2014 Riley No Shelter From the Storm Reclaiming the Right to Housing and Protecting the Health of Vulnerable Communities in Post-Katrina New Orleans

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

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.


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.



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,



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



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



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



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



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



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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