CERC Transcript 08 09 2016

Zika CERC Discussion: Cultural Competence

Presenters: Barbara Reynolds, PhD

Date/Time: August 9, 2016 1:00 pm ET

---------------------------------------------------------------------------------------------------------------------

Operator:      

Welcome and thank you for standing by. At this time, all participants are in a listen-only mode until the question and answer session of the call. If you would like to ask a question during that time, please press Star followed by number 1. Today's conference is being recorded. Any objections, you may disconnect at this time. Now I'd like to turn over the meeting to Barbara Reynolds. You may begin.

Barbara Reynolds:   

Thank you, Angela and welcome everyone to this week's Zika Crisis and Emergency Risk Communication discussion. We're going to talk a little bit about cultural competence and then I'm going to answer a couple of questions or bring up some topics that were sent to us through cercrequest@cdc.gov last week. And before I get into our conversation today on cultural competence, I want to tell you that next week will be the last in our series of weekly discussions. We may come back at different times but that's the last of our weekly series and if anybody has a topic area or a particular question that they'd like to bring up, please don't hesitate to e-mail us at cercrequest@cdc.gov. And what next week's topic area will be might be potpourri of different things and if nothing else, we'll just do a quick summary of some of the topic areas that we've discussed and try to put it into context of what's happening right now in relationship to Zika response.

With that in mind, let's talk a little bit about cultural competence. And I recognize that this might not be a conversation that is relevant to everyone responding to the Zika outbreak right now but more often than not because we're a very diverse nation, and we do have sometimes to work with other geographic regions around the world and different cultural within our own communities and others, it's probably not a bad idea to have a little refresher on what it means, what culture is, and what we can do with it. However, for those of you who are following along on these slides, you know I won't start without reminding everyone that the value of Crisis and Emergency Risk Communication is the prime communication principal in a crisis setting so that the right message at the right time from the right person can save lives or reduce harm. I also want to remind us that everything that we do in our communication work in an outbreak response is focused on helping the public get what they need from us to protect themselves in a public health emergency of some sort. And to do that, we need to recognize what the public wants from us from that communication. Sometimes I think we get a little focused on what we want to tell people instead of focusing on what is it that people need and what's the best way to give them what they need so that we can achieve what we want to achieve in our public health response.

The public wants us to give them the facts, that's important. They want to have empowered decision making. Most would like to be involved as a participant, not just be put on the sidelines. They want to know that the resources that they've entrusted to us are being used wisely and then more than anything, they want to get back to normal if it's possible depending on the kind of emergency that they're involved in. So how does cultural competence in crisis go together? What is critical and what isn't? We have a rich world that we live in and while there may be some context in which culture is highly important, there are other situations where culture may take a little step back and that's important for us to know what parts of that is important depending on the kind of emergency that we're involved in.

Before I do that, I want to make you aware of some of the communication assumptions that I'm using as I talk about this and we plan for responding to crisis here in the United States or anywhere else around the world and that is that what we're trying to do is to help prevent illness or death, restore, maintain calm, and engender confidence in the response. Those are some of the roles of professionals who are communicating on behalf of an organization in the rain of crisis or public health emergency. We also need to understand that emergencies by their very nature can be chaotic. So it's important that we simplify roles as much as possible, meaning sometimes we have to decide what is a must do versus wouldn't it be nice to do it but is it absolutely necessary.

And you'll see what I meaning in relationship to culture as we go forward. And then we need to know that confusion can be reduced through communication as a staff relevant simple and consistent and so the question is how do we manage cultural differences in terms of messaging and still be consistent? And that is a challenge especially initially in the crisis situation. And then none of us have to be reminded of this but I can't help but say it. We know communication resources will be limited so if we go into this discussion having the same assumptions about communication in a crisis, it will perhaps help us delve into the issue of culture in a slightly different way.

For those on the slides, I have a map of cultural regions across the world and in the United States, we're part of the western industrial culture. There are other cultures around the world. Some say there are about nine major regions of culture in the world and those are big chunks and billions of people that maybe enveloped into one or another of these cultures. So I don't think knowing what cultural region you belong to or the people you're speaking to belong to necessarily gets you to just making sure you have the absolute right message but there's a place to start the discussion about culture.

We also know that within our dominate culture that the more information we share with people, the more they tend to trust us and that messages will be judged on their trustworthiness and we also know that some differences don't matter but some do. And a challenge for us is to know which ones do and which ones don't within the context of a crisis. So as I have studied this as a social psychologist for a number of years, I think that I was taught a basic understanding and I think it's worthwhile to remind everyone to give back to the basics a little bit. When we want to talk about culture, we need to recognize where culture fits in in the context of our communication and the human dynamic. And so I was taught this and I think it's very useful. I'm going to share it with you. All individuals are like no other. Take a minute and think about that, all individuals are like no other meaning that each of us has our unique DNA and if we share the DNA with someone else, a twin, perhaps we also have our unique experiences and no one's life tracks another person's life, minute by minute the same way. So we are individuals and we are different based on our individual character and inherited genetic code and our experiences.
Then, what's interesting is all individuals are like some others and that's where we find culture. And then interestingly also is all individuals are like all others and that's where we get to the human species, the homosapien, so we are all humans. We are like some people in which we share a culture but we are also unlike all others in some ways and that makes us an individual.

So why am I talking about this? Well, because we need to know among those which ones are most important in a crisis setting. And I would suggest that when we get to the threat of, mortal threat, to the idea that we could be, we could lose our lives or our loved ones could lose their lives, that sometimes those differences are not as apparent. We're going to be more like all others, we're going to be human beings and as human beings, we share certain experiences, I mean, certain common ideas and that those come to the forefront when there is a crisis of some sort.

However, we do need to understand culture in the context of a crisis and sometimes culture does matter. One of the major ways I see it does matter and can affect the way we talk to a culture, a cultural group is is it a culture that is collectivism or individualism? And if you think about it in the United States, we highly price the idea of our individualism but there are some cultures for example, the Japanese culture where collectivism, the idea of working together for the good of the whole, is so prized that they may react to messages in a crisis situation different than we may in the United States. So and one of the things that can happen is within a culture of collectivism, you have very strong sense of in-group versus out-group and while you may have great cooperation within the in-group, they may also be more quick to push away people from the out-group. Well how does that matter to us? Well, it would matter if we were a member of the out-group trying to get help from people within the in-group but it also would matter if we are response officials going to work with a community that has very strong culture of collectivism. So if you're not in, you're definitely out and that's going to make it harder for us to respond and do work with that community as quickly as we might want in a situation.

Another way the culture matters in a crisis context is that we know that when there's a big crisis and there is again, a threat of mortal harm, the cultural belief may be held more strongly in that context. So sometimes well, in fact, let me talk a little bit about what culture is. Culture in the broadest sense is cultivated behavior. It's behavior through social learning. So we're not born with our culture, we're born into a culture and then learn sometimes just by experience. In fact, often times you learn the way of life of a particular group that you're a part of. Their beliefs, values, and symbols they accept and you do sort of without thinking about it. It's just happening and along the way, communication and imitation from one generation to the next is how the culture continues.

Culture is for the most part considered a tradition of a group of people and there's different levels of culture within a culture even which sometimes makes it a little bit more difficult for us but difference cultural groups typically may think, feel, and act differently. I don’t want to over stress the feel because at some level, at the human level, we all feel the same about the importance of being human of protecting our lives, that sort of thing. Within each culture, it's manifested through a number of ways, symbols, gestures, pictures, objects, is one way and then also by who have we hold up in esteem, that gives us a sense of a culture. So who are the heroes of a particular culture? That's actually a very good way to not only learn a little bit about a culture, so the literature of the folklore, the story telling that comes out of the culture. It's important. It also gives you into a hint about the part of the culture that's much harder to see and that is their values. So the values have to do with good or evil, right or wrong, and then natural or unnatural. So it's sort of the seven of, I want to say rules, but accepted practices and they come out of the values and so knowing the heroes of the culture is a quick way to understand a little bit more about the culture.

And then every culture has a set of rituals. They again, you may be born into a culture not even be aware that you're, you've been ritualized in some way, the things happen the way that they do within that culture. Sometimes a person may follow the rituals of a culture but not necessarily the value set. So when you hold the values of the culture is when you're really part of that culture along the way. What we do know is that communication styles differ by culture and it's important to recognize that there are differences in the way meaning is drawn. Is it directly from the work themselves or is it context in which those words are shared?

When we're talking about cultures, I told you there were nine geographic regions that have been identified across the world but that again, is such a big group of people. How do we really know how to communicate? We, the literature is fractured in the sense of what a, how many cultures we have in the world. Some people say we have the nine regions, some say we have nine thousand cultures and others think we have nine million cultures. We use the word culture in a very informal way. I was thinking about this earlier and I recognize that my son is now wearing Yankee's t-shirts and I thought why is he a Yankee's fan? He spent most of his life in Chicago and Atlanta. Well, because he adopted the rituals and perhaps and the beliefs from his father who was born in New York City and is a Yankee's fan and so I thought it was kind of amusing to see that my son now is a Yankee's fan even as an adult. So you know, does he belong to the Yankee's culture? Maybe? I don't know. But we might say something like that along the way. So we, it depends on how we define a culture how many there are. I don't think we need to worry about that so much because there's no way for any one person to really deeply know the culture of all others but there are some things that we can do to make us a little more competent or aware of cultures which could help us when we're trying to do our crisis communication.

We also need to recognize especially if we're part of a diverse community the idea of acculturation and that is the means by which you modify perhaps your culture through the inclusion of other pieces of other people's culture along the way. So you start to borrow things from other cultures and before you know it, yours says has been, yours has been changed in some ways. I think it's apparent with the speed of information and communication today that we're all sharing and borrowing different pieces of culture from different places along the way. And the reason I wanted to bring up acculturation because someone may have a culture of origin that you may think that they share the same values and rituals of that culture by looking at them but it's not necessarily true. You have to understand as an individual where did that person grow up? Where did their experiences come from? How much of it is true to perhaps the culture of the generation or to before them in their family? So just understand that you can't just point at someone and say, oh I know which culture they belong to. You have to know where did that social learning occur. So that's just another wrinkle or another little bit of confusion that could occur as we're trying to think through culture in our communication in a crisis situation.

So it's sometimes useful if you want to think about culture is to ask yourself a set of questions if you're trying to compare your culture to another, not to judge but just to see where the differences are. If you talk to experts, there are a few things that you're supposed to think about right away if you want to try to be culturally competent. One is that you need to understand where the power comes from. So what is the sources of power meaning is it hierarchal or is spread out among the group, so where is power? The other thing is how does the culture respond to time? That seems to be a big divider among different types of cultures and you, if you come from two cultures where the way they respond to time is very different, there's also a greater chance of conflict. And then one other way that the experts tend to want us to think about culture is spatially and that has to do with our approach to communication and the idea of how close we are literally to someone else as we talk to them.

Well, those are big categories but I think if you just break them down a little bit you can find through a few questions of yourself that you can look at cultures in a way that's interesting and you can learn something from them. So some of the things that I would want to know is what are the crowd or audience behaviors? I mean, some of us queue up in a line and follow the road and directions and signs when we're driving and then you go into another culture and oh my goodness, the, there is no such thing as a line and that's totally acceptable in that culture. Our values might be different in that regard but we need to know what is the culture and one of the ways to avoid some of the conflict as we're working within cultures is to understand that they're not being rude. This is their accepted ritual in that regard.

How often we smile or to whom, this is as simple as when we choose to smile and smile is universal. Smiling is homosapien behavior. We all smile. But we may through our culture, socially learn when it is or is not appropriate to smile. Some cultures for example will smile when they're uncomfortable or embarrassed and if you're in a culture that's not when you smile, then you may think that person is being disrespectful when in fact they're following their cultural learning.

How we see old, how we see old age in some cultures, elderly people are revered, in others, they're discarded. How open or guarded we are with information, I will tell you in my own experience traveling around the United States I came from a culture that was pretty closed about sharing information. And I had to learn as I moved to other places that yes, people in the grocery store will walk up to you and ask you what I think from my social learning is private information but the culture is different. What is or is not ethical behavior, the importance of competition, again, when we talk about individualism versus collectivism there is a difference in terms of competition. How time is understood, I talked about that. The importance of harmony in a group, what's polite or impolite, if, how, and when we touch each other. I think this one is very exciting too, what is beautiful or ugly. And then what we believe we need or don't need and you can see there are some undercurrents of values within those questions but they're good questions to use if you want to start to get a sense of another culture and have that sense in a way that you can compare it to your own. And again, the idea is to learn, not to judge necessarily but to understand so you can reduce conflict in a situation with multiple cultures.

I want to again stress that there are, there's plenty of research that shows that there are some basic human emotions that all people share. Now these emotions may be invoked in different settings or situations but we all have them. And the reason I think it's important to talk about that is because when Crisis and Emergency Risk Communication stresses the idea of empathy, I know with a level of certainty that you can be empathetic even in a cross-cultural situation because some of the emotions that we all have in one time or another as human beings are happiness, sadness, grief. And this is the important one, where the bereavement and mourning rituals may be very different some people may exhibit their grief in a very public loud way and some people may hold it in. It doesn't mean that one grieves more than the other it just means they grieve differently. All humans have the emotion of discomfort, satisfaction, embarrassment. I'm convinced that my kitty cat knows to be embarrassed so I think that might even go beyond humans I’m not sure, anxiety, and pleasure. All of those are emotions that humans share as a species. And so when we're looking for that connection with others, don't be afraid of reading the situation and being empathetic for others in that. And certainly some of those emotions are ones that we would expect to have people feeling in a crisis situation.

So what is the true value of cultural competence in a crisis setting, and I'm making that very clear? The more we can reduce ethnocentric thinking and behavior, meaning that we believe that our culture is the you know, the best, the right one, the less we do that , the quicker we can build trust with others and start to be able to communicate in a meaningful way. And ultimately that is our objective to help ensure the right message at the right time from the right person or organization is sent so that we can save lives.

I want to say two things that I think is really important, when I'm doing any kind of preparedness planning within the cultural context where I know that I will be working within a culture that is homogenous, so it's not because if we have a situation where we have a very diverse population and there's all different cultures, then we probably will fall back to the dominant culture of the country that we're in, but there are cultural taboos and I use that word importantly. A lot of our culture is nice to have sort of things, things that help define us, the way we may dress, our habit in terms of the way we celebrate a wedding or a funeral or something, but in a culture, there may be a cultural taboo, that is something that is more sacred. It's more severe. And if you violate the taboo or if you're asking people to violate their own taboos within their culture in order to respond to the crisis situation, you need to be aware that and you need to express your understanding of how uncomfortable it may be for them to have to go against that cultural taboo.

An example of that we know recently would have been when we've asked people to modify the way they bury their family members in a infectious disease outbreak, that might be one. Another might be if you have to shelter people in mass settings because homes have been destroyed and you're trying to keep families together but that also puts men and women together in the same place. That might not be acceptable in some cultures where there's an expectation where the sexes will be divided.

So we need to be aware of cultural taboos but there's one other aspect I want to, I want you to think about. I want, frankly, get a little irritated when we start to go into the cultural gotcha's, when we do it to self or others and what I mean is it's very nice to know about someone's culture. And there is an expectation that you should at least know the cultural taboos of a culture that you want to work with, but it is again, impossible for me to know the cultures if there are 900, nine thousand, nine million, I don't, I can't know all of the ins of outs of every culture. And it will frustrate me when you're there in you know, with good intentions and then there's somebody around you who is going to point out every mistake you make in relationship to that culture, that person's culture. It's a little bit of pride on the part of some other person that you're necessarily working with but it can get frustrating in that situation and if I were in that position, and if I were you, based on my experiences, I would ask that person to help me understand the culture and bring them in as an ally to do it.

In fact, one of the first things I try to do when I go into a different cultural setting where it's important for me to be able to achieve something is I want to find the confidant within that culture who will help me understand it at least enough that I don't do any cultural taboos but also to try to show some respect that I recognize that, I should know something more about the culture. And if you come into it with an open mind and an eagerness to learn, that's exciting and if you find you spend some time in another culture, you may actually have a little bit of acculturation going on. You might adapt some of their rituals or think that some of their heroes are grand or you might want to share some of the symbols within their culture. I don't know about you, but I know when I go to another culture, I'm always looking at the jewelry just to see who knows what those symbols are and whether I can share them in some way.

All right, so now let's talk a little bit about cultural conflict. We've talked enough in these discussions that we know that conflict is going to exist but there are times when conflict also contains a cultural dimension. And I would suggest that if we're being culturally competent, if we're trying to be aware of cultures and cultural differences and a conflict arises because of that, it would be wise for us to at least acknowledge where that difference is coming from because it's going to be very hard to look for any kind of agreement or modification of the approach to a situation without some of that. So it's just worthwhile to know conflict occurs within a culture itself but conflict can also occur between cultures and we need to recognize that if it does happen. I would suggest that you're going to have a very hard time managing those conflicts if you're really attacking again, a core value of that culture along the way or some of their highly prized believes. So we need to know when we are in a situation like that.

 Part of this discussion I think is open ended and I hope that you all will bring some of your perspectives into this but I also wanted to share with you a question that came from Jennifer and I thought that it married well with our discussion of cultural competence today. And she asks or said she would love to hear more about how to communicate and write about Zika for non-English speaking audiences, how do we reach this group? What are the best tools to communicate with them, especially Spanish speakers and those who are from Zika-infected countries? She wants to know what is the best way to get our information to them, social media, face groups, cultural centers, traditional advertising, question mark, this is a constant challenge.

I certainly empathize with Jennifer and the challenge and I appreciate that Jennifer has the desire to be culturally competent and think through how to communicate to non-English speaking audiences. If you're talking about a situation within the United States, I will tell you the fastest way I get answers to the kinds of questions that Jennifer is asking. I go find somebody from that culture and I ask them. Now, there's good research that exists out there and I don't think it would be a bad idea to do a little bit of Google searching. I know also that CDC for example, has done research about how to reach different ethnic groups based on their past use of social media and that sort of thing. We kind of didn't tend to do it knee-jerked, and I've actually heard from faith based organizations and from religious leaders that they sometimes get tired of us always going to them to carry the message. I'm not saying that's not a bad idea but let's not do that as just a knee-jerk, but find someone within that community or an organization that serves that community, who has more cultural competence and has worked more closely with it and asked those people so you just start asking questions. Understand that one person from that culture may not represent the entire culture but it is a place to start to get more information.

And then allow them a platform to tell you so if you, this is where social media is so exciting, so if you go to a social media group that serves or is a platform for people who you are trying to reach, find out what they want. Ask them and see what they say. If sometimes when we think we're supposed to know everything, it puts so much pressure on, we forget the simplest ways to go about getting the answers and that is to go to the source and just ask and be open to the information that you share and cross-check it along the way.

And as far as Spanish speakers, well we know that there are many cultures within Latin-American cultural region and so there will be some differences and I also want to stress that here at CDC we do have and in fact if your following along on slides, you'll see that I have a slide up that has a screen shot of our information about Zika translated into Spanish. We also have it translated into Portuguese where is that, for that matter and it's worthwhile to check it out if you haven't or if you weren't aware of it that we actually have the information sheet and some very useful community information translated into Spanish. So I hope that helps a little bit Jennifer. If there is some expertise out there that we might be able to get more support for you if you wanted to explore even further, send an e-mail to cercrequest@cdc.gov, but just know we do have Zika communication resources for you in Spanish.

And we're talking about trying to do cross-cultural or cross-language communication. We need to recognize where some of the barriers are. Sometimes we think that we have to be so sensitive to a culture and this is what I eluded to earlier in the conversation, that we bog ourselves down in trying to communicate perfectly in a crisis situation when sometimes we've got recognized well first all people, so let's talk about safety in a way that most people can get it. It's wonderful and I think it should be something we strive for to translate information that's important to someone's well-being in the language they're most comfortable receiving it in. Sometimes in a crisis situation, we may not have all the time necessary to do it. So I would suggest then look for proxies. Are there people who can take this information in English for example and you can give it to them and then they can translate it? I would expect that media outlets that serve a particular audience may be the conduit you will have to use in an emergency to get that information translated so it's important to think about that along the way. And we have a tool at CDC, I'm not going to read the whole URL for the website but there is a tool for special population assessment and it's been used broadly for years now that will help you in the preparedness process to think through what are some of the communication barrier, the message, messenger, and receiver and what you can do to help overcome some of those barriers.

Now I want to go to another question that's not quite as related to cultural competence but I thought was important and Chris asked it, excuse me, he said he's on a border state to Florida and he's already seeing cases related to travel and he wants to know if we can address some of the technologies that we're seeing in Miami that appear to be from CDC. He wanted to know how we felt about media outlets and the fact that they're getting the same information over and over and over in his community, so it's bleeding over, and then wanted to know a little bit about some of the video he was seeing. So I don't know exactly Chris what you were seeing. I think it had to do with mosquito control but mosquito control is a local and state function and so I would be curious if you had to reach out to your vector or pest management control people in the state to see what kind of equipment they're using. And this might be a good idea right now before you're dealing with it to see if you couldn't share with media who are serving your population, let them take a look at what could happen, what might be used in a situation that you'd be dealing with. And I want to tell Chris that it's okay if people are getting the same message over and over again because when people are feeling threatened, it's almost reassuring to get a consistent message and so we might think that it's boring but actually it's reassuring to people who are seeking information about a particular threat along the way. So Angela, I'm going to end it there and see if there's anyone who would like to join the discussion or ask a question.

Operator:      

Thank you. We are now beginning the question and answer session. If you'd like to ask a question, please press Star 1 and record your name clearly.

Barbara Reynolds:               

Okay while we're waiting for people to ask a question, I'd like to take a minute and take a drink. Okay, Angela, do we have any questions or comments?

Operator:      

No questions at this time.

Barbara Reynolds:               

Okay I'm going to remind you all that there are six principles of Crisis and Emergency Risk Communication that can be useful when we're thinking through how to communicate. Be first, be right, be credible, express empathy, promote action, and show respect. I believe these principles are universal in their appeal across cultures and I think it's important for us to plan for and execute them whenever possible. I also wanted to share with you before we leave today that there is a Zika community action response tool kit on the CDC web, online and if you go to our slides from today's discussion, the website is there. And you're welcome to take a look at that and it may also help you in some of the things we've been talking about over the recent weeks. Angela, do we have any comments or questions?

Operator:      

We have no questions.

Barbara Reynolds:               

Okay well then let's call this discussion over and we'll be looking forward to talking to you next week as the last in our series of Zika Crisis and Emergency Risk Communication discussions and if you do have any topics that you would like us to address, you can do that, get it to us through an e-mail to cercrequest@cdc.gov. Thanks all.

Operator:      

Thank you for your participation in today's conference. Please disconnect at this time.