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Intercultural Communication in Counseling Communication is described as an action chain meaning that one phrase or action is followed by the next We communicate o Verbally o Non verbally Misunderstanding may come from Actual words Gestures Posture Spatial relationships Concepts of time Status and hierarchy Role of individual in a group When someone doesn t respond communication breaks down Expectations are largely cultural Context the affective and physical cues used to indicate meaning Ex Tone of voice facial expression posture gestures Low context 0 Actual words more important Focus is on the speaker Information presented in linear logical sequences Western cultures Conflicts may occur because of violations of individual expectations 0 Deal with conflict by revealing their dissatisfaction with a direct attitude High context 0 Homogeneous populations Nonverbal signifiers are highly meaningful o Misunderstandings easily occur Read between the lines Wording may be vague or incomplete Group oriented Use spiral logic 0 Indirect non confrontational attitude 0 Examples small eye movements small sounds squirming emphasis Individuals and Groups Low Context 0 Individual separate from group 0 Value personal accomplishments self realization Use one to one interviews High Context 0 All members interact according to predetermined patterns 0 Values awareness of group members as mutually dependent preserve group s identity fulfill set roles more silence Use focus group discussion Time Perception o Low context Deadlines most important Monochronistic o High context Deadlines not valued Courtesy and kindness most important Polychronistic Groups 0 Very high context Asian Middle Eastern Native American Africans o Mildly high context Latino 0 Low Context Americans A mismatch between a low context and high context sender and receiver can cause impatience or offense Looping talking about one thing then talking about another before continuing with the first subject high context Biomedicine is usually low context o High context clients may feel dissatisfied and discontinue treatment 0 Low context convey information accurately rather than to promote a positive relationship Obtaining Health Information from a client Questions must be clear and unambiguous What race are you ambiguous has many meanings Change to quotWhat ethnicity are you Open ended vs close ended questions Can what you eat help cure your sickness close ended How may what you eat cure your sickness open ended Close ended questions Help to identify skip patterns quotAre you of Hispanic originquot quotAre you a vegetarianquot Open ended questions Also called respondent driven questions Five Causes of Misunderstandings in Health Care Systems quotI 5 quot Provider not aware of client s thoughts Provider must depend on verbalnonverbal information which may cause miscommunication Provider interprets misunderstandings into their own which may not match the patient s Provider s state of mind may bias perception of client s behavior Provider s interpretations are often incorrect Result noncompliance rejection of treatment failure to return for follow up Iceberg Model of Multicultural Influences Race Gender Ethnicity Age A can tell from looking at a person quotabove waterquot AcculturationAssimilation Socioeconomic Status Occupation Health condition Religion Sexual preference Group membership Educational background Political Orientation quot need to ask the person for certain information below water Other Challenges 0 Stereotyping Assuming that all members ofa group communicate similarly 0 Differences within a group There are as many differences as similarities 0 Assume responsible authority Practitioner is the superior position 0 Understanding Practitioner must understand what the client says and provide them with the information needed 0 Be familiar with culture and listen Cycle Unconsciousness Incompetence 9 Conscious Incompetence 9 Conscious Competence 9 Unconscious Competence 9 back to top Unconsciousness Incompetence speaker misunderstands Conscious incompetence speaker is aware of mistake but makes no effort to change Conscious Competence speaker modifies to avoid misunderstandings may miss information Unconsciousness Competence speaker is skilled to make cultural adjustments without thinking of them goal Communication Concepts 0 Message sent from sender to receiver Receiver interprets message based on cultural and social norms Understanding consists of actual message and message as given within the context of the personal relationship 0 Symbols represent objects ideas or behaviors 0 Language must be interpreted in the prevailing context Thoughts emotions attitudes 0 Person sending the message knows the meaning Components of Message 0 Content must be culturally acceptable 0 Messages violating those may have a negative impact Cultural considerations 0 Many label their audience as quothard to reachquot not recognizing the underlying cultural differences and problems associated with people Obstinate Disadvantaged iterate Malfunctional Three Groups Labeled quotHard to Reachquot 0 Low SES Lowest SES have highest risk of death and disease Ethnic minority Low literacy Level of Literacy 0 Functional literacy Obtain information wanted and use it for own and other s well being iteracy Affects Health 0 Incorrect use of medications 0 Poor compliance 0 Occupational accidents 0 Lack of access to servicesresources 0 Errors in infant formula Power Distance 0 Miscalculation of one s power distance 0 Know your limits 0 The client needs to follow directions Gender Orientation 0 Gender issues may also predominate o Masculine culture Power highly valued Aggressive task oriented materialistic Gender roles strongly differentiated Men accorded more authority 0 Feminine culture Quality of life is important Equal power amongst menwomen Spatial Relationships 0 quotPersonal space 0 Distance between people in community Pg 60 68 Tables and Table 32 Successful Intercultural Communication 0 Know the culture 0 Accord respect 0 Assessaffirm 0 Be sensitive Self aware o Humility 0 Name traditions Power names used a lot 0 Appropriate language Specific verbs Slang Idioms Avoid yesno questions 0 Use a translator if needed Intercultural Communication Skills Translators 0 Title VI 6 ofthe Civil Rights Act no discrimination based on language 0 Problem is use of nonprofessional translators 0 Speak directly to the client even if using a translator 0 Problems with informed consent patient safety and noncompliance can occur 0 Telephone interpretation services are appropriate Successful Intercultural Communication 0 Practitioner needs to increase the client s comfort Be flexible Share control Seek feedback Show sincere concern Mirror client Obtain client s cooperation Intercultural Nutritional Assessment The In Depth Interview 0 Determine iceberg issues 0 High context May feel personal questions are invasive Many indicate practitioner incompetence Elicit issues but don t be invasive Respondent driven open ended questions 0 Cover social background healthnutrition Standardized tools may be unreliable Cultural unfamiliarity with concepts and terminology Mixed dishes Underestimation of nutrients Health attitudes model acculturation scales may be unsuitable Anthropometric measurement tools may be inappropriate 0 Development of culturally specific techniques and tools is a critical need in nutritional assessment 0 Standardized tools may not be applicable Food frequency questionnaire works most of time Observational assessment often works Group xtics may comprise same ethnicity gender lifestage religion Data Collection 0 Body composition differs across cultures BMI interpretation may differ Body fat composition differs Height of stature in relation to body proportions differs Dietary Data 0 Needs to customize existing databases USDA s food composition table online 0 Food Frequency Questionnaire FFQ Forms can be scanned computer assisted 0 24 Hour Dietary Recall Computer assisted Nutrition Calc Plus Dietary Analysis Food Processor Nutritionist My Pyramid website 00000 Data Collection Groups Background Data 0 Social and Demographic data Age and gender distributions Source and location of water Major occupation Location and distance to school Source of electricitypower Presence of churchreligious denomination Public waste disposals Community setting 0 Available play ground for children 0 Existence of a town hall Intercultural Nutrition Education and Intervention 0 Fig 33 0 Identify the nutritional problem in the culture 0 Find out heart felt needs of the group 0 Do not impose your ideas on them but modify or add on to theirs A Well Designed Program 0 Reflects the cultural health beliefs attitudes and values of the target audience 0 Uses culturally appropriate consistent verbal and nonverbal messages Culturally Relevant Program Preparation 0 Target Audience Gather demographic information Involve members in planning Keep culturally homogenous 0 Goals and Objectives Clear realistic Include cultural beliefs Emphasize positive cultural dietary patterns and values Contact health care providers in targeted community to be part of the team 0 Feedback and Assessment are needed to evaluate and improve program design and delivery 0 If necessary readjust design Triangulation 0 Method used to confirm congruence between data collected on target audience and proposed program goals and objectives Fig 33 Developing the Program Content Message 0 Keep as direct and explicit as cultural norms allowreflect the group s perceived needs 0 Pilot test materials for appropriateness Pilot test the message Education Strategies 0 Focus group discussions 0 Group participation Let culture contribute to solve problem especially women 0 Visual aids VIP 0 Use relevant examples from the community 0 Story telling 0 Use the media Videos local television shows comedies short documentary radio etc Communication Strategies 0 Language use local language Literate interpreters 0 Message style use power names Power beans Super rice Golden rice 0 Visualvisual aids VIP 0 Communicate in context ofthe culture Native Americans talk with them not to them Implementation Strategies 0 Influence channels How message is transmitted 0 Each cultural group has distinct media patterns 0 Most effective presentation requires pictures sounds videos Marketing mix 0 Product Well developed message 0 Price Minimal economical or psychological cost of taking the action 0 Placement Channels of delivery 0 Promotions Ways for target audience to quottestquot new behaviors Program Evaluation 0 Process evaluation Monitor progress Monitor conditions that impede progress 0 Summative evaluation Assess program results Use results to refine future programs Intercultural Nutrition Education Assessment 9 Policy 9 Implementation 9 Audit back to Assessment FNS 271 FOOD AND CULTURE Exam 2 Study Guide Note Exam 2 contents will be based on what has been covered in class since the last exam Traditional food preparation and effects on nutrients 0 Some advantages 0 Some disadvantages 0 Common practices Intercultural communication 0 Summary table of characteristics of ethnic groups in the US page 6065 of text African Americans speak quickly with rhythm direct eye contact when speaking avert if prolonged lnterject often very quick response expressive demonstrative respectful direct approach assertive questioning firm handshake smile touching common high context polychronlstlc Asians speak softly avert eyes as sign of respect head nodding may indicate active listening delayed auditory polite restrained articulation of feelings considered immature indirect approach Japanese direct approach Chinese Koreans rarely ask questions may or may not exchange soft handshake nontouching culture very highcontext polychronlstlc Latinos speak softly eye contact direct between members of same sex aversion an insult seldom make responses of active listening mild auditory delay men restrained women expressive but not emotional indirect approach will ask questions when encouraged firm handshake among men soft handshake amongst women touching common moderately highcontext polychronlstlc Middle Easterners speak softly direct gaze between members of same sex facial gestures express responses mild auditory delay expressive emotional indirect approach will ask polite questions numerous greetings touching common between members of same gender highcontext polychronlstlc Native Americans speak softly and slowly indirect gaze when speaking and listening seldom makes responses for active listening delayed auditory expression restrained indirect approach rarely ask questions quick handshake smlle minimal touching veryhigh context polychronlstlc Majority whites speak loudly quickly direct eye contact when speaking and listening head nodding quick response taskoriented focused direct approach ask direct questions firm handshake moderate touching low to medium highcontext monochronlstic o Verbal and nonverbal cues Verbal messages are most useful for communicating content while nonverbal messages usually convey information about relationships If the nonverbal message is consistent with the verbal message it can build the relationship and help the receiver correctly interpret the meaning intended by the speaker When the nonverbal message is inconsistent with the verbal message both the relationship and the content are undermined Barriers to intercultural communication Causes of cultural misunderstanding 1 N 5 w A provider can never fully know a client s thoughts attitudes and emotions especially when the client is from a different cultural background A provider must depend on verbal and nonverbal signals from the client to learn what the client believes about health and illness and these signals may be ambiguous A provider uses his or her own cultural understanding of communication to interpret verbal and nonverbal signals from the client which may be inadequate for accurate deciphering of meaning in another cultural context A provider s state of mind at any given time may bias interpretation of a client s behaviors There is no correlation between what a provider believes are correct interpretations of a client s signals or behaviors and the accuracy of the provider s belief Misunderstandings of meaning are common Messages that violate cultural expectations may be accurate in content but have a negative impact on the relationship If the message consistently offends the receiver the relationship will deteriorate and the message will be disregarded May come from actual words gestures posture spatial relationships concepts of time status and hierarchy and the role of individual in a group The iceberg model of multicultural influence in communication used to describe how a person s cultural heritage can impact communication What is obvious and what is not Ethnicity age and gender are most visible personal characteristics tip of the iceberg Accultu ration or assimilation SES health condition religion educational background group membership sexual orientation or political affiliation are beneath the surface Challenges of intercultural communication The provider can control only her or his side of the conversation if the words are ineffective the client may reject recommended medications or therapies The advice of the health care provider often impacts not only the patient but also the patient s family The health care professional relies on the client to provide accurate detailed information about his or her medical history and current symptoms so that the appropriate diagnosis and treatment can be determined The client depends on the practitioner to explain any medical condition in terms that are understandable and to describe treatment strategies and expectations clearly o The four stages of intercultural communication Unconscious incompetence when a speaker misunderstands communication behaviors but doesn t even know misinterpretation has occurred Conscious incompetence when a speaker is aware of misunderstandings but makes no effort to correct them Conscious competence when a speaker considers his or her own cultural communication characteristics and makes modifications as needed to prevent misinterpretations Unconscious competence when a speaker is skilled in intercultural communication practices and no longer needs to think about them during conversation ntercultural communication concepts The two components of the message are the content and the relationship between the speaker and the receiver Messages that demonstrate respect for the individuality of the receiver are called personal messages and improve relationships Messages that are disrespectful are termed object messages and often degrade relationships Message sent from sender to receiver Receiver interprets message based on cultural and social norms Understanding consists of actual message and message as given within the context of the personal relationship Symbols represent objects ideas or behaviors Language must be interpreted in the prevailing context Person sending the message knows the meaning Intercultural counseling 0 Synonymslabels used to describe different groups Three audience segments labeled quothard to reach Low SES 0 Lowest SES have highest risk of death and disease Ethnic minority Low literacy 0 Low and high context cultures Veryhigh context include Asian Middle Eastern Native American Africans Mildly highcontext include Latinos Lowcontext include Americans Explanation of context 0 Context the affective and physical cues used to indicate meaning Ex Tone of voice facial expression posture and gesture Differences 0 Low context actual words more important focus is on the speaker information presented in linear logical sequences common in western cultures conflicts may occur because of violations of individual expectations deal with conflict by revealing their dissatisfaction with a direct attitude 0 High context homogenous populations nonverbal signifiers are highly meaningful misunderstandings easily occur read between the lines wording may be vague or incomplete grouporiented use spiral logic indirect and nonconfrontational attitude examples small eyes movements small sounds squirming emphasis Low and high context ethnic groups 0 Low context individual separates from the group value personal accomplishments and selfrealization use onetoone interviews 0 High context all members interact according to predetermined patterns values awareness of group members as mutually dependent preserve group s identity fulfill set roles more silence in highcontext use focus group discussion Uncertainty avoidance 0 Some groups exhibit great discomfort with what is unknown and different high uncertainty avoidance cultures They typically have a history of central rule and complex laws that regulate individual action on behalf of the group o Cultures with low or weaker uncertainty include people who are usually curious about the unknown and different They are more informal willing to accept dissent within a group and open to change 0 A person from a high uncertainty avoidance culture may be quite willing to take familiar risks or even new risks in order to minimize the ambiguity of a situation However risks that involve change and difference are difficult for people with strong uncertainty avoidance 0 Working with family or peers in a group setting to effect dietary change may be more successful for persons with a low tolerance for uncertainty Power of authority 0 ln lowcontext cultures where individuality is respected power or status is usually attributed to the role orjob that a person fulfills People are seen as equals differentiated by their accomplishments o In highcontext cultures where group identification is esteemed superiors are seen as fundamentally different from subordinates Authority is rarely questioned 0 Although there is usually some combination of both small and large power distance tendencies in a culture one is predominant Gender orientation 0 Gender issues may also predominate o Masculine culture power highly valued aggressive taskoriented materialistic gender roles strongly differentiated men accorded more authority 0 Feminine culture quality of life is important equal power amongst men and women Intercultural communication skills 0 Know the culture 0 Accord respect 0 Assessaffirm 0000000 0 Be sensitive self aware Humility Names traditions power names used a lot Appropriate language specific verbs slang idioms avoid yesno questions Use a translator if needed Title VI 6 of Civil Rights Act no discrimination based on language Problem is use of nonprofessional translators Problems with informed consent patient safety and non compliance can occur Precounseling preparation 0 The basic competencies needed by practitioners include 1 information transfer the verbal and nonverbal ability to convey object messages 2 relationship development and maintenance the ability to create rapport establish trust and demonstrate empathy and respect 3 compliance gaining the ability to obtain client cooperation A health care provider cannot be expected to become an expert in intercultural communication or to fully understand the communication modes best suited to each of the many clients from different cultural heritagess lndepth interview 0 O 0 Essential in intercultural counseling to determine many of the iceberg issues that may affect communication and cooperation in health care However a client may believe that personal questions about his background are invasive or unnecessary especially if from a highcontext culture One approach is the respondentdriven interview in which openended questions by the provider initiate conversation The client can express their understanding and experience in their own words Intercultural nutrition assessment 0 Why standardized tools may not work Standardized tools may be unreliable O O 0 Cultural unfamiliarity with concepts and terminology Mixed dishes Underestimation of nutrients Health attitudes model acculturation scales may be unsuitable Anthropometric measurement tools may be inappropriate Development of culturally specific techniques and tools is a critical need in nutritional assessment Standardized tools may not be applicable 0 000 Food Frequency Questionnaire FFQ may not be applicable Food security scales may not be compatible with the culture 24 hr diet recall often works Observational assessment works most of time 0 Focus group discussion often works 0 Group xtics may comprise same ethnicity gender lifestage religion Data Collection 0 Body composition differs across cultures BMI interpretation may differ body fat composition differs height or stature in relation to body proportions differs Items that introduce differences in what the practitioner heard versus what was said Intercultural nutrition education When communication conflict develops an inexact period of time exists when the client is willing to negotiate toward resolution of the message lf dissatisfaction continues a poor weight loss outcome results because the person 1 is never motivated to sign up 2 drops out of the program before completion 3 attends but never learns skills or 4 learns skills but does not apply them in practice Goals and objectives 0 Define clear and realistic goals and objectives within the cultural context of the target audience 0 Strategies emphasizing continuation of positive cultural dietary patterns or portion control rather than elimination of certain foods are reportedly of interest to African Americans Asian Americans Latinos and Native Americans as well as Whites o A welldesigned program reflects the cultural health beliefs attitudes and values of target audience and uses culturally appropriate consistent verbal and nonverbal messages Targeting the audience 0 One of the most important steps in program planning 0 Demographic information about the target audience can guide program development 0 Primary language should be identified as well as gender average age SES educational attainment religious affiliation and other iceberg factors 0 Involving members of the targeted audience in program planning is one of the best ways to determine cultural orientation 0 The educator establishes a relationship with the group through asking for permission to present the health message to its members Triangulation 0 Method used to confirm congruence between data collected on target audience and proposed program goals and objectives 0 Community Nutritionists Perspectives Method Interviews 9 Stores Available foods and costs Method Observation 9 Community Women Needs preferences current activities Method Focus group discussions Implementation strategies 0 Dissemination of a nutrition education message should include analysis of cultural influence channels and media preferences development of an effective marketing mix and evaluation of the program Influence channels are the ways in which message materials are transmitted to the 0 target audience including television video computers radio magazines newspapers newsletters direct mail and telephones 0 Most African Americans 97 favor the radio Latinos favor television programs Asians enjoy watching the television Computerbased interactive nutrition education programs are an emergent 0 educational tool particularly suitable for audiences with low literacy or limited English language skills The most effective presentation of a message requires a combination of pictures 0 sounds and words in the broadcast and print media Marketing mix 0 Product price placement and promotion 0 They refer to a welldeveloped message product that advances program goals and objective at minimal economic or psychological cost to target audience members price and presents this message in a method congruent with target audience media preferences placement in such a way that the target audience members are encouraged to become more involved in the program either through phone numbers or further information or through attendance at group meetings promotion Program evaluation types and importance 0 Process evaluation keeps track of progress throughout the program especially the identification of larger community conditions that may be presenting barriers to dissemination of the message 0 Summative evaluation is used to assess program results after completion of the effort 0 Evaluation data are useful in refining intercultural nutrition education strategies both during implementation and in future programs 0 Publication of culturally sensitive nutrition education program results greatly benefits other health professionals and their clients through shared knowledge about intercultural communications techniques and tools