Vol 3 No 1 - May 2015

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International
Journal of
Humanities &
Social Sciences
Vol. 3, No. 1
IJHSS.NET
e-ISSN: 1694-2639
p-ISSN: 1694-2620
May 2015

Vol 3, No 1 – May 2015
Table of Contents
A solution for great peace in agape of Luke’s gospel 1
Younghoon Kim (Ph.D)
Measuring and assessing gender violence 9
Fred Spiring, Ph.D., P. Stats.
A framework for mainstreaming patient-centered communication in
community-based healthcare organizations
28
Dr. Dina Refki, Dr. Stergios Roussos and Dr. Grace Mose
Effective Teaching in History: The Perspectives of History Student-
Teachers
38
Gideon Boadu
AAJHSS.ORG

1 http://aajhss.org/index.php/ijhss
International Journal of Humanities and Social Sciences
p-ISSN: 1694-2620
e-ISSN: 1694-2639
Volume 3, No 1, pp. 1-8, ©IJHSS
A solution for great peace in agape of Luke’s gospel
Younghoon Kim1
(Ph.D)
Korea University
Seoul, Korea
Abstract
Agape is the core emphasis in Jesus‟ teaching in New Testament. Jesus usually taught his
disciples, Jews, and others agape. The important teaching of agape is to love and forgive
neighbors who were Jews, Christians, Romans, and even disciples each other. However, Luke
different from Matthew, Mark and John used agape in his unique reason. Luke made his writings
from sources different from other gospels. What was different from other gospels? Why did
Luke use them in different context? First of all, important words were taken in Luke‟s gospel. It
informs the reason why agape was different in Luke‟s gospel through researching. In doing so, it
shows intention of Luke which is educational meaning of agape for solving conflicts with peace
in Jesus‟ days.
Keywords: agape, teaching, neighbors, forgiveness, peace.
Introduction
With development of high technology in contemporary society, it looks like living in more
convenience and comfort than old ages. However, it is easy to access to look at wars,
disagreements, and conflicts in mass media such as T.V., radio, newspaper, internet, and etc. In
some cases, it is hardly to solve the problems. Likewise, it was some disagreement and conflict in
Jesus days. They were kinds of religious, racial, and sex conflicts. The paper introduced that
agape of Jesus could be one of great solutions especially in Luke‟s gospel.
There are 122 agapes in New Testament. Among these, 66 agapes are in four gospels.
There are 9 in Matthew, 5 in Mark, 13 in Luke, and 39 in John (Morrison, 1979). It shows that
the use of agape is more than half in four gospels. Even though John used the word agape much
more than in Luke‟s gospel, it is a little different from John‟s gospel. Luke different from other
gospels was interested in society. Luke concerned especially the weak of his community more
than John‟s gospel. The paper studies Luke‟s social interesting with agape. It also researches how
different agape was in Luke from Matthew and Mark. It focuses on the author‟s interesting of
Luke‟s gospel and why Luke used agape in educational situation as well. In fact agape which Jesus
emphasized to his disciples and people was the best lesson in Jesus teachings. Jesus did not teach
agape to his disciples simply, but purposed it as an intended word for solving social problems in
Luke‟s gospel. It shows that the lesson which Jesus taught for agape is the meaning of education
for his disciples and those who followed Jesus at that time for peace between them, and it would
1
Younghoon Kim is a Research Professor in Research Institution of Education, Korea
University in Seoul, Korea. His research interest is educational philosophy in east and west, and
comparative study between Christianity and other religions in education.

even give some valuable teaching to us for great peace in nations and others nowadays.
Purpose of the study
The purpose of the current research was to investigate why Luke used agape in different story
and circumstance from other gospels. The intention of using agapes was analyzed in the current
research.
Methodology
It researches as following to be clear for the purpose of the paper. First of all, it studies an
analytic concordance in New Testament. It also researches theological context in four gospels
about Jesus days.
It explores paragraphs used by agapes in Luke‟s gospel. It will show what different they are from
other gospels - Matthew and Mark - such as time, place, and the purpose which each author
intended.
Analysis
Three paragraphs which include words such as agape, enemy, neighbor, and forgive were
selected. Then, they are categorized into different points from other gospels based on history,
culture, and custom between Roman Empire and Israelites.
It researches how purpose Luke used agape. It needs to study history, culture, and
custom between the Roman Empire and Israelites. It informs the reason why Jesus intended to
teach agape to his disciples and those who followed him. We also analyzed how many times
Jesus intended to teach agapes and why. It studies three important paragraphs used by agape in
Luke‟s gospel.
Discussion and result
It states that agape which was used in Luke‟s gospel was intended by educational meaning over
one of great lessens for solving conflicts in Jesus‟ days. It informs why Jesus needed educational
teaching to his disciples and people who followed him. In doing so, it shows that agape which
Jesus used to teach had the intended educational meaning especially in Luke‟s gospel.
First paragraph
This paragraph is considered as the lesson of plain because the place is on the plain. However,
Matthew used the similar paragraph on the mount. Luke different from Matthew had different
focus. Luke was interested in the word “enemies.”
“But I say to you that hear, Love your enemies, do good to those who hate
you, bless those who curse you, pray for those who abuse you. To him who
strikes you on the cheek, offer the other also; and from him who takes
away your coat do not withhold even your shirt. Give to everyone who
begs from you; and of him who takes away your goods do not ask them
again. And as you wish that men would do to you, do so to them. If you
love those who love you, what credit is that to you? For even sinners love
those who love them. And if you do good to those who do good to you,
what credit is that to you? For even sinners do the same. And if you lend to
those from whom you hope to receive, what credit is that to you? Even
sinners lend to sinners, to receive as much again. But love your enemies,
and do good, and lend, expecting nothing in return; and your reward will

be great, and you will be sons of the Most High; for he is kind to the
ungrateful and the selfish.”2
The parallel of this paragraph is Matthew 5:47-48. It is very famous for the Sermon on
the Mount to those who have read New Testament. Matthew chapter 5 begins with preaching of
the Sermon on the Mount. Matthew 5:47-48 placed in it. The contents of the Sermon on the
Mount were Jesus‟ useful teaching about the law, anger, adultery, divorce, oaths, retaliation, and
even love for enemies. According to Matthew chapter 5 especially Matthew 5:47-48, Jesus‟
sermon looked so typical such as other teachings. However, as for love for enemies in Luke, it
looks that Luke purposed something special for educating his disciples. Luke chapter 6 starts that
disciples ate ears on Sabbath. And then Jesus taught and worked on Sabbath, and Jesus selected
12 disciples, and then Jesus preached sermons called “plain lesson” with the golden rule. Among
sermons, Luke used the lesson of agape. As for the place of agapes, it looked that Luke had
some intention for using agape in this place. In this reason, according to Luke chapter 6, the
plain lessons of “love for enemies” could be some special purpose different from Matthew
definitely.
In Luke 6, a Greek word “exthlous” means “enemies” as plural, “eulogetei” as “bless”
and “ploseukesthe” as “pray” much more emphasize “love” as agape. Then, who were enemies?
According to plural, they could be a group or an organization other than ordinary persons
(Plummer, 1977). The expression of “enemies” could mean the group who persecuted Israelites
because of religious conflict between Roman Empire and them in those days. Therefore
Theissen (2000) stated that “enemies” could be Roman Empire or Roman soldiers. Steven M.
Bryan (2002) mentioned that Israelites was ruled by Romans after they had power of attacking
Macedonia. Roman Empire served many gods and wanted Jews to take the emperor like their
God. However, Jews did not like to do that. Although Romans did not totally interfere with
religious practices, sometimes they did, and then Jews would rebel against it (Justo, 1984). Jews
had always hoped to recover their political power with their religion in Israel. It was firmly
rooted on the words of Bible. They had waited their religious leader eagerly who will recover
Israel (Isaiah 29:18-19; 35:5-6; 61:1). So Jews were very anxious to restore their politic authority
including religious power. Although zealots insisted violence to resist it, Jesus taught them
nonviolence especially to his disciples (Cassidy, 1978). As a matter of fact his disciples very
wanted that Jesus would recover Israel politically and religiously from Roman Empire. However,
Jesus came out the nonviolent person to Roman Empire or others. In fact nonviolence is against
violence and would expect the change of action in the other parts for nonviolence.
In Luke 6:12-19, Jesus took Simon named Peter who was one of zealots. After selecting
his disciples, he taught nonviolence lessons to them. Why did Jesus teach it to them? Actually
nonviolence makes people avoid violent action. In addition, nonviolence attitude to Roman
Empire was one of good ways for coexistence between Christians and Romans (Rowe, 2005). In
doing so, Christians could stay peace with Romans. This makes naturally Romans contact the
gospels of Bible as well. Therefore agape which Jesus taught to his disciples is not simply the
lesson for loving people but intended one for peace with Romans and Christian mission.
Accordingly agape could include educational meaning for peace with Romas in Luke‟s gospel. If
Christians would not stay peace with Romans, Roman Empire would attack or persecute Jews
definitely and they would not have attention of the gospel which Christians introduce them as
well. Therefore, Jesus selected his disciples including Peter as a zealot. Then Jesus purposed to
show his purposed teaching as loving enemies in Luke‟s gospel. It is much more than simple
lessons. It is religious and educational teaching for his disciples very clearly for survival.
2
Luke 6:27-31.

Especially Jesus used golden rule which was usually used in bad relation with business and
friends in those days with agape (Kirk, 2003). Jesus must have wanted that Christianity was not
against Roman Empire and to stay peace with them. Wink (1970) mentioned that the nonviolent
teaching of Jesus to his disciples makes Romans themselves know that the persecution to
Israelite was not proper and they have open mind to Christians and even Jews.
Agape of Jesus is one of religious and ordinary lessons in Christians and even not involved
people of Christianity. Matthew, Mark, and John used agape in meaning of loving neighbors on
usual teaching of Jesus. However, Luke used the usual agape lesson as special educational
purpose for peace and mission with Romans. It is not only religious goal but also survival.
Second paragraph
Luke different from other gospels had different thought of neighbor. In this paragraph, Jesus
informed the meaning of neighbor as the story of Good Samaritan.
“And behold, a lawyer stood up to put him to the test, saying, “Teacher,
what shall I do to inherit eternal life?” He said to him, “What is written in
the law? How do you read?" And he answered, “You shall love the Lord
your God with all your heart, and with all your soul, and with all your
strength, and with all your mind; and your neighbor as yourself.” And he
said to him, “You have answered right; do this, and you will live.” But he,
desiring to justify himself, said to Jesus, “And who is my neighbor?” Jesus
replied, “A man was going down from Jerusalem to Jericho, and he fell
among robbers, who stripped him and beat him, and departed, leaving him
half dead. Now by chance a priest was going down that road; and when he
saw him he passed by on the other side. So likewise a Levite, when he came
to the place and saw him, passed by on the other side. But a Samaritan, as
he journeyed, came to where he was; and when he saw him, he had
compassion, and went to him and bound up his wounds, pouring on oil
and wine; then he set him on his own beast and brought him to an inn, and
took care of him. And the next day he took out two denarii and gave them
to the innkeeper, saying, „Take care of him; and whatever more you spend,
I will repay you when I come back.‟ Which of these three, do you think,
proved neighbor to the man who fell among the robbers?” He said, “The
one who showed mercy on him.” And Jesus said to him, “Go and do
likewise.”3
This paragraph was traditionally famous for the great commandment by Jesus. The
parallels of these are Matthew 22:34-40 and Mark 12:28-31. The contents of Matthew and Mark
were very similar. It is that Sadducees came to Jesus and discussed about resurrection. It was
followed by the great commandment. A lawyer asked Jesus “Teacher, which is the great
commandment in the law?” and then Jesus answered “love the Lord thy God with all thy heart,
and with all thy soul, and with all thy mind.” However, unlike Matthew and Mark, there was no
discussion of resurrection in Luke. A lawyer asked to Jesus “Teacher, what shall I do to inherit
eternal life?” and then Jesus said to him, “What is written in the law? How do you read? And he
answered, you shall love the Lord your God with all your heart, and with all your soul, and with
all your strength, and with all your mind; and your neighbor as yourself.” In Luke the lawyer
asked how to inherit eternal life, and then Jesus answered the great commandment. It was very
different from Matthew and Mark. In addition, the lawyer asked “who is my neighbor”, and then
3
Luke 10:25-37.

Jesus mentioned the story of Good Samaritan as the example of agape. Actually this story
appeared only in Luke. Therefore it was generally accepted as the special source of Luke. Even
though it shows what is living with agape, the story has over meaning for loving neighbor.
Definitely, it is the lesson for loving neighbor by Jesus (Sprinkle, 2007). However, it is not easy
to understand that the story looks a simple lesson for loving neighbor because it is very difficult
to accept the story normally. A man faced with difficulty due to robbers, but both a priest and a
Levite were going down that road. In those days, they were high class persons in Jewish religion.
In addition it is guessed that they were respected by people. However, they just passed by the
person who had difficulty. Unlike them, a Samaritan helped him. This story is strange very much.
If the person who helped him was the priest or the Levite, it would be so natural. As we know,
those who have lots of wealth and things could help those who need help. It is very curious why
did Luke show the story different from Matthew and Mark? Reinstorf (2002) stated that Luke
would expect that the story of Good Samaritan would give the lesson for practicing agape with
Jews as loving neighbor. However, Luke had another purpose for the story. In Bible the
relationship between Jews and Samaritans came from Old Testament. After the death of the king
Solomon, Israelite was separated as north and south in 8 B.C. Then Assyrian Empire attacked
the north and ruled it, and then there were international marriages between them. This marriage
started to make a kind of tension between south and north. According to Bible, Jews were
prohibited that they have other religions in the law. In addition some people in north had
different God in Assyrian Empire other than God in Bible. It resulted in conflict between north
and south because north did not keep the first commandment in Law (Esler, 2000). Besides,
Samaritan worshiped for Zeus Xenios as Greek god in welcoming ceremony in Gerizim temple.
It made that the relation between them was getting worse (Thornton, 1996). For example
Matthew10:5-6 “These twelve Jesus sent out, charging them, go nowhere among the Gentiles,
and enter no town of the Samaritans, but go rather to the lost sheep of the house of Israel.”
When Jesus sent his disciples for mission, he said “don‟t go to town of the Samaritans.” It shows
that there was still some conflict between them in those days. If the Good Samaritan story was
intended just as loving neighbor, the priest or the Levite would help him who needed help.
However Luke used the Good Samaritan story to explain “who is neighbor?” with agape of
loving neighbor. Here, it shows that Luke had another purpose with the Good Samaritan story.
Stein (1981) introduced two kinds of Good Samaritan stories adapted from original one. It is a
brief summary. First, he informed the Cotton Patch Version of Luke and Acts of Clarence
Jordan. It is Good Samaritan story adapted from the Bible to help Black-American to easily read.
When a man was going from Atlanta to Albany, a few robbers blocked and hit him. A white
preacher passed by on the other side. And then, a white leader of church choir passed by on the
other side as well. This story shows to replace the priest and the Levite into the white preacher
and the white leader of church choir. Therefore, it is not that Luke informed simple agape as
loving neighbor but that Luke intended a solution in tension and confliction between Jews and
Samaritan. In the Good Samaritan story Jesus taught a lawyer what is true neighbor? And what is
agape? Luke purposed to teach true meaning of neighbor and agape as loving neighbor. True
neighbor is not simply thinking what is a law? but keeping and practicing the law (Sprinkle, 2007).
As a matter of fact Samaritan was always hurt by Jews. It is natural that Samaritans have to
receive care and love by others. However, it is the Samaritan who helped him. Therefore, it
shows that true agape is to first open others. In the same manner, the confliction between White
and Black people in America was very severe. Black people were always hurt, hit, and persecuted
by White people. However a Black one helped the person who really needed help.
In addition, Stein introduced another Good Samaritan story. When a man was going to
attend politic meeting for Hitler from Berlin to Frankfurt, he was attacked by robber. And then,
a high executive of Nazi passed by on the other side. A pastor of Lutheran Church also passed
by on the other side. However, a Jew found and helped him. It means that Good Samaritan story

is not simple lesson for loving neighbor. The story shows the lesson of solution in strong
confliction between Nazi and Jews. As we know Jews was severely persecuted by Nazi at that
time. However a Jew opened his mind to apology, and helped others as agape. Therefore the
clauses of Luke were not simple lesson but good teaching of true agape. Furthermore it means
that Luke wanted agape with educational meaning over loving neighbor through Jesus
(Longenecker, 2009).
The three gospels Matthew, Mark, and John except Luke used agape in ordinary meaning
of loving neighbors on usual teaching of Jesus. However, Luke used agape lesson into more
specialized educational purpose for peace between Jews and Samaritans. It shows not only peace
between Black and White people but also true forgiveness to assailants who are never forgiven.
Third paragraph
In this paragraph, Luke is interested in forgiveness to a woman specially. Furthermore, the
intention of Luke was focused on sex discrimination in Jesus days.
“One of the Pharisees asked him to eat with him, and he went into the
Pharisee's house, and took his place at table. And behold, a woman of the city,
who was a sinner, when she learned that he was at table in the Pharisee's
house, brought an alabaster flask of ointment, and standing behind him at his
feet, weeping, she began to wet his feet with her tears, and wiped them with
the hair of her head, and kissed his feet, and anointed them with the ointment.
Now when the Pharisee who had invited him saw it, he said to himself, “If
this man was a prophet, he would have known who and what sort of woman
this is who is touching him, for she is a sinner.” And Jesus answering said to
him, “Simon, I have something to say to you.” And he answered, “What is it,
Teacher?” “A certain creditor had two debtors; one owed five hundred
denarii, and the other fifty. When they could not pay, he forgave them both.
Now which of them will love him more?” Simon answered, “The one, I
suppose, to whom he forgave more.” And he said to him, “You have judged
rightly.” Then turning toward the woman he said to Simon, “Do you see this
woman? I entered your house, you gave me no water for my feet, but she has
wet my feet with her tears and wiped them with her hair. You gave me no
kiss, but from the time I came in she has not ceased to kiss my feet. You did
not anoint my head with oil, but she has anointed my feet with ointment.
Therefore I tell you, her sins, which are many, are forgiven, for she loved
much; but he who is forgiven little, loves little. And he said to her, “Your sins
are forgiven.” Then those who were at table with him began to say among
themselves, “Who is this, who even forgives sins?” And he said to the
woman, “Your faith has saved you; go in peace.”4
The paragraph appears in Matthew 26:6-13 and Mark 14:3-9. It placed in similar sequence.
The chief priests and the elders of people discussed about arresting Jesus. When a woman
poured an alabaster cruse of ointment, disciples discussed regarding acting Jesus. Then Judas
Iscariot who was one of 12 disciples delivered Jesus to the chief priests. However, Luke placed
this in chapter 7 which is in plain lesson. The similar story of Matthew and Mark is in Bethany, in
the house of Simon the leper. In case of Luke, this is in one of Pharisees. Therefore it means that
Luke used this in different situation from Matthew and Mark. As for contents, there were some
different parts. In case of Matthew and Mark, when a woman poured, disciples said that this
4
Luke 7:36-50.

ointment might have been sold and given to the poor. But Luke did not use the expression. In
Matthew and Mark, Jesus said that wherever this gospel shall be preached, the woman shall be
spoken for memorial of her. On the other hand, there is no word like this in Luke. According to
these facts, Matthew and Mark, they focused on pouring ointment, but Luke was interested in
forgiveness of her with agape.
A woman who was a sinner wanted to pour the ointment to Jesus. As a matter of fact
there was a law - if you contact with a sinner even chatting with him, you would be a sinner. A
Pharisee was simply looking at how Jesus would do with the woman. However, Jesus knew what
he thought through seeing him and showed him agape which is in forgiveness for great harmony.
Jesus did not discuss about what is right or not about laws. Rather Jesus taught audiences to
forgive her as agape. Furthermore Jesus even loved her truly as agape (Crabbe, 2011). Fitzmyer
(1981) mentioned that Luke added 7:44-47 and purposed to emphasize the act of forgiving the
sinner. Therefore it is clear that Luke intended that Jesus taught agape for great harmony to his
disciples and others as an educational meaning which you have to love and forgive others.
It is very obvious that Luke showed this story with another purpose. In those days,
females did not receive right equally in the society of Jews and the early part of Christianity. In
Exodus 20:17 “You shall not covet your neighbor's house; you shall not covet your neighbor's
wife, or his manservant, or his maidservant, or his ox, or his ass, or anything that is your
neighbor's.” In this clause, female was thought by one of things as property. Jeremias (1969)
mentioned that females could not attend official meetings. When a female went also out, she
must take a veil. The status of female was much less than male in those days very clearly.
Therefore the different purpose of Luke was going to give the solution regarding discrimination
between male and female to audiences in Jesus‟s days.
In addition, Cosgrove (2005) stated that the woman was not a usual sinner in Luke. He
insisted that she had long hair. It would symbolize the meaning of sexual intercourse. So he
guessed that the sin of the woman would be adultery. As a matter of fact Jesus was born in
authenticity of Jews and respected by people in those days. When he was invited by a Pharisee,
he contacted with the woman who was the sinner. Simon saw it and wanted to point out her
fault. However, Jesus knew his thought and taught the true meaning of agape to him. It showed
that the law of love and forgiveness is greater than Jew‟s law. Flender (1967) mentioned that this
story is teaching for disciples to respect the repressed woman at that time. Unlike Matthew and
Mark, Luke showed that agape was over simply forgiving sinners and had the great power for
harmony. Luke purposed to show the power of agape and to overcome discrimination between
female and male in Jesus‟ days as well. Luke was interested in the weak in Jesus‟ days very much.
He saw the story in another angle and informed the solution of social problems in those days. It
was educational meaning for Jesus‟ disciples and people.
Although three gospels Matthew, Mark, and John also introduced the woman, they did not
emphasize her as the sinner. However, Luke used agape lesson not only in ordinary meaning of
loving neighbors but also in educational teaching for great harmony intended by Luke. It is very
obvious intention in educational teaching.
Conclusion
Agape is the best teaching of Jesus such as loving neighbors and forgiving enemies in
New Testament. However, Luke used agape in different story and circumstances as Jesus‟
teaching. Luke made his writings from other sources and intended agape with his special purpose.
It showed how the author of Luke used agape different from others for peace. The reason is that
agape would be the good way of teaching and learning for solving strong disagreements with

peace. Therefore agape in Luke was not a simple lesson but the word with educational meaning
for great peace and harmony even in contemporary society with social problems between black
and white, male and female, and etc.
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p-ISSN: 1694-2620
e-ISSN: 1694-2639
Measuring and assessing gender violence
Fred Spiring, Ph.D., P. Stats.
Statistical Research Officer
Bureau of Women’s Affairs
Office of the Prime Minister
5-9 South Odeon Avenue
Kingston, JAMAICA
Abstract
As Jamaica moves through implementation of their National Policy on Gender Equality (NPGE)
and develops harassment legislation, there is a need to be able to identify and assess the impact
of such programs and initiatives. In addition Funding Agencies are increasingly requiring
evidence that developed initiatives are reaching their target audience and are having a measurable
impact. With the assistance of the Jamaica Constabulary Force, procedures for monitoring and
assessing Violence, Gender Based Violence, Domestic Violence and Intimate Partner Violence
are proposed and illustrated.
Keywords: Gender Based Violence, Domestic Violence, Intimate partner Violence
Introduction
The current mission of Jamaica’s Bureau of Women’s Affairs (BWA) is “To enable women to
achieve their full potential as participants in Jamaica’s social, cultural and economic development
and with equitable access to benefits from the country’s resources”. The BWA seeks to carry
out this objective through Policy Development, Analysis, Research, Documentation, Project
Planning, Monitoring, Public Education and Community Outreach.
In order to assess and monitor the impact of legislation, policies, programs and initiatives
quantitatively, it is necessary to first develop procedures for measuring the processes of interest.
Recently a huge outcry from the Jamaican public and media saw a call for action to reduce the
frequency of violent acts. Several recent cases (Jamaica Observer (2012), The Gleaner (2012))
mobilized the public to call for action in preventing future rape and murder incidents. Many
Government Agencies as well as NGOs promoted various actions or interventions in response.
Calls for action were wide spread across Jamaica, all having the public’s safety of primary
importance.
One such call was for a mechanism to measure, monitor and assess violence. In this
manuscript we develop a mechanism for measuring violence, illustrate processes for gathering
the data and conclude with two examples of assessing, monitoring and triggering an intervention.
In both examples, data from Jamaica’s Constabulary Force (JCF) are used to illustrate the value
in having a formal measuring technique for violence, as well as monitoring quantitatively the
impact of programs set in place to reduce the frequency and impact of violence in Jamaica. In
both examples victim data is used to signal the need for attention and to assess the impact of the
actions. Perpetrator and geographic profiles are then used to identify potential strategies
designed to reduce the frequency of violence.

Violence Performance Indicators
Currently the most comprehensive set of violence performance indicators (PI) are those
proposed by the “Friends of the Chair” (United Nations Economic and Social Council (2008))
and involve four types of violence including Physical, Sexual, Economic and Psychological. We
propose a hybrid version of the “Friends of the Chair” performance indicator that reads as
follows:
[a] The total number & age-specific rate of men and women subject to violence in the last 12 months by type,
severity, relationship to perpetrator and frequency, where the types of violence include Physical, Sexual,
Psychological and Economic; Severity includes moderate and severe; Relationship to perpetrator includes
intimate, other relative, known person, stranger, state authority; and Frequency includes one, few or many
times;
And
[b] The total number & age-specific rate of men and women subject to violence over their lifetime by type,
severity, relationship to perpetrator and frequency, where the types of violence include Physical, Sexual,
Psychological and Economic; Severity includes moderate and severe; Relationship to perpetrator includes
intimate, other relative, known person, stranger, state authority; and Frequency includes one, few or many
times.
Following this definition of Violence, Figure 1 illustrates through the use of a Venn diagram, the
relationship of the four violences with respect to women and men. In this case we have broken
down violence into that against women and men and then further suggest that all four types of
violence (Physical, Sexual, Economic and Psychological) occur for both female and male victims.
Figure 1 does not reflect incident rates, only that males and females are potential victims of the
four violences.
Many have attempted to define Gender Based Violence (GBV) with varying degrees of
success. The Declaration on the Elimination of Violence against Women outlined in United
Nations Department of Public Information (1996) provides a definition of gender based
violence as “any act of gender-based violence that results in, or is likely to result in, physical,
sexual or psychological harm or suffering to women, including threats of such acts, coercion or
arbitrary deprivation of liberty, whether occurring in public or private life”. Unfortunately this
definition fails to consider any form of economic violence. In a similar vein, The United
Nations Secretary-General’s coordinated database on violence against women, Questionnaire to
Member States of April 2012 (United Nations (2012)) goes as far to suggest that all violence
against women is gender based. Although taking this perspective facilitates data gathering, it
does not recognize the fact that there is violence against both women and men that is not
necessarily gender based. Developing data acquisition techniques that allow for the assessment
of gender-based, domestic and intimate partner violence will, in the long term, better serve the
various users of the information. To prevent repeating problems similar to those encountered
with Millennium Development Goal 7, Indicator 7.8 the “Proportion of Population Using An
Improved Drinking Water Source” (BBC News: Science & Environment (2012)), where the
indicator was promoted as a proxy for “Access To Safe Drinking Water”, rather than strictly
“access to improved drinking water source” without a measure of water quality. It would seem
prudent to develop a measurable assessment of gender based, domestic and intimate partner
violence that would avoid this type of controversy. The development of a performance indicator
that a) is informative, b) addresses the issue directly and c) is repeatable should be the first stage
in the process.

Violence
Figure 1. Physical, Sexual, Economic & Psychological Violence Against Women and Men
We propose that Gender-Based Violence be considered to be any act of violence that is
attributable to the sex of the victim(s). This definition would include all sexual violences
including Rape, Carnal Abuse, Sex with Child Under 16, Incest, Buggery and Sexual Assault,
while also including violence against sex workers, gay bashing, with-holding of marital funds or
property, genital mutilation, neglect, emotional abuse, ... . Figure 2 is used to illustrate that
Gender Based Violence is not restricted to female or male victims and can manifest itself in any
of the four defined violences.
Against Women Against Men
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Violence
Figure 2. Gender Based Violence Against Women and Men
The United Nations Fund for Population Activities (2005) State of World Population
2005 report suggests that “Gender-based violence is perhaps the most widespread and socially
tolerated of human rights violations.” The report goes on to say that “Gender-based violence
may involve intimate partners, family members, acquaintances or strangers.” Similarly the UN
Special Rapporteur (1996) on Violence Against Women defined domestic violence “as violence
that occurs within the private spheres, generally between individuals who are related through
intimacy, blood or law.”
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Gender Based

Violence
Figure 3. Relationship of Domestic Violence to Gender Based Violence
Figure 3 captures the United Nations Fund for Population Activities (UNFPA) point
that Gender-Based Violence includes all cases of Domestic Violence, but that there are situations
where Gender-Based Violence is not considered to be Domestic Violence. Examples would
include violence against an unrelated sex worker and gay bashing. Domestic violence includes,
but is not limited to spousal/partner abuse, as violence against children and the elderly are also
forms of Domestic violence. Figure 4 illustrates this concept by including all forms of Intimate
partner violence within Domestic violence, while allowing other violence including child and
elderly abuse to be considered Domestic Violence.
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Gender Based
Domestic

Violence
Figure 4. The Relationships among Intimate Partner, Domestic and Gender Based Violence
Capturing Gender Based Violence Data
Defining the relationship among Gender-Based, Domestic and Intimate Partner Violence allows
us to then devise methods that will provide accurate, reliable data for monitoring and assessing
levels of the various violences. Unfortunately the definitions associated with the various
violences have often been manipulated to reflect the focus of a particular study or the availability
of existing data. All too frequently the assessment as to whether an incident is Domestic or
Intimate Partner violence has been left to the recording individual or agency. Cultural norms
and societal stigmas often play a role in this assessment. In many instances the onus is placed on
the victim’s first contact to assess whether or not the incident should be identified as Domestic
or Intimate Partner violence. The victim’s first contact maybe a member of the local police
force, an agency social worker or a crisis centre volunteer each with differing levels of training
and knowledge. These types of issues in turn hinder comparisons among violence indicators at
all levels including local, national and International.
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Gender Based
Domestic
Intimate Partner

Rather than asking the first contact to make a judgement, it is proposed that if the sex
and age of the victim and the perpetrator are recorded, then the relationship between the victim
and perpetrator can be used to identify the vast majority of Intimate Partner and Domestic
Violences. For those Gender-Based violences that are not considered Domestic or Intimate
Partner, input from the incident reporter may be required. In such cases the reporting person
would be asked to assess whether or not the “Root cause of the violence was Gender-based”
with possible responses being Yes, No or Unknown. If the first contact reports the incident as
Unknown and the incident is not a case of Domestic Violence or Intimate partner violence, then
as the incident proceeds through the investigation period more information may become
available. For example as the perpetrator proceeds through the court system, clearer indications
as to the motive for the violence may become evident.
Consider the following Generic reporting form (Figure 5):
Type of Violence:
Physical
Sexual
Psychological
Economic
Perpetrator: Female
Grandfather/Grandmother
Father/Mother
Stepfather/Stepmother
Partner(Spouse/Comm Law)
Ex-Partner
Boyfriend/Girlfriend
Sibling
Son/Daughter
Grandson/Granddaughter
Relative
Visiting Relationship
Friend or Acquaintance
State Authority
Other Org/Enterprise
Self
Other
Victim: Female
Root cause of the violence was Gender based: Yes
Figure 5. Generic Reporting Form
where the reporting person would include a) the type of violence by checking the appropriate
box (i.e., Physical, Sexual, Economic or Psychological), b) the sex and age of the
perpetrator/aggressor as well as the relationship to the victim and c) the sex, age and root cause
of the violence for the victim. This would allow the assessment of Domestic, Intimate Partner
and Gender Based Violence for females and males.

Figure 6. An Example of a Report indicating Domestic Violence
Consider the above report (Figure 6), where the victim of Economic violence was
identified as a 64 year old female, the perpetrator a 19 year old male and the perpetrator
relationship to the victim being Grandson/Granddaughter. The relationship of the perpetrator
to victim in the report would indicate this was a case of Domestic Violence.
In the second example (Figure 7), the victim of Sexual violence is a 38 year old female,
the perpetrator a 44 year old male and the perpetrator relationship to the victim identified as
Partner (Spouse/Common Law). Since the perpetrator relationship to the victim was identified
as Partner(Spouse/Common Law) the report would be identified as a case of Intimate Partner
Violence.

Figure 7. An Example of a Report indicating Intimate Partner Violence
Figure 8. An Example of a Report indicating Gender-Based Violence

In the third example (Figure 8) the victim of Physical Violence is a 24 year old male, the
perpetrator a 19 year old male and the perpetrator relationship to the victim being Other with
the added input that the recorder indicated the “root cause of the violence was Gender Based”,
the report would be identified as a case of Gender Based Violence, that was neither Domestic or
Intimate Partner violence.
Figure 9. An Example of a Report indicating Gender-Based Violence
In the fourth example (Figure 9) the incident was identified as a case of Sexual violence
with the victim a 15 year old female, the perpetrator a 16 year old male and the perpetrator
relationship to the victim being “Friend or Aquaintance”. The report would be classified as a
case of Gender-Based Violence, but neither Domestic or Intimate Partner violence.
In most jurisdictions, recording the age and sex of both victim and perpetrator as well as
the type of violence is already being done. The required changes are in the area of the
completeness of the perpetrator relationship to the victim. In the case of Jamaica, the Integrated
Crime and Violence Information System’s (ICVIS) Sexual Assault Form and related instructions
(see Appendix: Working Copy) currently requires that the age and sex of both the victim and
perpetrator be recorded in addition to including the relationship between the victim and
perpetrator/aggressor. The form asks that the aggressor/perpetrators be identified as:
father, mother, stepfather, stepmother, common law spouse, ex-partner, sibling, son/daughter, relative, friend or
acquaintance, other.
A minor modification to this list of aggressor/perpetrator to include:
grandparents, partner, grandchildren, girlfriend/boyfriend, relative, state authority, Other
Organization/Enterprise (e.g., community based leader, faith based leader) and stranger

would facilitate compliance with the proposed Violence Indicators. The proposed definition
would remove much of the subjectivity involved in the interpretation and classification of
Gender-based, Domestic and Intimate Partner violence.
Figure 10 illustrates where the four examples would fall when using the proposed
violence performance indicators. Recall that Example 1 (depicted as Ex. 1 in Figure 10) was
identified as a case of Domestic Violence (Economic) against a female. Example 2 was a case of
Intimate Partner Sexual Violence against a female (depicted as Ex.2 in Figure 10). Example 3
was a case of Gender-Based Physical Violence against a male (depicted as Ex.3 in Figure 10) and
Example 4 was a case of Gender-Based Sexual Violence against a female (depicted as Ex.4 in
Figure 10)
Violence
Figure 10. Relationships among Intimate Partner, Domestic and Gender Based Violence
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Gender Based
Domestic
Intimate Partner
Ex. 4
Ex. 2
Ex.1
Ex. 3

Analyzing the Performance Indicators Using Existing Data
Tables 1, 2, 3 & 4 contain the data frequencies and Figures 11, 12, 13 & 14 the frequency charts
for Physical, Economic, Sexual and Psychological violence by sex and age for 2011 in Jamaica
(Jamaica Constabulary Force Statistics and Information Management Unit (2012a), Jamaica
Constabulary Force Statistics and Information Management Unit (2012b), Jamaica Constabulary
Force Statistics and Information Management Unit (2012c), Office of the Children’s Registry
(2012)). Looking first at Physical Violence defined as the frequency of Murders and Shooting,
we can address the proposed Physical Violence performance indicator:
[a] The total number & age-specific rate of men and women subject to Physical Violence in the last 12 months
Figure 11. Frequency chart of Physical Violence Against Females and Males for 2011 by age
Figure 11 illustrates the first rising, then declining age group frequencies of Physical
Violence for both females and males for 2011. Also from Figure 11 it is clear that the Physical
Violence frequencies for males are approximately an order of magnitude (10 times) larger than
those frequencies for females. Table 1 contains the Total and Age-specific frequencies (rates) of
Physical violence for the calendar year 2011.
Table 1. Physical Violence Frequencies and Totals by sex and age for 2011
Age M F
0-4 5 5
5-9 9 4
10-14 17 3
15-19 197 29
20-24 344 40
25-29 329 45
30-34 283 37
35-39 267 36
40-44 213 27
45-49 157 26
50-54 113 21
55-59 50 11
0
100
200
300
400
500
600
700
800
900 Victims of Physical Violence
2011 M
2011 F

60-64 28 7
65-69 25 5
70-74 9 7
75-79 3 2
80-84 4 0
85-89 0 0
90-94 0 0
95-99 0 0
Unknown 854 30
Total 2907 335
Economic Violence
Next looking at Economic Violence defined as the frequency of Break-ins, Robbery and
Larceny, we can again address the proposed Economic Violence performance indicator:
[a] The total number & age-specific rate of men and women subject to Economic violence in the last 12 months
Figure 12. Economic Violence Frequencies and Totals by sex and age
Table 2. Economic Violence Frequencies and Totals by sex and age
Age M F
0-4 0 0
5-9 2 2
10-14 52 25
15-19 245 221
20-24 451 469
25-29 527 481
30-34 507 492
35-39 531 410
40-44 457 357
45-49 420 329
50-54 365 231
55-59 249 209
0
100
200
300
400
500
600 Victims of Economic Violence
2011 M
2011 F

60-64 170 106
65-69 115 59
70-74 83 48
75-79 40 25
80-84 21 18
85-89 6 10
90-94 5 2
95-99 0 0
Unknown 73 41
Total 4319 3535
Figure 12 illustrates the similar rising then declining age group frequencies of Economic
Violence for both females and males for the calendar year of 2011. Table 2 contains the Total
and Age-specific frequencies (rates) of Economic violence for the same year (2011).
Sexual Violence
Next looking at Sexual Violence defined as the frequency of Rape and Carnal Abuse/Sex with
Child under 16, we can address the proposed Sexual Violence performance indicator for females:
[a] The total number & age-specific rate of women subject to Sexual violence in the last 12 months
in the case of females and no assessment of any kind for males.
Figure 13. Sexual Violence Frequencies and Totals by age
Figure 13 again illustrates the familiar rising then declining age group frequencies for Sexual
Violence (Rape only, as Carnal Abuse/Sex with child under 16 is not yet age disaggregated)
against females in the calendar year of 2011. Table 3 contains the Total and Age-specific
frequencies (for rape) of Sexual Violence against females for the same year (2011).
Table 3. Sexual Violence Frequencies and Totals by sex and age
age 2011
0-4 2
5-9 19
10-14 211
15-19 280
20-24 127
0
50
100
150
200
250
300
0-4
five-9
ten-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
unknown
Victims of Sexual Violence 2011

25-29 63
30-34 48
35-39 14
40-44 8
45-49 14
50-54 6
55-59 2
60-64 3
65-69 4
70-74 1
75-79 0
80-84 0
85-89 0
90-94 1
95-99 0
unknown 3
Sub Total (Rape) 806
Sub Total (Carnal) 830
Total 1636
Psychological Violence
Lastly examining Psychological Violence defined as the frequency of Emotional Abuse and
Neglect, we can address a portion of the proposed Psychological Violence performance indicator
including:
[a] The total number of men and women under 18 years of age subject to Psychological Violence in the last 12
months
Figure 14. Psychological Violence Totals by sex
Figure 14 illustrates the total frequencies for Psychological Violence against females and males in
the year of 2011. Table 4 contains the Total for Psychological Violence against females and
males for the same year (2011). Note that the Psychological data is not age disaggregated at this
time.
1700
1800
1900
2000
2100
2200
2300
2400
Male Female
Psychological Violence 2011

Table 4. Psychological Violence Totals by sex
Age Male Female
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
Total 1958 2318
Emotional 351 474
Neglect 1607 1844
Unknown 125
Conclusion
Currently Jamaica’s Major Crime Reports do not include relationship to Aggressor/Perpetrator,
however the JCF acknowledges the importance of such information and has started to retrieve
perpetrator information. The Jamaica Constabulary Force Statistics and Information
Management Unit (2012b) Executive Summary on Rape addresses the issue of relationship to
perpetrator by including the information “that of the 228 rape incidents from January to April
22, 2011, approximately 167 or 73% of the offenders were known to the victims”. This is a
terrific start, however further refinement is required in order to adequately address the
perpetrator. The 73% of perpetrators known to the victim needs to be further broken down
into Grandfather/Grandmother, Father/Mother, Stepfather/Stepmother, Partner
(Spouse/Common Law), Ex-Partner, Sibling, Son/Daughter, Grandson/Granddaughter,
Relative, Visiting Relationship, Friend or Acquaintance, while the remaining 27% of perpetrators
need to be further broken down into stranger, state authority or Other Organization/Enterprise
(e.g., community based leader, faith based leader).
Once formally adopted, the revised ICVIS form (see Appendix for working copy) will form
the basis for all data acquisition involving violence in Jamaica. The associated agencies, including
the JCF and OCR, will be mandated to complete the ICVIS form in all cases of violent crime.
The goals of this manuscript were to develop a reliable, repeatable measure of violence that
includes the categories Gender-based, Domestic and Intimate Partner and to illustrate methods
for measuring and assessing violence in Jamaica. In addition the manuscript illustrated several
shortcomings in the JCF’s data acquisition which they are currently addressing. Please note that
a) data provided by the JCF comes with the warning “Figures included in this document are

subjected to change due to discoveries from on-going investigations” and b) both OCR data and
population figures for 2011 are denoted as “provisional”.
References
Jamaica Observer (2012). Horror in St. James! 8-y-o among five females brutally raped by
gunmen. Jamaica Observer, Jamaica, WI.
The Gleaner (2012). Pregnant woman shot dead in police confrontation, another injured. The
Gleaner, Jamaica, WI.
United Nations Economic and Social Council (2008). Friends of the Chair of the United
Nations Statistical Commission on the indicators on violence against women.
E/CN.3/2009/13.
United Nations Department of Public Information (1996). Women and Violence.
http://www.un.org/rights/dp1772e.htm.
United Nations (2012). United Nations Secretary-General’s coordinated database on violence
against women, Questionnaire to Member States, April, Secretary-General’s in-depth study
on all forms of violence against women. A/61/122/Add.1.
BBC News: Science & Environment (2012). Harrabin's Notes: Safe assumptions.
www.bbc.co.uk/news/science-environment-18020432.
United Nations Fund for Population Activities (2005). State of World Population, Chapter 7.
http://www.unfpa.org/swp/2005/english/ch7/.
UN Special Rapporteur (1996). Violence Against Women, its causes and consequences.
http://www1.umn.edu/humanrts/commission/thematic52/53-wom.htm .
Jamaica Constabulary Force Statistics and Information Management Unit (2012a). Age Group
and Gender for Victims of Major Crimes 2007-2011.
Jamaica Constabulary Force Statistics and Information Management Unit (2012b). Executive
Summary-Rape.
Jamaica Constabulary Force Statistics and Information Management Unit (2012c). Jamaica
Constabulary Force Annual Major Crime Statistics Review (Provisional).
Office of the Children’s Registry (2012). Statistics on the total number of reports received by the
OCR by type, gender, month and year, 2007 to 2011.

APPENDIX
Working Copy of ICVIS Sexual Assault Form

p-ISSN: 1694-2620
e-ISSN: 1694-2639
A framework for mainstreaming patient-centered
communication in community-based healthcare organizations
Dr. Dina Refki1
University at Albany, U.S.A
Dr. Stergios Roussos2
Alliance for Healthcare Research & Quality, U.S.A
Dr. Grace Mose3
Family Planning Advocates of New York State, U.S.A
Abstract
This study examines the improvement of health centers’ organizational ability to reach and serve
communication vulnerable patient populations (i.e. defined as patients who are Limited English
Proficient (LEP) and do not speak the dominant language of providers). The objectives are to
develop a Language Access Framework tailored to the needs of community-based health centers.
Outcome of the study includes a portrait of challenges and opportunities for language assistance
in community-based health centers and a replicable model for language assistance that is
applicable to similar settings. We conducted a cross-sectional study of family planning
administrators on language assistance policies, practices and programs and a quasi-experimental
study of organizational development intervention on language assistance policies, practices and
programs. The study took place in New York State from September 2009 – August 2012.
Keywords: Language Assistance, communication vulnerable patients, healthcare
Introduction
Communication Vulnerable patients are a marginalized minority in society. They face significant barriers in
accessing culturally and linguistically competent services. They are a growing segment of the population that
experience disparities. There is significant evidence that when communication is hindered because of
lack of language and cultural concordance, the ability of the healthcare system to provide quality
care to Limited English Proficient (LEP) patients is seriously compromised (Hale, 2008). Poor
communication due to language and cultural non-concordance results in lack of access to
preventive services (Derose & Baker, 2000); denial of and/or receipt of wrong benefits and
services; misunderstanding of treatment; significant delays in treatment; poor shared decision-
making; ethical compromises; difficulty obtaining informed consent, not being given all available
options for care (Commonwealth Fund, 2003); increased risks for medical errors; misdiagnoses,
legal liabilities, malpractice and negligence; compromised comprehension of required treatments
and medication instructions; decreased ability to manage chronic conditions with appropriate
1 Refki is the Director of the Center for Women in Government & Civil Society, Rockefeller College of Public Affairs &
Policy, University at Albany
2 Roussos is the Director of the Alliance for Community Research & Development
3 Mose was the Director of the Diverse Communities Health Initiative at Family Planning Advocates of New York State

follow-up care (Youdelman, 2003), and unnecessary and expensive diagnostic testing (Hampers
et. al.1999).
Moreover, women’s reproductive healthcare is highly sensitive in many cultures. Candid
discussions are often obstructed by cultural taboos. There is often a reluctance to speak about
sexual matters. Bodily exposure and touch are taboo in certain cultures (US Department of
Health & Human Services, 2000). Homosexuality and STDs are stigmatized. There are varying
views on contraceptive methods, and some cultures use traditional medicines. Women who are
survivors of rape, sexual torture and/or female genital mutilation may be reluctant to seek care
or speak openly. These are factors that may cause great complications and require effective
linguistic and cultural mediation.
The healthcare system in the U.S. struggles to provide patient-centered culturally and linguistically competent care
to its LEP patients. Organizational level interventions that are not patient-centered do not always yield
improvement in patient health outcomes - There are significant gaps in the provision of effective
linguistic and cultural mediation. Despite the existence of legal frameworks and policies that
mandate the provision of language services in healthcare facilities, a recent study in New York
State points to the existence of major disparities in the application of laws and regulations
(Center for Popular Democracy, 2013), with less than half of this segment of the population able
to access linguistically sensitive information. Currently providing language services is the law in
New York State. There is, however, wide variation between healthcare facilities we studied in the
quality and quantity of the services provided (Rand, 2007 ; Rudmin, 2007). Practices range from
the provision of dedicated bilingual staff interpreters who serve as patient advocates and cultural
bridge builders, to the provision of an impersonal and time limited telephone interpretation that
serves as a translator machine. The latter has become the default for many healthcare facilities
especially for non-Spanish speaking LEP patients.
Overcoming linguistic and cultural disparities demands a deliberate proactive patient-focused approach - Among
LEP patients there is need for health advocates/coaches who will guide them, redress power
imbalance and empower their voice (Morris, 2010; Bahadir, 2010; Apostolou, 2009). They also
are in need of linguistic and cultural mediators. Having effective linguistic and cultural mediation
decreases communication errors, increases patient comprehension, equalizes healthcare
utilization, improves clinical outcomes, and increases satisfaction with communication and
clinical services for LEP patients (Karliner, Jacobs, Chen & Mutha, 2007).
Barriers to these patient-centered care approaches include funding limitations. Healthcare
providers are under extreme pressure to cut costs and increase patient visits and volume so they
can stay financially viable. Serving LEP patients is a complex effort that requires longer visit time
and increases service costs. Institutionalization of LEP interventions may be hindered by the
perception that they place an undue financial and/or human resource burden on the
organization. There is strong evidence, however, that these interventions actually reduce medical
costs and improve the bottom line (Youdelman, 2003). Facilitative factors of language access
intervention uptake include an ability to capture a bigger share of the patient market; ability to
comply with existing legal requirements and accreditation policies; and a high degree of
leadership awareness of the changing patient demographics and commitment to the need to
address disparities affecting LEP patients.
Methods
The study sought to understand how implementation of organizational level language access
intervention may improve the organizational management system with the potential of

improving patient health outcomes. Enhanced management system was measured by ability to
achieve 3 outcomes: identify/document language of communication; secure language assistance
to enable communication and monitor and evaluate language assistance and health outcomes of
LEP. Patient outcomes were measured through increased testing for STD with Latina patients.
We defined increased testing as an indictor of success since language barriers hinder the
provision of prevention services such as STD testing. An increase in testing is considered
increased provision of preventive services.
Participants
Participants in the study were members of Family Planning Advocates of New York State, a
statewide organization with approximately 200 member health centers throughout the State.
Design and Procedures
The study was conducted in two phases. In Phase 1, a Baseline Survey was administered to
deepen understanding of the operating systems, policies, protocols and procedures related to
communicating with LEP patients at family planning clinics in New York State. The survey also
assessed perceptions of whether clinics thought that language access was important and whether
they felt satisfied with the way language assistance is provided at their clinics. Staff
knowledgeable about language assistance within each clinic completed the survey instrument.
In Phase 2, six clinics purposively selected from the pool of survey respondents were invited to
participate in developing and testing a language access organizational intervention at their clinic.4
These clinics were selected based on the following criteria: interest, Limited English Proficient
Latina Patient volume; having a service area with sizable population of LEP residents. The 6
clinics were divided into two groups; A and B. A delayed intervention methodology was used.
Group A received the intervention 4 months before Group B receives its intervention. Delayed
intervention allowed an opportunity to use Group B as a control Group for the initial 4 months.
Data collection in phase 2 included, observational site visits; key informant interviews, action
plan development sessions, technical assistance sessions, patient chart reviews and review of
organizational records.
Social Learning Theory and Behavioral Ecological Model guided the study (Glanz et. al., 2008).
The study emphasized factors in the physical environment (e.g., healthcare system, time and staff
pressures) as well as history of personal and organizational performance (e.g., clinic policies) that
may shape patient-centered communication. We also used prior work in the area of language
access including Refki et. al, 2007, 2012, and Wilson-Stronks& Galvez, 2006. The analysis plan
examined relationships among variables related to the quantity and quality of language assistance.
The University of Albany Institutional Review Board reviewed conduct of the research.
Results
1. Cross-sectional study of family planning administrators
4 Development and implementation of the Language Access Intervention used the following process: (a) each clinic
established a Language Access Team composed of staff members who are serving in key and different roles in the
organization; (b) using an organizational self-assessment, each team individually and collectively rated the
organization on the patient centered communication scale; (c) the team then collectively identified gap areas that are
of priority to the organization and created an action plan which included the following components: goals,
measurable, quantifiable objectives, activities, organizational resources that are needed to accomplish each objective,
timeline for each activity; and an evaluation plan that clearly delineates process efficiency and outcome effectiveness
measures. The Team selected strategies from a toolbox of possible interventions that the authors developed based
on a review of literature, and executed the action plan.

The Family Planning project is aimed at understanding how family planning organizations can
use language assistance services to improve preventative services for limited English proficient
(LEP) patients. The current cross-sectional interview study was conducted with administrators of
family planning clinics to investigate factors, organizational history, resources, and availability to
participate in this research, as well as quantity and quality of language assistance services offered.
Sixty family planning clinics from 11 New York State Regions participated. A variety of
organization factors were observed, such as number of staff, languages spoken at the clinic,
number of bilingual staff, staff training, number of patients seen per week, etc. Community
factors included racial make-up of surrounding community, languages spoken in the community,
political climate, etc.  
Descriptive analyses were run to examine frequencies of specific variables across clinics. Table 1
describes the number of patient languages and ethnicities/races that clinics serve. Patients could
choose more than one language and ethnicity/race, so percentages may not add up to 100%.
Over half (59%) of the clinics reported having patients who spoke Spanish, with other (44%)
and Chinese (44%) being the next two popular patient languages spoken. All clinics served
patients who identified themselves as other with respect to ethnicity/race. 76% of clinics served
White patients and 75% of clinics served Black patients. Table 2 describes the availability of
funding sources and availability of staff at clinics.
A few number of clinics reported receiving funding, outside of Title X, for language assistance
services. None of the clinics reported receiving County Council Office funding, 9% reported
receiving state funding, and 7% reported receiving federal funding. 93% of the clinics had full
time staff, 88% had employed part time staff, and 29% of clinics used volunteers. 64% of clinics
had bilingual staff and 76% of clinics provided an incentive to bilingual staff to interpret. Table 3
describes the specific types of language services provided, funding for each service, and the
number of patients who use particular services.
Ninety-eight percent of clinics provided language assistance services. The types of services
provided had little variation between clinics. More than 90% of clinics had bilingual
providers/nurses, bilingual staff, telephone interpreters/language line, professional interpreters,
translated educational material, multilingual signs/pictograms, and multilingual videos. 85% of
clinics provided language assistance services for deaf and hard of hearing patients. With respect
to funding for specific types of language assistance services, 75% of clinics received funding for
both bilingual providers/nurses and telephone interpreters/language lines. 73% of clinics
received funding for bilingual staff, translated educational client material, and multilingual
signs/pictograms. Only 68% of clinics received funding for multilingual videos and professional
interpreters. Further, 70% of clinics received funding to provide language assistance services to
the deaf and hard of hearing.
The number of LEP patients who used specific services across clinics varied. All of the clinics
reported patients using translated educational materials and support for deaf and hard of hearing.
66% of clinics reported patients using bilingual staff and 61% of clinics reported telephone
interpreters/language lines being used by LEP patients. A little more than half (53%) of the
clinics reported LEP patients using professional interpreters. However, less than half of the
clinics reported multilingual signs/pictograms and multilingual videos being used by LEP
patients. 75% of the clinics reported that their strategic plan included goals for language
assistance services, but only 64% confirmed that their strategic plan measures the success of
these services. 98% of clinics reported using language posters, language signs, and bilingual

staff/providers to identify a patient’s language. Table 4 describes the reported barriers that
clinics face when serving LEP patients.
There was little variability between clinics and perceived barriers. The majority of clinics felt that
all barriers affected their ability to serve LEP patients, with language differences being the
highest reported barrier among clinics. Eighty percent of clinics reported hiring bilingual staff to
speak Spanish, 76% of clinics reported using language lines, and 70% of clinics reported working
with professional interpreters. Table 6 describes the ways clinics monitor LEP patients’ use of
their language assistance services.
Sixty-eight percent of clinics reported having hard copy access to patient charts and 20%
reported having electronic access. Only 12% of clinics used both. 95% of the clinics verified
that they collect information on LEP patients getting some form of help to communicate and
document the patient’s language. All of the clinics reported document LEP patient use of their
language assistance services. More than half (78%) of clinics evaluated their staffs’ ability to
speak the languages for which they interpreted. Tables 7 and 8 describe the different language
assistance services offered for common and rare languages. Table 9 illustrates the different
assistance/training that clinics provide to their staff to enable them to better serve LEP patients.
Ninety-three percent of clinics reported training staff on identifying LEP patients, helping staff
correctly and consistently getting patients the right type of help they need to communicate, and
assisting staff in using the interpreter services offered. 85% of clinics verified that they helped
their staff learn how to communicate best through an interpreter and 81% of clinics train staff
who interpret know how to interpret correctly.
Bivariate correlations were run on three main dependent variables: 1) how are different types of
languages identified by the clinics, 2) how the clinics provide language assistance services, and 3)
whether or not clinics track/monitor the use of these services. Several predictors were expected
to be correlated with each of these dependent variables.
For the outcome “identifying different languages” we examined number of patients by
race/ethnicity, languages in the community, and number of people in the community by
race/ethnicity. Bivariate correlations were run examining the relationship of these predictors
with what languages were spoken at the clinics. As expected, a significant correlation emerged
between languages spoken at the clinic and number of patients by race/ethnicity. Significant
relationships were also found for all languages in the community, except Spanish, and languages
spoken in the clinic. The number of people in the community by race/ethnicity was also
significantly correlated with the types of languages spoken at clinics.
Next, analyses were run to investigate the outcome “how are language assistance services
provided” with various predictors. A dichotomous variable was created to account for whether
or not a clinic provided any type of language assistance service. Bivariate correlations were run
to examine whether a significant relationship existed between if a clinic offered language
assistance services and several predictors. We expected several clinic demographic factors to be
correlated with a clinic’s language services such as what languages exist at the clinic, number of
staff, funding for each form of language service, the number of bilingual staff, number of
patients of different ethnicities, number of patients who use language services in an average
week, date the clinic hired bilingual staff, and if the clinic offers an incentive to bilingual staff to
interpret. Clinic factors related directly to serving LEP patients were also predicted to be
correlated. These included if the clinic has written procedures for staff working with LEP
patients, date the clinic began serving LEP patients, what actions a clinic takes to serve LEP

patients, if the clinic has written policies for helping LEP patients, clinic’s perceived barriers in
serving LEP patients, and whether or not the clinic includes providing language assistance
services in their strategic plan.
In addition, several community factors, such as the number of people in the community of
different ethnicities, availability of bilingual staff in the community, and the public policy climate
of the surrounding community, were also predicted to be significantly correlated with a clinic’s
availability of language assistance services. Training opportunities provided by clinics were also
expected to be related. These included if the clinic trains staff on helping LEP patients, if the
clinic evaluates staff’s ability to speak the language they interpret, and clinic’s perceived barriers
to training staff. Results suggest that funding is the only predictor significantly correlated with a
clinic’s availability of language services, but only for the telephone interpreters/language line
(p<.0001, r=.567) and translated client educational materials (p<.001, r=.431). All other
predictors were not significantly correlated with whether or not language assistance services were
provided at clinics.
Lastly, we examined relationships with the outcome “how language assistance services are
tracked.” The number of staff, availability of patient charts, if clinics collect any information
LEP patients, the methods staff use to identify LEP patients, and if clinics prepare reports on
language difference outcomes were expected to be predictors. The number of staff (p<.05, r=-
.345), availability of patient charts (p<.05, r=-.377), and method used to identify LEP patients
(p<.05, r=.367) were significantly correlated with whether or not a clinic tracks language services.
Whether or not clinics prepare reports on language outcomes and collect of information on LEP
patients were not significantly related to a clinic’s likelihood of monitoring the use of language
services.
Taken together, the descriptive results suggest that all of the clinics provide language assistance
services, with some providing several different kinds. All clinics reported offering language
assistance services for both common and rare languages (see Tables 7 and 8). Very few of the
clinics receive funding beyond Title X, but the majority of clinics receive funding for the
different types of language services (see Table 2). Further, all clinics reported that LEP patients
use their translated educational material and that they provide language assistance services for the
deaf and hard of hearing. All clinics also reported using various methods to identify patients’
languages (see Table 3). Various barriers to serving LEP patients were shared among the
majority of clinics, with language differences, cultural differences, and limited availability of
bilingual staff/interpreters being the three biggest barriers (see Table 4). In addition, all clinics
reported document LEP patients use of their language assistance services and documenting
patients’ languages (see Table 6). Lastly, the majority of clinics provide training and assistance to
their staff on serving LEP patients (see Table 9).
The correlational results reveal that the types of languages that exist in the surrounding
community of a clinic significantly influences what kinds of languages are spoken at that clinic.
Similarly, the ethnic make-up of the community and clinic patients also significantly affects what
languages are spoken at the clinic. In addition, results indicate that only funding significant
impacts whether a clinic offers language assistance services, particularly funding for telephone
interpreters/language line and translated client educational materials. The more funding a clinic
has, the more likely it is to offer these types of services to LEP patients. Further, whether a
clinic monitors the use of their language services depends on the number of staff, availability of
patient charts, and the method used to identify LEP patients. Two reasons for the lack of
significant correlations in this study are its small sample size and low variability among clinics
who offer language assistance services. It is possible that the 70% of clinics that did not respond

to the survey were less likely to provide language assistance services. All, but one of the clinics,
provides at least two kinds of language assistance service to LEP patients. In addition, only 59
clinics participated in this study that may further contribute to low variability among clinics.
Future research should strive to include a greater number of clinics.
2. Quasi-experimental study of organizational development Language Access
Intervention
Table 10 shows the types of interventions employed by four of the participating clinics. Two of
the clinics involved failed to produce consistent data reports. Measurement of intervention
impacts for those clinics relied on key informant interviews. The decision to examine how the
organizational interventions may have influenced STD rates was driven by our work with family
planning clinics for the past 10 years. Clinic administrative leaders and other staff who have
been working on linguistic disparities have been struggling to understand if changes in language
access influence patient clinical outcomes. This analysis of patient outcomes was a secondary
aim of the study because the time period and resources of the study were not designed for a
comprehensive and rigorous assessment. Given prior research and the study team’s experiences
with organizational interventions, it did not seem that 6 months to 1 year of time would be
sufficient to all most clinics to fully establish comprehensive interventions with the potential of
influencing patient outcomes. However, we designed an approach that might be most sensitive
to changes related to the organizational interventions. The target patient group was LEP Latinas
aged 40 years or younger. This patient group would be most common of LEP groups across the
participating clinics. STD rates were selected as the common outcome because both our clinical
advisors and prior research indicated that they may be sensitive to improvements in language
assistance services.
Analyses were based on patient records from the participating clinics from December 2010 thru
March 2012. This period would provide a long enough baseline (at least 3 months) and long
enough follow-up (6 months or more) for both Groups A and B to determine potential changes
due to each clinics organizational intervention. STDs included chlamydia and gonorrhea.
Clinics were asked to provide monthly STD rates for Latinas in the target age group. If the clinic
had information on LEP status, they were asked to provide that information too. Analyses
examined each month during the target period as a cross-sectional sample. Given this design, it
is possible that some Latinas are represented more than once during the target period, but this
was considered to be relatively rare (less that 10%) by the participating clinics. Of the six clinics,
four were able to provide all the necessary information for the analysis. Of the two clinics that
were not included in this analysis, one grouped chlamydia and gonorrhea along with other
conditions into one category called “STI” and the other clinic used a reporting system that could
only provide semi-annual aggregate data for the target STDs and not separately for Latinas.
Descriptive analyses were run to examine frequencies of specific variables across clinics. Tables
11 and 12 describe the number of patients, patient languages, races, and ethnicities that clinics
serve by site for each STI. Patients could choose more than one language and ethnicity/race, so
percentages may add up to greater than 100%.
The two larger sites (Clinic 3 and 4)) had a larger proportion of Latinas among their overall
patient population for patients with chlamydia and gonorrhea than the two smaller sites. The
examination of the descriptive data for the participating clinics indicate that there were
differences in how some clinics categorized Latino and Hispanic patients that may have resulted
in an undercount of actual patients of that ethnicity.

Analysis of Change in Monthly STD Rates was conducted by running one-way repeated
measures ANOVAs to examine significant relationships across and within sites for patient
monthly STD screening rates. No significant relationships (P> 0.05) were found within each
site. The rates across participating sites are described in Tables 13 and 14.
Discussion
The language access intervention induced efficiencies in some participating clinics evidenced by
perceptions of staff at the clinics that reflected on improved management of patient flow and
increased patient volume. However since the intervention coincided with some of the clinics
transitioning to electronic medical records that undoubtedly contributed to increased efficiencies.
However, none of the participating clinics showed improvement in patients’ outcomes measured
by increased testing for STDs for Latina CVP patients.
We attribute the results to the fact that interventions selected by participating clinics did not take
into account the interconnectedness of the levers of change in an organization (its internal
infrastructure, people and external environment). Action steps implemented in one domain
needed reinforcing and supporting actions in the other two domains to ensure effectiveness. For
example, when a clinic chooses to develop language access goals, measurable objectives (internal
infrastructure), such action became useless because it was not accompanied by equal efforts to
incorporate evaluation of disparities by language in its patient population as well as in the
external environment, and staff accountability and oversight to achieve those goals.
An integrated mainstreaming approach of language access need to introduce change on a multi-
dimensional level and language access considerations must be integrated within each level in
order to be effective. In our study, none of the clinics targeted all three leverage points of
intervention; internal environment, people and external environment. Interventions targeted
only one or two leverage points without taking into consideration the interplay between these
three dimensions in an organization: internal infrastructure, people and external environment.
There is a dynamic interplay between situational and personal factors within an organization as
well. So to effect change within an organization, there is a need to integrate efforts that are staff-
centered and target modification of behaviors and practices with environmentally-focused
interventions that enhance organizational systems. Similarly, when instituting policies and
procedures to identify, document and assist patients who are communication-vulnerable (internal
environment) a clinic must ensure training of staff about these policies, enforcing
implementation by including benchmarks in staff performance evaluations (People), and
reaching out to the community to disseminate affirmative messages that these policies exist and
the clinic provides a welcoming environment. A clinic which institutes language access policies
and affirmative patient’s Bill of Rights but fails to fortify and reinforce such action in the internal
infrastructure with similar actions in the people domain and external environment so as to
neutralize the impacts of hostile local policies on access of patients and behavior of its staff is
unlikely to see improvement in patient’s overall health outcomes or a realization of its mission to
provide quality care. The community climate can have tremendous impact on a health center’s
ability to attract and retain foreign-born patients and the extent these patients can access
healthcare services. In recent years, several New York municipalities have considered or enacted
local ordinances intended to force undocumented immigrants and their families to leave.
Immigrants have become distrustful of local government and fearful of accessing services.
Reinforcing and supporting measures may include training, sensitizing, oversight, accountability
measures for staff and consistent linguistically and culturally appropriate outreach programs that

address fear and apprehension to access services in its communities. A clinic that continues to
capture data on language assistance needs ought to incorporate evaluation mechanisms that use
this data collected to assess disparities in communication vulnerable patient population and
implement corrective actions when disparities exist. It needs to incorporate staff training to
assess patient satisfaction. Clinics do not exist in a bubble but are significantly affected by the
context in which they operate. The high level of satisfaction expressed by clinics in their ability
to serve patients is both gratifying and troubling; gratifying because there is a sense of self
efficacy, but troubling because such sense of efficacy is misleading when considering the health
indicators in communities some of which suffer the worst health indicators in the State in terms
of teen pregnancy and STD infections. High levels of disparities exist in ethnically diverse and
communication vulnerable residents. A clinic needs to measure its success in relation to the
health of the communities it serves.
Overcoming linguistic disparities entails a deliberate proactive approach that consistently and
systematically evaluate CVP’s outcomes before, during and after services are provided.
Mainstreaming occurs at the point of intersection of the three levers of change: internal
infrastructure, people and external environment. Access can only be mainstreamed or weaved
into the fabric of an organization when the three levers of change support and reinforce each
other. Language access interventions need to be institutionalized within three domains; internal
organizational infrastructure; people who drive the organization and the external environment.
A framework for mainstreaming language access includes the following components:
Internal Infrastructure:
 Leadership commitment to develop clear language access goals and measurable
objectives; reinforce staff accountability; identify gaps through integrating language
access in audits, quality improvement programs and patient satisfaction surveys, and
include language access in budgets.
 Solid policies and protocols that direct planning and actions, set priorities and guide day-
to-day operations. They are widely used, accepted and periodically evaluated and
updated. Communication and monitoring strategies ensure that staff understands and
consistently implements them.
 Data captured, analyzed and used to implement corrective actions. Data systems record
provision of language services during each visit; patients’ decision to decline or refuse an
interpreter, patients’ satisfaction, and patients’ health outcomes. Baseline data on LEPs
are monitored and evaluated over time.
People
 Staff reflects the communities served.
 Staff interpreters are proficient in the languages used as well as in medical terminologies.
External Environment
 Linkages with the external health economy. “Learning organizations” do not exist in a
bubble, but proactively engage their communities (O’Conner et. al., 2008). Community
partnerships leverage resources, and enables service of hard to reach communities through
trusted cultural and linguistic brokers. Outreach and service levels must be responsive and
tailored to the magnitude of need in a community. Health indicators of community members
must inform levels of outreach and service.

Conclusion
The language access intervention introduced and tested in this study induced efficiencies in some
participating clinics in the area of patient flow and management, but none of the participating
clinics showed improvement in patients’ outcomes measured by increased testing for STDs for
Latina CVP patients. This is attributed to the limited focus of the interventions that each clinic
opted to adopt. An integrated mainstreaming approach of language access must introduce
change on a multi-dimensional level. Language access considerations must be integrated in three
leverage points of intervention; internal environment, people and external environment. The
interconnectedness between these three dimensions means that the positive impacts of reforms
in a single domain can be thwarted by lack of positive interventions in other domains.
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