access to services, adherence to recommended treatment regimens, continuity of care, preventive care, screening practices, patient-clinician communication, immunization rates, and prescription practices (Flores, 2000).

Patient diversity occasions the need for cultural and linguistic competence. Such competence involves the knowledge and interpersonal skills that allow clinicians to understand and respond effectively to individuals from cultures and backgrounds other than their own (Campinha-Bacote, 1998, 1999). Culturally influenced definitions of abuse may influence patients’ and also clinicians’ expectations concerning interventions around family violence in the health care setting. When the health care professional does not speak the primary language of the patient, difficulty with identifying and intervening in family violence increases. For abused individuals with limited English proficiency, the use of family members as interpreters can present particular barriers to disclosure, confidentiality, assessment, reporting, safety, and referral. In addition, the health care professional’s own cultural background and social class may influence the clinical care that is provided to patients experiencing family violence and their families. An understanding of the sociocultural backgrounds of individual patients and of their physical, cultural, social, and community environments is crucial to addressing family violence; therefore, clinicians who have limited cultural and linguistic competence also may have limited effectiveness in the assessment and management of family violence patients (Campbell and Campbell, 1996; Bell and Mattis, 2000).

Various ethnic groups comprise a large percentage of the American population. For example, in California, New Mexico, and Hawaii, “minority” groups make up more than 50 percent of the population (U.S. Census Bureau, 2000). These changing demographics pose a challenge to practitioners involved in offering services to abused immigrants. Victims of family violence who have immigrated illegally or who have recently relocated to the United States as refugees are in a particularly problematic situation, since their predominant fear of deportation may prevent them from contact with appropriate helping agencies, either governmental or private (Gelles, 1997; McGoldrick et al., 1996).

Of particular relevance to health care professionals, cultural practices can be mistaken for abuse, especially in the pediatric population (Bullock, 2000, 2001). For example, cupping or spooning (a method used to treat upper respiratory infections that leaves discrete markings on the skin) and certain treatments for empacho (a gastrointestinal illness) can be misunderstood by Western practitioners and labeled as abuse. A culturally sensitive physician familiar with some of these indigenous therapies may be able to address these issues, educating parents about negative effects on health, rather than reporting abuse.

Beyond these issues of ethnic cultures, community cultures may also create difficulties for health professionals. Family violence within rural, remote, or wilderness communities may present challenges distinct from those in urban settings. Although studies have shown that rates of abuse may be the same,



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