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Cultural Awareness Training for United States Public Health Service Commissioned Corps

This cultural awareness training was presented to the U.S. Public Health Service Commissioned Corps on January 29, 2020. The webinar presented strategies to improve leadership and service by increasing Commissioned Corps officers’ cultural awareness and ability to serve individuals from diverse backgrounds in their agencies and during deployment. It included an overview of the National CLAS Standards and offered resources about providing culturally and linguistically appropriate services (CLAS).

Welcome to the U.S. Public Health Service Commissioned Corps Cultural Awareness Training. The purpose of today's training is: to increase effective leadership and service by elevating Commissioned Corps officers’ cultural awareness; to provide the knowledge and skills to help officers advance the Commissioned Corps mission and; to better serve individuals from diverse backgrounds and their agencies and during deployment.

The learning objectives are, at the conclusion of this activity officers will be able to: define the cultural and linguistic factors of cultural identity, stereotypes, bias, cultural awareness, cultural competency, and cultural humility; describe their cultural identity and evaluate their biases to enhance responsiveness in addressing the multidimensional expectations and needs an internal and external stakeholders; and describe cultural awareness as it relates to disaster in crisis response.

Let's start with culture, cultural identity, and intersectionality. Culture determines how we see the world or our worldview. It is a way to make meaning of things. There's a quote, “we don't see things as they are we see them as we are.”

Culture is defined as “the integrated pattern of thought, communications, actions, customs, beliefs, values and institutions associated wholly or partially with racial ethnic or linguistic groups, as well as religious, spiritual, biological, geographical, or sociological characteristics.” Culture is dynamic in nature and individuals may identify with multiple cultures over the course of their lifetime. This broad conceptualization helps underscore the fact that every encounter is a cross-cultural encounter.

Cultural awareness is the process of conducting a self-examination of one's own biases against other cultures and the in-depth exploration of one's cultural and professional backgrounds. This diagram shows you some broad aspects of culture and how they may coexist within a given person. Keep in mind that this slide does not provide an exhaustive list of the elements of culture. Most of us do not identify with just one part of the diagram below. For example, someone may closely identify with their race, ethnicity, language - including dialects, socioeconomic status, spirituality, sexual orientation, and gender identity; and therefore be influenced by all aspects simultaneously. Remember that the individuals you are working with will be the best authority on their own cultural identities and which one's they consider most important.

USPHS Commissioned Corps officers represent multiple professions. Think about which professional category you fit in, who are you- In uniform? In the community or as a citizen? Or in the service of the public, and in daily operations?

How are cultural competency and cultural humility related? Cultural and linguistic competency is defined as “a capacity for individuals and organizations to work and communicate effectively in cross-cultural situations.” In addition, this includes the adoption and implementation of strategies to ensure appropriate awareness, attitudes, and actions; and through the use of policies, structures, practices, procedures; and dedicated resources that support this capacity. Cultural linguistic competence is an important way for professionals to respond to the growing diversity of the U.S. population. Cultural competence can mitigate health disparities and improve the quality of services and outcomes.

Competency often implies that you did or did not reach the finish line, but it is important to remember that cultural competency is a journey and to work effectively in cross-cultural situations it is important to be open to cultural differences and be willing to learn in a zap.

Cultural humility is defined as “redressing the power imbalances in the service dynamic, establishing a lifelong commitment to self-evaluation and self-critique, and developing mutually beneficial partnerships with communities on behalf of individuals and defined population.” Cultural humility is different from cultural competency because it focuses on self-humility rather than achieving a state of knowledge for awareness. This includes a continuous process of self-reflection; examining these stereotypes; and openness to learning more about the cultures, perspectives, beliefs, values and worldview of those you lead and serve; prioritizing the culture, perspective, beliefs, values and worldviews those you serve; acknowledging one's limitations - meaning that we will never know everything there is to know about everyone's culture; and continued growth and development over time.

Here's a checklist of some ways that you can practice cultural humility. Some of these examples are: I understand my cultural identity; I have a six-year belief that I can explore different values without losing a sense of integrity; I am always open to explore others' cultural identity and I ask questions when I'm uncertain; I express curiosity and interest about others beliefs, values, and worldview; I'm committed to learning and growing from interactions of individuals with beliefs values and worldviews differ for mine; I always pursue further training or seek consultation from experts than needed.

Cultural competency and cultural humility can improve the quality of services. Whereas cultural competency includes the commitment to practice cultural humility, cultural humility acknowledges that even with training and cultural and linguistic competency, we always have more to learn.

What impacts effective cultural based operations? Anytime we interact with someone, our interaction is shaped by who we are, our backgrounds, attitudes, values, and beliefs and those of the other person. What are things we notice about people when we meet them? We are influenced by many factors, such as our beliefs about the person's physical appearance, including their skin color, facial features, clothing, gender, sexual orientation, socioeconomic status, and country of origin, accents, and many other characteristics.

Bias are “conscious or unconscious judgments we make in our daily lives. Everyone has biases and they impact all aspects of our lives. Biases are often based on our cultural beliefs, attitudes, or opinions that we are typically not aware of.” Biases are mental shortcuts that help us simplify an otherwise complex world. Some different forms of bias include: national origin bias, sexual orientation bias, racial bias, size or weight bias, gender bias, disability bias, age bias, religion or spirituality bias, and CLAS bias.

Hidden bias, or implicit bias, refers to bits of knowledge about social groups that are stored in our minds because we encounter them so frequently in our social environment. Once lodged in our minds, hidden or implicit biases can influence our behavior toward members of these cultural groups without us being aware of their role. If we don't get to know our biases and how they play out in our lives they can turn into stereotypes and even prejudice and discrimination. The Implicit Association Tests (IATs) can help assess the strength of implicit biases. When you get a chance, visit the website - Project Implicit.

Let's examine some stereotypes. Stereotypes are common, but when left unchecked they may cause us to treat individuals differently based on our assumptions about them. How does reading these stereotypes make you feel? Perhaps you feel angry, offended, defensive, or even hurt? Do you think about the stereotypes those you lead and serve encounter in their daily lives? Stereotypes and microaggressions go hand-in-hand. Microaggressions are the everyday slights, put downs, invalidations and insults often times aimed at people from non-dominant groups by people who may be unaware that what they have said or done is harmful. Even though microaggressions are often subtle, microaggressions can be very insulting and can affect someone in much the same ways as overt discrimination.

When you believe a stereotype, it's easy to notice the things that fit with that stereotype and it's easy to disregard the things that do not. So combating stereotypes requires intention and effort. Try to identify stereotypes you agree with this will make it easier to recognize how stereotypes shape your actions, especially when interacting with those you lead and serve. Start by practicing being aware of any judgments you automatically make about someone that are solely based on a social identity of theirs. Label these judgments of stereotypes and try resisting them.

This slide shows some techniques for combating stereotypes. Stereotype replacement means becoming aware of stereotypes you hold and creating a non-stereotypical alternatives to them. Counter-stereotypic imaging means remembering or imagining someone from a stereotype group who does not fit the stereotype. Individuating - seeing someone as an individual not a group member, paying attention to things about them besides the stereotypes of their group. Perspective - taking imagining the perspective of someone from a group different than your own. And contact - speaking opportunities to get to know people from stereotyped groups.

So what can you do next? Here are some cultural humility strategies: try to be other oriented, learn to think accurately about and empathize with others life experiences with stereotypes discrimination and oppression, create a cultural feedback that offers those you lead and serve a safe space to discuss their experiences with microaggressions and oppression as well as their experiences with you, when you recognize that you committed a microaggression address it and apologized for it.

Being able to recognize microaggressions will help you build strong relationships because you'll better understand the life experiences of those you lead and serve and better avoid committing microaggressions. Practicing cultural humility will help you both recognize and avoid committing a microaggression and it will be very helpful to help you repair a relationship following a microaggression.

Now, we're going to take some time to discuss the five elements of cultural competence. Let's start with awareness and acceptance of difference. Racial and ethnic diversity is increasing in the United States, which makes the issue of cultural awareness even more important if you are to be prepared to lead and serve racially and ethnically diverse individuals. This graphic demonstrates these changes over time.

The United States does not have an official language and actually has over 250 languages spoken at any given time. This graphic shows the top languages besides English spoken in the United States. The order of the languages can be very different from where you reside versus where you may lead, serve, even be deployed.

Despite the increasing racial and ethnic diversity of the United States, this diversity is not represented among first responders – namely, social workers, EMTs/Paramedics, and firefighters. Let's examine this close.

Throughout this presentation we have discussed the importance of cultural awareness and understanding our own culture. This quote represents the importance of understanding the cultures of those we lead and serve. An officer said, “I would see disaster personnel go into a situation… they felt that their presence alone and the fact that they were there to provide a service should be reason enough for these people to be accepting of them and accepting of the services that they wanted to give, and although your heart might have been in the right place and this is your job… if you don't understand or take the time out to try to understand their culture and what makes them tick your services may although be needed not wanted.”

Let's discuss the next element of cultural competence, awareness of our own cultural values. It’s important to acknowledge the impact of power and privilege. Power is defined as a person or institutions ability to exert influence over others. Privilege is defined as greater support for one's perspective interests and beliefs along with greater access to information resources and opportunities due to one's membership in a dominant group.

Although we'll never know everything learning more about the experiences of different social groups can equip you to build a better relationship with those you lead and serve who identify with these groups. Here are some factors you can consider to better understand different social identities. You may want to be aware of key historical events or socio-political issues or perhaps even some basic values and beliefs, as well as cultural practices. Getting to know the social identities of those you lead and serve is not only about understanding the discrimination and oppression they have faced, it can also position you to help those you lead and serve find ways to cultivate strengths and find inspiration.

Let's turn to element three, understanding and managing the dynamics of difference. From the deployment and readiness perspectives, we define a disaster in three phases: preparedness, response, and recovery. Let's take a look at the RESPOND mnemonic that is shown on this slide. The RESPOND mnemonic gives you a way to gather information from individuals that you may serve in a way that is culturally and linguistically appropriate.

To truly understand what dynamics or at work in any given situation it's important to tailor your questions to the individuals with whom you're speaking. This will help you make sure that you get the right information from them.

So let's review the RESPOND mnemonic. R stands for build rapport with the individuals you come in contact with. E is explain the purpose of your conversation to help build rapport establishing clear intentions and expectations about the nature of the conversation will go a long way in making communication more efficient and effective. S - identify what community based services and resources are available to community members to help them re-establish their lives in addition be aware that many individuals might not understand that these service are available let alone that they are often offered and no cost to them. P - encourage individuals to be proactive in seeking help and identifying their needs. O- offer assistance for individuals in the affected communities by helping them identify their needs as much as you were able. N - negotiating what was normal prior to the disaster may help an individual in identifying their needs as much as you are able. And D - finally determine what the next steps are for that individual, as people affected by a disaster are likely to feel increasingly vulnerable. Providing them the security of structure and normalcy can improve their ability to recover more quickly.

Element 4, development of cultural knowledge. When serving individuals during deployment it is important to understand and recognize factors that can effective individual’s disaster preparedness and crisis response. Some of these include evacuation information that is only distributed in English preventing or delaying receipt of important information to non-English speaking residents in disaster zones. Stacking emergency supplies, making structural reinforcements to homes, or purchasing certain types of insurance, such as earthquake or flood insurance, can be prohibitively expensive. Living in unsafe housing creates even greater risk in disaster situations. Often times there's a lack of transportation options, there may be limited access to financial resources and insurance to help rebuild. There may be reluctance to seek federal aid. Residents may see or mistrust government agencies or residents may experience real or perceived discrimination from aid agencies.

And lastly, element 5 - ability to adapt activities to fit into different cultural contexts. To communicate effectively, you and those you serve must have a shared language or you may need to use language assistance services to provide a common language. Always ask all persons for their preferred language. If that language is not English, arrange for language assistance services, which include providing a certified interpreter to facilitate any verbal communication between a provider a staff member and a client or community member, and then providing translated materials for the necessary forms you will need to be able to serve them. Keep in mind though that some individuals who are able to speak in English may still lack the language skill to accurately explain their issues in English, especially in a time of crisis. Another thing to consider is that sometimes older adults, if their first language is not English, they may speak English fluently, but during times of crisis they revert back to their first language. So even though you may have grown up speaking or have training in a foreign language, we may not always have the language skills needed to communicate effectively in that language in various settings.

Culturally and linguistically appropriate services, or CLAS, are defined as services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and are employed by all members of an organization, regardless of its size at every point of contact.

To operationalize culturally and linguistically appropriate services or CLAS the HHS office of minority health develops guidelines called the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. These standards and an accompanying guidance document called The Blueprint are housed on the Think Cultural Health website. These 15 action steps help guide health and healthcare professionals in providing services that are respectful, understandable, effective, and equitable.

The standards are an important tool that help professionals to promote and implement CLAS. There are 15 standards each of which is an action step that guides us in implementing culturally and linguistically appropriate services or CLAS. There's a Principle Standard, which is the overarching standard, meaning that this takes a very broad view of who this applies to. When these originally came out it was just a race, ethnicity, and language - now it applies to all those different areas we mentioned when we talked about cultural identity and many more, including health literacy.

Several the themes deal with Governance Leadership and Workforce. We just spoke about Language Assistance and this includes communication. And then there's a huge piece talking about engagement, engaging communities, continuous improvement, oftentimes data collection and analysis, as well as accountability. The goals of the National CLAS standards are to improve quality services, advance health equity, and help eliminate disparities.

To learn more about the National CLAS standards and cultural linguistic competency, visit the Think Cultural Health website, which is hosted by the HHS office of minority health. Various resources are available, such as the National CLAS Standards, education programs, the Communication Guide, which talks about how to create language assistance services, and there's a track for both providers, as well as administrators, the Tracking CLAS map, and a Resource Library.

If you would like to learn about more about cultural linguistic competency especially how it applies to your field, take one of the following eLearning programs as it relates to your profession. These free e-learning programs can be completed online or at your own pace and the ones with an asterisk next to them offer continuing education credits at no cost to you. In addition, if you would like to learn more about how to provide culturally and linguistically appropriate services in disasters or emergencies, you should take the cultural competency curriculum for disaster preparedness and crisis response. Please note though that a revised version will be launched leader at this year, so keep an eye out for that. Don't forget to visit the Think Cultural Health and Office of Minority Health websites for additional information. And we'd like to acknowledge the HHS Office of Minority Health, Commander Anthony Johnson of the USPHS Commission Corps, Captain Matthew Weinberg of the USPHS Commission, and Mrs. Cheri Wilson of the Health Determinants and Disparities Practice General Dynamics Information Technology. Thank you for your time and please remember to keep cultural linguistic competency, cultural humility, and culturally and linguistically appropriate services in mind when we work with our colleagues and we serve individuals in a disaster or crisis.

Thank you.

  • Presented 01/29/2020
  • Presenter Cheri Wilson