Cultural Competence and Risk Communication

1. Cultural Competence and Risk Communication Presented by Darci L. Graves, MA, MA University of Maryland-Baltimore County

2. 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

3. Terrorism/Violence 9/11 Iraq Virginia Tech Natural Disasters Tsunami Katrina Celebrity “Missteps” Michael Richards Isaiah Washington Don Imus Richard Gere Not to mention Health Insurance Immigration Cultural Competence & The Front Page

4. 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.

10. Every encounter is a cross-cultural encounter. - Robert C. Like, MD, MS

11. 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).

12. Aspects of Culture that are also Health Determinants

13. Cultural Competence A historic progression in the U.S.: Cultural awareness… Then cultural sensitivity… And now cultural competence.

14. 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.

15. 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.

16. 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.

17. Federal Legislation & Policies Hill-Burton Act 1946 Civil Rights Act – Title VI 1964 Establishment of federal Office of Minority Health 1985 Healthy People 2000 1990 Healthy People 2010 2000 Executive Order 13166 2001 CLAS Standards Graves, D., Like, R., Hohensee, A. and Kelly, N. 2007.

18. Cultural Competence Legislation

19. 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

20. 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.

21. 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

22. … 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

23. 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 Anticipate Community Needs Through OUTREACH

24. 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?

26. Understand Audience Beliefs and Bias • 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

27. Understand Audience Beliefs and Bias

28. 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

29. Understand Audience Beliefs and Bias • trust and credibility Center for Risk Communication

30. 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?

31. 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?

32. 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.

33. 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.

34. 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?

35. Resource Inventory • What services do you already utilize? • What partners do you already have? • What experts do you have access to?

36. 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?)

37. 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.)?

38. 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.

39. 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?

40. 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

41. 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?

42. 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.

43. Engage Community http://quickfacts.census.gov/qfd/states/34000.html

44. Engage Community http://quickfacts.census.gov/qfd/states/34000.html

45. 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

46. % Speakers of Languages Other than English by county Engage Community http://www.mla.org/census_compare

47. Language Total % English 262,340 80.11% All languages other than English combined 65,117 19.88% Spanish 29,170 8.90% Italian 4,410 1.34% Polish 3,545 1.08% Chinese 3,320 1.01% French 2,325 0.71% German 2,285 0.69% French Creole 1,755 0.53% Korean 1,430 0.43% Russian 1,410 0.43% Gujarathi 1,299 0.39% Arabic 1,279 0.39% Hindi 1,154 0.35% Ukrainian 1,015 0.30% Urdu 985 0.30% Tagalog 714 0.21% Greek 600 0.18% Japanese 590 0.18% Kru, Ibo, Yoruba 550 0.16% Hungarian 505 0.15% Mandarin 490 0.14% India 440 0.13% Tamil 400 0.12% Telugu 385 0.11% Hebrew 384 0.11% Formosan 340 0.10% Panjabi 325 0.09% Dutch 295 0.09% Turkish 275 0.08% Portuguese 270 0.08% Total: 327,457 Engage Community Mercer County http://www.mla.org/map_data_results&state_id=34&county_id=21&mode=geographic&zip=&place_id=&cty_id=&ll=top&a=&ea=n&order=r

48. 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?

49. 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?

50. 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