Working in a cross cultural context considering Culture and Health Behavior

Working in a cross cultural context considering Culture and Health Behavior Ruth Margalit, MD Rebecca Haworth, OTR/L, MPH student Melissa Baughman, AmeriCorps Cara Flower, Undergraduate student Amanda Gehle, Runa Acharya, medical students University of Nebraska Medical Center, January 2013

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness and communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 2

1. Learning Objectives When completing this module, participants will be able to: Define culture Recognize the effect of culture on health & illness List key elements of effective cross-cultural communication Utilize resources to plan/prepare work in a cross-cultural context Discuss key theories of behavior change Increase self-awareness for cultural competency and sensitivity *You can gain the big picture on this topic by staying with the slides. If you have special interests please find additional information in the links and references. 3

1. Pop Quiz! 1. Cultural Competency can be acquired after attending a sufficient course T/F 2. Cultural perceptions can affect health behavior T/F 3. What are the CLAS standards? Why are they required in all US government funded healthcare institutions? 4. The Trans-theoretical model of behavior change has 5 key elements that are important to consider when developing interventions T/F What are they? 5. Cultural Humility refers to the development of selfawareness and life-long learning T/F 6. Which communication strategies are essential when working in a cross-cultural context? 4

1. Pop Quiz Answers 1. Cultural Competency can be acquired after attending a sufficient course F, it is a life-long process 2. Cultural perceptions can affect health behavior T 3. What are the CLAS standards? A collective set of mandates, guidelines and recommendations intended to inform, guide and facilitate required and recommended practices related to culturally and linguistically appropriate health services. Why are they required in all US government funded healthcare institutions? CLAS standards support legislation that outlaws discrimination of race, ethnicity, gender, and religion. 4. The Trans-theoretical model of behavior change has 5 key elements that are important to consider when developing interventions T What are they? Describes the process for readiness to change negative behavior in 5 steps: Pre-contemplation, contemplation, preparation, action, and maintenance 5

1. Pop Quiz Answers 5. Cultural Humility refers to the development of selfawareness and life-long learning T 6. Which communication strategies are essential when working in a cross-cultural context? Respect personal space, learn and follow cultural rules about touch, establish rapport, express interest in people, listen carefully, value stories, notice eye contact and body language, reach the appropriate family member, study a person s responses, check for understanding; ask questions, avoid jargon and stereotyping based on looks, language, dress, and other outward appearances, be careful not to impose your personal values, morals, or beliefs, learn to laugh at yourself and listen to lessons brought to you by humor. 6

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness and communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 7

2. Culture Definition: An integrated pattern of human behavior that includes thoughts, communications, languages, practices, beliefs, values, customs, courtesies, rituals, manners of interacting, and roles, relationships and expected behaviors, of a racial, ethnic, religious or social group; and the ability to transmit the above to succeeding generations. National Center for Cultural Competence (NCCC) 8

A single fixed cultural identity? In reality, we all belong to many cultures: of our parents, peers, partners and neighbors; those with whom we worship, work and vote; our media market and socioeconomic class. At any moment, one of our cultural identities may be more salient or influence health behavior more directly. Stop for a moment and reflect: what is your culture? How do you describe yourself? Is there more than one identity? 9

Cross-Cultural identities are multifaceted! These women may identify by: Family status: Mother Daughter Sister Friend Widow Employee/Employer SES Tribal identity Religious identity Other 10

2. Culture: Cultural Competence: The knowledge, interpersonal skills, and behaviors that enable a system, organization, program, or individual to work effectively cross-culturally by understanding, appreciating, honoring, and respecting cultural differences and similarities within and between cultures. The acquisition of cultural competence is a dynamic, ongoing, developmental process that requires a longterm commitment and is achieved over time. Maternal and Child Health leadership: http://leadership.mchtraining.net/?page_id=126 11

Eurocentric approaches to culture, health and health promotion: Although shifting in recent years, the historical perspective of culture and health demonstrate how European and North American paradigms underestimate the role of culture in health, define development in narrow economic terms, and favor medical rather than public health solutions. Culture should be at the center of health promotion interventions Freudenberg N. commentary on Health and Culture: Beyond the Western Paradigm, C. O. Airhihenbuwa. Health Educ. Res. (2000) 15 (4): 508-510. 12

How to Achieve Cultural Competence 1. Understand the relationship between social, political and economic dynamics that result in the community s behaviors/beliefs 2. Recognize one s own subconscious and conscious bias (including stereotyping, recognition or privilege, etc.) 3. Identify that mistrust is born from historical and institutional practices 4. Use non-authoritarian, cross-cultural communication & apply cultural brokering 5. Engage in participatory decision making with community partners 6. Identify/analyze manifestations of power distribution in practices/policies 7. Relinquish the role of the expert through self-reflection Ross L. Notes From the Field: Learning Cultural Humility through Critical Incidents and Central Challenges in Community-Based Participatory Research. J Community Pract. 2010;18:317. 13

Cultural Competence Organization & clinician professional responsibility: Health services, that are respectful of, and responsive to, the health beliefs and practices and cultural and linguistic needs of diverse patient populations. The United States Department of Health and Human Services, Office of Minority Health The National Standards on Culturally and Linguistically Appropriate Services (CLAS): are primarily directed at health care organizations; however, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=15 14

The National Standards on Culturally and Linguistically Appropriate Services (CLAS): A collective set of mandates, guidelines and recommendations intended to inform, guide and facilitate required and recommended practices related to culturally and linguistically appropriate health services Provided for under Title VI of the Civil Rights act of 1964 Apply to all healthcare entities that receive Federal funds in any area of operation in their organization Also apply to the legal system and education, where they are already more firmly established 15

Fourteen Standards Standards 1-3 address culturally competent care Standards 4-7 address language access services Standards 8-14 address organizational support for cultural competence Standards 4-7 are a federal requirement (law) Standards 1-3 and 8-13 are recommended for adoption by Federal, State and national accrediting agencies 16

Other terms applied to the concept of cultural competence include: Culturally sensitive Culturally appropriate Cultural awareness and diversity Cultural humility 17

Cultural Humility Cultural humility Acknowledgement of your own barriers and limitations to intercultural understanding, and working to overcome those barriers to provide better care 30 18

Health Behavior in any given culture is affected by the following key elements: 1. Normative Behaviors/ Lifestyles 2. Conceptual Frameworks 3. Socio-political and Economic Structures 4. Aesthetic Preferences 5. Environment 19

Health and Illness through a Cultural Lens 1. Normative Behaviors/ Lifestyles: the standard cultural practices and beliefs that contribute to the level of health in a community 2. Conceptual Frameworks: the typical and preferred thought and course of action in a given cultural context 3. Socio-political and Economic Structures: how the general social normative environment, government, policy, and the economy contribute to beliefs and practices surrounding health 4. Aesthetic Preferences: making health behaviors based on cultural judgments about what looks to be acceptable and preferable 5. Environment: Incorporates all of the above factors into the systematic contributions of how individuals and communities make choices that effect health and health care delivery, including how the physical environment plays a role 20

Health and Illness through a Cultural Lens In the next four scenarios, look for cultural aspects that may impact health outcomes based on: 1. Normative Behaviors/ Lifestyles 2. Conceptual Frameworks 3. Socio-political and Economic Structures 4. Aesthetic Preferences 5. Environment 21

Health and Illness through a Cultural Lens 22

Health and Illness through a Cultural Lens This smiling women is cooking in the extension of her house, in Ghana, Africa. Potential health issues: Machete - cuts Open fire burns Smoke inhalation Boiling water/foods burns/eradication of infection? Storage of food products & cooked food 23

Health and Illness through a Cultural Lens 24

Health and Illness through a Cultural Lens This young mother is bathing her kids near her house. Potential health issues: Method of cleanliness Scarcity of water for hygiene purposes Repeated use of water Water drainage is it down stream for drinking? Bare feet any diseases may be contracted? Cuts, Hookworm http://www.cdc.gov/parasites/hookworm/ 25

Health and Illness through a Cultural Lens This women is making fufu from Cassava the basic means of nutrition: South Ghana Potential health issues: Cohabitating and cooking with animals; Increased chance of spreading parasitic disease Good source of carbohydrates, but a poor source of protein - causing protein malnutrition Storage of food Beating on the Cassava gets hard with old age 26

Health and Illness through a Cultural Lens 27

Health and Illness through a Cultural Lens This young women is breast-feeding her 5 th child. Potential health issues: Breast feeding is good practice! Birth control is absent Malnutrition is immanent in big families of low income Female teens do not complete middle/high-school education, becoming very young wives/mothers Young mothers are often bread-winners but limited if caring for many children, resulting severe poverty 28

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness sand communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 29

3. Theories/Approaches to Health Behavior Change Culture and Behavior: Culture is a tool for the passage of health beliefs and practices from one generation to the next It influences human behavior, and thus influences the patients desire to seek help and maintain care It is interrelated with behavior, and the interventions designed in communities should come from an understanding of behavior change theories 30

Theories/Approaches to Health Behavior Change Social Cognitive Theory: Explains how people acquire and maintain certain behavioral patterns, while also providing the basis for intervention strategies. Human behavior is explained in terms of a triadic, dynamic, and reciprocal model in which behavior, personal factors, and environmental influences all interact. An individual s behavior is uniquely determined by these interactions. https://sph.uth.edu/course/.../social%20cognitive%20theory.ppt 31

Theories/Approaches to Health Behavior Change Trans-Theoretical Model Describes behavior change as a process of five stages that assesses the readiness of a person to act in order to change their negative behavior: Relapses are expected. After determining the stage that the person is in, they are matched to pre-designed interventions. Smoking cessation counseling is one example where this model has been highly utelized 15 32

Theories/Approaches to Health Behavior Change Social-ecological Model: Views people in the context of their families, communities and cultures. Emphasizes relationships between environmental, biological and behavioral determinants of health. Being aware of community resources may help with healthy lifestyle, help in implementing interventions to change an individual s behavior. 2 Comprehensive lifestyle interventions are sought. This includes integrating the person s family as an agent of change. 33

Theories/Approaches to Health Behavior Change Theory of Planned Behavior States that behavior depends on one s attitude and subjective norm. Can be used to change behavior by presenting information in a way to help shape positive attitudes toward the behavior. Subjective norms or opinions that support the change in behavior are stressed as well 14 34

Theories/Approaches to Health Behavior Change Social Marketing (SM) SM is a strategy for translating scientific knowledge into effective education programs 12. It consists of voluntary exchanges between providers and consumers, who both have a resource that they might want to exchange for some other benefit. In most situations, this benefit is monetary. However, in context of health promotion programs, the reported benefits can include features such as better quality of life, higher selfesteem and more social contacts. 12 It is essential to seek the audiences perceived needs through random sampling surveys, observational techniques, personal interviews or focus groups. 12 35

Social Marketing: Example: Nepal USAID Newsletter from September 2012 in Nepal educating the public on wellness shots provided by community health workers Newsletter was also located on the USAID social media website: https://www.facebook.com/usaidnepal 36

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior interventions case studies 5. Self Awareness and communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 37

3. Health behavior interventions case studies Conceptual framework and cultural beliefs: how it impacts the health intervention Positive: Cultural messages that reinforce your message Existential: Cultural messages deeply rooted in beliefs related to a person s existence; may or may not conflict with your health strategy Negative: Cultural message that poses a threat to health 38

Health behavior change case studies Positive Messages Drinking a lot of fluids when you are sick is good for healing Tribal leaders have special powers - a natural and accepted role in influencing behaviors Banana porridge helps treat diarrhea in young children Reflect: What other examples, based on your own culture or experiences with another, are positive messages? 39

Health behavior change case studies Existential Wearing a turquoise bead on a child s forehead wards off the evil eye Looking at a deformed infant during pregnancy is harmful to the fetus Walking under an open ladder may pose a risk to your well-being Having a child with a disability may mean your family is cursed in some cultures Reflect: What other examples, based on your own culture or experiences with another, are existential messages? 40

Health behavior change case studies Negative Messages Feeding a child eggs and meat causes the child to steal Immunizations may reduce fertility Animal fat increases body strength, and is a healthy food ingredient for adult men Reflect: What other examples, based on your own culture or experiences with another, are negative messages? 41

Health behavior change; Hematuria right of passage case Adolescent males in farming communities in Egypt develop Hematuria: right of passage or health risk? Begin work in the fields (often barefoot) Over time develop blood in their urine Culturally viewed as a sign of maturity - similar to the female menarche, it is perceived to be a right of passage In fact, hematuria cause by infection with a parasite: Schistosomiasis 42

Health behavior change; Hematuria right of passage case Transmission: stagnant or slowmoving fresh water where infected bulinus snails live Farmers working near water are at high risk Clinical presentation: Urinary symptoms (hematuria) noted after 3-6 months to 12m incubation Schistosomiasis Other symptoms noted throughout infection with systemic health concerns 43

Health behavior change; Hematuria right of passage case http://www.rayur.com/schistosomiasis.html 44

Case Study: Lia s Story Summary Lia is the central character in the memoir, The Spirit Catches You and You Fall Down. She suffers from seizures and has been in and out of the hospital in the United States a dozen times because of her seizure disorder. Her family belongs to a traditional Hmong ethnic group. They believe Lia s condition makes her special, in that her seizure's are spirits that could contribute to her becoming an important religious figure called a shaman. The family and the healthcare providers have a completely different view on what her disease means. 45

Case Study: Lia s Story, cont. Challenge: Healthcare professionals did not consider the family s beliefs and what Lia s parents thought of their daughter s condition, and hence missed a critical cultural perspective of the disease. This lead to many misunderstandings and difficulties in managing Lia s care. Discussion: Demonstrating cultural humility to seek important information from family and the community would have been critical to Lia s care. Asking patients and their families what they know about a health condition and what their beliefs and concerns are provides crucial insight to how one s culture may impact his/her health. 46

2. Culture and Health Education Health educators face a complex task: Mastering health complexity, specifically with regard to culture, requires a systems approach Establish cultural humility and competence Enlist all sectors of the population (who are the stakeholders) Design appropriate interventions with the community Assess their relevance to health 47

2. Viewing Health Through a Cultural Lens Before approaching a community about behavior and how it effects health, it is first critical to define health: Health - A state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity 6. Culture impacts health 2 Disease - Abnormalities in the structure and function of body organs and systems 7 Illness - Patient s experience. Can suffer illness without disease 48

2. Viewing Healers Through a Cultural Lens Culture of Traditional Healers on Health Traditional healing and popular health care mainly deal with treating the human experience of sickness (illness) 10 and many patients report that their chronic medical problems are improved by folk practitioners rather than modern physicians 7 Healers provide meaningful explanation for illness and respond to the personal, family and community issues involved in the illness 11 Traditional practices can often be misinterpreted 49

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness and communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 50

3. Self Awareness Practitioner s perspective Self-Awareness Consider the following self-assessment: I ve found that I can only change how I act if I stay aware of my beliefs and assumptions. Thoughts always reveal themselves in behavior. As humans we often contradict ourselves- we say one thing and do another. We state who we are, but then act contrary to that: If we want to change our behavior, we need to notice our actions, and see if we can uncover the belief that led to that response. What caused me to behave that way and not some other way? 31 Now consider the following self - assessment tool: 51

Self - assessment tool The following 15 personality-related abilities are related to notions of social, emotional, cultural, and spiritual intelligence. Reflect: How well developed is this ability in my life? What life experiences have helped form this ability? Then, on a scale of 1(low) to 5 (high), assign a rating beside each attribute. From: Richard Slimbach. (2010). BECOMING WORLD WISE - A GUIDE TO GLOBAL LEARNING (1st ed.). Sterling, Virginia: Stylus Publishing, LLC. 52

Capabilities My ability to identify and assess personal strengths and weaknesses (Integrity) Rating My interest in learning about new cultures (Inquisitiveness) My ability to think positively about the cross-cultural situation ( Optimism) My confidence in being able (mentally and physically) to accomplish goals (Selfconfidence) My ability to self-start and approach unfamiliar situations in a proactive manner (Initiative) My ability to remain composed in stressful situations (Emotional stability) My ability to laugh things off, including my own cultural blunders (Sense of humor) My ability to withhold judgments until I can absolutely see behind the scenes (Openmindedness) My ability to read local situations based on knowledge of the country s social, cultural, and political systems (Context awareness) My ability to form effective working relationships with people from different cultures (Collaboration) My ability to feel into the experiences of others and to see form their perspectives (Empathy) My ability to try on different ways of speaking, valuing, believing, and behaving (Experimentation) My ability to appreciate what s good and true in other cultural traditions (Respect) My ability to follow through on self-directed tasks (Conscientiousness) My ability to persevere in the face of unfavorable conditions and failures ( Hardiness) 53

Your abilities: These abilities or personal traits appear to positively influence cultural integration and are typically formed through transitional life experiences like sojourns abroad. Study the ones you scored low and think about ways these may impact your experience. What can you do to enhance the weak abilities? The following communication strategies may assist you: 54

Communication Strategies Respect personal space Not in your face, female/male rules. Learn and follow cultural rules about Touch In some Asian cultures a person s head shouldn t be touched because its considered the seat of wisdom and some American Indians see a vigorous handshake as a sign of aggression 13 Establish rapport Build relationship. Allow TIME! Share experiences, exchange information, greet and respond in culturally appropriate ways 13 Express interest in people Smile, be genuine, ask open honest questions, pay attention to children 13 55

Communication Strategies (cont.) Listen carefully Don t interrupt or put words in one s mouth 20 Listen and observe more than you speak 13 Value stories Notice eye contact and body language 13 Reach the appropriate family member In some cultures the oldest male is the head of the family and in others it might be an elderly female 13 Study a person s responses: A yes doesn t necessarily indicate understanding or willingness, it may just be showing respect. Check for understanding; ask questions 13 Avoid jargon and stereotyping based on looks, language, dress, and other outward appearances 20 Be careful not to impose your personal values, morals, or beliefs 20 Learn to laugh at yourself and listen to lessons brought to you by humor 20 56

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness and communication strategies 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 57

5. Discussion Questions 1. Understanding the impact of social, political and economic dynamics that contribute to a community s behaviors/beliefs, how might this impact health? (provide examples) 2. How might one recognize their own subconscious and conscious bias (including stereotyping, recognition or privilege, etc.)? 3. Community mistrust comes from historical and institutional practices. Discuss examples (actual or hypothetical) 4. What are ways to demonstrate cultural competency with communicating with community partners? 5. Engaging in decision making with community partners is critical. Why is this a major construct to health and development? 6. How might you relinquish your role of expert? Note: These questions can be discussed in small groups, individually or all together. Participants should have adequate reflection time to answer each question. 58

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency Health and Illness through a Cultural Lens 3. Theories/Approaches to Health Behavior Change 4. Health behavior change case studies 5. Self Awareness The practitioner s perspective 6. Discussion questions 7. Summary 8. Quiz 9. Supplementary information and References 59

6. Summary Working in a cross cultural context, requires one of a genuine interest in the other; a high level of self awareness of one s abilities, assumptions, and prejudices; humility and willingness to learn first from local wisdom; collaborative and partnership building skills; resilience; adaptability; flexibility and creativity. The most successful interventions world-wide are based on sensitive partnerships, careful learning of the field and no helicoptered experts. 60

Working in cross-cultural environment What can you do: Understand and respect the multiple cultural identities within a population (gender, age, ethnicity, experiences, race, roles, etc.) Assess how relevant these identities are to health/health behavior Understand the needs of the community (based on the communities perceived needs) Design appropriate interventions with community Apply a system s approach to deal with complexity Plan for ongoing assessment, learning, and improvements of the intervention when needed 61

Module sections 1. Learning objectives 2. Culture Definitions Cultural Competency/Humility Cross-cultural environments Health and Illness through a Cultural Lens Culture shaping Health and Health Behaviors (case studies) 3. Theories/Approaches to Health Behavior Change 4. Self Awareness The practitioner s perspective 5. Discussion questions 6. Summary 7. Quiz 8. Supplementary information and References 62

7. Self-Quiz Try answering these questions in your mind, or on paper. How far can you get? How easy, or difficult, was it to come up with answers. The numbers in (#) refer to the slide(s) where you can find the answers. 1. Provide definitions of Cultural Competency and Cultural Humility (10, 17) 2. Describe two theories of health behavior change and their applicability with an example (30-35) 3. Identify five key communication strategies effective when working in a cross-cultural context (54-55) 4. When considering your work in a cross-cultural context, what are your biggest challenges? (60) 5. Describe the CLAS standards and how they apply to work outside the US (13-15) 6. Describe one example with culture having significant implications on health (see slides 19-28; Also, think about examples from your own work) 63

Thank you for your attention and best wishes on your journey! For more - check out the Resources section of CUGH s website www.cugh.org Next see references 64

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References (cont.) 11. The World Bank s Communication for Governance & Accountability Program. Theories of Behavior Change. Available at http://siteresources.worldbank.org/extgovacc/resources/behaviorchangeweb.pdf. Accessed on December 22, 2011. 12. Lefebvre RC, Flora JA. Social Marketing and Public Health Intervention. Health Educ Q. 1988;15(3):299-315. 13. Vermont Department of Health. Cultural Awareness in Nutrition Services: Screening Recommendations for Children and Adolescents. Available at: http://healthvermont.gov/family/toolkit/tools%5cf-7cultural%20awareness%20in%20nutrition %20Services.pdf. Accessed on December 22, 2011 14. The World Bank s Communication for Governance & Accountability Program. Theories of Behavior Change. Available at http://siteresources.worldbank.org/extgovacc/resources/behaviorchangeweb.pdf. Accessed on December 22, 2011. 15. Prochaska J, Johnson S, Lee P. The transtheoretical model of behavior change. In: Schumaker S, Schron E, Ockene J, McBee W, eds. The Handbook of Health Behavior Change. 2nd ed. New York: Springer; 1998. 16. Smedley BD, Stith AY, Nelson AR. Institute of Medicine. US Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003. 17. Ross L. Notes From the Field: Learning Cultural Humility through Critical Incidents and Central Challenges in Community- Based Participatory Research. J Community Pract. 2010;18:317. 18. Hansen KK. Folk Remedies and Child Abuse: A Review with Emphasis on Caida De Mollera and its Relationship to Shaken Baby Syndrome. Child Abuse Negl. 1997;22(2):117-127. 19. Berger JT. Culture and Ethnicity in Clinical Care. Arch Intern Med. 1998;158:2085-2090. 20. Department of Health and Human Services. Culture Card: A Guide to Build Cultural Awareness-American Indian and Alaska Native. January 2009. Available at: www.samhsa.gov/shin 66

References (cont.) 21. Alexander MA, Blank JJ. Factors Related to Obesity in Mexican-American Preschool Children. Journal of Nursing Scholarship. 2007;20(2):79-82. 22. Toubia N. Female Circumcision as a Public Health Issue. N Engl J Med. 1994;331:712-716. 23. Choudhry UK. Traditional Practices of Women From India: Pregnancy, Childbirth, and Newborn Care. JOGNN. 2006;26(5). 24. Connorton E. Perry MJ, Hemenway D, Miller M. Humanitarian Relief Workers and Trauma-related Mental Illness. Epidemiol Rev. 2012;34:145-155 25. Fadiman, A. The Spirit Catches You and You Fall Down. New York: Farar, Straus, and Giroux; 1997. 27. Kidder T. Mountains Beyond Mountains. New York: Random House, Inc.; 2003. 28. Hewlett BS, Amola RP. Cultural Contexts of Ebola in Northern Uganda. Emerging Infectious Disease. 2003; 9(10): 1242-1248. 29. Nichter M. Drink boiled water: A cultural analysis of a health education message. Social Science & Medicine. 1985; 21(6): 667-669. 30. Wear D. On Outcomes and Humility. Academic Medicine. 2008; 83(7): 625-626. 31. Wheatley, MJ. Turning to One Another: Simple Conversations to Restore Hope to the Future. San Francisco, CA: Berrett-Koehler Publishers, Inc.; 2002: 18. 32. Slimbach, R. Becoming World Wise: A Guide to Global Learning. Sterling, VA: Stylus Publishing, LLC; 2010: 169. 33. BMJ. 2006 May 20; 332(7551): 1207-1210. 34. (2012). Program details. National Association of County and City Health Officials, Retrieved from http://www.naccho.org/topics/modelpractices/database/practice.cfm?practiceid=676 35. Cameron, D., Christie, N., Cockburn, L., Hashemi, G., Parnes, P., Yoshida, K. (2009) Disability in low-income countries: issues and implications. Disability and Rehabilitation, 31(14), 1170-1180. doi: 10.1080/09638280902773778 36. McMahon SA, Winch PJ, Caruso BA, Obure AF, Ogutu EA, Ochari IA, Rheingans RD (2011) 'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya BMC Int Health Hum Rights, 11. 67

Credits Ruth Margalit, MD; rmargalit@unmc.edu Rebecca Haworth, OTR/L, MPH student Melissa Baughman, AmeriCorps Cara Flower, Undergraduate student Amanda Gehle, Runa Acharya, medical students University of Nebraska Medical Center 68

The Global Health Education Consortium and the Consortium of Universities for Global Health gratefully acknowledge the support provided for developing teaching modules from the: Margaret Kendrick Blodgett Foundation The Josiah Macy, Jr. Foundation Arnold P. Gold Foundation This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.