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Weaving Latino Cultural Concepts IntoPreparedness Core
Competency Training
Mary Riley-Jacome, MA; Blanca Angelica Gonzalez Parker, RN, MPH;
Edward C. Waltz, PhD
Introduction: The New York New Jersey Preparedness andEmergency
Response Learning Center (NYNJ PERLC) is one of14 Centers funded by
the Centers for Disease Control and
Prevention designed to address the preparedness and response
training and education needs of the public health workforce.
One
of the important niches, or focus areas for the Center, is
training
to improve the capacity of public health workers to respond
with
competence to the needs of vulnerable populations.
Background: During every phase of a disaster, racial and
ethnicminorities, including Latinos, suffer worse outcomes than
the
general population. Communities with diverse cultural
origins
and limited English speakers often present more complex
issues
during public health emergencies. Training that incorporates
cultural concepts into the Preparedness Core Competencies
may
improve the ability of public health workers to engage the
Latino
community in preparedness activities and ultimately improve
outcomes during disasters. Methods: This article
describesinitiatives undertaken by the NYNJ PERLC to improve
thecapacity of the public health workforce to respond competently
to
the needs of Latino populations. In 2012, the Center
collaborated
with national, state, and local partners to develop a
nationwide
broadcast founded on the Preparedness Core Competencies,
Latinos During Emergencies: Cultural Considerations
Impacting
Disaster Preparedness. The widely viewed broadcast (497
sites
in 47 states and 13 nations) highlighted the commonalities
and
differences within Latino culture that can impact emergency
preparedness and response and outlined practical strategies
to
enhance participation. Outcomes: The success of the
broadcastspurred a number of partner requests for training and
technical
assistance. Lessons learned from these experiences,
including
our undercover work at local Points of Dispensing, are
incorporated into subsequent interactive trainings to improve
the
J Public Health Management Practice, 2014, 20(5),
S89S100Copyright C 2014 Wolters Kluwer Health | Lippincott Williams
& Wilkins
competency of public health workers. Next Steps:
Participantsrecommended developing similar training addressing
cultural
differences, especially for other ethnic groups.
KEY WORDS: cultural competency, Latinos, Public
HeathPreparedness, training
Understanding various cultural beliefs or ways of life,
withinthe community within which one lives and works is thebroader
necessity, though, and is the key to success fordisaster
professionals . . . .. In either case, it is important toknow the
culture of the community affected, for you cannotchange long-held
beliefs if you do not understand thosebeliefs, and you cannot
expect people to take action contraryto their common sense if you
do not understand whatmotivates them.
Scott1
TheNewYork NewJerseyPreparedness andEmer-gency Response Learning
Center (NYNJ PERLC),located at the University at Albany SUNY
Schoolof Public Health, is one of 14 PERLCs* funded
Author Affiliation: New York New Jersey Preparedness and
EmergencyResponse Learning Center, University at Albany School of
Public Health,Rensselaer, NY (Mss Riley-Jacome and Parker and Dr
Waltz).
This work was supported by a Preparedness and Emergency Response
Learn-ing Center grant from the Centers for Disease Control and
Prevention, underFOA CDC-RFA-TP10-1001 to the University at Albany,
grant 5U90TP000404-03. Its contents are solely the responsibility
of the authors and do not necessarilyrepresent the official views
of the Centers for Disease Control and Prevention.
The authors declare no conflicts of interest.
Correspondence: Mary Riley-Jacome, MA, New York New
JerseyPreparedness and Emergency Response Learning Center,
University at Al-bany School of Public Health, One University
Place, Rensselaer, NY 12144([email protected]).
DOI: 10.1097/PHH.0000000000000093
*The PERLC program is designed to address the preparednessand
response training and education needs of the public
healthworkforce. Supported by Federal funding (2010 to date), the
pro-gram includes 14 centers in Council on Education for
PublicHealth accredited Schools of Public Health. For additional
infor-mation, see www.cdc.gov/phpr/perlc factsheet.htm.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized
reproduction of this article is prohibited.
S89
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S90 Journal of Public Health Management and Practice
by the Centers for Disease Control and Preven-tion (CDC) and
designed to address the prepared-ness and response training and
education needs ofthe public health workforce. One of the
importantniches or focus areas of the Center is training pub-lic
health workers to improve their capacity to re-spond with
competency to the needs of vulnerablepopulations.
During every phase of a disaster, disadvantagedracial and ethnic
minorities tend to suffer worse out-comes than the general
population.2,3 Communitieswith diverse cultural origins, limited
English speak-ers, and immigrant populations often present
morecomplex issues during public health disasters. Lati-nos
represent the largest immigrant population in theUnited States,4
and the failure to respond adequately totheir needs has been
documented extensively in AfterAction Reports, such as those
following Hurricane Ka-trina and the California Wildfires. Reports
suggest thatlack of cultural and linguistic competencywithin
disas-ter relief agencies prevented or discouragedmany Lati-nos
from accessing needed services. Inadequate accessto critical
information and services during these eventsimpacted the ability
ofLatino communities to copewithand recover from disaster.5-7
While progress has been made, the ability to engageand
effectively communicate with culturally diverseand limited English
proficient (LEP) populations re-mains challenging today. InNewYork,
investigators re-ported that language and eligibility barriers
alongwiththe lack of outreach efforts and culturally
appropriatecommunication strategies kept many immigrants
fromseeking assistance during Superstorm Sandy.8 Similarreports
came out of New Jersey, where media sourcesreported that unequal
access to information duringthe recovery efforts led the Latino
Action Network tofile a formal complaint against the governor of
NewJersey.9
Disproportionately affected by adverse outcomes indisasters, the
United States Latino population standsas the largest minority group
in the nation. With 1 in 6US residents identifying as Latino or
Hispanic on theUnited StatesCensus Survey of 2010, effective
planningand communication with this group has never beenmore
essential.10
Cultural competence, defined here as the ability toprovide
services that are responsive to the cultural be-liefs, practices,
and linguistic needs of constituents, sitsat the very core of
communicating with and engag-ing at-risk and vulnerable populations
in preparing foremergencies. Conversely, lack of cultural
competencein public health messaging and risk communicationcan
become a barrier and lead to ineffective initiativesin disaster
preparedness and public health emergency
planning. Research by CDC with Hispanic subgroupsduring the H1N1
flu pandemic indicates that informa-tion gaps and a lack of trust
and understanding werekey barriers to vaccine uptake in this
population.11 Thelack of comprehension betweenLatinos andhealth
pro-fessionals is not just language and literacy, nor is itlimited
to interactions with emergency responders. Asurvey conducted by the
Commonwealth Fund foundthat Latinos are twice as likely as White
and African-Americans to leave the physicians office with
unan-swered questions.12 Miscommunication often ensuesbecause
physicians assume that patients understandor agree to their
recommendations, when in reality cul-tural values of respect and
paternalism preventpatients from questioning their physicians when
theyhave outstanding questions and concerns.13
As outlined in the new Public Health Preparednessand Response
Core Competencies (PCCs),14 under-standing cultural differences
that might impact emer-gency preparedness (EP) is critical to
improve out-comes within diverse communities. Like most
otherPERLCs, all of which were Academic Centers for Pub-lic Health
Preparedness in the previous funding cycle,the NYNJ PERLC has
nearly a decade of addressingissues
ofworkingwithvulnerablepopulations andpro-moting cultural
competency during disasters.15-18 Morerecently, the U.S. Office of
Mental Health has released acomprehensive online program to train
first respon-ders, emergency medical technicians,
psychologists,psychiatrists, and social workers to improve
culturalcompetency. These activities all make significant
con-tributions to the body of work on cultural competencyin
disaster preparedness. Most take the approach ofsuggesting what to
do and how to achieve the desiredoutcome. Less attention has been
paid to the whyquestion, with recommendations of best practices
ex-plicitly drawing on a deeper understanding of the cul-tural
beliefs and norms that influence behavior withina given group.
The objective of this article is to describe educa-tional
activities the NYNJ PERLC developed andimplemented to improve the
capacity of the pub-lic health workforce to respond competently to
theneeds of Latino populations. Founded on the newPCCs, and guided
by partner and stakeholder input,the trainings weave in Latino
cultural constructs tohelp public health professionals (1)
understand howLatino cultural values and norms may impact
com-munity preparedness, (2) learn strategies for engagingthe
Latino community in preparedness activities and,(3) learn how to
frame messages that will resonate,engage, and promote resiliency
within Latino commu-nities. These 3 training activities are
summarized inTable 1.
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Weaving Latino Cultural Concepts S91
TABLE 1 Weaving Latino Cultural Construct
Latinos During Culturally Competent Culturally CompetentTraining
Title Emergencies Brainstorm #1 Brainstorm #2
Training modality Satellite broadcast In-person interactive
training Interactive webinar
Date/Location NY Network, Live broadcast,March 2012
National Preparedness Summit,March 2013
NYS DOH webinar, June 2013
Objectives Describe at least 2 culturaldifferences that might
impactemergency preparedness andresponse activities
Identify strategies for assessingthe needs of the
Latinopopulation in a community.
List 2 approaches used by thespeakers to engage membersfrom the
Latino community inemergency response andpreparedness
activities
Identify culturally sensitive,cross-cultural riskcommunication
methods thatincorporate issues oflanguage, trust, literacy, andthe
use of new media
Describe at least 2 culturaldifferences that might
impactemergency preparedness andresponse activities
Identify culturally sensitive,cross-cultural risk
communicationmethods
Recognize examples in whichmainstream messaging in publichealth
campaigns and activitiesmay not be reaching the Latinocommunity
Recognize examples in whichmainstream messaging publichealth
activities can be adapted toincrease interest and
participationamong the Latino community
Describe at least 2 culturaldifferences that might impactmass
dispensing activities
Identify culturally appropriatestrategies and practices
toenhance participation during MCMclinical operations.
Describe Promising Practicesimplemented by local
healthdepartments.
Recognize and develop examples ofmessaging to help
increaseparticipation at MCM clinicaloperations.
PCCs and KSAs 1.5 Demonstrate respect for allpersons (all
KSAs)
1.5 Demonstrate respect for allpersons (all KSAs)
1.5 Demonstrate respect for allpersons (all KSAs)
2.2 Use principles of crisis andrisk communication KSAs 7, 8,11,
13, 14, 15
2.2 Use principles of crisis and riskcommunication KSAs 7, 8,
11, 13,14, 15
2.2 Use principles of crisis and riskcommunication KSAs 7, 8,
11, 13,14, 15
3.3 Plan for and improve practice,KSA 8
3.3 Plan for and improve practice,KSA 8
Audience National/international audiencerepresenting 47 states
and 13countries.
National audience of public Health,EM professionals, and
firstresponders
Bioterrorism coordinators in NYSLHDs
Participants 497+ registereda 75+ 84 registeredaEvaluations
completed N = 79 (15.8%) N = 10 (13.3%) N = 54 (64.3%)Would
recommend
training to others92.4% 90.0% 92.6%
The training enhancedor addressed a gapin knowledge
91.1% 100.0% 88.9%
The training wasrelated to what Imight be expectedto do in
anemergency
92.4% Would apply information given theopportunity 100%
b
Select participantfeedback
Understanding that Latinos makedecisions that are based onfamily
and community needsmore than individual needs willhelp inform our
approach
This was one of the best sessionswith great practical
informationand ideas help us recognizemore effective ways to
sendmessages to Latinos
It was helpful hearing specificscenarios in which
culturalcompetence could have preventedmisunderstanding or created
amore positive outcome
Abbreviations: EM, emergency management; KSA, Knowledge Skills
and Attitudes; MCM, Medical Countermeasures; NYS DOH, New York
State Departmentof Health; PCC, preparedness core
competencies.aRegistered sites, actual participation may be
higher.bQuestion not addressed on Department of Health survey.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized
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S92 Journal of Public Health Management and Practice
MethodsTraining 1: Web and SatelliteBroadcast
Beginning in late 2011, NYNJ PERLC staff met reg-ularly to
consider proposed training topics, review-ing both partner requests
and identified gaps in thePCCs. One topic for consideration emerged
from a re-cent study conducted by Dr Blanca Ramos of the
Uni-versity at Albany School of Social Welfare, document-ing the
experience of earthquake survivors within theLatino cultural
context. Previous research suggests thatLatinos share many cultural
values that may impacthealth beliefs and behaviors.19 Unique to
this studywas research examining how Latino core cultural
con-structs (familism, collectivism, fatalism, respect, andtime
orientation) impacted coping in the aftermath ofdisaster.
Although a consensus was developing internallythat disaster
preparedness in the Latino communitywas the highest priority for a
training topic, Centerstaff assembled a variety of information
pertinent toour needs assessment process. Three important
criteriainformed the final decision: (1) the absence of
relevanttraining materials within the PERLC network, (2)
theavailability of subject matter experts, and (3) strongsupport
from our partners and stakeholders, especiallyLatino community
members, for the deep need andtimeliness of the topic.
With their support, the Center moved forward toplan a broadcast
entitled Latinos During Emergencies:Cultural Considerations
Impacting Disaster Preparedness.Using the PCCs (1.5 and 2.2) and
the correspondingKnowledge Skills and Attitudes as a guide,20 the
plan-ning committee recruited a panel of subject matter ex-perts to
develop training that would both improve un-derstanding of Latino
cultural beliefs and provide con-crete steps to enhance
participation of Latinos in pre-paredness and response activities.
Each presenter, withguidance from Center staff, took the lead on a
specificarea of the PCCs.
The first presenter, Dr Ramos, focused on describ-ing cultural
differences that might impact EP activities(PCC 1.5 Knowledge
Skills and Attitudes 4). Her pre-sentation outlined the potential
impact of specific coreLatino values, such as collectivism (placing
emphasison group over individual needs) and familism (plac-ing
emphasis on family over individual needs) andprovided suggestions
for developing positive messag-ing that supports those cultural
beliefs. For example,Dr Ramos suggested that promoting EP
activities thatfocus on the community (collectivism) or family
(famil-ism) rather than the individual may enhance participa-tion
among Latino populations. Recent media reportsfrom Superstorm Sandy
suggest that prioritizing com-
munity values is an approach that resonates with Lati-nos and
helps promote resiliency.21
The second presenter, Mr Charles Kamasaki,Executive Vice
President of the National Council of LaRaza, presented practical
steps for reaching, engaging,and addressing the needs of Latino
communities in dis-asters, as outlined in their newly released
EmergencyManagers Tool Kit: Meeting the Needs of Latino
Com-munities. While this resource is designed to engagethe Latino
community, the practical steps outlined forassessing the needs,
developingmessaging, and imple-menting crisis and emergency risk
communication canbe replicated in any community. In fact, Federal
Emer-gency Management Agency (FEMA) recently reportedthat their
innovative team adopted strategies similar tothose outlined in
theToolKit during SuperstormSandy.To help improve communications
with LEP popula-tions, the FEMA team identified local
multi-lingualradio and newspaper mass media channels and passedthat
information to non-local responders for commu-nity messaging.22
The last presenter, Ms Ladan Alomar, ExecutiveDirector of Centro
Civico of Amsterdam, New York,provided input on community
engagement and devel-oping partnerships with key stakeholders
(KnowledgeSkills and Attitudes 3). Ms Alomar emphasized the
im-portance of being connected to all segments of the com-munity,
particularly the elderly and extended fam-ily members, which may
include godparents, friends,and neighbors. She also noted the
fundamental roleof faith within the Latino community. Suggestions
forsuccessful partnerships included engaging representa-tives into
the planning process so that the communitytakes ownership of the
programs; organizing eventsto include extended family members; and
partner-ing with faith-based organizations to cohost EP
educa-tional events and trainings.
Results/Outcomes (Training 1)
The 1-hour 15-minute program was broadcast live onMarch 22,
2012. A total of 497 sites from 47 states and13 countries
registered for the program. A site mayrepresent any number of
learners, from an individualviewing on a tablet computer to an
auditorium full ofstudents viewing the program in an academic
class.Apart from the large numbers of sites, the programmayhave had
the broadest reach of any broadcast the Cen-ter has ever produced.
The agency affiliations providedby registrants encompassed local
community-basedagencies, state and local health departments
(LHDs),federal agencies (Homeland Security, Health andHuman
Services, Labor, Transportation, Commerce,
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Weaving Latino Cultural Concepts S93
United States Department of Agriculture, Food andDrug
Administration, and FEMA), several organiza-tions in Puerto Rico,
and 8 Mexican consulates.
Evaluation data on the trainings will be presentedlater in this
article. We focus here on the unintendedoutcomes and how they
influenced the directionof subsequent trainings developed by the
NYNJPERLC. One significant, unanticipated outcome fromthe broadcast
was increased interest from LHDs inhaving the NYNJ PERLC assist
with evaluations,pertinent to cultural competence, of their Point
ofDispensing (POD) drills in 2012 and 2013. Thesepartner requests
provided us with a hands-onopportunity to evaluate the capability
of the publichealth workforce to respond with competency to
theneeds of culturally diverse populations in a PODscenario.
Undercover work
The NYNJ PERLC agreed to help our partners withtheir Medical
Countermeasures exercises, providingstaff with expertise in
evaluation and cultural compe-tency at various PODdrills, flu POD,
andmigrant farmclinics in the Capital Region of New York. During
theexercises, our staff served as both actors and eval-uators to
assess this critical functionality. One specificrequest was to help
evaluate the use of various inter-pretation services and
translation tools to communicatewith LEP participants. At the
request of the LHDs, anative Spanish-speaking (Latina) staff member
playedthe role of a nonEnglish-speaking patient and cycledthrough
the POD several times. This undercover per-spective served to
highlight areas of improvement aswell as strengths in exercise
planning in the area ofcultural competence.
Although language translation ability alonedoes notdefine
cultural competence, it is often considered to bean important first
step. Participating in the POD ex-ercises allowed us to compare and
contrast the useof different methods for communicating with
LEPpopulationsonline language translation tools, tele-phonic
interpreter services, bilingual family memberinterpretation, and
face-to-face trained interpreter ser-vices. One exercise, in
particular, at an LHD that expe-riences a summer population influx
of Latino migrantworkers, made clear the challenges of relying on
theonline Google Translator as a means of communicatingin Spanish
during a POD exercise. An excerpt from theevaluation read:
. . . . Google Translator added processing time and
wasineffective in correctly translating and obtaining
vitalinformation in the area of medical screening. Althoughthe
medical assessment questions were translatedcorrectly in terms of
word-for-word translation, there
were instances in which intended meaning was lost. Asan example,
the question pertaining to breastfeeding,originally intended for
use in the present tense, was infact asked in the past-tense upon
being translated.Therefore I was asked if I have ever breastfed
insteadof if I am currently breastfeeding. Lastly, usingGoogle
Translator will not be useful in instances wherethe patient is
unable to read, whether due toeducation-level, or visual
difficulties.
Four other counties we assisted communicated withLEP
participants during the PODs using bilingual staff,bilingual
extended family members and friends, andtelephonic interpreter
services. Oneida County, in up-state New York, was the only health
department weobserved utilizing face-to-face trained interpreter
ser-vices to communicate with LEP participants. Alongwith trained
interpreters, Oneida County Health De-partment (OCHD) displayed
signage and patient ed-ucation materials in multiple languages and
providedmental health services through interpreters and bilin-gual
providers.
Our experiences with the local POD exercises indi-cated that
there was significant variation in the abilityof LHDs to
effectively serve the needs of culturally di-verse and LEP
populations in a Medical Countermea-sures scenario. Some LHDs, such
as Oneida County,demonstrated capability in engaging and
communicat-ingwith limited English speakers during the
PODexer-cises.With one of the highest concentrations of refugeesin
the United States, Oneida County has ample expe-rience working with
culturally diverse and LEP com-munities; in fact, they have
incorporated many of thestrategies recommended in the National
Council of LaRazas Emergency Managers Tool Kit. Figure 1 listssome
of the actions implemented for engaging diversecommunities in EP
activities. Most seem amenable toreplication by other public health
agencies, resourcespermitting.
A critical component of the OCHDs success hasbeen its
collaboration with the Mohawk Valley Re-source Center and the
Multicultural Association ofMedical Interpreters. These 2 partner
agencies facili-tated access to diverse communities, recruited
partic-ipants for the EP activities, provided volunteer
inter-preters for the drills, and translated materials.
Trainedinterpreters also served as cultural brokers, helpingto
bridge communication gaps and ensuring cultur-ally competent
communication with LEP populations.Center staff collected
additional recommendations forcommunicating with culturally diverse
communitiesfrom the interpreter agencies, and several of theirbest
practices were incorporated into subsequenttrainings.
Other LHDs found it challenging to communicatewith LEP
populations during the POD exercises and
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S94 Journal of Public Health Management and Practice
FIGURE 1 Oneida County Health DepartmentPromising Practices
identified training in this area as a priority. At a min-imum,
evaluators recommended training to reviewstrategies for
implementing the Culturally and Lin-guistically Appropriate
Services Standards in EP. Otherpotential training topics suggested
by exercise partici-pants and evaluators included
identifying cultural differences that might impactPODs;
information on how to develop and disseminate cul-turally
appropriate messaging; and
sharing promising practices and tools (ie, signage,videos,
forms).
MethodsTraining 2: 2013 NationalPreparedness Summit
Building on the content from the broadcast, the NYNJPERLC
developed a training proposal for the 2013 Na-tional Preparedness
Summit to incorporate the lessonslearned from our POD experiences.
In particular, weexpanded our training to address common
challengesand promising practices identified in the After Ac-tion
Reports. We asked the OCHD to partner with usto develop and deliver
the interactive learning session,titledCulturally Competent
Brainstorm: Incorporating Tra-ditional Latino Core Cultural
Constructs Into Public HealthMessaging and Planning #1. We divided
this into 4 sec-tions: (1) an overview of traditional core values
foundin Latino culture; (2) how Latino culture can interfacewith
PODplanning activities and lead tomiscommuni-cation; (3) the role
of cultural competence in increasingparticipation in public health
planning and prepared-
ness activities, and (4)OCHDpromising practices forPODS.
Using the example of a POD in a mass vaccina-tion scenario, the
training included practical steps onhow to tailor public health
preparedness activities, fly-ers, and announcements to cultural
trends and valuesto promote participation. Short vignettes written
fromthe perspective of Latino POD participants were pre-sented to
highlight common barriers to participationand emphasize potential
mainstream and Latino cul-tural clashes. One segment required
trainees to brain-storm which traditional Latino core values need
tobe addressed to attain a level of cultural competence.Another
section provided participants with the oppor-tunity to speak about
their own experiences in PODplanning or Latino community outreach;
several par-ticipants shared personal experiences. This was
fol-lowed by a presentation of the promising practices ofOneida
County. At the conclusion of the session, recentreal-life examples
of public health messaging and mar-keting were displayed. We asked
participants to usewhat they had just learned regarding Latino core
val-ues to analyze the cultural competence and relevanceof these
marketing tools (see Figure 2).
Audience response system
An important component of the CulturallyCompetentBrainstorm #1
training was the incorporation of inter-active training
methodologies, including group exer-cises andanAudienceResponse
System (ARS).AnARSis a real-time data collection system comprising
small,handheldkeypads or clickers that audiencemembersuse to answer
questions posed by the instructor.23-25
The system can be used to engage students, assess
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Weaving Latino Cultural Concepts S95
FIGURE 2 Incorporating Cultural Concepts into Preparedness
Messaging
understanding, and help instructors guide discussions.A recent
systematic review of the effect of ARSs onlearning outcomes in
health professions education pro-vides some evidence of their
effectiveness.26
The NYNJ PERLC staff developed and adaptedthe traditional
Microsoft PowerPoint presentationand interspersed slides posing ARS
questions usingproprietary software from the vendor. During the
ses-sion, audience members respond by selecting an an-swer from the
choices provided and pressing thecorresponding number on their
clickers. Afterward,the trainer can display the tabulated response
datain a preformatted chart or graph. This technologyhelps
presenters tailor the training, exercises, and dis-cussions to meet
the specific training needs of theaudience.
Presentation attendees were also asked to respondto opinion,
polling, and knowledge-based ques-tions using the ARS system.
Forty-five individualsresponded to the questions using their
assignedclickers. Their responses were used to guide the
groupdiscussion on successful strategies for improvingcultural
competency in EP. The responses from theSummit ARS session below
illustrate this point. Forexample, Table 2 shows that more than 45%
of re-
TABLE 2 Audience Response SystemSampleResponses From Summit 2013
Training
ResponsesHow Do You Normally CommunicateWith NonEnglish-Speaking
Clientsor Patients? Percent Count
Telephonic interpreter services 24.44 11Bilingual speaker
(friend, relative, community
leader)20.00 9
Written (online) language translation services 26.67 12In-person
trained interpreter/navigator 17.78 8Bilingual provider 11.11
5Total 100.00 45
spondents indicated that they normally communicatewith
nonEnglish-speaking clients using writtenonline language
translation services or a bilingualspeaker.
Based on these responses, NYNJ PERLC staff tai-lored the
remainder of the presentation to include adiscussion of the pros
and cons of various communi-cation strategies and tips for avoiding
miscommuni-cation with LEP populations. Figure 3 illustrates
rec-ommendations provided to us by the MulticulturalAssociation of
Medical Interpreters, as used in thepresentation.
Results/Outcomes (Training 2)
Approximately 75 individuals attended the session,representing a
cross section of public health and emer-gency personnel from across
the country. A numberof positive outcomes resulted from the
training. First,we received a request from New York State
Depart-ment of Health (NYS DOH) to provide the training toLHD
staff. Second, the information learned through theARS system helped
us identify common strengths andadditional areas of improvement.
Third, the sharingsessions provided us with additional information
toweave into subsequent trainings. For example, partic-ipants
shared strategies and discussed agency policiesfor dealing with
families encompassing members withdifferent immigration
statuses.
MethodsTraining 3: CulturallyCompetent Brainstorm #2
As noted previously, the NYNJ PERLC received apartner request
from the NYS DOH to present thetraining in a webinar format to a
statewide audiencein June 2013. The Culturally Competent
Brainstorm#2 webinar sponsored as part of the DOHs Medical
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S96 Journal of Public Health Management and Practice
FIGURE 3 Communicating With Limited English Proficient
Populations
Countermeasures Clinical Operations series wasadapted to
incorporate polling and knowledge-basedquestions and a scaled back
discussion for the POD sce-narios and existing advertising. In
addition, the train-ing incorporated some of the best practices
sharedby health departments across the country during theSummit
presentation. This training was marketed toemergency preparedness
coordinators at LHDs inNewYork State. Eighty-four individuals
registered for thewebinar representing public health workers in 38
of 62counties.
Evaluation methodology
Although technology-based, adult-learning programs,such as
satellite broadcasts andwebinars, have demon-strated effectiveness
in increasing knowledge andimpacting behavior among public health
workers,especially those involved in preparedness and immu-nization
activities, it remains incumbent upon trainingprofessionals to
monitor and evaluate the successes
and challenges of their programming.27,28 In ourexperience in
public health, the Kirkpatrick EvaluationFramework29 is the most
widely used frameworkfor evaluating training programs. The Centers
forDisease Control and Prevention PERLC evaluationcommittee has
developed a set of standardizedguidelines on the basis of this
framework to help usmeasure the impact of our programs individually
andcollectively.30,31
Briefly, the Framework recognizes potential trainingoutcomes on
4 levels: Level 1: ReactionParticipants satisfaction with
thetraining
Level 2: LearningKnowledge gained from thetraining
Level 3: BehaviorChanges in behavior as a result ofthe
training
Level 4: ResultsThe overall impact of the training
Each successive level moves toward a deeper, morecomprehensive
measure of the training programs
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Weaving Latino Cultural Concepts S97
impact. Typically, for trainings of short duration (75-90
minutes), evaluation is limited to levels 1 and 2.For each of the 3
cultural competency trainings de-scribed previously, participants
and/or credit-seekingstudents were sent an online survey by the
respectivelead agency sponsoring the training.
The NYNJ PERLC is committed to evaluating ourtraining within the
Kirkpatrick Framework, and wecontinually strive to use tools that
can consistently andaccurately measure the benefits of our
trainings. In thiscase, however, additional requirements of the
partner-ing/sponsoring agency necessitated that each of
theevaluation forms be developed virtually de novo. Forexample, the
evaluation developed by the NYS DOHwas designed to assess the broad
impact of the train-ing. It included questions about participant
satisfac-tion, program content and objectives, and how
partic-ipants intend to incorporate the training informationinto
their daily work. Their evaluation also providedparticipantswith
the opportunity to share some of theirbest practices. In contrast,
the National PreparednessSummit committee targeted evaluation only
to indi-viduals requesting continuing education credits. TheNYNJ
PERLC evaluation for the Latinos during emer-gencies broadcast
included the standardized questionsdeveloped by the PERLC
Evaluation Committee. Par-ticipants applying for continuing
education credits orcontact hours were required to complete an
additionalquiz to assess knowledge gained from the broadcast.
Capturing evaluation data continues to be one ofthe biggest
challenges for our Center and these train-ings were no different.
Of the 3 agencies administeringthe evaluations, NYS DOH clearly had
the best successin gathering evaluation data from participants.
Localhealth department staff are required to attend the NYSDOH
trainings as part of their agencys Public HealthEmergency
Preparedness deliverables, and submittingthe completed evaluation
is an essential componentof course completiona strong incentive.
Fifty-four(64.2%) individuals completed the NYS DOH partic-ipant
evaluations of the Culturally Competent Brain-storm #2 training. In
comparison, 79 individuals (15.8%of the number of sites) completed
the NYNJ PERLCevaluations of the Latinos during emergencies
broad-cast. Typically, participants of our online trainings,
in-cluding live andarchivedbroadcasts, complete only theonline
evaluation if they are requesting credit or contacthours. For the
Latinos during emergencies broadcast,with a diverse audience, the
percentage of individualsapplying for continuing education credits
was small(15.8% of registrations). In addition, some viewers
re-ported difficulty in accessing the link to the evaluationon our
Web site due to temporary problems in our sys-tem. Finally, the
percentage of participants completingevaluations at the National
Preparedness Summit was
even smaller (13%). As noted earlier, the evaluationcommittee
provided evaluation forms only to thoseparticipants requesting
credits or contact hours, whichlimited responses significantly.
While limited in number, the training evaluationswere
overwhelmingly positive (see Table 1.) Morethan 90% of participants
who completed evaluationsreported that they were satisfied with the
trainingsand would recommend them to others. Respondents(92.4%)
indicated that the trainings provided contentthat was relevant to
their daily job and relevant towhat they might be expected to do to
(prevent, preparefor, or respond to) an emergency. Survey
respondentsalso agreed that the content and learning materials
ad-dressed a need or a gap in knowledge or skills, andthat given
the opportunity, they would be able to ap-ply the knowledge gained
from the session. Qualitativecomments (Table 1) are equally
positive, indicating thatparticipants found the information useful;
intend toshare it with their colleagues; and plan on implement-ing
recommended strategies to promote improvementsin cultural
competency in their daily work.
The posttest survey,which is required to receive con-tinuing
education credits, also offers some insight intothe success of our
trainings. Of the 48 participants whocompleted the posttest survey
for the Latinos duringemergencies broadcast, only 1 person failed
to receivea passing grade of 80% or more, indicating that
partic-ipants retained knowledge of the program content, atleast to
this limited level.
Discussion
Our cumulative experiencedrawing on the litera-ture review, our
undercover work at local PODs, thepromising practices implemented
by the OCHD, theshared experiences of interactive session
participants,and trainee evaluation and feedback formsclearly
in-dicates that LHDs experience varying levels of successin
implementing EP activities with culturally
diversecommunities.During our trainings, participants sharedstories
of success in developing partnerships with keystakeholders
fromdiversepopulations (PCC1.3);main-taining diverse community
partnerships to assist withcommunicating preparedness planning (PCC
2.2.5);and developing cross-cultural strategies to
disseminateinformation (PCC1.5.5.). Local health departments
thatdedicate resources to engaging Latino communities(employ Latino
staff, conduct outreach with migrantfarm workers, partner with
Latino faith-based organi-zations, etc) have found that those
efforts spill over intothe preparedness arena. This validates our
experience-based perception that the ability of public healthto
engage diverse communitiesthat are sometimes
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S98 Journal of Public Health Management and Practice
mistrustful of any contact with government on per-sonal and
family health issuescan improve healthstatus in general, as well as
contribute to the overallresiliency of communities to prevent,
respond to, andrecover from disasters.
Alongwith these successes, our experience indicatesthat training
gaps in the PCCs persist, particularly inthe area of cultural
competency. While some programparticipants reportedmaking small
strides in includingdiverse populations in planningmessages
(PCC2.2.11),in general, achieving competency in crisis and
riskcommunication with diverse populations continues tobe extremely
challenging. One of the guiding princi-ples to come out of the
National Consensus Panel onEmergency Preparedness and Cultural
Diversity is theneed to engage community representatives to
design,implement, and evaluate emergency risk communica-tion
strategies, ensuring that they are culturally andlinguistically
appropriate.32 Many of our partners re-ported struggling with
implementing this principle, asresources to develop and evaluate
marketing materi-als are limited. Latinos are underrepresented in
PublicHealth Emergency Preparedness, and as one attendeelamented,
it is very hard to find anyone that has thatskill that is also
sensitive to public health, etc.
The second obstacle is a lack of understanding ofhow specific
cultural values impact actions. To date,cultural competency
training for disaster preparednesshas focused primarily on
strategies for engaging di-verse communities. Moving beyond that
first step re-quires more information about how to frame our
mes-sage so that Latino populations may be more opento
participating. One training participant aptly notedthat
Information is factually correct, can be translatedquickly, but
understanding the cultural norms andvalues can help. I need to
understand the nuances, sothat I dont offend. And understand the
values, so that Ican promote behavior that will encourage
beingprepared.
More needs to be done to help public health pro-fessionals
develop competency in understanding howthe values of diverse
cultural communities impact be-havior so that they can develop
clear and culturallytargeted messaging.
Lessons Learned
Cultural competence is an essential component of Pub-lic Health
Preparedness exercises that can be attainedthrough training of the
public health workforce, andLHDs should be encouraged to engage LEP
popula-tions and to include that dimension in their PODs and
other EP activities. Key lessons learned include the fol-lowing:
Community engagement starts with knowing yourcommunity. The
National Council of La RazasEmergency Managers Tool Kit provides
detailedsteps for engaging the Latino community in allphases of EP
and response. These useful strategiesfor engagement can be
replicated by any community.
Partnering with trained interpreters and others whoserve as
cultural brokers can help prevent miscom-munication, particularly
during times of stress.
Cultural competency in PublicHealth Preparedness,beyond the
level of appropriate language translation,requires an understanding
of the cultural differencesthat might impact behavior and the
ability to incor-porate messaging and strategies that promote
positiveoutcomeswithin thewhole community.Our experiencesuggests
that weaving in Latino cultural concepts intoPCC training can help
midlevel public health work-ers better understand how culture may
impact disasterpreparedness and to learn strategies to fully
engageand respond to the needs of Latinos during disasters.We hope
that these programs will serve as a trainingtool for other
LHDs.
Next Steps
Participants and partners have guided our next stepsthroughout
this process and continue to lead the pathforward for us. Program
participants suggested thatmore training addressing cultural
differences (PCC1.5.4) needs to be developed. When asked to
recom-mend other training topics, respondents replied withcomments
such as This (training) would be usefulfor other ethnic groups and
Information on thissame topic relative to other populations, i.e.,
Asians,Middle Eastern or other vulnerable populations wouldbe
useful.
Increasing cultural competence in the field of pub-lic health
preparedness is a continual process andmust be renewed through
ongoing training to adjustto emergent issues and local
demographics.33 In ad-dition to training that can be provided from
withinthe PERLC network, public health will need to leadthe way on
developing and sharing culturally appro-priate messaging for
diverse cultural groups. Theseculturally and language-appropriate
crises and emer-gency risk communication messages can be
adaptedlocally with input from key partners. Finally, basedon
responses received using the ARS at the Summit,more resources need
to be invested in making trainedinterpreter services available in
the preparednesscommunity.
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Weaving Latino Cultural Concepts S99
REFERENCES
1. Scott JC. Concept Paper: Importance of Cultural Competency
inDisaster Management. Prepared for Center for Public
ServiceCommunications, OMH; 2007:11.
http://www.hsdl.org/?view&did=6108. Accessed April 7, 2014.
2. Office of Minority Health Web site.
http://minorityhealth.hhs.gov/. Published 2013. Accessed January
28, 2014.
3. DisasterLawand Inequality, 25LAW&INEQ. 297, 302
(2007);Tomlinson SA. No New Orleanians left behind: an examina-tion
of the disparate impact of Hurricane Katrina on minori-ties. 38
CONN. L. REV. 2006;1153:1161.
4. Motel S, Patten E. Statistical Portrait of the
Foreign-BornPopulation in the United States. Washington, DC:
PEWResearch Hispanic Trends Project; 2011.
http://www.pewhispanic.org/files/2013/02/Statistical-Portrait-of-Hispanics-in-the-United-States-2011_FINAL.pdf.
AccessedApril 7, 2014.
5. Benitez S, Rodriguez E. Averting Disaster: What the
CaliforniaWildfires Can Teach Us About Reaching Latinos in Times of
Crisis.Washington, DC: National Council of La Raza; 2008.
6. Munoz B. In the Eye of the Storm: How the Government and
Pri-vate Response to Hurricane Katrina Failed Latinos.
Washington,DC: National Council of La Raza; 2006.
7. Office of Minority Health. Cultural Competency in
DisasterResponse: A Review of Current Concepts, Polices and
Practices.Washington, DC: U.S. Department of Health & Human
Ser-vices; 2008.
8. Make theRoadNewYork.UnmetNeeds: Superstorm Sandy andImmigrant
Communities in the Metro New York Area. Brooklyn,NY; Make the Road
New York; 2012.
9. CNN Politics political ticker Web site.
http://politicalticker.blogs.cnn.com/2013/10/08/latino-action-network-nj-governor-christie-mislead-latino-families-after-superstorm-sandy/.
Accessed March 13, 2014.
http://www.nbcphiladelphia.com/news/local/Latino-Action-Network-Files-Complaint-Against-Christie-Administration-229603281.html.Accessed
January 28, 2014.
10. Perilla J, Norris FH, Lavizzo E. Ethnicity, culture, and
dis-aster response: identifying and explaining ethnic differencesin
PTSD six months after Hurricane Andrew. J Social ClinPsychol.
2002;21(1):20-45.
11. Sheedy K. CDC messages and influenza vaccination
com-munication plans for the 2010-11 season. Paper presented
at:National Influenza Vaccine Summit; May 17-19, 2010; Scotts-dale,
AZ.
12. The Commonwealth Fund. Health Care Quality
Survey.Washington, DC: The Commonwealth Fund; 2001.
13. Deas L. Culturally competent care in the EmergencyMedical
Services. Texas EMS Magazine. July/August 2007:34-39.
14. GotschA,KeckCW,SpencerH.Knowledge, Skills andAttitudes(KSAs)
for the Public Health Preparedness and Response CoreCompetency
Model. Washington, DC: CDC and ASPH; 2012.
15. Graves D. Applying Cultural Competency to Emergency
RiskCommunication. Presentation developed for CDC and Of-fice
ofMinorityHealth; 2011. http://disasterlit.nlm.nih.gov/record/5403.
Accessed January 7, 2013.
16. Assuring cultural competence indisaster response.
Presen-tation and online training, University of South Florida,
Cen-
ter for Leadership in Public Health PracticeWeb site.
http://health.usf.edu/publichealth/clphp/index.htm. AccessedJanuary
29, 2014.
17. Andrulis DP, Siddiqui NJ, Purtle J. Guidance for
Integrat-ing Culturally Diverse Communities Into Planning for
andResponding to Emergencies: A Toolkit. Recommendations ofthe
National Consensus Panel on Emergency Preparednessand Cultural
Diversity; 2011.
http://www.hhs.gov/ocr/civilrights/resources/specialtopics/emergencypre/omh_diversitytoolkit.pdf.
Accessed April 7, 2014.
18. Miami Center for Public Health Preparedness. Hispanic
Dis-aster Training for Public Health Professionals. Miami, FL:
Mi-amiCenter forPublicHealthPreparedness.
http://deep.med.miami.edu/x196.xml. Published 2008. Accessed
January 29,2014.
19. Quintana SM, Scull NC. Latino ethnic identity. In:
VillarruelF, Carlo G, et al., eds. Handbook of U.S. Latino
Psychology.Thousand Oaks, CA: Sage Publications, Inc.; 2009;
Chapter6: 81-98.
20. Association of Schools and Programs of Public Health andthe
Centers for Disease Control and Prevention. Knowledge,Skills, and
Attitudes (KSAs) for the Public Health Prepared-ness and Response
Core Competency Model.
http://www.aspph.org/educate/models/public-health-preparedness-response/.
Published September 2012. Accessed July 3, 2014.
21. Conde A. Occupy Sandys Spirit of Solidarity Resonates
WithLatino Values. Doral, FL: Fusion Media Network, LLC;
2012.Accessed January 29, 2014.
22. FEMA. Hurricane Sandy FEMA After Action Report.Washington,
DC: FEMA; 2013.
23. Institute for Teaching, Learning & Academic
Leadership,University at Albany, State University ofNewYork.
Teaching& Learning Resources. Clickers. 2014.
http://www.itlal.org/index.php?q=node/182. Accessed January 29,
2014.
24. Caldwell JE. Clickers in the large classroom: current
researchand best-practice tips. CBE Life Sci Educ. 2007;6:9-20.
25. Rush BR, Hafen M Jr, Biller DS, et al. The effect of
differ-ing Audience Response System question types on
studentattention in a veterinary medical classroom. J Vet Med
Educ.2010;37(2):145-153.
26. Nelson C, Hartling L, Campbell S, Oswald AE. The effects
ofaudience response systems on learning outcomes in
healthprofessions education. A BEME systematic review: BEMEGuide
No. 21. Med Tech. 2012;34(6):e386-405.
27. Peddecord KM, Holsclaw P, Jacobson IG, et al.
Nationwidesatellite training for Public Health Professionals:
Web-basedfollow-up. J Contin Educ Health Prof. 2007;27:111-117.
28. Catlett C, Perl T, Jenckes MW, et al. Training of
Clini-cians for Public Health Events Relevant to Bioterrorism
Pre-paredness: Summary. In: AHRQ Evidence Report
Summaries.Rockville, MD: Agency for Healthcare Research and
Qual-ity (US);1998-2005.
http://www.ncbi.nlm.nih.gov/books/NBK11842/. Accessed April 7,
2014.
29. Kirkpatrick DL. Great ideas revisited. Techniques for
evalu-ating training programs. Revisiting Kirkpatricks
Four-Levelmodel. Train Dev. 1996;50(1):54-59.
30. Kirkpatrick DL. Program design and development: evalua-tion.
In: Craig RL, ed. The ASTD Training and DevelopmentHandbook. 4th
ed. New York, NY: McGraw-Hill; 1996: 294-312.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized
reproduction of this article is prohibited.
-
S100 Journal of Public Health Management and Practice
31. Sarpy S, Chauvin S, Hites L, et al. The south central center
forpublic health preparedness training system model: a
com-prehensive approach. Public Health Rep. 2005;120(suppl
1):52-58.
32. Andrulis D. National Consensus Panel on Emergency
Pre-paredness for Racially and Ethnically Diverse Communities.
The Center for Health Equality, Drexel University School
ofPublic Health. OMH. 2008.
33. U.S. Department of Health & Human Services.
DevelopingCultural Competence in Disaster Mental Health Programs:
Guid-ing Principles andRecommendations. Rockville,MD:
SAMSHA;2003.
Copyright 2014 Lippincott Williams & Wilkins. Unauthorized
reproduction of this article is prohibited.