Cultural Competence
and Risk Communication
Presented by
Darci L. Graves, MA, MA
University of Maryland-Baltimore County
Today’s Objectives
• Explain how preparedness messages are
perceived across various cultures
• Discuss the significance of delivering
culturally appropriate preparedness
messages
• Describe strategies for culturally
competent communications during a
public health emergency
Cultural Competence & The Front Page
• Terrorism/Violence
– 9/11
– Iraq
– Virginia Tech
• Natural Disasters
– Tsunami
– Katrina
• Celebrity “Missteps”
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Michael Richards
Isaiah Washington
Don Imus
Richard Gere
• Not to mention
– Health Insurance
– Immigration
• People prepare, respond, and recover from disaster
within the context of their culture.
• Culture offers a protective system that is both
comforting and reassuring.
• It defines appropriate behavior and furnishes a
support system, and identifies a shared vision for
recovery.
• Despite the strengths of culture, responses from
some groups may make them more vulnerable than
others.
Every encounter is a
cross-cultural encounter.
- Robert C. Like, MD, MS
Defining “Culture”
Culture refers to integrated patterns of
human behavior that include the language,
thoughts, communications, actions, customs,
beliefs, values, and institutions of racial,
ethnic, religious, or social groups.
» [Based on Cross, T., Bazron, B., Dennis K., & Isaacs, M.,
(1998). Towards A Culturally Competent System of Care
Volume I. Washington, D.C.: Georgetown University Child
Development Center, CASSP Technical Assistance
Center).
Aspects of Culture that are also
Health Determinants
Language
Urban/Rural
Race/Ethnicity
Occupation
Ability/Disability
Religion/Spirituality
Socio-Economic
Status
Health Status
Gender
Sexual Orientation
Cultural Competence
A historic progression in the U.S.:
Cultural awareness…
Then cultural sensitivity…
And now cultural competence.
Cultural Competence
Cultural Competence is a set of
congruent behaviors, attitudes, and
policies that come together in a system,
agency, or among professionals that
enables effective work in cross-cultural
situations.
» [1] HHS Office of Minority Health Culturally and Linguistically Appropriate
Services Standards, at www.omhrc.gov/assets/pdf/checked/executive.pdf.
Need for Cultural Competence
• Respond to current and projected demographic changes in the
United States
• Reduction of long-standing disparities in the physical and mental
health - status of people from differing racial, ethnic and cultural
backgrounds
• Improvement of the quality of services and primary care outcomes
• Compliance with legislative, regulatory and accreditation mandates
• Creation of a competitive edge in the market place
• Decrease in the likelihood of liability/malpractice claims
National Center for Cultural Competence. 2003.
Health Disparities
The Institute of Medicine, in its
publication, “Unequal Treatment:
Confronting Racial and Ethnic
Disparities in Health Care,” determined
that the “development and
implementation of training programs for
health care providers [around topics of
cultural competence] offer promise as a
key intervention strategy in reducing
healthcare disparities”. [1]
[1] Smedley, Stith and Nelson. 2003.
Federal Legislation & Policies
1946
Hill-Burton Act
1964
Civil Rights Act – Title VI
1985
Establishment of federal
Office of Minority Health
1990
Healthy People 2000
2000
2001
Healthy People 2010
Executive Order 13166
CLAS Standards
Graves, D., Like, R., Hohensee, A. and Kelly, N. 2007.
Cultural Competence Legislation
National Standards on Culturally and
Linguistically Appropriate Services (CLAS)
•
The CLAS standards are primarily directed at health care organizations;
however, individual providers are also encouraged to use the standards to
make their practices more culturally and linguistically accessible. The
principles and activities of culturally and linguistically appropriate services
should be integrated throughout an organization and undertaken in
partnership with the communities being served.
•
The 14 standards are organized by themes: Culturally Competent Care
(Standards 1-3), Language Access Services (Standards 4-7), and
Organizational Supports for Cultural Competence (Standards 8-14). Within
this framework, there are three types of standards of varying stringency:
mandates, guidelines, and recommendations as follows:
– CLAS mandates are current Federal requirements for all recipients of
Federal funds (Standards 4, 5, 6, and 7).
– CLAS guidelines are activities recommended by OMH for adoption as
mandates by Federal, State, and national accrediting agencies (Standards
1, 2, 3, 8, 9, 10, 11, 12, and 13).
– CLAS recommendations are suggested by OMH for voluntary adoption by
health care organizations (Standard 14).
www.omhrc.gov
Goal for Today’s Conference
The goal of the conference is to provide
information and education on effective
crisis communication principles using
real-life examples as a guide.
What Is Risk Communication?
Risk communication has many definitions.
Two basic ones are:
1) “An interactive process of exchange of information and
opinion among individuals, groups and institutions. It
involves…messages about the nature of risk and other
messages not strictly about risk…that expresses concerns,
opinions or reactions to risk messages…..”
2) "The exchange of information among interested parties
about the nature, magnitude, significance or control of
risk .”
http://www.njcphp.org/rc/index.cfm
… there many goals of risk communication
"Enable individuals to "make informed…
decisions for themselves and their community."
"Dispel myths…reduce fears, and, in times of
crisis, to alert the pubic and provide directions
for urgent action."
http://www.njcphp.org/rc/index.cfm
Anticipate Community
Needs Through OUTREACH
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O - Outline Goals
U - Understand Audience Beliefs & Bias
T - Training & Team Building
R - Resource Inventory
E - Engage Community
A - Adopt & Adapt Plan
C - Communicate
H - Hindsight
Outline Goals
• What is the threat you are trying to
prevent?
• What is the recommended response
to avert the threat?
• Who is the target audience?
Understand Audience Beliefs and Bias
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Gay/lesbian/bisexual/transgender
Those in poverty
Racial/ethnic minorities
Religious/Spiritual minorities
Persons with disabilities
Patients with HIV/AIDS
Children
Older adults
Cultural minorities (e.g., Amish, Appalachian)
Military culture
Migrant workers/homeless/displaced persons
Persons with mental illness
Understand Audience Beliefs and Bias
Language
Urban/Rural
Race/Ethnicity
Occupation
Ability/Disability
Religion/Spirituality
Socio-Economic
Status
Health Status
Gender
Sexual Orientation
Understand Audience Beliefs and Bias
• Know Your Organization’s Reputation in the
Community
– Recognize that some populations may have a
distrust or fear of government and health
institutions
– Refugees and immigrant populations
– Tuskegee Syphilis Study (1932-1972)
– Conduct research to better understand your
organization’s reputation
– Surveys and focus groups
– Meet with local leaders of community-based organizations
– Request feedback and input on how to improve or change
reputation
Understand Audience Beliefs and Bias
• trust and
credibility
Center for Risk Communication
Understand Audience Beliefs and Bias
• Who are the most vulnerable persons in the
community? Where do they live?
• What is the range of family composition (i.e.,
single-parent households)?
• What cultural groups (ethnic, racial, and
religious) live in the community?
• Where do they live, and what are their special
needs?
• What are their values, beliefs, and primary
languages?
• Who are the cultural brokers in the community?
Understand Audience Beliefs and Bias
• Does the community have any special
economic considerations that might
affect people’s vulnerability to
disaster?
• Are there recognizable socioeconomic
groups with special needs?
• How many live in rental property?
How many own their own homes?
Training and Team Building
• Training is perhaps the most
important step. Once staff have
taken a training program, their
awareness is heightened, and they
will be better equipped to design
plans & programs that take into
account the needs of culturally
diverse & Limited English Proficient
populations.
Training and Team Building
• Training – have staff members received
cultural competence training?
• “Champions” – are there any individuals
who are committed to this cause, and if
so, can they assist with the emergency
preparedness plan?
• Form an Internal Team - Cultural
Competence is an ongoing process and
must be revisited through continual
training and discussion.
Resource Inventory
• Representation – are any of your staff members
of diverse communities who can serve as
liaisons/advisors?
• Knowledge – Do existing staff members have a
good understanding of the ethnic and linguistic
composition of the community?
• Partners – Can vendors/suppliers support the
plan?
Resource Inventory
• What services do you already utilize?
• What partners do you already have?
• What experts do you have access to?
Resource Inventory
• Language Support
– Translation Services (are written materials
available in other languages?)
– Interpreting Services (can we communicate
with members of the community via
telephone and in person?)
– Bilingual Staff (how do I evaluate staff
members’ language proficiency?)
Resource Inventory
• Factors to Consider for TRANSLATION (written documents)
– Do we have a partner for translation services?
– If using in-house staff to translate, consider:
– Are these individuals truly qualified (ATA certified)?
– What are the indirect costs of taking this individual away
from other work?
– What about errors and omissions insurance ($71 million
lawsuit in Florida)?
– Does my staff have the tools and expertise necessary for
industry standards related to professional translation
(terminology management software, translation tools,
desktop publishing, localization expertise, etc.)?
Resource Inventory
Questions to Ask for Quality Translation Services
– Does the provider use translation memory tools? This is the industry standard. All
professional providers should offer this as a feature to you. This results in cost savings
due to economies of scale & translation terminology memory that is leveraged over
time.
– Are there any hidden costs? Do not judge only on price per word. Ask for a clear list of
all charges; if certain services are not offered (editing, proofreading, desktop
publishing), where will these services be obtained?
– Does the provider offer culturally appropriate services? Ensure that your provider does
cultural adaptation - not just simple linguistic transfer.
– Can the provider assist with literacy issues? If you know the average reading level of
your target population, the translation provider should be able to adapt the reading
level.
– Am I protected? The organization should provide qualified and certified translators only,
and should offer comprehensive insurance.
Resource Inventory
• Factors to Consider for INTERPRETING (spoken language needs)
– Do we have a partner for interpreting services?
– What happens if the local area is affected (will the partner be
affected as well?)
– Do we have access to an interpreting service that is available
24/7?
– Do we have access information readily available?
– Does the partner have a back-up/emergency redundancy plan?
– Do we have a list of volunteer interpreters/bilingual staff
available for emergencies?
– Do we have a plan in place to notify/activate our back-up
interpreters/volunteers?
Resource Inventory
• Factors to Consider for BILINGUAL STAFF (spoken
language needs)
– Have staff members been tested for language
proficiency?
– Written vs. oral
– Incentive or recognition program for testing
– Is there a roster of individuals with proven language
proficiency?
– Proficiency does not equal interpreting or translation
ability
Engage Community
• What resources and supports would community
and cultural/ethnic groups provide during or
following a disaster?
• Do the groups hold pre-existing mutual aid
agreements with any State or county agencies?
• Who are the key informants/ gatekeepers of the
impacted community?
• Has a directory of cultural resource groups, natural
helpers, and community informants who have
knowledge about diverse groups been developed?
• Are the community partners involved in all phases
of disaster preparedness, response, and recovery
operations?
Engage Community
• Ensure access to services and information
• Consider teaming with other organizations
• Public safety / education resources /
partnerships
• Identify Partners - Places of worship, other
Government organizations, FBOs, CBOs,
staff/volunteers, etc. Use all of these to
share information.
Engage Community
Percent Distribution of NJ Population
2004 Census Data
New Jersey
U.S.
Population, percent change,
April 1, 2000 to July 1, 2005
3.6%
5.3%
Population, percent change,
1990 to 2000
8.6%
13.1%
Persons under 5 years old, percent,
2004
6.7%
6.8%
Persons under 18 years old, percent,
2004
24.8%
25.0%
Persons 65 years old and over,
percent, 2004
12.9%
12.4%
Female persons, percent, 2004
51.3%
50.8%
http://quickfacts.census.gov/qfd/states/34000.html
Engage Community
Percent Distribution of NJ Population
2004 Census Data
New Jersey
U.S.
White Persons
76.9%
80.4%
Black Persons
14.5%
12.8%
American Indian and Alaska Native
Persons
0.3%
1.0%
Asian Persons
7.0%
4.2%
Native Hawaiian and Other Pacific
Islander
0.1%
0.2%
Persons Reporting Two or More Races
1.2%
1.5%
Persons of Hispanic or Latino Origin
14.9%
14.1%
White Person, not Hispanic
63.8%
67.4%
http://quickfacts.census.gov/qfd/states/34000.html
Engage Community
Most spoken languages in New Jersey:
English is spoken by 74.53% of people over 5 years old in New Jersey.
Languages other than English are spoken by 25.46%.
Speakers of languages other than English are divided up as follows.
http://www.mla.org/cgi-shl/docstudio/docs.pl?map_data_results
Engage Community
% Speakers of
Languages
Other than English
by county
http://www.mla.org/census_compare
Engage Community
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Mercer County
Language
Total
%
• Tagalog
714
0.21%
English
262,340 80.11%
• Greek
600
0.18%
All languages other than English combined
• Japanese
590
0.18%
65,117 19.88%
• Kru, Ibo, Yoruba 550
0.16%
Spanish
29,170 8.90%
• Hungarian
505
0.15%
Italian
4,410
1.34%
• Mandarin
490
0.14%
Polish
3,545
1.08%
• India
440
0.13%
Chinese
3,320
1.01%
• Tamil
400
0.12%
French
2,325
0.71%
• Telugu
385
0.11%
German
2,285
0.69%
• Hebrew
384
0.11%
French Creole 1,755
0.53%
• Formosan
340
0.10%
Korean
1,430
0.43%
• Panjabi
325
0.09%
Russian
1,410
0.43%
• Dutch
295
0.09%
Gujarathi
1,299
0.39%
• Turkish
275
0.08%
Arabic
1,279
0.39%
• Portuguese
270
0.08%
Hindi
1,154
0.35%
• Total:
327,457
Ukrainian
1,015
0.30%
http://www.mla.org/map_data_results&state_id=34&county_id=21&mode=geographic&zip=&place_id=&cty_i
d=&ll=top&a=&ea=n&order=r
Urdu
985
0.30%
Adopt & Adapt Plan
• What are the Federal, State, and local roles in
disaster response?
• How do Federal, State, and local agencies relate
to one another?
• Who would lead the response during different
phases of a disaster?
• How can mental health services be integrated
into the government agencies’ disaster response?
• What mutual aid agreements exist?
• Do any subgroups in the community harbor any
historical or political concerns that affect their
trust of government?
Adopt & Adapt Plan
• What are the roles of the American Red
Cross, interfaith organizations, and other
disaster relief organizations?
• What resources do non-government agencies
offer, and how can local mental health
services be integrated into their efforts?
• What mutual aid agreements exist?
• How can mental health providers collaborate
with private disaster relief efforts?
Adopt & Adapt Plan
• Is there support for your plan from all
participating parties?
– Internal staff
– External vendors / suppliers
– Organizational partners
– Community partners
– Public at large
Adopt & Adapt Plan
• Is the emergency preparedness plan appropriate from a
cultural and linguistic standpoint?
– Communication – make sure that the communication
channels in place are appropriate for reaching all
affected populations
– Preparedness – have key messages (e.g. evacuation
instructions, maps, emergency preparedness guides,
etc.) translated in advance and distribute information
to the community through channels
– Input – ask community leaders to provide insight for
how to improve upon existing plans
Adopt & Adapt Plan
• Are policies and procedures in place
to collect, maintain, and review
current and emergent demographic
data for any area that might be
affected by a disaster?
• How could individuals be identified
and reached in a disaster?
Communicate
• In your plan, identify communication channels
and means of access, for example:
– Will printed copies of the
information/resources be available? If so, at
what locations (community centers, places of
worship, other frequently visited sites within
the community)?
– Will information be available in other media
(web, telephone, etc.)? If so, will the access
method be linguistically and culturally
appropriate?
Communicate
• Is the emergency preparedness plan appropriate from a
cultural and linguistic standpoint?
– Communication – make sure that the communication
channels in place are appropriate for reaching all
affected populations
– Preparedness – have key messages (e.g. evacuation
instructions, maps, emergency preparedness guides,
etc.) translated in advance and distribute information
to the community through channels
– Input – ask community leaders to provide insight for
how to improve upon existing plans
Hindsight
• What have we learned from the past?
– Katrina
– Anthrax
– Pandemics
Hindsight
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Does the plan meet the goals?
Was the plan developed with the audience in mind?
Are all the available resources being utilized?
Are all stakeholders being trained?
Has the community been engaged in developing the
plan?
• Has the plan been adopted and adapted as
necessary?
• Have past lessons been incorporated?
Considerations for Ongoing Evaluation
• Can there be a task force dedicated to cultural and
linguistic aspects of emergency preparedness in the
state? If so, what other government entities might
support this? (e.g. public safety)
• Can there be work teams within individual counties and
cities that focus on these tasks?
• Will there be ongoing dialogue and sharing of best
practices on this topic? If so, in what venue?
Cultural Competence
• Should be a part of an organization’s
overall mission and objectives as a
component of all services (not just
emergency preparedness).
• Cultural competence will aid in the
establishment of trust and rapport
which will be key when and if an
emergency occurs.
Keys to Implementation
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Journey Mentality
Training
Collaboration
Expert Partners
Research
Internal/External Policy Review
Methodology
Shared Understanding of Definition
of “SUCCESS”
Graves, D., Like, R., Kelly, N. and Hohensee, A. 2007.
Questions?
Darci L. Graves
[email protected]
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Health Policy Initiatives: Cultural Competence and