Relating Ethnicity and Culture to Healthcare Marketing

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Relating Ethnicity and Culture to Healthcare
Marketing

• August 8, 2003

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Pamela L. SchneiderSenior VP, Client Services
DirectorRick Johnson Company, Inc.
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Our Agency Has a Plethora of Healthcare Experience

• Integrated Health Systems
• Hospitals
• Managed Care
• Physician Specialty Groups
• Clinics and Solo Practitioners
• Recruitment and Retention
• Community Healthcare Leadership
• The list goes on

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(No Transcript)
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Lets Begin Today by Discussing Some
Statistics
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Percent of Persons Who Are American Indian and
Alaskan Native by County in New Mexico
36.9 to 74.7 Includes San Juan, McKinley and
Cibola Counties
10.9 16.3 Includes Rio Arriba, Sandoval and
Socorro Counties
Source United States Census Bureau Data
www.census.gov
NOTE Bernalillo County 13.5 of NM NA pop. or
23,623
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Percent of Persons who are Hispanic or Latino by
County in New Mexico
72.9 81.6 Includes Rio Arriba, Mora, San
Miguel and Gaudalupe Counties
44.9 63.4 Includes Taos, Colfax, Harding,
Santa Fe, Valencia and Socorro as well as Grant,
Hidalgo, Luna and Dona Ana Counties
Source United States Census Bureau Data
www.census.gov
Note Bernalillo County is 30.4 of NM Pop. or
236,285
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Percent of Persons who are Anglo in New Mexico by
County
Source United States Census Bureau Data
www.census.gov
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U.S. Census Data on Nativity and Language
Proficiency in New Mexico
Source United States Census Bureau Data
www.census.gov
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U.S. Census Data on Nativity and Language
Proficiency in New Mexico
Source United States Census Bureau Data
www.census.gov
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Other Population Statistics Census Bureau
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10 LEADING CAUSES OF DEATH IN THE AMERICAN INDIAN
Source The Center for Disease Control Website
www.webapp.cdc.gov
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10 LEADING CAUSES OF DEATH IN THE HISPANIC
POPULATION
Source The Center for Disease Control Website
www.webapp.cdc.gov
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Our DMA is One of the Top 15 Hispanic Markets in
the Country
Market /TV Households Hispanic Rank Los
Angeles 30 (1,585,390) 1 New York 15
(1,100,030) 2 Miami-Ft. Lauderdale 37
(550,190) 3 Houston 22 (399,220) 4 Chicag
o 12 (384,140) 5 Dallas-Ft. Worth 15
(324,120) 6 San Antonio 44
(317,810) 7 San Francisco Oak- SJ 13
(317,200) 8 Phoenix 16 (246,160) 9 Harl-W
slco-Brns-Mca 81 (232,270)
10 Albuquerque-Santa Fe 33 (206,710)
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Source 2003 Nielsen Universe Estimates
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Approximately 38 of the DMA Population is
Hispanic
Total DMA Population 1,597,000 Hispanic
Percentage 38 Hispanic Population
602,000 Non-Hispanic Percentage 62 Non-Hispanic
Population 995,000
Source 2003 Nielsen Universe Estimates
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Hispanics Growing Twice as Fast as Non-Hispanics
A Rapidly Growing Population 1990 2000
Change Hispanic 579,224 785,386
32 Non-Hispanic 935,845 1,053,660 13
Source 1990 and 2000 Census (New Mexico state
population
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More Than Four Out of Five Hispanic Households
Speak Spanish
Speak Spanish 82 Speak English Only 18
Source 2003 Nielsen Universe Estimates
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More Than Four Out of Five Hispanic Households
Speak Spanish

• Conveying your message to your target audience
  is accomplished most effectively in their
  language of comfort.
• The language of comfort is the language spoken
  at home.
• Spanish-language dominant Hispanics think and
  feel in Spanish.

Source 2003 Nielsen Universe Estimates
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But Its More than Just Spanish
ñ
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Its About Reaching Them with Relevance

• Its necessary to connect with target consumers
• Emotionally
• Rationally
• Intellectually
• Culturally
• To connect in these ways, you must know about
  their level of acculturation

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Acculturation, Not Assimilation

• Assimilation
• A group leaves culture and customs behind and
  adopts culture and customs of another group
• Acculturation
• A group adopts or borrows customs and traits from
  another culture

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Acculturation is Defined as

• Change resulting from contact between cultures
• The process by which people adopt or borrow
  customs and traits from another culture
• A merging of cultures as a result of prolonged
  contact
• Mutual influence of different cultures in close
  contact

Source Acculturation Microsoft Encarta Online
Encyclopedia 2000 Strategy Research Corp. Webster
New World Dictionary, Third College Edition
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Key Indicators of Acculturation

• Language
• Values

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Latino Acculturation Values (L.A.V.s.)
UNACCULTURATED
ACCULTURATED
Success Family/group satisfaction
Success Personal Achievement
Obedience/ attached to traditions
Class distinction/ authority
Freedom/ open to change
Equality
Collectivism
Individualism
Avoidance of direct confrontation
Assertiveness/ aggressiveness
Cooperation/ respect
Competition
Control over destiny
Fatalism
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Latino Acculturation Stratification
UNACCULTURATED
ACCULTURATED
CROSSCULTURER
CULTURAL LOYALIST
CULTURALINTEGRATORS
CULTURAL EMBRACER
(TM)

• Foreign Born
• Resident
• Spanish
• Preferred
• Professional
• Aspirational

• U.S. Born
• 2nd, 3rd Generation
• English
• Preferred
• Latino Proud
• Retro-acculturation
• Influential

• Foreign Born
• Recent arrival
• Spanish
• dependent
• Traditional values

• U.S. Born
• First generation
• Bilingual
• Bicultural
• Professional
• Fashion-forward
• In touch with roots

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Acculturation Nationally Among Hispanic Adults 18
Source Strategy Research Corp.
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Albuquerque is Highly Acculturated Market

• Top 3 Most Acculturated Markets in U.S.
• San Antonio
• Albuquerque
• San Francisco

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Acculturation Among HA 18 - Albuquerque
Source Strategy Research Corp.
Source Strategic Research Corp. 2002
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Factors Influencing Acculturation

• Employment
• Length of Residency in U.S.
• Language Use/Preference (home and work)
• Birthplace of Parents
• Education
• Generation U.S. Born (1st, 2nd, 3rd, etc)
• Media Preferences (Spanish or English)
• Values and Attitudes

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Research Shows

• Advertising to Hispanics in English is not as
  effective as speaking to them in Spanish
• Spanish language commercials have better ad
  recall. (61)
• Hispanics have better comprehension of
  Spanish-language commercials (57).
• Spanish commercials are 4.5 times more
  influential in making purchases decisions.

Source Roslow Research Group Inc., Spanish vs
English Advertising Effectiveness Among Hispanics
2000
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Ethnicity is defined asrel of, relating to,
or originating from the traits shared by members
of a group as a product of their common heredity
and cultural tradition(s)
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Culture is defined as synbreeding,
cultivation, polish, refinementrel
development, education, learning enlightenment
refinement, breeding, erudition, manners, class
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Culture-Sensitive Healthcare Hispanic
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• Hispanic
• The term Hispanic was created by the U.S.
  Census Bureau in 1970 as an ethnic category for
  persons who identify themselves as being of
  Spanish origin.
• Hispanic denotes neither race nor color, and
  a Hispanic may be White, Black or American
  Indian
• Many members of the younger Hispanic population
  demographic now prefer the term Latino.

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• Hispanic
• The classification Hispanic includes people
  of many different origins and cultures.
• Although there is a unifying thread of language
  and some cultural similarities inherited from
  the Spanish settlers There is also a
  tremendous variety within the Hispanic community

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Keys to a Good Professional Relationship with
Your Hispanic Patients
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• Show respeto
• People from many Hispanic cultures offer (and
  expect to receive) deference on the basis of
  age, sex and status.
• Patients will naturally offer respeto to the
  health provider, an authority figure with high
  social, educational, and economic status.
• In return, patients rightfully expect to be
  treated with respect.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• The Healthcare Provider Shows respeto by
• Addressing Adults by title and family name
  (Mr./Señor, Mrs./Señora Y, or Madam/Doña)
• Shaking hands at the beginning of each meeting.
• Using usted rather than the informal tu for
  you, when speaking Spanish.
• Making eye contact, without necessarily
  expecting reciprocation, since some (especially
  rural) patients may consider it disrespectful to
  look the health provider, an authority figure,
  in the eye.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• The Healthcare Provider Shows respeto by
• Speaking directly to the patient, even when
  speaking through an interpreter.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Show personalismo.
• Patients from many Hispanic cultures expect to
  establish a personal, one-on-one relationship
  not to be confused with an informal
  relationship with the health provider.
• Although establishing a relationship based on
  personalismo may seem time-consuming, it can
  actually save time and prevent negative
  outcomes.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• The Healthcare Provider Shows personalismo by
• Treating patients in a warm and friendly but
  not unduly informal manner.
• Showing genuine interest in and concern for
  patients by asking them about themselves and
  their family.
• Sitting close, leaning forward and using
  gestures when speaking with the patient.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Involve the Family in Decision Making and Care.
• Families are a source of emotional and physical
  support and are expected to participate in
  important medical decisions.
• The definition of la familia is much broader
  in most Hispanic cultures than in Anglo cultures
• La familia may show loyalty and support by
  gathering at the hospital.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Accept a different sense of time.
• Many people from Hispanic cultures have what
  might be called a global or indefinite sense
  of time rather than an exact sense of day and
  hour in making and keeping appointments.
• Similarly in presenting a complaint, they may
  not be able to attach a specific calendar date
  to the onset or conclusion of a medical
  complaint or an event.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Accept a different sense of time.
• They may instead be able to link the event to a
  season, a phase of the moon, or a particular
  occurrence, such as a holiday or celebration.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Take pains to establish understanding and
  agreement.
• Many patients sense of respect for authority
  may cause them to avoid conflict or
  confrontation with the health provider by saying
  too readily that they understand how to take a
  medication or will follow a treatment plan.
• The health provider must ensure that
  understanding is achieved and must try to gain
  real acceptance of the treatment plan and a
  commitment to follow it.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Respect the spiritual side of physical
  complaints.
• Many Hispanic patients complain that health
  practitioners, by discounting supernatural and
  psychological causes of complaints, offer only a
  fragmentary approach to care.
• To these patients, this amounts to treating the
  symptoms, not the disease itself.
• Practitioners are advised to ask their patients
  what they believe to be the cause of a complaint
  and to refrain from ridiculing or discounting
  the patients belief in supernatural or
  psychological causes.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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Potential Culture-Related Health Concerns Among
Hispanic Populations Source Virginia
Techs Office of Multicultural Affairs Home Page
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• Persons from some Hispanic cultures may have
  tendency toward certain health concerns because
  of cultural factors.
• Specific concerns include
• High incidence of teenage pregnancy
• Low incidence of breast feeding
• Where breast feeding is practiced, a tendency
  to do so for a short period and to introduce
  solid foods earlier than recommended
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Specific concerns include
• Very low intake of vitamin A.
• Alcohol abuse, especially by young Mexican
  males (abetted by cultural taboos against female
  disclosure of alcohol use).
• Drug use at levels higher than among
  non-Hispanic Whites.
• A high prevalence of undetected
  non-insulin- dependent diabetes
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Specific concerns include
• A high incidence of tuberculosis (recommend
  aggressive screening
• A high risk for mental health problems such as
  depression, anxiety, and substance abuse.
• Dietary concerns due to
• High consumption of fats (often lard,
  especially for lower income people) and fried
  foods
• A traditional diet high in carbohydrates from
  beans and rice or corn tortillas
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Specific concerns include
• Dietary concerns due to
• Low intake of green or leafy vegetables and/or
  milk and eggs, especially in conjunction with
  increased consumption of meat and fast foods as
  acculturation occurs.
• Little tradition for recreational physical
  exercise outside the context of field or other
  physical labor.
• Excessive reliance on Azarcon which is about 90
  percent lead, as a home remedy for
  gastrointestinal/intestinal complaints.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Specific concerns include
• Sharing with family and friends, of hypodermic
  needles and syringes, which in Mexico are often
  used to administer vitamins, medications, and
  contraceptives.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Folk Beliefs of Some Hispanics About Health and
  Illness That Can Affect Care and Treatment
• Good health is a matter of luck that can easily
  change. Sick persons may be the innocent
  victims of fate, with little responsibility
  for taking action to regain health.
• Illness may be the result of negative forces in
  the environment or a punishment for
  transgressions.
• Balance and harmony are important to health and
  well-being. Illness may be the result of an
  imbalance.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Folk Beliefs of Some Hispanics About Health and
  Illness That Can Affect Care and Treatment
• The natural and supernatural worlds are not
  clearly distinguishable, and body and soul are
  inseparable. Telling a patient that an illness
  is all in the mind is meaningless because there
  is little or no distinction between somatic and
  psychosomatic illness.
• Cure requires family participation and support.
  The familys role is to indulge the patient,
  provide unconditional love and support, and
  participate in health care decision making.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Folk Beliefs of Some Hispanics About Health and
  Illness That Can Affect Care and Treatment
• While education and training may be somewhat
  important, what truly matters is the caregivers
  gift or calling for curing illness.
• Moaning, far from being a sign of low tolerance
  to pain, is a way to reduce pain and to share it
  with interested others.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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• Folk Beliefs of Some Hispanics About Health and
  Illness That Can Affect Care and Treatment
• Diseases may be divided into Anglo and
  traditional diseases and may be either natural
  or unnatural.
• Many people mix and match modern medicine and
  traditional care, consulting modern health
  providers for Anglo and natural diseases, and
  folk healers for traditional and unnatural
  diseases.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page

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American IndianNative American
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• Culture-Sensitive Healthcare American Indian
• The term American Indian refers to members of
  Indian Tribal nations who live in the United
  States.
• Native American, a term that has become
  unpopular among American Indian groups, refers
  to American Indians, Eskimos, and Aleuts as one
  racial ethnic group.
• Fact The Native American group as a whole is
  expected to reach 4.3 million by 2050.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Culture-Sensitive Healthcare American Indian
• The majority live in Oklahoma, California,
  Arizona and New Mexico.
• Poverty is higher than in the rest of the
  population and continues to increase.
• In 1979, 27 of the American Indian population
  lived below the poverty line by 1989 this
  figure had grown to 31, by 1999 this figure had
  grown again to 33.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Make the Patient Welcome. First meetings are
  important.
• Extend a warm greeting and smile.
• Shake hands, introduce yourself, and allow the
  patient to do the same (thereby showing respect
  to his or her ancestors)
• Thank the patient for having chosen your health
  facility.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• A western style handshake is appropriate and
  appreciated, dont be surprised if it is
  returned by an unusually weak or strong one.
• The traditional Navajo greeting is not to shake
  hands, but to extend the hand and gently touch
  the other persons hand.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Use Eye Contact Judiciously.
• Prolonged eye contact is considered a sign of
  disrespect and should be avoided.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

63

• Keys to a Good Professional Relationship with
  American Indian Patients
• Take Your Time.
• It is important to spend time with the patient
  and to avoid appearing hurried or nervous.
• Patients often travel great distances at great
  financial hardship to see a physician if the
  physician spends only five or ten minutes with
  them, the message is clear and negative.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Speak Plainly.
• Avoid medical or other terms that may not be
  understood, but at the same time, dont talk
  down to the patient or appear to treat him or
  her as a child.
• A soft concerned voice will do much to make the
  patient feel at ease.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Respect Silence.
• Be concise and give the patient time to reflect
  on what you are saying.
• Dont try to fill up the time.
• American Indians are taught the value of
  silence and may also need time to mentally
  translate what they hear into their own
  language.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Understand Tribal Diagnosis.
• The patient may have come to you following
  diagnosis by a tribal diagnostician.
• Due to this, the patient may be unfamiliar with
  the technique of identifying the specific
  location of pain.
• Instead of asking the patient, Where is the
  pain?, ask the patient to point to the most
  intense area of pain.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Accommodate Tribal Healing.
• Patients may wish to perform certain tribal
  healing ceremonies, even in the hospital.
• Try to accommodate these healings as a way to
  improve both the patients and the familys
  confidence in the care.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

68

• Keys to a Good Professional Relationship with
  American Indian Patients
• Show Special Respect to the Elderly.
• Great respect is given to the elderly, in spite
  of taboos connected with death.
• Caregivers gain approval by treating the
  elderly with kindness and respect and not
  appearing to criticize or scold them.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Think Carefully About Family Care.
• Poverty, distance from the medical facility,
  and taboos against dying in the home may make it
  impractical to release to the family a patient
  needing long-term or terminal care.
• Discuss options with the family and try to
  ascertain attitudes about home care before
  releasing a person into the family care.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Involve the Extended Family.
• Extended family plays an important role in
  healthcare decision making.
• Often many family members will appear with a
  patient who is to be admitted for a hospital
  stay.
• Include family members when decisions regarding
  treatment options are needed.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Involve the Extended Family.
• Very often, a patient will postpone surgery
  because the consent of the family leader, often
  the eldest female must be obtained first.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Accept a Different Sense of Time.
• Most American Indians are present-oriented and
  take a casual approach to clocks and time, which
  is viewed as a continuum with no beginning and
  no end.
• Poses difficulties with regulation of
  medication.
• Watch telling the patient to take medications
  with meals, as the patient may have three meals
  today, two meals tomorrow and four the meals the
  day after that.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Accept a Different Sense of Time.
• Many Indians are task-conscious rather than
  time- conscious, paying more attention to
  finishing task than to a clock or to an
  appointment schedule.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

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• Keys to a Good Professional Relationship with
  American Indian Patients
• Give and Expect Generosity.
• Indian culture discourages competitive behavior
  and encourages giving, sharing, and cooperation.
• Generosity and doing things for others are
  regarded highly.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

75

• Potential Culture-Related Health Concerns Among
  American Indians
• Average life expectancy of 71.1 years lower
  than all other races in the United States.
• Many health problems and the high incidence of
  accidents and suicides.
• The Infant death rate is high, a fact
  attributed to a high incidence of diarrhea and a
  harsh physical environment.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

76

• Potential Culture-Related Health Concerns Among
  American Indians
• Women may choose not to seek prenatal care,
  because pregnancy and birth are considered
  normal processes and health facilities are
  associated with illness and disease.
• Pregnant Navajo women are forbidden to attend
  traditional healing ceremonies to avoid contact
  with illness or disease.
• Hold your maternal and child care clinics in a
  location separate from other clinical services.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

77

• Potential Culture-Related Health Concerns Among
  American Indians
• A high incidence of non-insulin-dependent (Type
  II) diabetes increased dramatically in New
  Mexico.
• American Indians are genetically predisposed to
  the disease triggered by a radical change in
  eating habits and increase in obesity among this
  population.
• Myocardial infarction incidence is higher among
  Navajo men and a gradual increase among Navajo
  women.
• Alcoholism among this population is very high.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

78

• Potential Culture-Related Health Concerns Among
  American Indians
• Fetal Alcohol Syndrome is also fairly high
  among this population.
• Navajo children have low length-for-age and
  high weight-for-length measures because of
  suboptimal nutrition.
• Of the 10 leading causes of death among
  American Indians, 5 are related to diet.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

79

• Religious and Spiritual Beliefs That Can Affect
  Care and Treatment
• Tribes share a number of fundamental health,
  illness, and illness prevention beliefs.
• Life comes from the Great Spirit (or Supreme
  Creator) and all healing begins with him.
• Man is a threefold being made up of body, mind
  and spirit.
• Health or wellness is due to a preservation of
  harmony among the body, heart, mind and soul.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

80

• Religious and Spiritual Beliefs That Can Affect
  Care and Treatment
• Tribes share a number of fundamental health,
  illness, and illness prevention beliefs.
• Plants and animals, as well as humans, are part
  of the spirit world that exists alongside, and is
  intermingled with, the physical world.
• Death is not an enemy but a natural phenomenon of
  life
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

81

• Navajo Application of These Beliefs
• Navajo society is matriarchal - Women hold a
  higher position than men
• Focus of Navajo traditional religion is on
  maintaining a harmonious relationship with all
  living things.
• Illness is thought to result from improper
  thought and behavior affecting oneself as well as
  the external, natural world of plants, animals,
  and the environment.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

82

• Navajo Application of These Beliefs
• Illness also is attributed to an improper use of
  ceremonies.
• As a rule, Navajo may not seek medical care for a
  number of discomforts and acute illnesses for
  which a non-Navajo would seek relief.
• Illness, like death, is simply viewed and
  accepted as a natural part of life.
• Source Virginia Techs Office of Multicultural
  Affairs Home Page Updated 2002

83
Marketing and Advertising to Hispanic and Native
American Populations Be culturally sensitive and
aware Spanish language spots (radio or television
should be produced specifically for the market
and not a lift of the English spot) Native
Americans can be spoken to in their own language
on radio (much tougher there are many different
dialects within the state) Source Virginia
Techs Office of Multicultural Affairs Home Page
Updated 2002