Center for Mental Health

Title Seperator

PART TWO

Cultural Sensitivity in Health Promotion Work

Table of Contents

2.1 Introduction
2.2 Understanding Our Shared Communities
2.2.1 Becoming Familiar With Refugee Communities
2.2.2 Improving Your Organization's Ability to Work With Diverse Groups
2.3 Developing Culturally Specific Materials for Refugee Communities
2.3.1 Fitting Materials to Meet the Needs of People in Your Community
2.3.2 Translating Information
2.3.3 Adapting Materials

2.1 Introduction

In Part Two of this manual, we talk about culture. In doing so, we ask you to think about both your own culture and the culture of people in your community.

We also discuss why culture is important to consider when you design health promotion and disease prevention programs.

Part Two consists of two sections:

2.2 Understanding Our Shared Communities

At the end of this section, you will be able to

  • Identify experiences common to refugees in the United States.
  • Better understand what culture is and its importance in health promotion and disease prevention.
  • Improve your organization's ability to work with other cultures.

This section answers the following questions:

  1. What are some of the health challenges that refugees face in settling into their new communities?
  2. What is culture?
  3. What is cultural competence and how can your organization achieve it?

Each year, new refugees come to the United States from countries all around the world. Each group brings its own beliefs and preferred way of doing things. These ideas and behaviors represent a group's culture. You might already know some of the different cultural practices in your community. Others may seem new or different to you.

It is important to understand these cultural practices when promoting health in the community for the following reasons:

Working with other cultural groups will also benefit your own organization. You will create new relationships and work with people who share a common goal of creating and maintaining a better community. You will see life through the eyes of people whose backgrounds and experiences are different from yours.

What Are Some of the Health Challenges That Refugees Face in Settling Into Their New Communities?

The United States is currently home to over 500,000 refugees from countries all around the world. Each year, another 50,000 to 70,000 refugees are admitted to the United States.

Refugees face health challenges both when they arrive in the United States and after they have been in the United States for some time.

It may be helpful to think about these challenges in terms of the stages refugees go through to get to the United States, starting with conditions in their country before leaving it (premigration), their travels to the United States (migration), and their eventual resettlement in the United States.

A refugee is any person who is outside the country of his or her nationality and who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.

www.acf.hhs.gov/programs/orr/geninfo/ index.htm

Premigration Health Issues. Many refugees come from countries with poor public health systems. They may need medical services to treat infectious diseases that exist in their home country or chronic health conditions that previously have not been addressed.

Refugees may also come from countries in war, where they saw or experienced torture and persecution. These events may lead to a greater risk for depression, stress-related disorders, or other mental health problems. Some individuals may benefit from clinical psychiatric services to help them cope with ongoing stress or for treatment of disabling symptoms. For some, this struggle may be lifelong, requiring ongoing support from those around them.

Migration Health Issues. Many refugees do not come directly to the United States. Instead, they first have to go to a refugee settlement (or camp) in a nearby country. These settlements or camps are usually crowded, and diseases are easily spread. Many times, the camps do not have adequate resources to meet the health needs of the people living in them. Therefore, many refugees need medical attention when they first arrive in the United States to treat infectious, parasitic, or other conditions from their travels. Additionally, the process of being forcibly displaced or experiences of torture and persecution during migration can contribute to mental health issues for refugees.

Resettlement-Initial Health Issues. Once in the United States, refugees usually settle in communities that are unfamiliar to them. Many of their day-to-day tasks are new. For example, grocery stores may not have the foods they are used to. Refugees often have to develop new skills, such as how to use the local buses or trains to get around town, or how to find a job.

Refugees also may face new challenges to staying healthy. For example, new diets can lead to obesity and diabetes. They may have to address and respond to such chronic illnesses as heart disease and high blood pressure, or with conditions that were not treated in their native countries. Refugees might not know of or use such prevention screenings as mammograms or cholesterol tests.

Even though refugees now live in the United States, many continue living in ways similar to those of their home country. Others adopt many of the common practices of their new community. Differences within families are also common, with older generations following traditional practices and young people adopting many new practices.

People's adjustment to their new community may be important to their well-being. Refugees who do not participate in their new community can feel lonely and can suffer from depression or other mental health conditions. Depression and alcoholism are just two health conditions refugees may be more likely to experience over the years while adjusting to their new community.

Health may not be the most important thing to refugees when they arrive in the United States. Many are first concerned with meeting their basic needs, such as finding a place to live and work. Many cannot speak English and find it difficult to do these activities. Translation services for non-English speakers might not be available in communities where refugees settle. In working with refugees, your organization may need to consider language and other communication issues first.

U.S. Committee for Refugees. (2003). World refugee survey 2003 country report.
Retrieved from http://www.refugees.org/world/countryrpt/amer_carib/2003/united_states.cfm

2.2.1 Becoming Familiar With Refugee Communities

Refugees' Strength

Don't be surprised if you find that many members of the refugee community are doing just fine in their new community. Many of those who have made it to the United States already have overcome a number of obstacles and have shown great strength in getting to the United States. Your organization should try to find ways to recognize and celebrate their accomplishments in making it to your community.

Try to learn the answers to some of the following questions as you get to know members of a refugee community:

Understanding culture will be important to your group when promoting health and preventing disease. In this section, you will learn about culture and what to consider when working with different cultural groups.

What Is Culture?

Many different definitions of "culture" exist. Most people know that culture has something to do with the customs and beliefs of a group of people. It is common to explain a holiday tradition, a spiritual belief, or a child-rearing practice as part of someone's cultural background.

Culture can strongly influence people's behavior, beliefs, attitudes, and values. This fact is not surprising since many of us recognize that our day-to-day choices often are determined by what we learned growing up in our families and communities-our own cultures.

Culture is not permanent; it can change. Groups who move and live among new cultural groups are likely to experience changes in their practices and beliefs. The changes are the result of blending the old culture and the new. Many refugee groups will experience these changes, as they combine practices from their previous country with those of their new community.

Important Cultural Components

To work effectively in your community, you need an appreciation of the individuals' different cultural backgrounds. Gaining appreciation requires learning about the beliefs and practices of others.

The following pages offer a good place to start in thinking about culture. We provide you with six sets of questions to ask. Finding answers to these questions will help you understand both the culture of the people in your community and your own culture:

  1. Language and communication style
  2. Health beliefs
  3. Family relationships
  4. Gender roles
  5. Spirituality and religion
  6. Social issues

Question Set 1:  Language and Communication Style

Language and communication style refers to the patterns and behaviors people use to interact with each other. Some people talk a lot to communicate with people (verbal), but others get their message across without using words (nonverbal). Each culture has its own preferences and expectations about how to communicate, including social customs about who speaks to whom. It is important that you learn about the target audience's language and communication preferences when promoting health and preventing disease in your community. Learning about these preferences and expectations will help ensure your messages are understood the way you expect them to be.

Below is a series of questions to try to answer about the people in your community and how they communicate. Answering these questions for yourself, too, will help you see the ways in which you differ from the people in your community that you are trying to help:

Question Set 2:  Health Beliefs

People from around the world have their own cultural practices when it comes to staying healthy and responding to illness.

Causes and Treatment of Diseases

Health beliefs refer to people's understanding of the causes of and explanations for disease. Getting information on people's health beliefs can help you better understand what they do about illness and how they treat it. For example, people from one culture might think a disease is caused by a spiritually unhealthy activity.

Trusted Sources

Who do people turn to for medical care if they are sick? For many who live in the United States, the answer is to a doctor or other health professional, such as nurses and physician's assistants. For many others, both in the United States and in other countries, other kinds of healers are sought out, including spiritualists, herbalists, and shamans. Often, both Western doctors and "traditional" healers are consulted, which can be to everyone's advantage.

To promote health and prevent diseases in your community, you need to think about the health beliefs and practices people use and trust in their lives. You will need to design your program so that it complements what people already know and trust about health. Answering the questions below will help you better understand your health beliefs and those of the people in your community:

Question Set 3:  Family Relationships

The family is the basic building block of all societies in the world. In the family, children are socialized into the ways of their community and its culture. You will need to understand how families are organized, so that you can promote health within them. Answering the questions below will help you better understand the family structure of the people in your community:

Question Set 4:  Gender Roles

Gender roles refer to what is considered appropriate and acceptable behavior for men and women. Much change has occurred in the past 20 years in terms of gender roles. However, many deeply held beliefs still exist about which behaviors are feminine and which are masculine.

Health concerns and risks can be different for men and women. For your work in addressing health, you may find it important to know how men and women act and behave in the community. Answering the following questions can help you identify any critical differences:

Question Set 5:  Spirituality and Religion

In many societies, spirituality and religion are central to people's lives. They can be an important resource in promoting health. It will be important for you to understand both spirituality and religion so that you can successfully work with members of other communities.

Spirituality is the part of us that seeks to find meaning or understanding in our life. In terms of health, spirituality is thought to be important to our ability to handle illness. You should be aware of people's spiritual needs and, when possible, support those needs through health services and programs.

Religion refers to a specific set of beliefs and practices regarding the spiritual, including belief in the existence of a single being or god, or group of beings, who created and govern the world. Ritual, prayer, and other spiritual exercises are commonly part of religious practice.

Below is a series of questions to try to answer so that you can learn about the spirituality and religion of the people in your community. Answering these questions for yourself, too, will help you see the ways in which you differ from the people you are trying to help:

Question Set 6:  Social Issues

Here are more questions concerning culture and community that may be helpful to consider and answer when working with people from different cultures in your community:

Questions about political power

Questions about ethnic acceptance

Questions about socio-economics

Resources:

Gavagan, T., and Brodyaga, L. (1998, March 1). Medical care for immigrants and refugees. American Family Physician.
Retrieved from http://www.aafp.org/afp/980301ap/gavagan.html

Messina, S. A. (1994). A youth leader's guide to building cultural competence. Washington, DC: Advocates for Youth.

Muecke, M. A. (1992). New paradigms for refugee health problems. Social Science and Medicine, 35(4), 515-523.

Palinkas, L. A., Pickwell, S. M., Brandstein, K., Clark, T. J., Hill, L. L., Moser, R. J., and Osman, A. (2003). The journey to wellness: Stages of refugee health promotion and disease prevention. Journal of Immigrant Health, 5(1), 19-28.

Toole, M. J., and Waldman, R. J. (1993). Refugees and displaced persons: War, hunger, and public health. The Journal of the American Medical Association, 270(5), 600-606.

U.S. Committee for Refugees. (2003). World refugee survey 2003 country report.
Retrieved from http://www.refugees.org/world/countryrpt/amer_carib/2003/united_states.cfm

Work Group on Health Promotion and Community Development, University of Kansas. (2004). Community tool box.
Retrieved from http://ctb.ku.edu/

Section 2.2.1 was adapted with permission from the following source: Messina, S. A. (1994). A youth leader's guide to building cultural competence. Washington, DC: Advocates for Youth.

2.2.2 Improving Your Organization's Ability to work with Diverse Groups

All organizations can improve their work with other cultural and ethnic groups by developing what is called cultural competence. This section provides information on how your organization can become more culturally competent in its work.

What is Cultural Competence and How Can Your Organization Achieve it?

Cultural competence is the policies and practices of an organization, or the values and behaviors of individuals, that promote effective communication across cultures.

A culturally competent organization is one that has taken the time to learn about other cultures and to develop relationships with individuals from those communities.

  1. The individual level. Your organization can encourage and hire individuals who are culturally competent. That is, these individuals have a good understanding of their own culture as well as other cultures. As an organization, you can
  1. The organizational level. Your organization can become more culturally competent if it is willing to promote policies and practices that lead to effective work between groups. Often, it is helpful to have a committee with members from all levels of your organization to work on developing these policies or practices. As an organization, you can
  1. The community level. Your organization can help create an understanding of diverse cultures in the community. Organizations can develop programs that promote cultural awareness outside of the organization. As a first step, you will need to look at how things are in your community. What are the different cultures of the people in your community? How well do people from different cultures interact? As an organization, you can

The following pages provide some exercises and handouts that you and your organization can use to help you move toward becoming a more culturally competent organization:

  1. Building Cultural Competence (Exercise)
  2. Guidance for Developing Individual Cultural Competencies (Handout)
  3. Cultural Competency Inclusivity Checklist (Handout)

Building Cultural Competence (Exercise)

This exercise provides an opportunity for members of your organization to focus on various aspects of culture that may impact on personal, organizational, and community beliefs. Use this exercise to open discussion among your staff and other members of your organization on ways to build and increase cultural competency.

To help build cultural competence:

Option A. Reflect on how you would use your understanding of your culture and that of the local community to establish a relationship with people in the local community.

Option B. Reflect on how you would use your understanding of your culture and that of the local community to design an intervention intended to benefit people in the local community.

  1. What is your self-identity (e.g., female, Hispanic, or professional)?
  2. Who lives in the community served by your organization?
  3. What events have shaped your life experiences?
  4. What have your life experiences been like (e.g., success or inequity)?
  5. What do you value (e.g., respect, responsibility, or interdependence)?
  6. What gives you a sense of belonging (e.g., religion, occupation, or history)?
  7. What is valued about people, genders, and generations?
  8. What are your religious beliefs?
  9. What language is used?
  10. What are important customs?
  11. What emotions are valued?
  12. What beliefs are important for solving problems?
  13. What institutions are valued (e.g., school or church)?
  14. What are the important features of family?
  15. What is the most valued form of social organization?
  16. How is formal education valued?
  17. What is the most valued community unit (e.g., neighborhood, city, or county)?
  18. What are the attitudes about others or outsiders helping to solve problems?
  19. What are the attitudes about solving problems?
  20. Who are the most valued help-giving persons?
  21. What are economic conditions like?

If answers to some questions are not known, how would you obtain information to understand more about these cultural issues?

Guidance for Developing Individual Cultural Competencies (Handout)

This list provides some guidance for ways to increase your personal cultural competency. Read and think about each issue and then discuss among your staff and other members of your organization ways to integrate these issues into your daily interactions.
  1. Be nonjudgmental.
    Shut down the tendency to view another person in a negative light or to view him with disfavor.
  2. Be flexible.
    Readjust quickly and effectively to changing situations.
  3. Be resourceful.
    Know how to get the things you need quickly to respond well to any situation.
  4. Personalize observations.
    Express your personal feelings, thoughts, ideas, and beliefs in a personal way, whether or not they are the same as someone else's. Use "I-messages" rather than "you-messages" (e.g., "I disagree" rather than "You're wrong"). Repeat back what you are hearing in conversation ("Am I hearing you say?"). Listen actively by giving verbal indicators regularly while in conversation ("Uh huh" or "Yes").
  5. Pay attention to your feelings.
    Take your feelings seriously, and keep in touch with how you feel about what the other person is saying in conversation. This approach will put you in better charge of yourself and in better command of the interpersonal situation.
  6. Listen carefully and observe attentively.
    Do this to help increase sensitivity to the whole message, not just what is being said in words.
  7. Assume complexity.
    Recognize multiple perspectives in any culturally diverse environment.
  8. Tolerate the stress of uncertainty.
    In an overlap with No. 3, avoid showing irritation or annoyance in a culturally diverse situation.
  9. Have patience.
    Use this positive way to respond to stress.
  10. Manage personal biases.
    Look beyond your personal view so that you can treat the person with you as an individual deserving your respect.
  11. Keep a sense of humor.
    Avoid taking yourself so seriously that you can't laugh at yourself.
  12. Show respect.
    Go out of your way to express in a genuine manner your understanding, honor, and esteem of the person you are dealing with.
  13. Show empathy.
    Put yourself in the other person's shoes. This act is critical in a culturally diverse encounter.

Cultural Competency Inclusivity Checklist (Handout)

This checklist will help you measure how prepared your organization is for work with different cultural groups and identify areas for improvement. Go through the list, and put a checkmark next to the items that already describe your organization. If you cannot check off an item, that may indicate an area for change.

  1. The leadership of our organization is multiracial and multicultural.
  2. We make special efforts to support new leaders, particularly women and people of color.
  3. Our mission, operations, and products reflect the contributions of diverse cultural and social groups.
  4. We are committed to fighting social oppression within the organization and in our community work.
  5. Members of diverse cultural and social groups are full participants in all aspects of our organization's work.
  6. Speakers from any one group do not dominate meetings.
  7. All segments of our community are represented in decision making.
  8. We show sensitivity and awareness regarding different religious and cultural holidays, customs, recreational preferences, and food preferences.
  9. We communicate clearly, and people of different cultures feel comfortable sharing their opinions and participating in meetings.
  10. We prohibit the use of stereotypes and prejudicial comments.
  11. Ethnic, racial, and sexual slurs or jokes are not welcome.

Additional Resources to Promote Cross-Cultural Understanding:

  • http://www.has.vcu.edu/psy/iam/compendium_intro.htm
    "Excellence in Cultural Competence Training and Education: A Compendium of Best Practices." This site is a resource for training and education in cultural competence.
  • http://gucdc.georgetown.edu/nccc/ncccexchange.html
    The National Center for Cultural Competence at Georgetown University increases the capacity of health care and mental health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems. Publications and Web links are available.

    The Cultural Competence Exchange includes such success stories as this "Journey Towards Cultural Competence" example from Wisconsin: http://gucdc.georgetown.edu/nccc/ncccexnov19999.html

  • http://www.peacecorps.gov/wws/culturematters/index1.html
    Culture Matters is a cross-cultural training workbook developed by the Peace Corps to help new volunteers acquire the knowledge and skills to work successfully and respectfully in other cultures.
  • http://www.bphc.hrsa.gov/culturalcompetence/Default.htm
    "Cultural Competence: A Journey," a publication from the U.S. Department of Health and Human Services, presents examples of five essential elements that contribute to a system's, institution's, or agency's ability to become more culturally competent.
  • http://www.has.vcu.edu/psy/iam/compendium_intro.htm
    Virginia Commonwealth University's Institute for African-American Mental Health makes available a thorough compendium of best practices in cultural competence training and education.
  • http://www.edchange.org/multicultural/
    The Multicultural Pavilion offers resources and dialogue for educators, students, and activists on all aspects of multicultural education.
  • http://home.wmis.net/~russon/icce/
    The International & Cross-Cultural Evaluation Topical Interest Group, an organization that is affiliated with the American Evaluation Association, provides evaluators who are interested in cross-cultural issues with opportunities for professional development.
  • http://www.clas.uiuc.edu/
    The Center for Culturally and Linguistically Appropriate Services collects and describes early childhood and early intervention resources. It also serves as a point of exchange for users.
  • http://ericae.net/faqs/Cognitive_Styles/Cognitive_styles.htm
    This site offers information on different learning styles, possibly another dimension in understanding a person's culture. It is provided by the ERIC (Educational Resources Information Center) Clearinghouse on Assessment and Evaluation at the University of Maryland.

2.3 Developing Culturally Specific Materials for Refugee Communities

At the end of this section, you will be able to

  • Develop materials that are tailored to the communication needs of people in your community.
  • Know how to effectively translate materials for your audience.

This section answers the following questions:

  1. What do I look for in a translator?
  2. How do I decide which materials to adapt?

2.3.1 Fitting Materials to Meet the Needs of People in Your Community

Overcoming language barriers is one of the most challenging aspects of promoting health and preventing diseases among people from diverse cultures. Consider some of the different types of communication needed when addressing your work with diverse groups.

Two Types of Communication:  Verbal and Written

Verbal Communication

Verbal communication (speaking) within your community is most significant when you are providing direct care to people. If you are trying to communicate with a person who speaks a different language than you do, the potential for mistakes is greater. To reduce mistakes, we recommend you use a trained interpreter in the health care setting. Many hospitals and health clinics provide these services.

Verbal communication also is critical when promoting health messages, assuming some members of your community have limited reading ability. You may want to use other methods of communication, such as the following:

Written Communication

Written materials will likely be a main form of communication your organization uses in your health promotion and disease prevention efforts. If these materials are for people in your community who speak and read another language, they will need to be translated into these individuals' native language. Even if the members of a community speak English, they may not be able to read well, especially if the subject is unfamiliar or complex. Even some people who are able to read in English still prefer reading in their native language. In most cases, organizations find it is worth their time and money to translate or adapt materials to members' native language.

2.3.2 Translating Information

You are likely to find that translating existing materials requires less time and fewer resources than developing new materials. However, translations of English to other languages may not always convey the desired messages and have the potential to be insensitive or offensive if done wrong.

It is important to work with your community to be sure the language you use is appropriate. In many cases, the best solution is to translate some of the material, while adapting or developing other parts specifically for the community.

Professional translation services are an option and should be the first choice when translating important health information. For other tasks, consider asking members of your community that you are working with to volunteer to help in translating or, if your budget allows, pay them on an hourly basis.

Avoid using either online dictionaries that translate English into other languages or computer software to translate materials. These programs are not reliable for this type of work because they are able to do only word-for-word translations and cannot take your intended message into account.

Tip: Back-Translating

One technique you can use to improve translation is to have an individual translate materials from one language to whatever language you are interested in using. Then, ask another person-someone who does not know the original content of the materials-to translate the materials back into the original language. As a last step, compare the original version with the newly translated one. This process can help you identify places in which there may be difficulties in the translation, particularly where concepts or meanings might have been distorted.

You may never be able to get a perfect translation; the important thing is getting one that works for you. Pretest materials with members of the community by asking them to read and talk about what they are reading. This step also can help you understand where there may be confusion in a translation.

What Do You Look for in a Translator?

If you do decide to use a professional translator, these tips can help you identify an appropriate person.

Look for someone who has the following characteristics:

2.3.3 Adapting Materials

How Do You Decide Which Materials to Adapt?

These questions may be useful in deciding whether all or parts of your material can be adapted:

The following are additional tips to help you adapt materials. You should consider three main issues when adapting materials for your needs:

  1. Text
  1. Visuals

Helpful Hints

  • Use images of people who look like your intended audience.
  • Use visuals that represent the geography and setting where your audience lives, works, and plays.
  • Show people doing things that are realistic and reflective of their lives.
  • Use clothes and other belongings familiar to the audience.
  1. Format

Resources:

AMC Cancer Research Center. (1994). Beyond the brochure: Alternative approaches to effective health communication. Denver: Author.

Center for Medicare Education. (n.d.). Translating materials for non-English-speaking audiences. Issue Brief, 1(3).

Kentucky Cabinet for Families and Children. (June-July 2002). CFC Online.
Retrieved from http://cfc.state.ky.us/cfconline/2002June-July/From%20the%20Editor.htm

National Cancer Institute. (2002). Making health communication programs work: A planner's guide (NIH Publication No. 02-5145). Bethesda, MD: National Institutes of Health.

National Conference of State Legislatures, Resources for Cross Cultural Health Care, and Henry J. Kaiser Family Foundation. (2001). Diversity Rx.
Retrieved January 2004 from http://www.diversityrx.org

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