And welcome to our latest webinar, Exploring Culture in CLAS: Religion and Spirituality. My name is Darci Graves, and I serve at the Senior Health Education and Policy Specialists with the Health Determinants and Disparities Practice at SRA International, which helps to support the Department of Health and Human Services Office of Minority Health Think Cultural Health project and its webinar catalog; which is where you found this webinar today. We hope that this will be a part of a series of webinars for Exploring Culture in CLAS.

First, let me introduce you to the HHS Office of Minority Health. At OMH, we work to improve the health of diverse populations through the development of health policies and programs that will eliminate to eliminate health and healthcare disparities. As you may know, there is a significant body of research that documents the persistent and widespread disparities experienced by many communities in our nation.

The OMH established the Center for Linguistic and Cultural Competency in Health Care (CLCCHC) to address the health needs of populations who speak limited English. Its mission is to collaborate with federal agencies and other public and private entities to enhance the ability of the health care system to effectively deliver culturally and linguistically appropriate health care.

The CLCCHC is considered a "center without walls," encompassing all existing and new policy, partnership, communications, service demonstrations, and evaluation activities related to cultural and linguistic competency. Among its goals are to: Facilitate access and the exchange of information on literature, research and programs for removing language and cultural barriers to health care for limited English-speaking populations. In addition, its goal is to provide technical assistance to health care providers to enhance their ability to deliver linguistically appropriate and competent health care to diverse minority populations.

Think Cultural Health and the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, which I will talk more about in just a little bit, are two of the key initiatives born out of these goals.

Before we go too far however, we want to talk about what are Culturally and Linguistically Appropriate Services, or CLAS? CLAS is an acronym that stands for culturally and linguistically appropriate services. CLAS is defined as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs. CLAS should be employed by all members of an organization, regardless of it.s size, at every point of contact. Implementing CLAS helps health and human services professionals treat individuals with respect and be mindful of their culture and language.

CLAS helps a mental health providers better respect and consider a client.s cultural background, from the diagnostic interview to the formulation and implementation of a treatment plan in which they can adhere. This respect and consideration lays the foundation for a trusting relationship, which is a vital part for the success of treatment and recovery.

CLAS also helps create a system for recognizing communication barriers and taking steps to reduce those barriers. For example, a health system that implements CLAS will collect data on language needs and preferences at intake, and then ensure that clients who may have limited English proficiency, or other needs, have trained and qualified staff to facilitate communication at every point of contact.

The Office of Minority Health has developed a framework for operationalizing CLAS. It.s called the National CLAS Standards, or the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare. The Standards are an important tool for promoting and implementing culturally and linguistically appropriate services.

The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000. In 2010, the Office of Minority Health launched an initiative to update the Standards, which incorporated public comment, a literature review, and ongoing consultations with an advisory committee comprised of 36 experts representing a variety of disciplines and organizations.

In April of 2013, we were very happy to released, what we refer to as the enhanced National CLAS Standards through numerous events. There are now 15 Standards, each of which is an action step that guides professionals and organizations in their implementation of culturally and linguistically appropriate services. So now we just want to provide you with an overview of some of the core concepts that underpin the National CLAS Standards.

What is the purpose of the National CLAS Standards?. The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities. The Standards establish a blueprint for health and health care organizations to implement and provide culturally and linguistically appropriate services.

But what do we mean when we talk about health. When we talk about health, we are referring to the physical, mental, social, and spiritual well-being of individuals. This definition of health reflects the fact that many aspects of health influence one.s well-being, and today we are going to talk a little bit more about the spiritual aspects of health and how health professionals might be able to begin that conversation with your patients.

This broad definition of health results in a broad audience that may be able to utilize the National CLAS Standards, which is a valuable tool. This definition of health encompasses medicine, behavioral health, mental health, public health, social work, community health centers, emergency health centers, and more. Because of this, the audience of the Standards is considered to be .health and health care organizations,. which are any public or private institutions addressing individual or community health and well-being.

Now, what do we mean when we talk about culture when we are talking about cultural competency, when we are talking about culturally and linguistically appropriate services? What does that entail and who are we referring to? Well within the Standards .culture. encompasses race, ethnicity, and linguistics, as well as geographical, religious and spiritual, biological, and sociological characteristics.

Culture is defined as the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetimes. This definition attempts to reflect the complex nature of culture, as well as the various ways in which culture has been defined and studied across multiple disciplines; and that.s why we use the Venn diagram to represent culture because it shows the overlay of all of these various aspects of culture- one.s age, race, ethnicity, linguistic characteristics, socioeconomic status, spirituality, religiosity, and more.

Today we are going to talk more in depth about religion and spirituality. There are countless definitions of both religion and spirituality. For the purposes of this webinar we are going to use this global conceptualization that appears in the National CLAS Standards Blueprint documents, which I will talk about a little later. But, at its core, Religion and Spirituality include beliefs, practices, and support systems related to how an individual finds and defines meaning in his or her life.

This pie chart represents data from a recent Pew Research Forum survey on Religious Affiliation. The United States remains a primarily Christian country, but religious and spiritual identities are changing and evolving annually.

Gallup routinely does surveys on the importance of religion in an individual's life. As you can see from this chart, a majority of those surveyed consistently indicate that religion is very important in their life. You can see the respondents have consistently, from 92 to 2012, more than half of the individuals surveyed have stressed that religion is very important.

Therefore it is not a surprise that religion, spirituality, and health often intersect. in an article that appeared in the American Family Physician the authors found the following results. 91 percent of Americans believe in God, 74 percent feel close to God. 77 percent believe physicians should consider their spiritual needs. 73 percent believe they should share their religious beliefs with their physicians. 66 percent of individuals surveyed want physicians to inquire about religious or spiritual believe. 37 to 40 percent believe that physicians should inquire, but only 10 to 20 percent report that their physicians discusses religion or spirituality with them. The next two slides I will talk about two case studies that help these aspects of religion and spirituality.

This case study stresses the importance of culturally and linguistically appropriate communication with patient so that they can assist in providing quality care. Juana had a patient from the Philippines who kept getting into conflicts with the Filipino nurses because she refused to eat during the day, would not take her medications at the assigned time, and kept asking for time for prayer.

The nurses did not take the time to ask her why, they merely grumbled to themselves about her noncompliance. It was not until Juana asked Emilita-Jacinto why she was not eating that she explained that she was Muslim and it was Ramadan. Juana then notified the physician to change her diet and adjust her medications to fit her religious needs. Once Juana.s coworkers understood the situation, they realized had stereotyped Mrs. Jacinto as Catholic because she was from the Philippines, and viewed her simply as noncompliant.

This case study reflects on the importance of taking a patient history that includes sociocultural aspects such as religious or spiritual beliefs. During Mary most recent visit to her doctor, she received a diagnosis of rheumatoid arthritis in her hands. Following the diagnosis, she fell into a deep depression. What the doctor failed to realize is that Mary self-identifies as a grandmother first, and a gardener second. The diagnosis of rheumatoid arthritis in her hands was devastating to Mary because she thought this was the end of playing with her grandchildren, working in her garden, and connecting with her friends in the gardening club, where she was just voted in as the president.

If the physicians had inquired about Mary.s spirituality, or how she defines meaning and finds support within her life, he might be able to identify the potentiality for depression or anxiety regarding this diagnosis and be able to help Mary treat this, as well. So, what are some key ways that you can begin to ascertain the role of religion or spirituality in your patients. lives?

This slide represents three examples that we found of intake forms help to ascertaining the importance of religion and spirituality on a patient in-take form. These are just three examples that were found. On your intake form, the history forms that you already provide, you can simply add a question about, Is there anything we need to know about your religion or culture in order to care for you? Yes or no? Or, Religion and Spirituality, do you have a religious affiliation? Is religion/spirituality important to you, and depending on what your practice is, asking questions that may relate to the type of treatment that you may be delivering. So, in this case, would blood transfusion be an option for you? Because not all religions allow blood transfusions.

This last example goes even deeper, into patient history. Do you have any beliefs or practices from your religion, culture, or otherwise that your doctor should know? For example, that you.re a Jehovah.s Witness and that you will not accept blood or blood products. That you do not use birth control because of personal or religious beliefs. That there is fasting going on for period of time for personal or religious reasons. That an individual has chosen to be vegetarian or vegan or has other special diets or eating habits. All of these things can simply be added to an intake form to allow for additional information to be gained and you can acetate the importance of this information for your individual patients.

The next two slides will provide history taking mnemonics that can assist providers with spirituality assessments during an interview process. So there is the more passive communication ways that intake forms and there is active spirituality assessment tools that can be used during an interview.

One such spirituality assessment tool is the HOPE questionnaire

H: Sources of hope, meaning, comfort, strength, peace, love and connection

O: Organized religion

P: Personal spirituality/ practices

E: Effects on medical care and end-of-life decisions.

So what are some of the questions you can ask under .H.?

We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support?

What are your sources of hope, strength, comfort and peace?

What do you hold on to during difficult times?

What sustains you and keeps you going?

Any of these questions could have helped Mary or Emilita in the previous case studies, explain and provide insight into their prospective into their individual diagnosis and health experiences.

Questions that you can ask under .O.?

Do you consider yourself part of an organized religion?

How important is this to you?

What aspects of your religion are helpful and not so helpful to you?

Do you belong to a religious or spiritual community? Does it help you?

All of this information can assist a doctor in understanding, doctor or health care provider, an understanding of what support systems this individual has access to and how they can help with the treatment and recovery for whatever the patient may be undergoing.

Finally E is Effects on medical care and end of life issues. Questions you can ask, Has being sick (or whatever your current situation is) affected your ability to do the things that usually help you spiritually? (Or affected your relationship with God?)

As a doctor, is there anything that I can do to help you access the resources that usually help you?

Are you worried about any conflicts between your beliefs and your medical situation/care/decisions?

By inquiring about these things, you open up an opportunity for dialog to determine if what you are prescribing or what is being prescribed to the patient is something that is congruent with the patient.s beliefs and therefore the patient is more likely to adhere and comply to the treatment plans being outlined. If there is a disconnect between medical care being offered and one.s spiritual beliefs or religious beliefs, there may be a lack of adherence or compliance, not because they don.t want to but just because it doesn.t fit with their life. So, that negotiation process and that information gathering process is critical.

Another spirituality assessment tool that is out there is the FICA tool. FICA represents faith, the importance and influence, community, and address. Some specific questions you can use to discuss during these activates are:

F: What is your faith or belief?

Do you consider yourself spiritual or religious? and

What things do you believe in that give meaning to your life?

As it was for Mary, meaning was gathered from being a grandmother and being a gardener, and with the rheumatoid arthritis diagnosis, she was afraid that those two things were going to be taken away from her.

I: Is it important in your life?

What influence does it have on how you take care of yourself?

How have your beliefs influenced in your behavior during this illness? and

What role do your beliefs play in regaining your health?

C: Are you a part of a spiritual or religious community?

Is this of support to you and how?

Is there a person or group of people you really love or who are really important to you?

And then finally,

A:How would you like me, your healthcare provider to address these issues in your healthcare?

There are also members of the healthcare team that can assist in providing insight and spiritual care. Frequently hospitals have chaplains of multiple denominations and religious backgrounds that can assist providers in providing spiritual care, or making sure that the spiritual well being of patients is being taken care of. These are just some of the tools available for examining religion, spirituality, and medicine. There are a number of academic centers and institutes focusing on this topic, including ones at George Washington University in Washington DC and Duke University in North Carolina.

For more information on integrating religion and spirituality into your broader cultural and linguistic competency efforts, we recommend that you please visit Think Cultural Health.

You can find the National CLAS Standards and other resources on the Think Cultural Health website. As I mentioned earlier, Think Cultural Health is an initiative of the OMH Center for Linguistic and Cultural Competence in Health Care. The goal of Think Cultural Health is to Advance Health Equity at Every Point of Contact through the development and promotion of culturally and linguistically appropriate services. And as we talked about today, this includes one.s spiritual health and ascertaining the role of religion and spirituality in a patient.s perspective.

Think Cultural Health houses the National CLAS Standards and its implementation guide, A Blueprint for Advancing and Sustaining CLAS Policy and Practice . simply referred to as The Blueprint. Think Cultural Health is the only place to find both the PDF and the web-based versions of the content.

The Blueprint outlines the Case for CLAS and explains the concepts that the Standards are grounded in, such as the OMH definitions for culture and health, which I talked about earlier. Then, The Blueprint offers one chapter per Standard that explains the Standard.s purpose and provides strategies for implementation. Each chapter also provides a list of additional resources for more information.

Think Cultural Health.s suite of free e-learning programs are based on the National CLAS Standards. These e-learning programs have over 250,000 registrants total. We.ve awarded over 900,000 Continuing Education Credits. Our eLearning programs include:

A Physician.s Practical Guide to Culturally Competent Care is accredited for physicians, physician assistants, and nurse practitioners.

Culturally Competent Nursing Care: A Cornerstone of Caring e-program is accredited for nurses and social workers.

Cultural Competency Curriculum for Disaster Preparedness and Crisis Response is accredited for first responders, psychologists and psychiatrists, social workers, and dentists.

Cultural Competency Program for Oral Health Professionals is accredited for dentists, dental hygienists, and dental assistants.

Promoting Health Choices and Community Changes: An E-learning Program for Promotores de Salud

Think Cultural Health also offers communication tools, including a communication and language assistance guide for administrators and providers. In the next few weeks, we will be publishing an updated version of this guide!

The Guide is a tool to help organizations provide effective communication and language assistance services to diverse individuals receiving care and services. It includes strategies for communicating in a way that considers the cultural, health literacy and language needs of clients and patients, thus increasing their access to health care. The knowledge and skills gained through reading the Guide will help you and your organization provide effective communication at all points of contact within an organization.

Think Cultural Health also has a CLAS Clearinghouse which is a compilation of online resources, tools, and publications on health equity and CLAS, searchable by keyword.

Join the CLCCHC , which is likely where you found this webinar is an initiative at Think Cultural Health for health and health care professionals. Registering will give you access to a quarterly e-newsletter and specialty educational units. As well as an .Ask the Expert. feature, in which you can contact our team to ask a question about cultural and linguistic competency.

It also offers this webinar catalog, which houses on-demand webinars (narrated PowerPoint presentations) on a variety of topics related to CLAS, including:

Why CLAS matters

communication and language assistance

CLAS in mental health

An overview Think Cultural Health

An as I stated at the beginning of this webinar, we are hoping to do a serious of Culture within CLAS, and providing more in debt information about various aspects of culture.

I invite you to visit www.ThinkCulturalHealth.hhs.gov. You will find a variety of resources that can support and inform you and your organization.s efforts to implement CLAS and the National CLAS Standards.

I would like to acknowledge the contributions of those who have worked on this project including our technical team at Astute Technology. We have our HHS office of Minority Health contributors, as well as my colleagues at the Health Determinants and Disparities Practice at SRA International.

I encourage you to send questions, ideas and your stories of implementation to AdvancingCLAS@ThinkCulturalHealth.hhs.gov. Successful implementation of the National CLAS Standards and Culturally and Linguistically Appropriate Services, in general, will depend on you! We look forward to collaborating with you to promote, implement, and assess all of these efforts.

Thank you.