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  • Implicit Bias: Impact on Maternal Health in Minority Populations

    Calista Kelly, PT, DPT, ACEEAA, Cert. MDT

    Disclosures 

     

    Presenter Disclosure:

    • Financial: Calista Kelly is employed by Continued.com.
    • Non-Financial: Calista Kelly has no non-financial disclosures.

    Content Disclosure: This learning event does not focus exclusively on any specific product or service.

    Sponsor Disclosure: There is no external sponsor for this course.

     

    Limitations/Risks

     

    • Awareness is not impact. Reading about bias can raise knowledge and self-awareness, but it does not reliably change clinical behavior or patient outcomes on its own; completion should not be mistaken for improvement in practice.
    • DEI and cultural competency. Cultural-competency framing can drift toward checklist "mastery" of groups and reinforce the very stereotyping it aims to reduce, so it must be paired with cultural humility; learners should also remember that implicit bias, structural racism, cultural competency, and DEI are often separate licensure requirements, and that this is a contested space where defensiveness can undermine engagement.
    • Format and assessment. As a self-paced written activity assessed by a multiple-choice test, the course measures knowledge rather than skill or team behavior, and it can only model interprofessional collaboration rather than have learners practice it.
    • Data currency and fit. The statistics are time-sensitive and will need updating. Reliable data for some high-risk populations are limited or suppressed, and national figures may not reflect a learner's local patients or setting.

     

    Learning Outcomes

     

    After this course, participants will be able to:

    • Describe implicit and explicit bias, explain how each develops through lifespan socialization and can influence interprofessional team members’ interactions with childbearing patients, and identify resources team members can use to examine their own biases.
    • Recognize how bias and power differentials between clinicians and patients can affect the patient and the patient and team relationship.
    • Describe structural racism and how it forms, explain its impact on maternal health, and identify risk factors for and patterns of maternal morbidity and mortality across White, Black, Hispanic, Asian, and American Indian and Alaska Native populations in the United States.
    • Describe infant mortality in the United States and its ties to maternal health, and explain the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients.

     

    Introduction: Why This Topic Belongs to the Whole Team

     

    Pregnancy and the year that follows it are among the most medically and socially intensive periods in a person’s life, and they are also a period in which the United States performs poorly relative to its wealth. Maternal deaths in this country have remained stubbornly high, and they fall unequally. In 2023, the national maternal mortality rate was 18.6 deaths per 100,000 live births, but the rate for Black women was 50.3 per 100,000, more than three times the rate for White women (Hoyert, 2025). These differences are not explained away by income or education, nor are they a recent accident. They are the visible surface of two deeper and interacting forces: the everyday operation of bias inside clinical encounters, and the long history of structural racism that shapes who gets sick, who is believed, and who survives.

     

    This course is written for an interprofessional audience. The perinatal team is larger than many clinicians assume. It includes obstetric and nursing staff, but it also includes behavioral health clinicians who treat perinatal mood and anxiety disorders, physical therapists who manage pelvic floor dysfunction and musculoskeletal pain in pregnancy and postpartum, occupational therapists who support feeding, infant development, and a parent’s return to daily activities, speech-language pathologists and audiologists who screen and treat newborns and follow infants at developmental risk and respiratory therapists who manage the breathing support that premature and medically fragile newborns depend on and who help care for mothers facing respiratory complications of pregnancy. Each of these professionals interacts with childbearing patients and their families, often at moments of vulnerability, and each carries the same human cognitive machinery that produces bias. A course built for only one discipline would miss the central point of this material: that bias and its consequences are a team problem and a team responsibility.

     

    The interprofessional framing also matters because the evidence base points toward team-level change rather than individual heroics. Education planned by and for the healthcare team, in the language of Joint Accreditation, is designed to change how team members work together, not simply to update one clinician’s knowledge. The four competency domains commonly used to organize interprofessional practice, namely values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork, will recur throughout this material because reducing the harm of bias depends on all four. A physical therapist who notices that a patient’s pain reports are being dismissed, an occupational therapist who hears a colleague describe a family in stereotyped terms, or a behavioral health clinician who recognizes that a patient has stopped trusting the care team, each holds a piece of the solution, but only if the team has the shared values, role clarity, and communication habits to act on it.

    This is sensitive material. Discussions of racism, bias, and preventable death can be uncomfortable, and discomfort is an expected part of learning in this area (Campbell, 2025). The goal here is not to assign guilt but to build accurate understanding and practical skill. Bias is a feature of normal human cognition, present in well-intentioned people, and the question is not whether a clinician has biases but what the team does about them. With that framing in mind, the course moves from the psychology of bias to how bias forms and operates in clinical relationships, to the structural forces surrounding those relationships, to the maternal and infant outcomes at stake, and finally to what the interprofessional team can actually do.

     

    A word about how to engage with this material will help. The most useful posture for a learner here is neither defensiveness nor self-flagellation, but curiosity. The aim is to leave with a more accurate model of why a group of well-meaning professionals can nonetheless participate in a pattern of unequal outcomes, and with a concrete sense of which of one’s own habits and which of the team’s routines are worth changing. Where the course presents numbers, it presents the most recent national figures available and names their source, so that a reader can see that the disparities described are not rhetorical but measured. Where it makes a claim about how bias operates, it ties that claim to the research literature rather than to anecdote. And throughout, it keeps returning to the same practical question that interprofessional education is designed to answer: not what should I, alone, believe, but how should we, together, work, so that the next patient is heard, believed, and kept safe regardless of who she is.

     

    Section 1: Implicit and Explicit Bias Defined and Differentiated

     

    A bias, in the most general sense, is a tendency to favor or disfavor a person, group, or idea in a way that interferes with fair judgment. In healthcare, the term usually refers to attitudes about social groups that shape how a clinician perceives, communicates with, and treats a patient. Two broad categories are useful to distinguish at the outset, because they form and operate differently and call for different responses.

     

    Explicit bias refers to attitudes and beliefs that a person holds consciously and can report. A clinician who openly believes that members of a particular group are less reliable historians of their own symptoms holds an explicit bias. Explicit biases are, by definition, available to introspection, which means they can be stated, defended, argued with, and, in many settings, socially discouraged. Most clinicians sincerely endorse the value of treating every patient equally, and on explicit measures, healthcare professionals tend to report egalitarian attitudes (FitzGerald & Hurst, 2017). That sincerity is real and part of what makes the second category so important.

     

    Implicit bias refers to attitudes and associations that operate outside of conscious awareness and intention. These are automatic mental shortcuts: learned associations between a social group and a set of traits, evaluations, or expectations that activate quickly and without deliberate thought. Because they are unconscious, implicit biases can run contrary to a person’s consciously held, explicitly egalitarian values, and a person can be entirely unaware that the bias is influencing a decision (Campbell, 2025). This is the crucial difference. A clinician can honestly believe that they treat all patients the same and still, in the rushed and cognitively demanding environment of clinical care, act on associations they would reject if asked about them directly.

     

    The mechanism is rooted in ordinary brain function. Implicit associations are formed through repeated exposure to messages and patterns in the surrounding culture, and they can be rapidly activated when the brain encounters socially relevant cues, producing a fast, automatic evaluation before slower, deliberate reasoning has a chance to engage (Campbell, 2025; Josiah et al., 2023). This speed is adaptive in many contexts because the brain must constantly categorize and predict, but it becomes a liability when learned associations are inaccurate and attach negative expectations to a patient based on race, ethnicity, language, body size, age, disability, or other group membership.

    A widely used research tool for detecting implicit associations is the Implicit Association Test, which measures how quickly people pair concepts, on the premise that more strongly associated concepts are paired more quickly. Research using such measures has repeatedly found that healthcare professionals, as a group, show levels of implicit bias similar to those of the general population, and a systematic review of this literature concluded that such bias among healthcare professionals is associated with measurable differences in the care patients receive (FitzGerald & Hurst, 2017; Hall et al., 2015). In other words, entering a caring profession does not exempt a person from the associations absorbed from the broader culture. It is worth noting that individual scores on these tests are not a diagnosis of a clinician’s character and do not perfectly predict any single decision; the value of the research lies in establishing, at the population level, that the phenomenon is real and pervasive.

     

    Why does the distinction between explicit and implicit bias matter for the interprofessional team? Because the two require different countermeasures. Explicit bias can sometimes be addressed through policy, accountability, and direct feedback, since the attitude is available to the person holding it. Implicit bias is not reachable in the same way, because the person is not aware of it. Telling a team to simply try harder to be fair is therefore an incomplete strategy, since the biases most likely to slip through are the ones no one intends. Effective approaches, discussed in Section 7, work by changing the conditions under which automatic associations get a chance to drive behavior, for example, by slowing decisions at high-stakes moments, by standardizing how symptoms are assessed, and by building team habits that catch what an individual misses.

     

    It also helps to see how an implicit association becomes a clinical decision, because the pathway is rarely dramatic. Clinical reasoning depends heavily on rapid pattern recognition, the experienced clinician’s ability to size up a situation quickly, and that same speed is what allows an unexamined association to enter the judgment unnoticed. The bias does not announce itself as prejudice. It shows up as a slightly lower index of suspicion for one patient than another, a quicker readiness to attribute a complaint to anxiety or drug-seeking, a marginally shorter visit, less eye contact, fewer open-ended questions, or a faster move to reassurance rather than investigation. Any one of these is small, and any one could have an innocent explanation, which is exactly why bias is so difficult to catch in the moment and so consequential in the aggregate. Across thousands of encounters, small differences in suspicion, attention, and effort accumulate into measurable differences in the care that groups of patients receive (Campbell, 2025; FitzGerald & Hurst, 2017).

     

    A further nuance is that implicit and explicit attitudes can point in different directions within the same person, and the relationship between what a clinician sincerely believes and how a clinician automatically reacts is loose rather than fixed. A clinician may hold strong, genuine egalitarian commitments and still carry implicit associations absorbed from the surrounding culture, and under ordinary conditions of fatigue, time pressure, and cognitive load, it is the automatic system that often wins (Campbell, 2025). This is why the sincerity of a team’s stated values, though real and important, cannot be the whole of its safeguard. Values shape the explicit layer; they do not automatically reach the implicit one. Recognizing this gap is not cynicism about clinicians’ character. It is an accurate account of how the mind works, and it points toward solutions that do not depend on individuals simply wanting to be fair.

     

    It is also worth being precise about what implicit-bias measures can and cannot tell us, because misunderstanding this point has fueled both overclaiming and backlash. Tools such as the Implicit Association Test are research instruments that reliably detect automatic associations at the group level, and the body of evidence using them demonstrates that clinicians, like everyone else, hold such associations (FitzGerald & Hurst, 2017). What these tools do not do well is predict, with precision, what a particular clinician will do with a particular patient on a particular day. A clinician should therefore neither treat a personal test result as proof of guilt nor dismiss the entire phenomenon because the prediction at the individual level is imperfect. The defensible reading of the science is the moderate one: implicit bias is real, common among well-intentioned clinicians, and capable of influencing care, while remaining only one of several forces acting in any given encounter (Campbell, 2025; FitzGerald & Hurst, 2017).

     

    For every profession on the perinatal team, the practical translation is the same. The audiologist interpreting a parent’s response to a newborn hearing screen, the speech-language pathologist judging whether a feeding concern warrants follow-up, the physical therapist deciding how seriously to take a postpartum patient’s report of pain, the occupational therapist assessing a parent’s engagement with an infant, and the behavioral health clinician forming an impression of a patient’s risk, are all making rapid judgments under time pressure and uncertainty, which are exactly the conditions in which implicit associations exert the most influence. None of these clinicians is choosing to be unfair, and most would be distressed to learn that an outcome had turned on an association they never endorsed. That is precisely the point. Recognizing that these everyday, well-meant judgments are vulnerable is the first step toward protecting them, and protecting them is a task that the following sections show is best carried out by the team rather than left to the individual.

     

    It is worth naming explicitly the conditions under which an automatic association is most likely to slip past a clinician’s better judgment, because those conditions describe ordinary clinical life rather than rare exceptions. Bias tends to exert the greatest influence when a decision is made quickly, when the clinician is fatigued or stressed, when cognitive load is high, when the information available is ambiguous, and when the clinician must rely on first impressions rather than accumulated knowledge of the individual patient (Campbell, 2025). Each of these is a routine feature of perinatal care: the triage decision made in a busy unit, the late-shift assessment by a tired clinician, the brief first encounter with a patient whose history is incomplete. This matters for the team because it means that the moments of greatest vulnerability to bias are predictable, and predictable vulnerabilities can be designed around. If the team knows that the rushed, ambiguous, first-impression decision is where bias is most likely to enter, it can build in the deliberate pause, the second look, and the standard protocol precisely at those points, rather than relying on individuals to summon extra fairness at the very moments when their capacity to do so is most depleted (Campbell, 2025; Hagiwara et al., 2024; Kirwan Institute, 2013).

     

    Bias also comes in more than one form, and a shared vocabulary helps a team recognize the particular pattern at work in a given encounter. Beyond the racial and gender bias most often discussed, the cognitive-science and healthcare literatures describe a family of related tendencies: affinity bias, the pull toward people who resemble us; confirmation bias, the tendency to notice and weight information that fits an expectation already formed; anchoring, the overreliance on the first piece of information encountered; attribution bias, the tendency to explain another person’s behavior in terms of character rather than circumstance; the halo and horns effects, in which one salient trait colors the whole impression; and name bias and bias based on perceived weight, body type, age, education, or socioeconomic status (Kirwan Institute, 2013). These are not separate phenomena from implicit bias but specific shapes it takes, and in the perinatal setting, each has a concrete cost. Anchoring on an initial impression of a patient as anxious can crowd out later physical signs; confirmation bias can lead a clinician to register findings that fit a benign explanation and discount those that do not; and weight or age bias can quietly lower the seriousness with which a symptom is treated. Naming the specific pattern is useful precisely because the countermeasure differs: confirmation bias calls for deliberately seeking disconfirming evidence, while anchoring calls for revisiting the initial assessment as new information arrives. 

     

    Section 2: How Bias Forms: Socialization, Stereotypes, Prejudice, and "Isms" Across the Lifespan

     

    If implicit biases are learned associations, the natural question is where they are learned. The short answer is that they are absorbed over a lifetime from the social world a person grows up in and lives in. No one is born with a fully formed set of biases, and no one chooses them deliberately. They accumulate through the ordinary process of socialization, the lifelong process by which a person takes in the norms, categories, images, and expectations of family, community, schooling, media, language, and institutions (Campbell, 2025). Understanding this process helps the team see bias as a product of the environment rather than a personal moral failing, which, paradoxically, makes it easier to confront it honestly.

     

    Several related terms are useful to define here, because they are often used loosely. A stereotype is a generalized belief about the characteristics of a group, applied to individuals who belong to it. Stereotypes are cognitive: they are the brain’s categories and the traits it attaches to them. Prejudice is an attitude or feeling, usually negative, directed toward a group or its members. Where a stereotype is a belief, prejudice is the affective charge, the liking or disliking, that often accompanies it. Discrimination is behavior: the differential treatment of people based on their group membership. The suffix “ism,” as in racism, sexism, ageism, ableism, or classism, names a system in which stereotypes and prejudice become organized and reinforced at the level of institutions and culture, so that the disadvantage no longer depends on any single biased individual. These distinctions matter because an intervention aimed at a belief, a feeling, a behavior, or a system will look different in each case.

     

    The lifespan dimension is important. Children absorb associations from the earliest years, often before they have the language to question them, simply by noticing patterns in who is present, who is praised, who is feared, and who is absent in their environment. These associations are then reinforced across decades by repeated exposure to the same patterns in entertainment, news, professional training, and the structure of the institutions a person passes through (Campbell, 2025). For healthcare professionals, there is a specific occupational layer to this story. Clinical training and longstanding medical literature have at times transmitted inaccurate beliefs about biological differences between racial groups, and such beliefs, once learned, can persist and distort clinical judgment, for example, in the historically documented tendency to underestimate the pain of Black patients (Josiah et al., 2023). A clinician, therefore, arrives at the bedside carrying both the general biases of the surrounding culture and any specific misconceptions transmitted through professional socialization.

     

    It is worth dwelling on each of the key terms, because precise language helps a team diagnose what it is actually facing. A stereotype can be positive in valence and still cause harm; the belief that a particular group is unusually resilient or tolerant of pain is a stereotype, and in maternity care, a stereotype of toughness can translate directly into undertreatment. Prejudice need not be intense hostility; a faint, automatic discomfort or a reflexive lowering of warmth toward members of a group is prejudice in the sense that matters clinically, and it shapes the emotional tone of an encounter that the patient feels even when nothing is said. Discrimination, the behavioral layer, includes not only overt acts but also the quiet differentials described in Section 1, the shorter visit and the lower suspicion. And the “ism” layer is what makes the problem self-sustaining: once stereotypes and prejudice are built into curricula, guidelines, institutional routines, and the surrounding culture, they reproduce themselves in each new cohort of professionals without anyone deciding to pass them on (Campbell, 2025; Njoku et al., 2023). A team that can identify which layer it is dealing with is better positioned to choose an appropriate response.

     

    The developmental account also explains why exhortation alone fails. By the time a person reaches professional training, decades of socialization have already laid down the associations, and a sincere adult decision to be fair operates on top of that foundation rather than erasing it (Campbell, 2025). This is not a counsel of despair. Associations that were learned can be weakened and counteracted, and the surrounding environment that produced them can be changed. But it does mean that the goal of self-examination is not to reach a state of being bias-free, which the evidence does not support as a realistic endpoint, but to become reliably aware of one’s vulnerabilities and to build the personal and team habits that keep those vulnerabilities from reaching patients (Campbell, 2025; Hagiwara et al., 2024).

     

    The occupational layer deserves particular emphasis for a clinical audience, because it is the part of socialization that professional training is directly responsible for. Historically, medical and clinical education transmitted false beliefs about biological differences between racial groups, including the durable and damaging myth that Black patients experience or tolerate pain differently, and such beliefs, absorbed during training, can persist into practice and distort assessment and treatment long after they have been formally discredited (Josiah et al., 2023). The maternal health literature treats this history as directly relevant to present-day disparities, because pain and symptom assessment are exactly the judgments through which warning signs of serious complications are recognized or missed (Josiah et al., 2023; Montalmant & Ettinger, 2024). A team that understands this history is less likely to be surprised when a patient’s reported pain is discounted and more likely to build checks to catch such discounting.

     

    Turning to resources, several categories support honest self-examination, and they work best in combination. Validated self-assessment and program-level instruments allow individuals and teams to measure awareness of and mitigation of bias in maternity care and to track change over time, replacing impressions with data and enabling assessment of whether anything is actually improving (Bower et al., 2023). Structured reflective practice, in which clinicians examine specific encounters and their own emotional reactions to particular patients, helps surface associations that stay hidden under the smooth surface of routine. Continuing education, including activities like this one, provides the shared vocabulary and evidence that allow a team to discuss bias without each conversation collapsing into defensiveness or blame. Confidential implicit-association measures can be a useful prompt for personal reflection, provided they are framed as conversation-starters rather than verdicts. And cultural humility, the disposition to approach each patient as the authority on their own life and to remain a learner rather than assume expertise about a patient’s experience, gives self-examination a durable orientation rather than a finish line.

    Putting these resources into practice is itself a skill, and a few principles make the effort more honest and more durable. Reflection is most useful when it is specific rather than general: examining an actual encounter that left a clinician uneasy, or a particular patient toward whom the clinician felt an unexplained reluctance, surfaces more than an abstract intention to be fair. It is also most useful when it is routine rather than occasional, because the associations being examined are themselves the product of constant, lifelong reinforcement and will not be undone by a single sitting (Campbell, 2025). Carrying the work out in the company of colleagues, in a setting where it is safe to name discomfort without fear of judgment, tends to be more sustainable than solitary effort, both because others can see patterns a clinician cannot see in themselves and because shared reflection builds the team culture in which raising the subject of bias is normal rather than threatening. The aim of all of this is not the impossible one of becoming a person with no associations, but the achievable one of becoming a clinician who knows where their judgment is most likely to slip and who has built, with their team, the habits that catch it before it reaches a patient (Campbell, 2025; Hagiwara et al., 2024).

     

    A word of realism is appropriate here, because it will recur in Section 7. The mere act of measuring or naming one’s biases does not, by itself, reliably change behavior, and some popular training approaches rest on weak evidence and have not demonstrated lasting effects on practice (Hagiwara et al., 2024). Self-examination is necessary but not sufficient. Its value lies in opening the door to the structural and team-level changes that do the heavy lifting, and in sustaining the personal vigilance those changes require. For the interprofessional team, the shared goal of this section is a common understanding: that every member arrived with biases they did not choose, that some of those biases were transmitted by the professions’ own training, that these biases are knowable through honest and repeated reflection supported by validated tools, and that naming them is the beginning of the work rather than the end of it.

     

    Section 3: Bias, Power Differentials, and the Patient

     

    Bias does not operate in a vacuum. It operates within a structurally unequal relationship. In almost every clinical encounter, the clinician holds more power than the patient: more specialized knowledge, control over access to tests, referrals, medications, and documentation, the authority to define what counts as a legitimate concern, and the social standing conferred by a professional role. The patient, by contrast, is often unwell, anxious, undressed, in pain, or afraid, and is dependent on the clinician’s goodwill and judgment. This asymmetry is the power differential, the amplifier that turns a clinician’s private associations into consequences for a real person (Campbell, 2025).

    The amplification works in several ways. First, because the clinician controls the interpretation of the encounter, a biased expectation can quietly become the official account. If an implicit association leads a clinician to expect that a particular patient is exaggerating symptoms, the clinician may document the visit in those terms, and that documentation then follows the patient through the system, shaping how the next clinician approaches them. Second, the power differential makes it costly for patients to push back. A patient who senses that they are not being believed may hesitate to insist, precisely because they depend on the clinician and fear being labeled difficult, which can further reduce the information the clinician receives and confirm the original misjudgment. Third, the differential is steeper for patients who already occupy a marginalized social position, so that a Black patient, a patient with limited English proficiency, a patient with a disability, or a patient with a low income may face a compounded gap in power that makes the effects of bias harder to resist (Njoku et al., 2023).

     

    It is useful to trace how a small interpersonal moment can cascade into a clinical outcome, because the chain is what makes the power differential a safety issue rather than merely a matter of courtesy. Consider a patient whose report of severe pain or unusual symptoms is met with a subtly skeptical response shaped by an implicit association. The immediate effect is that the symptom is investigated less thoroughly. The patient, sensing skepticism and aware of the cost of being labeled difficult, may soften or withdraw the complaint, thereby removing the very information that might have prompted action. The encounter is then documented in language that reflects the original skepticism, and that documentation primes the next clinician to view the patient the same way. The patient, having learned that raising concerns is unproductive, discloses less at the next visit, attends less reliably, and waits longer before seeking help when something is genuinely wrong. In the perinatal period, where the difference between a good outcome and a catastrophe can hinge on whether a warning sign is acted on early, this cascade is not abstract. It is a plausible route from an unexamined association to a preventable harm, and it runs entirely through the power differential (Campbell, 2025; Josiah et al., 2023).

     

    The maternal health literature describes precisely these effects. Implicit bias among clinicians has been linked to differences in communication, in the patient’s experience of care, in treatment decisions, and ultimately in outcomes, and perceived discrimination is repeatedly associated with erosion of the trust that childbearing patients place in their care teams (Josiah et al., 2023; Montalmant & Ettinger, 2024). Studies that ask patients directly find the same pattern from the other side of the encounter: Black and Latino patients have reported lower ratings of provider communication, trust in the provider, patient-centeredness, collaboration in decision-making, and the clinician’s contextual knowledge of them as a person (Blair et al., 2013). Trust is not a sentimental concern in this setting; it is functionally load-bearing. A patient who trusts the team tells the team things, returns to the team, and follows through with the team. A patient whose trust has been damaged, often by an accumulation of small dismissals rather than a single dramatic insult, may do none of these, and the resulting gaps in information and engagement are themselves risks. Because trust is built and broken across many encounters with many professionals, it is inherently a team property, which is part of why the response has to be a team response.

     

    A particularly common channel through which bias reaches patients is the microaggression, a term for the everyday slights, dismissals, and subtle verbal or nonverbal behaviors that communicate a hostile, demeaning, or diminishing message to members of marginalized groups, often without the speaker’s awareness or intent (Sue et al., 2007). If implicit biases are the unconscious associations, microaggressions are among the behaviors that flow from them. In a clinical setting, they take recognizable forms: a comment that presumes a patient’s family structure, a term of endearment used in place of a name in a way that infantilizes, an expression of surprise at a patient’s competence, or a documentation choice that subtly casts doubt on a patient’s account. Language is central here because subtle word choices can carry biased assumptions and because the effects of biased language extend beyond a single bruised feeling, shaping health outcomes and reinforcing the belief systems behind discriminatory practices (American Medical Association, 2021). Nonverbal behavior matters as well, since bias can register in reduced eye contact, greater physical distance, or a colder tone that the patient perceives even when nothing overt is said. For the interprofessional team, the practical point is that respectful, person-centered language and attentive nonverbal communication are not merely courtesies but are themselves part of safe care, because they protect the trust on which a patient’s willingness to disclose depends.

     

    The differential is also not uniform across patients, and the concept of intersectionality helps explain why. A patient may occupy several marginalized positions at once, for example, as a Black woman with a low income and limited English proficiency, and the disadvantages do not simply add; they interact, producing a steeper and more complex power gap than any single characteristic would predict (Njoku et al., 2023). A clinician who is attentive to race but not to language, or to disability but not to class, may still leave large blind spots. The practical implication is not that clinicians must catalog every dimension of a patient’s identity, which is impossible in the moment, but that they should hold their confident first impressions loosely, especially for patients whose social position differs most from their own, and lean on the structures and the team that the rest of this course describes.

     

    The interprofessional lens makes the power differential more visible because different team members sit at different points in the hierarchy and see different parts of the patient’s experience. A patient may feel unable to question a physician but may speak more freely with a physical therapist during a longer hands-on session, with an occupational therapist working in the patient’s own environment, or with a behavioral health clinician whose role is explicitly to listen. These professionals often function as the team’s early warning system, hearing concerns that the patient did not feel safe raising elsewhere. Audiologists and speech-language pathologists, who frequently have repeated contact with families during newborn screening and developmental follow-up, occupy a similar position of trust. The value of this distributed vantage point is lost, however, if the team lacks the communication channels and the shared sense of permission to escalate what these members hear. A concern that a patient confides to the one clinician she trusts is worth little if that clinician has no reliable way to convey it to the people who can act, or no confidence that doing so is welcome. Recognizing the power differential, therefore, points directly to a teamwork solution: structures that flatten the hierarchy enough for patient concerns to travel, regardless of which team member first receives them, and a culture in which raising another professional’s possible blind spot is treated as good care rather than as an affront.

     

    It is worth dwelling on trust as a clinical resource because it is easy to file under bedside manner and thereby underestimate it. In the perinatal period, the patient is often the first, and sometimes the only, person who can detect that something is wrong in her own body, and the system’s ability to act on that early signal depends entirely on whether she reports it and is believed. Trust is what makes the reporting happen. A patient who trusts her care team will mention the headache, the swelling, the strange breathlessness, the dark mood, and will do so early, when intervention is easiest; a patient whose trust has been worn away by accumulated small dismissals may say nothing until a crisis forces the issue, by which point the window for easy intervention may have closed. The maternal health literature links perceived discrimination to this erosion of trust and treats the resulting disengagement as a contributor to worse outcomes rather than as a mere matter of patient satisfaction (Josiah et al., 2023; Montalmant & Ettinger, 2024). Because trust is built and spent across many encounters with many different professionals, no single clinician owns it, and no single clinician can repair it alone, which is one more reason that protecting it is a shared, interprofessional responsibility rather than an individual courtesy.

     

    A final point concerns the patient’s own account of being treated unfairly. Patients are often accurate observers of how they are treated, and a patient’s report of feeling dismissed or disrespected is clinical information, not a complaint to be managed away (Campbell, 2025). Treating such reports as data and responding to them with curiosity rather than defensiveness is one of the most direct ways an individual clinician can reduce the harm that flows from the power differential. It is also a behavior that any member of the team can model, regardless of discipline or seniority, making it one of the few high-value responses that do not require a system change to begin.

     

    Section 4: Structural Racism: What It Is, How It Forms, and Its Impact on Maternal Health 

     

    The bias discussed so far lives inside individuals and the relationships they form. Structural racism is different in kind. It refers to the way that laws, institutional policies, established practices, and cultural norms work together, often without any individual intending harm, to produce and maintain disadvantage for racially and ethnically minoritized groups (Sonderlund et al., 2022). The defining feature of structural racism is that it does not require a biased person in the room. It is built into the systems themselves, so that ordinary institutional functioning automatically reproduces inequity. For this reason, structural racism is increasingly described in the health sciences as a fundamental, upstream cause of health inequities rather than as one factor among many (Sonderlund et al., 2022; Njoku et al., 2023).

     

    How does a structure like this form? It accumulates historically. Practices established in one era, such as residential segregation, unequal access to education and employment, discriminatory lending, and concentrated policing and incarceration, become embedded in the geography and institutions of a society and continue to shape opportunity long after the original policies are formally ended (Sonderlund et al., 2022). One useful way to operationalize the concept for research is to trace specific structural domains and the pathways by which they affect health. For example, scholars have examined how the spatial and racialized clustering of incarceration, itself a product of structural racism, is associated with adverse birth outcomes in the surrounding communities, illustrating how a structure seemingly remote from the delivery room can reach into pregnancy and birth (Sonderlund et al., 2022). The general lesson is that structural racism operates through many intermediate channels, including where people can afford to live, the quality of the hospitals accessible to them, the chronic stress of navigating discrimination, and the resources their neighborhoods do or do not contain.

     

    In maternal health specifically, several pathways are well described, and it helps to walk through them, because each suggests a different point of intervention. One is differential access to high-quality care. Because of residential and economic segregation, Black patients in the United States are disproportionately likely to give birth in a concentrated set of hospitals, and care quality across such facilities is, on average, lower on multiple measures, so that two patients with similar needs can receive systematically different care depending on where structural forces have routed them (Montalmant & Ettinger, 2024). This is a clear example of how a structure produces a disparity without any individual at the bedside intending it: the segregation that determines neighborhood, the economics that determine which hospital serves that neighborhood, and the resourcing that determines that hospital’s quality are all upstream of the delivery room, yet they shape what happens in it.

     

    A second pathway is the cumulative physiological toll of living with chronic stress and discrimination over the life course, sometimes described through a weathering framework, in which the sustained wear of stress contributes to earlier onset and greater severity of the chronic conditions, such as hypertension and cardiovascular disease, that drive maternal risk (Njoku et al., 2023). The idea of weathering is important because it dissolves false comfort. It is tempting to assume that a patient who is educated, insured, and financially secure has escaped the effects of racism, but the weathering framework predicts, and the data confirm, that the bodily costs of navigating a discriminatory society accumulate regardless of achievement. This is one reason the Black and White disparity in maternal mortality persists, and in some analyses widens, across higher levels of education and income, with Black women who hold a college degree experiencing worse maternal outcomes than White women with far less education (Kaiser Family Foundation, 2025). If the disparity were simply a matter of poverty or schooling, it would close as those improve. It does not, which points to racism rather than race as the operative force (Njoku et al., 2023).

     

    A third pathway connects structural racism back to the interpersonal bias of earlier sections. Structural and interpersonal racism are not separate problems but two expressions of the same system, and they reinforce each other. Structures determine who ends up in front of which clinician, under what time pressures, and with what prior documentation, and the clinician’s implicit biases then operate within those structurally shaped encounters (Montalmant & Ettinger, 2024). A patient routed by segregation to an under-resourced, overstretched facility meets clinicians who are more rushed, which, as Section 1 noted, is exactly the condition under which automatic associations exert the most influence. The structural and the interpersonal thus compound one another, and an account that addresses only one will leave the other in place. A comprehensive understanding of maternal health disparities, therefore, has to hold both levels at once. Addressing only individual bias while leaving the structures intact will leave most of the problem in place; addressing only structures while ignoring the daily encounters in which patients are believed or disbelieved will miss the mechanism by which much harm is delivered.

     

    The history matters because it explains why the structures are so durable. Researchers operationalizing structural racism for empirical study stress that present-day inequities are the continuation of arrangements built over generations, and that structures established in one era persist through the institutions and geography they shaped long after the original policy is formally repealed (Sonderlund et al., 2022). The illustrative case of the spatial and racialized clustering of incarceration is instructive: incarceration patterns, themselves a product of structural racism, are associated with adverse birth outcomes in the surrounding communities, showing how a structure that has nothing obviously to do with pregnancy reaches into birth through the stress, instability, economic loss, and disrupted social ties it imposes on whole neighborhoods (Sonderlund et al., 2022). The general lesson for the team is that the causes of a disparity visible in the delivery room frequently lie far outside it, in domains, housing, criminal justice, education, and employment that no clinician controls but that together determine the health a patient brings to pregnancy.

     

    A further structural pathway operates through the simple geography of where care is available. Access to maternity services is not evenly distributed, and communities that have been disinvested through the same historical processes of segregation and economic exclusion are also those most likely to face closures of obstetric units, shortages of perinatal providers, and long travel distances to the nearest facility capable of managing a complication (Montalmant & Ettinger, 2024). A patient who must travel far for care, or who has no nearby provider she trusts, is more likely to enter prenatal care late, to attend fewer visits, and to reach a higher level of care only after a complication has advanced. These access barriers are commonly described as social determinants of health, but it is important to see that they are not random misfortunes; they are the predictable products of the structural arrangements described in this section, which is why they fall along the same racial and economic lines as the outcomes they help to produce. For the interprofessional team, this pathway is a reminder that a patient’s pattern of engagement with care, how early she came, how reliably she attends, how quickly she seeks help, reflects the structure of access around her at least as much as it reflects any choice of her own, and that interpreting missed appointments or late presentation as a personal failing repeats the very error this course is meant to correct.

     

    It is worth stating plainly what this section does and does not claim. It does not claim that any particular clinician is racist, nor that race is a biological cause of poor outcomes. The claim, grounded in the literature, is that a system built over generations distributes risk unequally by race, that this system is a major driver of the maternal health disparities documented in the next section, and that it continues to function through ordinary institutional practice unless it is deliberately changed (Sonderlund et al., 2022; Njoku et al., 2023). For the interprofessional team, the importance of naming structure is that it widens the field of possible action beyond the individual encounter, toward the policies, referral patterns, hiring, data practices, and institutional habits that the team and its organization can influence. It also guards against a demoralizing misreading of the earlier sections. If bias were purely a matter of individual minds, the persistence of disparities despite decades of good intentions would be baffling and discouraging. Once structure is in view, the persistence makes sense, and so does the strategy: change the systems, not only the minds.

     

    Section 5: Maternal Morbidity and Mortality: Risk Factors and Patterns Across Populations

     

    To act on maternal health disparities, the team needs a clear picture of the outcomes themselves. Two related terms anchor this section. Maternal mortality refers to the death of a person while pregnant or within a defined period after the end of pregnancy from causes related to or aggravated by the pregnancy or its management. Severe maternal morbidity refers to unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a person’s health, a broader category that includes the many patients who survive a life-threatening event. Morbidity is far more common than mortality, and the two share many of the same risk factors and the same disparities, so that mortality, though rarer, serves as a visible index of a much larger burden of harm.

     

    The clinical risk factors for maternal morbidity and mortality are reasonably well established and will be familiar to many on the team. They include cardiovascular conditions and hypertensive disorders of pregnancy, such as preeclampsia, hemorrhage, infection, venous thromboembolism, and complications of chronic conditions, such as diabetes and obesity, as well as mental health conditions and substance use disorders that contribute substantially to deaths in the year after birth (Njoku et al., 2023). Older maternal age raises risk, and access-related factors, including late entry into prenatal care or no prenatal care, lack of insurance, and limited access to facilities, compound clinical risk (Kaiser Family Foundation, 2025). Several features of these risk factors are worth emphasizing for an interprofessional audience. Many of the conditions are chronic and predate the pregnancy, which means the window for prevention opens long before conception and stays open well after delivery. Many of the deaths occur not during the dramatic hours of labor but in the weeks and months that follow. And the mental health and substance use contributions place behavioral health clinicians squarely among the disciplines whose work bears directly on maternal survival, not at the margins of it.

     

    It is important to connect these risk factors back to the preceding sections rather than to read them as a list of individual patient failings. The chronic conditions that drive maternal risk are themselves unequally distributed by the structural forces of Section 4, and the weathering framework predicts their earlier onset among populations exposed to sustained discrimination (Njoku et al., 2023). The access-related factors are likewise structural rather than personal: whether a patient enters prenatal care early depends on insurance, transportation, work flexibility, the availability of nearby providers, and prior experiences of being treated with respect, far more than on individual motivation. And whether a developing complication is caught in time depends on the interpersonal dynamics of Section 3, on whether the patient’s early reports are believed and acted on. The risk factors, in other words, are where the structural and interpersonal forces described earlier become concrete clinical events.

     

    The way these forces show up in maternity care has been documented directly. In obstetric anesthesia, for example, Black women have been found more likely than White women to receive general anesthesia for cesarean delivery, which carries greater risk than neuraxial anesthesia, and more likely to receive no analgesia for vaginal delivery (Tangel et al., 2020). This is exactly the kind of differential that the earlier sections predict: not a dramatic act of overt discrimination, but a pattern of treatment decisions that diverges by race in ways that accumulate into disparate risk. The same pattern appears in the management of pain more broadly, where Black and Hispanic patients have been shown to receive less effective pain treatment across a range of conditions, a disparity rooted partly in the historical and durable misconceptions about pain described in Section 2 (Aronowitz et al., 2020). For the perinatal team, these findings are not distant statistics but a description of the specific clinical decisions, about anesthesia, analgesia, and the seriousness with which pain is treated, through which bias becomes a measurable difference in the care a childbearing patient receives.

     

    The timing data make this concrete and have direct implications for the team. Among pregnancy-related deaths, roughly one in five occur during pregnancy, nearly a quarter occur during labor or in the first week after birth, and more than half occur between one week and one year postpartum (Kaiser Family Foundation, 2025). The postpartum year, in other words, is not an afterthought but the period in which the majority of these deaths happen, which is precisely the period when physical therapists, occupational therapists, behavioral health clinicians, and pediatric-facing audiologists and speech-language pathologists are often the professionals a family sees most. A patient who has been discharged from obstetric care may still be in active contact with these disciplines, which positions them to notice the warning signs, severe headache, shortness of breath, chest pain, heavy bleeding, signs of severe mood disturbance, that can herald a late and preventable death. Equally important, the great majority of these deaths are considered preventable. Estimates indicate that more than eight in ten pregnancy-related deaths could be prevented (Kaiser Family Foundation, 2025). Preventability is the hopeful core of this material: these are not inevitable tragedies but outcomes that better systems, communication, and follow-up can avert, meaning the team’s vigilance is not a mere formality but a determinant of survival.

     

    It is worth being concrete about what preventability means, because the abstract statistic can obscure the practical opportunity. When review committees judge a maternal death preventable, they identify points at which a different action could have changed the outcome, and those points are distributed across the system rather than concentrated in a single dramatic moment. They include missed or delayed recognition of warning signs, gaps in communication and coordination among clinicians, failures to escalate care in a timely manner, and breakdowns in follow-up after discharge, alongside patient and community factors and the access barriers discussed elsewhere in this course (Kaiser Family Foundation, 2025). Most of these are precisely the failures that an attentive, well-coordinated interprofessional team is positioned to catch. A warning sign recognized during a physical therapy session and escalated promptly, a postpartum mood disturbance identified by a behavioral health clinician and acted on, a feeding or developmental visit that becomes an occasion to ask a recovering parent how she is truly doing, each of these is a potential point of prevention. Seen this way, the preventability finding is not a distant policy abstraction but a description of the everyday clinical opportunities that the team already encounters, and a strong argument that improving how the team recognizes, communicates, and escalates is among the most direct contributions any discipline can make to maternal survival.

     

    The patterns across populations are stark and the empirical heart of this course. In 2023, the overall United States maternal mortality rate was 18.6 deaths per 100,000 live births, a decline from 22.3 in 2022, with 669 maternal deaths recorded in 2023 compared with 817 in 2022 (Hoyert, 2025). That overall improvement, however, masks a persistent and severe racial disparity. In 2023, the maternal mortality rate for Black women was 50.3 per 100,000 live births, while the rates for White, Hispanic, and Asian women were 14.5, 12.4, and 10.7 per 100,000, respectively (Hoyert, 2025). The Black rate was more than three times the White rate and more than four and a half times the lowest group rate. While rates declined significantly for White and Hispanic women between 2022 and 2023, the rate for Black women did not improve and remained the highest by a wide margin (Hoyert, 2025). It is worth pausing on what these numbers represent. A rate of 50.3 per 100,000 is not an abstraction; it means that the everyday experience of pregnancy and birth carries a categorically different level of danger for Black women in the United States than for their White, Hispanic, and Asian counterparts, and that this has remained true even as the overall picture improved.

     

    American Indian and Alaska Native populations require specific attention, both because the relevant learning outcome names them and because the standard reporting can render them invisible. National vital statistics typically report stable rates only for the largest race and Hispanic-origin groups, and for 2023, the data were insufficient to publish a reliable maternal mortality rate for American Indian and Alaska Native and for Native Hawaiian and Other Pacific Islander populations (Kaiser Family Foundation, 2025). This statistical suppression is itself a manifestation of how systems can obscure the populations at highest risk, since small population counts lead to fewer cells being detected, and the groups most affected become the hardest to see in the headline figures. Earlier data make the stakes clear: in 2021, American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander people had pregnancy-related mortality rates of 118.7 and 111.7 per 100,000, respectively, the highest of any groups (Kaiser Family Foundation, 2025). Any honest account of maternal mortality across the five populations named in this course must therefore include the caveat that the groups facing some of the gravest risk are also the ones most often missing from the published rates, and that the absence of a number is not the absence of a problem.

     

    It also bears emphasizing that mortality, however grave, is the narrow tip of a far larger burden. For every maternal death, many more patients survive a severe maternal morbidity event, a near miss in which hemorrhage, eclampsia, sepsis, cardiac failure, or another life-threatening complication is survived but often at the cost of lasting physical and psychological harm. These survivors carry the consequences into the postpartum year and beyond, where they intersect directly with the work of the rehabilitation and behavioral health professions: the patient recovering from an emergency hysterectomy, the patient managing the aftermath of a stroke or cardiac event, the patient whose traumatic birth has left both a physical injury and a mental health sequela. Severe maternal morbidity follows the same racial gradient as mortality, so that the populations dying at higher rates are also those surviving complications at higher rates, which means the inequity reaches a far wider group of patients than the mortality figures alone suggest (Njoku et al., 2023; Montalmant & Ettinger, 2024). For an interprofessional team, this is a reminder that addressing disparities is not only about preventing the rare death but about the much more common experience of harm that falls short of death and shapes a family’s health for years.

     

    Two further facts about the disparity deserve emphasis because they shape how the team should think about causes. First, as noted in Section 4, the Black-White gap persists across education and income levels and is not explained by socioeconomic status, which directs attention to racism rather than individual patient characteristics (Kaiser Family Foundation, 2025; Njoku et al., 2023). This finding is worth repeating because it is the single most effective counter to the common but mistaken assumption that the disparity is really about class. Second, the persistence of the disparity in a period when overall rates improved suggests that whatever drove the general improvement did not reach Black patients equally, a pattern consistent with structurally unequal access to the gains. For the interprofessional team, the central message of this section is that maternal mortality is racially patterned, largely preventable, and concentrated in a postpartum window during which many team members are actively involved, which makes the team’s vigilance and coordination directly relevant to whether a patient lives.

     

    Section 6: Infant Mortality and Its Ties to Maternal Health 

     

    Maternal and infant health are bound together, biologically and socially, and the disparities in one are mirrored in the other. Infant mortality is defined as the death of an infant before the first birthday, and it is widely used as an indicator of the underlying health of mothers, the quality of perinatal care, and the social conditions in which families live (Ely & Driscoll, 2025). When a population’s mothers are sicker, less well cared for, and more stressed before and during pregnancy, its infants die at higher rates, which is why infant mortality cannot be understood apart from maternal health.

     

    The national figures provide the baseline. In 2023, the United States infant mortality rate was 5.61 deaths per 1,000 live births, essentially unchanged from 2022, with 20,162 infant deaths recorded, a 2 percent decrease from the prior year (Ely & Driscoll, 2025). The leading causes of infant death are closely tied to the course of pregnancy: congenital malformations, disorders related to preterm birth and low birth weight, sudden infant death syndrome, injuries, and maternal complications of pregnancy (Kaiser Family Foundation, 2025). Several of these causes, particularly those stemming from preterm birth and low birth weight, are direct downstream consequences of maternal health and the conditions of pregnancy, which is the mechanical link between the two outcomes. An infant born too early or too small because of an inadequately managed maternal condition, a stressful pregnancy, or barriers to timely care begins life at a disadvantage that the best neonatal care cannot always overcome.

     

    The racial patterning of infant mortality parallels the maternal data. Infants born to Black mothers die at more than twice the rate of infants born to White mothers, with Black infant mortality reported at roughly 10.9 per 1,000 live births compared with about 4.5 for White infants and 3.4 for Asian infants (Ely & Driscoll, 2025). American Indian and Alaska Native infants also experience elevated mortality relative to White and Asian infants. The leading contributors to the Black and White gap are the higher rates of preterm birth and low birth weight among Black infants, which again routes the explanation back through maternal health and the structural and interpersonal forces that shape it (Kaiser Family Foundation, 2025). The same disparities, the same upstream causes, and the same persistence across socioeconomic lines that characterize maternal mortality reappear in infant mortality data, providing strong evidence that the two are manifestations of a single underlying problem rather than two separate ones.

     

    For the interprofessional team, this connection is not abstract. The infants who survive complicated pregnancies and difficult births are precisely the population that occupational therapists, physical therapists, speech-language pathologists, and audiologists follow most closely. A preterm infant may need feeding support from a speech-language pathologist, developmental and motor support from occupational and physical therapists, hearing surveillance from an audiologist, and respiratory support managed by a respiratory therapist while the parent navigates the physical recovery and the mental health consequences of a high-risk pregnancy and a fragile newborn, often with behavioral health involvement. These professionals therefore meet the downstream effects of maternal health disparities every day, frequently without naming them as such. Understanding that an infant’s developmental risk and a parent’s distress can both trace back to the same structural and interpersonal forces gives the team a more accurate picture of the family in front of them and a stronger rationale for coordinated, respectful, and vigilant care. It also reframes the team’s work as part of the prevention story: supporting maternal recovery, catching warning signs early, and sustaining a family’s trust in the care system all contribute, however indirectly, to better outcomes for the next pregnancy and the next generation.

     

    The preterm birth pathway deserves a closer look because it is the mechanical hinge connecting maternal health to infant survival and because it carries the same disparity. Preterm birth and low birth weight are among the leading contributors to infant death, and they are more common among Black infants, which accounts for much of the Black and White gap in infant mortality (Kaiser Family Foundation, 2025). The forces that drive preterm birth are not separate from the forces described in earlier sections. The chronic stress captured by the weathering framework, the differential access to high-quality prenatal care produced by structural segregation, and the interpersonal dynamics that determine whether an emerging complication is caught and treated all feed into whether a pregnancy reaches term. An infant born too early because a maternal condition went unrecognized or untreated enters a neonatal course that the most skilled team can only partly rescue. Understanding this chain helps every discipline see that the infant outcomes they manage downstream were partly written upstream, in the quality and equity of the care the mother received, and that improving maternal care is, in a direct sense, infant care as well.

     

    There is also a reciprocal direction to the maternal and infant relationship that matters for the postpartum team. A medically fragile newborn intensifies the stress, sleep disruption, and emotional strain on a recovering parent, raising the risk of perinatal mood and anxiety disorders at exactly the time when the parent is also managing their own physical recovery and the infant’s complex needs. Behavioral health clinicians supporting these parents, and the rehabilitation professionals helping both parent and infant regain function, are therefore working on two interlocking recoveries at once. Recognizing the dyad as a single unit of care, rather than treating mother and infant as separate cases, is consistent with the interprofessional emphasis on coordinated, whole-person care and positions the team to support the family in ways that fragmented, discipline-by-discipline attention cannot.

     

    It is also worth stepping back to see why infant mortality carries such weight as a measure. Because an infant’s first year of life is so sensitive to the health of the mother, the quality of perinatal care, and the social conditions surrounding the family, the infant mortality rate is widely treated as a barometer of the underlying well-being of a whole population, not merely as a count of individual losses (Ely & Driscoll, 2025). When that barometer shows a rate for one group more than double the rate for another, and when the gap traces back through preterm birth and low birth weight to the same maternal health and structural forces examined throughout this course, the disparity is best read as a signal that the conditions supporting healthy pregnancy and infancy are themselves unequally distributed. For the interprofessional team, this reinforces a theme that runs through the entire course: the outcomes that appear at the very end of the causal chain, an infant lost, a mother dead, a complication survived with lasting harm, are produced by forces that operate long before and far upstream, many of which the team’s everyday practice can influence. Improving the equity of maternal care is therefore not a separate project from improving infant survival; it is, in large part, the same project viewed from a different point in the lifespan.

     

    Section 7: The Interprofessional Team's Role in Reducing Bias and Structural Racism 

     

    The preceding sections describe a problem with two levels, the interpersonal and the structural, and the response has to operate at both. This section turns to what the interprofessional team can actually do, with attention to what the evidence supports and what it does not.

    Begin with a note of humility about training. Implicit bias training has become widespread and is now legally required for healthcare professionals in several states (Shah & Bohlen, 2023). Yet a systematic review of implicit bias training for healthcare providers and trainees found that such training is frequently characterized by methodological weaknesses and translational gaps, often diverging from the underlying science and lacking strong evidence of internal, face, and external validity, which means a single training module cannot be assumed to change behavior on its own (Hagiwara et al., 2024). This finding should not be read as a reason to abandon education, which builds the shared understanding this very course aims to provide, but rather as a reason to embed education within a larger system of change and to be skeptical of any claim that a single workshop has fixed the problem. The honest message to a team is that awareness is a starting point and that durable change requires ongoing reflection and structural support (Campbell, 2025; Hagiwara et al., 2024).

     

    At the level of the individual encounter, several evidence-informed strategies can reduce the influence of automatic associations. Honest self-assessment is the starting point, and a widely used entry point is a confidential implicit-association measure, such as those hosted by Project Implicit, which can prompt reflection by making a clinician’s automatic associations visible, provided the result is treated as a conversation starter rather than a verdict (Kirwan Institute, 2013). Counter-stereotypic imaging and the deliberate practice of individuating, that is, focusing on the specific person rather than the group category, can weaken the grip of stereotypes, and perspective-taking and structured reflection can increase a clinician’s self-awareness and empathy, with simulation-based and reflective approaches showing some of the more consistent positive effects in the literature (Campbell, 2025). Practices that reduce cognitive load and stress, including mindfulness and emotional regulation techniques, can help because bias exerts the most influence precisely when a clinician is rushed, tired, and overwhelmed, which is the ordinary condition of much clinical work (Campbell, 2025). Underpinning all of these is the disposition of cultural humility, defined as the ability to maintain an other-oriented stance that remains open to the aspects of cultural identity most important to the patient rather than assuming expertise about the patient’s experience (Hook et al., 2013). None of these is a cure, and measured effects on implicit-association scores tend to be modest and may fade, which is why they work best as habits sustained over time rather than as one-time exercises (Campbell, 2025).

     

    Closely related is the team’s and the organization’s capacity for cultural and linguistic competence. Cultural competence has been defined as a set of congruent behaviors, attitudes, and policies that come together in a system or among professionals to enable effective work in cross-cultural situations (Cross et al., 1989), while linguistic competence is the capacity of an organization and its staff to convey information in a way that is readily understood by patients of limited English proficiency, low literacy, or sensory disability (National Center for Cultural Competence, n.d.). The stakes are concrete: without it, encounters produce incomplete or inaccurate histories, misunderstandings of diagnoses and treatment, problems with medication and informed consent, and avoidable repeat visits. A practical, high-yield example is the use of trained, qualified medical interpreters rather than family members or friends, with attention to difficult-to-translate terms and to the physical arrangement of the encounter. For a perinatal team serving diverse families, including the audiologists and speech-language pathologists whose work centers on communication itself, building cultural and linguistic competence into routine practice is one of the more tangible ways to prevent bias and miscommunication from reaching patients.

     

    The more powerful levers are at the team and system levels, where the interprofessional framing pays off. Standardizing assessment and decision processes, for example, using consistent protocols for evaluating and escalating warning signs such as postpartum pain, bleeding, or mood changes, reduces the room for unexamined judgment to determine who is taken seriously. Validated instruments allow a team or organization to measure awareness and mitigation of bias and to track whether interventions are actually changing practice rather than assuming they are (Bower et al., 2023). Building communication channels that allow concerns to travel across the hierarchy means that what a physical therapist or occupational therapist hears during a long session, or what a behavioral health clinician learns about a patient’s eroding trust, can reach the people who can act on it. Treating patient reports of disrespect or dismissal as safety data and reviewing adverse outcomes with an explicit eye to whether bias or unequal access played a role turns individual events into system learning. Each of these maps onto the interprofessional competency domains: shared values and ethics that center equity; clear roles and responsibilities so that no warning sign is anyone’s blind spot; communication that crosses disciplinary lines; and genuine teamwork that distributes the work of vigilance.

     

    First Domain: Values and Ethics for Interprofessional Practice

    It is worth taking each of those four domains in turn because they give the team a practical structure for organizing its response and convert a broad commitment to equity into specific, assignable behaviors. The first domain, values and ethics for interprofessional practice, asks the team to place the patient’s interest and dignity at the center of its shared work and to treat equity as a professional obligation rather than an optional virtue. In concrete terms, this means the team agrees that a patient’s report of pain or distress is to be believed and investigated regardless of the patient’s race, language, body size, or insurance status, and that respectful communication is held as a standard of care rather than a matter of individual temperament. When equity is named as a shared value, an individual clinician who slows down to take a dismissed concern seriously is acting on team policy rather than swimming against the current, and a clinician who treats a patient curtly can be understood to have departed from an agreed standard rather than merely having an off day.

     

    Second Domain: Roles and Responsibilities

    The second domain, roles and responsibilities, asks each profession to understand both its own contribution and those of the others well enough that important observations do not fall through the cracks between disciplines. In the perinatal context, this means that the physical therapist knows that the postpartum pain she is hearing about could signal a complication that belongs to the obstetric team, that the speech-language pathologist understands that a parent’s flat affect during a feeding session may be relevant to the behavioral health clinician, and that everyone knows who is responsible for escalating a warning sign and how. Role clarity is a safeguard against bias because much of the harm described in this course occurs in the spaces between professionals, where each assumes someone else has noticed and acted. A team that has mapped its roles explicitly leaves fewer such spaces.

     

    Third Domain: Interprofessional Communication

    The third domain, interprofessional communication, asks the team to communicate in a manner that is responsive, respectful, and sufficiently structured to reliably carry concerns across the hierarchy. The relevance to bias is direct, because the distributed vantage point described earlier, in which the patient confides in the clinician she trusts most, is useless if that clinician has no dependable way to convey what she heard to the people who can act, or no confidence that doing so is welcome. Structured handoffs, shared documentation that travels with the patient, and an explicit norm that raising a colleague’s possible blind spot is an act of good care rather than an accusation all serve this domain. Communication is also where trust is protected or damaged, so the team’s communication habits with the patient, not only among its members, fall under this domain.

     

    Fourth Domain: Teams and Teamwork

    The fourth domain, teams and teamwork, asks the team to apply the values, the role clarity, and the communication into a coordinated practice that performs better than the sum of its individuals. This is the domain in which the standardized protocols, the measurement of bias awareness, the review of adverse outcomes, and the flattening of hierarchy live, because each of these is a property of how the team works together rather than of any one member’s knowledge or goodwill. The evidence reviewed throughout this course points consistently toward this conclusion: because bias is a feature of normal cognition that no amount of individual effort fully eliminates, and because structural forces operate above the level of any single encounter, the durable protections are the ones built into the team’s shared routines (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023).

    Structural racism, by definition, is not solved at the bedside, but the team and its organization are not powerless before it. Within their sphere, teams can examine their own referral patterns and access barriers, advocate for the data practices that make high-risk populations visible rather than suppressed, support workforce diversity and culturally responsive care, and align with institutional and policy efforts aimed at the upstream causes (Montalmant & Ettinger, 2024; Sonderlund et al., 2022). The point is not that an audiologist or a physical therapist can dismantle structural racism single-handedly, but that the structures are made of countless ordinary practices, many of which a team can influence, and that naming the structural level keeps it from being treated as someone else’s problem.

     

    Measurement

    Measurement deserves a place of its own in the team’s response, because without it good intentions cannot be distinguished from good results. A team that wishes to know whether it is reducing the harm of bias has to look at data, and several kinds are available. Validated instruments can assess awareness of and mitigation of bias within a maternity care setting, providing a team with a baseline and a way to detect change over time, rather than relying on the assumption that training or a policy must have helped (Bower et al., 2023). Stratifying clinical and experience measures by race and ethnicity, for example, examining whether pain is assessed and treated equally, whether warning signs are escalated equally, and whether patients of different groups report equivalent respect and trust, can make a hidden disparity visible and turn it into an actionable target. Reviewing severe morbidity and mortality events with an explicit question about whether bias or unequal access contributed converts individual tragedies into system learning. None of these measurements is punitive in spirit; its purpose is to replace the comfortable assumption that a team is doing well with evidence about whether it actually is, and to direct effort toward the points where the data show the largest gaps. This emphasis on measurement also guards against the documented risk of mistaking a single educational intervention for a solution, since the data will make it plain whether practice has changed (Hagiwara et al., 2024).

     

    Care Models and Programs That Have Reduced Maternal Harm

    The strategies in this section are not only theoretical; they are embodied in established programs whose results have been measured. The leading national example is the Alliance for Innovation on Maternal Health (AIM), a federally funded program coordinated through the American College of Obstetricians and Gynecologists that develops and disseminates maternal patient safety bundles, which are standardized, evidence-based sets of practices aimed at the leading preventable causes of maternal death and severe morbidity, including obstetric hemorrhage, severe hypertension and preeclampsia, sepsis, and perinatal mental health and substance use conditions. As of early 2025, AIM bundles were being implemented in roughly 2,000 birthing facilities across 49 states, the District of Columbia, and Puerto Rico (Health Resources and Services Administration, 2025). Each bundle is organized around the domains of readiness, recognition, response, reporting, and respectful care, and the deliberate inclusion of respectful and equitable care places the trust and bias concerns of this course within the safety framework rather than beside it (American College of Obstetricians and Gynecologists, n.d.).

    This model has a measurable track record. The California Maternal Quality Care Collaborative (CMQCC) pioneered bundle-based perinatal quality improvement, and in a peer-reviewed evaluation of 99 collaborative hospitals, patients experiencing obstetric hemorrhage showed a 20.8 percent reduction in severe maternal morbidity compared with a 1.2 percent reduction in non-participating comparison hospitals, with a larger 28.6 percent reduction in hospitals that had prior collaborative experience (Main et al., 2017). At the state level, California’s maternal mortality rate fell by roughly 65 percent between 2006 and 2016, a period when the national rate was rising, a decline that CMQCC attributes substantially to these collaborative quality-improvement efforts (California Maternal Quality Care Collaborative, n.d.).

     

    Two features make these programs directly relevant to this course. First, the gains are produced through precisely the team and system mechanisms described above, namely standardized recognition and escalation, rehearsed emergency response, and the routine review of data, rather than through individual exhortation; the bundles have since been revised to embed respectful and equitable care, and collaboratives increasingly stratify outcomes by race and ethnicity so that improvements reach the patients at highest risk (American College of Obstetricians and Gynecologists, n.d.; Montalmant & Ettinger, 2024). Second, they give the interprofessional team a concrete picture of what success looks like: a patient is less likely to die or to suffer severe harm when every discipline recognizes the warning signs, the team has practiced its response, and the data are watched to see who is being left behind. For the disciplines represented in this activity, these programs are the structural counterpart to the individual habits of listening and believing, and they show that the layered response this course recommends is not aspirational but already at work.

     

    Finally, every team member's role includes the conduct of individual relationships, where evidence and ethics converge. Listening to patients, believing their reports of their own bodies, communicating respectfully, and protecting trust are not soft additions to clinical care but, in a period when most maternal deaths are preventable, and many depend on a patient’s warning being heard, are themselves safety interventions. The interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant and postpartum patients is therefore both modest and essential: modest because no single profession or person controls the outcome, and essential because the outcome is built from exactly the encounters, hand-offs, and habits that the team controls together.

     

    Pulling these threads together, the response the evidence supports is layered rather than singular. At the level of the individual clinician, it asks for honest, sustained self-examination and for the everyday discipline of listening to patients and believing their reports of their own bodies. At the level of the team, it asks for shared values that center on equity, clear roles so that warning signs are no one’s blind spot, communication that carries concerns reliably across the hierarchy, and coordinated routines that perform better than the sum of their members. At the level of the system, it calls for standardized processes, measurements that reveal disparities rather than hide them, and engagement with structural and access barriers that route patients to unequal care. No single layer is sufficient on its own: individual goodwill without team structure leaks; team structure without individual listening has nothing to carry; and both together still operate within structures that must be named and addressed. One way to hold these layers together is the image of a cycle that can turn in either direction: structural determinants and biased decision-making can feed a vicious cycle of diminished care and worse outcomes, while sound decision-making and supportive structures can feed a virtuous cycle of improved care and better outcomes, with the clinician and the team positioned at the point where the cycle can be redirected (Vela et al., 2022). What makes this an interprofessional rather than a single-discipline task is that each of these layers depends on contributions from every profession that touches the childbearing family, from behavioral health to audiology, and that the safety of the patient emerges from how those contributions are coordinated. The hopeful conclusion, grounded in the finding that the great majority of maternal deaths are preventable, is that this is a problem largely within the team’s power to influence, provided the team takes it up together rather than leaving it to the conscience of individuals (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023; Kaiser Family Foundation, 2025).

    Application to Team-Based Practice

    The material in this course reaches each represented profession differently, and naming those connections helps every reader locate their own role. Behavioral health clinicians often hold the relationships in which a patient feels safe enough to disclose distrust, perceived discrimination, or worsening symptoms, and they treat the perinatal mood and anxiety disorders that contribute to maternal deaths in the postpartum year, which places them at the center of both the trust and the clinical-risk dimensions of this material. Physical therapists frequently spend extended, hands-on time with patients managing pelvic floor dysfunction, musculoskeletal pain, and postpartum recovery, and that time is an opportunity both to hear concerns that were not voiced elsewhere and to model the practice of believing a patient’s report of pain, a domain with a documented history of biased underestimation. Occupational therapists support feeding, infant development, and a parent’s return to daily roles, often in the patient’s own environment, where they can observe context that the clinic never sees and where the power differential may relax enough for honest exchange. Speech-language pathologists and audiologists conduct newborn feeding and hearing screenings and follow developmentally at-risk infants across repeated visits, which makes them trusted longitudinal contacts for families navigating the downstream consequences of high-risk pregnancies and positions them to notice and escalate parental concerns over time. Respiratory therapists manage the ventilation and oxygen support that medically fragile newborns rely on and assist with the maternal respiratory complications that can arise during pregnancy and the postpartum period, which places them among the clinicians most likely to encounter warning signs such as shortness of breath and to act on them quickly.

     

    Across all of these roles, the shared behaviors are the same. Each profession makes rapid judgments under pressure that are vulnerable to implicit associations, each occupies a position in a power differential relative to the patient, each meets families who carry the effects of structural forces they did not choose, and each can either protect or undermine a patient’s trust in the care system. The interprofessional opportunity is to ensure that the distinct vantage points add up to more than their sum, so that a concern heard by one discipline reaches the whole team, and so that the values, role clarity, communication, and teamwork that reduce the harm of bias are built into how the team works rather than left to individual goodwill.

     

    A few illustrative situations show how these principles become concrete and how the team functions as a single safeguard. Consider a postpartum patient who mentions to her physical therapist, during a session for pelvic pain several weeks after delivery, that she has also been having headaches and some shortness of breath, symptoms she has not raised with anyone else because a previous clinician seemed to brush off her concerns. The physical therapist who has absorbed this material recognizes two things at once: that these symptoms can signal a serious late postpartum complication, and that the patient’s reluctance to report them is itself a product of an eroded trust that bias can cause. The values domain tells the therapist to take the report seriously; the roles domain tells her that escalation belongs to the obstetric or emergency pathway; the communication domain gives her a reliable way to convey the concern; and teamwork ensures the handoff is received rather than lost. The same chain could begin with an occupational therapist noticing a parent’s distress during a home visit, a speech-language pathologist observing that a parent seems disengaged during a feeding session, or a behavioral health clinician learning that a patient has stopped trusting her care team. In each case, the discipline that first receives the information is not expected to manage the complication alone, but to recognize its significance and to move it into the team’s shared field of action.

     

    These scenarios also illustrate why the individual relationship and the team structure are complementary rather than competing. The therapist’s decision to believe the patient and to respond with curiosity rather than dismissal is an individual behavior, available to any clinician without waiting for a system change, and it is exactly the behavior that keeps a patient willing to disclose. But whether that disclosure leads to timely care depends on the team structures around it, the channels, the role clarity, and the shared norms that carry the concern to the people who can act. A clinician with excellent personal habits embedded in a team that has no way to escalate her observations will still watch concerns evaporate, and a well-structured team staffed by clinicians who do not listen will have nothing worth escalating. The interprofessional response to bias, therefore, asks for both at once: the individual disposition to listen, believe, and respect, and the collective structures that turn what is heard into what is done.

     

    Summary

    This course examined implicit bias and its impact on maternal health in minority populations, building from individual psychology toward structural forces and the outcomes at stake, and it returns now to each learning outcome. It differentiated implicit bias, which operates automatically and outside awareness, from explicit bias, which is consciously held, and explained how both can shape clinical interactions even in well-intentioned clinicians (LO1). It described how stereotypes, prejudice, and “isms” form and evolve through lifespan socialization, and identified self-assessment instruments, reflective practice, and continuing education as resources for examining one’s own biases, while noting that awareness is a beginning rather than an end (LO1). It examined how bias and power differentials affect the patient and the patient-team relationship, eroding communication and trust in ways that pose safety concerns in the perinatal period (LO2). It gave examples of structural racism, described how it forms and accumulates historically, and explained its impact on maternal health through pathways such as differential access to quality care and the cumulative toll of chronic stress (LO3). It identified the major risk factors for maternal morbidity and mortality and described the patterns across populations, including a 2023 Black maternal mortality rate more than three times the White rate, the persistence of that disparity across education and income, and the elevated and often statistically suppressed rates among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander populations (LO3). Finally, it described United States infant mortality and its ties to maternal health and pregnancy-related complications, and summarized the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients, a role that is modest at the level of any one profession and essential at the level of the team’s shared encounters, hand-offs, and habits (LO4). The through-line is that most maternal deaths are preventable, that the harm is racially patterned and structurally produced, and that the perinatal team, working as a team, holds many of the levers that determine whether a patient is heard, believed, and kept safe.

     

    References

    Please see the additional handout.

     

    Citation

    Kelly, C. (2026). Implicit Bias: Impact on Maternal Health in Minority Populations. Continued-Respiratory Therapy. Retrieved from https://continued.com/respiratory-therapy.

    Sep 11, 2026

    1 CE Hour

  • Human Trafficking Prevention and Awareness

    Angie Hernandez Harris, MA, LCPC

    Editor’s note: This text-based course is an edited transcript of the webinar, Human Trafficking Prevention and Awareness, presented by Angela Hernandez-Harris, MA, LCPC. 

    It is recommended that you download the course handout to supplement this text format.

    Learning Outcomes

    After this course, participants will be able to:

    • Define human trafficking
    • Recognize key indicators of human trafficking
    • Identify myths and misconceptions about human trafficking

    What Is Human Trafficking?

    When You Think of Trafficking, What Comes to Your Mind?

    Have you ever contemplated the harrowing realities of sex trafficking, the insidious nature of forced labor, the grim existence of domestic servitude, and the astounding profitability of these criminal enterprises? If these are indeed the notions that crossed your mind, you would be absolutely correct.

    Human Trafficking Defined

    The US Department of Justice (USDOJ) in 2023 defines human trafficking, also referred to as trafficking in persons, as a criminal activity involving the compelling or coercing of individuals to provide labor or services, or to engage in commercial sex acts. This coercion can manifest in subtle or overt forms, whether physical or psychological in nature. Alarmingly, millions of people are subjected to trafficking each year.

    This course serves to elucidate the concept of human trafficking, exploring its various manifestations and shedding light on the indicators healthcare professionals should be vigilant for. Furthermore, it equips learners with the necessary tools for identifying and reporting suspected victims of human trafficking.

    It is crucial to emphasize that the exploitation of a minor for commercial sexual purposes constitutes human trafficking, irrespective of whether force, fraud, or coercion were involved. Human trafficking is an omnipresent issue, even within the United States, with victims hailing from diverse backgrounds - US citizens or individuals of any nationality, age, socioeconomic status, or gender. In essence, it amounts to contemporary slavery, the exploitation of individuals through force, fraud, or coercion, encompassing any person under the age of 18 engaged in commercial sex activities. Thus, sex trafficking, forced labor, and domestic servitude all fall under the umbrella of human trafficking.

    Statistics

    Human trafficking is a pervasive global issue with far-reaching implications, impacting millions of individuals across the world. According to data from the International Labor Organization, a staggering 24.9 million people are estimated to have fallen victim to human trafficking on a global scale.

    Disturbingly, children constitute a significant portion of these victims, as highlighted by the United Nations Office on Drugs and Crime, which reports that almost 20% of all trafficking victims are minors. Furthermore, the incidence of identified victims has exhibited an alarming upward trajectory in recent years. For instance, in 2018, the Office for National Drug Control Policy identified approximately 49,000 victims across the globe. Over an eleven-year period spanning from 2008 to 2019, the number of human trafficking victims recognized worldwide more than quadrupled, surging from around 30,000 to nearly 120,000.

    Different Types of Trafficking

    Human trafficking encompasses various forms. Let's define them, and provide examples of sex trafficking, forced labor, and domestic servitude.

    Sex Trafficking

    Sex trafficking victims find themselves manipulated or coerced into engaging in sexual acts for financial gain. Sex traffickers employ a range of tactics, including violence, threats, manipulation, and the false promise of affection, to ensnare their victims. The grim reality is that these victims can be found in a multitude of locations, including truck stops, hotel rooms, rest areas, street corners, clubs, and private residences - just a few of the places where they are compelled to sell sex.

    Sex trafficking constitutes a subset of human trafficking and stands as a contemporary form of slavery, casting a dark shadow on public health. In 2016, the International Labor Organization estimated that a staggering 4.8 million individuals experienced sex trafficking and commercial sexual exploitation worldwide. Among these victims, 3.8 million were adults, and 1 million were children. Alarmingly, women and girls accounted for a staggering 99% of these victims. Understanding the true nature of this problem is essential, as it underpins our ability to formulate enduring solutions to combat trafficking.

    The aforementioned estimate plays a pivotal role in assessing the global prevalence of trafficking, thereby enabling us to employ targeted measures encompassing prevention, protection, and prosecution. In the United States alone, it is estimated that between 18,000 and 20,000 individuals fall victim to trafficking annually. However, the U.S. State Department's estimate suggests that the actual number of women and girls affected falls within a wide range of 15,000 to 50,000. it is crucial to note that these figures solely reflect reported cases, thus failing to capture the full extent of human trafficking.

    Forced Labor

    Forced labor victims can be found across various settings, including factories, farms, and construction sites, where they are often coerced into manufacturing or cultivating products that we rely on daily. These victims endure this grueling reality through the application of force, fraud, or coercion, all while receiving minimal or no compensation. Forced labor is defined as any form of work or service extracted from an individual under the threat of penalties, without their voluntary consent.

    Forced labor, in essence, encompasses work performed involuntarily, carried out under the looming threat of penalties. It encompasses situations where individuals are coerced into work through a spectrum of means, ranging from overt violence and intimidation to subtler tactics such as the manipulation of debt, confiscation of identity papers, or threats of denunciation. The International Labor Organization's 2016 findings underscore the staggering scale of labor trafficking, with an estimated 20.1 million victims globally. This category encompasses anyone who has been compelled to work or provide services under the constant specter of penalties or harm. In many instances, this takes the form of forced labor in factories, on farms, or in domestic roles, as previously described. Of these victims, 9.2 million were men, 10.9 million were women, and 3.3 million were children.

    Several avenues exist for aiding victims of forced labor, including:

    • Strengthening legislation: Bolstering legal frameworks to combat forced labor effectively.
    • Promoting fair labor recruitment: Ensuring ethical labor practices are upheld in recruitment.
    • Supporting the empowerment of at-risk individuals: Equipping vulnerable populations with the tools to resist exploitation.
    • Addressing root causes: Tackling the underlying factors that make individuals susceptible to forced labor.
    • Enforcing labor and relevant legislation effectively: Ensuring that existing laws are enforced rigorously.
    • Enhancing education and outreach efforts: Spreading awareness and knowledge, as we are doing today, particularly targeting at-risk groups.

    Domestic Servitude

    Now, turning our attention to domestic servitude: Victims of this form of exploitation are often hidden in plain sight, compelled to toil within homes across the United States. They effectively become prisoners working in roles such as nannies, maids, or domestic help. Traffickers frequently confiscate their victims' identification documents and travel papers to restrict their freedom. Domestic servitude represents a subset of forced labor, where the trafficker compels the victim to perform work within a private residence. Such circumstances create distinct vulnerabilities.

    Domestic workers typically find themselves in isolation, often working alone within a household. Their employers exercise significant control over essentials like access to food, transportation, and housing. Indicators of domestic servitude may include:

    • Living and working within a private family home.
    • Eating separately from the rest of the family.
    • Lack of proper sleeping accommodations.
    • Absence of time off.
    • Minimal or nonexistent compensation.
    • Incidents of physical abuse or threats.

    Crucially, domestic servitude knows no boundaries, transcending age, race, ethnicity, gender, or socioeconomic status, as evidenced by the shared statistics.

    Case Study: Sex Trafficking, Forced Labor, or Domestic Servitude (Or All Three)?

    Luiza, originally from Uzbekistan, left her young son with family and traveled to Kyrgyzstan in search of work. Without a Kyrgyz ID or university degree, the 22-year-old single mother struggled to find employment in Osh, Kyrgyzstan until she heard about a waitressing opportunity in Bishkek. Eager for the prospect of a job, Luiza made the fateful decision to pursue this lead. But it was a trap. In Bishkek, she was sold into slavery and trafficked to Dubai against her will. For 18 agonizing months, Luiza was subjected to unspeakable abuse. Eventually arrested, she was thrown in jail before being able to return home.

    Today, Luiza Karimova works with Podruga, an organization in Osh, Kyrgyzstan supported by UN Women that assists women subjected to sex trafficking, forced labor, domestic servitude, and other forms of violence. This is her story. As you hear Luiza bravely recount her harrowing experience, consider: was this sex trafficking, forced labor, domestic servitude, or all three?

    I was a 22-year-old single mother, desperate for work when I left my son with family and traveled to Osh to find work. When I arrived in Bishkek, things were not as they seemed. We were held in an apartment while our passports were taken away. They claimed we'd be re-photographed for new waitressing documents. It felt strange, but we believed them.

    We boarded the plane passport-less, told the pilot would return them. But the documents he brought were fakes. We were taken to a crowded apartment in Dubai, met by women who said coldly, "Fresh arrivals - we'll work much less now." We were to be sex slaves, doing whatever clients demanded.

    The next day, I was sent to a nightclub with a $10,000 monthly quota. For 18 agonizing months, this was my life - imprisoned, exploited, abused. One night, I walked out and let the approaching police catch me. Deported with my fake ID, I spent a year in jail in Osh. Though ashamed, I returned to sex work when released.

    Podruga's outreach found me in a sauna. Wary, I began trusting them and joined their work. My husband knows my past fully yet says, "Go forward, not back. We are a family now."

    I visit saunas, distributing condoms, offering health information, legal aid, and support. Girls share dreams of Turkey and Dubai. I urge them - do not go. I detail my trafficking, emphasizing how we earned nothing, only buying cigarettes from tips. The pimps took it all, often burning us.

    My mission is keeping the girls safe, getting checkups if needed. Preventing trafficking requires informing about its realities from a young age, providing legal help and mental health support for returnees. Luiza's powerful story highlights the need for awareness, victim assistance, and policy change.

    Key Indicators: How to Identify a Victim

    When considering Luiza's story, take note of the crucial indicators for identifying a victim. According to research conducted by the US Department of Justice in 2023, there is no one-size-fits-all profile for a trafficking victim. Human trafficking victims can emerge from any demographic, irrespective of their race, color, national origin, disability, religion, age, gender, sexual orientation, gender identity, socioeconomic status, education level, or citizenship status. As is often the situation in many cases of exploitation and abuse, human traffickers frequently target individuals within marginalized communities and exploit other vulnerable adults.

    Vulnerable Individuals

    Consider the demographics your organization serves. Where is your operational scope? Who constitutes the most vulnerable groups? What policies has your company established regarding advocacy and reporting?

    Here is a list of some particularly vulnerable groups:

    • Migrant Laborers
    • Individuals with Disabilities
    • Persons Struggling with Substance Use Disorders
    • Individuals without Lawful Immigration Status in the United States
    • Black People and Other Communities of Color
    • American Indians, Alaska Natives, Native Hawaiians, Pacific Islanders, and Indigenous Peoples of North America
    • Children within the Child Welfare System, or those who have crossed paths with the Juvenile Justice System, Runaway and Homeless Youth, and Unaccompanied Minors
    • LGBTQ+ Population, Encompassing Lesbian, Gay, Bisexual, Transgender, and Intersex Individuals

    Your organization's approach to serving these diverse groups should align with your policies on advocacy and reporting. According to the Department of Health Services, each year in the United States, thousands of human trafficking cases are reported, but many more remain hidden from view.

    Human trafficking is a covert crime. Victims often live in fear of coming forward, and we may fail to recognize the signs, even when it unfolds before our eyes. It is imperative that we shed light on this hidden atrocity. Two decades ago, at the inception of the anti-trafficking movement, law enforcement and advocates primarily focused on enslaved irregular immigrants. Gradually, it became apparent that the same types of trafficking suffered by foreign nationals also afflicted citizens, albeit under different names like child prostitution or labor violations. Law enforcement then shifted its attention to domestic human trafficking and responded accordingly. Nevertheless, anti-trafficking advocates still encounter challenges in educating policymakers, police, prosecutors, judges, social welfare agencies, and communities to identify human trafficking in all its guises.

    Exploitation takes numerous forms, constantly evolving. It could be a child begging on a street corner, a woman trapped in domestic servitude, a young girl coerced into pornography, a foster child engaged in survival sex on the streets, a restaurant busboy, a nail salon worker, a door-to-door salesman, a legal visa holder advertised as an online escort, or an irregular migrant unwittingly coerced into trafficking. The central element of human trafficking is the exploitation itself, transcending considerations of origin or movement. Our commitment to focusing primarily on exploitation is the cornerstone of our efforts to identify and aid more trafficking victims in becoming survivors, a mission we share with the United States and the Organization for Security and Cooperation.

    Exploitation and How to Protect Yourself

    Let's look into the topic of exploitation and discuss how to safeguard oneself, as well as how to educate children, nieces, nephews, and others in our lives. By understanding what exploitation entails and how it initiates, we can equip ourselves with the tools to say no and protect both ourselves and those around us.

    Exploitation, in a general sense, involves treating a person unfairly in order to gain an advantage from their labor or actions. This can encompass various tactics, including the use of threats, manipulation, or physical force to compel someone to engage in activities they do not wish to participate in, all for the benefit of another individual. Exploitation takes on many forms, such as an employer coercing an employee into working for minimal or no compensation, or it can manifest as a romantic partner using threats of harm unless their partner engages in sexual acts in exchange for money, drugs, or shelter.

    False Job Promises

    You may encounter false job promises in various forms, and it is essential to remain cautious. If an offer sounds too good to be true, it probably is. Be especially alert when considering job offers in industries that are traditionally challenging to enter, such as modeling, acting, or positions in remote locations, far-off states, or foreign cities. Dangerous individuals may attempt to draw victims into isolation, separating them from their friends and family.

    Indicators of a false job promise include discrepancies between the offered payment and the job description, such as an unusually high hourly salary for a typically low-paying position. Be cautious if the employer does not request any information about your prior work experience or if they ask for a photo of you as part of the application process. Additionally, be wary of employers who ask many personal questions that are irrelevant to the potential job. Other red flags include employers requesting a substantial fee to cover uniform or other expenses, asking you to keep the job a secret or lie about your age, and making false promises of love.

    Individuals seeking to exploit others often use emotional, mental, and financial manipulation to establish trust and dependence. Indicators of potentially exploitative relationships may include a partner who insists on knowing your whereabouts at all times, requires permission for you to leave the home or socialize with others, limits your communication with friends and family, threatens harm to you or your loved ones if you do not comply with their demands, or withholds your identification cards, personal documents, or money.

    Furthermore, be cautious if your partner makes you feel unsafe, provides financial support that obligates you to ask for money when needed, forces you to work in a job where you do not receive your own paycheck, or coerces you into engaging in sex acts for money or other items of value, such as drugs.

    Myths and Misconceptions

    Let's address some common myths about human trafficking and explore why misconceptions persist, along with the realities of this pervasive issue.

    Myth: Human trafficking does not happen in the US. It is only a problem in other countries.

    Reality: Human trafficking occurs in every country, including the United States, with cases reported nationwide in cities, suburbs, and rural areas, possibly even within your own community. While the visibility and reporting of human trafficking may vary from state to state, it is a significant issue in the US. In some cases, human trafficking may not be as readily apparent or prosecuted at the federal level, but it can still be prosecuted at the state level or go undetected.

    For example, in Idaho, although there were zero new criminal human trafficking cases filed in federal courts in 2021, this does not indicate that human trafficking is absent in the state. There were eight human trafficking cases reported in Idaho in 2018, and the National Human Trafficking Hotline received 109 trafficking-related calls in 2021. These statistics reveal the complexity of the issue and the need for awareness and resources.

    Idaho faces unique vulnerabilities to human trafficking due to its rural nature, proximity to major highways and borders, a significant agricultural sector, and a lack of awareness and resources. However, various organizations and initiatives are actively working to prevent and combat human trafficking in Idaho.

    As you consider your role in combating trafficking in your city or state, it is essential to research and connect with local agencies and organizations dedicated to this cause. These entities play a crucial role in raising awareness, providing support to victims, and advocating for stronger legislation and enforcement. Collaborative efforts can make a significant impact in addressing and ultimately eradicating human trafficking in your community. Below are some of the barriers and risk factors that can make a state vulnerable to human trafficking. 

    • Barriers and Risk Factors for Human Trafficking:
      • Rural Nature: Rural areas can be more challenging to monitor and may lack resources and awareness to combat trafficking effectively.
      • Proximity to Highways and Borders: States located near major highways and international borders may be susceptible to human trafficking due to increased movement of people and goods.
      • Agricultural Sector: States with a significant agricultural industry may attract labor trafficking, with workers vulnerable to exploitation.
      • Lack of Awareness and Resources: A lack of awareness about human trafficking and limited resources for victim support can hinder prevention and intervention efforts.

    Myth: Human trafficking victims are only foreign-born and poor.

    Reality: Human trafficking victims can come from any age, race, gender, or nationality and may belong to any socioeconomic group. Socioeconomic status is determined by factors like education, income, and occupation.

    Myth: Human trafficking is exclusively sex trafficking.

    Reality: While sex trafficking is a form of human trafficking, it is not the only type. Forced labor is another significant form of human trafficking. Victims can be found in various industries, both legitimate and illegitimate, including sweatshops, massage parlors, agriculture, restaurants, hotels, and domestic service. The common factor is the exploitation of individuals for profit.

    Myth: Victims must be forced or coerced into commercial sex acts to be considered trafficking victims.

    Reality: Under US federal law, any minor under the age of 18 who is induced to perform commercial sex acts is considered a victim of human trafficking, regardless of whether they were forced or coerced. The focus is on their age and the inducement to engage in commercial sex acts, recognizing their vulnerability and the need for protection.

    Understanding these barriers, risk factors, and dispelling common myths is essential in effectively combating human trafficking and ensuring that victims receive the support and protection they need. It also helps promote a more comprehensive understanding of the different forms and facets of this issue. Regardless of whether or not they were forced or coerced, this is really important for our children to understand, people we know that are minors. 

    Myth: Human trafficking and human smuggling are the same.

    Reality: Human trafficking and human smuggling are distinct concepts. Human trafficking revolves around exploitation and does not necessarily involve crossing borders. It encompasses various forms of exploitation, such as forced labor or commercial sexual exploitation, and can occur within a single country.

    Human smuggling, on the other hand, involves the illegal movement of a person across a country's border with their consent, typically in violation of immigration laws. This often occurs when individuals seek a better life in another country and willingly pay a smuggler, often referred to as a "coyote," to facilitate their journey.

    However, an essential point to understand is that human smuggling can evolve into human trafficking if the smuggler resorts to force, fraud, or coercion to hold people against their will for the purposes of labor or sexual exploitation. In such cases, what initially began as a consensual act (smuggling) transitions into a criminal act of exploitation (trafficking). This highlights the importance of recognizing the distinction between the two while acknowledging the potential for overlap in certain situations.

    Under federal law, any minor induced into engaging in commercial sex is deemed a victim of human trafficking. Human smuggling, on the other hand, is defined by the Department of Homeland Security as the deliberate evasion of immigration laws through the importation of individuals into the United States. This involves the transportation of people across national borders and the unlawful harboring of those who are already within the United States, a key point being the intentional evasion of immigration laws.

    In contrast, while transportation does feature prominently in many human trafficking cases, the fundamental characteristic of human trafficking does not hinge on movement. Rather, it centers on commercial exploitation, bearing a resemblance to slavery. Irregular migrants, owing to their undocumented status, are especially susceptible to human trafficking, both during their journey and upon arrival in their destination country.

    Certain smuggling networks share common ground with trafficking networks, occasionally serving as conduits for irregular migrants delivered into the hands of traffickers. In instances where migrants voluntarily seek entry into a country outside established channels, they may find themselves burdened with substantial debts imposed by smugglers. Tragically, these debts can become chains, coercing individuals into debt bondage—a distinct form of human trafficking.

    Myth: Human trafficking victims will attempt to seek help when they are in public

    Reality: However, the reality is that human trafficking is often a concealed crime, shrouded in secrecy. Victims are frequently too terrified to come forward and seek assistance. They may endure coercion or force, subjected to threats and violence that instill paralyzing fear. The specter of retribution from their traffickers, including potential harm to their families, looms large, further inhibiting any inclination to seek help. Additionally, victims may lack possession or control over their identification documents, as exemplified in the story of Luiza, adding yet another layer of constraint to their ability to reach out for aid.

    Identify Warning Signs in Health Care

    Let's identify warning signs and indicators of human trafficking in the healthcare field, and what healthcare providers can do if they suspect they have encountered a trafficking victim. This is crucial for raising awareness and facilitating appropriate responses.

    Warning Signs and Indicators:

    • Injuries and Physical Signs: Unexplained injuries, signs of physical abuse, or evidence of neglect can be indicators.
    • Controlled Communication: A patient who seems to be closely monitored or controlled by another person, especially if they refuse to speak without that person present.
    • Inconsistencies in Story: Inconsistencies between the patient's explanation of their situation and their physical condition or appearance.
    • Signs of Fear or Anxiety: Patients who display extreme fear, anxiety, or depression, particularly when discussing their living conditions or the people they are with.
    • Restricted Movement: A patient who cannot move freely, such as having limited access to their identification or personal belongings.
    • Lack of Documentation: Patients without identification, passport, or personal documents, which may be held by their traffickers.

    Assessing for Human Trafficking:

    • Ask Indirect Questions: Use open-ended questions to create an environment where the patient feels safe disclosing potential exploitation.
    • Be Non-Judgmental: Ensure the patient knows you are there to help, not judge, and that their well-being is your priority.
    • Document Everything: Accurate documentation of physical findings, statements made by the patient, and any red flags is essential for potential legal actions.

    What to Do if You Suspect a Victim:

    • Do Not Confront Traffickers: Avoid confronting the suspected traffickers, as it may endanger both the victim and healthcare staff.
    • Notify the Appropriate Authorities: Follow your facility's policies for reporting, which may involve contacting local law enforcement or reporting to a designated agency or hotline.
    • Offer Support: Provide information on support services and resources available to trafficking victims.
    • Maintain Confidentiality: Respect the patient's privacy and confidentiality while adhering to mandatory reporting requirements.

    Resources for Reporting:

    • National Human Trafficking Hotline: Call 1-888-373-7888 or text "HELP" or "INFO" to 233733.
    • Local Law Enforcement: Contact your local police department or law enforcement agency to report suspected cases.
    • Your Healthcare Facility: Inform your facility's designated personnel or follow internal reporting protocols.

    Identifying and responding to potential human trafficking cases in the healthcare field is essential for assisting victims and preventing further exploitation. Healthcare providers play a critical role in identifying these red flags and connecting victims to the help they need.

    National Human Resource Center Provides Resources on:

    Common red flags and indicators for human trafficking are provided by the National Human Resource Center. These signs are vital for healthcare providers to be aware of when assessing patients who may be victims of trafficking:

    • Identifying red flags and indicators for human trafficking
    • How to access for human trafficking
    • What to do if you are a health care provider and believe you have identified a victim of human trafficking
    • Resources for reporting suspected victims of human trafficking

    Red Flags and Indicators for Human Trafficking:

    Please bear in mind that this list is not exhaustive, and each indicator on its own may not definitively indicate a trafficking situation. Furthermore, not all victims of human trafficking will display these signs. However, recognizing several of these indicators in a patient's situation may signal the need for referrals and further assistance. It is essential to approach these situations with sensitivity and care.

    • Injuries and Physical Signs: Unexplained injuries, evidence of physical abuse, or signs of neglect.
    • Controlled Communication: The patient appears to be closely monitored or controlled by someone else, and they may not speak without that person present.
    • Inconsistencies in Story: Discrepancies between the patient's explanation of their situation and their physical condition or appearance.
    • Signs of Fear or Anxiety: The patient displays extreme fear, anxiety, depression, or nervousness, particularly when discussing their living conditions or the people they are with.
    • Restricted Movement: The patient has limited freedom of movement, such as not being allowed to leave the examination room or having limited access to their identification or personal belongings.
    • Lack of Documentation: The patient lacks identification, passport, or personal documents, which may be withheld by their traffickers.
    • Multiple Sex Partners: If the patient presents with signs of sexually transmitted infections (STIs) and is unable to provide a reasonable explanation for multiple sex partners.
    • Tattoos or Branding: Tattoos or branding marks, often used by traffickers as a form of control or identification.
    • Controlled Finances: The patient has limited control over their finances, and their earnings may be controlled or taken by someone else.
    • Inability to Speak Freely: The patient seems unable to speak freely or make independent decisions.

    These indicators are critical for healthcare providers to be aware of when evaluating patients, as they can help identify potential trafficking situations. However, it is essential to handle these situations with care, respecting the patient's privacy and dignity, and following appropriate reporting and referral protocols. Additional red flags and indicators for human trafficking may encompass a range of behaviors and circumstances that healthcare providers should be attentive to. Here are some more indicators to consider:

    • Scripted or Inconsistent History: The victim's narrative appears scripted, rehearsed, or inconsistent, especially when explaining their injury or illness.
    • Unwilling or Hesitant to Answer Questions: The victim is unwilling or hesitant to respond to questions about their injury or illness, potentially due to fear or coercion.
    • Accompanied by a Dominating Individual: The victim is accompanied by someone who does not allow them to speak independently, refuses to grant the patient privacy, or insists on interpreting for them.
    • Evidence of Controlling Relationships: There are signs of a controlling or dominating relationship, such as the victim expressing excessive concerns about pleasing a family member, romantic partner, or employer.
    • Fearful or Nervous Behavior: The victim exhibits fearful or nervous behavior, potentially avoiding eye contact or appearing agitated.
    • Resistance to Assistance or Hostile Behavior: The victim is resistant to receiving assistance, demonstrates hostile behavior, or appears confrontational.
    • Lack of Awareness: The victim is unable to provide their address, is unaware of their current location, date, or time.
    • Absence of Identification Documents: The victim is not in possession of their identification documents, which may be withheld by traffickers.
    • Financial Control: The victim does not have control over their own money, and their wages may be withheld or controlled by someone else.

    These indicators collectively form a comprehensive set of cues that healthcare providers should be prepared to recognize when assessing patients. However, it is important to remember that not all victims will exhibit all these signs, and context matters. Handling such situations with sensitivity and following proper reporting procedures is crucial to ensuring the well-being of potential trafficking victims.

    Labor Trafficking Indicators

    Certain indicators of labor trafficking may include instances of workplace abuse or threats of harm by an employer or supervisor. Victims may be denied sufficient breaks, access to food, or the opportunity to drink water during their work hours. In addition, they might lack the necessary personal protective equipment for hazardous tasks. Some individuals may have been initially recruited for one type of work but are now engaged in a different role, as exemplified by Luiza's case. Originally, she anticipated working as a waitress, which did not materialize. Furthermore, victims may be compelled to reside in employer-provided housing or find themselves burdened by insurmountable debts owed to employers or recruiters, creating a state of financial entrapment.

    Sex Trafficking Indicators

    • Age Under 18: One significant indicator of potential sex trafficking is the patient's age, particularly if they are under 18 and involved in the commercial sex industry, irrespective of coercion.
    • Tattoos or Branding: Look for tattoos or other forms of branding, such as those bearing phrases like "Daddy," "Property of...," "For sale," or similar markings.
    • Unusual Number of Sexual Partners: Another red flag is when the patient reports an exceptionally high number of sexual partners, which may point to their involvement in commercial sexual exploitation.
    • Inappropriate Attire: Pay attention to whether the patient's clothing is inappropriate for the weather or the setting, as this can be a sign of their involvement in sex trafficking.
    • Use of Industry Terminology: Be mindful of the patient's language, as they may use terminology common in the commercial sex industry, including slang or specific jargon.

    These indicators are critical for healthcare providers to recognize when assessing patients who may be victims of sex trafficking. Identifying these signs can help initiate appropriate interventions, connect victims with support services, and ensure their safety and well-being. It is essential to handle these situations with care, particularly when dealing with underage victims.

    Health Indicators of Human Trafficking

    Here's another list of indicators of human trafficking (NHRC, 2023). This is broken down by physical health, mental health and social developmenta

    Physical Health:

    • Physical Signs of Abuse: Look for signs of physical abuse or unexplained injuries, such as bruising or evidence of torture.
    • Neurological Conditions: Be aware of neurological conditions, including traumatic brain injuries (TBI) and difficulties with concentration.
    • Cardiovascular Strain: Observe cardiovascular conditions that appear to worsen due to stress, such as arrhythmia or high blood pressure.
    • Gastrointestinal Distress: Note gastrointestinal issues that worsen under stress, like irritable bowel syndrome (IBS) or constipation.
    • Dietary Health Problems: Pay attention to dietary health issues, including malnourishment and unexplained weight loss.
    • Reproductive Concerns: Investigate reproductive issues such as sexually transmitted infections (STIs) and genital trauma.
    • Substance Abuse: Be vigilant for signs of substance abuse.

    Additionally, there may be other health-related signs not included in this list that could be relevant. When encountering patients with potential indicators of trafficking-related trauma, it is crucial to consider these signs in the broader context of the patient's condition and experiences. Here are some additional examples of indicators within the physical health category. Look for worsening GI issues like IBS or constipation, malnutrition, sudden weight loss, reproductive problems including STIs or genital trauma, and substance abuse.

    • Gastrointestinal Issues: Patients may exhibit gastrointestinal problems, such as irritable bowel syndrome (IBS) or chronic constipation, often exacerbated by the stress of their situation.
    • Dietary Health: Look for signs of malnourishment or unexplained weight loss, which can result from inadequate nutrition.
    • Reproductive Health: Investigate potential reproductive health concerns, including sexually transmitted infections (STIs) and genital trauma, especially among those involved in sex trafficking.
    • Substance Abuse: Be vigilant for signs of substance abuse or dependency, which can be a coping mechanism for trafficking victims

    Mental Health:

    • Depression: Watch for signs of depression.
    • Suicidal Ideation: Be alert to indications of suicidal thoughts or intentions.
    • Self-Harm: Observe signs of self-harm.
    • Anxiety: Be attentive to symptoms of anxiety.
    • PTSD Flashbacks: Look for flashbacks associated with post-traumatic stress disorder (PTSD).
    • Shame/Guilt: Be aware of feelings of shame or guilt.
    • Hyper-Vigilance: Observe hyper-vigilance, which may indicate a constant state of alertness.
    • Hostility: Note any expressions of hostility.
    • Dissociation: Watch for signs of dissociation, where the individual feels disconnected from reality.
    • Depersonalization: Observe signs of depersonalization, where the person feels detached from themselves.
    • Attachment Disorders: Investigate signs of attachment disorders that may affect relationships.

    Mental health cues include depression, suicidal thoughts, self-harm, anxiety, PTSD, flashbacks, shame, guilt, hypervigilance, hostility, dissociation, depersonalization, and attachment issues like difficulty socializing or forming relationships. With depersonalization, they may feel detached from themselves, as if watching a movie, along with emotional/physical numbness and a sense of unfamiliarity with surroundings. Dissociation could involve memory loss, detachment from self, lack of identity, alternate identities, and distorted perceptions.

    Social/Developmental:

    • High-Risk Behaviors: Identify high-risk behaviors, such as running away or early sexual initiation, particularly among minors.
    • Trauma Bonding: Be aware of the phenomenon of trauma bonding, where the victim forms a strong emotional connection with their trafficker or other victims.
    • Relationship Challenges: Recognize difficulties in establishing and maintaining healthy relationships.
    • Developmental Delays: Investigate signs of delayed cognitive or physical development.
    • Impaired Social Skills: Observe impaired social skills that may result from trafficking experiences.

    Minors may exhibit running away, early sexual activity, trauma bonding, delayed development, and poor social skills. Staying alert to these red flags, asking questions sensitively, and offering support can encourage potential survivors to open up, receive assistance, and eventually heal.

    These indicators can be invaluable for healthcare providers when assessing patients and potentially identifying human trafficking victims. it is essential to remember that this list is not exhaustive, and survivors of trafficking may display a range of these indicators or none at all. By remaining attentive to these indicators and approaching patients with sensitivity, healthcare providers can play a crucial role in identifying and supporting potential trafficking survivors. 

    Victim Identification & Response

    The resource center also addresses essential questions, such as how to conduct an assessment or examination when encountering a potential human trafficking victim, especially when you observe certain indicators.

    It is crucial to bear in mind that victims of trafficking rarely disclose their situation in clinical settings. Hence, healthcare practitioners must approach patients with care, employ trauma-informed practices, and establish a conducive environment for discussing human trafficking. Before initiating any conversation with a patient, it is important to evaluate potential safety risks that may arise from asking sensitive questions. Recognize that the primary objective of your interaction is not to elicit disclosure or effect a rescue, but rather to create a safe, non-judgmental space that facilitates the identification of trafficking indicators and supports the patient.

    Recommendations for Assessments

    In terms of assessment recommendations, these steps are essential in creating a safe and supportive environment for potential trafficking victims.

    • Allow the patient to choose whether they would prefer a male or female practitioner for their comfort.
    • When interpretation is needed, always employ professional interpreters who have no personal connection to the patient or the situation.
    • If the patient is accompanied by others, find a suitable time and location for a private conversation. it is essential, as we cannot be certain whether they may be coerced by those accompanying them.
    • Invest time in establishing rapport with potential victims. If you lack the availability, consider delegating this task to another staff member who can build trust with the patient.
    • Ensure that the patient fully comprehends confidentiality policies and practices, including mandatory reporting laws, which vary by state. Familiarize yourself with your state's regulations, as it is crucial.
    • Refer to established institutional protocols for handling victims of abuse or sexual abuse.
    • Whenever possible, utilize multidisciplinary resources such as social workers.
    • If you haven't already developed a protocol for responding to human trafficking victims, consider reaching out to the National Human Trafficking Resource Center hotline. They can provide assistance with conducting assessments and determining the appropriate next steps. Their website also features an assessment tool.

    What Should I Do If I Believe I Have Identified A Victim of Human Trafficking?

    Every instance of human trafficking is distinct, and it is crucial to adopt a victim-centered approach, as previously discussed. It is essential to understand that not all trafficking victims will feel comfortable divulging their circumstances, nor will they all be prepared to seek help from service providers, law enforcement, or even medical professionals.

    Medical providers hold a unique position where they can offer potential trafficking victims information and choices while providing support throughout the process of connecting with advocates or service providers, should the victims decide they are ready to report their situation.

    IF a Patient Discloses That They Have Been Trafficked

    If a patient discloses that they have been trafficked, you can provide them with the NHTRC hotline number and encourage them to call if they need assistance or someone to talk to. If the patient is concerned about having something with the number written on it due to safety reasons, you can suggest they memorize the number: 1-888-373-7888. This hotline is available 24/7. Alternatively, they can text HELP or INFO to BeFree at 233733.

    In situations where there is an immediate, life-threatening danger, follow your institutional policies for reporting to law enforcement. Whenever possible, collaborate with the patient to make the decision to contact law enforcement. Offer the patient options for services, reporting, and resources, and ensure that safety planning is incorporated into the discharge planning process. If the patient is a minor, adhere to mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth. While documenting instances of abuse can be valuable in building a case against a trafficker, it is essential to be aware that information about the victim could potentially be used against them in a court proceeding.

    Case Study: Exam Room Encounter of Human Trafficking

    Let's look into a case study featured in the Harvard Public Health magazine from the winter of 2016. Kimberly Chang shares her experience in a community healthcare center, addressing some of the barriers she encountered and her journey in advocacy. Let's hear her story.

    In 2003, Kimberly Chang had just completed her medical residency when a 14-year-old girl entered her examination room at Asian Health Services in Oakland, California. The young girl smelled of marijuana, had bloodshot eyes, and displayed numerous bruises on her body.

    The girl requested to be checked for sexually transmitted infections (STIs), and Chang diagnosed several STIs in the teen. With a sinking realization, she also discovered that her patient was being forced into sexual exploitation, battling addiction, and subjected to regular physical abuse. Over the next few years, Chang would encounter this harrowing scenario repeatedly among her primarily impoverished immigrant patients.

    "Back then, I referred to them as child prostitutes. That was so unfair of me," Chang admits, cringing at the implicit blame in that term. "We did not have the right language, and I lacked the awareness." However, she persisted in viewing her role primarily as addressing their medical issues, until a pivotal moment when a severely ill teenage girl arrived at the clinic.

    This girl had a high fever, a racing heart, and a rash covering her body. She had lost 30 pounds in just three months but adamantly refused to go to the hospital due to the fear of being arrested for her previous involvement in prostitution. Chang spent the entire evening negotiating with her. The girl was only willing to leave with her purchaser, a man who purchased unprotected sex from her three times a week for two hours. Chang attempted to convince the man to take the girl to the emergency room, but they never made it there. It took another day before Chang and her colleagues managed to locate the girl through her MySpace page and community contacts.

    This time, Chang took personal responsibility for arranging someone to drive the girl to the hospital, where she spent two months recovering. "Guess what happened when she got out," Chang asked incredulously. "She was still sent to jail." Chang is driven by the conviction that human trafficking should be treated as a public health issue rather than solely a law enforcement matter. "How can we strengthen the healthcare system so that it can stand on equal footing with the criminal justice system?" she pondered. This question led her to Harvard Chan School of Public Health through the Commonwealth Fund Mongan Fellowship in Minority Health Policy. At Harvard Chan School of Public Health, Chang connected with individuals who, like her, were dedicated to serving populations often marginalized in mainstream medical practice. Her overarching goal was to elevate human trafficking into a prominent health concern. She expressed, "Harvard Chan has provided me with a platform to effect practical changes and reach more patients, not only within my healthcare center but across every healthcare center willing to tackle this issue."

    Chang further explained that many of her teen patients came in heavily influenced by drugs and bearing signs of physical abuse. She learned to communicate with them directly yet compassionately to discern who was being coerced into sex and to provide care without judgment. Additionally, she took it upon herself to educate them about their rights. In cases involving adult patients working as domestic help, she clarified, "It is not acceptable for your employer to confiscate your passport and prevent you from leaving the country." As a newly minted public health professional, Chang also directs her attention upstream, focusing on addressing root causes. She believes that the initial step in combatting trafficking at its source is to view it as a public health concern. She sees this as a form of community surveillance.

    She added, "We engaged in conversations with Cambodian elders about this issue, and they began to pay attention, realizing that their daughters were not merely going out for leisure but returning home with bruises." Although Chang's patients were primarily trafficked by individuals outside their families, such as pimps or boyfriends, it is not uncommon for people to exploit their own family members due to economic hardships. "Addressing the underlying poverty that drives these families to desperate measures is crucial," Chang emphasized. Equally important is persuading them to reevaluate what they may have accepted as commonplace. Whether in the examination room, schools, or community gatherings, she stressed, "We must alter the prevailing social norms and redefine what communities consider acceptable." Within the intricate world of trafficking, a victim today could potentially become a recruiter tomorrow.

    Chang asserts that by helping young individuals evade involvement in the trade or exit it early, we can significantly mitigate the problem downstream. "By reducing the number of victims," she argued, "we can also reduce the number of traffickers." Taking a broader perspective, Chang encourages leaders in public health to actively participate in initiatives against human trafficking, as she observes that currently, most such initiatives are administered by the criminal justice sector, with a dearth of healthcare and public health involvement.

    To summarize, some key takeaways from Chang's message include the red flags and indicators she identified, such as weight loss, rashes, rapid heart rate, bruises, substance use, and resistance to treatment. She emphasized the importance of adopting a victim-centered approach and highlighted the significance of working with victims to reduce the number of traffickers.

    Reflecting on her most disturbing cases, Chang has witnessed that the right treatment and policy can indeed transform lives. The initial 14-year-old girl, who entered her clinic in a state of intoxication and covered in bruises, received treatment for her STDs from Chang. She was encouraged to leave the sex trade, and Chang provided her with a letter of support to enroll in a health-assisted training program. Now in her twenties and in a stable relationship, this young woman has found a new perspective on life. Her primary challenge today, according to Chang, is tackling college algebra. However, it is important to acknowledge that not all stories from the clinic end happily. Chang lost contact with the 15-year-old patient who was incarcerated for prostitution. She later heard that the girl became pregnant and was still engaged in sex work.

    Nonetheless, such setbacks do not deter Chang. She underscores the importance of her next message by stating, "I want to emphasize the significance of this message." She goes on to say, "I am often asked how I avoid becoming demoralized. Well, my patients do not have that luxury." She elaborates, "I do not become demoralized because I possess the ability to effect change. If I do not harness that power, then who will?"

    This profound message warrants a moment of reflection. How do you feel about it? Please take a moment to check in with your own emotions. I know that when I heard this impactful message, it resonated deeply with me and evoked memories of some of my most challenging cases. Some of these cases resulted in profoundly positive transformations, while others left me pondering the unknown paths certain individuals might have taken. Chang's resounding message reminds me that I, too, possess the power to effect change, and if I do not utilize that power, who will?

    Summary

    Human trafficking is a criminal act that involves coercing individuals into providing labor or services, or engaging in commercial sex acts. it is essential to overcome misconceptions about human trafficking, particularly the tendency to associate it solely with sex trafficking. Differentiating between human smuggling and human trafficking is crucial, and remember that any minor under the age of 18 induced into commercial sex acts is considered a victim of human trafficking, regardless of whether they were forced or coerced. Human trafficking encompasses various forms, including sex trafficking, forced labor, and domestic servitude, often found across legitimate and illegitimate labor sectors.

    Healthcare professionals occupy a unique position to identify potential human trafficking victims by recognizing key indicators related to physical health, mental health, and social development. If a patient discloses being a victim of human trafficking, adopting a victim-centered approach is vital. Utilize your role as a healthcare provider to raise awareness and educate your community about these indicators and red flags.

    Remember that reporting standards for human trafficking vary from state to state, so it is essential to be aware of the specific regulations in your state. Lastly, a survivor of human trafficking offers a powerful message: extend compassion and empathy to those who may have experienced trafficking, as small acts of kindness can make a significant impact.

    References

    National Trafficking Resource Center. Identifying victims of human trafficking: what to look for in a healthcare setting. Retrieved June 19, 2023 from https://humantraffickinghotline.org/sites/default/files/What to Look for during a Medical Exam - FINAL - 2-16- 16.docx.pdf

    US Department of Homeland Security. Blue Campaign. What is human trafficking. Retrieved on June 15, 2023 from https://www.dhs.gov/bluecampaign/what-human-trafficking

    US Department of Homeland Security. Blue Campaign. Tools that teach: what is human trafficking. Retrieved on June 19, 2023 from https://www.dhs.gov/blue-campaign/what-human-trafficking

    US Department of Justice. What is human trafficking. Retrieved on June 19, 2023 from https://www.justice.gov/humantrafficking/what-is-human-trafficking

    Citation

    Hernandez-Harris, A. (2023). Human trafficking prevention and awareness. Continued.com - Respiratory Therapy, Article 200. Available at www.continued.com/respiratory-therapy

    Aug 21, 2023

    1 CE Hour

  • Sexual Harassment Prevention and Training

    Angie Hernandez Harris, MA, LCPC

    Editor’s note: This text-based course is an edited transcript of the webinar, Sexual Harassment Prevention and Training, presented by Angela Hernandez-Harris, MA, LCPC. 

    It is recommended that you download the course handout to supplement this text format.

    Learning Outcomes

    After this course, participants will be able to:

    • Define sexual harassment
    • Identify behaviors that could be considered sexual harassment
    • List employee rights and discuss ways employers should take precautions to prevent and address sexual harassment in the workplace

    What is Sexual Harassment?

    To establish a foundation, let's delve into the essence of harassment. Harassment can be succinctly defined as any form of unwelcome conduct grounded in an individual's actual or perceived attributes, such as race, color, religion, national origin, ancestry, age, sex, marital status, order of protection status, disability, military status, sexual orientation, pregnancy, unfavorable discharge from military service, citizenship status, or work authorization status.

    This conduct serves the purpose or bears the effect of substantially impeding the individual's work performance or engendering an environment that is intimidating, hostile, or offensive. It is pertinent to note that the scope of the term "working environment" extends beyond a physical location assigned for work duties. Consider the case of remote work—an apt illustration of this concept. You may find other instances that resonate similarly.

    With a clear understanding of harassment as unwelcome conduct, let's now narrow our focus to sex-based harassment. In this context, the Office for Civil Rights (OCR) at the US Department of Health and Human Services plays a pivotal role in enforcing protections against sex discrimination, which encompasses areas such as pregnancy, sexual orientation, and gender identity. In the forthcoming sections, we will delve further into the intricacies of these definitions and explore practical strategies for addressing and preventing harassment in the workplace.

    Sex-Based Harassment

    A widely recognized principle within federal courts and agencies is the inclusion of sex-based harassment within the ambit of discrimination on the basis of sex. This inclusion applies when such harassment reaches a threshold of severity that it effectively obstructs an individual's capacity to engage in or derive benefits from the pertinent program. There are three primary manifestations of sex-based harassment, each with distinct facets: sexual harassment, sexual violence, and gender-based violence.

    These delineations reflect the acknowledgment that discrimination encompasses not only overt differential treatment based on sex but also the insidious impact of harassment. This recognition emphasizes the significance of creating an environment free from any form of gender-based mistreatment. As we delve further, we will explore the nuances within these categories and delve into strategies for addressing and eradicating such behaviors from the workplace.

    Sexual Harassment Defined

    In accordance with the US Equal Opportunity Commission (EEOC), sexual harassment is distinctly characterized as the presence of unwelcome sexual advances, requests for sexual favors, and other forms of verbal or physical misconduct that bear a sexual connotation. This definition situates sexual harassment as a manifestation of sex-based discrimination and underscores its classification as a violation of human rights. Moreover, it is crucial to recognize that sexual harassment constitutes an unlawful act, firmly prohibited by legal statutes.

    In particular, the framework of Title VII of the Civil Rights Act of 1964 stands as a bulwark against sex discrimination, incorporating sexual harassment as a fundamental facet of such discrimination. This extends inclusively to instances involving pregnancy, sexual orientation, and gender identity. Importantly, Title VII serves as a robust defense against the proliferation of sexual harassment within the workplace. By explicitly stipulating the impermissibility of these actions, Title VII encompasses both the prohibition of sexual harassment and the elimination of related discriminatory practices.

    This legal framework operates to safeguard the rights of employees in workplaces where there are 15 or more individuals employed. It serves as a potent deterrent against any form of discrimination, thereby fostering an environment characterized by equality and fairness. As we proceed, we will delve deeper into the various components of sexual harassment, its implications, and strategies for creating a workplace that actively prevents such conduct.

    Who and Where Are the Harassers?

    The identity and location of harassers encompass a broad spectrum. It is essential to remain cognizant of this diversity. Harassers can emerge from any background, regardless of gender. Both men and women can assume the role of a harasser. The gender of the victim need not necessarily be different from that of the harasser—an important consideration that underscores the complexity of harassment dynamics.

    Sexual harassment is not confined to specific settings; it can unfold in various contexts. While the list is not exhaustive, consider the following scenarios: the harasser could be the victim's immediate supervisor, an agent representing the employer, a supervisor from a different department, a fellow colleague, or even an individual who is not an employee of the organization. Furthermore, It is imperative to acknowledge that the victim of harassment need not be the direct target. Anyone affected by the offensive behavior, even indirectly, can be considered a victim.

    Crucially, unlawful sexual harassment can occur without resulting in economic harm to the victim or the victim's dismissal. The critical criterion hinges upon the unwelcome nature of the harasser's behavior, as judged by the victim. The individual who experiences the conduct is the sole determinant of whether the actions are unwelcome or not.

    Remaining vigilant about these nuanced aspects of harassment empowers individuals to identify and address instances of misconduct. By understanding the diverse forms that harassment can take, one can play a pivotal role in fostering a respectful and inclusive workplace environment. In subsequent sections, we will delve into strategies for recognizing, responding to, and preventing sexual harassment.

    Perspective- thoughts?

    The transformative impact of the #MeToo movement on our current landscape is profound. An article authored by Susan Strauss (2019) in The Online Journal of Issues in Nursing delves into the realm of sexual harassment within healthcare, shedding light on its historical context. Strauss aptly points out that although the term "sexual harassment" is a relatively modern construct, the phenomenon itself has deep historical roots spanning centuries. Strides towards addressing sex discrimination legally emerged with the passage of the Civil Rights Act of 1964. It is noteworthy, however, that the first instances of sexual harassment lawsuits only began surfacing in courts during the 1970s. In a pivotal moment, the US Supreme Court officially recognized sexual harassment as a form of sex discrimination in 1986, a significant milestone occurring 22 years after the Act's enactment.

    The evolution continued as Congress modified Title VII in 1991, bestowing victims of sexual harassment the right to pursue compensatory and punitive damages. The subsequent year, 1994, heralded the Violence Against Women's Act, marking another significant step towards addressing gender-based mistreatment. A further stride towards equality was made in 1995 when Congress subjected itself to the same legal framework as the broader citizenry through the Congressional Accountability Act.

    However, the true watershed moment seems to have materialized with the advent of the #MeToo movement. This grassroots campaign has significantly elevated awareness, ignited conversations, and compelled societal reckoning with the prevalence and repercussions of sexual harassment. By exposing the magnitude of the problem and prompting a cultural shift, the movement has propelled us to the juncture we find ourselves in today.

    The continuous evolution of laws and attitudes underscores the necessity of ongoing efforts to cultivate safe, respectful, and inclusive workplaces for all. In the ensuing sections, we'll explore strategies for creating an environment that actively prevents and addresses sexual harassment.

    What Are Specific Examples of Sexual Harassment?

    The four primary types of sexual harassment you have outlined—verbal, physical, non-verbal, and visual—form a comprehensive framework for categorizing such behaviors. In addition to these, other forms of sexual harassment can manifest, each highlighting the multifaceted nature of this issue. Here are a few additional forms of sexual harassment:

    Verbal/Written

    Verbal and written sexual harassment can encompass a range of behaviors, often marked by their explicit or offensive nature. Here are examples illustrating the various facets of such harassment:

    • Sexually Explicit Comments: Making comments about an individual's appearance, body, or clothing that are sexual in nature and unwelcome, such as lewd remarks or innuendos.
    • Sexual Jokes: Sharing jokes, anecdotes, or stories that have sexual undertones or are explicitly sexual, creating an uncomfortable or hostile environment for the recipient.
    • Unwanted Requests: Soliciting sexual favors, dates, or intimate interactions despite the other person's lack of interest or discomfort.
    • Spreading Rumors: Propagating rumors or gossip about someone's private or sexual life, causing emotional distress and discomfort for the target.
    • Coercion or Threats: Using the promise of rewards or threats of punishment to pressure an individual into engaging in sexual activity against their will.
    • Excessive Flirting: Persistently and aggressively engaging in flirtatious behavior, despite clear indications that it is unwelcome, making the recipient uncomfortable.
    • Inappropriate Texts or Emails: Sending messages or emails with explicit content, sexual references, or suggestive language that crosses personal boundaries.
    • Sexualized Comments About Work Performance: Making remarks linking an individual's work performance or advancement to sexual activity or appearance, creating an uncomfortable atmosphere.
    • Catcalling: Shouting sexually explicit comments, often of a demeaning nature, at someone in public spaces, causing embarrassment and discomfort.
    • Unwanted Advances: Pursuing someone romantically or sexually despite their clear lack of interest or expressed discomfort.
    • Invasive Questions: Asking personal questions about an individual's sexual history, preferences, or experiences that are unrelated to work and invade their privacy.

    These examples emphasize the critical importance of cultivating a respectful and professional environment in which individuals can work without fear of encountering such inappropriate and offensive behavior. It is crucial for individuals and organizations to be vigilant in recognizing and addressing verbal and written sexual harassment to create a workplace that values dignity and equality for everyone.

    Physical

    Certainly, physical, sexual harassment comprises a range of behaviors that involve unwanted and inappropriate physical contact, gestures, or actions. Here are examples illustrating various forms of physical sexual harassment:

    • Impeding Movement: Blocking an individual's path or movement, either deliberately or in a manner that makes them feel trapped or uncomfortable.
    • Inappropriate Touching: Engaging in unwelcome touching of an individual's body or clothing, violating their personal space and boundaries. This could include touching their arms, shoulders, legs, or any other part of the body.
    • Unwanted Hugging or Kissing: Initiating hugs or kisses without consent, especially if the recipient has not indicated a desire for physical contact.
    • Patting, Stroking, or Rubbing: Touching someone in a way that is overtly sexual or intimate, such as patting their back, stroking their hair, or rubbing their shoulders, without their permission.
    • Sexually Suggestive Gestures: Making explicit or offensive gestures with sexual undertones that create discomfort or offense for the recipient.
    • Offensive Music Selection: Playing music that contains offensive, degrading, or sexually explicit language, contributing to a hostile or uncomfortable environment.
    • Brushing Up Against Someone: Deliberately brushing up against another person in a way that is unwelcome and intrusive, often used as a means to initiate physical contact.
    • Unwanted Physical Advances: Initiating advances such as attempting to hold hands, sit on someone's lap, or engage in any form of physical intimacy without consent.
    • Unwanted Gifts or Objects: Offering gifts, objects, or items of a sexual nature that are intended to be sexually suggestive or offensive.
    • Blocking or Cornering: Physically positioning oneself in a way that restricts another person's movement or makes them feel cornered and uncomfortable.
    • Forced Physical Contact: Forcing someone to engage in physical contact against their will, such as forcing them to hold hands or engage in a hug.

    These examples underscore the importance of fostering a workplace culture that prioritizes respect, consent, and personal boundaries. Recognizing and addressing physical sexual harassment is essential for creating a safe and inclusive environment where all individuals can thrive without fear of such inappropriate behavior.

    Non-Verbal

    Certainly, non-verbal sexual harassment encompasses a variety of behaviors that communicate sexual objectification, disrespect, or discomfort. Here are examples that illustrate the different forms of non-verbal sexual harassment:

    • Ogling or Staring: Looking at a person's body in a suggestive or objectifying manner, often making the individual feel uncomfortable or violated.
    • Derogatory Gestures: Making gestures that have sexual connotations or demeaning implications, such as mimicking sexual acts or using hand gestures to communicate explicit messages.
    • Sexually Suggestive Facial Expressions: Using facial expressions, winks, or lewd smiles to convey a sexualized message or intention.
    • Invading Personal Space: Frequently standing too close to an individual, invading their personal space intentionally, and making them feel uncomfortable or unsafe.
    • Unwanted Following: Persistently following someone, particularly in a manner that causes unease, anxiety, or fear, creating an environment of discomfort.
    • Whistling or Catcalling: Whistling or shouting explicit or suggestive comments at an individual, often in public spaces, and often with the intent to objectify or demean.
    • Invasive Gazing: Staring at an individual in a way that is suggestive, offensive, or inappropriate, causing discomfort and feelings of violation.
    • Inappropriate Use of Visual Aids: Displaying images, drawings, or visual content that is sexually explicit, offensive, or degrading, contributing to a hostile environment.
    • Intrusive Photography: Taking photographs or videos of someone without their consent, often in a manner that is intended to capture their private moments or body.
    • Leering: Casting a prolonged and conspicuous gaze at an individual's body in a way that is disrespectful, objectifying, and makes them feel uncomfortable.

    These examples highlight the significance of recognizing and addressing non-verbal sexual harassment to ensure that individuals are treated with dignity, respect, and consideration for their personal boundaries. Promoting a culture of consent and understanding is essential in creating a workplace environment that values the well-being and comfort of all employees.

    Visual

    Indeed, visual sexual harassment involves the use of images, objects, and media that are sexually suggestive, explicit, or offensive. Here are examples that illustrate the different manifestations of visual sexual harassment:

    • Sexually Suggestive Objects: Displaying objects or items with sexual connotations or innuendos in a way that creates discomfort or offense for others.
    • Inappropriate Pictures or Cartoons: Exhibiting pictures, cartoons, or artwork that contain sexually explicit content, often with the intention of demeaning or objectifying individuals.
    • Offensive Posters or Calendars: Hanging up posters, calendars, or artwork that contains sexual imagery, derogatory messages, or offensive content, contributing to a hostile environment.
    • Sexually Explicit Computer Screens: Displaying sexually explicit images, videos, or content on computer screens in a shared workspace, making others uncomfortable or offended.
    • Sharing Inappropriate Texts or Messages: Sharing texts, messages, or emails of a sexual nature without the consent of the recipients, creating an uncomfortable atmosphere for those involved.
    • Sending Sexually Inappropriate Images or Videos: Sending sexually explicit images, videos, or pornography to coworkers or colleagues without their consent, fostering a hostile environment.
    • Exposing Pornographic Content: Sharing or displaying explicit pornography or sexual content in the workplace, creating an environment that is offensive and inappropriate.
    • Inappropriate Use of Visual Aids: Using visual aids, presentations, or materials that contain sexual content or imagery during professional meetings or presentations, creating a demeaning atmosphere.
    • Sharing Explicit Content via Electronic Devices: Sharing explicit images, videos, or content through electronic devices or platforms in a way that offends, objectifies, or makes others uncomfortable.
    • Leaving Sexually Inappropriate Materials: Leaving explicit materials, such as magazines or photographs, in shared spaces where others can see them, contributing to a hostile environment.

    These examples underscore the importance of maintaining a respectful and professional workplace by refraining from displaying or sharing sexually explicit or offensive content. Creating an environment that values dignity, equality, and personal boundaries is essential for promoting a culture of respect and well-being for all employees.

    Disparities: Most Impacted

    Identifying those who bear the brunt of disparities in the workplace is crucial in fostering a fair and equitable environment. It is essential to recognize these imbalances, particularly if you belong to a group that experiences heightened vulnerability. This applies whether you are a colleague, a supervisor, a member of the HR team, or anyone involved in shaping the work culture.

    As a colleague, being aware of disparities allows you to empathize and support coworkers who might be facing challenges due to discrimination or harassment. Acknowledging these imbalances helps in creating an inclusive and supportive network.

    If you are a supervisor, understanding the disparities enables you to actively address inequality and ensure that your team members are treated with fairness and respect. By recognizing disparities and taking proactive steps to rectify them, you contribute to a healthier and more productive work environment.

    Members of the HR department play a pivotal role in shaping workplace policies and procedures. Recognizing disparities helps HR professionals create and implement strategies that prevent discrimination and harassment, ensuring that the organization adheres to legal and ethical standards.

    Regardless of your role, considering the disparities in your field of work empowers you to contribute positively to change. This could involve advocating for fair policies, participating in training programs, or supporting initiatives that promote diversity and inclusion. By understanding your role within the larger context, you actively contribute to a workplace culture that values equality, respects individual identities, and fosters a safe and respectful environment for all.

     

    Percentage of sexual harrassment charges filed FY2018-FY2021, EEOC.
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    Figure1. Gender disparities data between the fiscal year of 2018 and fiscal year of 2021 (EEOC).

    Figure 1 provides a visual representation of disparities in data spanning from the fiscal year 2018 to the fiscal year 2021. Within this timeframe, the Equal Employment Opportunity Commission (EEOC) reported a total of 98,411 charges related to various forms of harassment. Among these, 27,291 charges were specifically centered on allegations of sexual harassment.

    A noteworthy observation is the substantial uptick in the number of sexual harassment charges received by the EEOC during the two years that followed the viral spread of the #MeToo movement in October of 2017. This surge in reporting indicates the movement's profound impact on raising awareness and emboldening individuals to come forward with their experiences.

    Furthermore, an examination of the data reveals that women continue to be disproportionately affected, as they accounted for a significant majority of the charges filed with the EEOC related to sexual harassment. Specifically, women filed a notable 78.2% of the 27,291 charges lodged between 2018 and 2021, in comparison to men.

    These statistics underscore the ongoing prevalence of sexual harassment and its unequal impact on individuals, particularly women, within the workplace. As we proceed, we will explore strategies to mitigate these disparities and cultivate an environment that values equality, respect, and dignity for all employees.

    Race Disparities data between the fiscal year of 2018 and fiscal year of 2021 (EEOC).
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    Figure1. Race Disparities data between the fiscal year of 2018 and fiscal year of 2021 (EEOC).

    Turning our attention to Figure 2, we are presented with a visual breakdown of the percentage of sexual harassment charges filed concurrently in relation to race and national origin. The data reveals a particularly pronounced impact on the Black and African-American community when compared to other racial groups. Specifically, out of the 1,945 sexual harassment charges that were filed concurrently with a charge related to race, a significant 71.2% of these charges identified Black and African-American as the relevant racial background.

    Furthermore, within the context of national origin charges, the statistics continue to underscore disparities. Between the fiscal years of 2018 and 2021, of the 797 sexual harassment charges that were filed concurrently with a national origin charge, 37.6% of these charges indicated Hispanic as the designated origin, while 15.7% were designated as Mexican.

    This data carries personal significance for me as a professional Mexican woman, as it resonates with my own identity and underscores the heightened impact on individuals like me. It prompts a sobering reflection on the realities faced by those who belong to the most impacted groups. With this information in mind, it becomes imperative for me to consider how to navigate such dynamics and take appropriate action in case of any untoward occurrences.

    In the subsequent sections, I will delve further into the implications of this impact and offer practical strategies for preventing and addressing sexual harassment, fostering an environment of inclusivity, and empowering individuals to take proactive measures to create a safer workplace for all.

    Impact on LGBTQ+ Community

    Sexual harassment has a significant impact on the LGBTQ+ community, as evidenced by alarming statistics that underscore the challenges and vulnerabilities faced by its members. Research conducted by the National Sexual Violence Resource Center has revealed a stark truth: individuals within the LGBTQ+ community are four times more likely to experience violence throughout their lives compared to heterosexual individuals. This deeply concerning statistic sheds light on the pervasive nature of sexual harassment and violence within this community.

    Specifically, within workplaces, the impact is palpable. A staggering 70% of LGBTQIA members have encountered sexual harassment in their work environments, signaling a pressing need for change. Equally disheartening is the fact that 66% of these individuals fear reporting such incidents to their employers due to the risk of being outed.

    Furthermore, disparities within the community exacerbate these challenges. Bisexual women, trans women, and women of color are disproportionately vulnerable, facing an even higher risk of experiencing mistreatment. This reality resonates personally for many, including myself as a mother with a Black, queer, non-binary young adult who is entering the workforce. The safety and well-being of our loved ones become paramount concerns in such environments.

    It becomes evident that the responsibility lies with employers to create safe and inclusive spaces. Central to this is the commitment to preventing and addressing sexual harassment actively. As we progress through subsequent discussions, we will explore the obligations employers hold in fostering inclusivity, implementing preventative measures, and establishing an environment where every individual is treated with dignity, respect, and fairness. By shedding light on these issues and engaging in meaningful dialogues, we collectively work toward a workplace that prioritizes the well-being of all its members.

    Sexual Harassment Disparities

    The EEOC underscores a crucial point: the available data only scratches the surface of the extent of sexual harassment within our nation's workplaces. In June 2016, the EEOC unveiled a report that delved into the intricacies of workplace harassment, revealing a disheartening reality—workplace harassment often remains unreported. A poignant example from the report highlights that a staggering 90% of individuals who claim to have experienced harassment opt not to pursue formal action, such as filing a charge or making a complaint.

    This prompts an essential question: why does this underreporting persist? Reflecting on our own career experiences can offer valuable insights. Consider the jobs you have held throughout your life. Compare what you knew about sexual harassment then to your awareness now. Contemplate what information you wished you had possessed back then. Ponder whether you believe the circumstances might have been different with a heightened awareness. Have there been any perceptible changes in attitudes and practices?

    It is evident that numerous factors contribute to the underreporting phenomenon. Fear looms large as one of these factors. Individuals often recognize the inherent risks and potential repercussions associated with reporting harassment. Retaliation, damage to one's career, and negative impacts on personal relationships are all concerns that can deter victims from coming forward.

    By delving into these complexities and engaging in open dialogues, we lay the foundation for understanding the barriers that impede reporting and, subsequently, for instituting measures to break down these barriers. In the upcoming sections, we will explore strategies for creating environments where reporting is encouraged, where victims are supported, and where the risks and impacts of speaking out are mitigated through robust policies and cultural shifts.

    Impact of Sexual Harassment

    In a journal published by the National Library of Medicine, Stasenko et al. (2020) illuminate a significant perspective: harassment is not solely rooted in sexual desire. Rather, it manifests as behavior that communicates hostility, objectification, and the wielding of power. Alarmingly, more than half of American women have encountered unwanted and inappropriate sexual advances at some point in their lives. Within the workplace, the experience of sexual harassment can bring about detrimental repercussions, encompassing a decline in job satisfaction, heightened job stress, and a deterioration in productivity or overall performance.

    The repercussions, however, extend further than these. Prior research highlights that women who face sexual harassment in their professional lives report heightened levels of anxiety and depression, resulting in diminished productivity and subpar work performance. Moreover, these women are more likely to seek job changes, often transitioning into roles of inferior quality or compensation. The inability to address workplace sexual harassment may deprive them of the empowerment to advocate for their own salaries, consequently impeding their long-term earnings and financial growth.

    The pursuit of prevention is paramount in the workplace. How can we take action? How can we prevent sexual harassment from taking root in our professional environments? Perhaps one of the most empowering revelations is that we all possess rights. Looking back to my 13-year-old self, embarking on my journey in a restaurant, I find myself wishing I had known this. I wish I had understood that I possessed rights. As you absorb the forthcoming slides, reflect on your younger self, your present self, and the future self you aspire to be. These insights offer a powerful foundation for fostering change, promoting awareness, and crafting a work culture that upholds the dignity and equality of all individuals.

    Prevention in the Workplace

    Know Your Rights

    Knowledge serves as a powerful tool, and comprehending that sexual harassment is unlawful is paramount. Prevention stands as the most effective means to eradicate sexual harassment from workplaces. Employers bear the responsibility of taking proactive measures to prevent such incidents. Central to this effort is the clear communication of a zero-tolerance policy against sexual harassment. It is essential that employers display a "Know Your Rights Workplace Discrimination" legal poster. This poster informs employees about federal laws that prohibit job discrimination based on various factors, including race, color, sex, sexual orientation, gender identity, national origin, religion, age, equal pay, disability, and genetic information.

    In most instances, electronic posting supplements the physical requirement. There are exceptions, such as for employers without a physical location or for telecommuting employees who don't regularly visit the workplace. However, what if this clear communication hasn't transpired, and you find yourself facing sexual harassment? What further knowledge should you possess? An important point to understand is that you can take action, and there are additional insights you can glean today.

    For instance, if you have experienced sexual harassment, you possess the right to clearly inform your harasser to cease the behavior and that it is unwelcome. If the behavior persists, It is wise to start documenting the incidents. You have a window of 180 days from the day of discrimination to file a charge. This filing timeline can be extended, but for federal employees, regrettably, the window is limited to 45 days. While charges cannot be filed over the phone, you can initiate the process with a call.

    I urge you to jot down the provided number and explore the link below. This link serves as a comprehensive resource to address your queries and acquaint you with the forthcoming steps to undertake. By taking these measures, you empower yourself to navigate such situations with knowledge, confidence, and a commitment to securing your rights and well-being.

    What About Retaliation?

    Addressing the concern of retaliation is crucial, particularly considering the well-founded fear of such repercussions, especially among those who belong to the most marginalized groups—the very groups that are disproportionately impacted. This apprehension is valid, even when retaliation is deemed illegal, as the potential consequences, including the risk of job loss, can be daunting.

    However, It is essential to grasp that there are legal protections in place to combat retaliation. It is unlawful to retaliate against an individual who opposes discriminatory employment practices based on sex or who files a discrimination charge. This safeguard extends to those who testify or engage in any form of participation in an investigation, proceeding, or litigation under Title VII.

    The legal framework also guards against retaliation for reasonably opposing discriminatory practices or engaging in a discrimination lawsuit, investigation, or proceeding. Furthermore, Title VII of the Civil Rights Act imposes a financial penalty on covered employers who fail to post required notices. Currently set at $659, this penalty is adjusted annually to align with inflation, as mandated by law.

    An essential element in empowering employees is the presence of the "Know Your Rights Workplace Discrimination" legal poster. This poster encapsulates these legal provisions, outlining the laws and offering guidance on how employees and applicants can file complaints in cases of perceived discrimination. These posters should be strategically placed in conspicuous locations within the workplace, where notices to applicants and employees are typically displayed. Moreover, employers are encouraged to digitally share these notices on their websites, ensuring accessibility and awareness among covered employees.

    By comprehending these legal protections, employees can navigate potential situations of retaliation with confidence in their rights and the knowledge that there are mechanisms in place to counteract such acts. This knowledge empowers individuals to advocate for their well-being and helps foster a safer and more equitable workplace for all.

    Promising Practices

    Beyond the typical training opportunities and frequently asked questions, there are several key aspects to consider when evaluating a potential employer's commitment to fostering a culture of safety and inclusivity. Look for these principles in the leadership of the organization, as they provide valuable insights into the company's approach:

    • Committed and Engaged Leadership: Examine whether the leadership demonstrates commitment and engagement. This is evident when their actions align with their words, showcasing their dedication to creating a safe and respectful work environment.
    • Consistency in Accountability: Assess whether the employer demonstrates consistency in being accountable. Investigate their hiring and training practices, wage-setting procedures, and how they handle difficult situations, concerns, and questions. Consistency in these practices indicates a commitment to fairness.
    • Harassment Policies and Know Your Rights: Evaluate the strength and comprehensiveness of the harassment policies in place. Check if the "Know Your Rights" poster is easily accessible and clearly explained. This indicates whether the employer is proactive in informing employees about their rights.
    • Accessibility of Complaint Procedures: Consider whether your employer is accessible and trustworthy when it comes to addressing complaints. Review the process for raising concerns and understand who you can talk to, whether It is a supervisor, HR, or another designated individual.
    • Regular and Interactive Training: Examine the frequency and nature of training opportunities. Look for engaging and interactive sessions that provide essential insights. Consider whether the company invests in continuing education and encourages employees to stay informed about policies and practices.
    • Leadership Trustworthiness: Gauge whether the leadership is trustworthy. This involves a sense of accessibility and openness, as well as a demonstrated willingness to listen and address concerns promptly.

    While these practices are not mandatory under Federal Employment Discrimination Laws, they can significantly enhance an employer's compliance efforts and signal a commitment to providing a safe and inclusive workplace. This report includes checklists based on these principles, offering a practical resource for employers to prevent and respond effectively to workplace harassment. As you consider potential employers, reflecting on these principles can guide you in making informed decisions that align with your values and ensure your well-being in the workplace.

    Certainly, the "Know Your Rights Workplace Discrimination" legal poster is a valuable resource prepared by the US Equal Employment Opportunity Commission (EEOC). This poster serves as a concise and accessible guide, summarizing essential laws and outlining the steps that employees or applicants can take if they believe they have faced discrimination. This poster provides a crucial source of information to empower individuals with knowledge about their rights and avenues for action.

    You can access the "Know Your Rights Workplace Discrimination" legal poster at this link: EEOC Know Your Rights Poster.

    When evaluating a potential employer's commitment to preventing discrimination and fostering an inclusive environment, It is important to consider the presence and accessibility of this poster. You can look for it in common areas within the workplace where notices are typically displayed. Additionally, explore the company's online resources to ensure that this information is readily available to all employees. A commitment to sharing this resource reflects an employer's dedication to informing their workforce about their rights and creating an environment where individuals feel empowered to take action against discrimination.

    Perspective on Prevention

    In her article, Elizabeth Bille, JD, SHRM-SCP, provides a unique perspective on preventing sexual harassment in the workplace through her piece titled "7 Strategies Addressing How to Prevent Sexual Harassment in the Workplace." Bille's viewpoint highlights that while sexual harassment training is undeniably important, the way in which it is conducted can sometimes inadvertently cause more harm than good. Instead, she suggests alternative interventions that could be more effective and beneficial for both employers and employees.

    She gives a distinct perspective that while sexual harassment training is necessary, oftentimes, employers tell employees what not to do and the way in which the information is delivered can be more harmful than good. She shares that the following interventions might be more helpful for both employers and employees respectively. Consider these at your place of employment.

    7 Strategies That Can Help Prevent Sexual Harassment

    • Make it clear that sexual harassment is a company priority
    • Make sure that both employees and management understand what it is - accessibility and knowledge
    • Keep the training positive
    • Ease up on language that reflects laws and regulations
    • Have employees help with ensuring a harassment - free work zone
    • Enlist employees as the influencers
    • Take immediate and decisive actions as issues come up (EVERFI, 2023)

    First, make it clear that sexual harassment is a company priority. Based on the research, what we may conclude about prevention is that while it may be key in lowering sexual harassment from occurring in the workplace, figuring out the right approach can be challenging. Why do you think that is? The author shares that companies must take steps to educate and inform staff about these types of behaviors that will not be tolerated in the workplace. Organizations should review their harassment policies regularly and they should communicate about these policies and the principles they reflect frequently, not just during onboarding or annual training cycles, but all through the year in all staff and smaller team meetings in internal company communications and more. She goes on to say that not all communications are created equal.

    To help sexual harassment prevention at work, research shows that communication should not be tepid in tone. Rather, they should include strong unequivocal statements that the prevention of sexual harassment is a high priority for the company and that any employee who violates the policies against it will be held accountable regardless of the position in the company. Finally, to truly be effective, it is critical that these communications come from leaders throughout the organization, preferably top executives and not just HR. If company leadership regularly and authentically communicates that sexual harassment prevention training is a high priority and will be taken seriously, managers and employees will follow suit.

    Second, make sure that both employees and management understand what it is. Is there accessibility? But is the knowledge around that accessibility? Do you know where to find it? She says that it may seem that it should be obvious what sexual harassment at work is, but employers need to take steps to ensure that staff members understand exactly the types of actions and behaviors that are inappropriate. This isn't only about heinous acts of inappropriate physical contact. Sexual harassment encompasses a wide range of behaviors as we've discussed, and actions that are objectionable and undesirable, including making inappropriate sexual comments, displaying or watching the inappropriate content, etc. If employees know that these actions are unacceptable, it is easier for them to understand how to avoid sexual harassment claims in the future. Equally important is educating executives, managers, and employees about the more subtle forms of sexual harassment.These lower state behaviors or comments, not only damage working relationships and team culture, but also if left unchecked may escalate into more heinous harassment.

    Thirdly, keep the training positive. Employees don't respond well to insinuations or outright statements that they're doing something wrong, that they cannot be trusted or that they've assumed to be guilty of engaging in bad behaviors. Much sexual harassment training is focused on the negative, what not to do Which can signal to employees a belief that they may be part of the problem. That is if left to their own devices that they will harass others. Instead, prevention research shows that taking a positive approach is a better way to get the message across and engage employees in helping to create and nurturing the desired outcome.

    Using a positive messaging that assumes employees want to do the right thing because the vast majority of employees do engages them to be part of the solution to harassment in the workplace and motivates them to help promote a respectful culture that can be far more effective in shaping employee conduct than a stick approach that focuses on bad behavior and consequences to be avoided. Or ease up on language that reflects laws and regulations. Just as negative messaging fails to resonate with employees, a strong focus on the laws and regulations related to sexual harassment can be a quick deterrent for employees. Yes, these issues need to be covered for compliance reasons, but they don't have to serve as the sole foundation for your sexual harassment prevention training and communication efforts.

    Fourthly, Most employees aren't employment law experts, so using legal language as the yardstick against which unacceptable workplace conduct is measured and case law fact patterns to guide daily actions can drive behavior standards to the lowest common denominator. It can signal that as long as words or actions aren't illegal, they are acceptable. In contrast, a focus on professional respectful behavior is more likely to engage and influence employees and managers then a focus on identifying legal violations. Thus well as necessary to include legal compliance content where it is required by law, be sure to balance that with additional guidance and examples that reflect a higher standard. Your company's values, policies and culture. Enlist employees in ensuring a harassment-free workplace.

    HR leaders, managers, and supervisors cannot be monitoring harassment 24/7, but by enlisting the aid of employees themselves companies can boost the odds that incidents of warning signs or of harassment will be seen, reported and enacted upon. And even prevention. HR isn't responsible for the prevention of sexual harassment at work. All employees are. And all employees can be trained to serve as good bystanders. Helping to support a positive and respectful culture by interrupting incidences of harassment or its warning signs, supporting others who have experienced harm after the fact, formally reporting harassment, encouraging others allyship. Employees have an important role to play as active bystanders. Letting the employees know that they play this role in providing them with training and resources to help them take action are important steps in leveraging the power of the masses to create a culture of safety and respect.

    Of course, not all employees will feel comfortable personally stepping to diffuse a situation. There are other steps they could take though, including interrupting or distracting the individual who is acting inappropriately or reporting the issue to HR or management. So enlist these employees as the influencers. Who are employees most likely to listen to? Author asks. HR or their peers at work? Well, the latter of course. There is a lot of research by Edelman. The Edelman Trust barometer reveals that the biggest story of the last 16 years has been the demise of traditional authority and the corresponding rise of a person like me. Friends, peers, or a person we believe shares similar values or characteristics as a trusted source of information, which is really good news for organizations that can leverage key employees as social influencers to help support a harassment-free environment.

    Reach out to influential employees to seek their support for harassment prevention efforts and their input on how communication and training can be improved to be most effective. Last but not least, take immediate and decisive actions as issues come up. If employees feel that nothing will be done if sexual harassment issues emerge, the author speaks, to the fact that they will stop reporting these incidents and those employees will who commit harm may feel emboldened to continue acting inappropriately.

    It is critical that employers respond promptly to reports of sexual harassment in the workplace, engage in a thorough and objective review investigation of the matter, impose meaningful consequences as appropriate, and let the recorder know that they have done so. While organizations often are not able to share specifics and personal information about disciplinary actions taken, they can communicate generally about these actions and the organizations absolute commitment to holding people accountable for incidents of sexual harassment. So putting these preventative strategies to work in your organization can help you prevent sexual harassment at work while building a culture that is respectful and supportive.

    Frequently Asked Questions Regarding Sexual Harassment

    Let's now address some frequently asked questions regarding sexual harassment:

    Does harassment have to occur at work for it to be illegal? No. Federal law protects you from job discrimination and harassment, regardless of whether it occurs at the workplace or off-site.

    What will my employer do if I report harassment? Once your employer becomes aware of the harassment, it is responsible for taking corrective actions and ensuring your protection from further harassment. This includes conducting a thorough investigation by interviewing you, the harasser, and any witnesses. Swift and decisive measures should be taken to halt the behavior.

    What should I do if I am harassed by a manager, coworker, or other person in my workplace? If you experience harassment at work, it is your responsibility to inform your employer. You can also reach out to parents, other trusted adults, or the Equal Employment Opportunity Commission (EEOC). Check if your company has a harassment policy that designates individuals responsible for addressing such issues.

    What can I do if I witness workplace harassment? You should report the harassment to your employer. Additionally, you can directly communicate with the harasser that their behavior is inappropriate and must cease. It is crucial not to laugh or encourage such behavior, as this could perpetuate the harassment.

    Am I protected from workplace harassment if the harasser is not my supervisor? Yes. The laws upheld by the EEOC safeguard you from harassment inflicted by anyone within your workplace, regardless of their position. This includes managers, coworkers, and even clients or customers.

    If my coworker says something mean to me or flirts with me at work, is that illegal? The laws enforced by the EEOC do not cover minor, casual comments or isolated incidents that are not serious. For behavior to be deemed illegal, it must be unwelcome, severe, and frequent.

    Is it illegal to be harassed because I complain about job discrimination or talk to the EEOC? Yes, the EEOC-enforced laws protect you from harassment as a result of reporting discrimination within your company, talking to the EEOC, or confiding in trusted adults. This is referred to as your right to be protected from retaliation.

    Is it sexual harassment if someone I used to date will not leave me alone at work? If the individual persists in pursuing a relationship or continues making unwanted sexual advances or comments, you might have grounds for a potential claim of sexual harassment. Make sure you have clearly communicated that you are no longer interested in maintaining a relationship.

    What are some examples of workplace harassment? Examples of workplace harassment encompass offensive jokes, racial or ethnic slurs, pressuring for dates or sexual favors, unwelcome comments about religion or attire, and offensive graffiti or imagery. It is important to recognize these behaviors and address them immediately. All employees have a role in establishing a harassment-free environment, and It is incumbent upon employees to report inappropriate conduct.

    Case Studies

    Case Study: Sheila

    Part One: Sheila, a Black woman, works alongside Tim, a white male colleague. Tim, who recently experienced a breakup, has made comments on multiple occasions about feeling lonely and needing a new girlfriend. Despite their past friendly interactions and shared lunches at local restaurants, Tim's remarks gradually take a more personal turn. He eventually asks Sheila out on a date for dinner and a movie, to which she agrees. After enjoying the date, Sheila decides against pursuing a relationship with Tim and politely communicates her stance. However, Tim's persistence remains unrelenting.

    True or False: When Tim initially asked Sheila out, was it considered sexual harassment?

    • False. Tim's initial request for a date does not constitute sexual harassment. Although his comments may be considered inappropriate for the workplace, they were not explicitly sexual in nature. Sharing feelings of loneliness or discussing personal experiences, while not ideal for work conversations, do not necessarily constitute sexual harassment.

    True or False: Sheila cannot complain about sexual harassment just because Tim asked her out.

    • False. Sheila has the right to make a complaint about Tim's behavior. Their friendly history or prior date does not excuse Tim's inappropriate behavior towards her in the workplace. Respectful conduct should be maintained, regardless of past interactions.

    Part Two: Sheila reports her concerns to her supervisor, who duly informs the designated individual responsible for addressing complaints. Tim is confronted about his actions and offers an apology. He is instructed to cease his behavior, which he adheres to for a short period. However, Tim later begins leaving small gifts and accompanying love notes on Sheila's desk, causing her discomfort and concern.

    True or False: Tim's subsequent behavior with gifts and love notes is not sexual harassment, as he complied with the initial instruction to stop asking Sheila for dates.

    • False. Tim's behavior with gifts and love notes should be reported by Sheila. Although he stopped pursuing dates as instructed, his actions now constitute another form of inappropriate workplace behavior. Since Tim resumed unwanted advances after being told to stop, he could face severe disciplinary consequences for his actions.

    Case Study Two: Ana

    Ana, a Latina trans woman, transitions to a new hospital with her employer. Her supervisor, Victor, also Latino, helps Ana adjust to her new job. However, Victor's behavior takes an inappropriate turn. In a private conversation, he mentions visiting a strip club and comments that the female coworkers in the office are unattractive, except for Ana.

    True or False: Victor's comments are not harassment because he did not directly tell Ana that she is unattractive.

    • False. Victor's statements to Ana are derogatory and sexually explicit, regardless of the intention behind them. Even though he framed his comments as a compliment, the discussion remains offensive and demeaning towards Ana and her female colleagues.

    True or False: Victor's mention of the strip club visit constitutes inappropriate workplace behavior.

    • True. Discussing a visit to a strip club is inappropriate in the workplace, particularly for a supervisor. This conduct should be reported, and Victor should be instructed to cease such discussions.

    True or False: Victor's comments about female employees are not a serious matter and do not warrant significant action.

    • False. Victor's comments demonstrate a serious issue of contempt for women in the workplace. As a supervisor, he is obligated to model appropriate behavior and must not exhibit contempt based on protected characteristics. These comments warrant disciplinary action and potentially his removal from his current position.

    These case studies underscore the significance of identifying and addressing inappropriate workplace behavior. The persistent advances by Tim and the demeaning comments by Victor serve as poignant reminders of the imperative for a workplace environment characterized by respect and freedom from harassment. If you have any questions or thoughts, please don't hesitate to share. Recognizing that this information can be overwhelming, take a moment to check in with yourselves.

    Case Study Three: Wayne

    Let's move on to the next case study involving Wayne. Wayne is employed as a transcriber for a large company. He has a penchant for wearing jewelry, often adorning himself with earrings and necklaces. However, his boss, Karen, finds his choice of attire unusual for a man in a clerical role. She frequently makes sarcastic remarks about Wayne's appearance and jokingly refers to him as her "office boy." Wayne aspires to advance his career in customer relations and applies for a promotional position that involves patient interactions at the front desk. Karen informs Wayne that he should adopt a more conventional look if he wants the job, implying he should appear more "normal" or wait for a promotion to mail room supervisor.

    True or False: Wayne's boss is accurate in stating that wearing jewelry is unsuitable for customer service roles.

    • False. Wayne's jewelry is only considered an issue because Karen deems it unconventional for a man. Her comments to Wayne reflect sex stereotyping.

    Continuing, Karen also suspects that Wayne might be gay, which she claims does not bother her, but she views Wayne as secretive. She starts probing into his personal life, asking intrusive questions like "Are you married? Do you have a partner? Do you have children?" Wayne attempts to politely decline answering, but he is growing increasingly frustrated. Karen proceeds to gossip about Wayne's perceived sexual orientation with his coworkers.

    True or False: Wayne is being subjected to harassment based on his sex and sexual orientation.

    • True. Wayne is facing harassment grounded in his failure to conform to Karen's gender stereotypes. Additionally, he is being harassed based on his perceived sexual orientation. it is immaterial whether Wayne is actually gay; he still has a claim for sexual orientation harassment. Wayne might also be experiencing harassment linked to his gender identity, constituting a form of sex and possibly disability discrimination under human rights law. Wayne should report Karen's behavior, which blatantly contravenes the sexual harassment policy, to the designated person authorized to receive complaints.

    Lastly, Wayne concludes that he will not have a fair opportunity for the promotion under these circumstances. He lodges a complaint with the designated authority of his employer about Karen's conduct. An investigation is conducted, and the designee informs Karen that Wayne's jewelry is not in violation of any workplace rules. Karen is instructed to consider Wayne for the position without regard to his gender and to cease her harassing behavior, intrusive questions, and gossip. While Karen complies by stopping her comments and gossip, she recommends a less experienced woman for the promotion. This woman lacks Wayne's two-year degree in customer relations from a community college.

    True or False: Wayne is likely experiencing discrimination based on his sex, sexual orientation, and/or retaliation.

    • True. While we aren't certain about Karen's motives for not endorsing Wayne for the promotion, the situation does not look favorable for her. It appears she either holds biases against Wayne due to the same reasons she harassed him, or she's retaliating due to his complaint, or perhaps both. Wayne should further communicate with the employer's designated authority, and the circumstances of the promotion should be thoroughly investigated. If it is found that Karen unfairly treated Wayne by failing to adequately consider him for the role, she should face disciplinary action. This case exemplifies the necessity for more severe measures in response to harassment complaints to prevent future discrimination. How is everyone feeling? Take a moment to check in with yourselves. Once again, I recognize the volume of information, but it is crucial and highly relevant.

    Summary

    Sexual harassment is illegal under Title VII of the Civil Rights Act of 1964, which prohibits sex discrimination and harassment based on sex, including pregnancy, sexual orientation, and gender identity. This encompasses unwelcome sexual advances, requests for sexual favors, and other verbal or physical sexual harassment in the workplace. Workplace practices that discriminate or involve harassment are prohibited by Title VII, ensuring a safe and inclusive work environment for all employees. Employees have rights to work in an environment free from discrimination and harassment. Victims of sexual harassment are not at fault and have the right to speak up, report the behavior, and seek help. Witnesses to harassment also have a responsibility to report it. The laws enforced by the Equal Employment Opportunity Commission (EEOC) protect employees from harassment by anyone in the workplace, including managers, coworkers, and clients or customers. Employers should establish an inclusive and safe working environment that is free of discrimination and harassment. Clear communication about a zero-tolerance policy for any form of harassment is essential. Individuals should consider the steps they would take if faced with harassment and ensure they know who to talk to for assistance.

    Knowledge of your rights, recognizing inappropriate behavior, and taking action are crucial in maintaining a workplace that is respectful, inclusive, and free from harassment. If you have any questions or concerns, please feel free to share. This information might be overwhelming, so remember to take a moment to check in with yourselves.

    References

    Illinois General Assembly Compiled Statuses. Illinois Human Rights Act. Retrieved June 17, 2023 from https://www.ilga.gov/legislation/ilcs/ilcs4.asp?DocName=077500050HArt.+2&ActID=2266&ChapterID=64&SeqStart= 600000&SeqEnd=1393750

    National Sexual Violence Resource Center. Fact sheet on Injustice in the LGBTQ Community. Retrieved June 19, 2023 from https://www.nsvrc.org/blogs/fact-sheet-injustice-lgbtq-community

    Select Task Force on the Study of Harassment in the Workplace, Report of Co - Chairs Chai R. Feldblum & Victoria A. Lipnic , June 2016 at https://www.eeoc.gov/select-task-force-study-harassment-workplace#_Toc453686298

    Strauss, S., (January 31, 2019) "Overview and Summary: Sexual Harassment in Healthcare" OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 1, Overview and Summary. https://ojin.nursingworld.org/table-ofcontents/volume-24-2019/number-1-january-2019/os-sexual-harassment-in-healthcare/

    Sexual Harassment in Our Nation’s Workplaces. Office of Enterprise Data and Analytics (OEDA) Data Highlight No. 2. U.S. Equal Employment Opportunity Commission (EEOC), Washington, DC, April 2022.

    Stasenko M, Tarney C, Seier K, Casablanca Y, Brown CL. Sexual harassment and gender discrimination in gynecologic oncology. Gynecol Oncol. 2020 Nov;159(2):317 - 321. doi : 10.1016/j.ygyno.2020.08.014. Epub 2020 Aug 22. PMID: 32839027; PMCID: PMC7584749.

    US Department of Health and Human Services. Sex Based Harassment. Retrieved June 17, 2023 from Sex-Based Harassment | HHS.gov

    US Equal Employment Opportunity Commission. Sexual Harassment. Retrieved June 17, 2023 from https://www.eeoc.gov/laws/guidance/fact-sheet-sexual-harassment-discrimination

     

    Citation

    Hernandez-Harris, A. (2023). Sexual Harassment Prevention and Training. Continued.com - Respiratory Therapy, Article 201. Available at www.continued.com/respiratory-therapy

    Aug 21, 2023

    1 CE Hour

  • Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standards: What You Need to Know

    Kathleen Weissberg, OTR/L, OTD

    Editor’s note: This text-based course is an edited transcript of the webinar, Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standards: What You Need to Know, presented by Kathleen Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS.

    Learning Outcomes

    After this course, participants will be able to:

    • Define key concepts related to bloodborne pathogens, occupational exposure
    • Identify the minimum standards to which employers must comply related to bloodborne pathogens infection control
    • List the 4 main methods of compliance as defined by the Occupational Safety Health Administration (OSHA) Bloodborne Pathogens Standards
    • Identify best practices with regard to personal protective equipment, handwashing, handling contaminated items, record-keeping

    Definitions

    • Blood – human blood or component
    • Bloodborne Pathogens – microorganisms transmitted in the bloodstream that can cause disease
    • Contaminated – presence of blood or other potentially infectious materials on an item or surface

    Honestly, I have tried hard to figure out how to make OSHA fun, exciting, riveting, and engaging I have not figured it out yet. Maybe after this session, we will figure that out. This is standard 1910.1030, in case you need that information. We probably know these intuitively, but let's review what OSHA means by each of these items. First, blood, human blood, and human components are products that might be made from human blood. When we talk about the term bloodborne pathogens, these are microorganisms that might be transmitted through the bloodstream that can cause disease, particularly in humans. These might include things like hepatitis B or HBV. You will see it abbreviated throughout Hep C or HBC. The human immunodeficiency virus or HIV. When you hear the word contaminated, we talk about the space where we practice. This means the presence or the reasonably anticipated presence of blood or any potentially other infectious materials. You might see that abbreviated throughout this as OPIM or other potentially infectious materials. These can be on an item we might be using during treatment or on some surface where we are placing something. For example, let's say we are talking about laundry or a surface that has been contaminated, it is reasonably anticipated, or we know that it is been soiled with blood or some other potentially infectious materials. Maybe in the case of laundry in a nursing situation, there could be sharps rolled up into that laundry. That could mean any object carrying infectious material that could puncture the skin. It could be a needle, a scalpel, broken glass, exposed ends of a dental wire, or something else. All those things would need to be decontaminated using physical or chemical means to inactivate or otherwise destroy the microorganisms there.

    • Engineering Controls – things in a place of employment that isolate or remove a bloodborne pathogens hazard
    • Exposure Incident – means contact with infectious materials by eye, mouth, other mucous membrane, non - intact skin, or parenteral contact
    • Handwashing Facilities – adequate supply of running potable water, soap, and single-use towels or air-drying machines

    Continuing on engineering controls, This means controls or things that we do in our place of employment. It might be a sharps disposal container, in a nursing situation, probably a self-sheathing needle, safer medical devices that might be out there, such as sharps with engineer sharps, injury protection, needleless systems, et cetera, that are going to isolate or otherwise remove the bloodborne pathogens in that hazard from the workplace. An exposure incident, we will talk about procedures related to this toward the end. This would mean a specific eye, mouth, or other mucus membranes, non-intact skin or parental contact with blood or OPIM, or other potentially infectious materials that result from the performance of some job duty that you have. Some part of you that is "open," or exposed, has come in contact with infectious material. This is actual exposure versus occupational exposure. Occupational exposure means that during the course of your daily work, you may be going to come in contact with potentially infected blood or body fluids. In all of our practices, we would expect some occupational exposure. Hand washing facilities are pretty basic, but the facility provides an adequate supply of running water, soap, single-use towels, or air drying machines. In a few slides, we will talk in detail about how and when to wash.

    • Needleless systems – a device that does not use needles for:
      • Collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established:
      • Administration of medication or fluids; or
      • Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps

    A needleless system is a device that does not use needles to collect bodily fluids or withdraw bodily fluids after initial venous or arterial access is established. It could be for administering medication or fluids or any other procedure that might involve the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

    • Other Potentially Infectious Materials (OPIM) – body fluids
      • Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures
      • Any body fluid visibly contaminated with blood
      • Situations where it is impossible to differentiate between body fluids

    OPIM could mean unfixed tissues or organs from a human that could be living or dead or cells or tissues that contain some transmissible disease. For example, HIV, HPV, and other types of hepatitis, et cetera. For most of us, I think it is probably body fluids that we are coming in contact with. Things as cerebral spinal fluids, synovial fluid, semen, vaginal secretions, and pleural fluid. You can come across peritoneal fluid, amniotic fluid, saliva, suctioning, or something like that. , any body fluid visibly contaminated with blood, and all body fluids in situations where we cannot tell. It is difficult or impossible to differentiate what body fluids I see. Do they have blood, or do they not have blood? You are going to treat it as if it is potentially contaminated. How often we are indeed coming in contact with this, I do not know, but we have to know that definition as well.

    • Personal Protective Equipment – specialized clothing or equipment worn by an employee for protection against a hazard
    • Regulated Waste – liquid or semi-liquid blood or other potentially infectious materials or contaminated items

    A couple of other definitions of personal protective equipment (PPE). We will discuss this in more detail, but this is specialized clothing or equipment that we wear to protect against a hazard. Remember that our general work clothes, your uniform, pants, shirt, blouse, scrubs, whatever, are not intended to protect against a hazard. They are not considered to be PPE. I think we inherently know that. PPE includes gloves, gowns, a face shield, an eye shield, boot covers, et cetera. Regulated waste means liquid, semi-liquid blood, potentially infectious material, or contaminated items. We all know that these need to be disposed of in a certain way. Sharps with engineered sharps injury protections is a non-needle sharp or needle device used for withdrawing body fluids, accessing a vein or artery, and administering medications or other fluids with a built-in safety feature or a mechanism that reduces the exposure or risk of an exposure incident.

    Universal precautions are an approach to infection control recommended by the CDC and OSHA. According to universal precautions, all human blood and certain human body fluids are treated as if they are known to be infectious for various things, such as HIV, hepatitis, and other bloodborne pathogens. Work practical controls are controls that will reduce the likelihood of exposure by altering the manner in which a task is performed. For example, let's say you have to do a specific task. Needles are the easiest to talk about when doing something with sharps. A work practice control might be something like you are prohibited from recapping that by a two-handed technique. You have to use a one-handed scoop. That would potentially protect you from not an actual exposure incident.

    The Standard

    • Requirements state what employers must do to protect workers who are occupationally exposed to blood or other potentially infectious materials
    • Requires employers to:
      • Establish an exposure control plan
      • Update the plan annually to reflect changes in tasks, procedures, and positions that affect occupational exposure, and also technological changes that eliminate or reduce occupational exposure
      • Document procedure for the evaluation of circumstances surrounding exposure incidents
      •  Exposure plan is available and accessible
      • Feedback needs to be from non - managerial
        employees responsible for direct patient care

    Let's talk about the standard requirements of what employers must do to protect workers who are occupationally exposed to blood or other OPIM. This standard protects workers in healthcare who can reasonably be anticipated to come in contact with blood or other body fluids or other infectious materials as a result of just doing their day-to-day job. In general, this requires the employer to do a few things. They have to establish an exposure control plan. This is a written plan that exists to eliminate or minimize occupational exposure. This has to be done. They must prepare an exposure determination that contains a list of job classifications in which all workers have occupational exposure. Then a different list of job classifications in which some workers have occupational exposure, like the people that always have occupational exposure and some that have some occupational exposure, along with a list of tasks and procedures that those people would be performing that result in their exposure. It is this list of what you can expect with regard to exposure. The other thing is the employer needs to update this plan annually to reflect any changes in tasks, procedures, positions, job classifications, or anything that could potentially affect occupational exposure. It would also include updates of any technological changes they have implemented or now exist that eliminate or reduce that possible exposure. In addition, annually, they need to document in the plan that they have begun using appropriate commercially available, effective, safer medical devices designed to eliminate or minimize occupational exposure. It does not mean they have to change or do something; there may not be something on the market that they can change, but they have to evaluate, consider, and look at that.

    Employers must also document that they have solicited input from frontline workers in identifying, evaluating, and selecting some of those engineering controls and work practice controls. They are getting feedback from us on what is working, what is not, and what should change. The employer must document the procedure for evaluating circumstances surrounding those exposure incidents. How did they evaluate that this job classification or this task has an exposure, but this one does not? There has to be some methodology documented related to that. Employers we know must make sure that a copy of that exposure plan is available and accessible to all employers or employees. Typically you will find this in a policy procedure manual, maybe a clinical manual. I urge you to look at it and see what it says about the place where you are practicing. I talked about feedback because this is important in soliciting that feedback about things that are effective or ineffective. It must be from frontline workers, non-managerial employees responsible for direct patient care, and those potentially exposed to contaminated materials. Just in my history, I have seen where we do not always do that. Sometimes we keep it among the managerial team instead of going to the source to discover what could possibly help our frontline. We talked about exposure determination, but keep in mind without regard for the use of PPE. If I am going to be exposed, how was that determination made if I did not have PPE? If I did not have it, would I be exposed? What level of exposure would I see?

    Methods of Compliance

    • Universal Precautions
    • Engineering and Work Practice Controls
    • Personal Protective Equipment
    • Housekeeping Practices

    The four main methods of compliance refer to techniques and procedures that we can follow to minimize the risk of exposure to bloodborne pathogens. These are universal precautions, engineering work practice controls, PPE, and housekeeping practices. We will start with universal precautions because we all know about and have heard about this.

    Universal Precautions

    • Using disposable gloves and other protective barriers while examining all patients and while handling needles, scalpels, and other sharp instruments
    • Washing hands and other skin surfaces that are contaminated with blood or body fluids immediately after a procedure or examination
    • Changing gloves between patients and never reusing gloves

    The OSHA standards are crystal clear about practicing universal precautions. We should observe these to prevent contact with blood or other potentially infectious materials. When you are not sure, you cannot differentiate. It is not clear. Treat it as if it is infectious. It is always better to protect yourself than to take that risk. I think way back when we started doing a lot of these things, there was this worry, Am I going to be offensive to my patient? Are they going to think that I think they have something? I do not think that is the case anymore. If nothing else, as we have come through COVID. As a strong expectation that we wear gloves and masks as these things are very standard practices. It is a good thing. It is nice to see that we have gotten there. This approach treats all human blood body fluids as if they contain bloodborne pathogens. What do universal precautions include? It's disposable gloves and other protective barriers.

    We talk about what those are while examining all patients, handling needles, scalpels, sharp instruments, and the like. It is washing our hands. You cannot ever wash too much, I am convinced. Other skin surfaces, your arms, your elbows, your forearms, whatever could possibly be contaminated with blood or body fluids immediately after a procedure or an examination or as soon as practicable. I say that because sometimes, as we all know, the hand washing sink is not always readily available. We may pause and use hand sanitizer until we get to that sink. Changing gloves between our patients and never reusing gloves. There is nothing wrong with taking them off and grabbing a new pair. That is obviously what we should do. There are types of gloves that we can reuse, but certainly not the latex variety that we typically see in our clinics.

    • Used to eliminate or minimize employee
    • exposure
    • If occupational exposure remains, PPE is used
    • Employer must review, examine, maintain or replace controls on a regular schedule
    • Provide handwashing stations
    • If not feasible, provide appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes

    We have mentioned this should be used to eliminate or minimize any exposure we would have where occupational exposure remains even after controls have been used. We have put policies and procedures in place. If there is still occupational exposure, then we use our PPE. The question is, what is the employer required to do? They must review, examine, maintain or replace these on a regular schedule to ensure they remain effective. That is the critical piece: maybe something we put in place 2-4 years ago is not appropriate anymore. Considering where we are today versus where we were four years ago. We constantly reevaluate. We get feedback to make sure that they remain pertinent. They do need to provide hand washing stations. If it is not feasible or unavailable in your space, the employer must provide an appropriate antiseptic hand cleanser. A hand sanitizer in conjunction with clean cloth paper towels or antiseptic towelettes. This one important piece is that the hand sanitizer has to be of a particular medical grade. It has to have a certain amount of alcohol to be effective. it is essential to use the stuff that your employer gives. Maybe some of them give trial sizes you can stash in your pocket.

    • Handwashing
      • Hand sanitizer does not take the place of appropriate handwashing
      • Wash hands with soap and running water as soon as possible
      • Hand hygiene is the first line of defense, and hand washing is generally considered the single most important procedure for preventing the spread of infection

    Hand sanitizer is great. We love it, it is fabulous, but it does not take the place of appropriate hand washing. If you are using hand sanitizer as your stopgap, you want to quickly get somewhere where you can genuinely wash your hands with soap and running water. I am going to back up for just a quick second share that recently, I have been at several large national conferences, and I work in long-term care, and they were talking about tags related to state surveys. They said the number one most common tag deficiency that people are getting on their survey relates to infection control. It is not infection control as a global umbrella, it is hand hygiene. It is hand washing and the appropriate use of gloves. Those are such simple things. I do not know about you, but it seems like everywhere I go, signs say this is how you wash your hands or how long to wash your hands. I will call them engineering practices. Even on the doors, I do not have to pull the door open. I can pull it open with my foot, different things like that, that keep our hands nice clean. But it is the number one deficiency out there. I found that interesting. It is generally considered the most critical procedure for preventing the spread of nosocomial infection. It is used in conjunction with those standard precautions which keep us protected.

    When do we wash our hands? When you complete any required task before you leave a laboratory if you happen to be taking a specimen or doing something like that in the course of your work. Immediately after the removal of your gloves and other PPE. Upon contact or when contamination with blood or other potentially infectious material is visible. It is recommended if you get something on your gloves, change your gloves pretty quickly. Before eating, that is gross not to wash our hands before we eat. Drinking, smoking, applying cosmetics, handling contact lenses, anything where we would be close to one of our mucus membranes that would be exposed or open to a microorganism. Before using the bathroom. Then before any activities in which hand contact is made with mucus membranes, the eyes, or any break in the skin. If you had a cut or an abrasion, or a wound.

    How do you wash your hands? I have to say this is like kind of 101. I realize that but this is OSHA as I said, it is one of the most prominent tags that we see. You wet your hands with water, apply enough soap to cover all the surfaces, thoroughly wash all the parts of your hands and fingers up to the wrist, and rub your hands together between your fingers for at least 20 seconds. I do not know what you were taught, maybe it is saying the alphabet a couple of times, singing the happy birthday song, or you count. You rinse your hands with water, you dry them thoroughly with a paper towel. Use a paper towel to turn off the faucet, open the door if you can, turn off the light, and touch any surface that could have been touched by potentially contaminated hands now that your hands are clean. Employers need to ensure that employees wash their hands immediately or as soon as feasible after we remove gloves and other protective equipment. Additionally, we need to wash our hands and any other skin with soap water and flush the mucus membranes with water as soon as feasible following any contact with body areas, with blood, or any potentially infectious material. We do not go through like eye wash stations in this session, but I suspect those are on-site somewhere in your clinic or where you work. That might be another thing that you seek to say where is that? Should I ever need that? What is the procedure how do we go about using that? 

    Engineering and Work Practice Controls

    • Contaminated needles and other contaminated sharps should not be bent, recapped, or removed with a few limited exceptions
    • Shearing or breaking of contaminated needles is absolutely prohibited
    • If sharps are to be reused, storage container must be puncture resistant; labeled or colorcoded; and leakproof on the sides and bottom

    Contaminated needles contaminated sharps. There are a few limited exceptions there, but for the most part, they should not be bent, recapped, or removed. Shearing or breaking is positively prohibited. If they need to be bent, recapped, or something like that, that needs to be done through a mechanical device, or a one-handed technique may be where we scoop it but never two-handed. Because if you miss somehow, you can potentially puncture your skin. If sharps are reused, there are cases where that happens. They need to be in an appropriate container until they are reprocessed. We do not reprocess those. It will be by somebody else. Not sure who that is. If that is the case, that container does need to be puncture-resistant, labeled, and color-coded leakproof on the sides on the bottom. That is a general sharps container. My husband years ago had to give himself an injection once a month we had our very own little sharps container in our home. 

    • Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure
    • Food and drink shall not be kept anywhere potentially infectious materials are present
    • Standards also apply to equipment

    Handling contact lenses is prohibited in areas with a reasonable likelihood of occupational exposure. I think that makes a lot of sense. Additionally, food and drinks should not be kept in refrigerators, freezers, shelves, cabinets, countertops, benches, and table tops, or where we may have blood or other potentially infectious materials. All procedures involving blood or other potentially infectious materials should be performed to minimize splashing, spraying, spattering, generating droplets, et cetera. I will not get into this a lot of detail, but the standards also apply to equipment. You want to make sure that you examine any equipment that you are using before using it. A piece of equipment could have had a blood splatter or something sprayed on it. You want to make sure that you look at it, you review it. If you had that happen during your treatment session, you want to alert whoever would take care of that because that needs to be decontaminated as quickly as possible. Unless that is not feasible, you want that decontaminated, you want that cleaned before somebody else uses it. I think in a lot of our clinics now, I do not know if you have seen this, but there are like plastic, I do not even know what I would call them, almost like a plastic sheath or a plastic bag that can be used over a lot of tubing probes different things that it is a single-use, it is not contaminated then that cleanliness is retained.

    Personal Protective Equipment (PPE)

    • Provision
      • With occupational exposure, employer shall provide, at no cost to the employee, appropriate PPE
      • PPE is considered “appropriate” only if it does not permit blood or other potentially infectious materials to pass through or underneath

    What does the standard stay about PPE? The standard says provision. When there is occupational exposure, the employer shall provide PPE. I am reading directly from this at no cost to the employee appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields, masks, eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. There is a lot of stuff included there. PPE will only be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach your work clothes, your straight clothes, your undergarments, skin, eyes, mouth, or other mucus membranes under normal conditions of use for the duration of time that you are wearing the PPE. Sometimes, you see this fancy cute stuff that people might be using. It is not PPE unless it genuinely protects you, the wearer underneath, from something saturating through it or coming through it, getting on your skin or to your undergarments or such.

    • Use
      • Ensure employees use PPE unless employee temporarily and briefly declined to use it or professional judgement demonstrates increased hazard to the safety of the worker
      • Circumstances must be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future

    The employer shall ensure that the employee uses appropriate PPE unless the employer shows that the employee briefly declined to use PPE when it was the employee's professional judgment under rare extraordinary circumstances. In this specific instance, its use would have prevented the delivery of healthcare or public safety services or would have posed an increased hazard to the safety of the worker or the coworker, meaning the employer has to make sure you wear the stuff that you use this stuff unless under some rare circumstance there is absolutely no way you can wear it and here is why. If you make that judgment, maybe during an emergency situation, a code, or something like that, the circumstances need to be investigated. They need to be documented. The reason is to go back to what the employer must do. They have to consistently look at the workplace engineering controls. Do they need to determine if there is something that should be instituted to prevent this from occurring in the future?

    Also, with PPE accessibility, there are all sorts of rules related to this. The employers shall ensure that the appropriate PPE in the appropriate size is readily accessible at the workplace or is issued to the employee. It is either there for you to use on a day-to-day basis, or it is yours to keep. That could be hypoallergenic gloves, glove liners, powderless gloves, or things your size. How often have you seen you go in there are only large gloves, but you have small petite hands that just do not fit similar alternatives? You have to have something accessible for you. Allergies are big ones for people, such as latex allergies. Two other things are laundering and disposal. They need to clean, launder dispose of PPE. It is never to the cost of the employee. The employer needs to be responsible for that. Finally, repair and replacement. The employer shall repair or replace PPE as needed to maintain its effectiveness at no cost to the employee. If you have something your own, does it need to be repaired or replaced? That is up to the employer to do that. A few things about PPE. If a garment is penetrated by blood or other potentially infectious material, it must be taken off immediately or as soon as possible. For example, it may not always be feasible if you are in a code. It should be removed before leaving the work area. That could be your specific work area, or that could be the workplace. It is both. When PPE is removed, you are going to put it in the appropriate area, the appropriate container, depending on your employer, where they either store it, wash it, decontaminate it, dispose of it, replace it make sure you know where that is.

    • Gloves
      • Worn when it is anticipated to have hand contact with blood, OPIM, mucous membranes, nonintact skin and/or when handling or touching contaminated items
      • Disposable gloves should be replaced as soon as practical when contaminated or if torn, punctured, compromised
      • Should NOT be washed for re-use

    I think gloves are probably our most common PPE when it can be reasonably anticipated that you will have hand contact with blood, OPIM, mucus membranes, or non-intact skin when you are handling or touching some contaminated item or you are working on some surface that is possibly contaminated. Disposable or single-use gloves should be replaced as soon as practical when they are contaminated. Soon as feasible, if they are torn or punctured, the inability to function as a barrier in some way, shape, or form has been compromised. If that happens, you get them off as soon as possible and put them where they belong. Maybe it is a red bag, the trash, but get a new pair on whatever the case. We never want to wash them, decontaminate them or reuse them. I did mention there is a type of glove those are utility gloves, which we are probably familiar with. Maybe our housekeepers use these or maintenance almost like a dish glove. Those can be decontaminated for reuse if the integrity of the glove is not compromised, meaning it has not been punctured, torn, ripped, cut, or anything like that. There is a process for doing that that your facility would utilize. I do not think we are using those, but there might be some folks in our communities that are.

    How you take off your gloves sounds basic, but you would be surprised. You pinch to hold the outside of the glove near the wrist area, peel it downward away from the wrist, turn the glove inside out, and pull it away until the whole thing is removed from your hand. Hold the glove inside out with your other hand that still has the glove on it. With your unloved hand, you will go inside the other glove. that makes sense because the skin underneath is not contaminated. You take great care not to touch the outside of the glove with your clean hand, peel it downward away from the wrist, turn that glove inside out, and continue down until it is off. You will have both gloves contained in themselves inside out. This ensures that both gloves are inside out, one envelope inside the other, with no contamination on your bare hands. Now you will dispose of those and are free to wash your hands.

    • Masks, Eye Protection, and Face Shields
      • Worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated, and contamination anticipated
    • Surgical caps/hoods and/or shoe covers or boots
      • When gross contamination is anticipated

    Masks, eye protection, and face shields are worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated, and contamination anticipated to the eye, nose, or mouth. It cannot just be the front because things can certainly come in through the side, or we see a lot of those chin-length face shields, some that connect here come the whole way down. Surgical caps or hoods, shoe covers, or boots would be worn when there is gross contamination that could be anticipated. I am not sure what that situation looks like, but if there is a possibility of a lot of blood or body fluids, we will want to use those.

    • Gowns, Aprons, and Other Protective Body Clothing
      • Will depend upon the task and degree of exposure anticipated
      • Should fully cover torso from neck to knees, arms to end of wrists, and wrap around the back and be fastened in the back of the neck and the back

    Gowns, aprons, and other protective body clothing would be worn in occupational exposure situations, depending on the situation. I should say this, it does not necessarily say this in the standard explicitly, but I think most policies and procedures would say, where of course, whatever you feel comfortable wearing, that choice is yours as the employee. Sometimes, we need to also look at the situation and ask, what is the risk here? Do I need the full hazmat suit, or can the glasses, goggles, gloves, and a mask be fine? I do not know. you make that judgment, but of course, do whatever you feel comfortable doing.

    The gown type and the characteristic of that gown that you might wear depend on the task and degree of exposure that you might anticipate. To be effective, it should fully cover your torso, neck to knees, arms down to your wrists, wrap around the back, and fasten in the back, both at the neck and the back. That is important because sometimes, going back to having accessibility in your size, if you are very tall, some of the gowns that might be on the linen cart in the hospital or the clinic where you are working might not be long enough for you to come all the way down to your wrist down to your knees. But you want to make sure you are covered. If this is something you are wearing, your gloves are going to go far up, and your gown should cover over the end of that glove you want to make sure that that is happening. If that is not the case, you want to bring that up to management to have the right fit.

    Removing a gown is the same as taking off our gloves. Unfasten gown ties, taking care that sleeves do not contact your body when reaching for ties. Pull the gown away from the neck and shoulders, touching the inside of the gown only. Turn the gown inside out, fold or roll it into a bundle, and discard it in a waste container. Hopefully, that was pretty basic for you. I think we know those things, but a review is not bad.

    Housekeeping

    Let's talk a little bit about housekeeping. Housekeeping is probably not our primary responsibility, but this is the next level of control or the next thing that OSHA would say for us to do. Employers must generally ensure that the work site is clean and sanitary. They need to determine and implement appropriate written schedules for cleaning what the method is for decontamination based on the location within your community, the type of surface to be cleaned, the type of soil, and the tasks or procedures being performed in those areas. oftentimes when we talk about cleaning, I think most of us in our clinics have a cleaning schedule. This equipment gets cleaned these times. This is what we do immediately at the end of a procedure. This is what happens at the end of the day. We have to make sure that that is maintained. What does that mean? We already talked a little about equipment, but equipment, environmental, working surfaces, and everything needs to be cleaned and decontaminated after contact with blood or other potentially infectious materials. Contaminated work surfaces need to be decontaminated with an appropriate disinfectant after completion of procedures as soon as they have been overtly contaminated at the end of the work shift if the surface may have been contaminated after its last cleaning. This means you have to have a regular cleaning schedule. The appropriate cleaner is also going to disinfect. I would refer you back to wherever it is that you are working. Typically they will have that for you in a spray bottle-free mixed, ready-to-go. You are cleaning that equipment at the end of the day, I would say throughout the course of the day as well. All bins, pales, cans, whatever, any receptacle that you have there intended for reuse that has the likelihood of becoming contaminated. You have to inspect and decontaminate as well. That might be up to housekeeping, or that might be up to us. If you have broken glassware, maybe you were just in the break room, or something broke, that is pretty easy. It does not necessarily have to be in a clinic. If it is contaminated, do not pick it up with your hands. I would not pick it up with my hands because you might get cut. You clean it up using mechanical means. That could be a broom, dustpan, tongs, forceps, brush, or appropriate.

    Regulated waste is also a part of housekeeping practices. Contaminated sharps need to be discarded immediately or as soon as feasible. As I mentioned, those containers are puncture-resistant leaf proof on the sides on the bottom, labeled, and color-coded. They need to be easily accessible right near where we are using those sharps. They need to be maintained upright they need to be replaced routinely. Sometimes they overfill, which is super dangerous you cannot get anything new in there that should not be allowed to happen. These are things that are placed in closable containers. They are constructed to contain all the contents and prevent any leakage of the fluids in them during handling, storage, transport, and shipping. They are labeled, sometimes color-coded, and closed before removal to prevent any spilling or protrusion of the things in there while they are being moved or transported. Once the regulated waste is ready to go somewhere and be disposed of, it does not go in the regular trash. Your regular trashman does not pick this up. A waste management company that specializes in regulated medical waste will come to pick it up, take it offsite, and destroy it. They somehow process it and reduce any potential harm from it.

    • Regulated Waste/“Red Bag
      • Anything in contact with a potentially infectious agent
      • Blood - soaked items
      • Gauze
      • Bandages
      • Specimen cups
      • Items containing dried blood or other fluids
      • Gloves, gowns, intravenous bags
      • Table paper
      • PPE

    You probably know this as the red bag. Regulated waste, anything that is in the red bag or regulated, is biohazardous. It is potentially infectious, it is a biohazardous waste. you might wonder what goes in there. Anything that comes in contact with a potentially infectious agent. Blood-soaked items, you can read it right with me. Gauze, bandages, specimen cups, and anything with dried blood or other fluids. Gloves, gowns, IV bags, soft plastic items, table paper that came off an exam table or a plinth, any PPE, and anything that could possibly have blood or body fluids on it should go in there. If you are not sure, put it in there. there is no harm and no foul in doing that. You would instead do that to protect the end user than a setup situation that would be dangerous.

    The next part of housekeeping is laundry. Housekeeping practice is a big piece of the methods of compliance. contaminated laundry needs to be handled as little as possible. Bagged or containerized, right where it was used, we do not sort it, rinse it, or do nothing with it. These would be color-coded bags or containers. Typically red. They would be placed if there is any likelihood of soak-through or leakage. That laundry would be placed in a bag or a container which would prevent that leakage. If it is coming in contact with contaminated laundry, if you are, you want to make sure that you are wearing PPE. Now I am not going to go through this I do not even have it on the slide. there is also a whole section in the OSHA standards on the methods of compliance related to HIV, HEP B research laboratories production facilities. I do not think we work there, but I will mention that there are very specific requirements related to those types of facilities as to what we cannot do. If that applies to you, make sure you seek that information out. 

    • Hepatitis B Vaccination and Postexposure Evaluation and Follow-up
      • Employer must make Hep B vaccine available to those with occupational exposure
      • Must provide post - exposure evaluation and follow - up to all employees who have had an
      • exposure incident
        • No cost to the employee
        • Reasonable time and place
        • Under supervision of a licensed healthcare professional
        • According to recommendations

    Continuing on here, we have information on hepatitis. Generally speaking, the employer must make the Hep B vaccination, the whole vaccination series, available to all employees with occupational exposure. They must provide post-exposure evaluation and follow-up to all employees who have had an exposure incident. These are made available at no cost to the employee. They are made available to the employee at a reasonable time and place and performed under the supervision of a licensed physician or another licensed healthcare practitioner. Provided according to the recommendations of the United States Public Health Service, an accredited laboratory conducts all lab tests that would be required here at no expense and at no cost to the employee. The Hep B vaccination must be made available after the employee has received initial training within 10 working days of their initial assignment, i.e., their new hire to all employees who potentially have occupational exposure. Unless that person already had the vaccination series, antibody testing has revealed that the employee is immune. Or, for some reason, if the vaccination series is contraindicated for some medical or health concern. Now pre-screening cannot be a prerequisite for receiving the Hep B vaccination. Also, if the employee declines it but at a later date says, "I have changed my mind," while they are still covered under the standard they decide to accept, the employer needs to make it available at that time. If somebody does decline, they are required to sign a statement. If the routine booster is recommended at some future date down the road for whatever reason, maybe it was exposure, that booster needs to be made available as well.

    What happens if you have been exposed? Your guidelines in your facility may be a little bit different. Still, following a report of an exposure incident, the employer needs to immediately make a medical evaluation available to that exposed employee, which is a confidential follow-up. There are a bunch of things that have to be included in there. First is the documentation of the route or the roots of exposure and the circumstances under which that incident occurred. What happened? What was going on there? Identification documentation of the source individual. where, like to whom, or with whom did you come in contact? Unless the employer can establish that identification is infeasible or if it is, for some reason, prohibited by state or local law. The source individual's blood should be tested as soon as feasible after consent is obtained to determine if there is some hepatitis or HIV infectivity. The employer must establish that legally required consent cannot be obtained if consent is not obtained. That has to be documented. When that is not required by law, the consent, the source individual's blood, if available, should be tested the results documented. If the source is already known to be infected with HPV or HIV, testing does not need to be repeated. Results of the source individual testing need to be made available to the exposed employee. The employee shall be informed then of applicable laws and regulations surrounding any disclosure of that source's identity or infectious state.

    What else? The exposed employee's blood. It is also collected as soon as feasible and tested. Consent needs to be obtained there. If they consent to the baseline collection but do not consent to HIV serologic testing rights, the sample must be preserved for at least 90 days. If, within 90 days, the employees come back saying, "I changed my mind. I want to have it tested," they can have it tested as soon as feasible. The final thing that needs to be involved here is post-exposure prophylaxis when that is medically indicated and any counseling about the episode, mainly if that person has tested positive. then the evaluation of any reported illnesses. There is also information that is required to be provided to the healthcare professional, providing the follow-up or the vaccine. That would be a copy of the regulations. A description of the exposed employee's duties relating to the exposure incident.

    Why was this person exposed? What were they doing? If available, document the rude or exposure, the circumstances, and the results of the source individual's blood testing. Then, all relevant medical records to the appropriate treatment if those are available. Then what happens? The healthcare professional gives a written opinion. The employer needs to provide that to the employee who was exposed within 15 days after the completion of the evaluation. If that is the case, the written opinion for the Hep B vaccination should be limited to whether or not the vaccination is indicated for the employee, whether or not they have received it, and that it cannot go anywhere past that. The written opinion for post-exposure is limited to the employee being informed of the evaluation results and that the employee has been told about any medical conditions resulting from that exposure to the blood or the OPIM, which require further evaluation treatment. Everything else is confidential and does not go in that written report. after an exposure incident, all the employee is allowed to know from the healthcare professional is the results and the medical conditions that might require treatment here, evaluation or treatment. It cannot go anywhere past that.

    • Communication of Hazards to Employees
      • Warning labels must be affixed where potentially infectious material might be
      • Labels must be fluorescent orange or orange-red with lettering and symbols in a contrasting color
      • Affixed as close as possible by a method that prevents loss or unintentional removal
      • Red bags or red containers may be substituted for labels

    The warning labels need to be put on containers of regulated waste. Maybe it is on a refrigerator or a freezer with something. Any potentially infectious material, other containers that might be used to store, transport, ship, whatever. typically you see these little biohazard labels. You will see maybe the red bin or the red bag, it will also have this biohazard on it. Typically these labels are fluorescent orange, maybe orange-red, or predominantly red with lettering symbols that are in a contrasting color. Typically you see black on orange or black on red. Labels need to be affixed as close as possible to the container by string, wire, adhesive, or something that will prevent it from falling off, getting lost, somebody unintentionally removing it or getting it stuck on something, or it falling off. Red bags or red containers can be substituted for labels, but we often see them in conjunction. If it is regulated waste that has been decontaminated, that is not color-coded because there is no contamination. This red bag or this biohazard is only that which is genuinely contaminated. If you are working in a place with significant hepatitis or HIV, maybe it is a research laboratory or something like that, specific signage needs to be posted there. I will not get into great detail because I am not sure that affects too many of us.

    • Information and Training
      • Employer must train each employee with occupational exposure
      • No cost to the employee and during working hours
      • Training provided at initial assignment and at least annually thereafter
      • Re-trained with any changes (e.g., modification of tasks or procedures)

    I think the final method of compliance that we are going to talk about is information training. The employer needs to train each employee with occupational exposure in accordance with the requirements of this particular section of OSHA. That training needs to be provided at no cost to the employee. It needs to be done during working hours. The employer needs to implement this training program and ensure employees participate. this is just my advice, take it for what it is worth. I love being up to date on this and knowing what the requirements are, but I will also go back to my employer to be absolutely sure I know their requirements. We know what OSHA requires right now. What we do not know is what does my clinic require? What are their policies and procedures? Where are these things stored? Where do I take my biohazard waste?

    Training Program

    The training does need to be provided at the time of initial assignment, i.e., their new hire annually after that. Typically in conjunction with when we update that manual or look at our procedures in place. Annual training for all employees shall be provided within one year of their previous training. Additionally, additional training would be provided if something changes. there is a modification of a task, procedure, or task, whatever happens. The additional training could be just limited to that new information. Now keep in mind too, health literacy, literacy in general, we have to make sure that that training is appropriate to person's language, their education level, et cetera. The person conducting the training needs to be knowledgeable in the subject matter. I will tell you this is a complete aside. Suppose anybody listening in works in skilled nursing, the updated phase three requirements of participation that surveyors will start using, well, maybe they started using October 24th. In that case, those require that infection prevention be on-site at least part-time for each skilled nursing facility. As I said earlier, it is the biggest reason people get citations. the training program needs to contain a whole bunch of stuff we will discuss on the next couple of slides here. A copy of the regulations or, at a bare minimum, where they can be found. A general explanation of epidemiology, symptoms of bloodborne diseases, and the modes of transmission of bloodborne pathogens.

    What is the employer's exposure control plan? How can I get a copy of that Exposure Control Plan? Where is it kept? An explanation of the appropriate methods for recognizing tasks and other activities involving blood or body fluids exposure. An explanation of the use limitations of methods that will prevent exposure. Maybe it is those engineering controls that we talked about, the work practices, the PPE, the types, the proper use, the location, the removal, the handling, and the decontamination, all related to PPE. An explanation on the basis for the selection of PPE. Why do we have what we have in our clinic? Information on the Hep B vaccine, it is efficacy and safety. How is it administered? The benefit how that it is offered free of charge. Information on actions to be taken and persons to contact in an emergency. What is the procedure following an exposure incident? We just talked a little bit about what that would entail, but what is the facility's policy procedure related to that? What is the post-exposure evaluation follow-up that they are required to provide? What kind of signage do we use? What kind of labels? What kind of color coding? Where can you find that? then there has to be an opportunity for interactive Q&A with the person conducting the training session. You do not have to ask questions, but you must be allowed to do so. Now the final thing here is documentation. We cannot get away from it.

    Record Keeping

    The employer must establish and maintain an accurate record for each employee who potentially has occupational exposure. That record must include the employee's name and hepatitis vaccination status. Maybe it is a copy of when they got the vaccine, or if they declined, why. As a result of any examinations, medical testing, or follow-up, if there was an exposure incident, healthcare professional's written opinion, we talked about that. Then a copy of any information that was given to the healthcare professional. You, if you were exposed. The employer must ensure that all those records are kept confidential. They are not disclosed or reported without your written consent to any person within or outside the workplace unless it is required by law for some reason. Those records need to be maintained for the duration of employment plus 30 years, which is a pretty long time.

    Then the training records, we talked about the training, but those records need to include as well the date of the training sessions. What was the content? Is it just an outline or a time-ordered agenda, even if it is just a copy of the reviewed handout? The names, the qualifications of the person who conducted that training then who attended. The name, the qualifications, the job titles, et cetera, of those individuals who were there. Those training records need to be maintained for at least three years from the date on which the training occurred. That would be a rolling three years because we are doing it annually. You will always have three years' worth of data. Additionally, those records need to be made available upon request of authority. A healthcare director, assistant secretary, or somebody who comes in and asks for them to examine them or copy them, they have to be made available. That would also include employee training records and employee medical records.

    One final record we have to keep maybe not be pertinent to us, but it is a sharps injury log that is just what it sounds like. Any information on this log needs to be maintained to protect the confidentiality of the injured employee. At a minimum, it was the type, the brand of the device that was involved in that incident. Where did it occur? What was the department? What type of exposure was it? How did it happen? What is the explanation of how this incident occurred? The whole purpose of this is quality assurance and performance improvement that I can go back and look at, say, what happened here? What could we have done differently to prevent this from happening in the future? Those are engineering work practice controls that we continuously look up.

    Summary

    The employer is required, as per the OSHA standard, to establish an exposure control plan to update it, review it annually, implement the use of universal precautions, to identify the use of those engineering those work practice controls to ensure that they are being utilized. That is important because if they put all this stuff in place for us, yet, we do not use it, what is the point? We are only doing ourselves a disservice. We are not following policy procedures. They need to provide us with PPE. They need to make the Hep B vaccination available to all occupational exposure workers. They need to make available any evaluation or follow-up. If I am exposed, they need to make sure that I get the treatment and the evaluation to ensure that I am protected. They are responsible for using labels and signs, communicating, providing training, and maintaining those records. It is an awful lot. Typically, you will have a specific infection control practitioner, an infection preventionist, or a specific nurse. Somebody responsible for overseeing this. If it is a larger organization, maybe we will have more people to do that, but critically important. 

    References

    Centers for Disease Control and Prevention. (n.d.). Sequence for Putting on Personal Protective Equipment. Accessed at: https://www.cdc.gov/hai/pdfs/ppe/ppesequence.pdf

    Denault D, & Gardner H. (2021). OSHA Bloodborne Pathogen Standards. PMID: 34033323.

    Faguy, K. (2017). Bloodborne Pathogens: A Review and Update. Radiologic Technology, 89(2), 139-154.

    Michaels, D. & Wagner, G. (2020). Occupational Safety and Health Administration (OSHA) and Worker Safety During the COVID - 19 Pandemic. Journal of the American Medical Association, 324(14), 1389-1390.

    Mitchell A.H. (2020) Occupational Safety and Health Administration (OSHA) Regulatory Compliance. In: Preventing Occupational Exposures to Infectious Disease in Health Care. Springer, Cham. https://doi.org/10.1007/978-3-030-56039-3_5

    Mitchell, A. H., Pannell, M. A., Arbury, S., Thomas, R., & Hodgson, M. J. (2019). Bloodborne Pathogens Standard Enforcement at the Occupational Safety and Health Administration: The First Twenty-Five Years. NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy, 29(2), 172–185.

    United States Department of Labor. (2019). Occupational Safety and Health Standards Standard Number: 1910.1030. Accessed at: https://www.osha.gov/lawsregs/regulations/standardnumber/1910/1910.1030.

     

    Citation

    Weissberg, K. (2022). Occupational safety health administration (OSHA) bloodborne pathogens standards: what you need to know. Continued.com - Respiratory Therapy, Article 164. Available at www.continued.com/respiratory-therapy.

    Dec 1, 2022

    1 CE Hour

  • Health Literacy & Delivering Culturally Competent Care

    Kathleen Weissberg, OTR/L, OTD

    Editor's Note: This text-based course is an edited transcript of the webinar, Health Literacy & Delivering Culturally Competent Care, presented by Kathleen Weissberg, PhD.

    Learning Outcomes

    After this course, participants will be able to:

    • Define health literacy.
    • Recognize health literacy concepts including relevant statistics.
    • Identify appropriate assessment tools to evaluate health literacy levels.
    • Recognize factors that influence health literacy.
    • Describe techniques the practitioner can use to facilitate health literacy in his/her practice.

    Introduction

    Thank you to anyone who is listening today on this important topic, Health Literacy and Culturally Competent Care. I think these really go hand in hand and are critically important for anyone in any level of clinical practice.

    Health literacy is the ability to read, compute, understand, and act on health information so that we can make informed decisions. Low health literacy is a serious threat to the wellbeing of persons who are seeking out any sort of medical care. With the increasing diversity of the clients that we are serving in our practice, we may observe that our communication skills are less effective with people from backgrounds that are different from our own.

    In this session, we are going to provide an overview of health literacy and talk about techniques for clear and effective communication, both verbal and written. We are going to talk about selecting easy-to-read health materials, assessment tools, and some other things. Throughout all of this talk, we are going to be interweaving some conversation about cultural competence, because of course, these two items go hand in hand.

    Definitions

    • Literacy
      • Ability to understand and use reading, writing, speaking, and other forms of communication as ways to participate in society and achieve one’s goals and potential
    • Health literacy
      • The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

    These definitions come directly out of Webster's. Literacy is the ability to understand and use reading, writing, speaking, and other forms of communication as ways to participate in society and to achieve one's goals and potential. Again, we are going to be talking about health literacy more, but this is being able to participate in your daily life, go to the grocery store, go to a place of worship, or whatever it is that you want to do. That is general literacy. Health literacy takes it a step further. It is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. As we will see in just a few minutes, the statistics related to health literacy in this country are really staggering.

    We all work in the healthcare industry, and I think every one of us would even agree that sometimes it is even challenging for us to be able to navigate the healthcare system with all of the forms and different things that we need to do.

    Health Literacy

    • Individual and Systemic Factors
      • Communication skills of laypersons and professionals
      • Lay and professional knowledge of health topics
      • Culture
      • Demands of the healthcare and public health systems
      • Demands of the situation/context

    When we look at health literacy, it is dependent on several individual and systemic factors not only within myself but also within the environment where I happen to be. Some of those things are the communication skills of laypersons and professionals. How can I, as a professional, communicate to the person that I am trying to serve so that they can understand me? What are the lay and professional knowledge of health topics? It is not only the communication piece but also knowledge of the topic. As that person is communicating to me, can I understand and incorporate that knowledge? We also need to know about a culture, and we will talk more about this as we go on. There are also demands of the healthcare and the public health system, particularly for situations and content. A demand going to see your general practitioner for a checkup is one thing. A demand going to see your cardiologist because you are having a procedure is something totally different.

    • What Does Health Literacy Affect?
      • Affects people's ability to:
        • Navigate the healthcare system, including filling out complex forms and locating providers and services
        • Share personal information, such as health history, with providers
        • Engage in self-care and chronic-disease management
        • Understand mathematical concepts such as probability and risk

    Health literacy affects our ability to navigate the healthcare system. I just alluded to this. This includes filling out forms, locating providers, locating services, and choosing your healthcare benefits at open enrollment. It can be very difficult sometimes to navigate through that.

    This is also sharing personal information such as health history with providers. How much do I share? What should I not share? How do I share that in a way that is understandable by the healthcare providers so that they can provide care for me?

    This is also the ability to engage in self-care and chronic disease management. We are going to talk a lot about this. These are preventative types of things like getting your annual mammogram, routine cancer screenings, or as a diabetic checking your sugar.

    It is also important to understand mathematical concepts, such as probability and risk. We may need to understand the dosage of medications or tracking health numbers to determine if is it necessary to call a physician or change medication.

    Health Literacy Skills

    • Numeracy skills
      • E.g., measuring medications, choosing between health plans, calculating premiums & copays
    • Health topics
      • E.g., the body, causes of disease, diet, and exercise

    Health literacy includes those numeracy skills. This could be calculating your cholesterol level, blood sugar level, measuring out medications and dosages, or understanding nutrition labels. This is very important, particularly for someone who needs to manage their sugar and fat content. Other topics include choosing between health plans, comparing prescription drug coverage, and calculating premiums, copays, and Medicare deductibles. All of this requires numeracy skills. As an aside, I have two young children at home and my daughter always says to me, "I don't understand why I need all this math?" The answer is that we use math every single day.

    In addition to basic literacy skills, health literacy also requires knowledge of health topics. Individuals who have limited health literacy often do not have basic knowledge about health, their body, or the nature and cause of disease. In some cases, they may have misinformation about health. They may be getting their information from an unreliable source like social media. Somebody may have tried to give them the information, but they just could not process it. Without having that basic knowledge, they may not understand the relationship between lifestyle factors like diet and exercise and how that impacts various disease processes and health outcomes.

    I alluded to this earlier. Health information can overwhelm even individuals with advanced literacy skills. We know that medical science progresses quite rapidly. Perhaps what a person learned about health or biology during their school years has changed. As healthcare professionals, we are most likely more up to date. However, the average person may have outdated or incomplete information. Moreover, health information that is provided during a stressful or unfamiliar situation is unlikely to be retained. A stressed brain does not take in that information always accurately, and there can be gaps. And, the stressed brain may fill in those gaps with misinformation.

    Low Literacy

    • Global crisis affecting many
    • Plain language + Clear communication = A solution
      • Without clear communication, we cannot expect people to adopt the healthy behaviors and recommendations that we champion

    Low literacy is a global crisis as it affects a lot of people. This is why it is so important to address this issue and confront the facts head-on. Quite simply put, the responsibility is ours as healthcare professionals to communicate in what we call plain language. We will be talking more about that term in just a few minutes. Without clear communication, we cannot expect people to adopt healthy behaviors and the recommendations that we champion. When people receive accurate, easy to use, and easy to read information about a health issue, they are better able to take action to protect themselves and to promote their own health and wellness. 

    Plain Language

    • Plain language is communication that users can understand the first time they read or hear it
    • Elements include:
      • Organizing information so that the most important points come first
      • Breaking complex information into understandable chunks
      • Using simple language and defining technical terms
      • Using the active voice

    Plain language is a strategy for making both written and oral information easier to understand. Users can understand plain language the very first time they read and hear it. Oftentimes, it is very conversational in nature. There also may be anecdotes or stories to get a point across. A plain language document is one where the person can get the information that they need and understand it. What is most important for us as healthcare professionals is to act appropriately on that understanding.

    Key elements of plain language include the organization of information so that the most important points come first. These are the most important things that you want that person to know or takeaway. It has to be right up front. We also want to break down the complex information into understandable chunks. We do this when we are teaching and training. We want to use very simple language and define the technical terms. This is no place for jargon. Lastly, we want to use an active voice.

    What is important to know about plain language is that it may be plain to one set of readers, but it may not be plain to another set. To put this in perspective, I am talking to a big group of professionals here today. You have a college education, and your level of plain language is going to be something very different from a person who may only have a fifth-grade education or their GED. It is critical to know your audience and test your materials before, during, and after they are developed. Make sure that you are meeting your objectives with your target audience.

    Speaking plainly is just as important as writing plainly. These plain language techniques also apply to verbal messages. You want to avoid jargon and explain medical and technical terms. You must apply these concepts to both verbal and written information.

    Health Literacy Incidence and Statistics

    Let's talk a little bit about the incidents and statistics related to health literacy. I shared that some of these are really staggering.

    Low Literacy Statistics

    • 36 million adults in the US cannot read, write, or do math above a third-grade level
    • Low literacy costs the US $225 billion+ per year
    • $232 billion in healthcare costs are linked to low literacy
    • Each year about 2 million immigrants come to the US, many lacking proficiency in English

    More than 36 million adults in the United States cannot read, write, or do basic math above a third-grade level. Low literacy costs the United States about $225 billion or more every year in things like nonproductive work, crime, loss of revenue due to unemployment, and things like that. We spend in the United States about $232 billion every year in healthcare costs that are very specifically linked to low adult literacy skills. We will see more about this on another slide. A lot of that cost is in emergency room visits and other things that may have been mitigated through preventative services but were not. Each year about 2 million immigrants come to the United States. When you look at that group of people, about 58% of them lack a high school education and are not proficient in English.

    • 43% did not understand the rights and responsibilities section of a Medicaid application
    • 26% were unable to understand information on an appointment slip
    • 60% did not understand a standard informed consent
    • 33% were unable to read basic health care materials
    • 42% could not comprehend directions for taking medication on an empty stomach

    (Campinha-Bacote, D., 2005)

    A study was done on health literacy by Campinha-Bacote back in 2005. It is a little old, but they found that of the patients surveyed, 43% did not understand the rights and responsibilities section of a Medicaid application. Twenty-six percent were not able to understand the basic information on an appointment slip like when to go back to see the physician or to go to outpatient for services. Sixty percent did not understand a standard informed consent form, and 33% were not able to read basic healthcare materials. Lastly, 42% could not comprehend directions for taking medication on an empty stomach. I have not seen updated statistics for these parameters, but I can only imagine they probably have not changed a lot. You may start to question how much of your teaching and training is really getting through. Although limited health literacy affects almost every adult at some point in time in their lives, there are some disparities in prevalence and severity.

    Vulnerable Populations

    • Adults over the age of 65
    • Recent refugees and immigrants
    • People with incomes at or below poverty levels
    • Racial and ethnic groups other than white
    • People with less than a high school degree or GED
    • Non-native speakers of English

    (National Center for Education Statistics, 2006)

    Certain populations are more likely to experience limited health literacy. This is not saying that they absolutely will. For example, this does not mean that someone with only a high school diploma or GED has low health literacy. This is just saying that they are at a higher risk. Vulnerable populations include adults over the age of 65, recent refugees and immigrants coming to our country, people with incomes at or below poverty levels, racial and ethnic groups (other than Caucasian or white), individuals with less than a high school degree or a GED, and non-native speakers of English. Again, they are a little more vulnerable to the issue than maybe some other individuals.

    Incidence and Identification

    • Nearly nine out of every 10 people in the U.S. have limited health literacy
    • Education level is not a good predictor of  health literacy
    • AHRQ recommends “universal precautions”
      • Assume that most individuals will struggle to understand health information

    (HHS AHRQ, 2015; Kutner, Greenberg, Jin, & Paulsen, 2006; Weiss, 2003; Weiss, 2007; HHS ODPHP, 2010)

    Nearly nine out of every 10 people in the United States have limited health literacy and have experienced difficulty using health information to effectively manage their health and their health care. There is often a discrepancy between the health literacy level of the healthcare professional and that of the individual receiving health services. This discrepancy is a huge cause of poor communication in health and healthcare. I sometimes have to step back and think, "Did I say something over their head?" My parents are elderly, and I often have to explain different things to them. You have to give them the information in the language that they understand. 

    It is also important to note that somebody's education level is not a good predictor of his or her health literacy. Again, I can use the example of my parents. Both of them have college degrees, but they really struggle with setting up a new glucometer, doing their Medicare forms, et cetera. In fact, since almost 90% of individuals have limited health literacy, these are individuals of all races, ages, incomes, and education levels. For this reason, the Health and Human Services Agency's Healthcare Research and Quality (HHS AHRQ) recommends that we adopt a universal precautions approach. We are very familiar with that as it relates to infection control. But in this case, we are talking about is health and healthcare professionals. We need to assume that most individuals will struggle to understand health information.

    Again, literacy skills are a very strong predictor of health status even more so than age, income, employment status, educational level, and racial or ethnic group. We cannot necessarily identify individuals who are going to have limited literacy skills. We are going to talk more about that in just a second, but clients may speak well or appear well-educated. They often do not tell anyone about their difficulties with reading and writing. They become very skilled at masking some of these things. If you adopt that universal precautions approach, you assume that all of your patients can have difficulty somewhere when understanding health information. To reduce the risk of communication issues, it is recommended to simplify all communication and confirm comprehension for all patients. If you do that more often than not, somebody with a higher health literacy is not going to be offended by the fact that you simplified it a little bit. Actually, they will probably be a little bit more appreciative.

    Signs of Low Literacy

    • Poor compliance with treatments and appointments
    • Watching and mimicking others
    • Not knowing the names of regularly used medications
    • Making excuses for not reading
    • Bringing someone who can read to appointments
    • Vocalization or sub-vocalization when reading
    • Confusion or frustration when reading

    There are some signs of low literacy. There can be poor compliance with their treatments and appointments. They may not follow up on their medications. They often watch and mimic others to learn. They may not know the names of their regularly used medications or how often they need to take them. They may make excuses for not reading. "I'll just take this home with me," or "I'll read it later because I forgot my glasses for the appointment." Bringing someone with them to their appointments who can read and give them that information is helpful in these cases. They may also use vocalization or sub-vocalization as they are reading to themselves. They may demonstrate confusion or frustration on their face.

    • Behaviors
      • Patient registration forms are incomplete or contain mistakes
      • The patient does not take medication as directed
      • The patient does not follow through with lab tests, imaging tests, or referrals
    • Responses to receiving written information:
      • "I forgot my glasses. I’ll read this when I get home."
      • "I forgot my glasses. Can you read this to me?"
      • "Let me bring this home so I can discuss it with my children/spouse."
    • Responses to questions about medication
      • The patient is unable to name medications
      • The patient is unable to explain a medication’s purpose
      • The patient is unable to explain the schedule/frequency for taking a medication

    (Weiss, 2003)

    There are additional signs, and this comes from Weiss in 2003. They may make mistakes or have incomplete forms. The client may not take their medication correctly or not follow through with tests, referrals, or labs. They again use excuses like they forgot their glasses. They may ask if you can read the form to them or want to take it home. They may also say that they cannot make the decision right now or need to discuss it with their family member. They also often do not know the purpose of their medication or the schedule, dose, or frequency. Those are some of our signs that as you are working with individuals you may see.

    Relationship Between Health Literacy and Health Outcomes

    What is the relationship between health literacy and health outcomes?

    Preventative Services

    • More likely to skip important preventive measures
    • Those with low literacy enter the healthcare system when they are sicker

    (Scott, Gazmararian, Williams, & Baker, 2002; Bennet et al., 1998)

    I have already alluded to some of these. According to research studies, persons with limited health literacy skills are more likely to skip important preventative measures. These are things like mammograms, Pap smears, flu shots, and routine vaccinations like the pneumonia shot or something like that. When you compare that to those individuals who have adequate health literacy skills, these clients enter the healthcare system sicker as they are skipping a lot of preventative services. 

    Knowledge of Conditions and Treatments

    • More likely to have chronic conditions
    • Less able to manage chronic conditions effectively
    • Less knowledge of illnesses and management

    (Williams, Baker, & Parker, 1998; Schillinger et al., 2002; Schillinger et al., 2003; Williams, Baker, Honig, Lee, & Nowlan, 1998; Kalichman, Ramachandran, & Catz, 1999; Kalichman & Rompa, 2000; Kalichman, Benotsch, Suarez, Catz, Miller, & Rompa, 2000)

    Persons with limited health literacy skills are more likely to have chronic conditions, and they are less able to manage them effectively. Studies have found that patients with things like high blood pressure, diabetes, asthma, or HIV and AIDS often have limited health literacy skills. They have less knowledge about their illness and management. They then enter the healthcare system with more intense symptoms and are sicker than if they had this information.

    Hospitalization

    • Associated with increased preventable hospital visits and admissions
    • Higher rate of hospitalization
    • Higher frequency of emergency services use

    (Baker, Parker, Williams, & Clark, 1997; Baker, Parker, Williams, & Clark, 1998; Baker et al., 2002; Gordon, Hampson, Capell, & Madhok, 2002)

    The rates of hospitalization are higher as well. Limited health literacy skills are associated with an increase in preventable hospital visits and admissions. Studies have demonstrated a higher rate, not only of hospitalization but the use of ER services among patients with limited health literacy skills. They are not necessarily seeing routine physicians or using walk-in clinics. Instead, they are going straight to the ER.

    Health Status

    • More likely to report their health as poor

    (National Center for Education Statistics, 2006)

    Additional studies show that individuals with limited health literacy skills are significantly more likely to report their health as poor than persons with adequate health literacy skills.

    Healthcare Costs

    • Greater use of services designed to treat complications of the disease
    • Less preventative service use
    • Higher hospitalization and ER use associated with higher healthcare costs

    (Friedland, 1998; Howard, Gazmararian, & Parker, 2005)

    There are healthcare costs. Persons with limited health literacy skills make greater use of services that are designed to treat complications of the disease and less use of services that are designed to prevent complications. In my community, they are trying to change this narrative by offering incentives or contests for people that use more of those preventative services. Whether or not it is working, I have no idea. I have not seen any sort of research or evidence, but I know communities are really trying hard to flip that narrative. In the above studies, a higher rate of hospitalization was noted in those with a lower rate of health literacy. As stated, there is a higher use of ER services by those with limited health literacy. Unfortunately, this translates into higher healthcare costs.

    Stigma and Shame

    • Negative psychological effects
    • Sense of shame about skill level
    • Individuals may hide reading or vocabulary difficulties to maintain

    (Parikh et al., 1996; Baker et al., 1996)

    Low health literacy has negative psychological effects. One study found that those with limited health literacy skills reported a sense of shame. This shame causes them to hide their reading or their vocabulary difficulties to maintain their dignity. As healthcare practitioners, we need to do everything that we can to communicate in a way that does not further exacerbate that stigma and shame. This gives the person a place of comfort where they feel good about communicating and sharing their information.

    Practitioner's Role

    Practitioner Role

    • Ensure health-related information/education matches a person’s literacy abilities; cultural sensitivities; and verbal, cognitive, and social skills
    • Provide information and education that promote self-management for optimum health and participation
    • Facilitate health literacy by promoting systems of care or environments that adhere to health literacy principles and strategies

    (DHHS, 2013)

    We can make sure that all health-related information and education that we provide to our patients/families, colleagues, and other people match that person's literacy abilities, cultural sensitivities, and verbal, cognitive, and social skills. The Healthy People 2020 Campaign from the Department of Health and Human Services was published in 2013. It encourages that all clinicians use appropriate communication and education skills to help enable all people to gain access and to understand the services that we are providing. This includes information and education that promotes self-management for optimum health and participation. Besides, I believe we all have a role in facilitating clients' health literacy by promoting systems of care and promoting environments that adhere to health literacy principles and strategies. Within your own environment, you may have already adopted every single one of these principles. But if your environment is not adopting these, you may not be getting that leg up. It really has to be a systemic type of intervention and change.

    Link to Literacy

    • Stress the importance of:
    1.Capacities, functioning, participation, and empowerment of clients
    2.Holistic approach
    3.Client-centered practice
    4.Teaching of information and methods

    5.Access to services and equity issues

    (Levasseur & Carrier, 2010)

    We, as healthcare professionals, are linked to health literacy because we stress the importance of somebody's capacities, capabilities, function, and participation. We want to empower our clients and using a holistic approach. We do not look at our clients in a silo. We want to have a client-centered practice to make sure we are delivering what our clients need. We teach information and use different methods to do that. Lastly, we look at access to service and equity issues within our professions.

    Integrating Health Literacy Into Practice

    • Be informed about health literacy and recognize it
      • Learn about health literacy and ways to integrate it into practice
      • Do not assume that all clients understand what they are told even if they nod their head or that they can read
      • Recognize the powerlessness, shame, and sense of failure that some people may feel
      • Identify your client’s characteristics

    You might be wondering about strategies. How can I improve my client's health literacy? How do I integrate it within my practice? The first thing you need to do is be informed about health literacy and be able to recognize it. This refers to your knowledge, your ability to identify challenging health literacy information, and being able to look at an intake form or a brochure to identify if there is something amiss. What can we do to make this a little bit easier to understand?

    You can learn about health literacy and ways to integrate it. Obviously, this is not assuming that all of your clients understand what they are told, even if they nod their head or can read. I think there is a saying out there that it takes you seven times of hearing something before you truly learn it. Seven times may not be the answer, but we cannot assume that they get it on the first try.

    We also have to understand the powerlessness, shame, and sense of failure that some people may feel because they cannot understand and carry things through.

    We need to identify clients' characteristics. This is their knowledge and teaching preferences. Not everybody is a verbal learner. What are their skills? What are their beliefs? What is their culture? What are their barriers to healthcare? Obviously, culture plays a big piece in that as well. We know that clients with low literacy levels are usually very reluctant to ask questions as they are skillful at hiding their problems.

    • Important to recognize individual and societal barriers to the promotion of health literacy
      • Functional declines associated with aging
      • Lack of reading and writing proficiency
      • Low levels of formal education or lack of health knowledge and skills
      • Different mother tongue or cultural beliefs
      • Living with disabilities and social stigma
      • Experiences in early childhood

    Although there are diverging opinions about whether or not we can truly evaluate health literacy, it is important to recognize that there are both individual and societal barriers to the promotion of health literacy. There are functional declines associated with aging. There can be a lack of reading and writing proficiency. There are low levels of formal education or lack of health knowledge and skills. A client can have a different mother tongue. There can be a different native language or cultural belief from where this person is accessing their services. They can have disabilities and incur social stigma. Then, of course, they may have experiences from early childhood. This is outside of the scope of this session, but there is a lot of research on trauma-informed care in the literature. Experiences in early childhood have a significant impact on how someone accesses and utilizes health services and their overall health behaviors later in life. It is all interwoven.

    • Standardize practice to health literacy
      • Develop professional standards and position statements for health communications and interactions
      • Include health literacy criteria into quality and accreditation standards of health care organizations

    We can also standardize practice to health literacy. What does that mean? This focuses on your ability to take into account a client's level of health literacy during your intervention. In addition to being informed, we all can go back to our national professional associations or our regulatory and licensing bodies. Those different organizations can contribute to developing professional standards, position papers, and position statements that really help to standardize the integration of health literacy into our practice. I think all of our boards have certainly done that. In fact, all employees may value health literacy, and it may be included in every health and medical care facility's policies and goal. 

    • Consider health literacy by making information accessible
      • Adapt the information to individual needs, circumstances, and abilities to show how it is relevant
      • Communicate in a comprehensive way using more than one way of exchanging information
      • Combine oral instructions with written information
      • Use a structured educational approach
      • Use demonstration, experimentation, and repetition when teaching

    We also need to consider health literacy by making the information accessible. This refers to the ability of us to improve how we use the information to educate our clients. We are adapting the information to individual needs, circumstances, and abilities. Are we showing them how it is relevant to their particular situation? Are we communicating in a comprehensive way and in more than one way of exchanging information? This can be verbal, gestures, and written information. This is combining oral along with the written information in a clear simple language for future reference. You can also use demonstration, audio, visual aids, videos, or equipment. This is using a structured educational approach. We also need to use demonstration, experimentation, and repetition to increase the effectiveness of that teaching.

    • Design written information
      • Active voice
      • Clear simple language
      • Pictures or drawings to illustrate procedures
      • Interactive and with recaps
      • Most important information placed first
      • Personalized

    We need to do this in the active voice. These are common words, short words, and short sentences with 10 words or less. This is not using technical terms, value judgment words, jargon, abbreviations, or acronyms. We should use examples to explain difficult words or maybe a story to explain them. You can use the same words throughout the entire material or use pictures or drawings to illustrate. This can be for an exercise or a breathing activity. You can also use photos to do that. You want it to be interactive with recaps along the way. The most important information should be first and it should be personalized. If the information is not personal to them, they are probably not going to retain it.

    • Communicate effectively and simply
      • Announce the subject
      • Convey the message
      • Ask clients to say in their own words what they remember of the information or methods taught

    There are other ways to communicate. It is important to communicate effectively and simply in an atmosphere that is conducive to that communication. Announce the subject and convey the subject. We will talk about teach-back in a little bit. You want to ask the person about the information and have them say it back in their own words. "What do you remember about this information?" "What do you remember about what we just taught you?" I think we intuitively do this in our treatment. It allows us to identify any misunderstandings and correct them.

    • Use the Ask Me 3

    1.What is your main problem today?

    2.What do I need to do for you concerning this problem?

    3.Why is it important to you?

    Use the Ask Me 3 method. "What is your main problem today? What do I need to do for you?" Or, "What are you seeking from me concerning this problem?" And, "Why is it important to you?" You can start every single session with that so that you know you are doing what is most important to that client.

    • Help clients make optimal use of health services
    • Increase the quality of professional communication
    • Use anecdotal information as appropriate 
    • Do not overburden clients with information or recommendations

    We can help our clients to make optimal use of health services and increasing the quality of our own communication. We have talked about that in our own professional competencies as it relates to health literacy. We can use anecdotal information. I already shared that. Personal stories sometimes hit home more than anything. Obviously, this is not overburdening our clients with information or recommendations. I see this so many times when we deliver home programs or home instruction. We just bombard them with everything under the sun. We do not need to do that. Let's just keep it simple on what they really need to focus on.

    • Strengthen interactions
      • Encourage clients to ask questions
      • Take an understanding attitude
      • Shame-free environment
      • Increase the time spent on giving information
      • Observe and listen actively

    This goes back to creating an environment where they are comfortable. You want to encourage them to ask questions and have an understanding attitude rather than a blaming attitude. You wat a shame-free environment. We want to increase the time that we spend on giving information. Speak slowly, repeat, observe, and listen actively. One of the best things we can do is just be quiet. Give clients the time to organize their thoughts to identify what their issues are, their constraints, and to formulate their questions.

    • Strengthen interactions
      • Increase cultural competency
      • Follow up on interventions to see if recommendations have been followed and if clients have questions
      • Involve not only the client but also families

    Increase your own cultural competency. Be a professional who really respects those differences. You want to be open to learning and willing to admit that there is more than one way to look at the world. Follow up on those interventions to see if the recommendations have been followed and if they have any questions. We want to involve the client and their families. The families are often cultural brokers for our clients.

    • Intervene to increase client’s health literacy
      • Optimize reading/writing skills including use of the Internet
      • Increase knowledge of health
      • Encourage clients to read every day
      • Foster empowerment by using a client-centered approach

    We want to increase the client's health literacy. These are interventions focusing on the client's health literacy level. You can use the internet to optimize their reading and writing skills. You want to increase their knowledge of health and health determinants. We have that opportunity to teach and train. You want to encourage them to read every day and take a local health literacy program. This is outside of our scope, but it is a nice thing to do. If you know there are programs in the community, turn these folks on to them. We want to foster empowerment, using a client-centered approach. Give them confidence in their ability to take more control of their life. Empowerment includes making them responsible for taking care of their health, making decisions about their health, and truly being engaged. They are responsible for their health and not just along for the ride and doing what the physician says. They are responsible, and we can help them to find ways to do that.

    • Collaborate to increase clients’ health literacy
      • Participate in intersectoral activities
      • Provide education to other health care professionals about health literacy topics

    We have an important advocacy role in influencing the goals of the health facility where we work regarding health literacy. We may want to participate in public health initiatives or research. We can raise awareness among other players in the clinical setting within our own organization, other stakeholders, support staff, managers, and community partners to lead the charge and work on education.

    Effective Communication with Diverse Populations

    There can be communication challenges as we start to care for an increasingly diverse patient population. We need to effectively gather information from patients to foster individual care and to demonstrate a cultural understanding. When we look at effective health communication, it is influenced by cultural values, attitudes, and beliefs. It involves providing healthcare-related information to an individual in a way that is understandable and increases their knowledge. Again, our end goal here is to positively influence their health behaviors and interventions. 

    Communication

    • Verbal
      • Sharing information in a one-on-one interaction, usually orally, to achieve a shared meaning
    • Nonverbal
      • Conveying meaning without words, including using gestures, facial expressions, eye contact, body language, and clothing
    • Written
      • Using written symbols, such as letters and numbers, as well as pictures and graphics

    (Adeyanju, 2008; Wanless & Cameron, 2010; Norton, 1983; Poyatos, 1983)

    There are three different ways that we communicate. We have verbal, non-verbal, and written. We use all of these when we communicate, but the linguistic characteristics can also include dialects, regional variants, literacy levels, and more. Even though you are using these types of communication, there are variations within them.

    Communication and having a trusting relationship between the patient and the healthcare provider are critically important. Research shows that individuals with communication needs often have poor health outcomes, they have trouble following medical advice, and they are less satisfied with their healthcare interactions overall than individuals who do not have any sort of communication barriers. Recognize that every patient enters the healthcare system with their own unique illness experience. You can learn a lot about a person by adopting skills and communication techniques that are nonjudgmental to allow that person to share what is most important to them.

    • Compared to patients who are simply told what to do, patients who are encouraged to discuss their perceptions of illness and expectations for treatment:
      • Experience a greater sense of control and feel more involved in their care
      • Suffer less from anxiety
      • Are more likely to accept hospital routines and treatment schedules

    (Muñoz & Luckmann, 2005)

    Clients that are encouraged to be partners and discuss their perceptions and expectations have a greater sense of control. They feel more involved, have less anxiety, and most importantly are more likely to accept routines and treatment schedules. When a person cannot describe an experience of illness, you cannot communicate effectively about disease or treatment. You lack that basic connection that you need to provide appropriate care.

    This is where we get into some assessments and guides and additional information to help us. These are additional resources available to you. There are a lot of different models out there that can help you to provide or facilitate patient-centered care. They promote effective communication and cross-cultural encounters. I will present these, but you need to take some time to feel comfortable using them in your daily practice. As you do, you can gain a better understanding of that patient's perspective about their illness in light of social, cultural, historical, and other factors that contribute to that experience.

    Transcultural Assessment Guide

    • Bio-cultural Variations and Cultural Aspects of the Incidence of Disease
    • Communication
    • Cultural Affiliations
    • Cultural Sanctions and Restrictions
    • Developmental Considerations Restrictions
    • Educational Background
    • Health-Related Beliefs and Practices
    • Kinship and Social Networks and Practices
    • Values Orientation
    • Nutrition
    • Religious Affiliation

    (Boyle, 2003)

    The first tool that we are going to talk about is Andrews' and Boyle's Transcultural Nursing Assessment Guide. It was initially designed for nurses, but there is a lot of applicability to other groups. The authors of this particular model found that a comprehensive cultural assessment is a foundation for culturally and linguistically competent nursing or healthcare. Looking at, what is my communication? What are my values as it relates to my culture? How do I approach nutrition? What is important to me as it relates to nutrition, religion, et cetera? And again, how do those guide my healthcare interactions? There is a lot more information about this and additional handouts.

    Other Communication Models

    • LEARN Model (Berlin & Fowkes, 1983)
    • BATHE Model (Stuart & Lieberman, 1993)
    • ETHNIC Model(Levine, Like, & Gottlieb, 2000)

    Three others are out there, and these all use mnemonics. The LEARN Model suggests this framework for listening, explaining, acknowledging, recommending, and negotiating. The "N" or negotiating is what we put forth as a healthcare practitioner. We have to sometimes negotiate what the course of treatment is going to be and what kind of health outcomes we are looking for as it relates to what we are trying to achieve in this setting.

    The next one is something called the BATHE Model. This helps us to understand the psychosocial context of the patient's experience with illness. We ask them very simple questions about background, affect, trouble, handling, and then expressing empathy. What is the background? "Tell me a little bit about this illness and what you're experiencing." "How has this caused you trouble in your daily life?" "How have you been handling it?" "Have you been seeking medical attention from a physician?" "Have you been seeking medical attention from an herbalist or using over the counter remedies? Then, you start to get an understanding of what is their primary health concern, and how are they addressing that. Once you know that, the next question is, "How can we help?" Remember, what their primary health concern is and what my primary health concern is for them may be totally separate things. You have to step back and this leads to negotiation. I see this all the time in long term care. People will come in and develop these grandiose care plans for them like they are going to lose weight, but that is not what the patient wants. If the goal is not something the client wants, they are never going to adhere to it.

    The final one is ETHNIC. This is a framework to use for culturally competent clinical practice. Many of the questions are open-ended questions to garner their explanation (E) of their illness. The next is treatment. What treatment (T) have you tried or what advice have you have sought from healers (H)? Negotiation is the "N" and is about mutually acceptable outcomes. Lastly, there is intervention (I) and then collaboration (C). Obviously, you can see a theme with all of these models. One appeal of this particular model is that it does not frame the patient's beliefs as exotic or different. If they are seeing an herbalist or a cultural or spiritual type of healer, it is seen as okay as it is part of their culture. It looks at how that fits with what they are engaging in right now in the healthcare continuum. Your most successful care plans are the ones where you marry those two together. 

    Language Assistance Services

    Overview

    • Interpretation of verbal communication
    • Translation of written documents
    • Using interpreter services and translated documents ensure better understanding by providing a common language.
    • Language assistance services help you provide quality care to all of your patients by facilitating effective communication

    (Shi, Lebrun, and Tsai (2009)

    When we look at language assistance services, these include the interpretation of verbal communication and the translation of written documents. Using interpreter services and translated documents ensures better understanding by providing a common language. Hopefully, these are things that are available to you in your setting. Many settings have said that the provider must offer these types of services. You might need to just ask around what is available to you. Communicating in different languages during a healthcare encounter can lead to a lot of confusion. It affects the quality of care, treatment decisions, and understanding. The bottom line is that it affects compliance with healthcare recommendations and treatment plans. Therefore, effective clinical encounters depend on mutual understanding between the healthcare provider and the patient. The language assistance services can help you to provide quality care to all of your patients by facilitating effective communication with individuals with any sort of communication needs, including limited English proficiency. You will see this acronym, LEP, or limited English proficiency, in some of the other slides.

    Again, when we are talking about translation and interpretation, this may not just be somebody who maybe speaks a different language. It could be someone who has hearing difficulty. It could be somebody who maybe has a speech and language communication type of issue. We know that language assistance will help you do your job better when you and your patients can understand each other. You are more likely to deliver quality care and services because you are more aware of your patient's needs.

    With Language Assistance

    • Interpretation and translation
    • Trained interpreters, who can communicate fluently with both the patient and health care provider
    • Translated written materials such as intake forms and patient education
    • Graphics and signage

    (National Council on Interpreting in Health Care, 2008; Torres, 2001)

    With language assistance, your patients are more likely to understand their health conditions, to understand their treatment plans, to follow the recommendations that you are giving to them, and to rate their care satisfactorily. This might be outside of your scope, but this is very important for all of our providers is to have really good satisfaction surveys at the end of care. We want to make sure that we are giving people information in a way that they can understand.

    Language Assistance Services

    • Interpretation and translation
    • Trained interpreters, who can communicate fluently with both the patient and health care provider
    • Translated written materials such as intake forms and patient education
    • Graphics and signage

    (National Council on Interpreting in Health Care, 2008; Torres, 2001)

    Again, interpretation is verbal, and the translation is written. We are going to talk about both of those as we go along. These terms are very different and are not used interchangeably as they require two totally different skillsets. Interpretation requires strong listening and speaking skills. Translation involves reading and writing skills.

    When we talk about language assistance services, we are going to talk a lot about trained interpreters and trained translators. Trained interpreters are those who can communicate fluently with both the patient and the healthcare provider. These are people who can provide valuable assistance during encounters with patients with limited English proficiency and other issues to improve the quality of care.

    Also, we need to really look at our written materials. These are intake forms, consent forms, assessment tools, and patient education materials. I will only speak from my own experience. Within my organization, we started quite some time ago converting materials that we were giving out to our therapists, patients, and providers. We translated these into multiple languages because we realized that we just were not hitting the mark. Thus, we need to look at what we are doing so that we can develop and translate forms into a patient's language, into a provider's language, or a colleague's language.

    Graphics and signage are other areas. We will be talking a little bit more about that in just a few minutes. These help to make sure that individuals with limited English proficiency can understand healthcare instructions and navigate through the healthcare system. Even if the material is not verbal, you can oftentimes get there through photos, gestures, demonstration, and signage with pictographs.

    Issues with Language Barriers

    • Impact access to health services
    • Jeopardize comprehension of diagnosis, treatment, and follow-up care
    • Diminish quality of care
    • Increase health care costs

    (Perkins, 2003; Grantmakers in Health, 2003)

    When language assistance services are minimal or non-existent, the resulting language barriers present a lot of different challenges within the healthcare system. As an example, language barriers have been shown to impact access to health services at a lot of different entry points. It is not just when you are providing treatment, but it can affect whether a client has health insurance or receives basic preventative and specialty care. It may also jeopardize a patient's comprehension of their diagnosis, treatment, treatment options, and follow-up care. It can diminish the quality of care, and ultimately, lead to adverse clinical outcomes because the person did not follow through with recommendations. It can increase healthcare costs due to inefficiencies. Research suggests that language barriers can impede access to health services as much as the lack of health insurance can.

    Interpreter Services

    • “The process of understanding and analyzing a spoken or signed message and re-expressing that message faithfully, accurately, and objectively in another language, taking the cultural and social context into account “
    • Provided for low English proficiency status
      • Limited ability to read, speak, write, or understand English

    (HHS OCR, 2003; (National Health Law Program, 2010)

    Interpreter services facilitate communication between two or more individuals who do not speak the same language. This is a basic definition from the National Health Law Program. It is also defined as the process of understanding and analyzing a spoken or assigned message and then re-expressing that message faithfully, accurately, objectively in another language, taking the cultural and the social context into account.

    Interpreter services can be provided to those with limited English proficiency or low English proficiency, hearing loss, or any other circumstance that would make it difficult for that person to hear or understand a conversation. It can also be instructions, advice, or any oral communication. Limited English proficiency status includes a limited ability to read, speak, write, or understand basic English. The vast majority of our healthcare system is in English. We need to understand this to navigate.

    Interpreter Service Skill Set

    • Proficiency in both the language of the patient and the provider (typically English)
    • Cultural competency
    • The ability to work in stressful situations
    • Avoid the use of untrained interpreters and/or minors including family, friends, and ad hoc clinical staff interpreters

    Interpreters have different skills including proficiency in both the language of the patient and the provider, typically English. It is also not just the language. I find this so interesting because I am engaged in doing a lot of translation services. It is not just language, but it is also dialect. You may have someone who speaks Mandarin, Spanish, or Cajun French. There are also different dialects for very specific words and phrases. You really have to know where is that coming from and make sure that the interpreter is trained in that dialect, not just the language.

    The person should also have cultural competency and an understanding of what culture brings to the table. Culture impacts every aspect of communication. They also have to have the ability to work in stressful situations. When people use this service, it is because someone is accessing the healthcare continuum and need your services. They need respiratory services and are accessing your service. This is a stressful situation, and you do not want your interpreter to cause any more stress or grief for your patient than they are already going through.

    We know that interpreters sometimes can be really tough to find, but you can recruit them from bilingual staff members. Again, I will take a page out of my own book as this is what we have done within our own organization. We have found individuals who speak various languages, and they assist with those types of services. You can also use a dedicated staff interpreter that you have hired or use a contract agency. There are specific agencies out there and also community volunteers. I remember working in a community where the primary language was Russian. It was really interesting. We brought in individuals from that community at large to assist us with those types of activities. It does not matter who you use, but you do have to make sure that their language skills have been assessed and they are appropriately trained to provide these interpretation services.

    Do not use untrained interpreters, minors, family, or friends. Minors and family members do not always give the whole message as they are too close to the situation. Untrained interpreters have been associated with poor quality of care. There is a conflict of interest and mixed agenda. They have their own agenda. And, higher rates of interpreter errors can really lead to severe clinical consequences.

    Providing Written Materials

    • Written materials are appropriate for patients with communication needs
    • Translated written materials may include:
      • Signage
      • Applications
      • Consent forms
      • Medical/treatment/exercise instructions
    • Clearly identify the audience for the materials, including literacy level, culture, and language

    We have talked a lot about providing written materials already. Written materials improve communication. We want to make sure that written materials are available in other languages through the translation of existing written materials. Now, keep in mind that the translated written materials should never substitute for oral interpretation if an oral interpretation is more appropriate. If you want to do a verbal education, that would be the way to go.

    Again, when we think about translated materials, it is signage in our office and community, applications, consent forms, instructions, pamphlets, marketing materials, et cetera. Everything that you touch within your organization might need to be translated.

    There are web-based applications. My smartphone just updated, and there is a translation app on it now that I never had before. Those are great in a pinch, but those are not necessarily the types of translation materials that you want to create. If I use this app to translate something to another language and send it to a person that is fluent in that language, often they will say that the phase is not the way they would have said it. Thus, I would strongly caution you from overusing this option.

    As we start to look at the written materials that we might need to develop, we should identify the audience for the material and their literacy level? What is their culture? What is their language? What is their dialect? And as we are translating materials, they should go through a rigorous review and back translation. Back translation is the process where one translator translates a document into a target language, and then a second independent translator translates the document back into English to check that the appropriate meaning is conveyed. For example, I use a person to translate my Spanish materials for me. I am fluent in Spanish so I then translate the document back into English to make sure that it all looks and says what it should.

    Again, technology makes it a little bit easier, but it is really preferable to use professionally translated materials. And if possible, it is actually preferable to develop the materials in the language and the intended audience, rather than translating. I know this is not always possible, but that is definitely the ideal.

    Use of Symbols

    We already talked a little bit about the use of symbols and this comes directly from Hablamos Juntos which is a Robert Wood Johnson program. These are universal symbols that we see all over the place (Figure 1).

    Figure 1. Universal symbols in health care (Attribution: Hablamos Juntos and SEGD.ORG -permission granted).

    You can see symbols for things like a nurse, healthcare, or a physician. It is helpful to use some of these when creating signage. It helps our patients really to feel more comfortable and confident within the setting.

    Graphic Cards

    We can also use graphics cards. This particular graphic card is the Wong-Baker Faces Pain Rating Scale as seen in Figure 2.

    Figure 2. Wong-Baker Faces Pain Rating Scale (Lord Belbury, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons).

    These can be used for those who are not literate or may have developmental or cognitive impairments. You can have pictures to show services or symptoms. There are a lot of these different types of tools that are out there in the public domain. Keep in mind that this is where culture comes back into play. In Figure 2, these faces make sense to me, but this may not be universally appropriate to all cultures. For example, different cultures view pain in different ways. This may not be appropriate to use if a person's culture does not recognize, treat, address, or comment on pain in the same way that we would. 

    Obtaining Translated Materials

    • Using trained, internal bilingual staff members as translators
    • Hiring translation companies
    • Collaborating with the community of the target audience
    • Purchasing translated materials
    • Locating web-based resources
    • Researching other resources, such as state Medicaid programs, insurance companies, or pharmaceutical companies

    If you cannot create the materials in the original language, which is again our ideal, there are a lot of different options out there. I have already touched on some of these. Using trained internal bilingual staff as translators are one option. This could be part of their job description, or they do it on the side for you. If somebody is bilingual, often they will have a laptop or a keyboard in their language. In contrast, if you look at a traditional keyboard here in the United States, it is an English Anglo type of keyboard. But, if I speak Spanish or Russian, I may have a keyboard that has the symbols and the letters that are appropriate for that language. This can be a real bonus to have that available to you.

    We can hire translation companies. Collaborating with the community of the target audience may be another option. A family member who is part of this cultural group at large may be able to help you. You can certainly purchase translated materials, and there are web-based resources out there. There are a lot of other different resources.

    Our state Medicaid programs, insurance companies, and pharmaceutical companies have translated materials. I know Pfizer and Lilly and a couple of others have a lot of different translated patient education materials in a variety of different languages. I think whatever the source is of your written materials, you have to evaluate them to make sure that they really do state the health information and are appropriate for the intended audiences' literacy level, their culture, and their language.

    Translator Qualifications

    • Previous education, training, and experience in translation
    • Command of both English and the language into which the material will be translated
    • Familiarity with medical terminology

    If you are planning to use a translator, make sure that that person has the appropriate qualifications, education, and training. They also should have experience in translation. If they do not have the experience, you can put them through a rigorous on-the-job interview. They need to have a command of both English and the language into which the material will be translated and familiarity with medical terminology. This is really important. The medical terminology for respiratory therapy or terminology related to cancer as an example can include a lot of words with no equivalent in other languages. Thus, that person has to really understand what you are talking about to be able to put that into another language and be able to explain it with any degree of accuracy.

    Again, we have already talked about involving the community. If you have no other way to do it, bring in somebody from the community who speaks that language. It can be one of your volunteers or someone who visits your site.

    Involve the Community

    • Ensures materials:
      • Meet community needs
      • Reflect differences in dialect and culture
      • Are appropriate for the community’s cultures, education, and literacy levels

    Make sure your materials meet the community needs and reflect those differences that we have talked about as it relates to dialect and culture. Spelling, grammar, and punctuation might seem silly, but we need to make sure those are all appropriate, particularly as it relates to things like verb conjugation. This all needs to be appropriate for the community culture, their education, and their literacy level. This is where cultural competency intersects with health literacy. This is knowing what is important to that culture and knowing their general views and ideas as it relates to health and incorporating that. Again, it is not my story, but it is that person's story. We want to make sure that it is accurate, useful, and it truly reflects their lifestyle and what it is that they need to be doing.

    Signage for Right to Interpreter

    Many facilities post signage regarding the right to an interpreter as shown in Figure 3. These are posted in a language that is most appropriate for the culture of the community of clients that are being served.

    Figure 3. Example of signage for the right to an interpreter.

    I see these a lot of times in hospital-based systems. You want to look these types of things up because everyone has that right to interpretation services. This gets back to the provider to be able to offer this. I cannot stress this enough. Go back and ask the questions. What do we have available and how can we handle this? This is taking a page out of my own industry, which is long-term care. We are required to complete the minimum data set. It actually states right in there if they want interpreter services. If they do, you have to provide that. It is right there. A provider cannot say that they cannot do that. If we do not provide those services, we are limiting access to that person's ability to obtain the healthcare services they need.

    "I Speak" Cards

    We also may find that people have, "I Speak" Cards. Hopefully, you have seen these. An example is in Figure 4.

    Figure 4. Example of "I speak" cards (Attribution: https://www.census.gov/).

    There is a phrase in different languages so a patient can communicate to others which language they speak. They can hand this to someone. 

    Interpreter Qualifications 

    • Proficiency and ability to communicate information accurately in both languages
    • Knowledge in both languages of specialized terms/ concepts
    • Understand confidentiality and impartiality rules
    • Understand regionalisms, dialects
    • Understand and adhere to the role of interpreter

    (HHS OCR, 2003)

    Here are a couple of the things about interpretation and translation before we move on to some health literacy tools or readability tools. This comes directly from OCR and health and human services. They need to demonstrate proficiency and an ability to communicate information accurately in both languages. They also need to identify the most appropriate mode of interpreting whether that is verbal, written, or in some other way. They need to know both languages to the extent necessary to convey specialized terms or concepts and any specialized words or phrases that might be utilized in your particular industry or setting. They have to understand confidentiality, impartiality rules, regionalisms, dialects, and differences in language use. We will talk about this on another slide, but they have to adhere to the role of interpreter and cannot shift out of that role into some other role. They have to stick with that. This is a problem sometimes with interpreters. They are there solely to interpret and sometimes we see them getting a little more involved on a personal level. We do not want to see this.

    Interpreter Roles

    • Conduit
    • Conveys verbatim in the target language what has been said by the other in the source language, without additions, omissions, editing, or polishing
    • Culture Broker
    • Provides a cultural framework for understanding message interpreted
    • Clarifier
    • Explains terms that have no linguistic equivalent and checks for understanding

    There are three basic roles that an interpreter may have. The first one is called a conduit, and this is the default role. This is the most basic. This is the role that we typically see of an interpreter. In this role, the interpreter conveys verbatim to the target language what has been said by another person in the source language. They do not add, omit, edit, polish, or put their spin on it. It is a verbatim translation. This is the typical role that we will see of an interpreter.

    Another role is called a culture broker. I love this particular person. I will say that I have gone to this type of person many times because this person will give you a cultural framework for understanding the message that is being interpreted. This person gives you the background and framework of the person's culture and how this is impacting their health decisions and access to the healthcare system.

    Then, there is the clarifier. I like this role as well. In this case, the interpreter explains or makes what we call word pictures of terms that have no linguistic equivalent or whose linguistic equivalent will not be understood by the patient and then checks for understanding. As I translate materials, some phrases have no equivalent in other languages. You have to use something to describe what this activity or what this term means. We have a lot of jargon in our industry so we want to make sure that everything is understood.

    Again, in the healthcare setting, the preferred role for an interpreter is that of the conduit. 

    Child Interpreters

    • The HHS Office for Civil Rights discourages the use of minors
      • Role reversal
      • Editing
      • Mistakes

    (Kaiser Permanente, 2006)

    I alluded to this already, but child interpreters can create a lot of problems. This practice is highly discouraged. Many negative consequences have occurred with the use of children. The use of minors in healthcare interpreting is discouraged. It is because of the role reversal. The child ends up having to process information and provide support for the parent, when in fact it should be the other way around. A child may intentionally leave out information to spare parents from suffering, and that creates a significant burden on the minor child. There can also be mistakes. There is no guarantee that that child will truly understand the intended message even when they say they do. My personal take is that even older children of mom or dad will sometimes edit out information. They do not make mistakes necessarily, but they do not give the full picture to mom or dad because they are trying to spare them some of that information. This does not always occur. 

    Triadic Interview

    • Between you, the patient, and the interpreter
    • Face the patient
    • Speak directly to the patient
    • The interpreter should remain unobtrusive
    • Prior to the session, meet with the interpreter to clarify the purpose of the visit, establish ground rules, acceptable roles

    As we are talking more about interpreters, recognize that if you are using an interpreter in your session, you are conducting what we call a triadic interview between you, the patient, and the interpreter. You always have to go back to the fact that this is your session with the patient. This is not your session with the interpreter. You need to be face-to-face and speak directly to the patient. You are not speaking to the interpreter. The interpreter should remain unobtrusive. Before your session, ideally, you should meet quickly with the interpreter to clarify the purpose of your visit and the purpose of the intervention. Why are you here today? What are you trying to get out of the session? Establish the ground roles and how it is all going to go down before you get into that session.

    Keep in Mind

    • Interpreter and patient speak the same language and dialect
    • Give the interpreter a brief summary of the patient
    • Establish, with the interpreter, goals for the session
    • Insist on sentence-by-sentence interpretation
    • Explain that the interpreter is not to answer for the patient
    • Invite the interpreter to interrupt or intervene as necessary to ensure understanding
    • Document the name of the interpreter in the notes
    • Ask the interpreter to teach you to correctly pronounce the patient's name

    Here are a few things that you want to keep in mind as it relates to that. Make sure the interpreter and the patient speak the same language with the same dialect. You are going to give the interpreter a brief summary of the patient as we are going to assume that they do not know them. We are going to give them a summary. If they do know them, then maybe you do not need to do that. Again, we establish with the interpreter the goals for the session. You need to insist on a sentence by sentence, word for word interpretation. You do not want to give your whole spiel and then they summarize it. It does need to be sentence by sentence. We also need to explain that the interpreter is not to answer for the patient, but instead convey the message that we just conveyed, get the answer from the patient, and then convey that directly back. Say to the interpreter, "Feel free to interrupt, intervene, or do whatever is necessary throughout the course of this session to make sure that you understand what it is that I'm saying to you so that you can adequately convey it."

    It is important if you are going to use an interpreter for any kind of documentation that you use the name of the interpreter and any sessions that they sat in on. You may even have to go so far as to ask the interpreter to teach you how to correctly pronounce the patient's name. And, remember that you as the healthcare provider, not the interpreter, are responsible for the interview. You are conducting this session so that person should not be overtaking it.

    • Speak slowly and clearly use simple and straightforward language, and avoid metaphors, jargon, and slang
    • Clearly explain medical terminology
    • Allow the interpreter to ask open-ended questions to clarify what the patient says
    • Allow the patient time for questions and clarifications
    • Be aware of your own attitudes and shortcomings
    • Verify a patient’s understanding by having them repeat what they are to do and why

    Speak slowly and clearly. Go back to what we talked about at the beginning. Use clear, simple, straightforward plain language. Avoid metaphors, jargon, and slang as it is difficult to translate that. Clearly explain medical terminology and allow the interpreter to ask open-ended questions. Allow the patient time for questions. I think it is essential to be aware of your own attitudes and shortcomings. This is where your cultural competence comes into play. Make sure that you are not bringing any sort of attitudes or stereotypes to the triadic. And then, of course, verify the patient's understanding. Have them repeat back to the interpreter what they are to do and why or have them demonstrate it to you so you can get a visual and know that they have in fact understood.

    Readability Tools

    Statistics: Do You Know?

    • 75 out of 100 Americans can read at the 6th-grade reading level without difficulty
    • Readability score
      • 4th to 6th grade
        • Readable by most adults
      • 7th to 8th grade
        • Readable by half or more adults
      • High school and above
        • Readable by few adults

    Did you know that 75 out of 100 Americans can read at the sixth-grade reading level without difficulty? What does that mean? Sixth-grade reading level and no higher is what that means for 75% of Americans. A fourth to sixth-grade reading level is readable by most adults, and a seventh to eighth-grade reading level is readable only by about half or more adults. A high school and above is readable by few adults. I know I am talking to a group of professionals here. I am going to assume that the vast majority of your communication, written, or verbal is probably at a high school level and above. However, for the general population, we have to figure out what level they are at.

    Clinician Role

    • We need to provide education to our clients
    • We must be mindful of clients’ literacy skills, including reading ability and comprehension
    • We can formally assess reading ability
    • Can informally discuss with clients their previous level of schooling, educational achievement, and perceived reading ability

    Let's go back to the clinician role. Why is this important? Reading is important because we are providing education to our clients. We have to provide education so that they are involved in treatment decisions. They follow our treatment plan and our recommendations, and a lot of that is in writing. We have to be very mindful of literacy skills, including their reading ability and comprehension.

    We can formally assess their reading ability. There are some very quick reading assessments. Many of these are available out in the public domain and free of charge. This can help you to figure out how to develop materials. 

    We can also informally discuss their previous level of schooling and their perceived reading ability. There is nothing wrong with that. I think about the Mini-Mental State Exam (MMSE). I do not know if that is a familiar tool to you or not, but it is a cognitive assessment. One of the questions asks, "How far did you go in school? How are you at math?" If we ask this of every single person that we talk to then we are not creating any stigma or shame. We are not isolating a group of people. This can allow us to be the best clinicians that we can be and develop tools that are going to be useful and helpful to the clients whom we serve.

    Common Readability Tools

    • Fry Readability Formula
    • The Flesch-Kincaid Grade Level  Readability Formulas
    • Microsoft Word

    There are a few common readability tools, and they are listed here. 

    Fry Readability Formula.

    • Assigns an approximate grade-level reading to a passage of text
    • The formula depends on the vocabulary and sentence structure of the text, not the organization or content
    • Grade reading level is found by plotting the average number of sentences and syllables on a graph
    • The graph measures reading levels from 1st grade to college years

    The Fry Readability Formula is available to you in the public domain. You get a passage of text and put it into this tool. It assigns an approximate grade level of reading to a passage of text. All of these formulas depend on the vocabulary and the sentence structure of that text to assign a grade level. It is not the organization of the content. We will talk a little bit about organization and content in just a little bit. These tools just look at vocabulary and sentences. The grade reading level is found by plotting the average number of sentences and syllables on a Fry Readability Graph. The graph measures reading levels all the way from first grade up to college level. This is a way for us to assess the health literacy level of education materials, which can then be modified to fit the recommended reading level of the client based on their health literacy assessment. We want to make sure that the client can truly understand what it is that we are trying to impart to them.

    Flesch-Kincaid Grade Level Readability Formula.

    • Uses 7 different popular readability formulas to calculate the average grade level, reading age, and text difficulty of your sample text
    • Considered one of the oldest, yet most reliable readability formulas

    Here is the website that you can use: www.readabilityformulas.com

    Another one is the Flesch-Kincaid Grade Level Readability Formula. This uses seven different popular readability formulas to calculate the average grade level, the reading age, the text difficulty, et cetera. Again, you dump in the sample text, and it will give you that reading level. It is one of the oldest formulas, but it is also incredibly reliable. Below is a sample text.

    “The rate of medical complications following hip replacement surgery is extremely low. Serious infections, such as a hip joint infection, occur in less than 2 percent of patients. The most common cause of infection occurs when bacteria enter the bloodstream during dental procedures, urinary tract infections, or skin infections. After your surgery, you should take antibiotics before having any dental work or surgical procedure performed.  Blood clots in the leg veins or pelvis are the most common complication of hip replacement surgery. These clots can become life-threatening if they move to the brain, lungs, or heart. However, your orthopedic surgeon will have a blood clot prevention plan that includes medication and support stockings. If you do experience any symptoms of blood clots, you should call your surgeon immediately. Your doctor and nurse will discuss what symptoms to look for.”

    I found this in a handout related to hip surgery that was online and originated in California. It was published for patients receiving hip surgery at this hospital. I guarantee every one of you understood what this says. There are definitely some words in there maybe that are a little bit higher level. The sentence structure maybe is a little bit higher level. This is the pamphlet that this hospital was distributing to their patients. I ran it through the Flesch-Kincaid readability formula and no shocker, it came up at an 11th-grade level. I then went back to a different segment that was also at an 11th-grade level. I rephrased it and here is the edited example.

    “Most people who have hip surgery have less pain.  They can get back to doing things they need to do -- like getting dressed, bathing, and walking.  After surgery, you will not be allowed to do certain things like play certain sports or jog.  Before surgery, you need to see your doctor who will tell you if surgery is safe for you.  You will be in the hospital for surgery and it will only take a few hours.  You will usually stay in the hospital for a few days. After surgery, you will feel pain in your hip. The nurses will give you something to help with the pain. Exercise is important and you need to start moving as soon as you can.”

    When I ran this one through the Flesch-Kincaid Readability Formula, I got a fifth-grade level. As I noted, a fourth to sixth-grade level is readable by most adults. This means it will be readable by at least 75% of adults. That is pretty decent. You are going to miss out on 25%, but we will talk in a minute about what you might need to do for those individuals.

    Microsoft Word.

    • Includes a feature providing reading ease statistics:
      • Comprehensive counts
        • Words
        • Paragraphs
        • Characters
        • Sentences

    Many of us use Microsoft Word or some other type of program similar to that in our day-to-day life with patient education materials. There is a feature within Microsoft Word that also includes reading ease statistics. This gives you a comprehensive count for words, paragraphs, characters, and sentences.

    • Averages
      • Sentences per paragraph
      • Words per sentence
    • Readability level
      • Passivity
      • Flesch-Kincaid level

    It also gives you an average number of sentences per paragraph and an average number of words per sentence. We will see on an upcoming slide why this is so important. I have some screenshots on the next slide so you can kind of see where that is (Figure 5). 

    Screenshot of where to find microsoft tools
    View Full Size Image

    Figure 5. Screenshot to show where Microsoft Word tools are located.

    If you go under your options where spellcheck is, you can see where my arrow is pointing at the very last bullet point. This is readability statistics. You can choose the writing style and what have you. The next one shows spelling and grammar. If you go to that review and you already have that box toggled, you can highlight a passage of text or even a whole document. By clicking on spelling and grammar, you can look for commas and punctuation (Figure 6).

    Screenshot of the readability statistics
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    Figure 6. Screenshot showing where the readability statistics are located.

    You can see words, characters, et cetera. If you go down to the bottom, that is your passivity level. Remember as we just said, you are communicating as you are educating. As you are talking to your patients and developing materials, you want to develop those in an active voice, not a passive voice. It needs to be active and how you would normally speak. This is what that parameter is showing. 

    There is also a Flesch Reading Ease and a Flesch-Kincaid Grade Level. The Flesch Reading Ease is on a percentage level, and it also gives you a Flesch-Kincaid Grade Level. I love these options. As you are creating materials, like home exercise programs or whatever, you can use these tools to assess their readability. Using these tools, you may have to adjust the materials if needed.  

    Health Literacy Assessment Tools

    Health literacy assessment tools are also available in the public domain. They are all in English, but some have been translated into other languages as well.

    Test of Functional Health Literacy in Adults (TOFHLA)

    • Measures functional literacy using real-life health care materials including patient education information, prescription bottle labels, registration forms, etc.
    • Assesses numeracy and reading comprehension
    • Total of 67 items
      • Numeracy includes 17 items
      • Reading comprehension includes 50 items.

    The first test is the Test of Functional Health Literacy in Adults or the TOFHLA. This measures the functional literacy level of patients using real-life healthcare materials. You give the patient information about a specific health type of situation or prescription bottle labels. They are asked to read a prescription label and answer questions about that. There are sample registration forms, instructions for diagnostic tests, instructions for appointments, and that sort of thing. They are asked to read and then answer questions about these items. This assesses two main constructs numeracy and reading comprehension. There are a total of 67 items. The numeracy scale looks at reading and understanding numbers. There are 17 items for that area, and then the reading comprehension has 50 items. This shows how well a patient can read and understand healthcare-related passages.

    • Two additional versions of the TOFHLA
      • TOFHLA-S: Spanish translation
      • S-TOFHLA: Short form

    There are two additional versions of the TOFHLA. I do not know why they named them as such because it sometimes confuses me. The TOFHLA-S is a validated Spanish translation, and then there is the S-TOFHLA, which is the short form of this. The original TOFHLA, off the top of my head, takes about 25 or so minutes to administer. The short form takes about 12 minutes to administer.

    Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF)

    • 7-item word recognition test
    • A quick assessment of patient health literacy
    • Validated and field-tested
    • Excellent agreement with the 66-item REALM instrument

    The next one is the REALM, and this is the REALM short form. There is also a REALM longer form that gives an estimate of adult literacy in medicine. I love the short form as it takes just a couple of seconds to administer.  It is a seven-item word recognition test that provides you with a super quick but valid assessment of someone's health literacy.

    • Behavior _____
    • Exercise _____
    • Menopause _____
    • Rectal _____
    • Antibiotics _____
    • Anemia _____
    • Jaundice _____

    You show the client these words on a piece of paper and say, "Please read me these seven words," and you check how many they got right. Scoring is very easy as you can see in Figure 7.

    Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) Grade Range.
    View Full Size Image

    Figure 7. Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) Grade Range.

    If they get none correct, they are probably at a third-grade reading level or below. What that means for you as a clinician is they are not going to be able to read even the lowest literacy materials. Even if you have materials developed for the 5th-6th grade reading levels, they may not be able to read those. You may need to completely change how you educate and communicate with them. Perhaps, you might choose to educate orally, use illustrations or videotape with say YouTube clips.

    If they get one to three of the words correct, they are at a 4th-6th grade reading level, and they are going to need those low literacy materials. They may not, however, be able to read prescription bottles or prescription labels. You may need to do some additional education there if it is part of your treatment plan.

    If they get four to six words correct, they are probably at about a 7th-8th grade level. They are not going to struggle with a lot of patient education materials. However, as I said before if you give them the low literacy materials, they are not going to be offended by it.

    If they get all seven, they are at a high school level and are probably set. They should be able to read most of the patient education materials that are out there or in development.

    The Newest Vital Sign

    • Quickly and simply assess a patient’s health literacy skills
    • Administered in 3 minutes
    • English and Spanish
    • Uses ice cream nutrition label for review and questions

    The Newest Vital Sign is reasonably new. It was designed to quickly and simply assess a patient's health literacy skills. Hopefully, some of you are already familiar with it. This is also available in the public domain, and it is free of charge. It can be administered in three minutes. What happens is the patient is given a specially designed ice cream nutrition label to review, and then we ask them a series of questions about it. Based on the number of the correct answers that they get, we can assess what their health literacy level is and then adjust how we communicate with them.

    • Administration
      • Administer at the same time that other vital signs are being taken
      • Ask the patient to participate
      • “We are asking our patients to help us learn how well patients can understand the medical information that doctors give them. Would you be willing to help us by looking at some health information and then answering a few questions about that information? Your answers will help our doctors learn how to provide medical information in ways that patients will understand. It will only take about 3 minutes.”

    Why is it called The Newest Vital Sign? It was set up in a way such that a nurse or any other trained staff like a respiratory therapist, could administer it at the same time they are taking vitals like blood pressure, pulse ox, and respirations per minute. You ask the patient to participate. This is the language that comes directly from the assessment. We ask them this, "We're asking our patients to help us learn how well patients can understand the medical information that doctors give them. Would you be willing to help us by looking at some health information and then answering a few questions about that information? Your answers will help our doctors learn how to provide medical information in ways the patients will understand, it will only take about three minutes." Again, this is taken directly off the tool.

    • Administration
      • Hand the nutrition label to the patient
      • Retain label throughout the administration
      • Refer to label as often as needed
      • Asking the 6 questions, one by one, giving the patient as much time as needed to answer
      • No maximum time allowed – the average is 3 minutes
        • If struggling with the first or second question after 2 or 3 minutes, likely has limited literacy and assessment can stop

    You then hand the nutrition label to the patient. The patient can and should retain the nutrition label throughout the administration of the entire Newest Vital Sign, or the NVS. The patient can also refer to the label as often as they need to throughout the entire test. You ask the six questions one by one. You give the patient as much time as he or she needs to refer to that nutrition label to answer the questions. And, there is no maximum time allowed to answer the questions. The average time needed to do all six of the questions is about three minutes. However, if the patient is still struggling with the first or the second question after a few minutes, the patient likely has limited literacy, and you can probably just stop the assessment.

    • Administration
      • Ask the questions in sequence
      • Continue even if the patient gets the first few questions wrong
      • If #5 answered incorrectly, do not ask #6
      • With 4 correct responses, stop -- patient has adequate literacy
      • Do not prompt
      • Do not show the score sheet to patients
      • Do not tell patients if they have answered correctly or incorrectly

    You are required to ask the questions in a sequence, and you are going to continue the test even if the patient gets the first few questions wrong. However, and again this will make more sense when we start to ask the questions if the patient gets number five wrong you do not move to number six. You can stop asking the questions if the patient gets the first four questions correct. 

    With four correct responses, the patient almost certainly has adequate literacy. You cannot prompt a patient who cannot answer a question because as with any standardized assessment, prompting could jeopardize the accuracy of the test. You just need to say, "No big deal. We're just going to go on to the next question." You also cannot show the score sheet to the patients.

    When you look at this assessment, it is an entire assessment booklet, and the score sheet shows the answer. If they ask to see it, you say, "I can't show it to you because it contains the answers, and showing the answers spoils the whole point of asking the questions, does it not?" You also cannot tell them if they answer correctly or incorrectly. They are going to ask things like, "How did I do?" "Am I doing okay?" "How's it going?" You just say, "I can't show you the answers until you are finished, but for now you are doing just fine. Let's go on to the next question." You need to be encouraging without giving them the answers.

    As you score this, this is why that four questions make sense, you give them one point for every correct answer for a maximum of six points (Figure 8).

    Scoring for The New Vital Sign
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    Figure 8. Scoring for The New Vital Sign.

    With a score of zero to one, there is a high likelihood of 50% or more of limited health literacy. Again, your takeaway here is you need to go back and develop your materials in a way that is going to be a sixth grade or below and communicate in plain language. A score of two to three suggests the possibility of limited literacy. They are probably not going to be offended if you give them low literacy materials, but they may not need them either. A score of four to six almost always indicates that the person has adequate literacy. Again, if they get the first four questions right, you do not technically have to ask questions five and six. I like to complete the whole test, but if they get the first four, chances are pretty good that they have adequate literacy.

    • Why an ice cream label?
      • Analyzing a nutrition label requires the same skills to understand medical instructions
        • Understanding and application of words (prose)
        • Numbers (numeracy)
        • Forms (documents)
      • Whether it’s a food label or medical instructions, one needs to:
        • Remember numbers/make calculations
        • Identify potentially harmful ingredients
        • Make decisions about actions based on information

    Why does an ice cream label work as a predictor of the ability to understand medical instructions? A patient's ability to read and analyze a nutrition label requires the same types of analytical and conceptual skills that are needed to understand and then follow a provider's medical instructions. There are three different and specific types of skills here. An understanding and application of words are prose literacy. The application of numbers, which we have been talking about throughout the course, is numeracy literacy. And then, there are forms or documents.

    Recent research in the "American Journal of Preventive Medicine" has shown that poor comprehension of food labels correlates very highly with low-level literacy and numeracy skills. Whether they are reading a food label or following medical instructions, they need to be able to remember numbers and make mathematical calculations. It could be figuring out their caloric intake for the day. Or, figuring out on a sliding scale, what insulin dosage they need. Their physician may say to stop your medication on a certain date before a procedure. They need to remember those numbers and make calculations. It might be identifying and being mindful of different ingredients that could be potentially harmful to them. They need to make decisions about their actions based on the given information. Do I hold my meds? Do I take my meds? Do I do my breathing treatment? Do I not?

    Let's go back through those three examples before we do the test together.

    • Prose Literacy Example
      • Clinical example
        • The patient has scheduled some blood tests and is instructed in writing to fast the night before the tests
      • Ice cream label example
        • The patient needs this skill to read the label and determine if he can eat the ice cream if he is allergic to peanuts

    For the prose literacy example, the patient has scheduled some blood tests and is instructed in writing to fast the night before they take those tests. In that case, the patient would need that same skill to be able to read the label and determine if that person can eat the ice cream if they have a peanut allergy. It is the same type of literacy skills that would be utilized there.

    • Numeracy Example
      • Clinical example
        • A patient is given a prescription for a new medication that needs to be taken at a certain dosage twice a day
      • Ice cream label example
        • The patient needs this same skill to calculate how many calories are in a serving of ice cream

    A numeracy example would be if a patient is given a prescription for a new medication that needs to be taken at a very specific dosage, and they have to take it twice a day. For the ice cream label, the patient needs that same skill to calculate how many calories are in a serving of ice cream. 

    • Document Literacy Example
      • Clinical example
        • The patient is told to buy a glucose meter and use it 30 minutes before each meal and before going to bed. If the number is higher than 200, he should call the office.
      • Ice cream label example
        • The patient needs this skill to identify the amount of saturated fat in a serving of ice cream and how it will affect his daily diet if he doesn’t eat it

    Then, there is document or forms literacy. In the clinical example, the patient is told to buy a glucose meter or a glucometer and use it 30 minutes before each meal and before going to bed. If the number is higher than 200, he should call the office, or higher than around 120 to 140 to do something with the insulin dosage. The parallel on the ice cream label is to identify the amount of saturated fat in a serving of ice cream, and then determine how that will affect his or her daily diet if they do not eat it.

    We are going to have a little fun now. Take out a piece of paper, and as we go through the questions on the next slide, you can determine how well you do. Figure 9 shows the ice cream label that you are going to give to the patient.

    Ice cream label
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    Figure 9. Ice cream label.

    • Questions
      • 1.If you eat the entire container, how many calories will you eat?
        • Answer: 1,000 is the only correct answer
      • 2.If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have?
        • Answer: Any of the following is correct: 1 cup (or any amount up to 1 cup), half the container. Note: If the patient answers “two servings,” ask “How much ice cream would that be if you were to measure it into a bowl?”
      • 3.Your doctor advises you to reduce the amount of saturated fat in your diet.  You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day?
        • Answer: 33 is the only correct answer
      • 4.If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?
        • Answer: 10% is the only correct answer
      • READ TO SUBJECT: Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings.
      • 5.Is it safe for you to eat this ice cream?
        • Answer: No
      • 6. (Ask only if the patient responds “no” to question 5): Why not?
        • Answer: Because it has peanut oil.

    Follow along and write down your answers. Question 1: If you eat the entire container of ice cream, how many calories will you eat? Question 2: If you were allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? Question 3: Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 grams of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat will you be consuming each day? Question 4: If you usually eat 2,500, what percentage of your daily value of calories will you be eating if you eat one serving of ice cream? Pretend you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. Question 5: Is it safe for you to eat this ice cream? Yes or no? And then depending on what you answered, if you said, "No," why not? That is the whole test. As an aside, I read those to you verbally. This is ideally how you should do this. I suspect that if you had to, you could put these questions on like a cue card or something for the person to read them if that was necessary. I would need to confirm that with the test booklet.

    Let's go back through the questions. Question one, if you eat the entire container, how many calories will you eat? The answer here is 1,000. This is the only correct answer because there are four servings and each serving is 250 calories. If you were allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have? Any of the following answers would be correct. You could say one cup or any amount up to one cup, or half the container. If the patient were to say two servings, you need to go back to them and ask, "How much is a serving?" "How much ice cream would that be if you measured it out and you put it into a bowl?" Question three, your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 grams of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? The answer is 33 grams of saturated fat. If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving of ice cream? Again, the only answer is 10%, because it is 250 calories per serving. Lastly, with the allergy question, the answer to that is no. If they answer, "No," you ask them why. The answer is no as there is peanut oil in this ice cream.

    Again, you ask all the questions in order. If they get question five wrong, you do not even ask question six. If they answer, "Yes," it is safe for them to eat it, they clearly did not understand that there was peanut oil in the ingredient list, and they probably should not be eating it.

    This is a great test that was developed by one of the drug manufacturers. Again, it takes three minutes to administer it, and you immediately know with any one of these tasks reading comprehension and the literacy level of the client. It just helps you to put everything that you are doing with them into focus at a level that is going to be meaningful, useful, and get your point across. It also increases health outcomes.

    Recap of the Assessments

    Figure 10 is a recap of those assessments and the references for each of them.

    Chart showing assessment information
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    Figure 10. Chart showing assessment information.

    There is the TOFHLA. It takes 22 to 25 minutes to administer that. The short form of the TOFHLA takes about seven minutes. The short form of the REALM, that we just talked about, with the seven words takes one to two minutes. The full 66 item test takes about 25 to 30 minutes. Lastly, The Newest Vital Sign, from Pfizer, is about three minutes long. These tests are available for you to get the information that you need.

    Effective Verbal and Written Communication

    Ask Me 3

    • 1.What is my main problem?
    • 2.What do I need to do?
    • 3.Why is it important for me to do this?
      • Intended to help patients become more active members of their health care team
      • Improve communication
      • Develop patient-centered goals

    We talked about the Ask Me 3 earlier on. This is a great educational program that encourages our patients and families to ask three specific questions of their providers to help them understand their health conditions a little bit better. It also helps them to understand what they need to do to not only stay healthy but also to be compliant with any sort of healthcare regime or instructions. What is my main problem? What do I need to do? Why is it important for me to do this? We flip-flop those. Remember, when we talked about them before it was, "What problem are you bringing to me?" "What do you want from me to do this?" And, "Why is it important to you?" This is flip-flopping this narrative and helps patients become more active members of their healthcare team. It is a critical platform that improves communications between them and us. More than anything, it helps us to develop those patient-centered goals. If the goal is not centered on the patient, meaningful, or motivational to them, what is the point?

    Teach Back

    • The client repeats the information in his or her own words to show understanding
    • Useful to assess YOUR OWN communication skills with the patient
    • For example: 
      • Tell me what you have understood
      • Can you show me how you are going to do your exercises?

    We have talked about teach back before. We probably intuitively do this, but we do this to make sure that the client understands. They repeat the information back to us in their own words to show understanding. This helps us to assess our communication skills with the patient. Did I do my job? Did I get my point across? "Tell me what you understood. I want to make sure that I've explained it thoroughly to you?" "What I would like you to do for your respiratory home program. Tell me how you're going to do your exercises as it relates to your breathing?" Or, "How are you going to do your plan at home? Can you show me how you're going to do those exercises?" You are looking to see if you got your point across and how are they doing with it. If their return demonstration is not at 100%, then you have a little bit of work to do. You may even have to go back to the drawing board and figure out how to parlay that education a little bit differently.

    Content and Organization

    • Ensure the purpose is immediately outlined and clear to the reader
    • Ensure content is balanced, accurate, and up-to-date
    • Include a publication or revision date on all materials
    • Provide how-to information of relevance to the reader’s situation
    • Use subheadings, question and answer format, bullet points, and summaries

    Content and organization are critically important. Make sure that the purpose is immediately outlined and clear to the reader. The purpose of written documents should not be hidden at the end of the first paragraph or the end. It should be smack dab right there at the very beginning. You want to make sure that the content is balanced, accurate, and up to date. You may even want to put a reference date in the footer of your document so you know the last time that it was updated. Was it updated in 2003 or was it updated in 2020? Provide how-to, relevant information, and keep out the extraneous. Use subheadings to help you to organize. A Q&A format is wonderful. You can also use bullet points and short little summaries to break down the information into small and reasonable chunks.

    Layout and Illustrations

    • Use ample white space
    • Use serif typefaces, minimum 12-point font size, good contrast between text and background
    • Avoid capitalizing all letters in words, italicizing, and the use of Roman numerals
    • Use instructive, culturally appropriate illustrations but only if they augment the message
    • Position illustrations next to the text they refer to
    • Clearly label all illustrations

    When you look at your layout and illustrations, there should be ample white space. It is very distracting if there are tons and tons of words on a slide or a piece of paper. Ues serif typefaces. It is also good practice to use a minimum 12 point font size with good contrast between the text and the background. Some people will try to use white letters on a black background, and while that has good contrast, it is very difficult for people to read. Black on white is always going to be best. Avoid capitalizing all the letters in the words, italics, and the use of Roman numerals. If you use illustrations, make sure that they are instructive, culturally appropriate, and not offensive. Only include them if they actually augment the message. If not, they probably do not need to be there. And if you are going to use photos or illustrations, make sure that they are next to the text that they refer to. And of course, label all of your illustrations so that somebody knows what that illustration is about.

    Language

    • Aim for 5th to 6th-grade reading level
    • Use clear, simple, common language, and short sentences and words
    • Avoid jargon and define specialist terminology
    • Write in active voice and second person

    We have talked about language already quite a bit. Aim for the fifth to sixth-grade reading level with a simple, clear common language and short sentences. You want less than 10 words per sentence. Avoid jargon and special terminology. And, write in an active voice.

    Writing Tips for All Readers

    • Use plain English
    • Make every word count
    • Be clear and brief
    • Use positive words
    • Short lists or bullet points, not long sentences
    • Concrete, familiar words
    • Charts and pictures
    • One or two-syllable word when possible

    We already talked about plain English. These are just writing tips for all readers. I think that if you just do this consistently, no one is going to be offended. Everyone is going to be helped. Make every word count and cut out the unnecessary fluff if you do not need it. Be clear, be brief, and use positive words. Instead of saying, "Don't do this," instead say, "Do this." Use positive words, short lists, bullets, short sentences, and concrete and familiar words. If you use abstract words, sometimes the translation gets lost. Use very familiar words unless you have to use a very technical term. Charts and pictures are very helpful. Using one syllable or even two-syllable words when possible is going to be better. 

    • Follow grammar rules:
      • Subject and verb together if possible
      • Vivid, active verbs
      • Active voice
      • Short, simple sentences
      • Personal pronouns
      • Few – ing words
      • Few prepositional phrases

    Follow grammar rules. I am probably the only person in the world who uses proper grammar and punctuation in a text message. Use your subject and your verb together, and make them part of the same sentence. Vivid, active action verbs are better than passive. Use personal pronouns like we and you. Use few -ing words. Keep out those prepositional phrases. And when possible, do not end your sentence with a preposition.

    Text Appearance Matters

    • Text greatly affects readability
    • Use font sizes between 12 and 14 points
    • For headings, use a font size at least 2 points larger than the main text size
    • Use fonts with serifs
      • Serifs are the little “feet” on letters

    Text greatly affects your readability. Choose the appropriate font style and size. It is really important to create health communication materials that are easy for our patients to read. Font sizes should be between 12 and 14 points. If someone has low vision on top of other things, you might want to go a little bit bigger or use low vision materials. Anything less than 12 points can be too small for individuals. If you have headings, you are going to use a font size that is at least two points larger than the main text. We want to use serif fonts as they are easier to read than sans-serif fonts. The serif makes the individual letters more distinct and easier for our brains to quickly and easily recognize. The serifs are the little feet that are on letters. If you are not sure if something is a serif or not, go back to Microsoft Word. This is not certainly a plug for them, but if you look at your font list, it will say sans-serif. Sans-serif means it does not have feet. For example, Times New Roman font has the feet.

    • Do not use FANCY or script lettering
    • Use both upper and lower case letters
    • Use grammatically correct punctuation
    • Use bold type to emphasize words or phrases
    • Limit the use of italics or underlining
    • Use dark letters on a light background

    Do not use fancy or script lettering. I know it looks really fun, but it is very difficult to read. Make sure that you use both upper and lower case letters just as you would with any sort of paragraph that you are writing or reading. Do not use all caps. Make sure that you are using grammatically correct punctuation like commas, semi-colons, and periods. If you do want to emphasize a word or emphasize a phrase, use bold type to do that as italics and underlining are very difficult to read. You want to avoid those. Keep it simple. And I think simple plain language, go back to that. That's exactly what we need it to be.

    Summary

    This brings us to the conclusion of this session. Thank you so much for listening. My contact information is on the final slide. If you have any questions or would like additional information, do not hesitate to reach out. 

    References

    Available in the handout.

    Citation

    Weissberg, K. (2021). Health literacy and delivering culturally competent care. Continued - RespiratoryTherapy, Article 19. Available at www.continued.com/respiratory-therapy

    Jan 18, 2021

    2 CE Hours

  • Elder Abuse and Child Abuse: Know the Signs and Your Role

    Kathleen Weissberg, OTR/L, OTD

    Editor’s note: This text-based course is a transcript of the webinar, Elder Abuse and Child Abuse: Know the Signs and Your Role, presented by Kathleen Weissberg, OTD, OTR/L.

    Learning Outcomes

    • After this course, participants will be able to recognize possible clinical, behavioral, and physical indicators of suspected elder and child abuse and neglect.
    • After this course, participants will be able to list possible risk factors related to elder and/or child abuse and neglect.
    • After this course, participants will be able to describe the reporting procedure for abuse and neglect.
    • After this course, participants will be able to list resources that can be utilized for state-specific procedures.

    Elder Abuse

    Today, we are going to talk about elder abuse and child abuse, and sadly this is more common than you might think. Our goal for today is to learn to spot those warning signs and then to know what your responsibilities are or could possibly be with regard to reporting.

    Some Statistics

    • According to the U.S. Government Accountability Office (GAO), elder abuse is a widespread and growing problem
    • Data reporting is a challenge
    • Recent studies indicate that elder abuse incidence rates are far higher than once thought

    According to a study by the United States Government Accountability Office, the GAO, elder abuse is really a widespread and growing problem. The data reporting in this area is a challenge, but despite that, recent studies indicate that elder abuse incident rates are far higher than we probably thought. This slide show includes a few different stories that have come up in the public sector.

    • In NYS, incidence rates nearly 24X greater than the number of cases referred to authorities who can help (Lifespan of Greater Rochester et al., 2011)
    • One in five Americans older than age 65 had been defrauded (Kiplinger’s Personal Finance, 2011)
    • In most cases, the adult children of abused elders were unaware that their mother or father had received solicitations for money (Olson, 2011)

    A collaborative public-private report on elder abuse in New York State, for example, found an incident rate of elder abuse nearly 24 times greater than the number of cases referred to social service, law enforcement, or legal authorities who have the capacity and the responsibility to assist adult older victims. And, as a nation, our response is disjointed. The minimal federal investment is only about 12 million dollars, give or take, and it is spread sparsely across eight agencies and two departments with very little coordination. I am going to digress for a second and say that recently the Office of Inspector General came out with a report related to elder abuse. I am not going to go through a lot of the details, but basically they found that a lot of individuals were coming into the emergency room and had diagnosis codes or situations indicative of abuse that was never reported to state authorities. I think we are going to see a little more oversight in the near future on this topic and probably some additional training from some of these government agencies. An Investors Protection Trust Survey found that one in five Americans older than the age of 65 had been defrauded. This is something that we are hearing about quite a bit about in the news. The conservative estimates of the personal cost to victims of financial abuse are easily three billion dollars annually. These reported cases only hint at the extent of the problem. We are not hearing a lot of the other stories that are probably out there. And, in a New York Times article, they talked about financial exploitation and the knowledge of adult children. Many are unaware that their mother or father had even received solicitations for money. Even attentive children, as involved as you can be with your parents, sometimes miss the warning signs. In that particular article, they highlighted the story of Dr. Robert Parker. He is the chief of community geriatrics at the University of Texas Health Medical Center in San Antonio. He failed to notice that his own mother was a victim of financial abuse. So, no matter how involved you are, sometimes you still miss some of these things.

    A Chilling Example of Neglect

    Before we get into some of the definitions, I wanted to share this story. It was a widely publicized case in Michigan. An elderly female nursing home resident began coughing one night. Her caretakers were busy, and she continued to just cough throughout the night. A couple of staff observed "white things" in her sputum and near her trach collar. It was not until the next morning that somebody actually checked into her mouth, and they found maggots. The maggots had created a partial airway obstruction causing her to suffer abnormal blood oxygen levels and labored breathing. The emergency medical services staff said that they could not even suction because of the very active maggots in the airway. This is just a terrible example and there is no evidence that that staff was disciplined for clearly neglecting this woman so severely. 

    Definitions

    “Acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and/or welfare of an older adult.”

    Abuse Defined

    • Willful infliction of injury
    • Unreasonable confinement/Involuntary seclusion
    • Intimidation with resulting physical harm, or pain, or mental anguish
    • Punishment with resulting physical harm, or pain, or mental anguish
    • Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being
    • Corporal punishment & any physical or chemical restraint not required
    • Abuse that includes that which is facilitated or enabled through the use of technology

    I think the biggest piece here is that it is willful infliction. It can also include things like unreasonable confinement or involuntary seclusion, and that could happen in the home environment or in an institution. It might be where we are separating an individual from other individuals, from their room, or from another area where they want to go. This can be against their will or even against the will of that person's legal representative. It also could include intimidation or punishment with resulting physical harm, pain, or mental anguish. It could include things like deprivation by an individual, including a caretaker, of goods or services that are necessary to attain physical, mental, or psychosocial well-being. These are all the things that that person needs to be well. It can include corporal punishment or physical or chemical restraints that are not really required to treat that individual's symptoms or their issues. Again, it is anything that would cause pain or an issue, and it can also include things that are enabled through the use of technology. The individual acts deliberately.

    • Elder abuse includes physical, emotional, or sexual harm inflicted upon an older adult, their financial exploitation, or neglect of their welfare by people who are directly responsible for their care
    • Elder abuse tends to take place where the senior lives: where their abusers are often adult children, other family members such as grandchildren, or a spouse or partner. Elder abuse can also occur in institutional settings.

    Now elder abuse includes, as we just said, physical, emotional, sexual harm potentially inflicted upon an older adult. It can also include financial exploitation and neglect of their welfare. It is done by somebody who is directly responsible for their care. And in the United States alone, more than half a million reports of elder abuse reach authorities every year, and many more go unreported. Now as older adults become more physically frail, they are less able to take care of themselves. They cannot stand up to bullying, and they cannot fight back a lot of times if they are attacked in some way.

    The mental or physical ailment that they have can make them more trying to companions for those who live with them. They may not see, hear, or think as clearly as they used to. This leaves them open, unfortunately, for unscrupulous people to take advantage of them, and we definitely see that. The other thing to keep in mind is that elder abuse tends to take place where that individual lives. We hear stories of elder abuse that occurs somewhere out in the community, but typically, the senior lives with their abusers. The abusers can be adult children, other family members like grandchildren, a spouse, a partner, or a very good friend. The sad reality is that elder abuse can also occur in institutional settings especially long-term care facilities, that is where we hear about it most.

    Forms of Abuse

    • Verbal
    • Physical
    • Sexual
    • Mental/Emotional
    • Neglect
    • Abandonment
    • Financial exploitation
    • Self-neglect

    What are the different forms? Abuse of elders takes a lot of different forms. Some involve intimidation or threats against the elderly, some involve neglect and other financial trickery. The most common types are listed above. We will go through each one of these in a little more detail and look at some of the warning signs.

    Verbal Abuse

    • Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability

    This is almost like bullying. It is talking about that person in such a negative way so that they overhear it. The person feels, based upon this blame, diminished self-worth, or diminished ego, et cetera. This is, obviously, not something that we would want to do.

    Physical Abuse

    • The non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.

    Physical abuse is pretty straightforward. This does not just include physical assault such as hitting or shoving, but it can also include things like the inappropriate use of drugs or medications, restraints, or even confinement. This can be in an institutional or home setting. The more common types of physical abuse that we see are things like hitting, slapping, pinching, scratching, spitting, holding that person roughly, holding them in their chair, or forcing them into their wheelchair. It also includes controlling behavior through corporal punishment. Unfortunately, we continue to see this in some of our settings. This a corporal type punishment of influence.

    Sexual Abuse

    • Contact with an elderly person without their consent. Includes but is not limited to humiliation, harassment, coercion, or sexual assault. Activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.

    Again, you hear these outrageous stories on the news, and it makes you scratch your head. Sexual abuse includes but is not limited to things like humiliation, harassment, coercion, or even sexual assault. It is non-consensual sexual contact of any type with an individual. It is contact with that elderly person without their consent. It can involve physical sexual acts, but it can also involve other things like showing an elderly person pornographic materials and making them watch it or forcing the person to watch other sex acts or something else occurring in the environment. It can even include forcing the elder to undress in front of you. This would not be part of an ADL or helping them to use the restroom. This is forcing them to undress outside of those normal scenarios.

    Emotional/Mental Abuse

    • The treatment of an older adult in ways that cause emotional or psychological pain or distress, including:
      • Intimidation through yelling or threats
      • Humiliation and ridicule
      • Habitual blaming or scapegoating
      • Ignoring the elderly person
      • Isolating an elder from friends or activities
      • Terrorizing or menacing the elderly person
      • Harassment
      • Threats of punishment or deprivation.

    This is the treatment of an older adult in ways that cause emotional or psychological pain or distress. It can be intimidation through yelling or threats, humiliation or ridicule, habitual blaming, or scapegoating. It can also be ignoring that elderly person or ignoring their requests, isolating an elder from their friends or their activities, and terrorizing or menacing the elderly person. You may not think that some of these things are necessarily emotional elder abuse, but they could be under the right set of circumstances. For example, if you take a photograph, and that person does not want to be photographed, that could constitute mental, physical, or some sort of abuse. Again, we should not be doing that in any of our settings or doing anything that might be considered humiliating toward an individual. During the delivery of care, depending on what we are doing with that individual, we need to make sure that we are keeping the person from public view like undressing to do an ADL. We need to make sure that we prevent any unnecessary exposure of body parts. That is what we do all the time normally, but if we did not, it could be potentially considered emotional or mental abuse.

    My aunt, who has since passed away, was in a nursing home many years ago. She had dementia but she still knew enough to say I need to use the restroom when she truly needed to go. She had a urinary tract infection at the time was going much more frequently. I remember her saying, "I have to use the bathroom." She did not want me to take her and that was fine. She called for a nurse who came in and said, "Don't you realize you just went about an hour ago? You couldn't possibly need to go again. If you need to go, you're just going to have to go in your diaper." And I sat there and thought, "That's emotional abuse. That's humiliating to say to a person." And, this is in a premier community. There are the things that we need to look out for as they can certainly lead to emotional types of abuse. Whether that mental abuse has occurred or not is really determined by a reasonable person's standard and does not require a specific response from the individual. What I mean by that is a reasonable person would think that that is completely unacceptable. It does not necessarily have to have a response from the individual because that individual may have dementia or something else going on and cannot respond in an appropriate manner. We always use that "reasonable person standard" as our litmus test against whether or not something would be considered emotional or mental abuse.

    Medication Diversion

    • Knowingly, or intentionally, interrupting, obstructing, or altering the delivery, or administration of a prescription drug.

    The next one is medication diversion. This is an interesting one. This is one we are hearing more and more about, but I think particularly in a home environment by a companion or caregiver (not necessarily paid) who might be looking to steal those medications for their own personal or financial gain. We are seeing a little bit more of this out in the community.

    Elder Neglect

    • Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional.

    This is quite simply the failure to fulfill a caretaking obligation. Unfortunately, this constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional based on factors such as ignorance or denial that an elderly charge needs as much care as they do. Again, it is really just that failure to provide goods and services that are necessary for that person to avoid harm, and we will talk more about that in just a little bit.

    Financial Exploitation 

    • The unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside scam artist
      • Misuse an elder’s personal checks, credit cards, or accounts
      • Steal cash, income checks, or household goods
      • Forge the elder’s signature
      • Engage in identity theft
      • Scams targeting the elderly

    Another one that we are hearing a lot about now in the news is financial exploitation. This is the unauthorized use of an elderly person's funds or property either by a caregiver or by some outside person, a scam artist. It is deliberate misplacement, exploitation, wrongful temporary or permanent use of an individual's belongings or money without their consent. The important distinction is without their consent. An unscrupulous caregiver might do things like misuse a person's personal checks, their credit cards, or their accounts. They may steal cash, income checks, household goods, or get access to their accounts. They may be under the guise of helping the client with their bills, but they are skimming out of their accounts without that elder knowing. Forging the elder's signature and engaging in identity theft is very common. Another example is an announcement of a prize that the elderly person has won, but they have to pay money to claim. There can be phony charities and investment fraud. I have even heard of scammers showing up on an elder's doorstep. They claim to be from the utility company, or what have you, and they tell the homeowner that they need to pay their bill in cash.  

    Healthcare Fraud and Abuse

    • Not providing healthcare, but charging for it
    • Overcharging or double-billing
    • Getting kickbacks for referrals
    • Overmedicating or under medicating
    • Recommending fraudulent remedies for illnesses
    • Medicaid fraud

    You may not think of this as elder abuse but it really is. This is carried out by unethical individuals like doctors, nurses, hospital personnel, and other professional providers. This includes not providing healthcare but charging for it, overcharging or double-billing from medical care or services, getting kickbacks for referrals to other providers, prescribing certain drugs, over-medicating or under-medicating, or recommending fraudulent remedies for illnesses or other medical conditions. This is anything that benefits the medical professional, not the client.

    Elder Self-Neglect

    • Physical or mental impairment or diminished capacity can mean that an older adult is no longer able to perform essential self-care
    • May lack basic personal hygiene, appear malnourished, live in dirty conditions, be unable to pay bills or manage medications
    • Can be a sign of depression, grief, dementia, or other medical problem

    We already talked about neglect, but this is self-neglect. This is a common form of elder abuse that we see in healthcare. Physical or mental impairment or diminished capacity can mean that an older individual is no longer able to perform essential self-care, and we see that very commonly with cognitive decline, dementia, et cetera. They may lack basic personal hygiene, appear dehydrated, malnourished, underweight, or what have you. This can be a sign of depression, grief, dementia, some other medical problem, and in many cases, the older person refuses to seek assistance. They, oftentimes, are in denial. They feel ashamed about needing help or feel worried about losing their independence. If you see this self-neglect, this could be indicative of some other larger systemic issue going on with the elder.

    Signs of elder abuse can, unfortunately, be very difficult to recognize, mistaken for symptoms of dementia, the elder person's frailty, or again the caregivers may explain them to you in that way and just pass them off. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that does not mean that we want to dismiss them on the caregiver's say-so.

    Warning Signs

    If you suspect abuse but you are not sure, look for the warning signs. We are going to go through these quickly as it relates to each of the types of abuse.

    Physical Abuse Warning Signs

    • Unexplained signs of injury, such as bruises, welts, or scars
    • Broken bones, sprains, or dislocations
    • A report of drug overdose or an apparent failure to take medication
    • Broken eyeglasses or frames
    • Signs of being restrained, such as rope marks on wrists
    • Caregiver’s refusal to allow you to see the elder alone

    These can include unexplained signs of injury such as bruises, welts, scars, especially if they appear symmetrically on both sides of the body, broken bones, sprains, or dislocations, or fractures that are unexplained. Another warning sign is a report of either a drug overdose or an apparent failure to take their medication. When you go in to do your visit, you may see that there is a lot more of that prescription remaining than should be. They may have broken eyeglasses, broken frames, signs of being restrained, like rope marks on their wrists, or things maybe that came from a zip tie. The caregiver may refuse to allow you to see the elder alone. There can also be signs of burns, internal injuries, and abrasions. These are injuries that are unexplained or somebody is giving you an explanation and that explanation is just really not plausible.

    Emotional Abuse Warning Signs

    • Threatening, belittling, or controlling caregiver behavior
    • Behavior from the elder that mimics dementia
    • Depression, sleep and appetite disturbances
    • Decreased social contact
    • Evasiveness, anxiety, hostility

    When we look at emotional abuse warning signs, these are things like threatening, belittling, or controlling caregiver behavior. You may observe the caregiver and what they are saying may not ring true. Your "spidey sense" may be alerted. Behavior from the elder that mimics dementia such as rocking, sucking, or mumbling to themselves. Depression, sleep and appetite disturbances, decreased social contact, loss of interest in their own self, apathy, suicidal ideation, evasiveness, anxiety, hostility, or any of those changes can be potential warning signs. This person who has always wanted to go to activities and been very involved suddenly does not want to go and have isolated themselves would be a big red flag.

    Sexual Abuse Warning Signs

    • Bruises around breasts or genitals
    • Unexplained vaginal or anal bleeding
    • Torn, stained, or bloody underclothing
    • Fear of being touched
    • Inappropriate modesty on evaluation

    You may notice some of these things while doing an ADL. Other issues would be unexplained vaginal or anal bleeding, torn, stained, bloody underclothing, fear of being touched, or an inappropriate modesty when you are delivering standard treatment or evaluation. You might have draped that person appropriately, but they still just do not want you to see them. 

    Neglect Warning Signs

    • Unusual weight loss, malnutrition, dehydration
    • Untreated physical problems, such as bed sores
    • Unsanitary living conditions
    • Being left dirty or unbathed
    • Unsuitable clothing or covering for the weather
    • Unsafe living conditions
    • Desertion of the elder at a public place
    • Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference

    Elder neglect or even self-neglect have some warning signs. These are things like unusual weight loss without a weight loss program, malnutrition, dehydration, untreated physical problems like bedsores or something else that should be treated, unsanitary living conditions, so dirt, bed bugs, or soiled bedding and clothing. They may be dirty or unbathed, or have unsuitable clothing or covering for the weather. For example, it could be cold outside yet the person has no coat. There may be no heat or running water, faulty electrical wiring, other fire hazards, or maybe they have been deserted at a public place. Another indication is the misuse or the absence of medication or an assistive device. You can also see things like eccentric or idiosyncratic behavior, self-imposed isolation, and a marked indifference to anything that is going on around them. All of those can be signs of neglect.

    Financial Exploitation Warning Signs

    • Significant withdrawals from the elder’s accounts
    • Sudden changes in the elder’s financial condition
    • Items or cash missing from the senior’s household
    • Suspicious changes in wills, power of attorney, titles, and policies
    • Addition of names to the senior’s signature card
    • Financial activity the senior couldn’t have undertaken
    • Unnecessary services, goods, or subscriptions
    • The disparity between assets and appearance and general condition

    Some of the warning signs here include significant withdrawals from that person's account, a sudden change in their financial condition, and items or cash missing from their household. Maybe, there have been changes in the will, in the power of attorney, and in titles and policies. They may have signed over these items to someone that just makes you scratch your head. There may be new additions of names to a signature card for the bank or other accounts. There may be financial activity that the person could not have possibly undertaken. For example, an ATM withdrawal when the account holder is bedridden or paying an account online when the person does not even have a computer. There could be unnecessary services, goods, or subscriptions. The client may also display fear, vague answers, or anxiety when asked about their personal finances. You may see a disparity between their assets and their appearance and their general condition. 

    Healthcare Fraud/Abuse Warning Signs

    • Duplicate billings for the same medical service or device
    • Evidence of overmedication or under-medication
    • Evidence of inadequate care when bills are paid in full
    • Problems with the care facility

    Duplicate billings for the same medical service or device, evidence of overmedication or under-medication, evidence of inadequate care when the bills are truly paid in full are some warning signs in this category. All of their medical bills are paid, but they do not look like they are cared for. This could also happen in an institution where there are problems with the care facility. The staff could be poorly trained, poorly paid, insufficient staff, or overcrowding.

    Risk Factors

    • Caregiver stress
    • Depression in the caregiver
    • Lack of support from other potential caregivers
    • Substance abuse by the caregiver
    • The intensity of the elderly person’s illness or dementia
    • Social isolation
    • The elder’s role, at an earlier time, as an abusive parent or spouse
    • A history of domestic violence in the home
    • The elder’s own tendency toward verbal or physical aggression

    Taking care of a senior who has a lot of different care needs can be difficult. Both the demands of caregiving and the needs of that elder can create situations in which abuse is more likely to occur. Many nonprofessional caregivers, spouses, adult children, other relatives, and friends find taking care of an elder to be really satisfying and enriching, but the responsibilities and demands of caregiving can escalate and cause stress as that person's condition deteriorates. The stress of elder care can lead to mental and physical health problems that leave the caregiver burned out, impatient, and more susceptible to neglecting or lashing out at the elder in their care. Even caregivers in institutional settings can experience that stress that can lead to elder abuse. Nursing home staff particularly may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or they work under poor conditions. In addition to that caregiver's inability to manage stress, some other significant risk factors for elder abuse include depression in the caregiver and lack of support from other caregivers. The caregiver's perception that taking care of the elder is burdensome without any sort of emotional reward is another problem. Other risk factors include substance abuse by the caregiver, the intensity of the elderly person's illness or their dementia, social isolation, meaning that the elder and the caregiver are alone most of the time together, the elder may have been an abusive parent or a spouse, a history of domestic violence in the home, and the elder's own tendency toward verbal or physical aggression.

    Federal Reporting Requirements

    • Elder Justice Act (EJA): designed to address crimes committed against older persons, raise national awareness of elder justice issues and apply resources to the efforts of those confronting elder abuse and neglect on the front lines in healthcare settings

    These reporting requirements come from the Elder Justice Act. The purpose of that act is to detect, prevent, and prosecute elder abuse, neglect, and exploitation. The Elder Justice Act is designed to address crimes committed against older persons, raise national awareness of elder justice issues, and then apply resources to the efforts of those confronting elder abuse and neglect on the front lines in our healthcare settings. The Elder Justice Act as well adds new elder justice provisions and very specific provider requirements particularly in long-term care by amending various sections of several titles of the Social Security Act.

    • Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility
    • Facilities are required to conspicuously post, in an appropriate location, a notice for its employees specifying the employees’ rights, including the right to file a complaint under this statute. The notice must include a statement that an employee may file a complaint with the SA against an LTC facility that retaliates against an employee.

    Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, requires that very specific individuals in applicable long-term care facilities report any reasonable suspicion of crimes committed against an individual of that facility. Now, this is required of any facility that receives at least $10,000 in federal funds under the act in the preceding year. That community is required to notify every covered individual of their obligation to report to the Secretary of Health and Human Services, known as the Secretary, and at least one local law enforcement entity, for any reasonable suspicion of a crime. A covered individual, in this case, is an owner, an operator, an employee, a manager, an agent, or a contractor. It includes pretty much everybody. Additionally, communities are required to post in a very conspicuous place a notice for employees specifying their rights including the right to file a complaint, and the notice also has to have a statement in it that an employee can file a complaint with the Secretary and they cannot be retaliated against. 

    • You have a duty to report any suspected acts involving mistreatment, neglect, abuse, etc.
    • Facilities must report any reasonable suspicion of a crime against a resident or patient to:
      • The Secretary of the U.S. Department of Health and Human Services (HHS), and
      • The law enforcement authorities in the political subdivision where the facility is located.

    You do have a duty to report any suspected acts involving individual mistreatment, neglect, abuse, crimes, misappropriation of resident property, injuries of an unknown source, et cetera. Again, these are healthcare facilities again that are receiving federal aid. These facilities need to report any reasonable suspicion of a crime against an individual or a patient, number one, to the Secretary of the United States Department of Health and Human Services, and then also to the law enforcement authorities in the political subdivision where that facility is located. There are two specific federal reporting requirements, and most of these apply to the long-term care segment of the industry as that is where most of our elders reside.

    • Two-time limits for the reporting of reasonable suspicion of a crime
      • Serious Bodily Injury – 2 Hour Limit
        • Shall report the suspicion immediately, but not later than 2 hours after forming the suspicion
      • All Others – Within 24 Hours
        • If no serious bodily injury shall report the suspicion not later than 24 hours after forming the suspicion
    • “Serious bodily injury” is one involving extreme physical pain or substantial risk of death; or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

    There are two-time limits for reporting reasonable suspicions of crime depending on the seriousness of the event that leads to that suspicion. The first is whether or not there is a serious bodily injury. Now under the Elder Justice Act, serious bodily injury is one involving extreme physical pain, substantial risk of death, or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty. This is an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. If the events that cause a reasonable suspicion of harm or abuse and there is serious bodily injury, people are required to report immediately but no later than two hours after forming a suspicion to both local law enforcement and the Secretary of Health and Human Services. All others need to be reported within 24 hours. That is federal guidance. 

    State Reporting Requirements

    • Each state may have specific reporting requirements related to abuse
    • It is important that you familiarize yourself with the requirements for the state in which you work/provide services
    • Report as required by state law

    This is where it gets tricky because every state is different. Each state may have specific reporting requirements related to the abuse. And for you, it is important that you familiarize yourself with the requirements for the state where you work and where you provide the services. If you feel or have a reason to believe that somebody is being abused, you need to report this. As every state is different and you need to report as required by your state law.

    Resources

    Here are a couple of resources. One is the State Adult Protection Statutes, and the second link here is for State Mandatory Reporting Statutes. The second one specifically will tell you where to report, how to report, who is required to report, and what those timeframes are for your specific state. Hopefully, you can take the time to look those up as well. 

    Child Abuse

    Federal Definition of Child Abuse

    • Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g) defines child abuse and neglect as at minimum:
      • "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or
      • "An act or failure to act which presents an imminent risk of serious harm."

    According to the United States Department of Health and Human Services, federal legislation provides guidance to states by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act or CAPTA, as amended by a Reauthorization Act in 2010, defines child abuse and neglect at a minimum to any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, and an act or failure to which presents an immediate or an imminent risk of serious harm.

    Definitions

    • A "child" generally means a person who is younger than age 18 or who is not an emancipated minor
    • CAPTA does not provide specific definitions for types of maltreatment such as physical abuse, neglect, or emotional abuse
    • Federal legislation sets minimum standards for States that accept CAPTA funding, each state provides its own definitions of maltreatment within civil and criminal statutes

    Under these definitions, this definition refers very specifically to parents and other caregivers. A child under this definition generally means a person who is younger than the age of 18 or who is not an emancipated minor. And while CAPTA provides definitions for sexual abuse and the special cases of neglect related to withholding or failing to provide medically indicated treatment, it does not provide specific definitions for other types of maltreatment or things like physical abuse, neglect, or emotional abuse. While federal legislation sets those minimum standards for states that accept CAPTA funding, each state is going to go out on its own and provide its own definitions of maltreatment within civil and criminal statutes. 

    State Statutes

    • Definitions of child abuse and neglect are typically located in two places within each State's statutory code:
      • Civil statutes provide definitions of child maltreatment for mandated reporters
      • Criminal statutes define those forms of child maltreatment subject to arrest and prosecution

    The federal definition is out there, but the state has to be accepting CAPTA funding for that federal definition to apply. More often than not, each state is going to have its own set of statutes related to child abuse. We will talk about this on another slide, but that is again where it is up to you to figure out the requirements in your specific state. Are you a mandatory reporter? What are your training requirements? I gave you some resources to do that, and we will talk about that in a minute. The definitions of child abuse are going to be located typically in two places within each state's statutory code. The first statutory code will be the civil statutes, and these will provide those definitions of what is child maltreatment. It also will help to guide the mandatory reporters and other individuals as well as to identify and report suspected child abuse and determine the grounds for intervention by the state child protection agencies and the civil courts. This is the overarching area of what is abuse, who reports, how do you report, and what do we do when you report. The criminal statutes, on the other hand, will define those forms of child maltreatment that can subject an offender to arrest and prosecution in criminal courts. Most of them will list out very specifically the types of things that are absolutely positively against the law and what would warrant an arrest, prosecution, jail time, community service, or whatever it would happen to be.

    Types of Abuse

    • Many states recognize four major types of maltreatment
      • Neglect
      • Physical abuse
      • Sexual abuse
      • Emotional abuse or neglect

    Many states recognize four major types of maltreatment in their definitions and these include neglect, physical abuse, sexual abuse, and emotional abuse or neglect. Let's look at these in a little more detail. I think the first step in helping an abused or neglected child is learning those warning signs. The presence of a single sign does not prove that child abuse is occurring but it could be. But, when you look at the situation a little bit more closely, you may see signs appear repeatedly or in combination. When you see a pattern, that is when you want to take notice. If you do suspect at any time that a child is being harmed, you have to report your suspicions because that is going to help protect that child and get some help for the family. We will talk about reporting in a second, but any person can report suspicions of child abuse and neglect. Mandatory reporters need to report under very specific circumstances defined by the state. Healthcare providers with very few exceptions would be considered mandatory reporters in those states. 

    Recognizing Child Abuse

    • The Child:
      • Shows sudden changes in behavior or school performance
      • Has not received help for physical or medical problems
      • Has learning problems that cannot be attributed to specific causes
      • Is always watchful
      • Lacks adult supervision
      • Is overly compliant, passive, or withdrawn
      • Comes to school or other activities early, stays late, and does not want to go home

    These are the signs in a child that may signal child abuse or neglect. They show sudden changes in behavior or school performance. They were a wonderful student and now they are not. They have not received help for a physical or a medical problem that has been brought to the parent's attention. They have learning problems or difficulty concentrating in the classroom that cannot be attributed to a very specific physical or psychological cause. Or, maybe that child is always watchful as though they are always preparing for something bad to happen. They are looking for that other shoe to drop or looking over their shoulder. They lack adult supervision when they are not of an age to be unsupervised. They are overly compliant or very passive or withdrawn. They say yes ma'am or no sir to all requests. They come to school or to other activities early, they stay late, and they do not really want to go home when it is time for dismissal.

    • The Parent:
      • Shows little concern for the child
      • Denies the existence of—or blames the child for—the child’s problems in school or at home
      • Asks teachers to use harsh physical discipline
      • Sees the child as entirely bad, worthless, or burdensome
      • Demands a level of physical or academic performance the child cannot achieve
      • Looks primarily to the child for care, attention, and satisfaction of emotional needs

    This parent shows little concern for the child. They pass off some of the things that are happening with their child as not being important. They deny the existence of or even blame the child for the child's own problems in school or at home. They ask a teacher or a caregiver to use harsh physical discipline if that child misbehaves. It is okay to do X, Y, and Z if the child misbehaves. "This is what we do at home." They see the child as bad, worthless, or burdensome. They demand a level of physical or academic performance that the child cannot possibly achieve. This is different from encouraging them to be a better student or athlete. This is forcing something that they could not possibly achieve or do not have the physical or mental capacity to do. They look at the child primarily for care, attention, and satisfaction of their own emotional needs rather than providing the care to the child for the child's needs.

    • The Parent and Child:
      • Rarely touch or look at each other
      • Consider their relationship entirely negative
      • State that they do not like each other

    We can also look at the parent and child dyad together. They rarely touch each other or look at each other. You do not see that bond or connection between the two of them. They consider their relationship entirely negative, and they may just flat out state that they do not like each other and truly mean that. We talked about the types of maltreatment that are generally defined in the state statute, and now, we are going to go through now some of the signs that are associated with the types of child abuse and neglect. It is important to note however that these types of abuse are typically found in combination rather than alone.

    You will not typically just see physical abuse without also some sort of emotional or mental anguish as well. For example, a child who is sexually abused may also be neglected. You want to look for these in combination and look for some of those signs. And again, a lot of these are going to be very similar to what we just talked about with elder abuse. 

    Physical Abuse

    • Has unexplained burns, bites, bruises, broken bones, or black eyes
    • Has fading bruises or other marks noticeable after an absence from school
    • Seems frightened of the parents and protests or cries when it is time to go home
    • Shrinks at the approach of adults
    • Reports injury by a parent or another adult caregiver

    They may have unexplained burns, bites, bruises, broken bones, and black eyes. They may be consistently in the emergency room for some sort of treatment. They have fading bruises or other marks that are noticeable after an absence from school. They seem frightened of the parents. They protest or they cry when it is time to go home. They shrink at the approach of an adult and are wary of adults who are around them. They report injuries by a parent or another adult caregiver, or they report an injury and the explanation of that injury is just not plausible. The proverbial "I fell down the stairs" type of excuse.

    • Consider physical abuse when the adult:
      • Offers conflicting, unconvincing, or no explanation for the child’s injury
      • Describes the child as “evil,” or in some other very negative way
      • Uses harsh physical discipline with the child
      • Has a history of abuse as a child

    We might want to consider physical abuse if they are offering conflicting, unconvincing, or no explanation for the child's injury. "have no idea how that happened." Or, "Don't worry about it. It's no big deal." They describe the child as evil in some way, or they are very negative in their description of the child. They use harsh physical discipline with the child even when it is not warranted. Another one is that they themselves may have a history of abuse as a child. 

    Neglect

    • The child is frequently absent from school
    • Begs or steals food or money
    • Lacks needed medical or dental care
    • Is consistently dirty
    • Lacks sufficient clothing for the weather
    • Abuses alcohol/drugs
    • States that there is no one at home to provide care

    You want to consider the possibility of neglect when the child is frequently absent from school again without a reason. This is when they are not on vacation, not sick and at the physician, and not visiting their grandparents. They may beg or steal food in the cafeteria. They may lack the necessary medical or dental care that they should be having at their age. They may not have their immunizations not necessarily related to the opinions of the parent but because the parent refuses to give them. Maybe they need glasses, but they do not have glasses. They are consistently dirty and do not look well-kept. They have severe body odor or their hair is very dirty. They may have consistent issues with lice or other types of bugs. They may lack sufficient clothing for the weather, again very similar to elder abuse. It is cold outside but they do not have a coat. It is raining but they do not have anything to protect them from the elements. The child may be abusing alcohol, drugs, or other things more consistent in an older child. They may state that there is no one home to provide care for them. They may say, "I cook my own meals all the time." Another clue is, "I take care of a younger sibling." 

    • Consider neglect when the adult:
      • Appears to be indifferent to the child
      • Seems apathetic or depressed
      • Behaves irrationally or in a bizarre manner
      • Is abusing alcohol or other drugs

    You also want to consider the possibility of neglect again when we look at the parent or the adult caregiver and they are indifferent to that child. They are apathetic and do not seem to care. They themselves are depressed and not in a position to care appropriately for that child. They behave irrationally or in a bizarre type of manner. Or, they may be abusing alcohol or other drugs themselves.

    Sexual Child Abuse

    • Has difficulty walking or sitting
    • Suddenly refuses to change for gym
    • Reports nightmares or bedwetting
    • Experiences a sudden change in appetite
    • Demonstrates bizarre, sophisticated, or unusual sexual knowledge
    • Becomes pregnant or contracts a venereal disease
    • Runs away
    • Reports sexual abuse by a parent or another adult caregiver

    Consider the possibility of sexual child abuse when that child has difficulty walking or sitting. You see that they have pain in their genital area. It is observable that they are very uncomfortable. They suddenly refuse to change for the gym, participate in physical activities, or maybe participate in your treatment session. They may report having nightmares or bedwetting. Their appetite may have gone down or up, and they may also have sleep disturbances. They have bizarre, sophisticated, or even unusual sexual knowledge or behavior for their age. Things that they should not know but they do. They may become pregnant or have a sexually transmitted infection, particularly at younger ages. They run away or they report some sort of sexual abuse by a parent or another adult or caregiver. You have to take these comments very seriously. 

    • Consider sexual abuse when the adult:
      • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex
      • Is secretive and isolated
      • Is jealous or controlling with family members

    We also want to consider the possibility of sexual abuse when the parent, adult caregiver, or older sibling is really protective of that child. This severely limits the child's contact with other children or other individuals, especially of the opposite sex. They are secretive and isolated. They look like they have an unhealthy type of family bond. They are very jealous and controlling with other family members.

    Emotional Maltreatment

    • Shows extremes in behavior
    • Is either inappropriately adult or inappropriately infantile
    • Is delayed in physical or emotional development
    • Has attempted suicide
    • Reports a lack of attachment to the parent

    Signs of emotional maltreatment is when you see a child showing extremes in behavior. They may be overly demanding, extremely passive, or extremely aggressive. They are either inappropriately adult-like or infantile as examples. They may be delayed in their physical, emotional development, and cognitive development. Perhaps, they have attempted suicide or have even talked about suicide. They feel like their life is not worthy or unsatisfactory. They may report a lack of attachment to the parent. If we interact with that parent or caregiver, we may see that the adult constantly blames, belittles, or berates that child. They are really unconcerned about the child, their whereabouts, their well-being, and those sorts of things. They do not consider the offers of help for the child's problem. 

    How to Report Suspicions

    • Suspected Child Maltreatment
      • If in serious danger, call 911
      • National and local resources are available to provide assistance and information about reporting suspected maltreatment.
    • Suspected child abuse or neglect?
      • Contact your local child protective services office or law enforcement agency
      • Know the statutes if you are a mandatory reporter

    If you see suspicions, what do you do? If you or someone else is in immediate danger, call 911. That is the best thing to do because there are both national and local resources that are available to provide immediate assistance to that child and family. You would want to report that information about suspected maltreatment. Again this is very state-specific, but at a bare minimum, you would contact your local Child Protective Services office or law enforcement agency. If you are a mandatory reporter in your state, you are going to need to know what their requirements are. I can tell you that I am licensed in a couple of states, and I look at my licensing requirements. There are very specific rules that you need to follow about timeframes, phone calls, and specific people to contact. Unfortunately, in the scope of this presentation, we cannot go into that level of detail, but you need to know what the statutes are for your specific state. 

    Who Can Report?

    • Anyone can report suspected child abuse or neglect
    • All U.S. States and territories have laws identifying mandatory reporters
    • Mandatory reporters may include social workers, teachers, and other school personnel, childcare providers, physicians, and other health-care workers, mental health professionals, and law enforcement officers

    Again all states have laws that identify persons who are mandatory reporters like social workers, teachers, school personnel, childcare providers, physicians, mental health professionals, and law enforcement officers. They are all identified in those state statutes, However, any person who suspects child abuse and neglect can and should report.

    What Happens Next?

    • Report a complete, honest account of what you observed that led you to your suspicion. Any reasonable suspicion is sufficient.
    • Reports are sent to child protective services (CPS) for review
    • If an investigation is deemed needed, CPS may talk with the family, the child, or others to help determine what is making the child unsafe
    • For more information about where and how to file a report, contact your local child protective services agency or police department

    You need to provide a completely honest account of what you observed that led you to suspect the occurrence of child abuse or neglect and any reasonable suspicion is sufficient. Do not make up details or leave out details - be clear, be honest about what you saw, what you heard, or what you observed. Do not base that on hearsay. It should only be based on your own report. This report is going to be sent over to Child Protective Services or CPS for review. Generally speaking, again for states, when they receive that report, the worker will review the information and determine if an investigation is necessary. That CPS worker may talk to the family, the child, or other individuals to help determine what possibly is making this child unsafe. They can also help parents and other caregivers get services, get an education, and get other assistance to help them through the situation. 

    Resources

    • Childhelp National Child Abuse
      • Call or text 1.800.4.A.CHILD (1.800.422.4453). Professional crisis counselors are available 24 hours a day, 7 days a week, in over 170 languages.
    • National Center for Missing and Exploited Children’s Cyber
      • Report online sexual exploitation of a child or if you suspect that a child has been inappropriately contacted online

    There are national resources that are available. For the Childhelp National Child Abuse resource, there are professional crisis counselors there 24 hours a day, seven days a week available in 170 different languages. Every call that is placed is completely confidential, and the hotline offers things like crisis intervention, information, referrals out to other emergency services, social services, and other sorts of resources that are available in the community. There is also the National Center for Missing and Exploited Children's Cyber. This is an online reporting if you suspect any sort of sexual exploitation of a child, and that would include human trafficking. You can also report if you suspect that a child has been inappropriately contacted online. Information again is made available to law enforcement in order to conduct that investigation.

    Here are two resources for your states. The first one is the state statutes for Child Protective Services, and the second is the state reporting phone numbers. Now, these are not necessarily the end all be all. Again go back to your Practice Act, your licensure, etc. But, these are some good starting points so that you can start to read about what is required.

    Citation

    Weissberg, K. (2021). Elder abuse and child abuse: Know the signs and your role. Continued - Respiratory Therapy, Article 37 (originally published on OccupationalTherapy.com, 2019). Available at www.continued.com/respiratory-therapy

    Oct 10, 2019

    1 CE Hour

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