PROVIDING CULTURALLY COMPETENT HIV PREVENTION PROGRAMS.

Abstract: This paper argues for the importance of cultural competency in HIV prevention programs targeting Asian/Pacific Islander Americans in the United States. It critically examines the cultural barriers language (dialects and the role of interpreters), fatalism, shame and face saving, sexual norms and roles, death and dying beliefs, family structure, and self-care practices, as they impact HIV prevention and services.

The importance of cultural competency in HIV prevention programs for Asian/ Pacific Islander Americans (APIA) cannot be overstated. The ethnic profile of the U.S. has changed dramatically over the past few decades. During the 1990s, 75% of those entering the labor force were ethnic minorities and women. It is predicted that by the twenty-first century, White Americans will acquire minority status within certain states in the U.S. (Day, 1996), reducing the percentage of White entrants into the labor force from 83% in 1985 to 58% by the year 2000 (Jackson, 1992).

It is estimated that APIAs, one of the fastest growing populations in the country, will reach 12.1 million in the year 2000, which is a 65.8% increase since 1990 (U.S. Bureau of the Census, 1995). Immigration accounted for almost three-quarters of the APIA growth in the U.S. during the last three decades (Passel & Edmonston, 1992). Among APIAs in the U.S. 23.8% are of Chinese origin, followed by Filipinos, 20.4%; Japanese, 12.3%; Asian Indians, 11.8%; Koreans, 11.6%; Vietnamese, 8.9%; and other Asian Americans, 11.2% (U.S. Bureau of the Census, 1990). As health and social service agencies enter into the twenty-first century, they must change attitudes, initiate policies, and explore options to better serve the many ethnic individuals who will be part of their future clientele and workforce (Seek, Finch, Mor-Barak, & Poverny, 1993). To fulfill this task effectively will require an organization-wide commitment toward cultural competency.

The term cultural competency refers to the ability to work effectively with culturally diverse clients and communities because the individual or agency displays culturally appropriate attitudes, beliefs, behaviors, and policies (Texas Resource Center on Cultural Competency, 1997). In its most developed aspects, cultural competency includes advocacy for, as well as provision of, services to culturally diverse clients and communities (Randall-David, 1994). A clearly established policy to provide culturally competent services must be accompanied by specific changes in practices such as assessment, outreach, intervention, staffing, use of interpreters, and technical assistance (Kavanagh & Kennedy, 1992).

The term Asian Pacific Islander American or APIA includes more than 49 different ethnic groups (speaking over 100 languages and dialects) who originate from Asia, the Pacific Rim, and the Pacific Islands (Tanjasiri, Wallace & Shibata, 1995). The vast majority of Asian immigrants have come from three major geographic regions: (a) East Asia (China, Japan, and Korea); (b) Southeast Asia (Cambodia, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, Vietnam, Burma); and (c) South Asia (India, Pakistan, Sri Lanka, Bangladesh, Bhutan, Nepal). Pacific Islanders originate from Melanesia (Fiji, New Guinea, New Caledonia, Solomon Islands), Micronesia (Mariana Islands, Marshall Islands, Guam, Palau), and Polynesia (New Zealand, Tonga, Tahiti, Hawaii, Samoa). Often categorized as one group, APIAs come from diverse cultural backgrounds. For example, although most APIAs are Buddhist (Braun & Nichols, 1997), the majority of Filipinos are Catholic (Baysa, Cabrera, Camilon & Torres, 1980), Koreans are most often Protestant, South Asians are typically Hindu or Muslim (Ibrahim, Ohnishi, & Sandhu, 1997), and Pacific Islanders often use the services of traditional spiritual healers (Braun, Mokuau, & Tsark, 1997). Time of arrival, reason for emigration, and varying modes of adaptation to the U.S. host society have shaped unique experiences, lifestyles, and ethnic identities of APIA immigrants in the U.S. Such diversity has contributed to the formation of bipolar APIA communities that are divided between the two extremes of unskilled, working or welfare classes (with the highest rates of poverty) and successful, professional, entrepreneurial upper middle classes. Despite such diversity, rapid growth and increasing visibility, APIAs have been persistently stereotyped and subject to discrimination (Zane, Takeuchi, & Young, 1994).

CULTURAL BARRIERS AND APPROACHES

As recommended by Yep (1997), in designing, implementing and evaluating programs for APIAs, the influence of cultural beliefs on individual and group behaviors, how cultural norms define gender roles, language use, and ways in which intimate partners talk and interact sexually and interpersonally, must be considered. It is important, however, to remember that there may be differences among APIAs, so overgeneralizing and stereotyping must be avoided. It is often tempting to think that one has an understanding of how APIAs view the world, based on experiences with a few members from that group. However, all clients should be related to as unique individuals who may or may not hold all the same values, attitudes and beliefs as others from the same cultural group. Differences within the group could be greater than the differences between groups. Although specific examples related to HIV programming have been used in this paper, cultural norms and barriers highlighted here would apply to other health needs and services for APIAs.

THE ROLE OF THE FAMILY:

Westerners and APIAs have different ideas of what it means to be an individual. In the West, an "individual" is more likely to be regarded as an independent entity with absolute free will, personality, and emotions. In APIA culture, an individual is more likely to be thought of as incomplete until he or she is integrated with a social unit. For instance, the Chinese word for an individual (ren) comprises the character for "two" with a "human" radical. In essence, an APIA man cannot separate himself from obligations to others in his community. He is always aware of his social position in society (as being above, below, or equal to others), and of his corresponding obligations to them: son to father, wife to husband, subject to ruler. In doing so, he functions as an integral part of the social network. Although each APIA group has its own language, culture, and history, there is literature (Saldov, Kakai & McLaughlin, 1997; Braun, Mokuau, & Tsark, 1997) suggesting that APIA cultures are more collectivist than individualist. In other words, APIA cultures tend to de-emphasize individual goals in favor of those of the group. This innate concern among APIAs for others first and then for oneself can have significant consequences in social relationships relevant to HIV prevention. For instance, a client may hide her HIV diagnosis, fail to seek or adhere to treatments, or reject social services, if these actions threaten her role in the family (API Wellness Center, 1998). In terms of help-seeking, there is expectation that all help would be provided from within the family, avoiding obligations to an outside provider (Nichols & Braun, 1996).

Within the APIA culture, the family has profound effects on the individual's values, beliefs, and behaviors. In facing external adversity such as racism or harassment, the powerful bonds of loyalty and affection found in the traditional APIA family can be a source of great emotional strength and support of its members (Huang, 1991). Because individual needs are secondary to those of the family or community, many APIAs are uncomfortable disclosing personal matters related to sexuality and HIV. In addition, the family associates shame and stigma with sexually transmitted diseases, HIV disease, mental or psychological problems, and illicit drug use.

The strongest family ties are between parent and child rather than between spouses. Parental roles and responsibilities supersede the marital relationship. APIA parents are thus readily prepared to sacrifice personal needs in serving the interests of their children and in providing for the welfare and security of the family as a whole. In turn, the parent assumes the right to demand unquestioning obedience and loyalty from the child. Parental authority translates into personal accountability and responsibility for the child's behavior, which is considered a direct reflection of the parents' ability to provide proper guidance. Individual behaviors, therefore, reflect upon one's ancestors and race, for the APIA is viewed as the product of all generations of the family from the beginning of time (Braun & Nichols, 1997).

SEXUALITY AND GENDER ROLES:

The cultural value emphasizing sexuality only as it relates to the perpetuation of the family line have predominated throughout much of APIA cultural history. This value has fostered attitudes that discourage the uninhibited expression of sexuality, including homosexuality, bisexuality, and transgenderism. In terms of discussion of physical intimacy and sexuality, Fei, a Chinese woman says, "I'm very shy about sex ... When I need to talk (about sex), I would hint to my husband Jon (a White-American) hoping that he would get it ... but I can never say it straight out like some of my American women friends can ... I'm too ashamed to talk about sex." When asked about how she would persuade her husband to use condoms when they have sexual intercourse, Fei laughed nervously. Then she said, "I would probably tell him that I heard about a store on Melrose Avenue (in Los Angeles) that sells condoms ... maybe he will want to try them." (Yep, 1998). Brown (1992) found that Asian respondents reported significantly less AIDS-related interpersonal communication than their non-Asian counterparts. In particular, APIA adults were less likely to openly discuss sexuality, either directly or indirectly, seriously or humorously. Similarly, Kitano (1988), in her study of self-identified APIA gay men, reported moderate levels of apprehension and avoidance of safer sex discussion with intimate partners. Although these two studies examined two distinct segments of the APIA communities (heterosexual and gay), their findings confirmed the lack of sexual communication among partners.

FATALISM:

Being fatalistic, many APIAs believe that they have no power over destiny or fate. Some infected APIAs may believe that they contracted HIV because, "I did something to offend my ancestors, I am doing penance for past wrongs." Religious concepts such as karma and destiny (particularly among South Asians), can sometimes be very helpful in dealing with external adversity; within this framework, "certain challenges are simply preordained and must be handled appropriately" (Ibrahim et al., 1997, p. 45), and individuals are unlikely to internalize blame for a situation such as becoming HIV infected. However, this same asset can become a liability if appropriate actions to safeguard the vulnerable family member do not ensue.

The Vietnamese people place great value on the trait called t'anh can cu, which includes the combined characteristics of thrift, industriousness, patience, determination, endurance, tolerance, and accommodation (Braun & Nichols, 1997). This quality has contributed to the profound strength and resiliency demonstrated by the Vietnamese and other Southeast Asian people throughout their respective histories of war, disruption, and loss. When similarly expressed among Chinese, Korean, and other APIA groups, these characteristics translate into the ability to persevere without complaint, to "suffer in silence." Such characteristics are reinforced Within the context of a fatalistic orientation in which life is presumed to be essentially unalterable and unpredictable. There is thus a need for resignation to external conditions and events over which one presumably has little or no control. If human suffering is viewed as part of the natural order, then acceptance of one's fate, maintenance of inner strength, and emotional self-restraint are also considered to be necessary expressions of dignity (Koenig, 1997; Chan, 1986),

SHAME AND FACE SAVING:

Although shame and guilt are experienced in Western culture, they are much more magnified in APIA cultures as the entire family is affected by the actions of any one family member (Braun & Nichols, 1997; Zane, Takeuchi, & Young, 1994). As such, there are strong cultural prohibitions against revealing interpersonal sexual problems to anyone outside the family. Disclosures about illness or "deviant" behaviors such as illicit drug use or homosexuality are seen as bringing particular shame and stigma to the entire family. In APIA cultures, there are clear guidelines on what you can disclose to outsiders, as demonstrated in the Chinese expression, "Family disgrace should never be disclosed to outsiders." (Huang, 1991; API Wellness Center, 1998).

Engaging in appropriate self-disclosure helps protect the "faces" of family members and insiders. Such a cultural view reinforces denial rather than open discussion of problems and creates resistance to receiving help from non-family members. Obviously, the APIA's attitude against self-revelation of embarrassing information would interfere with the provision of services. Filial obligations can amplify the shame APIA clients feel for having HIV disease (API Wellness Center, 1998). In the effort to save face, APIAs hide their diagnosis and may try to appear competent and without needs. However, there is suggestive research (Atkinson & Gim, 1989) that once APIAs admit to personal problems, they show a preference for caregivers who were perceived as professional (authority figure) rather than as paraprofessional. This may have some effect on the use of paraprofessional volunteers to provide service.

In addition, families and individuals may not wish to undermine the myth of the "model minority," which members of the dominant culture typically apply to APIAs (Koenig, 1997). In general, APIA families and individuals may fear that the entire ethnic group will suffer if their problems become known. Consequently, many APIAs are reluctant to disclose personal HIV-related behaviors because of the fear of bringing dishonor to their family (Saldov, Kakai, & McLaughlin, 1998; Zane, Takeuchi, & Young, 1994; Chang, 1993). Many infected APIAs hide their illness until the last stages of the disease, or die in isolation. Obviously, care must be shown when designing instruments to collect data from APIAs. The traditional fear of losing face (shame) if a program does not succeed will make the task of program evaluation even more difficult.

The Chinese saying, "A person needs face like a tree needs bark" articulates an important reason why APIAs are so careful about their behavior in public. Their self-esteem is closely identified with the opinions of others: if they are positive, their self-esteem is boosted, providing them with "more face;" conversely if the remarks are negative, they have "lost face." Their concern for face inhibits their social networks and influences what and how much they disclose in personal relationships. There is extreme reticence among APIAs in addressing sexual concerns, including sexual orientation, knowledge about sexual facts, acknowledgment of erotic feelings, or history of sexual abuse. The taboo against discussing sexual matters is particularly strong for women, who may be labeled as "immoral" because of such dialogues. Because APIA communities associate HIV with taboo subjects such as death and illness, sexuality, drug use, and prostitution, an infected APIA often feels that he or she is responsible for bringing shame to the entire family, Obviously, this cultural attitude could affect the provision of prevention and treatment services. For instance, programs targeting APIAs need to emphasize anonymity and confidentiality in the delivery of HIV-related services. Given how important the issue of shame is for most APIA clients, they are likely to be highly sensitive to criticism and the staff must be careful not to make comments that can be construed as disapproving or judgmental (Cushner, 1996; Huang, 1991).

The concept of face saving (e.g., chaemyun among Korean Americans) is very important in all relationships. Maintaining face protects the dignity, honor, and self-respect of the individual and the family. APIA clients may be reluctant to disclose "vital" information if this will cause loss of face (Kim, 1996). Providers are cautioned against discussing sensitive issues or potentially controversial matters too quickly. It is always wise to take time to establish rapport and to allow discussion of unrelated matters to increase cultural comfort among clients. Consequently, there often is a need to reframe problems and approach them in a circular fashion while establishing mutual trust, respect, and movement toward a more personalized relationship (than, 1998). This may be determined by the provider's attention to small but important details that show continued interest and concern for the client, enabling the professional to "humanize" his or her relationship with the individual and family, and to gain their trust. The importance of this cultural dynamic is further illustrated by a Vietnamese phrase, "A good doctor is a good mother." (Koenig, 1997; Zane, Takeuchi, & Young, 1994).

Successful professional-client relationships among APIAs are often characterized by reciprocity and moral obligation. Such reciprocity applies to "favors" that are graciously given and willingly returned. APIA clients often display their gratitude through personalized gift giving, invitations to dinner or family celebrations (e.g., weddings, graduations). Such reciprocity is the basis of a longer term relationship or bond of friendship that persist well after the initial "debt" has been paid. Thus, a provider's refusal to accept a client's offer of gifts, favors, or invitations to participate in more personal social interactions may be construed as rejection and failure to give face (Behring & Gelinas, 1996).

DEATH AND DYING BELIEFS:

Traditional beliefs about death and dying among Chinese, Korean, Cambodians, Laotians, and Vietnamese are interrelated with various spiritual or religious orientations (Buddhism, Taoism, Shamanism, and Christianity). For instance, since a Buddhist's mind should be calm, hopeful, and clear at the time of death, a dying person or their family member may refuse medication that could alter consciousness (Freund & Ikeuchi, 1995; Tien-Hyatt, 1987). Discussions about death in the presence of someone with a terminal condition are taboo among most traditional APIA cultures (Nichols & Braun, 1996; Zane, Takeuchi, & Young, 1994). A holistic belief in the unity of mind and body, and their reciprocal interaction implies that the body reacts poorly to "bad" news received by the mind. Candid information about fatal diseases like AIDS should be avoided because this kind of truth-telling may seem like a death sentence. Such information could be provided privately to family members. The dying client also may prefer to let family members make important medical decisions on his or her behalf (Braun, Mokuau, & Tsark, 1997).

In many API traditions, a terminal diagnosis is often withheld from the patient. Therefore, medical informed consent practices can pose ethical dilemmas for providers when APIA family members request that the terminal diagnosis not be shared with the patient. How can the physician gain consent to proceed with treatment if the patient is not thoroughly informed of his or her diagnosis and treatment options? To insist that the patient be told, however, could cause significant cultural conflicts within the family.

In addition, the symbols of death also are avoided. Hospitals serving large populations of Chinese, for instance, have incorporated changes whereby they assign no Chinese patients to rooms with a number four (since it sounds like the word for death), nor do they place them in blue and white rooms, and physicians do not write prescriptions in red ink - all of which are associated with death. Among traditional Chinese Americans, there is a ritualistic practice, which they must perform after visiting a funeral service before they can enter their own homes. Otherwise, they fear that death will strike their family, too (Dresser, 1996).

SELF CARE AND TRADITIONAL/FOLK MEDICINE:

There is considerable variation among APIAs with regard to health beliefs and health care practices. Many families utilize a pluralistic system of care that includes a blending of traditional ethnic medicine and various folk medicine practices with Western medicine (Kraut, 1990). Among APIAs, there is a tendency to self-medicate and independently manage medication as well as to utilize more traditional herbal medications simultaneously or alternatively.

Among most APIA cultures there is a great value placed on the ability to control emotions and subjugate them to reason. However, Chinese individuals believe that when selected emotions are not openly expressed and accumulate in intensity within the body, they result in blockage of Chi and malfunction of the organs, thus producing physical illness. This tendency toward somatization corresponds to the holistic philosophy of APIA medicine that does not separate mental illness from physical illness.

Among Southeast Asians, beliefs in the supernatural etiology of illness are among the most widespread. Corresponding treatment can include soul calling, exorcism, ritualistic offerings, chanting or citation of sacred prayers, and sprinkling of holy water. This treatment is typically performed by, or in consultation with, priests, shamans, spiritual masters, or sorcerers. Western medications are perceived as very potent compared with the more natural herbal medicines. Concern with the side effects may lead some APIA clients to adjust the dosage of various prescriptions downward or stop taking them altogether if there has been no quick relief of symptoms. They may not appreciate the necessity of continuing medication (e.g., antibiotics) after the symptoms have abated. This attitude is particularly critical for HIV-infected APIAs on antiviral therapy, who sometimes cannot understand the need to continue therapy, "when I am feeling so great, why take medicine when I am not sick anymore?"

Pacific Islanders have a strong faith in herbal remedies and their folk doctors. Among the widely used traditional medications are herbal drugs, many of which are based on sound pharmacological principles. In particular, there is the fofo (Samoan massage) which is administered with leaves, roots, and fruits. This massage is used for every conceivable childhood illness.

LANGUAGE:

Language and dialect are two related issues that can affect the quality of HIV-related services for APIAs. The Chinese language alone has several spoken dialects (Mandarin, Taiwanese, Cantonese, Toisanese, Haka, Teochew, Shanghainese) that are commonly used by APIAs. In many cases, even fellow APIAs cannot verbally communicate with each other. When one considers the 100 dialects and languages that are in use among the approximately 49 subgroups of APIAs, one may begin to see the scope of the problem (Day, 1996; Zane, Takeuchi, & Young, 1994). Levels of acculturation and communication differ between immigrants and U.S.-born APIAs. The obvious solution is to employ a native language speaker, which may be more difficult than it seems. It is not always possible to find a trained HIV educator and professional with the appropriate APIA language. However, consultation with key informants is an effective substitute for bilingualism.

Also, there are many obstacles encountered when presenting to APIAs in different languages and dialects. The Tagalog language used among Filipinos does not have clinical terms for words such as penis, vagina or intercourse (Baysa, Cabrera, Camilon, & Torres, 1980). Therefore, the HIV worker has to either use vernacular terms, which some people, particularly women and more traditional Filipinos, find offensive or utilize English words, which many do not fully understand. In addition, many concepts and behaviors do not translate easily into APIA languages. For example, the Chinese character used for AIDS is literally comprised of the words for "love, disease, and death," and the word for homosexual in many Asian languages can be translated to mean "deviant" or "transgender."

Beside the inherent problem of dialect and language, APIAs may also experience problems with the self-report, a commonly used evaluation scale, because most East Asian languages are very contextualized; thus, they are often dependent on the receiver's ability to correctly interpret the speaker's intent without specific reference to what he or she means. An example would be the item, "Do you have difficulty making decisions?" An APIA respondent may sometimes want to know the period involved (e.g., during which month, at what time of the day), and the type of decision considered (family, career, financial, sexual) before making an appropriate response (Chan, 1998; Zane, Takeuchi, & Young, 1994).

Cultures differ in the amount of information that is explicitly transmitted through words versus information that is transmitted through context, relationship, and physical cues. The APIA community is a high-context culture that relies less on verbal communication than on understanding through shared experience, history, and implicit messages. Among APIAs, a look, a word, or a gesture may convey the equivalent of paragraphs of spoken words. Making prolonged eye contact with someone in authority is disrespectful to him or her. Among APIAs who are Muslim, use of the left hand to touch another person, to reach for something, or to take food is culturally inappropriate. Because the left hand is associated with more personal bodily functions, it is not used in other ways (Ibrahim, Ohnishi, & Sandhu, 1997). Sitting so that one's head is higher than the elders in the room is interpreted as an affront to Samoans (Markoff & Bond, 1980). Nodding the head up and down among APIAs means, "I hear you speaking." It does not signal that the listener understands the message nor does it suggest that he or she agrees; however, because disagreeing would be impolite, head nodding is used. In contrast, south Asians signal that they have heard what has been said by moving their heads in a quick, horizontal, figure-eight pattern. Although it may seem incongruous to a non-APIA, sometimes APIA clients may smile or laugh softly when describing something that is confusing, embarrassing, or even tragic. Laughter is often used to cover embarrassment or as a response when a request that could not be fulfilled was made. Under pressure or when faced with a different communication style, people rely on patterns of behavior reflecting their own zone of comfort. Thus, APIAs will speak less, make less eye contact, and withdraw from interaction, whereas low-context speakers (e.g., Whites) will talk more, speak more rapidly, often raising their voices. APIAs will feel that all the talking is evidence that the other individual does not truly understand them and cannot, therefore, be of help. Facial expressions, tensions, movements, speed of interaction, location of the interaction, and other subtle "vibes" are likely to be perceived by and have more meaning for APIAs (Hecht, Andersen, & Ribeau, 1989; Zane, Takeuchi, & Young, 1994). Relative to more Eurocentric cultures, the subtle and often distinctly different meaning of such nonverbal communication may create significant communication barriers and conflicts - well beyond basic language differences. The collectivist mode of silent communication relies on an implied understanding among APIAs. Because of cultural norms, implicit concerns are not expressed verbally. For instance, it would be culturally inappropriate for a daughter to discuss issues of death or dying with her parents, yet concern by either party may be expressed silently through nonverbal cues. Thus, the primary challenge is to recognize that the message perceived is not always the message intended.

When APIA clients and therapists share either a common language or a common ethnic origin, there is a significant increase in the number of client sessions with the therapist (Flaskerud & Liu, 1991). If we assume that language match can bring effects that are more beneficial to treatment outcomes, we need to have more trained bilingual health professionals. In our culturally diverse APIA population with its dramatic increase in immigrants whose primary language is not English, it is next to impossible to staff an agency with personnel who are competent in so many languages and dialects. Therefore, the use of interpreters is necessary to bridge the language and cultural gaps, although it may not be the ideal communication medium.

Although many organizations use interpreters, at least three problem areas exist: (i) Most interpreters are not properly trained in interpreting, particularly with APIA clients in HIV/AIDS programs; (ii) Most staff are not skilled in the use of interpreters; and (iii) most APIA clients are ill-informed as to their rights to receive services in their own language and often find it difficult to express themselves through interpreters. Interpreting requires three-way dyadic communication in two languages by three individuals. Each individual is different in terms of dialect, accent, grammar, and linguistic style. Generally, problems fall into two categories: technical difficulties, and role conflicts (Chan, 1998).

Many people have bilingual interpersonal competence that allows them to function in either language in daily life; however, their skills may not be adequate to understand or to explain issues that arise in intervention. A poorly trained interpreter can distort valuable information through omission or bad paraphrasing. For instance, Thuong, a Vietnamese refugee says, "I decided to escape Vietnam by boat but did not inform my brother about my plan. I did not want to worry him since my parents were still in prison", but the interpreter merely translates, "Mr. Thuong says he came by boat." The clinician asks, "Mrs. Goh, do you hear voices?" but the Cantonese interpreter paraphrases, "The doctor asks you whether you hear any noises?" ("Voice" and "noise" are the same word in Chinese). Mrs. Goh answers, "Yes, I hear noises all the time. I live on a busy street downtown." The physician asks the Filipino woman, "Are you allergic to any medications?" but the interpreter translates, "Does the Western drug make you vomit?"

In addition to technical errors, the quality of interpretation is often affected by role conflicts and confusion, for it is difficult for the interpreter to remain neutral and nonpartisan. This could lead to an overidentification of clients with the interpreter due to cultural and language bonds, or rejection of the interpreter by the client due to fear of breach of confidentiality. As the sole possessor and processor of information, the interpreter is in a unique position of power to manipulate not only the informational exchange but also the situation. The interpreter should at the minimum have a basic understanding of the specific nature and purpose of the interaction with the client, the content areas to be addressed, and the relative significance of these content areas in the larger context.

Given the lack of fully qualified interpreters, family members or friends and neighbors are often used to assist clinicians in their interaction with APIA clients. Even if the individuals are proficient in the native language, communication difficulties and role conflicts may be exacerbated by their interpersonal relationships with the clients, by the lack of direct training as interpreters, and by their limited knowledge of the content or issues that are addressed in the translation. As interpreters, family members may wish to censor what is disclosed either to shield the family or to keep information from the family. Because of the need for privacy and confidentiality, elders, adults, or women are often reluctant to disclose personal or sexual matters to family and nonfamily members.

In summary, a competent interpreter acts as cultural broker, helping to interpret with linguistic and cultural perspective, explaining why a suggestion from the staff may be unacceptable or unrealistic to the APIA client. Besides intimate knowledge of his or her ethnic community, including migration history, cultural values, social and power structure, cultural views of health and illness, the interpreter should demonstrate ability to make cultural connection and rapport with clients.

CONCLUSION

The suggestions of McLaughlin and Braun (1998) for helping professionals working with APIA clients are timely: (1) Learn about the cultural traditions of the group you are working with; (2) Pay close attention to body language, lack of response, or feelings of tension that may signify that the patient or family is in conflict but are perhaps hesitant to tell you; (3) Ask the patient and family open-ended questions to elicit more information about their assumptions and expectations; (4) Remain nonjudgmental when provided with information that reflects values that differ from your own; and (5) Follow the advice given to you by your clients about appropriate ways to facilitate communication with families and between families and other health care providers.

In summary, culturally competent organizations are characterized by acceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to service models in order to better meet the needs of minority populations (Texas Resource Center on Cultural Competency, 1997). Culturally competent agencies work to hire unbiased employees, seek advice and consultation from the APIA community, and actively decide what they are and are not capable of providing to these clients. Finally, cultural competency as it relates to APIAs is a dynamic process - not a goal or an outcome. It is a continuing process of growth in knowledge, experience, and understanding of individuals, groups, and systems, which translates into higher quality of service.

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Chwee, L. Chng, PhD, Department of Kinesiology, Health Promotion & Recreation, P. O. Box 311337, University of North Texas, Denton, TX 76203-1337. Phone [phone]. Email: [e-mail]. John R. Collins, Department of Kinesiology, Health Promotion & Recreation, University of North Texas, Denton, TX 76203-1337.