Read Microsoft PowerPoint - Cultural Diversity_May21_2010-v.1.ppt text version

Cultural Diversity: Does It Matter?

Dawna T. Mughal, PhD, RD, LDN Diabetes Management Overcoming Barriers to Education

May 21, 2010

Credit:(c)freefoto.com

Learning Objectives

After attending this presentation, participants will be able to: · Compare differences in prevalence of selected diseases or other quality measures among racial groups. · Explain how culture influences health-related behaviors. · State several culturally relevant ways for improving the effectiveness of client education (i.e. importance of cultural competency and communication)

What's on the Plate?

· Cultural factors and health problems · Cultural factors and client education related to health behaviors

What is cultural diversity? What about health disparity?

· So what? What can we do? - Communication - Education

What is Culture?

Culture · Integrated patterns of human behavior · Language, thoughts, communication, actions, customs, beliefs, values and institutions of racial, ethnic, ethnic, religious or social groups

http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11

Cultural Diversity · Variety of cultures

Influence of Culture (and Language)

· Belief systems: Health, healing, and wellness · Perceptions of illness, disease, and causes · Behaviors and attitudes toward health providers · Delivery of services by the providers who may view the world through their own culture lenses

· http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11

Influence of Culture, cont

Culture defines

· How rights and protections and exercised · What is considered to be a health problem and how symptoms and concerns are expressed · Who should provide treatment · What type of treatment should be given

Cultural Issues: Central to the delivery of health delivery services

· http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11

Cultural Outlook or World View and Biomedical Worldview

Biomedicine · Mastery over nature · Personal control · Time dominates · Informality · Directness Other Cultural groups · Harmony with nature · Fate · Personal interaction dominates · Formality · Indirectness

Kittler and Sucher, Food and Culture, 2008.

Cultural Competency

Cultural and linguistic competence · A set on congruent behaviors, attitudes and policies that enables effective work in cross-cultural conditions Cultural competency · One of the main tools for closing disparities in health care · Health care services that are respectful and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can bring positive health outcomes

http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11

Cultural Competency Why is it Important?

· The current demographic trend that has moved to cultural plurality, "where no single ethnic groups is a majority." · For dietitians: Need for intercultural competencies in nutrition research, assessment, counseling and education · Food habits: Intrinsic to culture

Kittler & Sucher, Food and Culture, 2008, p 19.

Food Habits and Culture

· Humans change language and food habits with greatest reluctance.

© Freefoto.com

·

Goody and Drago. Cultural Food Practices, 2010.

Racial and Ethnic Populations

· American Indian & Alaskan Native(AI/AN) · Asian American · Black or African American · Hispanic or Latino · Native Hawaiian & Other Pacific Islander · Multiracial · White

http://www.cdc.gov/omhd/Populations/definitions.htm

Racial and Ethnic Populations

· Distribution of U.S. Population in 2008 · Distribution in 2010 and 2050 · Disparities in selected indicators

Distribution of U.S. Population by Race/Ethnicity, 2008

Native Hawaiians & Other Pacific Islander 0% Asian 4%

(13.2 million) (0.4 million)

American Indian/ Alaska Native 1%

(2.3 million)

Two or more races 1%

(4.5 million)

non-Hispanic Black 12%

(37.2 million)

Hispanic 15%

(46.9 million)

non-Hispanic White 67%

(199.5 million)

Total = 304.1 million

NOTES: Data do not include residents of Puerto Rico, American Samoa, Guam, the U.S. Virgin Islands, or the Northern Mariana Islands. Totals may not add to 100% due to rounding. All racial groups and individuals reporting "two or more races" non-Hispanic. SOURCE: Kaiser Family Foundation, based on Table 3: Annual Estimates of the Population by Sex, Race and Hispanic Origin for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-03). Population Division, U.S. Census Bureau.

Distribution of U.S. Population by Race/Ethnicity, 2010 and 2050

White, Non-Hispanic

46.3% 64.7%

Hispanic African-American, NonHispanic Asian

30.2% 16.0% 0.1% 1.5% 12.2% 4.5% 0.8% 0.8% 11.8% 7.6% 3.0% 0.2%

Native Hawaiian and Pacific Islander American Indian/Alaska Native Two or More Races

2010 Total = 310.2 million

2050 Total = 439.0 million

NOTES: All racial groups non-Hispanic. Data do not include residents of Puerto Rico, Guam, the U.S. Virgin Islands, or the Northern Marina Islands. Totals may not add to 100%. SOURCE: Kaiser Family Foundation, based on http://www.census.gov/population/www/projections/downloadablefiles.html U.S. Census Bureau, 2008, Projected Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: July 1, 2000 to July 1, 2050.

Population

of the United States by Race & Hispanic Origin:

100

2008 & Projected 2050

Non-Hispanic White African American American Indian / Alaska Native

% Percent of Total U.S. Population

90 80 70 60 50 40 30 20 10 0

66

Asian Hispanic/Latino

46 30 14 1.6 2008 5.1 15 15 9.2 2 2050

Source: U.S. Census Bureau, 2008 National Population Projections, August 14, 2008 http://www.census.gov/Press-Release/www/releases/archives/population/012496.html

What is a "Health Disparity"? Conceptual Issues

· Inequality · Difference in condition, rank · Lack of equality as of opportunity, treatment, or status · Inequity

­ Unfair and unjust ­ Unnecessary and avoidable

­ http://www.cdc.gov/omhd/About/PDFs/OMHDPresentation.ppt#325,2

,

"Health Disparity" in Public Health ­ Operational Definition

· Quantitative measures: rates, percents, means... · The quantity that separates a group from a reference point on a particular measure of health · Calls attention to differences in health between groups regardless of cause · Can be measured in absolute or relative terms

· http://www.cdc.gov/omhd/About/PDFs/OMHDPresentation.ppt3

Health Disparities

Communities of Color are Disproportionately Affected

Racial and Ethnic Minority Populations

· American Indian/Alaska Native (AI/AN)

· · · · Asian American Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander (NHOPI)

http://www.cdc.gov/omhd/About/PDFs/OMHDPresentation.ppt CDC's Office of Minority Health (and Health Disparities), Definitions of Racial and Ethnic Populations, http://www.cdc.gov/omh/Populations/definitions.htm

Other Populations By . . .

· · · · · ·

·

·

Socio-economic status Geography (urban or rural) Gender Age Disability status Risk status related to sex and gender

http://www.cdc.gov/omhd/About/PDFs/OMHDPresentation.ppt#459, 3

Source: Functional Plan for CDC's Office of Minority Health and Health Disparities (OMHD)

Health Disparities

· Demographics · Unequal access · Language · Culture · Race and Ethnicity · Health care Quality

http://www.cdc.gov/omhd/

Examples of Health Disparities Selected Quality Measures

A series a slides showing disparities in the following by race/ethnicity · New AIDS cases and HIV-infection deaths · Cancer deaths · Death rates due to heart disease · Fair or poor health status, 2007 · Fair or poor health status by race/ethnicity and income, 2007 · Receipts of recommended tests for diabetes · Infant mortality rate for mothers age 20+ by race/ethnicity and education, 2003-2005 · Infant mortality rate, 2005 · Life expectancy at age 25 for U.S. black and white men, similar income · Age adjusted death rates (for all causes) per 1000 persons by race, 2005 · Age adjusted death rates for selected causes of death,2004 · Perceptions of disparity in health care · Changes in quality of care disparities of overtime: Summary by race and ethnicity, from 2001-2002 to 2005-2006

New AIDS Cases and HIV-Infection Deaths by Race/Ethnicity

Rate per 100,000 population

60.3

20.8 6.4 4.4 7.8 1.8 4.7

19.8

0.6

2.7

White Hispanic African Asian American American and Indian/ Pacific Alaska Islander Native

White Hispanic African Asian American American and Indian/ Pacific Alaska Islander Native

New AIDS Cases, 2006 (age 13 and up)

HIV-Infection Deaths, 2005 (all ages)

DATA: All racial groups non-Hispanics. Centers for Disease Control and Prevention, HIV/AIDS Surveillance System and National Vital Statistics System. SOURCE: National Healthcare Disparities Report, 2008, available at: http://www.ahrq.gov/qual/qrdr08.htm.

Cancer Death Rates by Race/Ethnicity, 2005

Deaths per 100,000 population:

White, Non-Hispanic Hispanic African-American, Non-Hispanic Asian or Pacific Islander American Indian/Alaska Native White, Non-Hispanic Hispanic African-American, Non-Hispanic Asian or Pacific Islander American Indian/Alaska Native

24 15 34 12 15 56 22 26 34 17 12 25 11 12 60

Breast Cancer

Lung Cancer

White, Non-Hispanic Hispanic Colorectal African-American, Non-Hispanic Cancer Asian or Pacific Islander American Indian/Alaska Native

NOTES: Breast cancer rate is per 100,000 female population; other rates are for both genders. DATA: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System - Mortality. SOURCE: National Healthcare Disparities Report, 2008, available at: http://www.ahrq.gov/qual/qrdr08.htm.

Death Rate due to Heart Disease by Race/Ethnicity, 2006

Deaths per 100,000 population:

320.6 250.0 212.5 175.2 136.3 170.2 160.9 118.9 87.3 113.2

White, Hispanic African Asian and American NonAmerican Pacific Indian/ Hispanic Islander Alaska Native

White, Hispanic African Asian and American NonAmerican Pacific Indian/ Hispanic Islander Alaska Native

Men

Women

NOTES: Rates are age-adjusted. DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Vital Statistics System. SOURCE: Health US, 2009 Table 32.

Fair or Poor Health Status by Race/Ethnicity, 2007

Share reporting fair or poor health:

17.1% 13.0% 14.1% 16.8%

8.3%

7.1%

White, NonHispanic

Hispanic

AfricanAmerican, NonHispanic

Asian Only*

American Indian/Alaska Native

Two or More Races

NOTES: Respondents assessed their health status as excellent, very good, good, fair, or poor. * The sample size for Native Hawaiian or Other Pacific Islander was not large enough for reliable estimates. DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2009, Table 57.

Fair or Poor Health Status by Race/Ethnicity and Income, 2007

Share reporting fair or poor health:

White, Non-Hispanic

22.6% 20.9% 21.0% 17.7% 15.2% 15.1%

Hispanic

African-American, Non-Hispanic

9.1% 9.4% 5.9%

<100% of Poverty

100-199% of Poverty

200% + of Poverty

NOTES: Respondents assessed their health status as excellent, very good, good, fair, or poor. The federal poverty level for a family of four in 2007 was $21,203 (http://www.census.gov/hhes/www/poverty/threshld/thresh07.html). DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Health Interview Survey. SOURCE: Health, United States, 2009, Table 57.

Receipt of Recommended Tests for Diabetics by Race/Ethnicity, 2003 White, Non-Hispanic Hispanic African American

100% 80% 60% 40% 20% 0%

Hemoglobin A1c Retinal Eye Exam Foot Exam All 3 Recommended Tests

91% 85% 85% 67% 69% 61% 51% 42% 42% 74% 70% 73%

Figure 18

NOTES: Data show share of adults with diabetes who received test within past year. Data for Asians and Pacific Islanders and American Indian/Alaska Natives not presented because data do not meet criteria for statistical reliability, quality, or confidentiality. DATA: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey. SOURCE: National Healthcare Disparities Report, 2006, available at: http://www.ahrq.gov/qual/nhdr06/index.html

Return to KaiserEDU.org

Infant Mortality Rates for Mothers Age 20+, by Race/Ethnicity and Education, 2003-2005

Infant deaths per 1,000 live births:

African American, Non-Hispanic American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic

Less than High School

15.1 10.1 9.1 5.9 5.4 13.9 8.2 6.6 5.8 5.4 11.5 6.5 4.2 3.8 4.7

African American, Non-Hispanic

High School

American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic

African American, Non-Hispanic

College+

American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic

NOTES: Data reported for 37 states, DC, and NYC. DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Vital Statistics System, Linked Birth/Infant Death Data Set. SOURCE: Health, United States, 2008, Table 19.

Infant Mortality Rate by Race/Ethnicity, 2005

Infant deaths per 1,000 live births:

13.6

8.1 4.9 5.6 5.8

Asian and Native Hawaiian/Pacific Islander

Hispanic

White, NonHispanic

American Indian/Alaska Native

African-American, Non-Hispanic

NOTES: Births are categorized according to race/ethnicity of mother. DATA: Centers for Disease Control and Prevention/National Center for Health Statistics, National Vital Statistics System, Linked Birth/Infant Death Data Set. SOURCE: Health, United States, 2009, Table 17.

Life Expectancy at Age 25 for U.S. Black and White Men with Similar Income Levels*

60 50 40 30 20 10 0

$25,000 or more $10,000-$24,999 $10,000 or less

White Men Black Men

52.9

50.2

50.2

47.4

45.0

41.6

* 1980s income levels SOURCE: NLMS: Lin et al 2003 and Nancy E. Adler, Health Disparities: Measurement, Mechanisms, and Meaning presentation, NIH

All Causes

Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

Age-Adjusted Death Rate per 100,000 Persons

1200

1016.5

1000

798.8

800 600

785.3 663.4 590.7 440.2

400 200 0

All Races White African American American Asian/Pacific Indian/Alaska Islander Native Hispanic

Source: Health, United States, 2007. http://www.cdc.gov/nchs/data/hus/hus07.pdf#029 Table 29.

Examples of Health Disparities Race and Ethnic

Table 1: 2004 Age-Adjusted Death Rates for Selected Causes of Death, per 100,000 Population All Population s All Causes Heart Disease Cancer Diabetes Unintentional Injury HIV Disease 800.8 217.0 185.8 24.5 37.7 4.5 African American s 1,027.3 280.6 227.2 48.0 36.3 20.4

Asian Americans & Pacific Islanders 443.9 117.8 110.5 16.6 16.7 0.7

% Relative Disparity 131.4% 139.1% 105.6% 189.2% 117.4% 2,814.3%

Source: Health, United States, 2007 Table 29. Note: This table compares the difference in the rate between African Americans and the group with the best rate for the selected diseases. More information on % Relative Disparity can be found at Measuring Progress in Healthy People 2010, HP2010 Statistical Notes #25, 2004.

Perceptions of Disparities in Health Care

Generally speaking, how often do you think our health care system treats people unfairly based on... Percent Saying "Very/Somewhat Often" Doctors Whether or not they have insurance 72% 70% 43% 58% 29% 47% 15% 27% The Public

Figure 22

How well they speak English

What their race or ethnic background is

Whether they are male or female

Source: Kaiser Family Foundation, National Survey of Physicians, March 2002 (conducted March-October 2001); Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, October 1999 (Conducted July ­ Sept., 1999)

Return to KaiserEDU.org

Perceptions of Disparities in Health Care

When going to a doctor or health clinic for health care services, do you think most African Americans receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

Same Higher

62% 36% 49% 3% 9%

Lower

Don't Know/Refused

2% 55% 24% 33% 12% 6% 9%

Whites Blacks Hispanics

When going to a doctor or health clinic for health care services, do you think most Latinos receive the same quality of health care as whites, higher quality of care or lower quality of health care as most whites?

Same Higher

55% 7% 5%

Lower

4%

Don't Know/Refused

26% 58% 48% 14% 6% 8%

Whites Blacks Hispanics

29% 38%

SOURCE: Kaiser Family Foundation, March/April 2006 Kaiser Health Poll Report Survey, April 2006 (Conducted April 2006)

Changes in Quality of Care Disparities Over Time: Summary by Race/Ethnicity, 2000-2001 to 2005-2006

18% 18% 29% 29%

Improving

47% 65% 41% 53%

Same Worsening

35% 18%

Black vs. White Asian and (n=17) Pacific Islander vs. White (n=17)

29%

18%

Hispanic vs. Non-Hispanic White (n=17)

American Indian/Alaska Native vs. White (n=17)

NOTES: "Improving" means disparity is becoming smaller over time; "worsening" means disparity becoming larger over time. Data on all measures are not available for all groups; "n" refers to the number of measures on which the groups were compared. Totals may not add to 100% due to rounding. Time period differs by measure and includes oldest and newest years of available data. SOURCE: Kaiser Family Foundation, based on AHRQ, National Healthcare Disparities Report, 2008, available at http://www.ahrq.gov/qual/qrdr08.htm.

Eliminating Health Disparities

Healthy People 2010: Goals · Increase quality and years of healthy life · Eliminate Health Disparities Ten leading Health Indicators (LHI) · Physical Activity · Overweight and Obesity · Tobacco use · Substance abuse

http://www.cdc.gov/omhd/AMH/AMH.htm

LHI, Continued · Responsible sexual behavior · Mental health · Injury and violence · Environmental quality · Immunization · Access to health care

Eliminating Health Disparities

· Racial and Ethnic Approaches to Community Health (REACH) 2010 · Center for Disease Control's (CDC) cornerstone: -to eliminate racial and ethnic disparities in health.

http://www.cdc.gov/omhd/AMH/AMH. htm

Six priority areas

·Infant Mortality ·Deficits in Breast and ·Cervical Screening & management ·Cardiovascular diseases ·Diabetes ·HIV Infection/AIDS ·Child and Adult Immunization

Education

· Education for prevention and treatment is part of the health care service. · In dietetics/nutrition: Medical Nutrition Therapy/MNT for people with diabetes · MNT is a comprehensive and systematic process. It includes diet (food) or nutrition counseling · Understanding of health beliefs and practices, food habits, preferences,religious influences, and holidays: Culturally relevant recommendations

Intercultural Communication Selected Concepts

· Language · Context in which the words are interpreted _____________________ · Cultural heritage and communication ­ Most visible personal characteristics affecting dialogue: Ethnicity, age, and gender

(c)Freefoto.com Kittler and Sucher, Food and Culture, 2008

Intercultural CommunicationContext

Context includes Issues common to cultural worldview: · Role of individual in a group · Perceptions of power, authority, status and time Significance of affective and physical expression (low or high context) Level of tolerance for uncertainty and ambiguity

Kittler and Sucher, Food and Culture, 2008

Communication Styles

Low context

Most western cultures Swiss, Germans, Scandinavians

High Context

Asian. Middle Eastern, and Native Americans

Precise wording, Straightforward

Meaning is in the context. Words may be vague Content: More objective Content: More personal, dependent on relationship than personal between speaker and listener Actual words more Latino: Moderately high important than who Context receives the message, how Americans: Low to they are said, or nonverbal moderate actions Kittler & Sucher, Food and Culture, 2008

Intercultural Communication

Individuals and groups Impact on health care delivery · Group oriented cultures: Greater participation of their members in health and illness matters

Example: Middle Easterners, Latinos and Native American

Kittler and Sucher, Food and Culture, 2008

Uncertainty Avoidance

High uncertainty avoidance culture · Anxious about behavior that deviates from the norm · Desire for consensus · African American women may resist certain prep or seasoning if the group objects or if foods undermine ethnic identity · If a peer group values a larger figure, the person in the group may avoid weight loss

Kittler and Sucher, Food and Culture, 2008

Power, Authority and Status

Low-context culture · Power distance is small · People are seen as equals · A client may ask for full explanation before following a therapy

· A few examples: Austria, Canada, Denmark, Germany, Great Britain, Ireland, Israel, The Netherlands, New Zealand, Sweden U.S.A.

Kittler and Sucher, Food and Culture, 2008

Power, Authority and Status

High -context culture · Superiors are seen as different · Authority is rarely questioned · Large power distance: Authority seen as the expert · Client empowerment via goal setting may be resisted

· Most African, Asian, Latino and Middle Eastern cultures

Kittler and Sucher, Food and Culture, 2008

Time Perception

· Perception of time varies by culture.

­ Being on time, sticking to schedules

· Low context cultures

­ Monochronistic- Completes one task at a time

· Polychronistic societies

­ Many tasks are pursued simultaneously ­ Courtesy and kindness more important that deadlines

Kittler and Sucher, Food and Culture, 2008

Nonverbal communications

Touching norms vary (gender, age, physical condition) · Handshakes · Hugging · Kissing · Placing a hand on the arm or shoulder · Touching the head and putting hand on the shoulder: May be offensive · Vigorous handshaking

Kittler and Sucher, Food and Culture,2008

Nonverbal Communications, Cont.

· Gesture, Facial Expression and Posture · Eye contact · Spatial relationships

­ Defining his or her own space ­ " Too close" ­ Appropriately close

Kittler and Sucher, Food and Culture, 2008

Communication in Health Care

Words

· Primary tool for conveying information/advice regarding treatment and prevention · Content or object messages versus personal messages and relationships · Misunderstanding can result in nonadherence to health advice and affect outcomes · Building interpersonal relationship is important

Kittler and Sucher, Food and Culture, 2008

Other Intercultural Communication Considerations

Name Traditions · Informal American style vs. more formal styles in other cultures · Name order in other countries Proper language · Common terms, words with several meanings, specific verbs · Slangs and idioms, questions that can be answered by yes or no

Kittler and Sucher, Food and Culture, 2008

Other Intercultural Communication Considerations, cont Use of a translator · Client's family or friends: Issues · Mistranslation of medical terminology · Important to have professional translator

Kittler and Sucher, Food and Culture, 2008

Intercultural Nutrition Assessment

· Errors in assessing dietary intake when using food lists derived from data on the U.S. population · Anthropometric measurement tools such as the standard body mass index (BMI) cutoff for overweight and obesity in Asians have been questioned · Qualitative approach in initial interviews for diet information

Kittler and Sucher, Food and Culture, 2008

Intercultural Nutrition Education Some of the Ingredients

· Cultural health beliefs, attitudes, and values of the group; program that has been developed in the context of the group's worldview, and culturally appropriate verbal and nonverbal messages delivered in appropriate medium · Effective intercultural communication is critical to the success of the program.

Kittler and Sucher, Food and Culture, 2008

Compelling Need for Cultural and Linguistic Competence: Conclusion

· To respond to current and projected demographic changes in the United States · To eliminate long-standing disparities in the health status of people of divers racial and ethnic and cultural backgrounds. · To improve the quality of services and health outcomes · To meet legislative, regulatory and accreditation mandates · To gain a competitive edge in the market place · To decrease the likelihood of liability/malpractice claims

National Center for Cultural Competence, Georgetown University Center for Child and Human Development

"Cultural Competence: It All Starts at the Front Desk"

Consequences when the front desk fails to use culturally and linguistically competent practices. · Families:

­ ­ ­ ­ Feeling of insulted or being treated rudely Feeling unwelcome, unwanted, and not valued Fear of contacting the office Confusion about appointments or treatments

· Children and youth with special care needs may not receive optimal treatment. · Providers may face problematic outcomes.

Bronheim S. (http://gucchd.georgetown.edu/nccc)

References

· · · · · · · · · · About Minority Health. Office of Minority Health and Health Disparities. CDC. Available at http://www.cdc.gov/omhd/AMH/AMH.htm. Accessed on May 14, 2010. Bronheim S. It All Starts at the Front Desk. National Center for Cultural Competence. Georgetown University. Available at htto.//guchd.georgetown.edu/nccc. Accessed on May 14, 2010. Compelling Need for Cultural and Linguistic Competence. National Center for Cultural Competence. Available at http://ncc.georgetown.edu/foundations/need.html. Accessed on May 17, 2010. Definitions of Racial and Ethnic Populations. Office of Minority Health & Health Disparities. Available at http://www.cdc.gov/omhd/Populations/definitions.htm. Accessed on May 14, 2010. Goody CM, Drago L . Introduction: Cultural Competence and Nutrition Counseling. In Goody CM, Drago L. (eds). Cultural Food Practices. Chicago, IL: Diabetes Care and Education Practice Group, American Dietetic Association; 2010: xii. Kittler P, Sucher K. Traditional Health Beliefs and Practices. In: Kittler P. Sucher K. Food and Culture, 5th ed. Belmont, CA: Wadsworth/Thomson Learning; 2008: 37-56. Kittler P, Sucher K. Intercultural Communication. In: Kittler P. Sucher K. Food and Culture, 5th ed. Belmont, CA: Wadsworth/Thomson Learning; 2008: 58-84. Minority Health Database Power Point Slides. Kaiser Family Foundation. Available at http://facts.kff.org/results.aspx?view=slides&topic=70. Accessed on May 14, 2010. Race, Ethnicity and Health Care Power Point Slides Kaiser Family Foundation. Available at http://www.kaiseredu.org/tutorials/REHealthcare/REHealthcare_download.ppt Accessed on May 14, 2010. What is Cultural Competency? The Office of Minority Health. Available at http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11, Accessed on May 17, 2010.

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