 So other than that, I wanted to welcome you this morning to the second in the five series workshop from the Alliance, which is focusing on building park research infrastructure in Orange County. And today's focus is on cultural competency, awareness, sensitivity, and Marianne, who from the Orange County Agents Pacific Islander are working with the Alliance for your presentation today. I just wanted to highlight the Delhaa Community Center, which is the space that we're in, just a little bit of information about how many of you know who Delhaa is, and this beautiful facility actually has been here, the space, it's been here since 1960, not just for you and me, and the space that we're actually in has been here since 2001, it seems like just yesterday. So it's hard to believe it's been so long and they continue to be a great resource in the community. This is their vision, mission, and values, and they have lots of great programs, including dance classes, which is the space that you in. They have health, humanities, socioeconomic courses, and whatnot, as well as, as you saw as you walked in, English as a second language course. So they're a great community resource and we just wanted to acknowledge them and recognize the space that we're in today. And as I mentioned, this is a series of workshops that started about a month ago and there are five workshops, many of you will be participating in all of them. This is the second in the series, and it really is a part of this larger project, which is the Orange County Alliance for Community Health Research, of CACHR, and the goal is really to build and encourage community-based participatory research projects that can help issues in the Orange County. So through these series of workshops, as well as just skills building in terms of informational topics, we're hoping that you will network and build partnerships to develop relationships in which we can address the health care issues here in the county. Just a little bit of background on the Alliance. These are our community partners, UCI's Institute of Clinical Translational Science, Cal State Fullerton, the Children and Families Commission of Orange County, the Health Care Agency, OCAPICUP, and Public Health Foundation Enterprises. And this project is based on the ICTS, which is one of 60 across the country, and there's only programs in 30 of the 50 states, so there's still a lot of work to be done looking at the very big disparities that exist in some of these other states. And the goal of the project is really to get benched to that side a lot quicker, but also a lot better, so really to be culturally competent, and to really translate information to our communities when we can make the decision to act. So that's really the purpose and goal of the Alliance. I wanted to highlight a funding opportunity from the Institute for Clinical Translational Sciences if you've had it recently, email. It's a part of your slide packet. We have a program called the Incubator Awards, which are kind of, if you will, seed grants to build CBTRI partnerships. So the first series of grants is actually due May 1st, which is not too far away, but the grants are not so tedious, and you can find information on the grant opportunity at the links provided here in Dr. Montoya, Michael Montoya at UCI will be open to contact if you have any questions. And we are also here as a resource, the Alliance to help you build these grant applications if you're interested, especially as participants of the workshop. So please contact me if you're interested in more information regarding that. So we're gonna start off this morning now that you're nice and settled with a little icebreaker, and I'm gonna pass around these gaskets, and if you could just get a piece of paper out and you're open to get, we're gonna start the morning with some introductions and we're gonna meet some new friends. So grab a piece of paper, you're not open to get, you're gonna get out and approach someone you do not know, and you're gonna introduce that to me first with your name and then doing whatever the instructions are on your really ill behavior. And then after that, you're gonna go ahead and find two other people to introduce yourselves to, and then come back to your seat and we'll call you. Go ahead and grab a piece of paper, get out and meet some new people. Thank everybody, because the buzz was awesome. So you guys, I'm sure met more than two new people, which is fabulous. And I wanna thank you for having the courage to just jumping in and doing it. I know about the open piece of papers and it looks like what is she thinking? So I appreciate that trust and just stepping forward and trying to go through the activity. So what do folks feel? Maybe folks can share, because folks have different readings, if you will. I'm finding this people as you didn't know. This is true. This is true. Do you have a question, Chris? Well, I had the big warm hug, so it was a big hug for myself, it was really easy. And everyone was happy with the hug, so I think it was good. Awesome. Maybe it was off to say I'm not a hugger, but I had the hug being one, so like, kind of like, right. All right. Well, did anybody have a rubbing noses one? Oh. How was that? I was like, am I supposed to rub the LVM? Okay. Any other thoughts? And if that was totally, people didn't realize that that was mine. Sorry, what's she think? Yeah, that's what we're so used to that. They didn't think that that was it. Right. Any other thoughts? That was a surprise for me that I came and kissed my cheek, because you know, you saw me just change your hand. Right. Yeah. Any other thoughts, comments? Well, I thought you had an inshirt. Okay, so if you look at the slide, these were the eight different greetings that were in the baskets. So we had kisses, various number of kisses. We had bowie and greeting someone, rubbing noses, hugging, a firm handshake, and then a light grip handshake. And then I also noticed, and I participated in this, the all-American, Hi, how are you? I'm across the room from people who walked in a little bit later, what is going on? So I thought it was a nice ice-creamer, and you guys were great at networking, which I'm really excited about. But I also thought it was a nice way to start our day, especially around the conversation and culture. And competency and awareness, those are pretty big words. And I don't know that we ever truly get fully confident, but we do strive to become more confident and to respect and understand other communities and cultures. And I think living in California, especially Southern California, we're very privileged to have the wealth of communities and diversity that we have. I think that's a blessing. And part of that is also learning and respecting others and then talking about what norms are. Like I said, shaking hands is a norm, right? But maybe rubbing noses not so much, and maybe I should rub their nose, maybe you should rub my nose. So, you know, understanding what that is, and then taking it a step deeper as to what it means in a community is also really important. I didn't put in there, but in the Chamorro community, you actually hug someone and take in their essence. So I'm supposed to breathe in your essence. That might have been actually a little bit more invasive than rubbing noses this morning. So I chose not to include that. But that's a very respectful piece of the culture, especially on elders. So it might seem like, well, I didn't take a shot of something else going on. But really, it's more powerful than I'm trying to take a sniff of you. Really, it's breathing in your essence. Gosh, it's really powerful, right? So I don't know if you guys want to guess where these come from. What countries they may come from. So the first one, and it can come from other countries, but I wanted to reference this particular activity in study, comes from the Netherlands or Belgium. Greeting people by embracing and kissing them twice is Portugal or Spain. Parisians actually can alternate four times. I think these could be multiple countries, but these are just some of the examples I wanted to share with you all. And to acknowledge this exercise from this particular project. Greeting others by placing your hands in prayer, bowing boards, Japanese. The rubbing noses is genuine. Very good. A lot of people call that. Reading someone with a big, warm hug comes from Russia. Right? Grouping with a very firm handshake is from Germany. And then keeping a distance of about two feet and gripping with a light grip is... I love the music in Oz, because some of those are norms and folks are like, yeah, Parisians, French. And some of them are not. And we also don't want to generalize the stereotype and assume that every German in the world is going to shake your hands with a firm handshake. But these are some ways to help us overgeneralize a little bit and understand communities. However, we don't want to make assumptions that every German who walks in is going to shake your hand with a firm handshake. And that's just one nuance of what culture and community really is. There's language about starting the day with different welcomes and different languages. There's the country that you come from. And culture is so much richer than just your racial and ethnic differences, right? And so today, we're going to have an opportunity to talk a little bit about that. And Marianne's also going to share some of that experience. As well as the culture within academic organizations and community-based organizations, which is a part of this marriage and the relationships we're trying to foster. So, thank you again everyone for participating at this faculty. So, today's training objectives are to increase awareness and understanding of culturally-competence, community-based participatory research methodology to identify local resources to ensure CBPR projects are culturally competent, to understand CBPR, how CBPR leads to cultural competence, and to inspire compassion and understanding. And within your packets today are the slides, so feel free to follow that and then you'll also have them up right next to you. As I mentioned, our great presenter today is Marianne Fu. She happens to be my boss. She's the Executive Director of Orange County Asian Pacific Islander Community Alliance. If you haven't had the opportunity to meet her, I think you will really enjoy, especially today's discussion with her. She will bring a fresh light to the notion of cultural competency, and you'll find her other skill sets along the way. Marianne is the Executive Director and Founder of Ocapaca a nonprofit-based organization serving APIs and other communities in Southern California regarding health, mental health, policy, youth leadership and development, community and economic development, and education needs. Ocapaca has almost 40 staff that speak 16 languages with programs that serve more than 80,000 community members a year. Marianne has been working for more than 20 years on health issues on national, state, and local levels at several different community and countywide organizations. She also helps to lead several community-based participatory research projects, including Ocapaca's National Center of Excellence to eliminate health disparities focused on Pacific Islanders and Southeast Asians in the United States, a California breast cancer research project focused on patient navigation for Southeast Asians, and a National Cancer Institute-funded Pacific Islander cancer project. Marianne received her Bachelors of Science and Psychology from University of California Davis and her Masters in Public Health from UCLA, and is a fourth-generation Chinese-Japanese Californian who's married to a Japanese Peruvian, and they have two beautifully young sons. You'll love this. When she's not exhausted, she enjoys going fishing with her family or playing natural maker for her co-workers. One of the skill sets that you might not be thrilled to learn about today is she has the best of intentions with her real-life skills. So please help me welcome Marianne. I'm sorry, Michael, I'm dancing, so if I need something to cross the room, you'll know why. I love that activity because actually, that's how I met my husband, so I'm going to use that for a matchmaking session. My husband is a Japanese Peruvian, and when I first met him, he kissed me, so I'm like, ooh, he likes me. And he didn't, but he meant for me. And when we got here, so eventually he became into me. But that's for me at first, because I'm Japanese and Chinese, and my parents were not big huggers until once I had children. Now they hug and kiss them all the time, but they weren't really big huggers because that wasn't our culture. And then when I met my husband's family and friends, there's like 60 Peruvians attacking me. And then they never went home. And they start, it's a dance floor, so I had to get used to a whole different culture, and just so many people kissing me all the time. But it's wonderful because you embrace it, and then you really enjoy it. Say, I love this, so I love that activity. I really am going to have like a gathering of singles. I think that's so great. Thank you, Jackie, for that. So I'm going to talk about, I know you've had another speaker, because all of my co-workers are like, oh God, what are you doing here? And I'm like, surprise, but the two other speakers could not make it. And so I'm hoping to just provide you with a little bit of information, because when I look in this room, oh my gosh, all the folks I know here, you are experts in cultural competence. So I'm sure we're going to learn from each other today as well. But I'm really going to talk about cultural competency and community-based participatory research, because that's been my experience. So these are just great pictures of the communities and the community leaders that I have the pleasure of working with. So my background is I'm somewhat culturally competent with some Asians and Pacific Islanders, some Peruvian and Mexican-American, some LGBTQ community, some youth, some adults, some older adults, farmers, I'm from a rural area, I know farming really well, so I'm really good with farmers. Rural populations, some animals, some Catholics, Muslims, Christians, and some others. So I'm not this big expert, and I didn't want you to think I was some big expert. I just know a little bit of some things, but I'm really, really willing to learn. And that's the whole thing about being culturally competent is that willingness to learn. And I make mistakes all the time, cultural competency for me has been a lifelong learning experience, which I really enjoy, just learning about other communities, other cultures, other experiences. I learn a lot about youth culture from my coworkers. They taught me about Facebook, and now I Facebook them all, and they were very sorry I do that, because I find out what they do on the weekend and they talk to me about it. I offend many, but I'm always apologetic, so I'm so sorry that I tend to joke a lot. So a lot of times my coworkers will be, that's not very culturally appropriate. So I'm sorry if I offend. I may not always understand something, but it's important, but if something's important culturally, I always stay open and accepting and just try and make it work for everyone in the situation. And that's something big, is that full negotiation of learning about others. I'm the executive director of the Asian Pacific Islander organization, and I've never taken an Asian American studies class. So that's what's so funny to me, is people see me as an expert for Asian Pacific Islanders, and I'm like, I've never even taken an Asian American studies class. I don't know anything. But I'm learning from all the coworkers, partners, people I get to work with. So you don't have to become an expert. You just have to have a willingness to learn. And just because somebody is that ethnicity or from that culture doesn't mean they know either. I really thought for most of my life I was in the Brady Bunch, so I was just lying. So I just want to start off with voices from the community. And this is from an experience that we've worked with researchers on. And this was way back, this was a while ago, this was when community-based participatory research started becoming popular. So this is the viewpoint from the university researcher. And the university researcher, we were at a community meeting and we had community members who were researchers too who were conducting the surveys with this researcher. So the researcher said, looking at the surveys, hey, all the writing looks the same. They aren't valid because you build them out for the participants. And the community researcher said, are you saying I'm being dishonest? University researcher, I'm not saying, I'm just saying I can't use any of these surveys because you build them out and not the participants. And the community researcher said, but the participants are elderly in my culture, as someone who is considered young, if I don't fill them out for them, it's considered highly disrespectful and rude and I'm not helping them as I should. That's my role. The university researcher said, but we want the participants to fill out the surveys because if you do it, you're biasing them. It's basic research methodology. And everyone at the table was like, ah! So the community researcher said, so you're saying I'm stupid and dishonest how did you research in my community and the university researcher? No, I'm saying you're doing it wrong. And then the other people at the end of the table, the other community members are like, she's saying that we don't know our communities! She's saying we're lying and dishonest. We're not working with her. So it was an explosion of what happened. And it was about 20 community members around the table all glaring at this researcher who just said you cannot fill out the surveys for them. And it turned out to be the person who was the community researcher. I'm going to fill those surveys out because that's really rude. And if I don't, this is not going to happen. We're not going to work with you. So you can just see a basic misunderstanding or just a way that this researcher was used to. No, you're going to give a survey out, they're going to fill it out. That's it, nothing. They weren't negotiating. Here's another one that we've had and I need you to have 300 surveys done by next month and I've only received about 20. You're supposed to be working full-time on this, what are you doing? It should be only 30 minutes to administer the survey. How many of you have heard that? I hear it all the time. I'm like, oh my god, give me a break. The community researcher was the questions you're asking are very personal. Income level, sexual history, personal trauma, I can't ask those in 30 minutes. Some of these things are never discussed in my culture. Plus, because I'm from the community, if I don't spend the first hour talking about who I am, where I came from, who my family is, they're not going to even be open to me. I then have to spend another hour helping them with other things like reading bills or doing paper work. Then I can ask the survey questions and because they don't speak English, it takes me twice as long to administer all the questions in another language. Then I have to eat with them because that's what I do. It takes me about three to four hours to do a survey. Everybody's laughing because I think you identified with this. The university researcher said, you can't do that. You should go in and do the survey. You shouldn't be in there all day eating with them. You're not using your time efficiently or effectively. Another relationship broke down because for the community, they're like, you just don't understand. I live in this community and I walk in here. I'm going to ask you all these questions. Every time you have sex, using condoms, I'll be kicked out. I have to live here, so don't do that to me. And then finally, some other voices from researchers that have questioned us. We're doing this great research project on your community. We want you to be a part of it. You're great. But can you just translate the survey and disseminate it to the community? Sorry, we don't have funding for the project, but don't you want to help your community? We get that a lot, too, where it's like, I thought you wanted to help your community. So this guilt, for an Asian cat, it really works. It's like, don't you just want to help these people? And then later, you find out, but you have $3 million. Yeah, I want to help my community. You should be helping too. Another university researcher. We love, love, love, love university researchers. These are just some of the poor experiences we've had. We've had some amazing, amazing experiences. I actually should have put them up. Here's another case. We analyzed the data and found that the parents in your communities, they don't want to get involved in their children's schools. So in this case, they didn't have the community members involved in the analysis. So they just looked at the data, which said, they didn't have community members involved in the analysis. They would have found out that these parents are working two to three jobs, that they don't have time, that they feel intimidated to go to the school because their English is a second language. When there was more analysis done, they found out that the parents were just heartbroken. They could not be involved in their children's school, but they wanted to be. So in this case, by not having the families involved poor, it looks like very negative. These families don't want to have anything to do with their child's education. So you're not going to get a good analysis. And then the next one. We want to do phone interviews in language with older adults. We'll just recruit our students to do them. One of my students have already translated the interview tool. We hear that a lot. Young people on average, especially if they've been in the country for a long time, their language skills they're not the same. And to translate an interview tool, it's really difficult. And we see that a lot. Also you have young students calling older adults and they'll be like, who's this little kid calling me? And so you want to make sure you're matching up and you're talking to the community. In some cases that might be really good. People, we did a voting, a phone banking, and the older adults really like to hear young people call them because they felt like oh you're really interested in the community and you want to help out the community. But when we talk about breast cancer or cervical cancer, they don't want to hear from someone younger than them. So it really depends on the issue. So what is cultural competence? And what is it all about? You're going to hear cultural competence, cultural competency, culturally competent, and appropriate. You're going to hear all of these terminology inter, kind of intertwiner, or used together. So I looked up on the online, Merriam-Webster dictionary online and I love that dictionary because it has the regular dictionary which I never understand. Then it has an English language or a dictionary which I really do understand better. And that one was better. And then it has the children's dictionary which is even better. So I use the children's dictionary because when I read it I have no idea what they're trying to say and what kind of language. So some of these will get easier. So culture is the customary beliefs, social forms, and material traits of a racial, religious, or social group. So that's one way to look at culture. It might be racial, it might be religious, it might be social. It's also the set of shared attitudes, values, goals, and practices that characterizes an institution or an organization. You know, scouts, you know, it could be anything or organization. It could be a non-profit organization, it could be a university, it could be anything. Culture is also the set of values, conventions, or social practices associated with a particular field, activity, or societal characteristic. You can tell I took that from regular dictionary because usually I won't understand everything. Culture is a way of thinking, behaving, or working that exists in a place or organization, such as a business. So again, it's just, you know, a set of thinking, believing, or practices. Competence or competency or competent is being adequate. Not being an expert is being adequate. It's having a better understanding, it's having a skill, it's doing something well and having the necessary abilities or qualities. So you're not an expert, but you have a better understanding and you have some abilities and you have qualities. So I took this definition of social competency, cultural competence from the National Association of Social Workers, I really liked it. Cultural competence refers to the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors in a manner that recognizes affirms and values, and that's the values, the worth of individuals, families, and communities, and protects and preserves the dignity of each. And I think that was such a nice definition because when I work with the community, what I always hear is, I just want them to respect me. I don't want them to call me a boat person. I don't want them to call me, oh, it's that poor person on MediCal, or oh, she collects food stamps. They want to be valued and they don't want to have that perceived discrimination and they want to feel that you know, that their culture has a lot of strength. So, I love that definition. And there's just tons and tons of information on cultural competency online as well. But the National Association of Social Workers I thought had a really nice definition. So, why is it culturally competent? I think it's pretty obvious. You know, you want to do your understanding. You want to do your job more effectively. You want to improve communication. You want to improve trust. You want to have improved relationships. You can work with diverse populations. You can improve self-awareness. And you have a reduction of barriers and disparities. And I think those are key. I had, I used to work for a great organization called Families and Children Health Beach. And we worked at a hospital. And there's two different cases where one doctor was culturally competent and the other was like, I don't need to do this. So, we had a Laos family and the woman needed to have a C-section. And the first doctor who's working with this family said, because the woman said, I don't want to have a C-section. And her husband's like, no, you're not having a C-section. And so, the patient navigator was telling the doctor, can you just talk to the family? Can you talk to the family about why she needs a C-section? Because she thinks you just want to cut her up and experiment and learn from her body. They don't want to do that. They're really worried about the health of the baby. They want to have the best possible labor. And they want to bring their child in healthy. And he goes, you know what? I don't care. I don't have time. They need to follow the rules if not leave this hospital. And so, he was just like, you know, I was respectful. If you're not going to follow what I'm saying, then go somewhere else. So they went somewhere else and they didn't have to have a C-section. So she had a normal pregnancy and she had normal delivery. So then the family went and told everyone, don't go to that place because they just cut you up and they don't listen to you. And so, the organization had to do a lot of damage control. And so, another case came up, very similar. Another foul family. Same thing. The different doctor was saying, I really think, you know, she needs to have a C-section and these are the reasons why. This woman said, you know, I really don't want to have a C-section. And the husband said, I don't want my wife to have a C-section. I'm worried about her. And so, the patient navigator said, please, please, you know, to the doctor, please just sit down with the entire family and talk about what. And this doctor was much more open. Okay, you know, how many people are going to come in? Let's just create a space and they can come in. Let's make an appointment. So, 14 people came in. People, parents, you know, everybody came in because they wanted to be a part of the decision-making. He took two hours and he explained why she needed a C-section, why she was at a higher risk, why they were concerned for her and she had had bleeding and things like that and that they weren't there to do anything bad but they were worried about the health of the baby. Once he explained, he talked to everybody and the patient navigator prepared him and greet them first. So, she really helped. Let's do that. Not giving him a recipe, but just who you want to acknowledge first and you want to listen to everybody. Because of that experience, the family left extremely happy, very confident in the hospital, very confident in the doctor and they went around talking to the community, I want to go here and I like that doctor. He's the best. He really took care of us. So, she had a really good experience. I understand why and taking the time. So, someone can make an informed decision. It really, really works. So, that's why we're culturally confident to be more open and to be better at what we do. So, culture can be anything. It can be... My favorite culture is pop culture. I love reading people magazine every single day and I'm learning about my friends, Angelina and Brad. They are my personal friends. I love those kids. And then I love Facebook. So, I love the whole social media culture. I don't have Twitter or anything like that but I like to follow people on Facebook. Food can be culture. Think about your favorite foods and where they come from. What it means. Like when I have Southern cooking, I just feel at home. I feel so good. Or when I have bowl of ramen, I feel that feeling you get from your favorite foods and culture from different cultures. Religion also has so much cultural meaning and context. I put farming because rural areas is a culture in itself. These are skateboarders, the skateboarder culture. This is Girl Scouts and I love this picture because all the girls are Muslim and I thought that we're not all American. You have Girl Scouts and these girls are so cute. And representing, you see that in the Vietnamese Girl Scouts, they have Chinese Girl Scouts. It's just exciting to see that in the United States. And you have street culture, you have urban culture. So, culture can be anything. It doesn't have to be about race or ethnicity. It could be about anything. Is it difficult to be culturally confident? People used to say when I worked with healthcare providers probably 99% were like I want to learn more about my patients. But I'd always have a few that are I don't need to be culturally confident. I'm just respectful. That's all I need to be. My job is to be a doctor and to respect them and provide them care. Why do I have to need anything more? Why do I have to worry about them? They just need to follow this. They used to tell me it's really hard to learn about every single patient's background. But if cultural competency is so hard, why is it that tobacco and alcohol companies can do it? Here, Spichanga resorts it at the most culturally confident group. Spichanga resorts it at the scene. A luxury bus. They have it in Chinese. They have it in Vietnamese. They go to Asian Garden Mall and wait for all the Vietnamese to come. You get money, you get tickets, you get food. You know, you have movies. You have Carousel by Night showing. They also have all the famous people coming in for Koreans and Vietnamese and Chinese playing music at the resort. So they're so good at marketing, at being aware. Bicycles have another gambling place in the South Bay. They serve fried fish at the tables. And just very, very much for the company. There's also a look at this one is for alcohol companies supporting lab, filtering out inequality. So knowing the messages. Knowing how to market, how to manage a community. And then also I have ER up here because I used to love this show in the first days. I think it was one time when Nurse Hathaway said, she was talking about language access and there was a Latino couple and the wife was really sick and she was going into renal failure and the husband didn't know and they were trying to figure out the entire show what happened to her and what they finally found was Nurse Hathaway was going to give it to me and she read it and it says take once a day in Spanish. What's in Spanish? She took 11 pills. So I was like, oh you are so great! Because Nurse Hathaway was like we need to be able to read the other labels so we should put it in language. The other thing we did too and it was together with Nurse Hathaway she always had the best lines. So one time there was a Vietnamese woman our Asian woman that came in and she was saying, we need to do a pap smear because Vietnamese women have the highest incidence rate of cervical cancer and I was like well so programs can be very cultured and confident. I love that. I wrote to them saying thank you so much. Now Lowes Lowes can be culturally confident When Lowes opens up I want to say I'm a home decode, I'm a gal but I walked into Lowes and the first sign I saw this is on their website word for word. Welcome. Lowes speaks your language. How many hospitals have something like this in them? Lowes speak your language. I just want to read it. We're making shopping for home improvement supplies easier for our international customers. Language line phone service available in most stores provides professional quality live translation of more than 140 languages. Whether customers speak Spanish or Hindi, Hmong or Mandarin I was like, they even know what Hmong is! You know what I'm saying? I translate the system in speaking to store employees and a card on display in the stores offers a short explanation of the service in 20 common languages. When you walk into Lowes I didn't see it in my Lowes lately because it was a big sign. We speak your language and there's like 40 languages there and I was so excited and then their name tags Hi, I speak Vietnamese I speak Korean, I speak Spanish and I was going up to every person like, oh you speak Spanish oh you speak Mandarin I'm so proud of Lowes and they have in addition to the language line some Lowes stores have Spanish speaking employees on staff and a sign on the door and it tells the customers to look for associates where I speak Spanish buttons the language of home and family is universal now the language of home improvement is too. So Lowes which sells hardware it sells whiteboards and it sells wood you know, lumber if they could do it why don't we have this in every setting and so I'm just really curious on cultural competency language competency language we do this everywhere so this is another slide, the iceberg concept of culture so culture is not simple there's so many nuances to it so when people think about culture they think of the tip of the iceberg food, dress, music visual arts, drama, crafts dance, literature, language, celebration and games but there's so much more to it there's for some unspoken rules, you go deeper into the culture you go underneath the surface you start to see courtesy, contextual conversations and patterns concept of time, personal speak it's hilarious, my husband is ethnically Japanese but born and raised in Peru and so you can see his whole changes so he has Japanese friends and we go to Japanese friends at four o'clock because everyone starts early for Japanese and then you see him bowing and being more serious and they're downing I'm sorry, I'm generalizing, these are stereotypes not all Japanese people do this but he's really very culturally different he's showing respect, he's pouring and then later on like at nine o'clock we go have dinner with his Peruvian friends and his whole demeanor changes he's loud, he's out there dancing he's singing and he's just talking and he's very effusive and he's talking really fast and Japanese talks really slow and you can just see there's so many hidden things that I didn't understand and I just watched him out of curiosity because it's so amazing how he can just change his worlds personal space you'll see him bowing and he's bowing to his Japanese friends and then to his Peruvian friends they're hugging and kissing and always together so it's very different rules of conduct, facial expressions non-verbal communication there's so much more attitudes towards elders concept of cleanliness notions of adolescence everything's different then there's unconscious rules completely below sea level emotional load there's so many other things when I started doing cultural competency training a lot of healthcare providers and teachers because I would work with teachers just tell me what to do with Asians or tell me what not to do with Asians and Pacific Islanders you know and at first when I started I'd be like don't touch their head don't point your foot why am I saying these things because they're not really that true there's some meaning behind it but I don't have that same understanding so there's certain things that are so unconscious there's certain things that it's hard to explain that you have to learn about them and there is no rest of people there's no don't do this don't do that I think basically it's about learning more about people trying to learn more of this and know that culture is just not about food, dress and music so world view I love this slide too because my view is western cultural orientation my husband's view is non-western cultural orientation so we always have cultural misunderstandings they're every single thing mine is very about being the individual it's all about me and it's about I'm going to do well I'm going to be in top of the class I'm going to work towards myself his is about everybody you're not thinking about the group why are you driving so fast you have three other people following you it's all about working together it's all about the group what do we all want let's all talk to everybody the nuclear family structure it's about my family it's about me him and our two kids for him it's about extended family structure it's about our parents it's about aunties and uncles it's about friends it's about their families it's everybody grandma, grandpa it's everybody is included in that and relationship is collateral and so you can see hierarchical top versus going all the way down and collateral also cultural orientation for western tends to be competition being very competitive which is non-western interdependence western cultural mastery over nature and non-western cultural harmony with nature being around knowing that things are within within God's control it's within the spiritual control future time orientation present time orientation all about the future we've got a plan today what are we going to do today religion is fragmented for western cultural orientation versus non-western cultural orientation about spirituality western cultural orientation scientific model and intuitive sense of knowing just knowing western cultural orientation very verbal and non-western cultural orientation is about being non-verbal so a lot of times my husband will say can't you tell what I'm thinking no you gotta tell me I don't understand you have to tell me or even if it's your own communication he likes to tell stories and they go on and on and on and I'm just sitting there at first he used to get really offended you know and I'm like you could have shortened that whole discussion from ten minutes down to one minute get to the point and so we used to get into fights about that because he goes no you're not getting all the things I'm talking about from I'm saying a whole bunch of things I just want the answer I want it quick so now I've become very more sensitive to that and I listen and I really appreciate because I am learning I'm learning all the things he's trying to say so some other social, cultural, economic and political considerations and I use these because this is something when I was trying to learn more about issues like the civic islanders because I didn't know very much I knew my experience I knew what it was like to be fourth generation growing up in a rural area I knew about racism because I experienced it on a daily basis I knew about what it's I probably know have more than experience of a civil rights era going through KKK things like that I understand that I didn't understand the immigrant experience or the refugee experience I needed to learn more about that personally so some of the things I use to understand a community better is the diversity how diverse is the population before I met my husband I thought Latino, well everyone speaks Spanish we should all understand each other I learned Spanish from my teacher was from Mexico when my husband speaks Spanish I don't understand him because he's got terminology he's got all this stuff that is from Peru that I really don't understand and the words are constantly changing so even when his friends are coming from Lima some of the words he's like what word is that I don't know that but there's such a diversity even ethnically too there's over 60 different ethnicities and we're all different language and language is different Chinese when I think oh do you speak Chinese well which dialect there's 100 you know there's so many different dialects in every language gender how males and females are perceived age how you treat someone older versus younger generation someone who has been here for 8 generations it's going to have a very different experience from someone who's been here for first generation background and history what was their experience in one case of a woman who was giving birth at a hospital at a teaching hospital and she had been gang raped in a refugee camp and she had a really bad experience and had severe trauma she had gotten pregnant and her boyfriend left her so she was by herself single mom 22 with a child already she had a child and she has no family they had been killed she's having her baby she's by herself in the hospital it's just really going through an emotional experience this teaching hospital brought in 6 men 6 of the interns to learn what was going on they didn't know anything about her background they surrounded the bed and they were taking notes and looking at her and watching her and you know at a teaching hospital she didn't speak English and so they're doing this when you're having a baby they're checking your service they're touching you and you feel just so emotional and vulnerable she relived her trauma of being raped and she didn't want to touch her baby she just had a horrible experience she was in severe depression and no one knew what was going on because she couldn't speak English and convey it and she didn't want to but just finding out a little bit of her background and history talking to a patient navigator talking to someone about you know here's a woman can you talk to her a little bit about her experience she's by herself it's a great honor immigrant or refugee immigrant has come here by choice but you know their experiences as an immigrant is not always good in the trauma we've had friends who have come here to work and left their children behind you know because they're trying to make money send money back but the experience of the child feeling like they've lost their parents and being raised by their grandparents and then we've had families who have sent for their children to come and in the immigration experience it's not been good they've been really traumatized they've been used by people if they had to pay people to take care of the children coming over the trauma that they felt and the same for the refugee experience coming over as an African refugee as a Southeast Asian refugee the horrors or trauma you've gone through is really difficult when I started working at another organization I didn't know anything about the Southeast Asian experience and I'm running in and dancing and slamming the door and I didn't realize every time I slammed the door it would really scare them because they would think it was a gunshot or they would experience something I was really insensitive to my co-workers and I'm playing loud music and dancing and yelling and for them it was just they were going through so much that I needed to be more respectful when they started telling me their stories and what was going on one co-worker who witnessed her husband being killed in front of her seeing her children tortured being pregnant and trying to escape escaping up a huge mountain to get into Thailand and being forced by the guards to go back just those experiences I never knew about them so just listening to people and hearing about what's happening to them rural versus urban if you're from a rural area you have a really different experience growing up in a city it will be totally different than a rural area I still do work up in northern California meaning north of San Francisco in Tuolumne or Eureka all of the areas up there to see a doctor you have to drive like 60 miles to get to them to go to school I remember I grew up in Marysville and the kids from the foothills could never come to school in it they got snowed in just living in the mountains you get snowed in and you couldn't come anywhere so imagine if you needed a healthcare provider to try and get through that your environment where you live, how safe it is I always compare Santa Ana with Irvine in Irvine I have four grocery stores within a quarter mile of me I have a park on every corner I can walk anywhere my kids can walk anywhere they didn't really how many parks are open here in Santa Ana until Latino Health Access and Dell High started doing work on that and several other organizations started really looking at the community environment I know that early on I was working in South L.A. and they were we worked with community health councils in South L.A. and people were blaming the community well your communities have high diabetes because they don't eat fresh fruits and vegetables and our partner community health council says show me how many grocery stores how many mainstream grocery stores are here we have liquor stores how many fresh fruits and vegetables can we get no one wants to come into this community there's no one dedicating businesses down here so your environment finally I was working in Long Beach at the time in the early 90s when a lot of we had a really high rated teen pregnancy among the Southeast Asian girls a lot of the policy makers were blaming the family in Southeast Asian culture they want their daughters pregnant and I'm like where would you get that you want your daughters to go to college and to have a job and have a career and they said no no no in cultures they're supposed to have 9 children so I was like I don't understand it and so what we had the youth do we had the girls do is what's happening why is there such a huge rate of pregnancy what was happening is they were getting jumped into the gangs because no one was doing community after school programs the girls were getting jumped into the gangs and they were having to ride the train have sex with the boys and they were getting pregnant through that they were also getting pregnant when they wanted to get out of the gang you would have a 3 minute head start run and people would shoot at you and chase you throughout Long Beach instead if you got pregnant you got respected out of the gang like oh Mary can't come out anymore because she's pregnant with a kid and for safety got pregnant was all environmental wasn't anything about their culture the other thing is social economic status if you're low income you really have a hard time with access to care no matter what versus higher income insurance and then also I think for the communities we work with because they are low income there's also perceived discrimination they feel and I see it too they get discriminated against quite a bit when you're low income oh you're on food stamps they really get I think targeted community issues what are the community issues going on we had a case of a woman we were promoting breast cancer education and we finally got her in to get screened and it turned out that she had stage 1 breast cancer and when her husband found out about it he's like well she's gonna die she's gonna leave her and find a new wife so he left her because he didn't know who's gonna take care of the kids what happened she was fine she got treatment she was fine but it went through up and down the state that if you go get screened for breast cancer your husband's gonna leave you and that became a big community issue we had to go in and do more education about breast cancer and finally family community support what kind of community support do you have what kind of family support do you have so and before we take a break just some other issues to think about patients these are just common things there's so many things there's thousands and thousands of things you can think about and working with communities but here's some things that I really learned pain tolerance for your communities that you're working with what's the pain tolerance is it their culture not to complain I was on a call at St. Joseph at the cancer center and they had a patient on Korean mail he had had cancer and he talked about well they said what did you do when you had cancer you needed treatment oh I would leave work and I would take the train and I would go and then I would go get my treatment then I'd go back to work sorry we were just to interrupt that one in the previous slide I would also like to add religion I understand where they're from either Buddhism or Muslim and also it's related to the issue to think about let's say people like in Buddhism culture believe that because of the karma they're determined to help because they did something bad in the past life and it is out in this life that's why they deserve that one they don't want to see it religion sometimes plays a role it's huge you're absolutely right it's really key thank you for that so this man he never complained he didn't tell any of his co-workers he had had cancer with getting treatment he didn't say anything when the doctors said are you in pain and they knew he was in pain he would just never complain he was okay and what he said was I don't want to be a bother I don't want to bother my son and they were like but you took the train yourself all the way for an hour to go get treatment and then you went straight back to work and what do you do at work he never complained and he said he didn't want to bother anyone but he also wanted to tolerate the pain scale for health a lot of times you see these questionnaires how healthy do you think you are are you very healthy not healthy someone that is really hard to translate also you have to ask for the community is it bad luck to say that I'm really really healthy is it bad luck to say that I'm not healthy so you have to find out some of that also are there different terminology for common words I learned a lot when I was asking people do you feel depressed do you feel sad you know people didn't understand that but they kept telling me I'm thinking too much I'm thinking too much and I go oh okay what are you sad and I found that thinking too much was depression I just wanted to share a story I was working in a doctor's office one time in rural North Carolina and this lady was telling the doctor that she has depression depression is just getting so bad and the doctor was trying to like doing this mental health interview trying to get at her depression first out she had a sinus infection oh she said that the pressure pressure yeah yeah but that's so common it's just a terminology understanding how do you want to explain it it is trying to figure things out so a lot of it is a negotiation but it's really about communication and that's so great that the provider was just really trying to figure out what are you talking about let me try and really get to that are symptoms somatic we will see a lot of community members come in I've had stomach aches, I've had headaches tired and we have a therapist who is depressed all those things will show depression stomach aches how is it showing a lot of times when you are going into the doctor you have 15 minutes so how do you explain your symptoms you can't just go in and I'm depressed I don't feel and respect for providers we see a lot of this with patients just being respectful of providers so really trying to please and give the right answer to bother some I'll see this too showing that respect other issues to think about and implementing and this is now transitioning from patients to going to interviews and research and then we're going to do some more activities so I'm sorry I'm just talking to you but I'm trying to give you some background information startups doesn't always equal agreement or yes I used to do questionnaires like have you ever been screened before this and people were like yes this doesn't always mean yes not in your head I'm hearing you I'm listening I don't understand you it doesn't always mean yes a lot of times when I'm talking to people I'm all and what I'm just saying is yeah, yeah, yeah, yeah so you know or being silent not just not in your head but just being silent and listening that always doesn't mean yes either surveys and questionnaires review review review make sure there's no double negatives because it doesn't translate I've seen questions don't you think that you know you should go get screening but not this or this so there'll be like compound sentences there'll be double negative and it's hard to say do I answer yes or do I answer no and when you translate those difficult questions too if they're not pressed in English or they're too long translating them is really difficult and don't just choose anyone to translate students or healthcare professionals when I first started out in health education I thought oh I'm going to get the doctor downstairs to translate this whole survey well that doctor has so many degrees and he was very proud of his Chinese so he translated it in really good Chinese but no one else understood none of the Chinese community and they're like I have no idea what this says another case I had my husband review thinking oh he speaks Spanish and he re-expanded that's his first language I'm going to have him review two things because we had a job applicant I needed someone to review their translation he chose the first one and he goes her Spanish is really good her translation is good I didn't tell him what it was for I just said which translation do you like better this one this one's better it's grammatically correct I then showed it to my friend who worked for the county he goes no I would choose this who are you trying to reach and I was like I'm trying to reach low income women who education is fifth grade or less and he goes no no no choose this one choose this one because my husband when I told him he just chose what he thought was the best Spanish that had correct grammar and it was written by someone who had a college education in Spanish and my translator is key you don't always have to back translate we have so many times when we're working on a research project we translate the questionnaire we translate a hundred questions then the researchers do not translate it now into English so make sure it makes sense and what we found that doesn't always we don't always have to do that we found a small group to review and discuss the translation and go through each question and we found that doing regional differences so if we do something in Korean we ask Oakland people Northern California people to review it as well as Southern California people because there's always regional differences too there's new terminology I just had someone review a Korean book and she could read everything but she's like I don't know what this word is what is this new word they had someone from Korea translate it and there's so many new words that come out from a country of origin that she's like I don't know what this word is and folks who've been here for a while even if they read Korean and Korean is their first language they might not know what this word is it seems like it's a new word and in some words don't exist in other languages when we started in 1999 doing work in South East Asian community the words pap smear there wasn't a word for it a mammogram and then we thought let's just describe what a mammogram is we'll put mammogram and describe it a lot of the South East Asian communities we were working with they thought it was the TV X-ray when you're coming in as a refugee and if you have active TV you get an X-ray that's what they thought the mammogram was so I was like 90% of the lemon are getting mammograms you know it was that there wasn't that word and they didn't we didn't explain it well so MMR HPV, HIV all the acronyms it's really hard to translate and folks don't know what that is I didn't know what that was the MMR all the things that especially for the children parents get really afraid we had one case of a woman where she brought her child in and when you get to your children's immunization you get a lot so there's like a trade there's four shots there and the nurse was saying it's the MMR it's a DPT but when she heard DPT she thought they were giving her child DDT so she thought they're giving my child I'm taking my child and I'm leaving because they thought they were giving her a pesticide you know and she's trying to protect the child so making sure for acronyms those aren't explained so what I want to do now and I want you at your cables and to have a piece of paper and I know it's just been a lot of talking but these are common questions that we always ask in healthcare in research all the time and I want you at your cables as a group to think about what are better or more appropriate or culturally appropriate ways to ask this when I ask these questions people don't want to answer them a lot of times because they're like why do you think so nosy we had a family who lived with two other families why do you want to know my household the number of people living in my household why do you want to know are you going to tell somebody about this so what are ways that you would want to ask these questions think of some different ways we also had what's your household size the Pacific Islander the festival association in Pifa in San Diego they did a survey and they asked what's your household size and they were saying two stories and I was like yeah how do we interpret it as that too so here are common questions we use every day how would you want to change these so take about 10 minutes to talk in your group and think about these questions what are better ways to ask these common questions that you can ask every day healthcare or research have these questions been asked to you think about when you go to their provider or when you go to school or you go to anyway so much are these questions really common have they happened to you have you had to ask this so in your discussions at your table what did you think about these questions did any of them make you feel uncomfortable yes I heard a net say I'm not ever going to ask this question to another I can't do that that's so rude so maybe let's go around the room and think about each of these questions what are ways that you ask them so that there isn't any misunderstanding what's your household size two stories how would you make these more clear, more appropriate or culturally sensitive so what's your household income I get that asked all the time and I'm kind of always like what do you mean I always put the wrong answer I don't want to put what it really is so what's your household income did anyone, what were some of the tables well what we discussed what we discussed was if you were to tell the audience or the participants why you were asking that question then maybe they would be more in tune to answer such as the benefits of certain ranges and what each of the households can benefit that's good so Charlene had said that if you make a point of giving the background of why you're asking that question that is not just to ask it to be nosy but maybe you're asking to see what they could qualify for which you could help them to qualify for maybe you're asking it for research purposes and it's very confidential you're not sharing it but it just helps you to understand better sometimes when you ask it straight out you hear someone asking so when I try to say well we're talking about the assistance program so the highest income that you're allowed to have is this amount based on that number or do you think you would qualify sometimes instead of them feeling you have to give you the exact amount that they're uncomfortable giving you then they can give it to you that way that's a good point because if you have ranges like 30,000 to 50,000 you can say to qualify for this if you're around this range you'd be able to be qualified for that is any of this fit you know and that would be very sensitive also we would change we would not change it just refers to what is your family income and also we give you more explanation because it depends on what the research or interview about you are looking for the individual income or the family and family can be given a different definition whether your son is there your children under 21 can make do they earn income and why so we give you more explanation what is your family income what the family mean that's why surveys take so long because it's not in which household because we'll have families say there's three families living with us do we count everybody or do we just count our family or do I just count so it takes a long time is there any other to get all this answer through the conversation what they ask and also first of all the confidentiality because after you talk about confidentiality they are open to share yes exactly when we were doing a really long survey what we started off with exactly was the confidentiality this is just to help us learn we'll never be identified it's not about individuals but it helps us and then we do we just had a conversation and then the interviewer would just go back and answer the question and they would just be taking notes but they wouldn't be sitting there checking off things because you're right it is a conversation it's to make sure people go comfortable I would say also to set up some trust is to tell them what you're going to be doing with the information exactly it's going to be available for them because I have participated in many surveys you know being part of a person that's a survivor and they can make questionnaires and I'm always like am I going to get to see this information what are you going to do with it and I think that would help with a level of trust exactly and that's perfect because it is what's this information going to be used for is it going to be used against me are you going to say this about my community is someone going to come in and ask me out you're right so what is it for and then how it's going to be used and what kind of information is going to go back out into the community we're going to find if someone knows I want to ask about your household income because we want to tell the county that housing is a big issue for everybody and that so many people are having a hard time meeting basic needs so your information no one's going to come and investigate you we want the county to build more affordable housing finding out that background and then this will be released in all the newspapers we'll give you the information back we're writing a report and we'll give it back to you because people don't want to feel used they're giving personal information and then they don't know what happened we're talking about who you're targeting the question will be dependent on how we will ask the question depending to the audience that you're going to be targeting how people are going to take it in a different culture yes exactly so how you even who's your population that you're talking to how you approach it how you're going to say it really really depends you have to really target it appropriately another point is what is the process before it's even published just to make sure that they interpret the right information yes exactly because people could just look at the numbers household income you're just looking at the numbers you're not really processing it and analyzing it what does this mean a lot of times when we first did some surveys we just got household income and I'm like I know that 00123 is that family and I go I know their income is lower but they were counting when they thought household income they might have been counting auntie and uncle over here they might have been counting grandma and grandpa and making sure you ask the question correctly and appropriately that had analyzed who's involved in that analysis so what about household size how would you ask that or what are issues you found with that because that's a common question too oh go ahead okay so our group was thinking about asking how many people are moving with you so that's the way and then they do it in the range of like more than three people two people and then this is the very sensitive question so that is the way two months ago I knocked the door at the ministry in Santa Ana and then there are 12 people in one apartment and then when you walk I was standing outside the door but literally they invited me to go in and then you see little four or five beds in the living room and then they look at you saying should I tell you the truth or what so you have to explain the reason why it doesn't affect you because they might think that you are from the landlord and they want to do a survey to keep them out because in the contract there's only two or three people so we have to firmly keep telling them all the way along that it doesn't affect you, we just want to gather information and even that if you see five beds they just tell only three people so for sure they will not reveal it but you cannot do anything about it whatever the answer they give to you so they're going to keep looking at you even though you've been with them for more than an hour and then you look at their face and then they're going to look back to you it is, it's really hard because people are afraid and with this economy we have three, four families living together and they don't want to say that oh yeah I have 12 people here don't look at the beds and things like that so it's really hard to get accurate and we don't want to invade people's privacy too much and make them more afraid so it is very difficult yeah I was going to say they are afraid when we're doing the census they did not want to disclose how many people are living not only because they're afraid that they're going to be deported they think as soon as you say government that's it they're pretty much shut down and also because they're afraid that if you call social service if you're working with the county and you're asking this question that they might have their kids removed because you're putting them in a risk environment risk environment or they might accuse you of neglect or not being clean there's so many things it's not just an easy question so I think our group is concurred with everybody else is that you have to disclose why you're getting this information it's disclosure it's not going to be used for it's not going to be used against them and it's the trust building because it is scary I hear stories all the time I was living with 16 people they took my kids away because they said the house was dirty so you hear that throughout the community I think it really helps some with trust when you really tell them this is my name and this is where I'm from and then you're like I'm from Seoul and they're just like what information did I just give them and it scares them and they know this is a number and they just know this is building from a good place and they're not scared to reveal who they are so it's kind of important it's not just what you're using the information for but who you are to it's so true because so what she was saying is really telling them who you are where you're from so if the county went so Joe went in and said hi I'm from public health he told me your household income your household size do you think he's going to ever get that information and he told us all stuff in the student time versus maybe someone asking who you are where you're coming from building that trust but some places it still will be so no matter what if you're from county of orange it sounds very hard so I think that's why it's so important to partner with community organizations with universities with everybody because it really does depend on who goes in to ask these questions what's your place of birth I get that all the time you know what you guys had a very good question on what's your place of birth and when did you come to the US as indigenous communities native Hawaiian, Alaskan natives and American Indians you're the immigrant we're here before you so that can be very offensive yeah so so working with and being from Native American communities what if you're native Hawaiian what if you're from long when did you come to the US or if you're American Indian or if you're from an indigenous community it'd be like when did I come to the US you came to so what she was saying is that's really offensive what's your place of birth how did people respond to these what's your place of birth and when did you come to the US where were you born where were you born we had an interesting I was curious to hear how our Latino would respond to that because she's born and raised here and the assumption is that she's from someplace else so that can be also translated very offensive as soon as born and raised so it's how you how you approach it and giving that background of why you're asking it so what happens if I used to get that all the time like no I mean really Northern California I think there's assumptions by the way people look oh you must have been born in Mexico where I was born here or you must have been born in Japan no I was born here how you approach it how you ask it I've had it asked where someone didn't really believe I was born here like no no no really really where are you born and I'm like no I swear to God I was born here I was born in New York City I ride out hospital I was at Castle Obama your other oh yeah I have the birth certificate I'm just kidding it's the opposite because people assume that they're African-American exactly so they may be insulted if you assume that they're armed that's a really good point immigrants, African refugees just assuming that they're African-American or we have so many incredible mixtures I have friends who are black but from Cuba or from Dominican Republic and people will assume when you're African-American are you from here and they're like no I'm Dominican so there's so much diversity and I'm Puerto Rican and so when I came here I was licensed in Puerto Rico and I came here to get my to work and I had to take the nursing test again even though I took it in Spanish it was the exact same thing I took in English and they said to me that I had to bring my passport so I bring my American passport besides that I was born in New York and I put it out and Blake says where'd you get this passport? yeah so it's been yeah it is yeah I can totally see that happening so these are things that you think which place of earth you think you know no questions but they can be offensive to people or how to ask it the attitude around it but if people understand why are you asking it when did you come to the US how about we put in what year did you come here and then they might say 1991 1992 something like that even though they may be Native Americans they said I came here 1800 or something like that yeah so there's a lot of different ways to ask it but it's how you ask it and giving that information yeah I was just going to mention I just come to the purpose of why you're asking I deal with Medicare issues so a lot of people ask me do I qualify well one of the things is did you have the way I would say well the requirements are okay so if they don't have that that could mean a couple of things so then I go from that it comes to like oh well I didn't work here because I came to the US when I was much older okay when did you get here so it's having a conversation like you're saying it's like multiple questions to get to the answer that's why when you do an assessment and you're trying to see if someone's qualified for Medicare you can fill out the piece of paper oh my god did you get into Spanish because again not everything translates exactly and so then I have to explain rather than just translate does your co-workers and supervisors know how hard that is I'm fortunate enough that my supervisor had mine here she knows that is all for me yeah because like one of the questions they ask an MSI application because I'm taking the MSI application too at the SNS and then they ask have you lived in Orange County for more than let's say for example five years or something like that this could be a good question how long have you lived in Los Angeles or LA County specifically ask those kind of thinking do you think you are qualified for that that's a good way because how long have you lived in Orange County they could say well I came first through New York I did this I was born here I've been in Orange County for three years but that's a good conversation and I think that's what everyone's saying it's having a conversation it's not just boom boom boom boom boom how did you ask what's your how many sexual partners have you had you never they want to ask that that's like this table said forget it did anyone kind of think about that how many sexual partners if I have to ask that question in a group I will again explanation what we need and all that to give them a piece of paper and just write it in there we will have the information but no one will know why so you have to find the way how you will make the question probably not go there because they are going to say how many have you or ask how many boyfriends or how many girlfriends and then you can kind of have an idea so it's not an idea I like to talk about the idea of having boyfriends or girlfriends you have to be careful about that because if you are working with caregivers you are overwhelmed with the situation caring for your loved one but I know you have a class you have a house and then she comes with the answer so you're talking to her more about her situation the support that she needs and then she comes with it so you really don't trust that's not a good question I think again why do you want to know these questions or the answers usually for HIV screenings you want to know if they are in any kind of a they are involved in risky behavior and it's for their benefit maybe to know that you can better assess their risk exactly I work in the radio and patient center and then I've done work places and usually we've warmed them up I've warmed them up I've warmed them up for how many how many births have you given and you can warm them up to are you going to get married and then you get some sexual partners they're just warmed up I call it dancing yeah it's building up just warming up I remember one time I had to translate for a person who came from Arkansas and they wanted to know it was a TV department they wanted to know if this person was exposing other people so one of the questions was so this person is keep asking a question and I'm translating right off and one of the question was ask him now he's with all these clothing and all that very elderly and he's asking me to ask him if he has sex with his wife now I'm right there first of all I didn't remember the vocabulary she just asked me he also asked me because she asked this form so I'm trying to say trying to kind of warm up it was very difficult for me and finally this woman says I was so happy that this gentleman among all these things in English had no idea but he knew that just thank you it was just so hard for me to ask that question it wasn't like if it was something that you know he was very happy to answer that but it was so hard for me to ask that so it was another way around to say it you know it was just me a difficult woman and then would it be because I'm sure it was probably hard as a woman to ask a man too so what are you doing those situations if you are helping on something and you're interpreting for somebody and they're saying ask sexual partners ask contraceptives and you're so inappropriate for it whether it's age or whether it's gender to ask those things but then the provider's saying just ask it, just ask it you got lucky he understood for example I have a blood donor so they make you do all that fill up all that questionnaire every time you go and you have to answer it and the questions are very straight and very like how many partners do you have or do you have a partner but they do it in a computer so you buy yourself and you always do it they make you inside and that's personally they walk out of the room and they say you can answer and the ones that you want to skip you skip it but you know that you're there and you know what it is for I have to say the truth because my blood is going to go to somebody else and you realize that and you got the information so they walk out of the room and you just fill out you just say yes or no they make the question have you had more than one partner do you have sex with the same very very money for sex with things like that like strong questions that you will ask because you're by yourself and you know what's the purpose of it but see that's perfect you know the purpose they're sensitive to these questions someone's not embarrassing you by asking them you know to have spent it every time and that everyone gets these questions and you get to do it privately and you say yes or no and you're saying yes or no the only thing for elderly who might not speak English would be as long as the computer has it verbally and language but that's really good they need those but you know why they need those questions are those answers and I think they ask you if you need to translate it and they put it because it's a legal thing they put it in English and then they put it on the language so that way they make sure that you know that's good Karen I was going to say about what you had mentioned brought up to be culturally sensitive to the population you're serving because there are some cultures that we had an experience where we had we were calling the doctor by the last name was he a doctor so and so and there was this gentleman from Egypt and he went in you know filled out all the paperwork about an hour worth and then he went in and then when as soon as he saw it he got up and walked away and he was I don't talk to women and then we found out by another doctor that in that culture that it's below their I don't know they don't really see them or hold them in high regard so the men would only relate to another man and tell them about their personality finding the right gender finding the right age fit okay Joe yeah yeah oh yeah oh yeah yeah yeah yeah finding the right match yeah that's really very very difficult I want to comment about what she said and then seeing an old man in Asia thinking about a government that's another stare maybe it was just that particular man getting in that way it's probably even more that we want to speak to a man whatever who was there so we have to prevent ourselves from general ideas exactly it could be personal preference and it's hard because I always do stereotypes of Asians all the time and I forget and so seeing my coworkers are laughing and then I have to really catch myself because what I'm saying sometimes it can't be generalized and it's really based on individuals that's why finding out everyone and this is I've had providers say you know it's hard I can't find out about every patient but it makes it worth it to find out who you're working with and who you're serving so that's why to find out about individual because everyone is different and then hang on in such situations maybe it's appropriate to say I'm uncomfortable also but this is very important and that's the point we need to do yeah that's a really good point I know when I had my baby they were like do you feel more comfortable with a female provider or is a male provider okay and I was like oh thank you for asking would you like someone who speaks your language and I was like oh yeah I could understand but just asking just asking I think is so important because I really appreciate that when someone will ask me what I want it shows respect hang and I think you just said it Marian in terms of interpreters hangphone is an expert in language access issues is that communication the few extra minutes that we all take to understand the patient, the customer to be able to set them at ease is important so understanding the age range gender and finding the best possible match for an interpreter and if you can't find the same gender match not that the patient or customer wants it but I think you do do that to let them know ahead of time exactly what to expect we have a male interpreter in his 40s he's trained and he's going to just be there to help us communicate I think setting the tone is very important to open up the best possible communication with the patient and the sensitivity to be the best and I think when you do that when you show you really care to have the right match when you want to make sure an individual knows what to expect when you're trying to find someone who they're going to feel comfortable with that's cultural competency that's making sure an individual feels comfortable no matter how much you know about this Lorraine one of the things that I try to do is that I work with people of better cultures so when I first meet someone doing assessment I always put it out there but I love to know that you know I meet them the first time and I do not know where they're coming from but I like them to educate me since they're the experts in their lives I don't want to assume anything if I don't know something then I'll ask them questions so that they kind of know the thing and let them know that just because I'm an expert I'm going to tell you how to showing that you're not an expert in their lives but they are and that just setting the whole team and that really helps because if someone is going to be like oh you have a master's in social work you went to USC, you know everything although I think UCLA is better but that's a different culture yeah I'm a public school baby but they could really put you higher and you're like no no no I'm just like you but I want to educate me so that really helps that's a hard question can I tell you a secret I never say the truth and I always put a lot less and I started to believe it so so the last question are you using any contraceptives every religion well first of all when I first got asked that question I'm like what's contraceptives and then they're like you know the pill, condoms oh I want you to say that but how do you like what you're saying it brings in religion I know a lot of my friends who are Catholic they will always say no but I know they are it's not a bunch of answers I think asking what you're doing to prevent pregnancy is really a better way because they are right yeah that's really good so what are you doing are you using any contraceptives what are ways that you're preventing any pregnancy anything else I just wanted to make a comment and I'm referring back to some of the research communications that you shared with us like in our culture which would be the Pacific Islander culture once they have our trust and it was alluded to in the conversation where the person said oh yeah but I stayed and I ate and all of that so they spent four plus hours well I tell you our culture if we were to do that by the end of that time period they would tell us how many sexual crimes they would they'd be so comfortable with us but it would be no thing for them to answer any of those questions it is it is and it's hard because you're trying to negotiate this you're trying to build trust and it takes time you can't just walk in and walk out but sometimes the system whether it's education whether it's healthcare it doesn't allow for that time so to make culturally competent healthcare system culturally competent systems of care we need time we need that understanding of that trust I would just comment too I keep thinking about the difference between being culturally competent and you know cultural relative or relativism where it's just kind of it's all good everything goes and I was a social worker too and I think it's important to understand that from the beginning that there may be a tension between you know kind of the cultural norms of the people that you're trying to work with and your own or the things that you find acceptable and the things that they find acceptable so if you assume that you have to kind of accept or agree with every cultural norm that you learn about it sets up an obstacle from the beginning as opposed to just understanding that tensions may arise and you may have your beliefs and they may and every may be different you know like with the gender and you know I grew up in a Muslim household and gender that was one of my issues why are women you know what's going on here but I understand that I have my ideas and my beliefs and the people that I'm working with make a different belief so it's a fine line because you really do want to be open enough to really be able to work with everyone and still understand that I don't have to adopt all of the beliefs or even if they reveal something about you know being in a domestic violence situation or just in a situation that you don't approve of that you don't think they shouldn't be and you really have to walk that line so that you hold your beliefs and you still try and serve them and work with them as much as possible if you don't know that in advance then you can kind of find yourself in a quick set that's an excellent, excellent point and spoken by a true therapist such a worker and that's your training and that's what I love about that because you do have to be aware of your own personal beliefs and you do have to walk that fine line and just like what you're saying I have on cases where there was domestic violence and you're just like you know my personal belief is like what are you doing but I can't do that because I can't be judgmental I can't be judgmental I don't know their whole situation I don't know what's going on so I have to ask the questions and say if you any time you want resources hear some things but you're right it is knowing who you are or your values on others and understanding where they're coming from that's why I like social workers I love social workers I was going to say that I agree with the lady there that it's key who you have as your staff asking these types of questions because they may be the best at what they do but if they cannot connect to the community that they're serving and exude that confidence they will never get those answers yeah and you know that's key it's the training because this is scary you know to ask like Harold, I work with Harold and he's a case manager I could never do his job because the things that he has to ask or the things that he has to have discussions with it's really hard and we don't have enough good training on that and on the background and what do you do that's why I think it's so important as right here is amazing resources that we keep talking to each other we keep supporting each other but I love that these are common questions and I falsify information all the time we're going to take a Jackie say is that one a 10 minute break so the bathrooms are right out there we wanted everyone to realize in this room just by the conversations we're having they're amazing amazing experts and so before we go on to our next activity I wanted you all to have a chance to stand up and say who you are and something that you're an expert in that you could share with the group because Jackie's going to be sharing the email list with all of us how we can help each other out and that kind of helps us also to prepare for the next activity so I'm going to have you go around and just be like hi I'm Mary Ann who and I work at Ocapica and one of my expertise is working with some of the Asian and Pacific Islander communities or at least I know who to ask for that information so something quick I'm going to have a start with a help it's oh my gosh did you hear the amount of experience even though you all are lying yes you are in this room you have so many resources and the whole idea of coming together is about working together so now you're looking for someone who's here to work you have like half the room you know whenever we're working with Latino communities you have so many people Muslim Middle Eastern we have so many groups if you want to become a sex part you see Joan back you'll never ever live that down but you have mental health you have healthcare it's all in this room so I know that we've come together for training but we're training each other is the main thing so I think there's so many connections that could be made to improve that because now we're going to do a quick break out kind of brainstorming again and I'm going to give you some different scenarios and in your groups I want you to be able to think what are some key issues that you need to think about you don't have to answer all the questions I just put some questions on the scenarios just to get you thinking and we'll do that for about 10 minutes and then have another 10 minutes the only thing is I made 8 case scenarios I need a couple of 2 tables to combine so we're going to get started again because we're getting it's almost lunch who had to promote HPV vaccine for Vietnamese girls who had the case promote HPV vaccine for Vietnamese girls or you did? there's one person who can just briefly just summarize the conversation or the issues that came up you don't have to have answers but just sort of what are issues that came up or things that you would want to do we got into a big debate as to how we don't need to talk about prevention and prevention trends but no in the community it's associated with sex how do you get half that barrier and it's for the protection when people feel like well it's not applicable to my child because she's not healthy for the young ages so try to get around that and more community education and explaining and taking that stigma away that it's more for your health and the future and that it's to the benefit of the person taking it to the 140 years old this is the window of time to take it and so get past this thing where there's sex and all of that stuff especially focusing on prevention and prevention I think that's really great so the scenario was Vietnamese women have a high incidence rate of cervical cancer but the HPV vaccine the what is it? whatever that is that virus if you eliminate that virus isn't it like 90% of cervical cancer can be prevented not an expert by promoting the vaccine you would just think oh let's just promote the vaccine everyone get vaccinated but just like what you're saying it's stated with sex it can be stigmatized so I like how you thought about let's destigmatize it let's talk about it being a part of our health care and a part of prevention it's something we want to think about do it now to prevent it later on and then the other issue is that it is covered by a lot of insurance but a lot of people don't have access to insurance so he was trying to find other alternatives like the Asian Health Center some other community-based organization does the websites provide for creators so that's that's excellent too so being aware of where the community if there's a high uninsurance rate if it's not covered, what community clinic where can they go to get it covered I think maybe Vietnamese media is huge in Orange County too just maybe going on a radio show and talking about it and having a provider and talking about that is safe too because not a lot of people know about it but I think that's great thank you the next let's conduct homography screening with Muslim women who had that what we talked about and what we felt was really key for this was to partner with a Muslim agency to understand all of the cultural aspects and whatnot of that culture and be sensitive to the fact that the women very much respect their bodies and they would prefer or almost are very adamant about a woman-to-woman gender basis, woman-to-woman screening and whatnot and also to check organizations such as Susan G. Coleman to see what grants were awarded that could help with the funding for some of the mammogram screening and to promote in some way maybe free screening like they said because that's a difficult thing we felt for that culture to go out and have the screening done and also take a look at the materials of brochures and whatnot that are available to the organizations and see if we could have that translated into the different languages Farsi and so on and and then I'll find out and find out where their communities are and then work with the partnership of the Muslim agencies in those certain communities but basically try to understand through the partnership how to approach and how to be to get the trust from that community to go in and tell them that the key message would be early detection saves lives and I think that's key for any of the cultural competency is to understand the culture before you go out there and try to promote anything because you have to be very, very sensitive because in some ways one certain thing may be affected in one culture and then in another culture it is not and I've had that happen to me where something I've done in one culture situation has been okay and then find out I could not use that same approach somewhere else so I don't know have I missed anything else using their media using their media any language with small quality Muslim languages okay that's good so what they were saying is finding working with the Muslim community working with community agencies working with Moss but also working with Susan G. Coleman breast cancer experts bringing together is Coleman probably already doing this someone so I know why I have that is because I think it's either in Ohio or in Iowa so one of the states has the pink hijab program which the women are wearing pink scarves and the Muslim community started a really good breast cancer program somewhere in the Midwest so I thought that was so great but it's really working in partnership I think you said it right you're saying we're not the experts we want to find out we want to work with in partnership and we want to find money not saying we're going to start a program and we're going to do it we're going to work in partnership improved diabetes control for elderly Latinos who had that? yes we had that that question for us and some of the issues we needed to be aware of was that we have a lot of cultural issues there's a lot of denial and distrust in the patient and the doctor the patient doesn't want to believe that they don't have the trust in the doctor to actually take the recommendations and if you don't accept your own disease you're not going to be able to make changes so there's that cultural trust denial barrier that we have we have a problem in the environment we have a problem with the lack of physical activity lack of diet and we have multiple diseases in addition to that that we need to be uncontrolled and then some of our barriers are language, education transportation issues and most of Latinos probably will have insurance the ones that are undocumented are already having these problems and they can't go to the doctor to give this any care of and diabetes is a very expensive thing to take care of and it's not just the pill it's either insulin which is expensive and all pills and the injections and the strips and the glucose monitor and sometimes they're not covered by insurance so it's a rich man's disease and we've been looking at the old income adults and seniors so that's going to be something that we really find to take care of here with and also what we want to do is we message them to go get screened for diabetes and of course with this adult population we would suggest to send them to the free health clinics where they actually do free testing and they're all over the place free health fairs or clinics or wherever there's something available and they get them for free and that would at least they could be aware and hopefully they could start doing something about it so we would use schools because diabetes is more of a family thing there can't be one person who has a lot more diet the whole family has to have a diet together so it would be a school because start up a school is giving out education to the entire family so they should look at kids and older adults and living in the house and we would use newspapers we would use churches a lot of Catholic organizations could actually help them maybe partnering up with other health fairs, health community programs out there to get them together to work and actually maybe take me to the church and have the fair there and also use legislative offices which like I said we're always there to help promote whatever you have to offer to the community that's great, that's excellent actually you hit on so many different things, ideas, it's a family issue, it's expensive it is really expensive people get blamed all the time why you have diabetes, lunch, teen care but if you don't have access to exercising to healthy food if you eat the strips the machine everything the medicine are so expensive we have a lot of people who end up sharing medications it's very common what happens when you go to the doctor sometimes you get blamed well I told you to do this I told you to do that so for a lot of community members they're like I'm trying, I'm trying but there's all these barriers say I really thought it was great that you want to go into the schools the churches, the media so it's great you hit on everything so that's excellent good job promote healthcare for homeless they're also at risk for drugs prostitution criminal activity some of the barriers that they have is that they are underaged they can have some access to clinics that are teen clinics that provide mental health and sexual health health-related care but they're not, they can get physical or they're immunizations or they're immunizations without pressure some kind of legal services can they're also these kids do go to school a lot of them aren't in schools there's a lot of services to schools we have laws that protect them and there's a lot of permissions in schools public health and how do we reach them but we thought that maybe the way to reach them is to really train people and how to help them get access but also to get things here and community health workers to be able to leave them in places where they're at and help them out they are a many fun I watched the homeless adult man and they also think that themselves when these kids are going to have something they can teach you text message they're never creative another thing is food problems so if they come in and get physical or whatever they can get some kind of incentive that's great I hadn't worked with homeless youth before we had a client a participant and I'm like you want a brand new backpack you want all these bus passes and she got beat up for all of that and I was just like I didn't even think about and the next time she was like can I have a beat up backpack or an older one this was too new or I can't carry all these gift cards around so I think what you're saying is working through the schools having the clinical services there working with the teachers and you guys were right on all of the issues that might come about to be sensitive to so I think that was great safety and things that folks don't even realize I just never realize about all the safety issues and you're right about the cell phones we text all the time and they get the 30 day the cards and everything promoting and conducting cervical cancer screening with transgender individuals go ahead you do I have to say I think we have the toughest I'm like wow we need this expert the first informer is that we need to be educated and really understand how transgender is identified and how they're identifying themselves and be sensitive to that and the most important thing we discussed is really going to that community because there's not a lot of information statistics and everything on this population so we really have to go straight to the source and have one of our groups suggested having focus groups and going through some of the associations they exist and one of our members talked to that on the university campuses now there's groups and clubs and so we would have to go to those sources to really find out what the barriers would be and really have an understanding of some of the misconceptions and they are involved and then we would need to educate that population on why their health is important that even though they've changed genders they still have issues to deal with from being female and now being male you know they're still they might have health issues that they matter that they care about them that they're interested in taking care of their health needs and then so they would use organizations and universities to get the word out that's how they would reach and then using social media and thinking of different age groups and how to reach the different age groups for younger people it might be but for an older person it would be something you know some other form and then using peer advocates to educate or promote tourists like that type of program and and then we already talked to who we would ask help from so I think we covered everything yeah you did you have our example but you know this is so important I think you hit it your group hit it right on the nose and really go and ask for help bring the community in and ask what they want well we were talking about what their resources will use once we educate ourselves on the culture as then what can we collect from you what you guys really need and who do we want to ask help for from them it's never for me it's always working together yeah so that's for me thank you need to recruit a young solo and female into mental health services who did that one was it the table in the back yeah no person like to stand up and okay so we talked about issues that we're aware of just she's a high school student and she's a female she lives with six other family members they have one bedroom apartment so just she's a teenager going through the high school experience she's also a female living with brothers and grandparents on the living conditions someone mentioned that there might be like needs at home low income families they don't have access to different resources just the mental health access barrier but that signifies mental health if we were talking to the parents she's 60 years old it's really difficult to try to get the parents to understand the importance of mental health and the resources provided for mental health and also somebody also mentioned sexual orientation of the student as well so how we reached the student it's just one of the parents that she is of other ages trying to get to the parents trying to walk up to them also find other community partners that also work with a similar community just so that they can feel comfortable to speak to others and maybe ask them if that's something they need so I also mentioned around the world she is in high school so working with the school to see there's a mentorship work there or maybe the school of psychology so the school counselor can help us with giving us the opportunity to put into the work with the family so another person also said just providing support services of tangible services such as the bus passes or the gift cards to buy groceries and she's shown signs of a severe depression outside external factors so just providing more tangible support services what resources will we use and what we ask for it's just the partners that we here in this room are just you know, Googling in Orange County there's the one community organization that comes out that's great one of the key issues that's actually one of our cases and one of the I guess not challenges but one of the things we had to do first we had to talk to the grandfather the grandfather was saying my child my granddaughter is not crazy we're not coming in and we had to build rapport and build trust and talk to the grandparents and for me I would have just went straight to the girl to the young woman and talked to her that would have been the wrong way and I wasn't even thinking about talking to the grandparents but I think all the resources and talking to organizations Google is like a life saver but just getting out there and talking to different people and talking to one of two someone clinicians in the area but even Lorraine who is someone and she's a clinician it takes her a long time to build rapport and trust she has to say this is who I am so but I think you're doing all the right steps so let's find information let's work with people let's try and offer resources let's build trust that was good so good job okay assist Korean adult male working in his own business and who has colorectal cancer who had that oh okay if you were aware of so who has other expertise regarding the Korean culture that he was male to be working very hard long hours and that one of the major problems would be that he may not have health insurance and what we do we're going to take into account what primarily may be work whether they go get treatment and we're going to take into account his cultural background so we would go into what may be barriers such as the insurance and the language so we would look for community based programs that would help us in researching what would be out there in the community in New York and to go for treatment or follow up for education and we would just also find out whether he supports his community his family his religion and I think that that's great this is actually a case that was presented at St. Joe's and it's true he was working all the time he had to work all the time he didn't have but he was going to get his treatment but I think for the Korean community and working with the pastors working with the churches to support him this case actually he didn't tell anyone he had cancer and he was uninsured so just being able to get those resources for him and helping this person working around with the resources that could support him so that's really good okay and the last one I'll say cancer screening for African-American men the middle one the man the man the man one of the issues that we're talking about is a group and it doesn't just apply to just African-American there's a lot of men instead of the exam itself doesn't seem to be very popular with them the actual process of doing the medical exam causes a lot of concerns about maybe demasculinating whether it's sexual orientation so because of that they may not go and get screened for this so instead of focusing on the actual screening we're promoting this program for screening is we thought about focusing on the role of being a guy seeing the positive roles what would happen if you were not here because you didn't go get screened you could be someone's father you could be someone's friend so we want to highlight those positive roles that we all have and then the screening process would happen that's perfect I like that you changed it from you're going to die so much to or get the screening and have them being your digital exam instead of really promoting what your role as a man including you take care of and really put it positive and I like that you changed the connotation because yeah when you think about cancer a lot of people might equate it with something worse or they might equate it with that but I think by changing it back to what your role so that was great so I think you did so great on all of the examples and I really appreciate it I think you should give her a clap for yourself so last slide I'm just going to tell you why I put the last slides in there we're about a Catholic experience of community based participatory research and how I think CBPR is equated with culturally competent research when you do CBPR you become culturally competent you're doing research in a culturally competent way and once a Catholic has started doing that we were able to get quite a bit of resources and support and funding to really do our work and I think that a lot of agencies are really recognizing a lot of different federal and county agencies are recognizing that but it's all about working together in the community and this just shows we did a lot of journal articles we have a community IRB where a national center is of excellence and it was really what we just talked about not just asking the community to translate but to truly partner and universities what they can do and universities gain so much and the community gains so much but it's about working together and understanding each other so we don't expect the universities or the hospitals to just say we'll do it our way this is our culture to be late every day or to do this we need to also understand each other's culture we know everyone's on deadlines and has to get things done so we have to respect each other's organizational cultures as well and these were just the meaningful aspects of doing community based participatory research that everything's from the community and that the community is very proud of what it's accomplished and thank you a few minutes did you guys have any questions thank you and I think oh thank you I feel like I think that this has some reminders I wanted everyone to thank Mary Ann once again for her presentation but I thought it was a really nice quote from the national centers of cultural competence so I thought it was a nice quote to remind us why we all came here I don't think that we will all become culturally competent as a result of today's screening but I think as folks have mentioned throughout the day that it is life is the journey of life and as we understand more and inspire new passion and respect for others I thought it was a nice quote to help out today just a couple of quick reminders on the left side of your folders is a bright neon green evaluation form you can fill that out and drop it off in the back that would be great this is not an endorsement but I wanted to share information with you in the back there's a bright pink neon form Prop 29 is on the ballot in June and I don't think that most people are aware of it what it is is a proposition that would add a dollar tobacco tax on cigarettes that doesn't affect you but if you do unfortunately it does but what we do, if all the smokers in California stay smokers, we're going in over $600 million in cancer research alone in the state of California which is more than NIH gives out to the entire country so if you care about cancer and the people around you and tobacco prevention programs and cessation, that's also where my needs will go this is something you might want to pick up and share with others there's also volunteer forms that are interested also in the middle of your tables my local orange and yellow cancer coalition has some free webinars that are upcoming that also make it really great and one of the upcoming ones is the cultural competency panel if you will I'm addressing breast health for most diverse communities in Orange County so those are just some information a reminder that there is a funding opportunity with the ICTS incubator awards and the main goal of these workshops so the networking, Marianne shared the wealth of resources in the room want to also start coming with these workshops is the opportunity to receive technical assistance from folks like myself who are masters of nothing but juggies of all trades in evaluation resources to help write grant proposals and also the opportunity to be a partner of the faculty researchers particularly from UCI in California especially those of you who are attending the whole series start coming with ideas opportunities and simply because someone's not in the room doesn't really know how to connect to the right resources and I was not joking and I might regret it later about the ICTS incubator awards this is why Shannon and myself are here to help build these relationships and to help provide technical support I know that you all have great agencies with lots of resources and we're also happy to help build those relationships and to provide those resources as well so please think about that and consider that and we're also open to meeting other opportunities Lastly, if you are participating in the five series there is a workshop segment so please fill out your WMIs to get those back to me and to recognize and thank you to all of the communities that are there for the wonderful space today and again to thank Mary Ann for her time and the ICTS folks for helping to bring those workshops. Thank you.