomen.MinnMed.Feb2005;88(2):36‐40.
92
Sudanese
CountryInformationa
Name:
Sudan
Location: NorthernAfrica,betweenEgyptandEritrea;
borderstheCentralAfricanRepublic,Chad,
Egypt,Eritrea,Ethiopia,Libya,andSouthSudan
Capital: Khartoum
Area:
1,861,484sq.km.(slightlymorethan¼thesize
oftheUnitedStates)
Climate: ariddesert,hotanddry;rainyseasonvariesbyregion(Apr‐Nov)
Terrain: generallyflat,featurelessterrain;desertdominatesnorth
Languages:Arabic(official),English(official),Nubian,TaBedawie,Fur
Population:
InSudan:45million(includesSouthSudan,est.8.3million)
InVT:140b
a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.https://www.cia.gov/library/publications/the‐world‐
factbook/geos/su.html
bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
93
94
95
Backgroundandculture
Civilwarcamefromirreconcilabledifferencesinreligionandpoliticsinthe1980sandwas
followedbyalmosttwentyyearsofhostilityandbloodshed.Hundredsofthousandsof
refugeesleftSudaninanattempttoescapeviolenceanddrought,whichcreated
uninhabitablelivingconditions.Apeacetreatyin2002wasdraftedinanattempttoend
fighting,butconflictinDarfur,aregionofSudan,continued.Itisestimatedthatby2005,
morethan2millionpeopleweredisplaced.Inanotherattemptatpeace,acontractwas
signedin2006betweenthegovernmentandrebelgroupsinDarfur.However,several
otherrebelgroupsdidnotsignthetreaty.Then,inFebruary2011,SouthernSudanseceded
fromSudanthroughapublicreferendumsupervisedbytheUnitedNations.
Language.TheofficiallanguageisArabic,althoughitissaidthatonlyhalfofthepopulation
speaksit.Over100differentlanguagesarespokeninSudan;manyofthemaretribal
dialectsandmanyhavenosystematicwrittenform.Englishisspokenbymoreeducated
citizenslivinginthesouth.
Religion.Morethan70%ofthepopulationisSunniMuslim,concentratedmostlyin
northernandcentralSudan.While5%identifyasChristian,theremaining25%areof
indigenousreligions.
Family.Differentwaysoflifeanddifferentcustomsarepracticedbytheinhabitantsof
northernandsouthernSudan.Thesouthallocatesmorerightsandfreedomtowomen,
whilemalesaredominantinthenorth.Ingeneral,menworkandleadthefamily,while
womentakecareofthehomeandthechildren.Thehouseholditselfisextended,often
housingthreegenerations.
Education.Childrenaregenerallyrequiredtocompleteatleastnineyearsofeducation,
althoughmanydonotbecauseofpoor,overenrolledschoolsystemsandtheneedto
providemoreincomeforthefamily.TheUniversityofKhartoumisafour‐yearuniversity
withcoursestaughtexclusivelyinArabic.Literacyratesare71%ofadultmalesand52%of
adultfemales.
Diet.ThetraditionalSudanesedietconsistsofmeatssuchasbeef,chicken,goat,and
mutton.Meatisoftenunavailable,however.Someeatfish,millet,vegetables,potatoes,
fruits,andbreads.Alcoholhasbeenoutlawed,butbeerisoftendrunkbythoseinthesouth.
Malnutritioniscommon.
HealthCare
DecadesoffightinghaveleftSudanwithfewoperatinghealthclinicsandhospitals.
BecauseSudanhasover500tribesand57ethnicgroups,healthdisparitiesdifferbetween
groups.Endemictothecountry,however,aremalaria,tuberculosis,leprosy,cutaneousand
visceralleishmaniasis,andschistosomiasis.Sicklecellanemiaiscommonamongthe
Messeyriatribes.InnorthernSudan,casesofheartdiseaseanddiabetesareincreasing.
Approximately260,000peoplearebelievedtobelivingwithHIV/AIDS,anadult
96
prevalencerateof1.1%.Theunmetneedforhealtheducationandawarenesshasbeen
recognizedasamajordeficitinSudan.Asaresult,theFederalMinistryofHealthworks
closelywithSudanesetelevisionstationstobroadcasthealth‐orientedinformationtothe
homesofSudanesefamilies.Programstoeducateaboutdiabetesandbreastcancerarealso
beingdeveloped.
MentalHealth.Mentalillnessisextremelyfeared,asitisthoughttoresultfromdemonic
possession.Treatmentformentalillnessisextremeandcanincludebeingkeptinsolitary
confinementwithonlybreadandwater.Whileinconfinement,thepatientisbeaten
repeatedlytodrivethedemonicspiritfromthebody.Mentalillnessisthusanimportant
healthissuetobeaddressed.
TraditionalMedicine.ResearchdonebytheUniversityofKhartoumhasfoundthatmost
citizensofSudanconsulttraditionalhealersbeforeseeingadoctor.Healingmethods,
dependingontheethnicgroup,mightincludeceremonies,readingsfromtheKoran,dances,
ortheuseofrootsorplants.Illnessisoftenthoughttobecausedbypossessionbydemonic
spiritsorbysomeonegivingthe“evileye.”
SocialEtiquette
Acceptedgreetingsvarybyregion.Generally,innorthernareas,Salaamalaykum,or“peace
beuponyou”isexchangedwithagentlehandshakebetweenthoseofthesamesex.Inthe
south,handshakesarelessfrequentandtheverbalexchangeisoftenGwonada,or“how
areyou?”
Eyecontactisprohibitedincertainsituations.Women,forexample,arenotpermittedto
keepdirecteyecontactwithunknownorholymen.
Worksconsulted
GeltmanPL,Grant‐KnightW,MehtaSD,etal.The"lostboysofSudan":functionaland
behavioralhealthofunaccompaniedrefugeeminorsre‐settledintheUnitedStates.Arch
PediatrAdolescMed.Jun2005;159(6):585‐591.
KempC,RasbridgeLA.CultureandtheEndofLife:EastAfricanCultures:PartII,Sudanese.
JournalofHospiceandPalliativeNursing.2001;3(3):110‐112,120.
97
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98
Vietnamese
CountryInformationa
Name:
Vietnam
Location: SoutheasternAsia;borderstheGulfof
Thailand,GulfofTonkin,andSouth
ChinaSea,aswellasChina,Laos,and
Cambodia
Capital: Hanoi
Area:
331,210sq.km.(slightlylargerthanNewMexico)
Climate: Tropicalinsouth;monsoonalinnorthwithhot,rainy
season(MaytoSeptember)andwarm,dryseason(October
toMarch)
Terrain: Low,flatdeltainsouthandnorth;centralhighlands;hilly,
mountainousinfarnorthandnorthwest
Language(s):Vietnamese(official),English(increasinglyfavoredasa
secondlanguage),someFrench,Chinese,andKhmer;
mountainarealanguages(Mon‐KhmerandMalayo‐
Polynesian)
Population:
InVietnam:90.1million
InVermont:1056b a
Unlessotherwisecited,allinformationonthispageisfromtheUnitedStatesofAmerica,CentralIntelligence
Agency,TheWorldFactbook.AccessedApril,2012.https://www.cia.gov/library/publications/the‐world‐
factbook/geos/vm.html bVTRefugeeResettlementProgram,RefugeesinVermontbyCountryofOrigin,FY89‐FY11.Colchester,VT:
2012.
99
100
101
Backgroundandculture
Vietnamisasocialistrepublicwithapopulationofabout85millionpeople.WorldWarII
andtheVietnamWarcreateddifficultconditionsforVietnam,includingatradeembargoby
theUnitedStateswhichlastedforover20years,duringwhichtimethepeopleofVietnam
experiencedyearsofpoverty,persecution,racism,andisolation.Thousandsoffamilies
tookrefugeinothercountries,includingtheUnitedStates,whichhousesseveralrefugee
andimmigrantpopulations.
Language.MajorlanguagesincludeVietnamese,French,Chinese,English,andKhmer.
Religion.ThemajorityofVietnamesepeople(>60%)areBuddhists.Smallerpercentages
practiceConfucianism,Taoism,orRomanCatholicism.
Family.Householdstypicallyincludeparents,unmarriedchildren,andmarriedsonswith
theirfamilies.Malesareconsideredtobethedominantauthority,butbothmalesand
femalesworkandshareresponsibilities.Elderlyarecaredforbythefamilyoftheyoungest
marriedson,whooftenhasinheritedhisparent’shome.
Education.Beginningatagefive,VietnamesechildrenattendschoolMondaythrough
Saturday.Schoolisonlyfreeforthefirstsixyears.However,educationisvaluedand
childrenareencouragedtofinishhighschool.Sadly,manydropouttobeginworking.
Universityeducationisfreeforcertainstudents,butspaceislimited.Currently,private
universitiesandsecondaryeducationfacilitiesareincreasing.Literacyestimatesare94%
formaleadultsand87%forfemaleadults.
Diet.Mostmealsincludewhiterice,meats,saltyfishorpork,vegetables,fruits,orsoups.
Foodisplacedatthecenterofthetableandeveryonesharesallofthedishes.
HealthCare
Thedoctor‐patientrelationshipinVietnamisoftendependentontheageofthedoctor.
Youngerphysiciansmightbeconsideredincompetentandaskedabouttheireducationas
theyhavenotyetacquiredmuchexperience.Olderphysicians,particularlythosewhohave
beenpracticingformorethan20years,areconsideredexperts.Theoldestmaleinthe
familymakesallofthehealthcaredecisionsandpatientsareveryrarelyeducatedabout
theirconditions.Itisoftenconsideredmoreimportanttospareapatient’sfeelingsthanto
tellthemthetruthabouttheirmedicalailment.Informationonmedicationsordiagnostic
proceduresisalsonotfrequentlycommunicatedwiththepatientandsoitisnot
uncommonforpatientstobeunfamiliarwiththeirmedicalhistories.
Specifichealthconcerns.Malnutritionandinadequatehealthcarearecommonin
Vietnam.HealthdisparitiesinVietnamaremostlytheresultofpoverty,inadequateaccess
tocleanwater,pollution,andwar.BecauseoftheuseofAgentOrangeduringtheVietnam
War,birthdefectswerefrequent.
102
Pollutedwater,malnutrition,andpooraccesstomedicationsandhealthcareareonlysome
ofthefactorscausinghighratesofdysentery,tuberculosis,choriocarcinoma,hepatitis,
typhoid,denguefever,Japaneseencephalitis,cholera,andcholoroquine‐resistantmalaria.
HIV/AIDSratesinVietnamareontherise,witharecentWorldHealthOrganization
estimateofabout.4%forages15to49.
LifestyleRiskfactors.LactoseintoleranceiscommonamongVietnamese.Malnutritionis
expectedtoaffectmorethanhalfofthepopulation.
MentalHealth.MentalhealthailmentscanbeaparticularconcernintheVietnamese
population,astheircountry’sviolenthistoryhasbeendifficulttobear.Thereisastrong
stigmaagainstmentalillness,however,andmanytimesemotionaldisturbancesare
actuallymanifestedsomatically.
TraditionalMedicine.PeoplefromdifferentregionsofVietnamhavedifferentbeliefs
abouthealthandsickness.Forexample,manymountainpeoplebelievethatsicknessisa
punishmentfromthegodswhilethoseinruralcommunitiesoftenplaceemphasison
imbalancedyin‐yangorchi.Treatmentscanincludemagical,religiousandWestern
medicine.Herbs,acupuncture,massage,anddermabrasivepracticesarecommon
treatments.Cuppingandcoiningarepopularwaystodrawillnessoutofthebody.In
coining,acoinisheatedandrubbedalloverthebody.TheVietnamesebelievethatred
weltsormarkswillonlyappearonthosewhoaretrulyill.Coiningandotherpractices
shouldbekeptinmindformanyAsianculturesandhealthcareprofessionalsshouldnotbe
quicktoassumecontusionsresultfromabuseormaltreatment.
Above:cuppingmarksroughlyonedayafter
treatment.Cuppingusesheatedairinattempt
tosuckout“badwinds”orunhealthyair
currentsfromthebody.
Above:coiningmarksonapatient’sback.
Incoining,ahotcoinsometimescovered
inboiledoilisrolledalongapatient’s
skintobringillnessoutofthebody.
103
SocialEtiquette
 Thereismoreemphasisonverbalcommunicationandgreetingthanonbody
language,whichisoftenconsideredimproper.
 Thetypicalgreetingmightincludeahandshakeandaverbalchao,whichmeans
“greetings.”
 AlthoughhandshakingisacceptedbymanyVietnamese,physicaltouchingisoften
consideredinappropriate.
 Itisconsideredinappropriatetotouchaperson’sheadasitisconsideredtobethe
centerofthesoul.Olderadults,however,arepermittedtotouchtheheadsof
youngerchildren.
 Itisalsoconsideredoffensivetobeckonanotherpersonbyusingonlytheindex
finger,asthisgestureisusedtocalladog.Instead,itispreferredtouseallfour
fingerswiththepalmfacingdownward.
 Directeyecontactduringconversationisconsidereddisrespectful.
 Besensitivetomedicalbeliefsandpractices,assomeAsianculturesdonotadhere
toWesternmedicine.Researchingaheadoftimecanprepareyouroffice.
AdditionalResources
StanfordUniversity:VietnameseHealthCare
http://med.stanford.edu/medicalreview/smrvietnam.pdf
VietnameseTraditionalMedicinebyLenaLopez
www.vietspring.org/custom/trad‐medicine.html
Worksconsulted
HuntPC.AnIntroductiontoVietnameseCultureforRehabilitationServiceProvidersinthe
U.S.Buffalo,NY:CenterforInternationalRehabilitationResearchInformationand
Exchange(CIRRIE);2002.
LindsayJ,NarayanMC,ReaK.Nursingacrosscultures:theVietnameseclient.HomeHealth
Nurse.Oct1998;16(10):693‐700.
McKelveyRS,SangDL,BaldassarL,DaviesL,RobertsL,CutlerN.Theprevalenceof
psychiatricdisordersamongVietnamesechildrenandadolescents.MedJAust.Oct21
2002;177(8):413‐417.
104
AfricanAmericans
Backgroundandculture
Definitions.Whenwesay“AfricanAmerican”
inthischapter,wearereferringtoAmericans
ofAfricanoriginwithmultigenerationaltiesto
theUnitedStates.Theinformationthatfollows
isspecificforthispopulation.However,itis
importanttopointoutthatthereisanother
populationofAfricanAmericanslivingin
Vermont,andelsewhereintheUnitedStates.TheseareAfricanrefugees.Theyhavebeenin
Americaforashorterperiodoftime,andcametothiscountryunderadifferentsetof
circumstancesthantheAfricanAmericanswediscusshere.Thatsaid,healthconcerns
notedhereandinindividualrefugeechaptersmayoverlapbetweenAfricanpopulations.
FordetailedinformationonrefugeeAfricanAmericans,seethecountry‐specificrefugee
chaptersinthismanual.
History.AfricanAmericanhistoryismarkedbyslavery,discrimination,andthefightfor
civilrights.AfricanAmericans’ancestorswereforciblytakenfromAfricaandsoldasslaves
intheWest—inCuba,Brazil,andthesouthernUnitedStates.TransportfromAfricatothe
Westwassevere,andmanyAfricansdiedenroute.TheAmericanCivilWarwasfoughtin
partoverslavery;whenitendedin1865,formerslaveswereostensiblyfree,howevera
centurywouldpassbeforesegregationwasendedandtheCivilRightsMovementachieved
legislationgraduallyaffordingequalrights.Despitethislegislation,however,
discriminationremained(andremains)aproblem;currently,AfricanAmericans
experienceasomewhatuneasyandsometimesincompletemeasureofequalitywithin
Americansociety1.AdetailedhistoryofAfricanAmericansintheUnitedStatesisbeyond
thescopeofthischapter;numerousotherresourcesareavailableforthatpurpose.
Demographics.In2010,13%oftheUnitedStatespopulationwasAfricanAmerican2and
by2050thisnumberispredictedtogrowto15%.3InVermont,between1990and2007,
AfricanAmericanswerethefastestgrowingpopulationinVermont,withtheirnumbers
morethantriplingduringthatperiod.4
Culture.AlthoughthetermAfricanAmericanisoftenappliedindiscriminately,“African
Americans”areactuallyanextremelyculturallydiversegroup,withancestraltiestostates
allovertheCaribbean,SouthAmerica,Africa,Europe,andmanyotherplaces.Becauseof
this,manyAfricanAmericanfamiliesareofmixeddescent,havingintermarriedwith
Europeans,SouthAmericans,AmericanIndians,orotherethnicgroups.Thiscomplicates
anyideaofaunifiedAfricanAmericanculture;indeed,culturalpracticesofonegroupmay
notevenberecognizedbyothergroups.
PriortoWorldWarII,AfricanAmericanslivedprimarilyarural,Southernlife.AfterWorld
WarII,themajorityofAfricanAmericansmigratedtoNorthernurbancenters.Today,the
citieswiththehighestpopulationofAfricanAmericansareNewYork,Chicago,Detroit,
105
Philadelphia,LosAngeles,theDistrictofColumbia,Houston,Baltimore,NewOrleans,and
Memphis.Ingeneral,religious,family,andcommunitytiesareimportantinAfrican
Americanculture.Childrenareoftenraisedinanenvironmentofstrongmoralvaluesand
strongincentivetosucceed.However,declininggovernmentaleducationassistanceand
decliningjobopportunitiesoftenmakesuccessdifficulttoachieve.
Healthcare
Severalfactorsconspiretomakethedeliveryofeffectivehealthcaremoredifficultinthe
AfricanAmericanpopulationthantheUnitedStatespopulationatlarge:ahistoryofsocial
andinstitutionaldiscrimination,overalllowersocioeconomicstatus,decreasedaccessto
healthcare,andtheobservationthatmanyAfricanAmericancommunitiesarestruggling
withpoverty,substanceabuse,andviolence.1,5
Lowersocioeconomicstatusisapredictorofpoordietarychoices,lowerphysicalactivity,
tobaccouse,andalcoholabuse;itisalsoassociatedwithahigherdegreeofchronicstress,
whichcorrelatespositivelywithdevelopmentofchronicdisease.5In2005,54%ofnon‐
elderlyAfricanAmericanswerepoorornear‐poor,comparedto26%ofnon‐elderlywhite
Americans;intheelderlypopulation,thesefigureswere67%and38%,respectively.6This
levelofpovertyleadstodecreasedaccesstohealthcare.5
Communitystructurecanalsoleadtopoorerhealthcare,albeitindirectly.Forexample,
propertyvaluestendtobelowerinpredominantlyAfricanAmericancommunities.This
leadstolesspropertytaxrevenue,lessbusinessinvestmentinthearea,and,overall,less
moneycomingintoinvestinthingslikehealthcareservices.5,7.Thebusinessesthatdo
investmaynotbethemosthealthconscious.Forexample,theretendtobemorefast‐food
restaurantsandalcoholvendorsinAfricanAmericancommunitiescomparedtowhite
Americancommunities,andlessavailabilityofaffordablefreshfruitsandvegetables.7
SpecifichealthconcernsintheAfricanAmericanpopulation6
 In2003,theinfantmortalityratewas13.6per1,000birthsintheAfricanAmerican
populationversus5.7inthewhiteAmericanpopulation.
 In2003,AfricanAmericansexperiencedhighermortalityateveryageoflifethan
whiteAmericans.
 In2003,AfricanAmericansdiedfromheartdiseaseatasignificantlyhigherrate
thandidwhiteAmericans.
 In2002,AfricanAmericansdiedatasignificantlygreaterratefrombreast,lung,and
colorectalcancerthanwhiteAmericans,despiteroughlyequalratesofscreening.
 In2004,14.3%ofAfricanAmericanshadtypeIIdiabetes,comparedto8.9%of
whiteAmericans.
 InVermont,between2003and2008,26%ofAfricanAmericanswereuninsured,
comparedto13%ofnon‐Hispanicwhites.4
106
 In2004,thepercentageofAfricanAmericanswhohadlateornoprenatalcarewas
5.7%,comparedto2.2%forwhiteAmericans.
 In2004,thepercentageofAfricanAmericanswhohadnotseenadentistinthe
previousyearwas43%,comparedto32%ofwhiteAmericans.
 In2004,17%ofAfricanAmericanchildrenhadasthma,versus12%ofwhite
Americanchildren.
 In2006,therewastentimesasmuchtuberculosisintheAfricanAmerican
populationthaninthewhiteAmericanpopulation(CentersforDiseaseControl,
2006).
 In2004,lifeexpectancywas73yearsforAfricanAmerican,and78yearsforwhite
Americans.8
 In2008,despiteonlybeing13%ofthepopulation,AfricanAmericansaccountedfor
50%ofnewHIVcases.3
Specificstepsforhealthcareproviders
 Focusonpreventativehealth,particularlywithrespecttoheartdiseaseand
diabetes,bothofwhichoccurathigherrateswithintheAfricanAmerican
populationthaninthegeneralpopulation.Screeneverypatient,everytime,forrisk
factorssuchasobesity,smoking,diabetes,andhypertension.Lifestylemodifications
forheartdiseaseandhypertensionhavebeenshowntobeparticularlyeffectivein
thispopulation,9,10ashavecommunityhealthadvisors.11Lifestylemodifications,
particularlydietandexercise,areespeciallyimportantinAfricanAmericanteens.12
 Screenfordepression.AfricanAmericansaremorelikelytoexperienceamental
disorderthanwhiteAmericans.Theyarealsolesslikelytoseektreatment.
 Sickle‐cellanemiaoccursmorefrequentlyinthispopulation,andalthoughAfrican
Americanwomengenerallyunderstandtheseverityofthiscondition,theymay
underestimatetheirlikelihoodofgettingit.13
 Understandthatthecommunitieswhereyourpatientsliveandworkarediverse,
maybedifferentfromoneanother,andwilllikelyhaveamajorimpactontheir
healthandhealthcare.Itisimportanttounderstandthesecommunitiesandyour
patients’placesinthem.
 Advisepatientsaboutfactorsthataffectbirthoutcomes,suchasmaternalsmoking,
substanceabuse,diet,stress,insufficientprenatalcare,andchronicillness.
 Providesexualhealthcounseling,especiallywithrespecttoHIV/AIDS.
107
 Ensurethatyouarecommunicatingclearlyandcompletelytoyourpatients–oneof
theexplanatoryfactorsforpooreroverallhealthinAfricanAmericansislimited
accesstohealthinformation.14
Additionalresources
VermontDepartmentofHealth,OfficeofMinorityHealthandHealthDisparities:
http://healthvermont.gov/local/mhealth/minority.aspx
UnitedStatesDepartmentofHealthandHumanServices,OfficeofMinorityHealth:
http://minorityhealth.hhs.gov/
108
References
1.
BrisbaneFL,ed.CulturalCompetenceforHealthCareProfessionalsWorkingwith
African‐AmericanCommunities:TheoryandPractice.In:CenterforSubstance
AbusePrevention,ed.Washington,DC:UnitedStatesDepartmentofHealthand
HumanServices;1998.
2.
UnitedStatesCensusBureau.StateandCountyQuickFacts.Washington,DC:United
StatesCensusBureau;2012.
3.
OfficeofMinorityHealthandHealthDisparities.HealthDisparitiesAffecting
Minorities:AfricanAmericans.Atlanta,GA:CentersforDiseaseControland
Prevention.
4.
VermontDepartmentofHealth.TheHealthDisparitiesofVermonters,
http://healthvermont.gov/research/documents/VTDisparitiesRpt2010.pdf.
Burlington,VT:VermontDepartmentofHealth;2010:50‐63.
5.
WilliamsDR,JacksonPB.Socialsourcesofracialdisparitiesinhealth.HealthAff
(Millwood).Mar‐Apr2005;24(2):325‐334.
6.
JamesC,ThomasM,Lillie‐BlantonM,GarfieldR.KeyFacts:Race,Ethnicity,and
MedicalCare,2007Update.Washington,DC:KaiserFamilyFoundation;2007.
7.
AirhihenbuwaCO,LiburdL.EliminatinghealthdisparitiesintheAfricanAmerican
population:theinterfaceofculture,gender,andpower.HealthEducBehav.Aug
2006;33(4):488‐501.
8.
AriasE.UnitedStatesLifeTables,2004.NationalVitalStatisticsReports.Vol56.
Hyattsville,MD:NationalCenterforHealthStatistics;2007.
9.
StephensT,BraithwaiteH,JohnsonL,HarrisC,KatkowskyS,TroutmanA.
CardiovascularRiskReductionforAfrican‐AmericanMenThroughHealth
EmpowermentandAngerManagement.HealthEducationJournal.2008;67(3):208‐
218.
10. RankinsJ,SampsonW,BrownB,Jenkins‐SalleyT.DietaryApproachestoStop
Hypertension(DASH)interventionreducesbloodpressureamonghypertensive
AfricanAmericanpatientsinaneighborhoodhealthcarecenter.JNutrEducBehav.
Sep‐Oct2005;37(5):259‐264.
11. CornellCE,LittletonMA,GreenePG,etal.ACommunityHealthAdvisorProgramto
reducecardiovascularriskamongruralAfrican‐Americanwomen.HealthEducRes.
Aug2009;24(4):622‐633.
12. Lewis‐MossRK,PaschalA,RedmondM,GreenBL,CarmackC.Healthattitudesand
behaviorsofAfricanAmericanadolescents.JCommunityHealth.Oct
2008;33(5):351‐356.
13. GustafsonSL,GettigEA,Watt‐MorseM,KrishnamurtiL.Healthbeliefsamong
AfricanAmericanwomenregardinggenetictestingandcounselingforsicklecell
disease.GenetMed.May2007;9(5):303‐310.
14. SandersThompsonVL,TalleyM,CaitoN,KreuterM.AfricanAmericanmen's
perceptionsoffactorsinfluencinghealth‐informationseeking.AmJMensHealth.Mar
2009;3(1):6‐15.
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110
DeafandHardofHearing
Background
Estimatingthesizeofthedeafandhard‐of‐hearing
populationintheUnitedStatesisdifficultbecause
populationestimateschangedependingonthedefinitions
usedtocategorizepeopleasdeaforhard‐of‐hearing.The
mostrecentdatasuggeststhatabout0.38%ofthe
populationisfunctionallydeaf—thatis,unabletohear
anything,evenwiththeassistanceofahearingaid,andthat
afurther3.72%ofthepopulationishard‐of‐hearing.
However,thesenumbersobscureconsiderableage‐relatedvariation.Infact,the
percentageofthepopulationthatisdeaforhard‐of‐hearingbeforeage18islessthan5%,
whileafterage65,morethan30%ofthepopulationisdeaforhard‐of‐hearing.Morethan
halfofalldeaforhard‐of‐hearingpeoplelosetheirhearinggradually,withtotalloss
occurringlaterinlife.1
Causesofhearingloss.Hearinglosscanbehereditaryoracquired,andhereditaryhearing
losscanbenon‐syndromicorsyndromic.Innon‐syndromichereditaryhearingloss,
hearinglossoccursaloneandistypicallyinheritedmonogenically,althoughpolygenic
formsdoexist.Todate,32genesresponsibleformonogenicnon‐syndromichereditary
hearinglosshavebeenidentified.2Incontrast,insyndromichereditaryhearingloss,
hearinglossoccursalongsideseveralothercomorbiditiescharacteristicofthesyndrome,
andisinheritedpolygenically.Todate,396syndromesincludinghearinglossasoneofthe
symptomshavebeenidentified.3Someofthemostcommonare4:
 Hemifacialmicrosomia,characterizedbyfacial,auricular,andcervicalspinal
abnormalities
 Sticklersyndrome,characterizedbyflattenedfacialprofile,cleftpalate,ocular
changes,andarthropathy
 Ushersyndrome,characterizedbyretinitispigmentosa
 Waardenburgsyndrome,characterizedbypigmentabnormalitiesoftheskinand
eyes
 Branchio‐oto‐renalsyndrome,characterizedbybranchialcleftcystsandrenal
abnormalities
 Pendredsyndrome,characterizedbyahypo–oreu–thyroidgoiter
 Neurofibromatosis2,characterizedbylate‐onsethearinglosscausedbyvestibular
schwannoma;patientsareatalsoatincreasedriskofothertypesofcancer
111
 Alportsyndrome,characterizedbyrenalandoculardisease
 JervellandLange‐Nielsensyndrome,characterizedbyprolongedQ/Tinterval
 Commoncausesofacquiredhearinglossincludeearinfections,ototoxicdrugs(e.g.
streptomycin,aspirin),exposuretohighlevelsofnoise,trauma,otosclerosis
(calcificationofthemalleus,incus,orstapes),vestibularschwannomas(atumorof
thecellsensheathingtheacousticnerve),Meniere’sdisease(adiseaseofunknown
origincharacterizedbyhearingloss,vertigo,andtinnitus),andage‐relatedhearing
loss(presbycusis).
Culture.Manydeafindividualsidentifythemselvesasmembersofadeafculturewhose
elementsinclude,amongothers,asharedlanguagewithdistinctregionalandnational
dialects,asharedhistoryandasharedsetofexperiencesresultingfromlivinginahearing
world,andadistinctsetofpublicandprivatedeafinstitutions,includingdeafschools,
clubs,andsportingevents.Indeed,manydeafpeopledonotregarddeafnessasatrue
disability,arguinginsteadthatthedifficultiesdeafpeopleexperienceindailylifearethe
resultoflivinginasocietydominatedbythehearing.Forexample,whilecommunication
betweendeafandhearingindividualscanbedifficult,adeafindividualmightsuggestthat
thisdifficultycouldbealleviatedifhearingindividualslearnedsignlanguage.5Manydeaf
organizationsadvocateforequitabletreatmentinareassuchascivilrights,accesstohealth
care,accesstofreepubliceducation,thecreationofdeaf‐accessiblemedia,andothers.6
Communication
Deafindividualscommunicatewithamixofsignlanguage(AmericanSignLanguage[ASL])
inAmerica,althoughotherdialectsexist),speech,readinglips,andwriting.5,7ASLisnota
writtenlanguage,however,andmanydeafindividualsdonothaveahighlevelofEnglish
literacy.ThismakescommunicationinwrittenEnglishaproblem.8
Askyourpatienthowtheyprefertocommunicate,andhaveatranslatorpresentifthey
prefertocommunicateusingsignlanguage.KeepinmindthatASLisanexpressive
language;bodylanguageandfacialexpressionimportmeaningtothesigns(forexample,
fear,urgency,orfrustrationcanbeconveyedwithlarger,morerapidsigning).Ifyour
patientpreferslipreading,makesureyouhavetheirattentionandthattheycanseeyou
clearlybeforebeginningtospeak.Chewinggum,wearingafacemask,orturningyourhead
whilespeakingcanimpedeunderstanding.Standinginfrontofabrightlightmayalsomake
communicationdifficult.Ifyourpatientpreferswriting,keepinmindthatASLdoesnot
followthenormalgrammaticalconventionsofEnglish;diagramsandpicturesmaybe
useful.7Inclinicalsettings,makesureyouincludeyourdeafpatientinthediscussionof
theirdisease,procedures,andtreatment.Miscommunicationaboutwhat’sgoingtohappen,
andwhen,inmedicalprocedurescancausefearandanxietyfordeafpatients,anddeaf
peopleconsideritrudetobeexcludedfromanyconversationalinformation.9,10
Whenspeakingwithapatient,rememberthatwhileEnglishcommunicationoftenworksits
wayuptothemainpointandthenconcludesabruptly,deafcommunicationoftenbegins
abruptlyandthenwindsdownslowly;deafpatientsmaystillbewindingdownwhile
112
healthcareprofessionalsfeelthattheconversationisfinished.10Beawareoflowlevelsof
Englishcomprehensionandhealthliteracy,andensurethatyou’veeffectively
communicatedallofthenecessaryinformationtoyourpatient(forexample,byhaving
themrepeatbacktoyouwhatyou’vesaidtothem).10Finally,ensurethatyourofficeisset
uptocommunicateeffectivelywithdeafpatientsforadministrativepurposes.Thisincludes
trainingyourstafftocommunicatewithdeafpatients(forexample,instructingoffice
assistantstowalkdirectlytoyourpatientinsteadofpagingthemwhenit’stimefortheir
appointment)andhavingdeaf‐appropriatetelephoneresourcessuchasTTYathand.See
“AdditionalResources”,below,forfurtherinformation.
Healthcare
Theconceptthatdeafnessisnotadisabilityhasledtohealthcareconflictsbetween
membersofthedeafandhearingcommunity.Oneofthemostnotableisthecontroversy
surroundingcochlearimplants.Thesearesmalldevicesthataresurgicallyinsertedintoa
deafpatient’scochleaandallowthemtohear.5,11Becausemembersofthedeafcommunity
donotfeelthatdeafnessisadisability,theyareunderstandablyoffendedbytheprospect
ofobtainingamedical“fix”fordeafness.11Additionally,thenormalbiologyofthe
developingbrainmakeslanguageacquisitionparticularlydifficultbeyondchildhood;tobe
effectiveinrestoringhearingandallowingthedevelopmentofnormalspeech,cochlear
implantsmustbeimplantedearly.However,thismeansthatthedecisiontoimplantis
oftengreatlyinfluencedbythepatient’sparents.Thepotentialconflictsofinterestbetween
thehearingmedicalcommunity,deafchildren,andparentswhomayormaynotbedeaf
makesthisaverydifficultissuetoresolve.11,12
Specifichealthconcernsinthedeafandhardofhearingpopulations7‐10,13‐15
 Effectivecommunicationwiththehearingworldisoftenthesinglebiggestconcern
fordeafindividualswheninteractingwiththehearingworld.Thisisaresultofdeaf
individuals’limitedEnglishcapacityaswellasthehearingworld’slimited
accommodationfordeafindividuals.
 Deafindividualsmaynottrusthealthcareprofessionals.
 Deafindividualsmaybeconcernedaboutbeingperceivedasdumb,aresultofthe
historicalclassificationofschoolsforthedeafasschoolsforthe“deafanddumb.”
 Deafindividualsmayhavelessaccesstohealthservicesasaresultof
communicationbarriers,butalsobecausedeafindividualsaremorelikelytobe
poorer,unemployed,and/orreceivingfederally‐fundedhealthcare.Inparticular,
deafindividualsmayhavelimitedaccesstomentalhealthservicesdespitehigher
levelsofanxietyanddepressioninthedeafcommunity.
 Healthliteracymaybelow;deafpatientsmayhavetroubleunderstandinggeneral
topicssuchasdisease,diseaseprevention,andtreatment,andspecifictopicssuchas
allergy,bodytemperature,nausea,constipation,andothers.Theymayalsohave
113
troubleunderstandingprescriptionlabels.Thisisaresultofpoorhealtheducation
aswellasdifficultyunderstandinginformationpresentedinEnglish.
 Deafindividualsmayhavelimitedknowledgeofsexualandreproductivehealth,
includingknowledgeofHIV/AIDS.
 Deafindividualsmayhavelimitedknowledgeofpreventativecare,includingcancer
prevention.
 Deafindividualsmayhavelimitedknowledgeofcardiovascularhealth,andmaybe
unabletolistthesymptomsofaheartattackorstroke.
 Deafindividualsmaysufferfromcomorbiditiesassociatedwithsyndromic
hereditarydeafness(seeabove).
Specificstepsforhealthcareproviders
Inadditiontobeingawareofsyndromiccomorbiditiesassociatedwithcongenitaldeafness,
healthcareprofessionalsshouldfocusonimprovingcommunicationandeducational
outreachtodeafpatients.
AdditionalResources
AustineSchoolfortheDeaf(Brattleboro,VT):
http://www.vcdhh.org/schools/austine‐school‐for‐the‐deaf
NationalAssociationoftheDeaf:
http://www.nad.org/
UniversityofRochesterMedicalCenter’sDeafWellnessCenter:
http://www.urmc.rochester.edu/deaf‐wellness‐center/
VermontCenterfortheDeafandHardofHearing:
http://www.vcdhh.org/
VermontCenterforIndependentLiving:
http://www.vcil.org/services/peer‐advocacy/deaf‐independence‐program
VermontRegistryofInterpretersfortheDeaf:
http://www.vtrid.org/
114
References
1.
MitchellRE.HowmanydeafpeoplearethereintheUnitedStates?Estimatesfrom
theSurveyofIncomeandProgramParticipation.JDeafStudDeafEduc.Winter
2006;11(1):112‐119.
2.
FriedmanTB,GriffithAJ.Humannonsyndromicsensorineuraldeafness.AnnuRev
GenomicsHumGenet.2003;4:341‐402.
3.
MoodyAntonioSA,StrasnickB.InnerEar,SyndromicSensorineuralHearingLoss.
2009;http://emedicine.medscape.com/article/856116‐overview.AccessedApril,
2012.
4.
SmithR,ShearerA,HildebrandM,VanCampG.DeafnessandHereditaryHearing
LossOverview.GeneReviews.1993.
http://www.ncbi.nlm.nih.gov/pubmed/20301607.AccessedApril,2012.
5.
SparrowR.DefendingDeafCulture:TheCaseofCochlearImplants.Journalof
PoliticalPhilosophy.2005;13(2):135‐152.
6.
NationalAssociationoftheDeaf.AbouttheLawandAdvocacyCenter.
http://www.nad.org/issues/about‐law‐and‐advocacy‐center.AccessedApril,2012.
7.
UniversityofWashingtonMedicalCenter.CommunicatingWithYourDeafPatient.
2012;http://depts.washington.edu/pfes/PDFs/DeafCultureClue.pdf.Accessed
April,2012.
8.
McKeeM.BetterHealthThroughAccessibleCommunication.Rochester,NY:
NationalCenterforDeafHealthResearch;2009.
9.
IezzoniLI,O'DayBL,KilleenM,HarkerH.Communicatingabouthealthcare:
observationsfrompersonswhoaredeaforhardofhearing.AnnInternMed.Mar2
2004;140(5):356‐362.
10. MeadorHE,ZazoveP.Healthcareinteractionswithdeafculture.JAmBoardFam
Pract.May‐Jun2005;18(3):218‐222.
11. DelostS,LashleyS.TheCochclearImplantControversy.
http://www.drury.edu/multinl/story.cfm?id=2442&nlid=166.Interdisciplinary
ResearchConference.Springfield,MO:DruryUniversity;2000.
12. GeersAE.Speech,language,andreadingskillsafterearlycochlearimplantation.
ArchOtolaryngolHeadNeckSurg.May2004;130(5):634‐638.
13. VernonM,LeighIW.Mentalhealthservicesforpeoplewhoaredeaf.AmAnnDeaf.
Fall2007;152(4):374‐381.
14. PollardRQ,BarnettS.Health‐relatedvocabularyknowledgeamongdeafadults.
RehabilPsychol.May2009;54(2):182‐185.
15. KvamMH,LoebM,TambsK.Mentalhealthindeafadults:symptomsofanxietyand
depressionamonghearinganddeafindividuals.JDeafStudDeafEduc.Winter
2007;12(1):1‐7.
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Elderly
Background
Demographics.Americansarelivinglongernowthanatanytimein
ourhistory.In1900,theaverageAmericanlifeexpectancywas47.3
years;in2000,itwas76.9.In1990,4.1%ofthepopulationwasaged
65orolder;in2003(intheUnitedStates)and2007(inVermont)this
numberhadgrownto12%and13.6%,respectively.By2030(inthe
UnitedStates),and2020(inVermont),asaresultofagingbaby
boomers,those65orolderareexpectedtomakeup20%ofthetotal
U.S.population.Thisdemographicshiftispredictedtohave
consequencesforthecostofAmericanentitlementprogramssuchasSocialSecurityand
Medicare(Medicarecostsarepredictedtorisefrom2.7%ofgrossdomesticproductin
2006to9%in2050.1)Itwillalsoimpactthestructureanddeliveryofhealthcareasmore
servicesareadaptedtomeettheneedsofanagingpopulation.2
Normalaging.AccordingtotheWorldHealthOrganization(2008),“agingisnotadisease;
agingisadevelopmentalprocess.”Factorsthataffecthowapersonagesincludegenes,
lifestyle,diet,co‐morbiddiseases,theenvironment,socialnetworks,andcopingabilities.
Commonly,visionandhearingsensitivitydecline.Muscleandbonestrengthlessens.Skin
becomeswrinkled,dry,lesselastic,andmorefragile;nailsbecomethickerandbrittle.Lung
capacitydecreases.Bladdermusclesweaken,andinmen,theprostatemayenlarge.The
speedofdigestionmayslow.Braincellswillbelost,andmemorymaydecline.3These
normalchangespredisposetosomecommonhealth‐relatedproblemsofagingofwhich
practitionersshouldbeaware.
Healthcare
Thetop5causesofdeathintheelderlypopulationin1980,1999,and2000,wereheart
disease,malignantneoplasm,cerebrovasculardisease,chronicrespiratorydisease,and
pneumonia/influenza;thefactthatthesenumbershavenotchangedsignificantlyinthe
pastseveraldecadessuggeststhattheywillcontinuetofigureprominentlyinelderly
healthcareinthedecadestocome.In2000,otherlikelycausesofdeathinthispopulation
includeddiabetes,Alzheimer’sdisease,renaldisease,accidents(includingmotorvehicle
accidents)andsepticemia(Heetal.,2005).In2010,accordingtotheCentersforDisease
Control,theseleadingcausesofdeathamongtheelderlyremainunchanged.
Specifichealthconcernsintheelderlypopulation4,5
 visiondisorderssuchasage‐relatedmaculardegeneration,cataracts,diabetic
retinopathy,visionloss
 neurologicaldisorderssuchasAlzheimer’sDiseaseorParkinson’sDisease,balance
problems(leadingtofalls),depression
 boneandjointdisorders,suchasrheumatoid‐andosteoarthritis,gout,osteoporosis
117
 cancers,especiallycolorectal,lung,oral,prostate,skin,leukemia
 chronicobstructivepulmonarydisease
 diabetes
 cardiovasculardisorderssuchasmyocardialinfarction,heartfailure,highblood
cholesterol,highbloodpressure,stroke
 mentalhealthissuessuchasworriesaboutdeclininghealthstatus,declining
memory,lossofsocialcontact–especiallyinpatientsover85yearsofage
 dentalconditionssuchastoothdecay,gumdisease,infection,oralcancer
 digestiveproblemssuchasconstipation,problemswithswallowing,other
conditionsassociatedwithslower‐movingdigestivetracts
 chronicconditions;mostelderlypeoplehaveatleastonechronichealthproblem1
 otherconditionssuchashearingloss,kidneydisease,shingles,easybruising
Specificstepsforhealthcareproviders
 Focusonestablishing/maintaininghealthylifestyle.Forexample,promoteage‐
appropriateexerciseregimestohelppreventcardiovascular,metabolic,boneand
joint,andotherdisorders;promotemaintenanceofcognitivefunctionby
encouragingphysicalactivity,cardiovascularfitness,andabstinencefromtobacco
andexcessalcohol(topreventvasculardementia);encouragecontinuouseducation
inolderage;providealcoholandtobaccocessationcounseling;andprovide
diet/nutritioncounseling.
 Accountforthepossibilitythatelderlypatientsmighthavepoorvision:makesure
lightingisadequate,installhandrailsonstairs.
 Accountforthepossibilitythatelderlypatientsmighthavehearingloss:sitface‐to‐
facewithpatients,don’tcoveryourmouth,speakslowly,reducebackgroundnoise,
speakonthesideofthe“good”ear,etc.
 Beawarethatdiseaseswithaneurologicalcomponent(e.g.stroke,dementia,or
Parkinson’sDisease)canaffectcommunicationbetweenyouandyourelderly
patient.
 Writethingsdownifnecessary.
118
 Besensitivetothelifechangesthattheelderlyareexperiencing.Transitionperiods
suchasretirement,movingtolongtermcare,orlosingfriendsandspousesareall
veryprofoundexperiencesthatshouldbeacknowledged.Educatingthepatient
abouthealthylivingandaidingthemastheycopewithlifechangesisimportantto
thepatient‐providerrelationship.
 Beawareof,andscreenfor,memoryloss,urinaryincontinence,depression,andfalls
(four“geriatricgiants,”accordingtotheWorldHealthOrganization),hypertension
anddiabetes.
 Conductage‐appropriatepreventativehealthscreeningsasrecommendedbythe
WorldHealthOrganizationinthefiguresbelow.
Bloodpressure,
heightandweight
Obesity
Cholesterol
PapSmear
Mammography
Colorectalcancer
Osteoporosis
Alcoholuse
YearsofAge
50
55
60
Everyvisit
Periodically
Everyyear
Every1to3years
Every1to2years
Dependsontests
Everyvisit
Vision,hearing
119
65
70
75
Routinely
Every1to2
years
Upperagelimitshouldbeindividualizedforeachpatient
Screenings
Counseling
Every10years
Yearly
65
70
75
Onedose
Periodically
Women:periodically
Periodically
Upperagelimitshouldbeindividualizedforeachpatient
Tetanus‐diphtheria
(Td)
Pneumococcal
Influenza
Assesscardiovascular
diseaseriskanddiscuss
aspirintopreventCVD
events
Calciumintake
Tobaccocessation,drug
andalcoholuse,STDs
andHIV,nutrition,
physicalactivity,sun
exposure,oralhealth,
injuryprevention,and
polypharmacy
YearsofAge
50
55
60
Immunizations&
Chemoprevention
AdditionalResources
Age‐friendlyPrimaryHealthCareCentresToolkit,fromtheWorldHealthOrganization.
Providesacomprehensiveoverviewofage‐appropriateprimarycare,recommendations
fordesigningaprimarycarepracticetomeettheneedsofanelderlypopulation,and
sampleformsthatcanbeusedforpreventativehealthscreening.
http://www.who.int/ageing/publications/Age‐Friendly‐PHC‐Centre‐toolkitDec08.pdf
HealthyAgingforOlderAdults.TheCentersforDiseaseControl’swebsitefocusedon
healthyaging.http://www.cdc.gov/aging/
UnitedStatesDepartmentofHealthandHumanServices,AgencyonAging.www.aoa.gov/
120
References
1.
OliverDP,DeCosterVA.Healthcareneedsofagingadults:unprecedented
opportunitiesforsocialwork.HealthSocWork.Nov2006;31(4):243‐245.
2.
HeW,SenguptaM,VelkoffVA,DeBarrosKA.65+intheUnitedStates:2005Current
PopulationReports.Washington,DC:U.S.GovernmentPrintingOffice;2005.
3.
WorldHealthOrganization.NormalAgeing‐powerpontpresentation.
http://www.who.int/ageing/publications/PPNormalAgeingfortoolkit.pdf.Accessed
April,2012.
4.
JeonHS,DunkleR,RobertsBL.Worriesoftheoldest‐old.HealthSocWork.Nov
2006;31(4):256‐265.
5.
MayoClinicStaff.Aging:WhattoExpectasyouGetOlder.
http://www.mayoclinic.com/health/aging/HA00040.AccessedApril,2012.
121
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blank.
122
LGBTQI(Lesbian,Gay,
Bisexual,Transgender,
Queer/Questioning,Intersex)
Background
Definitions1,2:
 Lesbian:Awomanwhoisemotionally,
romantically,and/orsexuallyattractedto
otherwomen.
 Gay:Amanwhoisattractedemotionally,romantically,and/orsexuallytoother
men.
 Bisexual:Apersonwhoisattractedtotwosexesortwogenders,butnotnecessarily
simultaneouslyorequally.
 Transgendered/Transsexual:Individualswhosegenderidentity(i.e.maleorfemale)
doesnotmatchtheirbiologicalsex(i.e.XY,XX);transsexualindividualsseekmedical
interventiontomorecloselyaligntheirphysicalappearancewiththeirgender
identity.
 Queer:Anumbrellatermforsexualminoritiesthatarenotheterosexual,
heteronormative,orgender‐binary.Thistermmaybecontroversial,butitis
sometimesusedbyyoungpeopleorforpoliticalpurposes.
 Questioning:Someonethatisquestioningtheirsexualorientation,unsurewhich
gender(s)theyareattractedto.
 Intersex:Peoplewhoarebornwithphysicalmarkers,sexchromosomes,external
genitalia,orinternalreproductivesystems,thatarenotconsideredstandardfor
eithermaleorfemale.
AlthoughdefiningthesetermsisnecessaryinordertodiscussLGBTQIpopulations,keepin
mindthatthesedefinitions,andothers,areimpreciseandoftencontroversialbecauseof
thefluidityofhumansexualitywithinandbetweenculturesacrosstime.1,2
Demographics.EstimatesofthesizeoftheLGBTQIpopulationaredifficulttomake.While
theUSCensusBureaupublishesstatisticsonthenumberofAmericanslivingassame‐sex
couples,nodataiscollectedonbisexual,transgendered,orintersexindividuals.Inaddition,
ahistoryofdiscriminationagainstLGBTQIindividualsmakesdatacollectiondifficult.3
Nonetheless,someestimatescanbemade.In2010,thepercentageofVermontersinsame‐
sexcoupleswas1.09%(upfrom0.8%in2000).4Thesizeofthebisexualpopulationis
hardertoestimate;inAlfredKinsey’soriginalstudiesonsexualbehavior,46%ofmenand
123
12%ofwomenadmittedtobisexualexperiences(Toufexisetal.,1992),whilestudies
conductedinthe1980sand1990sestimatedthesepercentagestobebetween3.3and6%
(men)and2.3%(women).5Morerecently,alargesurveyofAmericancollegestudents
estimatedthat5%ofwomenand2%ofmenwerebisexual.6Specificdataonthis
populationinVermontwasnotavailable.Dataontransgenderedortranssexualindividuals
isevensparser,althoughmostestimatessuggestthattheycompriselessthan1%ofthe
totalU.S.population.7Finally,estimatessuggestthataboutonein1500‐2000individualsis
bornintersex,8,9althoughthisfigureistentativeas“intersex”isdifficulttodefinewith
precision,andsome“intersex”conditionsmaygocompletelyunnoticedorunnoticeduntil
laterinlife.1
Discrimination.TheLGBTQIcommunityhasbeen,andstillis,
subjecttodiscrimination,harassment,andphysicalviolencein
boththeUnitedStatesandtheworldwide.WhileU.S.legislation
Manyolder
hasbeenmovinginrecentdecadestowardsgreaterequalityfor
LGBTQIpeople
LGBTQIindividuals,itwouldbeprematuretosuggestthattrue
feeltheword
equalityhasbeenachieved.Acomprehensivediscussionofthe
queerhasbeen
historyofLGBTQIdiscriminationisbeyondthescopeofthis
hatefullyused
manual.However,ifyouwouldliketoknowmore,thefollowing
againstthemfor
organizationsmaybeofinterest:AmericanCivilLibertiesUnion
toolongandare
Lesbian,Gay,BisexualandTransgenderedProject,GayRightsat
reluctantto
Change.org,TheIntersexSocietyofNorthAmerica,andThe
embraceit.
NationalCenterforTransgenderEquality.Pleaserefertothe
AdditionalResourceslistedattheendofthechapterforwebsite
listingsforeach.
Healthcare
ManyhealthconcernsoftheLGBTQIcommunityaresharedamongstallitsmembers.For
example,discrimination,harassment,andphysicalviolencecancauseanxietyand
depressioninLGBTQIindividuals,leadingtolowself‐esteem,feelingsofpowerlessness,
substanceabuse,andsuicide.2,10Whilenotconclusive,recent
datasuggestthatLGBTQIindividualsmayusetobacco,alcohol,
andotherdrugsathigherratesthandoesthegeneral
ManyLGBTQI
population.
individualsdonot
telltheirdoctors
Furthermore,theperceptionofLGBTQIdiscriminationinthe
abouttheirsexual
healthcarecommunityhasledtoloweraccessofhealthcare
orientation,
servicesamongstLGBTQIindividuals.Healthcareaccessisalso
becausetheydo
threatenedbecauseexistinglegislationoftendoesnotallow
notwant
LGBTQIpartnerstosharemedicalinsuranceandrestricts
discriminationto
medicaldecision‐makingrights.Domesticviolencebetween
affectthequality
LGBTQIpartnersmaygounnoticedbyphysicianswhoassumeit
ofhealthcarethey
isauniquelyheterosexualissue.Finally,LGBTQIindividualsalso
receive.
haveuniquehealthneedsasaresultoftheirsexualpractices.11
124
Specifichealthconcernsinthelesbianpopulation13
 Breastandgynecologicalcancer:lesbiansmaybeatanincreasedriskofthese
cancersduetolowerutilizationofhealthcareservices.
 Domesticviolence:althoughdomesticviolenceoccursinlesbianhomesathalfthe
rateitdoesinheterosexualhomes,itmaygounnoticedbyproviderswhoassumeit
isauniquelyheterosexualproblem.
 Hearthealth:smokingandobesityarethemostprevalentriskfactorsfordisease
amonglesbians.
 Alcohol,tobacco,andsubstanceuse/abuse:seegeneraldiscussionabove.
 Depression,anxiety:seegeneraldiscussionabove.
Specifichealthconcernsinthegaypopulation2,11,12
 HIV/AIDSandsafesex:althoughsafe‐sexeducationhasgreatlyreducedthe
incidenceofHIV/AIDSinAmerica,gaymenarestillatgreaterriskofcontracting
HIVthanthegeneralpopulation,andsafe‐sexpracticeshavebeendecreasingin
recentyears.
 Sexuallytransmitteddiseases(STDs):gaymenareatahigherriskthanthegeneral
populationofacquiringSTDs,whichmayincludeHepatitis,thereforeimmunization
againstHepatitisisrecommended.
 Prostate,testicular,andcoloncancer:gaymenmaybeatahigherriskofthese
cancersasaresultofdecreasedhealthcareutilization.
 Bodyimage:gaymenaremorelikelytodevelopanorexiaorbulimia.
 Analpapilloma:analinfectionwiththehumanpapillomavirusmayberesponsible
forincreasedratesofanalcanceramonggaymen.
 Alcohol,tobacco,andsubstanceuse/abuse:seegeneraldiscussionabove.
 Depression,anxiety,andsuicide:theseareaconcernforgaymenofallages,but
maybeparticularlypronouncedinadolescents.
125
Specifichealthconcernsofthebisexualpopulation11
 Sexualhealth:bisexualwomenreporthigher‐risksexual
behaviorthanheterosexualwomen,whilebisexualmen
Fearof
haveahigherriskofcontractingHIVthanheterosexual
encountering
men.
anothernegative
experiencewitha
 Breastcancer(inwomen)andanalcancer(inmen):see
healthcareprovider
discussionsabove.
canleadLGBTQI
individualstodelay
 Hearthealth,nutrition,fitness,andweight.
oravoidmedical
care.
 Lackofaccesstosocialsupport,particularlyinbisexual
women.
 Alcohol,tobacco,andsubstanceuse/abuse:seegeneraldiscussionabove.
 Depression,anxiety,self‐harm,andsuicide:seegeneraldiscussionabove.
Specifichealthconcernsofthetransgendered/transsexualpopulation14
 Accesstohealthcare:transgendered/transsexualindividualsmaybereluctantto
seekcarebecauseoffearofdiscrimination;also,medicalcareforhealthissues
specifictotransgenderedindividualsisoftenexpensiveandnotcoveredby
insurance.
 Healthhistory:transsexualindividualsmaybereluctanttosharerelevanthealth
history(e.g.gender‐reassignmentsurgery)withhealthcareprofessionalsforfearof
discrimination.
 Hormoneuse:estrogenandtestosteroneusecarriessignificantrisk;hormonesmay
alsobeobtainedthroughindirectchannelsoutsidethehealthcaresystem.
 Cardiovascularhealth:increasedriskbothasaresultofhormoneuseanddecreased
utilizationofhealthcareservices.
 Cancer:hormone‐relatedcancerisrare,butshouldbescreenedfor.Transsexual
menwhohavenothadtheirfemalereproductiveorgansremovedruntheriskof
gynecologicalcancers,whiletranssexualwomenruntheriskofprostatecancer.
 Injectablesilicone:sometransgendered/transsexualwomeninjectsiliconetogive
them“instantcurves.”Thisisoftenadministeredbynon‐medicalpersonnelandmay
migratetounintendedlocations,causingtissuedamage.
 Fitness:obesityisaconcerninthetransgendered/transsexualpopulation.
126
 Alcohol,tobacco,andsubstanceuse/abuse:seegeneraldiscussionabove.
 Depression,anxiety,self‐harm,andsuicide:seegeneraldiscussionabove.
Specifichealthconcernsoftheintersexpopulation
Thehealthconcernsofanintersexindividualwilldependonwhythatindividualis
intersex.Forexample,congenitaladrenalhyperplasia(CAH)maycauseanintersex
conditioninXXindividualsduetoexcesstestosteroneproduction.CAHcausesdecreased
levelsofcortisolproduction,leadingtoanimpairedstressresponse,anddecreasedlevels
ofaldosteroneproduction,leadingtopotentiallylethalsaltwasting.Thelistofintersex
conditionsislong,andeachpatientwillpresentwithauniquesetofhealthconcerns.1
Therefore,adetailedhistoryisthebestwaytodeterminethespecifichealthconcernofa
particularpatient.Thatsaid,intersexindividualssufferfromelevatedratesofdepression
andanxiety,andpossiblyshame,asaresultofhidingtheirconditionfromsociety.15,16
Specificstepsforhealthcareproviders11,17
Inadditiontobeingawareof,andscreeningfor,theuniquehealthconcernsofLGBTQI
individuals,healthcareprofessionalsshouldseektocreateaninclusiveenvironmentin
theirpractice.
 Behonestandawareofyourownbiasesandprejudices.
 ProvideeducationandtrainingontheLGBTQIcommunityforallstaff.
 Haveanunisexrestroomavailable.
 Changethephysicalenvironmentofyourclinic:displaypostersshowingLGBTQI
individuals.Postrainbow‐flags,pinktriangles,andotherLGBTQI‐friendlymaterials
throughoutofficeandmixedamongsttheothermaterialsintheoffice.Postavisible
non‐discriminationstatement.StockLGBTQI‐friendlyliteraturesuchasmagazines
andnewslettersinyourwaitingarea.
 Askpeoplehowtheywouldliketobereferredto,andusepronounsreflectiveofa
patient’sgenderidentityratherthanhisorherbiologicalsex.
 Providerinterviewsandintakeformsshouldbeinclusiveandnon‐judgmental.
Ratherthanaskingmaritalstatus,askaboutsignificantsupportsinapatient’slife
andleavespaceforsomeonetodescribetheirfamilystructure.
 Open,non‐judgmentalcommunication,acceptance,andtrustleadtoamoredetailed
andaccuratehistory.Thisinturnwillleadtobetterandmoreappropriatecarefor
allpatients.
127
 ConfidentialityisespeciallyimportanttotheLGBTQIpopulationwhoarestill
vulnerabletodiscrimination.Discussconfidentialityissueswithpatientsanddon’t
recordsexualorientationinapatient’schartwithoutconsent.
 Focusonbehaviorratherthansexualorientationwhentreatingallpatients.
HeterosexualindividualscanengageinthesamehighriskbehaviorsastheLGBTQI
population,andmanyindividualswhodoengageincertainriskybehaviorsdonot
self‐identifyasanythingotherthanheterosexual.
 IncludepartnersofLGBTQIpatientsinhealthcareplanninganddecision‐making.
 Havehealthpromotioncampaignsthatincludegay,lesbian,bisexual,transgender,
queer,andintersexindividualsandtheirfamilies.
Additionalresources
 GayandLesbianMedicalAssociation.AsitewithresourcesforLGBTQIpatientsand
practitioners:www.glma.org/
Referto:TopTenThingsLesbians[GayMen,Bisexuals,TransgenderPersons]Should
DiscusswithTheirHealthCareProvider:
 Lesbians:http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=691
 GayMen:http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=690
 TransgenderedPersons:
http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageID=692
 HopeWorks:www.hopeworksvt.org
 LGBTMentalHealthSyllabus,includesexamplesofhowtoaskinclusive,non‐
heteronormativequestions:www.aglp.org/gap/
 OutrightVermont:http://www.outrightvt.org
 NationalCoalitionforLGBTHealth.http://lgbthealth.webolutionary.com/
 RU12?CommunityCenter:www.ru12.org
 TheIntersexSocietyofNorthAmerica:www.isna.org
 VermontCares(HIV/AIDSresource):www.vtcares.org
 VermontDiversityHealthProject:www.vdhp.org
 VermontersEndingTransgenderOppression:http://vtveto.wordpress.com
 AmericanCivilLibertiesUnionLesbian,Gay,Bisexual,andTransgenderedProject:
http://www.aclu.org/lgbt/index.html
 GayRightsatChange.org:http://gayrights.change.org/
 TheNationalCenterforTransgenderEquality,http://transequality.org/
 CDC–Lesbian,Gay,Bisexual,andTransgenderHealthRetrievedJuly20,2012,
www.cdc.gov/lgbthealth/
References
1.
IntersexSocietyofNorthAmerica.WhatisIntersex?
http://www.isna.org/faq/what_is_intersex.AccessedApril,2012.
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3.
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6.
7.
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17.
JohnsonCV,MimiagaMJ,BradfordJ.Healthcareissuesamonglesbian,gay,bisexual,
transgenderandintersex(LGBTI)populationsintheUnitedStates:Introduction.J
Homosex.2008;54(3):213‐224.
BoslaughS.LocatingDemographicInformationonGLBTPeople:AGuidetothe
AvailableReferenceSources.InternationalGLBTArchives,Libraries,Museumsand
SpecialCollectionsConference.Minneapolis,MN:GLBTALMS;2006.
U.S.CensusBureau.(2010).Same‐sexcouplehouseholdstatisticsfromthe2010
census.RetrievedDecember11,2012from
(http://www.census.gov/hhes/samesex/).
SmithE,JohnsonS,GuentherS.HealthCareAttitudesandExperiencesDuring
GynecologicCareAmongLesbiansandBisexuals.AmericanJournalofPublicHealth.
1985;75(9):1085‐1087.
EisenbergM,WechslerH.Substanceusebehaviorsamongcollegestudentswith
same‐sexandopposite‐sexexperience:resultsfromanationalstudy.AddictBehav.
Jul2003;28(5):899‐913.
OlyslagerF,ConwayL.OntheCalculationofthePrevalenceofTransexualism.
WPATH20thInternationalSymposium.Chicago,IL:WPATH;2007.
MacKenzieD,HuntingtonA,GilmourJA.Theexperiencesofpeoplewithanintersex
condition:ajourneyfromsilencetovoice.JClinNurs.Jun2009;18(12):1775‐1783.
BlacklessM,CharuvastraA,DerryckA,Fausto‐SterlingA,LauzanneK,LeeE.How
SexuallyDimorphicAreWe?ReviewandSynthesis.AmericanJournalofHuman
Biology.2000;12:151‐166.
PeterkinA,RisdinC.CaringforLesbianandGayPeople:AClinicalGuide.Toronto,
ON:UniversityofTorontoPress;2003.
BGLAM.CaringforLesbian,Gay,Bisexual,andTransgenderPatients.AnnArbor,MI:
UniversityofMichiganMedicalSchool;2005.
SilenzioVMB.TopTenThingsGayMenShouldDiscussWithTheirHealthCare
Provider.SanFrancisco,CA:Gay&LesbianMedicalAssociation.
O'HanlanK.TopTenThingsLesbiansShouldDiscusswiththeirHealthCareProvider.
SanFrancisco,CA:Gay&LesbianMedicalAssociation.
AllisonR.TopTenThingsTransgenderedPersonsShouldDiscussWithTheir
HealthcareCareProvider.SanFrancisco,CA:Gay&LesbianMedicalAssociation.
FraderJ,AldersonP,AschA,etal.Healthcareprofessionalsandintersexconditions.
ArchPediatrAdolescMed.May2004;158(5):426‐428.
LGBTIssuesCommittee,GroupfortheAdvancementofPsychiatry.LGBTMental
HealthSyllabus.2011;http://www.aglp.org/gap/.AccessedApril,2012.
MineykoA,WilliamsR,AlexanderA,ChanL,Facey‐CrowtherL‐A,WatsonS.Gender
andSexualDiversity.GenderandHealthCollaborativeCurriculum
http://genderandhealth.ca/en/modules/sexandsexuality/.AccessedApril,2012.
129
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Homeless
Background
Definitions.AccordingtotheUnitedStatesDepartment
ofHousingandUrbanDevelopment’s2009regulations,a
homelessindividuallacksa“fixed,regular,andadequate
night‐timeresidence,”andislivinginashelter,an
institution,orinanyotherplacenotdesignedor
ordinarilyusedforsleepingaccommodation.The
McKinney‐VentoHomelessAssistanceAct(2002)
broadensthedefinitionofhomelessnessforchildren.For
example,childrensharinghousingduetoeconomic
hardship,livinginhotels,motels,ortrailerparks,
awaitingfostercareplacement,orsimplylivingin
substandardhousingareconsideredhomeless.
Thesedefinitionsmatterbecausetheyareusedtoincludeandexcludeindividualsfrom
governmentsurveysandthereisnofederalhousingassistanceforindividualsnotmeeting
theHUDdefinitionofhomelessness,buttheyarenotstatic.Forexample,in2008,certain
citiescompletingahomelessnesssurveyforHUDchosetoexcludemultiplefamiliesliving
inthesameapartmentandpeoplelivingintrailerparks,althoughthesepeoplewere
countedinprevioussurveys.Therefore,althoughhomelessnesshasofficiallydeclinedby
12%inrecentyears,homelessnessadvocatesarguethatthisreductionreflectsanarrowing
definitionofwhoishomelessratherthananyrealreductioninhomelessness.1Further
confusingcountsistheissueoftheinvisiblehomeless:individualslivinginautomobiles,
tents,underbridges,andinotherplaceswheredemographersmightnotfindthem.2
Finally,estimationsofhomelessnessareoftenmadeatasinglepointintime,but
homelessnessisanacuteaswellasachronicproblem,andthenumberofhomeless
individualsmayfluctuateonashort‐termbasis.Achronically‐homelesspersonisdefined
as“anunaccompaniedhomelessindividualwithadisablingconditionwhohaseithera)
beencontinuouslyhomelessforayearormoreorb)hashadatleastfourepisodesof
homelessnessinthepastthreeyears.3However,TheDepartmentofHealthandHuman
Services(2009)estimatesthatoverafive‐yearperiod,2‐3percentoftheU.S.population,or
5‐8millionpeople,willexperienceatleastonenightofhomelessness.Practically,this
meansthathomelessnessisdifficulttodefine,difficulttoquantify,andthatcountsmay
changewithinorbetweenyearsdependingonwhodoesthecounting,how,where,and
when,irrespectiveofanyrealchangesinhomelessness.Theseobservationsshouldbekept
inmindwhenreviewingdemographystatisticsbelow.
Causesofhomelessness.Povertyandhomelessnessareinextricablylinked.Thisis
becausehousingoftenabsorbsasizeable,andgrowing,proportionofafamily’sbudget
comparedtofood,childcare,healthcare,andotherexpenditures,andisthereforeoftenthe
firstitemcutwhenafamilyisexperiencingfinancialdifficulty.4Whiletherearemany
causesofpoverty,twoareespeciallyrelevant.Thefirstofthesehastodowith
employment:decliningemploymentopportunities,atrendofreplacingfull‐timewithpart‐
131
timeortemporaryjobs,andastagnatingminimumwage,makeitdifficultforindividualsto
obtainasecure,livablewage.Thesecondofthesehastodowithsocialassistance:stateand
federalassistanceprograms—e.g.welfare,subsidizedhousing,andMedicaid/Medicareand
otherprograms—aredecreasinginvalueandavailability.Practically,thismeansthat
impoverishedindividualsareoftenonelostpaycheckorillnessawayfromhomelessness.4
Otherriskfactorsforhomelessnessincluderelationshipproblems,physicalorsexual
abuse,substanceabuse,legaltroubles,and—forchildren—theinstitutionalizationordeath
ofaparent.5
Demographics.Accordingtothe2010“PointinTime”reportfromtheVermontCoalition
toEndHomelessness,62,782VermonterswerehomelessasofJanuary2010.Ofthese,
1,148weremembersof497families.Thetotalnumberofindividualsthatwere17years
oldoryoungerwere766,and317wereover50yearsold.MostlivedinRutland,
Chittenden,andBenningtoncounties.Themajorityweremale(andintheUnitedStatesasa
whole,40%ofhomelessmenwereveterans).4However,thesenumbersmay
underestimatethehomelesspopulationofVermont.Althoughthepopulationofhomeless
Vermontershasgonedownsince2000,in2007Vermonthadthehighestrateof
homelessnessinNewEngland,andthepercentageofhomelessfamiliesandchildrenhad
grown.Additionally,theaveragestayinahomelessshelterisgrowing,from12daysin
2000to26daysin2004.6,7
Healthcare
Awidevarietyofhealthproblemsareprevalentinthehomelesspopulation,andtheir
morbiditymaybeextremelyhighbecauseofdelaysinseekingcare,non‐adherenceto
therapy,andotherfactors.Additionally,middle‐agedindividualsmaydevelopdiseasesthat
ordinarilyappearinindividualsmanydecadesolder.8Theseproblemsmaybeexacerbated
bylackofhealthinsurance,andlimitedhealthliteracyinhomelessindividualsmaymake
treatmentdifficult.9
Mentalhealth.Homelessindividualsaremorelikelythanthegeneralpopulationtosuffer
frommentalillness.Thesemayprecede,follow,orbeexacerbatedbyhomelessnessand
includeschizophrenia,affectivedisorders,post‐traumaticstressdisorder,depression,low
self‐esteem,andhigherratesofsuicidalideationandsuicideattempts.Homeless
individualsalsoreportexperiencinggreaterlevelsofstressandarelesslikelytohave
adequatecopingstrategiesandsocialsupportnetworksthanthegeneralpopulation.
Substanceabuse.Homelessindividualsaremorelikelythanthegeneralpopulationto
abusesubstances,includingalcohol,tobacco,marijuana,cocaine(usuallycrackcocaine),
heroin,andprescriptiondrugs.Overdosesarecommon.Manyhomelesspeoplemayalso
haveaconcurrentsubstanceabuseproblemandmentalillness.
Otherhealthconcerns.8,10,11Homelessindividualsarelikelytohaveashorterlifespan
thannon‐homelessindividualsandtheyaremorelikelythanthegeneralpopulationto:
 bephysicallyorsexuallyassaulted
132
 develophypothermiaorfrostbiteorfreezetodeath
 developskindiseasessuchasimpetigo,venousstasisdisease,scabiesandbodylice
 acquiresexuallytransmitteddiseaseslikeChlamydiaandHIV
 beunabletocontrolchronicdiseaseslikehypertension,diabetes,andanemia
 developrespiratorydisordersincludingchronicobstructivepulmonarydiseaseand
tuberculosis
 developmusculoskeletalproblemssuchasosteoarthritis
 developfootdiseasessuchastineapedis,corns,andcallouses
 sufferfromunintentionalinjuriessuchasfallsormotorvehiclecollisions
Homelesschildrenaremorelikelythannon‐homelesschildrento8,12:
 becomepregnant
 developasthma
 havebehavioraldisorders
 comedownwithinfectiousdisease,includingupperrespiratorytractinfection,
scabies,lice,earinfections,anddiarrhea
 nothavecompletedtherecommendedscheduleofchildhoodimmunizations
 sufferfromleadpoisoning
 bemalnourished(becauseofaninabilitytoaffordnutritiousfood)butobese
(becauseofcheaperandeasieraccesstofastfood)
 havepoordentalhealthandpoorvision
 sufferfromchildabuse
Specificstepsforhealthcareproviders5,9,13
 Focusoninfectionpreventionbypromotingvaccinationschedules,facilitating
needle‐exchangeandsupervisedinjectionsiteswhereallowedbylaw,provide
laundryfacilitieswherepossible,providepodiatryservices,facilitateinsecticide
applicationtohomelessshelterbedding.
133
 Maintainalistofdrugtherapyprogramsintheareatowhichpatientscanbe
referred.
 Focusonpromotionofsexualhealth.
 Providecomprehensivecenterswherehomelesspeoplecanaccessmultipleservices
inoneplace,astransportationtoandfromhealthcareservicesmaybeanissue.
 Utilizeamultidisciplinaryteamconsistingofphysicians,socialworkers,mental
healthspecialists,andaddictionscounselors.
 Engageinhealthoutreachtolocalhomelessshelters.
 Beawarethathomelesspeoplemaybeconcernedaboutprivacyissues,fearfulof
largeinstitutionsandthepeoplewhoworkinthem,unawareofservicesavailableto
them,andembarrassedaboutdifficultiesmaintainingpersonalhygiene.
 Beawarethatasaresultofpreviousinteractionswiththepublic,police,family,and
healthcareproviders,homelesspeoplemayactinwaysthatseemresistant,bizarre,
ordisruptive.
AdaptedclinicalguidelinesfromtheHealthCarefortheHomelessClinicians’Network
TheHealthCarefortheHomelessClinicians’Network(NHCHC)publishesguidelineson
howtoadaptamedicalpracticetoaddressthespecialchallengesfacedbyhomeless
patientsthatmaylimittheirabilitytoadheretoaplanofcare.In2010,theyupdatedtheir
GeneralPracticesfortheCareofHomelessPatients.9Wehavereproducedthesummaryof
recommendationsbelow,initalics.Theentiredocumentisavailableat:
http://www.nhchc.org/wp‐content/uploads/2011/09/GenRecsHomeless2010.pdf
SummaryofRecommendations:
Diagnosisandevaluation
History
 Livingconditions:Askwherepatientisstaying.Exploreaccesstofood,water,
restrooms,placetostoremedications;exposuretotoxins,allergens,infection;threats
tohealth/safety.Bealerttopossiblehomelessness.
 Priorhomelessness:Whatprecipitatedit;whetherfirsttime,episodic,chronic;history
offostercare.
 Acute/chronicillness:Askaboutindividual/familialhistoryofasthma,chronicotitis
media,anemia,diabetes,CVD,TB,HIV/STIs,hospitalizations.
134
 Medications:Askaboutcurrentmedications,includingpsychiatric,contraceptive,and
OTCmedications,dietarysupplements,and“borrowed”medicineprescribedforothers.
 Priorproviders,includingoralhealthproviders:Whatworked/didn’twork,does
patienthaveregularsourceofprimarycare.
 Mentalillness/cognitivedeficit:Problemswithstress,anxiety,appetite,sleep,
concentration,mood,speech,memory,thoughtprocessandcontent,
suicidal/homicidalideation,insight,judgment,impulsecontrol,socialinteractions;
symptomsofbraininjury(headaches,seizures,memoryloss,lability,irritability,
dizziness,insomnia,poororganizational/decision‐makingskills).
 Developmental/behavioralproblems:Adaptive/maladaptive,underlyingpathology.
 Alcohol/nicotine/otherdruguse:Askaboutuse(amount,frequency,duration);look
forsignsofsubstanceabuse/dependence.
 Healthinsurance:prescriptiondrugcoverage,entitlements(Medicaid/SCHIP,
SSI/SSDI),otherassistance.
 Sexual:Genderidentity,sexualorientation,behaviors,partners,pregnancies,
hepatitis/HIV/otherSTIs.
 Historyandcurrentriskofabuse:Emotional,physical,sexualabuse;knowledgeof
crisisresources,patientsafety.
 Legalproblems/violence:againstpersonsorproperty,historyofarrest/incarceration,
treatmentwhileincarcerated.
 Regular/strenuousactivities:Consistentroutines(treatmentfeasibility);levelof
strenuousactivity.
 Workhistory:Longesttimeheldajob,occupationalinjuries/toxicexposures;
vocationalskillsandinterests.
 Educationlevel,literacy:Everinspecialeducation?If“troublereading,”offerhelpwith
intakeform;assessabilitytoreadEnglish.
 Nutrition/hydration:diet,foodresources,preparationskills,liquidintake.
 Culturalheritage/affiliation/supports:involvementwithfamily,friends,faith
community,othersourcesofsupport.
 Strengths:Copingskills,resourcefulness,abilities,interests.
135
Physicalexamination
 Comprehensiveexam‐atfirstencounterifpossible:height,weight,BMI,%bodyfat,
abdominalgirth,heart,BP,lungs,thyroid,liverdermatological,oral,fundoscopic,
genital,lowerextremities
 Serial,focusedexams:forpatientsuncomfortablewithfull‐body,unclothedexamat
firstvisit
 Specialpopulations:Victimsofabuse,sexualminorities
 Dentalassessment:ageappropriateteeth,obviouscaries,dental/referredpain,
diabetespatients
Diagnostictests
 Baselinelabs:IncludingEKG,lipidpanel,potassiumandcreatininelevels,HbA1c,liver
functiontests,MentalHealthScreening:PatientHealthQuestionnaire(PHQ‐9,PHQ‐2),
MHS‐III
 Asthma:spirometryorpeakflowmonitoring
 TB:PPDforpatientslivinginsheltersandothersatriskfortuberculosis;
QuantiFERON®‐TBGoldtest(QFT‐G),ifavailable
 STIscreening:Forchlamydia,gonorrhea,syphilis,HIV,HBV,HCV,trichomonas,
bacterialvaginosis,monilia
 Mentalhealth:PatientHealthQuestionnaire(PHQ‐9,PHQ‐2),MHS‐III,MDQ
 SubstanceAbuseScreening:SSI‐AOD
 CognitiveAssessment:Mini‐MentalStatusExamination(MMSE),traumaticbrain
injuryquestionnaire(TBIQ),RepeatableBatteryfortheAssessmentofNeuro‐
PsychologicalStatus(RBANS)
 Developmentalassessment:AgesandstagesQuestionnaires,Parents’Evaluationof
DevelopmentalStatus(PEDS),DenverII,orotherstandardscreeningtool
 Interpersonalviolence:PosttraumaticDiagnosisScaleforUsewithExtremelyLow‐
income
 Women
• Forensicevaluation:Ifstrongevidenceofchildabuse
• Healthcaremaintenance:Cancerscreeningforadults,EPSDTforchildren
136
Planandmanagement
Planofcare
 Basicneeds:Food,clothing,housingmaybehigherprioritiesthanhealthcare.
 Patientgoalsandpriorities:Immediate/long‐termhealthneeds,whatpatientwantsto
addressfirst.
 Actionplan:Simplelanguage,portablepocketcard.
 Afterhours:Extendedclinichours,howtocontactmedicalproviderwhenclinicis
closed.
 Safetyplan:Ifinterpersonalviolence/sexualabusesuspected;mandatoryreporting
requirements.
 Emergencyplan:ContactingPCPbeforegoingtoER,locationofemergencyfacilities,
preparationforevacuation.
 Adherenceplan:Clarificationofcareplan/patientfeedback;useofinterpreter,lay
educatorifLEP,identificationofpotentialbarriers.
Education,self‐management
 Patient/parentinstructions:Simplelanguage/illustrations,confirmcomprehension;
pocketcardlistingimmunizations,chronicillnesses,medications.
 Prevention/riskreduction:Protectionfromcommunicablediseases,riskof
delayed/interruptedtreatment.
 Behavioralchange:Individual/smallgroup/communityinterventions,motivational
interviewing.
 Nutritioncounseling:Diet,dietarysupplements,foodchoices,powderedformulafor
infants.
 Peersupport:Supportgroups,consumeradvocates.
 Educationofshelter/clinicstaff:specialproblems/needsofhomelesspeople.
137
Medications
 Simpleregimen:Lowpillcount,once‐dailydosingwherepossible;capsules/tabletsfor
child>5yrs.
 Dispensing:Onsite;smallamountsatatimetopromotefollow‐up,decreaseriskof
loss/theft/misuse;avoidwrittenprescriptionswhenpossible.
 Storage/access:Inclinic/shelters;ifnoaccesstorefrigeration,don’tprescribemeds
thatrequireit.
 Patientassistance:Entitlementassistance,free/low‐costdrugsifreadilyavailablefor
continueduse.
 Aidstoadherence:Harmreduction,outreach/casemanagement,directlyobserved
therapy.
 Potentialformisuse:Inhalants,bronchodilators/spacers,painmedications,clonidine,
needles.
 Sideeffects:Primaryreasonfornonadherence(diarrhea,frequenturination,nausea,
disorientation).
 Analgesia/symptomatictreatment:Patientcontract,singleproviderforpain
medicationrefills.
 Immunizations:Perstandardclinicalguidelines;influenza,pneumococcus,HAV,HBV,
Tdforadults.
 Antibiotics:Standardliquidmeasurements,importanceofcompletingregimen,RSV
prophylaxis.
 Dietarysupplements:Multivitaminswithminerals,nutritionalsupplementswithlower
resalevalue.
 Managedcare:Prescribemedicationsthatdon’trequirepre‐authorization,assistance
gettingRxfilled.
 Labmonitoring:Monitorpatientsonantipsychoticmedicationsformetabolic
disorders.
Associatedproblems,complications
 Noplacetoheal:Efficacyofmedicalrespite/recuperativecare,supportivehousing.
138
 Fragmentedcare:multipleproviders.UseEMR,listprescribedmedsonwallet‐sized
card.
 Maskedsymptoms/misdiagnosis:e.g.,weightloss,dementia,edema,lacticacidosis.
 Developmentaldiscrepancies:Focusonimmediateconcerns,notpossiblefuture
consequences.
 Functionalimpairments:Documentmedicalandfunctionalimpairments,assistwith
SSI/SSDIapplications,tailorplanofcaretopatientneedsandcapacities.
 Dualdiagnoses:Integratedtreatmentforconcurrentmentalillness/substanceuse
disorders.
 Lossofchildcustody:Supportforparentofchildabusedbyothers,andforabused
parent.
Follow‐up
 Contactinformation:Phone,e‐mailforpatient/friend/family/casemanager.
 Medicalhome:Tocoordinate/promotecontinuityofhealthcare.
 Frequency:Morefrequentfollow‐up,incentives,nonjudgmentalcareregardlessof
adherence.
 Drop‐insystem:Anticipate/accommodateunscheduledclinicvisits.
 Transportationassistance:Providecabfare/tokens,helpwithtransportationservices.
 Outreach/casemanagement:Connectwithcommunityoutreachprograms,HCH
providers.
 Monitorschoolattendance:Addresshealth/developmentalproblemswith
family/school.
 Peersupport:Clientadvocatetoaccompanypatienttoclinicalappointments,
ambulatorysurgery.
 Referrals:Linkagewithspecialists,probonocare,providerssensitivetounderserved
populations.
139
Modelofcare
Servicedeliverydesign
 Integrated/interdisciplinary:coordinatedmedical,dental,andpsychosocialservices
 Multiplepointsofservice:Clinics,drop‐incenters,outreachsites;electronicmedical
records,iffeasible.
 Flexibleservicesystem:Walk‐inspermitted,helpwithresolvingsystemsbarriers.
 Accesstomainstreamhealthsystem:Readyaccesstosecondary/tertiarycare.
 Accesstoconvalescentcare/supportedhousing:medical/respitecare,permanent
housingwithsupportiveservicesforpatientswithserioushealthconditions.
Outreachandengagement
 Outreachsites:Streets,soupkitchens,shelters,otherhomelessservicesites.
 Clinicalteam:Useofoutreachworkers,casemanagers,medicalproviderstopromote
engagement.
 Therapeuticrelationship:Person‐centered,trauma‐informed,recovery‐oriented,
nonjudgmentalcarebasedontrust,frequentencounters.
 Incentives:Topromoteengagement:food,drink,vouchers,hygieneproducts,
subway/busfare(tokens).
Standardofcare
 Clinicalstandards:scientificevidence,expertopinion,recommendationsof
experiencedhomelessservicesproviders.Makeeliminationofhealthdisparitiesa
clinicalgoal.
 Consumerinvolvement:inpeersupport,programgovernance,advocacy,research.
 Integratedserviceandadvocacy:toimproveserviceaccessforhomelesspeople,
addressstructuralcausesofhomelessness,preventstaffburnout,andfacilitateclient
recovery.
AdditionalResources
HomelessnessResourceCenter:http://www.nrchmi.samhsa.gov/default.aspx
140
HomelessinformationVermont(aprojectoftheU.S.DepartmentofHousingandUrban
Development,thissitehaslinkstohelpandshelterhotlines,foodbanks,servicegroups,
andawidevarietyofotherlocalresources:
http://www.hud.gov/local/index.cfm?state=vt&topic=homeless
NationalHealthCarefortheHomelessCouncil:http://www.nhchc.org/index.html
VermontHousingAwarenessCampaign:http://www.housingawareness.org/index.htm
141
References
1.
ThornburghN.Defining'HomelessnessDown'.TimeU.S.A.2008.
2.
PeuquetS.ThePersistenceofHomelessnessandtheInvisibleHomeless.2004;
http://www.housingforall.org/rop0304%20homelessness.pdf.AccessedApril,
2012.
3.
CatonCL,DominguezB,SchanzerB,etal.Riskfactorsforlong‐termhomelessness:
findingsfromalongitudinalstudyoffirst‐timehomelesssingleadults.AmJPublic
Health.Oct2005;95(10):1753‐1759.
4.
NationalCoalitionfortheHomeless.WhyArePeopleHomeless.2009;
http://www.nationalhomeless.org/factsheets/why.html.AccessedApril,2012.
5.
WrightNM,TompkinsCN.Howcanhealthserviceseffectivelymeetthehealthneeds
ofhomelesspeople?BrJGenPract.Apr2006;56(525):286‐293.
6.
StatewideHomelessReportJan.27,2010;.http://www.helpingtohouse.org.
AccessedJanuary,2013.
7.
VermontHousingFinanceAgency.FamilyHomelessnessinVermont.2008;
http://www.time.com/time/nation/article/0,8599,1827876,00.html.Accessed
April,2012.
8.
HwangSW.Homelessnessandhealth.CMAJ.Jan232001;164(2):229‐233.
9.
BoninE,BrehoveT,CarlsonC,etal.AdaptingYourPractice:General
RecommendationsfortheCareofHomelessPatients.2010;
http://www.nhchc.org/wp‐content/uploads/2011/09/GenRecsHomeless2010.pdf.
AccessedApril,2012.
10. NationalCoalitionfortheHomeless.HealthCareandHomelessness.2007;
http://www.nationalhomeless.org/factsheets/health.html.AccessedApril,2012.
11. HwangSW,TolomiczenkoG,KouyoumdjianFG,GarnerRE.Interventionstoimprove
thehealthofthehomeless:asystematicreview.AmJPrevMed.Nov
2005;29(4):311‐319.
12. KarrC,KlineS.Homelesschildren:whateveryclinicianshouldknow.PediatrRev.
Jul2004;25(7):235‐241.
13. ShekarS.HomelessandElderly:UnderstandingtheSpecialNeedsofElderlyPersons
WhoAreHomeless.Washington,DC:BureauofPrimaryHealthCare,U.S.
DepartmentofHealthandHumanServices;2003.
142
LatinoMigrantFarmWorkers
Background
PopulationinVermont.TheVermontAgencyof
Agricultureestimatesthatasmanyas3,000Latino
migrantfarmworkers(LMFWs)liveandworkin
Vermont.Othergroupsbelievethetruenumberis
closerto1,500,perhapsless.Byanyestimate,itis
surethatthispopulationhasgrownsignificantly
overthelasttenyears.ManyoftheseworkerscomefromsouthernMexico,fromsmall
townsintheareasofChiapas,Guerrero,andOaxaca.Therearealsootherswhocomefrom
GuatemalaandbiggercitiesinMexico.
Language.NearlyalloftheworkersspeakSpanishastheirprimarylanguage.Aportionof
theworkers,especiallythosefromruralareasinChiapasorGuatemala,mayspeakanative
dialectsuchasMamastheirprimarylanguage.Suchdialectsusuallyderivefromfrom
ancientMayanlanguagesandareunwritten.MosthavenothingincommonwithSpanish
andareunlikelytobeavailableinanytranslationprogram.LMFWsthatspeakadialectas
theirfirstlanguagearelikelytoalsobeproficientinSpanish,butafew,especiallywomen
(whoaremuchlesslikelytoreceiveeducationinruralareas),mayonlyspeaklimited
Spanish.
ApercentageofLMFWswillalsohavesomeabilitytospeakorunderstandEnglish,
especiallyiftheyhavebeenintheUnitedStatesforasignificantamountoftime.
Religion.Accordingtothemostrecentcensusdata,greaterthan90%oftheMexicanand
GuatemalanpopulationsidentifytheirreligionasCatholicorotherChristian.SomeLMFWs
fromthemostruralareasmayalsohavearichtapestryofbeliefsthatcombineshamanistic
andspiritualisticbeliefswithChristianity.Althoughtheymaynotcomeupnaturallyina
history,thesebeliefshavetheabilitytoimpacttheirperceptionofhealthcareandillness.
Family.WhilemostLMFWsaremale,therearesomefemaleworkersandsomecouples
whocametoVermonttogetherandhaveevenhadchildreninVermont.Manyofthe
workershaveaspouseand/orchildreninMexicowhomtheyaresupporting.Some
workersarealsosupportingothersinthecommunitybackhome.Generally,theymaintain
contactwiththeirfamiliesbackhomethroughcellphonesandcallingcards.
Education.TheeducationlevelofLMFWsalsovariesgreatlybyindividual.Thosefrom
ruralareasinMexicoandGuatemalaoftenleaveschoolandbeginworkingafterorduring
elementaryschool.SomemayevenhavearrivedintheUnitedStatesasteenagers.Many
areliterate,butitisnotsafetoassumethatanysingleLMFWwillbeabletoreadand
understandmedicalliteraturegiventothem.
Diet.Atsomefarms,theworkersareabletodotheirownshopping,butinmanyfarmsthey
arecompletelydependentonthefarmownersforanyshoppingneeds,notjustgroceries.
143
Somefactorstoconsiderwhenassessingaspecificworker’sdietcouldincludewhobuys
theworker’sgroceries,theworker’scountryoforigin,andhowlongtheworkerhasbeenin
theUnitedStates.
Legalissues.Immigrationstatusisbasedonacomplexsetoffederalregulations.Asking
abouttheimmigrationstatusofapatientshouldbeavoided.Havingdarkerskinand
speakingonlySpanishdoesnotmakeanyoneanundocumentedimmigrant.Afewstates
haverecentlyintroducedbillsthatmaysubjecthealthcareproviderstoprosecutionfor
aidingundocumentedworkers.Vermontisnotoneofthosestates.Additionalquestionson
thistopiccanbedirectedtotheVermontHumanRightsCommissionat802‐828‐2482or
human.rights@state.vt.us.
HealthCare
Priorhealthcareexperience.LMFWshavehadvariedexperienceswithhealthcarein
theirhomecountries,andinotherpartsoftheUnitedStates.Mexico,Guatemala,andmost
otherCentralAmericancountriesofferauniversalhealthcaresystem,wherecareisfree
butvariesgreatlyinavailabilitybetweenareas.Themostprevalentmodelforambulatory
careinmostpartsofMexicoandGuatemalaarewalk‐inconsultations,wherepatients
arrivewithoutanappointmentandwaittobeseen.Thestate‐runsystemiscomplemented
byapatchworkofprivatehealthservicesthatcharge.LMFWsfromurbanareasmayhave
hadeasyaccesstolow‐costandreliablehealthcareintheirhomecountries,whileothers
mayhavelivedaday’sjourneyfromthenearesthospital.Forexample,someworkersare
accustomedtohavingtheirchildrendeliveredintheirownhomes,oftenbyfamily
members,whileotherswouldneverthinkofhavingababyanywherebutinahospital.
Barrierstoseekingcare.LMFWsoftenliveinisolation.Somedonotleavetheirresidence
excepttowalktothemilkingbarnforwork.Thisisprimarilybecauseoffearofbeingseen
anddeported.Anythingtheyneedisbroughttothematthefarm,usuallybytheir
employer.Thisisparticularlytrueclosertothenorthernborderofthestatewhere
immigrationofficialshaveamuchstrongerpresence.InsomeareasofFranklinCounty
workersseeimmigrationvehiclesdrivebytheirfarmsregularly.Thisclimateoffearisa
majorbarriertohealthcareaccess.Othermajorbarriersincludelanguagedifficulties,fear
ofhighcosts,andlackoftransportation.Dueinparttothesebarriersmostworkersarenot
willingtovisitahealthclinicuntiltheyareinsignificantpainorareunabletowork.Many
workerswouldrathercontinueworkingthantaketheneededresttoresolvepain.Other
workersstatethatiftheybecameillorinjuredenoughthattheycouldnolongerwork,
they’dprefertoreturntotheirhomecountryratherthanseekcareintheUnitedStates;
onereasonforthisisthatworkerswouldratherbenearfamilytobenursedtohealthif
theywillbeunabletoworkforanextendedperiodoftime.
SpecifichealthconcernsintheLMFWpopulation
Somecommonproblemsexperiencedarerepetitivemovementinjuries,dentalproblems,
dermatologicalconditions,trauma,andgastrointestinalissues.
144
Specificstepsforhealthcareproviders
 Minimizethenumberofrequiredvisitstotheclinic.Especiallyinthenorthernpart
ofthestate,itisariskforLMFWstoleavehomeandgooutintothepublic.In
addition,LMFWsareoftendriventoappointmentsbybusyfarmownersor
volunteerswhoaregivingfreelyoftheirtime.
 Ifpossible,inviteLMFWsintoaconsultationroomsoonaftertheyarrive.LMFWs
mayfeeluncomfortablesittinginawaitingroomforextendedperiodsoftime,
especiallyinareaswhereimmigrationofficialsmakeupasignificantportionofthe
localpopulationandmaybeseatedinthesamewaitingroom.
 DiscusstheextenttowhichanLMFWwishestosharehealthcareinformationwith
thefarmowneroremployer.Theprioritymustbetoclearlycommunicateall
aspectsofcarewiththepatient,howeveritmaybebeneficialtoaskforpermission
tosharesomeinformationwiththeiremployer,whomaybeabletoprovide
assistancewithfollow‐upcare,suchasgettingmedications,scheduling
appointments,andprovidingtransportation.
 Ifthecostofmedicalcareiswithintheirmeans,LMFWswillusuallyprefertopayat
thetimeofservice,oftenwithcash.Billingforservicescanoftenleadto
complications,asworkersmaynotreliablyopenmailormaybelievethattheyhave
alreadysettledthecostoftheircare.Ifyoucanapplydiscountsandestablishafinal
feeatthetimeofthevisit,itmayreducethesecomplications.
Communication.AlthoughthistraitisnotuniquetoLatinculture,manyLMFWshavea
strongdesiretopromotepositiveinteractionsandavoiddiscomfortordisharmonyfor
anyonetheyinteractwith.Theymayhaveatendencytogivetheanswertheythinkis
expectedinsteadoftheirownanswer.Thiscangreatlyaffectcommunicationintheclinic.
 IfanLMFWisaskeditifisacceptabletouseawrittentranslationservicerather
thanavideoorin‐persontranslator,theymayassenteveniftheyarenot
comfortablewiththeservice.
 IfanLMFWgetsthesensethatusinginterpreterservicesisinconvenientforthe
clinicorprovider,heorshemaybelesslikelytoutilizetheserviceandleaveout
importantinformation.
 LMFWsmaydiscloseonlyasinglechiefcomplaint,eveniftheyhavemultiple
ailments.Direct,sequentialquestioningandcarefulprobingmayberequiredfor
themtofullydivulgehealthissuesorpasthistory.
 Verifyunderstandingusingmorethanyesornoquestions.
145
 Interpretationserviceshouldbemadeavailablenotonlyintheconsultation,butat
thereceptiondesk,especiallywhendiscussinginstructionsforfillingprescriptions,
payment,futureappointments,orpendinglabresults.
 Anyclinicthatusesphonetranslationservicesshouldbetrainedinusingthe
translationservicewhensomeonecallstheclinicdirectlyspeakingSpanish.
 KnowthelocationoftheSpanishpaperworkinyourofficeanduseitwithSpanish
speakers.
 Usingafamilymember,friend,ornon‐fluentfarmownerasaninterpreterwhen
professionalresourcesareavailableshouldbeavoided.Theinformationprovided
vianon‐professionaltranslationmaybebiasedorincomplete.
 EvenifapatientappearsnottospeakEnglish,youshouldneverassumethathe/she
cannotunderstandanycommentsyoumakeinEnglish.
 EvenifaLMWFappearstobeproficientconversinginEnglish,youshouldalways
encouragethemtouseaninterpreter,astheystillmaybefarmorecomfortable
providingahistoryinSpanish.
Additionalresources
CommunityHealthPharmacy:ThisisagoodoptionforLMFWswhoarenervousabout
leavingthefarmtopickupprescriptions.Itisa340Breduced‐costpharmacythatcanfill
prescriptionswrittenbyfederally‐qualifiedhealthcarecenters;theycanmailthe
medicationsdirectlytothefarm.1‐888‐669‐9017,158BrentwoodDrive,Suite#7,
Colchester,VT05446www.communityhealthpharmacy.com
 Thepharmacydoesnotofferaphone‐linetranslationservice,butmustcollectbasic
informationaboutthepatientinordertofillaprescription.Itmaybemost
appropriatetocallthepharmacywhenthepatientandtranslatorarestillpresent.
 Thepharmacyacceptsbutdoesnotrequireacreditcard;theywillacceptpayment
inmoneyorders,checks,orcash.
 AllthepackageinsertsdistributedwithprescriptionsisavailableinSpanish.
Everythingisautomaticallytranslatedexceptforspecificinstructionswrittenin
Englishbytheprovider.
PriceChoppergrocerystores:Diabetesmedicationsandmanystandardantibioticsare
availablefreeofchargeatpharmaciesinPriceChoppergrocerystores.
English‐SpanishOccupationalandHealthDictionary:
http://www.cbs.state.or.us/osha/pdf/dictionary/english‐spanish.pdf
146
NativeAmericans
Background
Definition.AmericanIndiansand/orAlaskanNativesare
descendantsoftheoriginal,pre‐EuropeaninhabitantsofNorth,
Central,andSouthAmericawhomaintainaffiliationswithoneofmanypre‐European
tribes.1,2MajorNativeAmericantribesinNorthAmericatodayincludeCherokee,Navajo,
Sioux,andEskimo.3
Inthischapter,theterm“NativeAmerican”willbeusedtorefertoallAmericanIndiansor
AlaskanNatives,althoughreadersshouldbeawarethatthisisalargeandheterogeneous
groupwithsignificantregionaldifferencesinculture,socioeconomicstatus,etc.
History.4ThefirstAmericansarrivedintheAmericasfromAsiasome12,000yearsagoby
wayofalandbridgethatspannedtheBeringStraitandconnectedpresent‐daySiberiawith
Alaska.Overmanythousandsofyears,thesesettlersfannedoutacrossNorthAmerica,
shiftedfromalargelynomadictoasettledexistence,learnedtodomesticateplantsand
animals,andbuiltupcomplexsocieties.
AlthoughEuropeanslikelyhadoccasionalcontactwithNativeAmericanspriorto1492,
Columbus’landinginthatyearwasthemosthistorically‐importantfirstpointofcontact
betweenthetwogroups.FollowingColumbus’arrival,Europeansspreadoutacrossthe
continent;overthenextseveralhundredyears,theyestablisheddominancebyforcein
NorthAmerica,therebyendingtheNativeAmericanwayoflife.Diseasewasonemethodby
whichEuropeanswereabletoovercomeNativeAmericantribes:smallpox,measles,
plague,andotherdiseasesaccompaniedEuropeanstotheNewWorldandkilledscoresof
NativeAmericans,whohadnoimmunitytothesediseases.5Someestimatesputthepre‐
EuropeanNativeAmericanpopulationofNorthAmericaat50millionpeople;in2011,it
was6.2million.1
InteractionsbetweenNativeAmericansandtheU.S.governmentintheperiodbetweenthe
Americanrevolutionarywar(1775‐1783)andtheendofthe19thcenturywere
characterizedprimarilybywestwardexpansionofAmericansandforceddisplacementof
NativeAmericansontoreservationlandthatwasoftenquitedistantfromancestrallands.
Atthistime,threepivotalSupremeCourtdecisionsknownastheMarshallTrilogywere
passed.Thefirstoftheseestablishedthat,althoughNativeAmericansweretherightful
occupantsoftheirland,theU.S.federalgovernmentheldtitletothatland.Thesecond
establishedthattheUnitedStateshasaresponsibilitytoprovidecertainbenefitsforNative
Americans.Thethirdestablishedthatthefederalgovernment,andnotthestates,hadfinal
legalauthorityoverNativeAmericantribes.6ThesedecisionshaveshapedUnitedStates
policytowardsNativeAmericanseversince.TheIndianHealthService,agovernment
agencythatprovideshealthcaretoNativeAmericans,isoneresult.
Demographics.In2008,4.9millionNativeAmericanslivedintheUnitedStates,makingup
about1%ofthetotalAmericanpopulation.Approximately1.9millionofthemlivedon
147
reservations.1AlthoughtheNativeAmericanpopulationincludesmembersof562
federally‐recognizedand100state‐recognizedtribes,thelargesttribesin2000werethe
Cherokee,Chippewa,Navajo,Sioux,andEskimo.3
In2010,NativeAmericansmadeup.9%ofVermont’spopulation.ManyofVermont’s
NativeAmericansareAbenaki;however,NativeAmericanswithothertribalaffiliationsdo
livehere.Whiletherearenofederally‐recognizedNativeAmericantribesinVermont,2in
2012theStateofVermontofficiallyrecognizedfourtribesofAbenaki.
Culture.NativeAmericansarealargeandheterogeneousgroupandeachtribehasitsown
uniqueculture,thereforeafulldiscussionofNativeAmericancultureisbeyondthescope
ofthischapter.However,afewpointsmaybemade.Forexample,manyNativeAmerican
traditionsteachthathumansareintimatelyconnectedwitheachother,withnature,and
withaCreator.7Patienceandstoicismarevalued.8NativeAmericanmedicineinvolvesa
significantspiritualcomponent,andoftentheentirecommunitytakespartinthehealing
process.7ManyNativeAmericansmaybe(withgoodreason,giventheirhistoryofbroken
treatiesandforceddisplacementatthehandsoftheUnitedStatesgovernment)distrustful
ofauthority.NativeAmericansmaybereticentinconversationandslowtosharepersonal
information—inparticular,sexualinformation—withoutagooddegreeoftrustestablished
withthehealthcarepractitioner.FamilyandextendedfamilyplayalargeroleinNative
Americans’lives.Finally,manyNativeAmericantraditionsemphasizelivinginthepresent,
withlessfocusonthefuture.ForamorecomprehensiveoverviewofNativeAmerican
culture,seeresourcesattheendofthischapter.
VermontAbenakiNativeAmericansaredescendentsoftheWesternAbenakitribewhich
historicallyoccupiedpartsofVermont,NewYork,Maine,andQuebec.Oraltraditionisvery
importantinAbenakiculture.9Decisionsaremadebyconsensus.10
Healthcare
Ingeneral,thehealthofNativeAmericanscomparedtothatofthegeneralpopulationis
quitepoor.Aswithotherminoritypopulations,NativeAmericanhealthcareismost
usefullyframedinthecontextofhealthdisparitiesbetweenNativeAmericanandwhite
Americanpopulations.
SpecifichealthconcernsintheNativeAmericanpopulation
TheUnitedStatesCommissiononCivilRights5statesthatin2002,NativeAmericanswere
“770%morelikelytodiefromalcoholism,650%morelikelytodiefromtuberculosis,
420%morelikelytodiefromdiabetes,280%morelikelytodiefromaccidents,and52%
morelikelytodiefrompneumoniaorinfluenzathantherestofthe[UnitedStates]
population,includingotherminoritypopulations.”NativeAmericanswerealsomorelikely
tosufferfrommentalhealthproblems,includingsubstanceabuse(alcohol,marijuana,and
cocaine),depression,anxiety,violence,andsuicide,forwhichtherateamongstNative
Americansis190%therateoftheUnitedStatespopulation.5Ratesofmetabolicsyndrome
andcardiovasculardiseasearealsoextremelyhighinthispopulation,asareHIV,liver
disease,teenagepregnancy,andsuddeninfantdeathsyndrome.Overall,theinfant
148
mortalityrateamongNativeAmericansis1.6timesthatofnon‐Hispanicwhite
Americans.11
TheUnitedStatesCommissiononCivilRights5determinedthatthesedisparitieshavebeen
causedbyseveralintersectingfactors.
 RacialbiasbyhealthcareworkersleadstosubstandardcareforNativeAmericans.
 Lackofculturallyandlinguistically‐competentdeliveryofhealthcareservices.
 Lowsocioeconomicstatusasaresultofdisproportionatelyhighpovertyandlow
educationinNativeAmericanpopulations.
 Poorlifestylechoices‐obesity,substanceabuse,andinactivityarecommoninNative
Americanpopulations.
 AccesstohealthcareispoorforNativeAmericans:healthcarefacilitiestendtobe
locatedfarawayfromwhereNativeAmericanslive;waittimesarelong;facilities
areoutdated;healthcarepractitionerturnoverishigh(andthereforepatient
continuityislow);andNativeAmericanshavelimitedaccesstoMedicareor
Medicaid.
Specificstepsforhealthcareproviders
 Appreciateeachpatient’sculturalidentityandallowroomfortraditionalmedical
practicestobeincorporatedintothetreatmentplan.
 AppreciatethatdirectcommunicationisnottypicalofmanyNativeAmerican
cultures,butaslowpacetoconversation,andlistening,areveryimportant.
 Returnpowertoyourpatientbyinvolvingtheminthedecision‐makingprocess
wherepossible.
 FocusoncommunitybyputtingyourpatientintouchwithNativeAmericanhealth
supportgroups.
 Tailoryourdeliveryofinformationtotheeducationallevelofyourpatient.
 Developanddeliverculturally‐appropriatehealtheducationmaterialsconcerning
thingslikesubstanceabuse,exercise,depression,etc.
 Focusonpreventativecare.
Additionalresources
AmericanDiabetesAssociation:
www.diabetes.org/communityprograms‐and‐localevents/nativeamericans.jsp
149
IndianHealthServices:http://www.ihs.gov/index.cfm
OfficeofMinorityHealthAmericanIndian/AlaskanNativeProfile:
http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=52
AmericanIndianHealth:http://americanindianhealth.nlm.nih.gov/
AprojectoftheNationalLibraryofMedicine,thissitehascompiledinformationonhealth
disparities,statistics,programs,andtraditionalhealthpracticesofNativeAmericans.
HealthofAmericanIndianorAlaskaNativePopulation:
http://www.cdc.gov/nchs/fastats/indfacts.htm
150
References
1.
OfficeofMinorityHealth.AmericanIndian/AlaskaNativeProfile.
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=26.Accessed
April,2012.
2.
BureauofIndianAffairs.WhoisanAmericanIndianorAlaskaNative?
http://www.bia.gov/FAQs/index.htm.AccessedApril,2021.
3.
OgunwoleS.WethePeople:AmericanIndiansandAlaskaNativesintheUnited
States:ACensus2000SpecialReport:UnitedStatesCensusBureau;2006.
4.
NationalParkService.OtherMigrationTheories.
http://www.nps.gov/bela/historyculture/other‐migration‐theories.htm.Accessed
April,2012.
5.
UnitedStatesCommissiononCivilRights.BrokenPromises:EvaluatingtheNative
AmericanHealthCareSystem.Washington,DC:UnitedStatesCommissiononCivil
Rights;2004.
6.
AmericanIndianPolicyCenter.BriefHistoryofU.S.‐TribalRelations.
http://www.americanindianpolicycenter.org/projects/history.html.AccessedApril,
2012.
7.
HendrixLR.HealthandHealthCareofAmericanIndianandAlaskaNativeElders.
EthnogeriatricCurriculumModule.SanFrancisco,CA:StanfordGeriatricEducation
Center.
8.
PottsC.CulturallyResponsiveCurriculumforSecondarySchools.Olympia,WA:
EvergreenStateCollege;2009.
9.
BruchacJ.TheAbenakiPerspectiveonStorytelling.
http://www.abenakination.org/stories.html.AccessedApril,2012.
10. COWASSNorthAmericaInc.TheConsensualDecision‐makingProcess.
http://www.cowasuck.org/lifestyle/consent2.cfm.AccessedApril,2012.
11. OfficeofMinorityHealth.InfantMortalityandAmericanIndians/AlaskaNatives.
http://minorityhealth.hhs.gov/templates/content.aspx?ID=3038.AccessedApril,
2012.
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Women
Inthischapterwomenaretreatedasahomogenousgroup;
differencesinhealthresultingfromrace,ethnicity,country‐
of‐origin,income,andeducationarelargelyignored.
However,practitionersshouldbeawarethatthese
differencesexistandthattheymayaffectboththehealthof
awomanandthatwoman’sinteractionwiththehealthcare
establishment.Practitionersshouldrefertospecific
populationchapterstosupplementtheinformationinthis
chapterwhenappropriate.
Itshouldbenotedthatwomenfarebetterthanmeninsomemeasuresofhealth,suchas
longevity(intheUnitedStates,theaveragelifeexpectancyatbirthis5yearslongerfor
womenthanitisformen).Thissection,however,focusesonhealthissuesthatare
disadvantageousforwomenandonthemanyhealthcareneedsthatareuniquetowomen.
Forarecent,comprehensivereviewofwomen’shealthintheUnitedStates,seetheOffice
ofWoman’sHealthLiteratureReviewonEffectiveSex‐andGender‐BasedSystems/Models
ofCare(2007),fromwhichmuchoftheinformationinthischapteriscompiled:
http://www.genderinscience.org/downloads/BM1_references/Brittle%20and%20Bird%2
02007.pdf
Background
Inrecentdecades,atremendousamountofattentionhasbeenpaidtowomen'shealthby
theAmericanmedicalestablishment.Thisisaresultoftherecognitionthatwomenand
menhavedifferenthealthcareneedsanddifferentexperiencesofthehealthcaresystem,a
recognitionthatwaslackingformuchofthe20thcentury.1Inadditiontothefactthat
biologicaldifferencesbetweenwomenandmencontributetouniquediseasesandunique
patternsofdiseaseinwomen(OfficeofWomen’sHealth,2007),issuesofgenderinequality
havedirectbearingonwomen’saccessto,andexperienceof,thehealthcaresystemaswell
astheprevalenceofsomediseasesinwomen.1
Demographics.In2010,womenmadeup50.8%ofthetotalUSpopulation,and50.7%of
theVermontpopulation.2
HealthCare
Disparities.Althoughthewomen’srightsmovementhasmadegreatstridesinadvancing
thecauseofgenderequality,men’sandwomen’sexperienceswiththeAmericanhealth
caresystemarenotequal.Inits2007report,1LiteratureReviewonEffectiveSex‐and
Gender‐basedSystems/ModelsofCare,theUnitedStatesDepartmentofHealthandHuman
Services,OfficeforWomen’sHealthnotedthefollowingdisparities.
Availabletimetoaccesshealthcare.Womenaremorelikelythanmentobecaregivers
(9%ofwomencomparedto4%ofmen).Thismakeswomenmorelikelytobetheprimary
153
medicaldecision‐makersinthefamily,butitalsoreducestheamountoftimewomenhave
availabletoseekhealthcareforthemselves.
Costofaccessinghealthcare.Thecostofaccessinghealthcareisasignificantburdenfor
manywomencomparedtomen.Forexample,womenoftenearnlessthanmen.Inaddition,
ifmarried,womenarelesslikelytohaveinsurancecoverageintheirownnames.This
makesthemvulnerabletolossofcoverageduetodeath,divorce,or,iftheyarecoveredby
theirhusband'semployer‐sponsoredhealthcareplan,achangeinhisemploymentstatus.
Thecostofcaringfordependentchildrenandeldersfurtherexacerbatestheburdenof
cost.Costcanalsodecreasethequalityofhealthcarewomenreceive,forexamplewomen
aremorelikelythanmentoskipprescribeddosesofnecessarymedicationsduetocost
constraints.
Continuityofhealthcare.Womenaremorelikelythanmentoreceiveeitherincomplete
orfragmentedprimarycare.Thisisaresultofwomen'swidespreaduseofgynecologistsas
eithertheirprimarycareproviderorasoneprovideralongsideaninternistorfamily
practitioner.Intheformercase,womenwhoseeonlygynecologistsmayreceivebetter
specializedcare,butpoorerprimarycare,whileinthelattercase,thefragmentationmay
resultinbetterprimarycareservices,butleadtoincreasedcostsintermsoftimeand
dollarsspent.
Themedicalinterview.Womenexperiencethemedicalinterviewdifferentlythanmen,3
whichcanleadtoinferiormedicalcare.Womenhavefrequentlybeensocializedtobelieve
thatcertainbodilyfunctionsshouldbekeptprivate;asaresulttheydonotreportsome
symptomsasfrequentlyasmen.Forexample,womenarelesslikelytoreportbowel
symptoms,makingtreatmentofirritableboweldiseasedifficult.
Otherexamples.Womenmayreceivelesspreventativehealthcounselingthanmen,less
accesstohigh‐techtreatments,fewerscreeningsforcoloncancer,andlessaggressiveHIV
treatment.
Specifichealthconcernsofwomen
TheCDCreportsthatin2008,themostrecentyearforwhichdataarecurrentlyavailable,
thetoptenleadingcausesofdeathforAmericanfemaleswere:
1. heartdisease
2. cancer
3. stroke
4. chroniclowerrespiratorydisease
5. Alzheimer’sdisease
6. unintentionalinjuries
7. diabetes
8. influenzaandpneumonia
9. kidneydisease
10. septicemia
154
Thefollowingaremorecommoninwomenthaninmen,oroccurexclusivelyinwomen1:
 urinarytractinfectionsandsexually‐transmitteddiseases(whichmayleadtopelvic
inflammatorydiseaseand/orapotentiallyfatalectopicpregnancy)
 vaginitis,uterinefibroids,ovariancysts,andendometriosis
 chronicpainand/orchronicfatiguesyndrome
 adversedrugreactions
 iron‐deficiencyanemia
 interstitialcystitis
 insomnia
 domesticandsexualviolence
 migraines
 incontinence
 cardiovasculardisease;inaddition,womenmayshowadecreasedawarenessof
theirriskforcardiovasculardisease
 osteoporosis
 autoimmunediseasessuchaslupus,rheumatoidarthritis,andmultiplesclerosis4
 certainkindsofcancer,includingendometrial,uterine,cervical,breast,andthyroid
cancer
 Alzheimer’sdisease(AD):
‐ womenaremorelikelythanmentohaveseverecognitiveimpairment
‐ inthepsychiatricmanifestationofAD,womenaremorelikelytohave
depressionandmultiplepsychiatricproblems
 eatingdisorderssuchasanorexiaorbulimianervosa
 post‐partumdepressionaftergivingbirth
Inaddition,practitionersshouldbeawareofthefollowing:
 Womenmetabolizedrugsdifferentlythanmen.Forexample,variousisoformsof
cytochromeP450s,amajorclassofmetabolically‐activeliverenzymes,are
differentiallyexpressedbetweenwomenandmen.
 Womenalsometabolizedrugsdifferentlyindifferentstagesoftheirlife,forexample
dosesofantidepressantmedicationmustoftenbeincreasedtoremaineffectivein
pregnantwomen.5
 Womenwhoplantohavechildrenshouldbeawareofpossiblemercurytoxicity
causedbyeatingmercury‐ladenfish(EPA,2008).
155
Specificstepsforhealthcareproviders1,3
 Hireadiversestaff,andensurethatwomenholdpositionsofleadership.
 Co‐sponsorwomen’shealthinitiativesinyourcommunity.
 Haveinformationaboutwomen’ssupportorganizationsavailable.
 Focusonpatienteducation,andspecifically,onheartdisease.
 Askfemalepatientsiftheyhaveexperienceddomesticorsexualviolence.Ifthey
have,makeaccommodationstoincreasethepatient’scomfortindiscussingthese
issues,suchasofferingtohaveafemalestaffmemberpresentorhavingafemale
staffmembercontinuetheinterview.
 Taketimetodevelopatrustingrelationshipwithyourpatients;don’tjustrushthem
inandoutoftheexamroom.
AdditionalResources
U.S.DepartmentofHealthandHumanServices:www.4women.gov
OurBodies,Ourselves(acomprehensivesitewithlinkstoinformationonmanytopicsin
women’shealth):http://www.ourbodiesourselves.org/publications/obos.asp
Womenshealth.gov(agovernmentsitewithmanyfactsheets,linkstoclinicaltrials,
statistics,healthinitiatives,andothers):http://www.womenshealth.gov/
Women’sHealthattheNationalInstitutesofHealth:
http://health.nih.gov/category/WomensHealth
VermontNetworkAgainstDomesticandSexualViolence:http://www.vtnetwork.org/
156
References
1.
BrittleC,BirdC.LiteratureReviewonEffectiveSex‐andGender‐based
Systems/ModelsofCare.Washington,DC:UnitedStatesDepartmentofHealthand
HumanServices,OfficeofWomen'sHealth;January30,2007.
2.
UnitedStatesCensusBureau.StateandCountyQuickFacts.Washington,DC:United
StatesCensusBureau;2012.
3.
HouleC,HarwoodE,WatkinsA,BaumKD.WhatWomenWantFromTheir
Physicians:AQualitativeAnalysis.JournalofWomen'sHealth.May23
2007;16(4):543‐550.
4.
FairweatherD,RoseNR.Womenandautoimmunediseases.EmergInfectDis.Nov
2004;10(11):2005‐2011.
5.
AndersonGD.Pregnancy‐inducedchangesinpharmacokinetics:amechanistic‐
basedapproach.ClinPharmacokinet.2005;44(10):989‐1008.
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AppendixA
ExcerptedfromtheVermontDepartmentofHealth’s2010reportTheHealthDisparitiesof
Vermonters.Theentirereportcanbefoundat
http://healthvermont.gov/research/documents/VTDisparitiesRpt2010.pdf
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