Changing demographics translate into changes in how care info is given

Rehab community could set standard for dealing with diverse population

You can hardly pick up a newspaper or watch a television newscast these days without seeing something about the thorny issue of managing cultural diversity. It’s easy enough to agree in principle that all people should be treated equally regardless of their background, but it’s much more difficult to figure out how to translate that to your everyday practice. But figure it out you must.

Census data show that the face of America is changing: Within the next 50 years, Caucasians will be in the minority. According to the 2000 census, 26 million individuals in the United States speak Spanish and almost 7 million individuals speak an Asian or Pacific Island language at home.

Title VI of the 1964 Civil Rights Act requires health care organizations that receive federal funds to provide equal access to treatment for patients with limited English proficiency (LEP).

It’s not enough to call in a staff person who took Spanish in high school to try to communicate with a Spanish-speaking patient. It’s also not acceptable to rely on friends or family members of a patient to translate. You must have a plan, and if you don’t, you could set yourself up to become one of the increasing numbers of health care organizations being reviewed by the Office for Civil Rights.

"The whole thrust of the legal responsibility is to ensure people have meaningful access to health care," says Robinsue Frohboese, the principal deputy director of the Office for Civil Rights in Washington, DC. "Communication is the very essence of the doctor/patient relationship in terms of everything from taking responsibility for your own health care to communicating ailments and problems to follow-up care."

People tend to underestimate the importance of hiring qualified interpreters, says Bonnie Breit, MHSA, OTR, president of BRB Consulting Inc. in Media, PA. Breit teaches seminars on managing cultural diversity and has written a book on the topic, Communication Helps All People. "If you don’t have somebody who knows what they’re doing, they may change the question. They may not give you the answer, or they may not give you all the details because they don’t understand the significance," she says. "They may not have the language skills to go from English to the target language or back to English. They may have a hidden agenda, especially if you’re dealing with a psychiatric situation. You don’t know that the mother has a million dollars and if she dies, the family member doing the interpreting gets it," Breit adds.

Providers can contract with a telephonic language bank or an agency that provides interpreters or they can hire bilingual staff. "I don’t think organizations want to not be doing this," she explains. "I think there is a general lack of awareness."

The Office for Civil Rights is developing a new guidance document that will help providers meet their Title VI requirements. The document should be released some time this fall. Frohboese says the document will give specific examples and solutions for problems providers might face. "Our guidance stresses that one has to be reasonable in terms of which documents to translate and when to bring in an interpreter," Frohboese says. "It is all a balancing act. It’s looking at the populations you serve, looking at the make-up and composition of those populations and the extent to which particular language groups are represented. And it’s looking at the need for translated documents and interpreters and looking at the resources that are available," she adds.

The Office for Civil Rights attempts to achieve voluntary compliance with Title VI requirements, Frohboese says. The office initiates compliance reviews and has the legal power to bring action against a provider or withhold federal funds. But in its 30-year history, only a handful of cases have not resulted in voluntary compliance, she says.

Even in the absence of fines or withheld federal funds, the voluntary compliance route can be a huge headache. Just ask Maine Medical Center in Portland, which in May completed a five-year process of implementing a series of requirements to ensure equal access for deaf and hearing-impaired patients. The hospital signed a consent decree in 1998 following a lawsuit alleging the hospital’s failure to provide auxiliary aids and services for deaf or hard-of-hearing patients as required by the Americans With Disabilities Act (ADA).

Maine Medical Center also signed a voluntary compliance agreement with the Office for Civil Rights in 2000 to ensure that LEP patients have access to interpreters and other language assistance. The result has been the creation of a plan for accommodating patients that has become a model for hospitals nationwide, says Suzanne Gardiner, MS, the ADA access coordinator for Maine Medical Center. Gardiner’s job was created to fulfill one of the requirements of the consent decree. The other requirements included:

  • Making a qualified sign language interpreter available at no expense to patients during pre-scheduled visits or within one hour of the request at other times.
  • Providing telephones in deaf patients’ rooms that have amplified sound or a TTY (telecommunications typewriter) with a printer.
  • Training all hospital personnel about the communication needs of deaf patients.
  • Creating a new hospital policy stating that people who are deaf or hearing-impaired will fully and equally enjoy all of the hospital’s services, benefits, and facilities.
  • Refraining from using relatives or friends of deaf patients as interpreters.
  • Maintaining TTY telephone numbers and installing public TTY pay phones.
  • Providing closed-caption televisions in patient rooms.

"I think people have a hard time wrapping their minds around thinking of deafness as a culture," Gardiner says. "People who are born deaf are really proud of their language, which is completely different from English. Within the deaf culture, there are even subgroups, such as people who were late-deafened or are hard of hearing."

Gardiner does monthly training sessions with new nurses to go over the hospital’s policy and teach the protocol of what to do when a deaf patient comes in. Staff in each department know how to use TTY equipment and who to call to get an interpreter.

"We teach staff to talk directly to the patient instead of to the interpreter and to have eye contact with the patient," she says. "When you’re waiting for the interpreter to come, don’t ignore the patient because you’re scared to communicate with them. Tap them on the shoulder, smile, write a note. Also, remember that an interpreter will interpret everything that is said in the room. If you get paged and you make a phone call, leave the room if you don’t want the patient to hear what you say. Basically, just treat them like a person."

For LEP patients, Maine Medical Center’s agreement with the Office for Civil Rights included data collection, training of interpreters, grievance procedures, use of telephonic language-assistance sources, effective monitoring for five years, and assessing whether signs and documents should be translated into additional languages.

Treatment based on needs

The rehab community has a special opportunity to help other providers deal with diversity, says Breit. "We could help organizations learn to accommodate without judgment because we do that so often with disability. Our job is to figure out ways to get people to function as independently as possible. We’re used to looking for modifications and accommodations we can make in the community or the environment. By understanding language and cultural differences, we could find ways to make the world a much more accommodating place."

It’s important to remember that diversity is not just about race or creed. It could mean age or gender as well, Breit says. "From a rehab perspective, understanding culture is important because how one interacts with a patient matters. In home care, if you want your services to be followed, you have to follow certain guidelines," she adds. "If you go into many of the Asian communities and you don’t take the time to do the formalities and the greetings with the elders in the household before you start working with the daughter, you may not be accepted. The likelihood that your treatment will be valued is going to be less. You need to go through certain cultural courtesies. Having that awareness will make your ability as a therapist more effective."

The difficulty lies in learning about different cultures without creating stereotypes, Breit says. It’s important to know, for example, that African-American males have more lower extremity amputations than any other culture in the country because of diabetes and that Vietnamese women have more cervical cancer.

"None of us can change our race, but what we can change is how we approach the world and our expectations of others," she says. "In the rehab continuum, many clinicians are white females. There’s nothing they can do to change that, but they need to understand that they come to the table with a different expectation than an African-American or Asian man might. Therapists can ask themselves: How do I build my treatment based on their needs?"

Breit advises that rehab providers:

  • Develop a diversity plan.
  • Become familiar with the law on this topic. This includes providing interpreter services so you can communicate effectively.
  • Become aware of changing cultures in your community.
  • Address stereotypes and learn about the cultural patterns of diseases.
  • Try to hire a more diverse work force.
  • Reach out to different cultures.

Barbara Hansen, MS, OTR/L, clinical assistant professor and academic fieldwork coordinator in the occupational therapy department at Ithaca (NY) College, says that lack of awareness is precisely why it’s important to include cultural information in the OT curriculum. At Ithaca, cultural issues have been infused into the existing curriculum.

"In the OT code of ethics, we pledge to provide fair and equitable service to all people that we treat. It makes sense to treat all people as they should be treated," Hansen says. "Cultural competency is something to strive for even though you probably never truly reach it. It starts with understanding yourself and knowing what your own culture is," she points out. "People start off thinking culture is ethnicity, but we try to broaden that scope so that you are an occupational therapist, or you are a freshman in college, or you are a student. Those are all cultures."

One exercise Hansen does with students is to ask them to close their eyes and picture a person based on four words. She starts with Vietnamese refugee, then adds single mother, then physician, then wheelchairbound. "Your image really changes as you go through those words. It’s a powerful exercise in looking at the total person," she says.

Hansen and her colleagues also include cultural issues in case studies that students perform. Students are divided into groups and given the same information about a patient’s health problems. But each group is given different information about the patient’s culture to see if that changes anything in the treatment plan the students create.

"Students often find they need more information from the patient. They learn that one particular diagnosis doesn’t mean the same thing for every person," she says. "If our ultimate goal is to allow the person we’re treating to have the most productive and meaningful life they can, then it behooves us to know what makes their life productive and meaningful rather than have them try to do what we think."

For example, one of the activities of daily living that an OT might work on with a patient is how to make a bed. "If they sleep on the floor at home, you’re just wasting your time," Hansen says. "If you’re going to work on meal preparation, make sure it’s something they actually eat. You will run into problems if you think your way is the only way."

Hansen offers this advice to providers:

  • Let clients tell you what is important to them.
  • Adapt your treatment plan to best meet their needs.
  • Do not make assumptions.
  • Ask the right questions. If you’re working with a child, be aware of the differing definitions of family. If the mother is single and has four other children, that alters how much you can ask for in a home program.
  • If their values are different from yours, go with theirs as long as it will not be harmful to them.

For more information, contact:

Robinsue Frohboese, Principal Deputy Director, Office for Civil Rights, 200 Independence Ave. S.W., Washington, DC 20201. Telephone: (202) 619-0403.

Suzanne Gardiner, MS, American with Disabilities Act Access Coordinator, Maine Medical Center, Department of Vocational Services, 22 Bramhall St., Portland, ME 04102-3175. Telephone: (207) 871-3847. E-mail:

Bonnie Breit, MHSA, ORT, President, BRB Consulting Inc., P.O. Box 515, Media, PA 19063. Telephone: (610) 566-2828. E-mail:

Barbara Hansen, MS, OTR/L, Clinical Assistant Professor, Occupational Therapy, Ithaca College, 207 Smiddy Hall, Ithaca, NY 14850. Telephone: (607) 274-1798.