Promoting Health

Educationin a
Multicultural Societv

Jodi Brookins-Fisher,Ph.D., C.H.E.S.

StephenB. Thomas, Ph.D.

t:,::l?ii li i.T"rii
i*eL;?:" ri,Ariid
ffiF;'{-Hj4F,ffiutH
Author Gomments
we reallyfeel that relatingto peopleon a humanlevelis the most importantthing
we can do to make a differencein people'slives.Howare we to developand im_
plementeffectiveprogramsif we do not knowthe peoplewith whomwe
are worK_
ing?lt seems so basic, yet it is a point that has been overrookedfor years.The
focuson diversityis longoverdue.we needto realizeand validatethe important
differences in people.Theyshouldnot haveto be like ,,us,'in orderto recerveserv_
ices in this country.Unfortunately,
just the oppositeis often true.
This chapteraddressesdiversityfrom a practicalperspective.But beyondthat,
we needto realizediversityin health educationbecauseit is the humanthing
to
do. we shouldall be able to enjoyour healthbecausewe are citizensof a great
country-not becauseof our skin color,sexualorientation, or age.Healtheduca_
tors can make the world a better place,and we can beginby acknowledging all of
the peoplethat make up its uniqueness.

Inlroduclion
In the last few years, an increased emphasis on the recognition ofunderserved
populations in the United Stateshas played a major role in health education
efforts. Community-based efforts have been initiated in responseto increasesin
diseaseamong particular populations (e.g.,stroke among African Americans).
In addition, an understanding of concepts such as cultural awareness,culturaj
sensitivity,cultural competence, and multiculturalismhas becomenecessaryfor
a health educatorp be effective.It is easyto give terminology lip service,but
what do these terms really mean? what must hearth education professionals
do to effectively address the issues of diversity in the many settings in which

31_
 32 Ghapter2:PromotingHea|thEducationinaMu|ticu|tura|Society

they are expected to play their professional roles? How does an individual
health educator become better prepared to work with diverse populations?
This chapter addressesthe need for a multicultural focus in health education
and presents ideas on how to facilitate the development of a multiculturally
.orrrp","n, health care setting, as well as lists diversity resoulces available to
health educators.

Increasing Diversity in the United Statesl The Need

for Multicultural Awareness in Health Education
From an ethnic and racial standpoint, the U.S. population is changing from one
that is largely white to one that is more diverse.lt has been projected that by the
year 2030,the ethnic group with the largestpercentageof increasein population
will be Hispanic Americans, equating to a\87o/oincrease.It is also projected that
during the same time, Asian Americans, Pacific lslander Americans, and Native
Americans will experiencea 680lopopulation growth. ln contrast, only a25o/oin-
"minority" ethnic groups,
creasewill occur among the white population, so that
collectively, will surpassthe white population in numbers, accounting fot 5lo/o
of the population.l This shift will result in the United Statesbeing more in line
with global starisrics,in which people of color comprise the majority
Other demographic indicators also demonstrate growing diversity in
America. By the year 2o3},one-fifth of the U.s. population will be over the age
of 65, with individuals over 85 years being the fastest-growing population in
America.2 Additionally, studies suggest that gay and lesbian persons currently
represent2o/oto l0o/oof the U.S. population.3 With health disparities being a pri-
-ary focu, of public health efforts, it is essentialthat health educators,in both
the present and the future, continue to be aware of and respond to demographic
"minority" and other hitherto underserved populations
changes. Growing
will need services that are appropriately delivered to them and that meet their
specific needs. Regardless of the specific population to be
targeted, the development of health education services will
need to take into consideration the population's culture' This
requires the target population's input in community health as-
Suicide is the leading sessment and improvement, program planning, implement-
cause of death among
ation, and evaluation.
gay and lesbianYouth.
Forall othersin this age Some U.S. populations have continued to experience
group,motorvehicleac- problems with certain health issues. Poverty, lack of proper im-
cidents accountfor the munizations, heart disease,cancer,stroke, chronic obstructive
majorityof deaths.
pulmonary disease,pneumonia, and diabeteshave continued
to fugu" ethnic groups, while older adults continue to ex-
perience chronic diseasessuch as arthritis, h)?ertension, osteoporosis, and
l
dementing illnesses.As the country's demographicschange,it is imperative that
I
 I
I

Introduction 33

healtheducatorsprovide programming that addressesrhe dynamic

hearthcon-
cernsof their diversepopulations.

The Languageof Diversity

Terminologypertaining to multiculturalism abounds.At times,
the meaning of
a particular word or how that word differs from another can
be confusing.
Although the following is an a*empt to define the language
of diversrty,one
should always consider the source,as words may be used interchangeably
in
somecircumstancesor settings.
t Diversity refers to divergenceamong people,rooted
in age,curture, health
statusand condition, ethnicity, experience,gender,sexual orientation,
and various combinations of thesetraits.
t Cultural awarenessis the consciousnessof cultural
similarities and
differences.a
t Cultural sensitivityhas been describedas "the
knowledge that cultural
differencesexist-" It is the ability to apply the understanding that
stems
from that knowledge in different settingsand situations to ensure
or
facilitate a useful interaction for all parties concerned.
t Cultural conlpetence is a "characteristicof those individuals who hold
academicand interpersonalskills which allow an increasedunderstanding
and appreciationof another group'sdifferencesand similiarities."I
Culturally comperenrindividuals have made an effort ro learn about
other
cultures and have incorporated the information to the point where
assumptionsabout others are not made. other definitions of cultural
competencehave included institutions, systems,and practitioners,
with
the ultimate result being the ability to respond to the unique needs
of
populations that differ from the majority, mainstreamculture.5
t Multiculturalismhas been defined as a recognirion
of racial and culturar
diversity,respectfor the beriefsand curture of others, and a recognition
that all members of a society have contributions to make for its
betterment.6It includes the concept of equality among peopreregardless
ofsuch factors as race, ethnicity, gender,sexual o.r"rrtutio.r,ug.,"o,
ability
In addition, multiculturalism can be both a vocaburaryt.r- urrd
u
phenomenon at the individual or institutional level, inclusive
of cultures
outside of the majorityT
Multiculturalism has been an integral component in expanding
the notion
of education. The term mukicurtural educationhas been dwelopeJ
"the to refer to
process of gaining an enhanced knowledge, understaniing,
and ac_
ceptance. of the-Srthods of constructiveinteracrionsamong people of differing
cultural backgrounds."Twithin the health educationprofession,
multicultural
34 Chapter 2: Promoting Health Educationin a Multicultural Society

health education has been defined as learning opportunities that are carried out
in relevant languages and are designed with sensitivity to culture, values, be-
liefs, and practices. These education activities are developed and implemented
with the active participation of people reflective of the target
population and take into account their cultural diversity,s
While sociery has become trapped in the muddied waters of
"political
correctness," the present and future of the health edu-
The poorest of the
poor in Americaare cation professionrequiresan understandingof multicultural issues
"correctness."For health
black women over beyond education practitioners, the im-
the age of 85. portance lies deeper than that oflearning the language,it lies in
equalizing the playing field for all players. In addition to knowing
the terminology, health education professionalsshould contribute to change in
societal structure for the betterment of all people in order not to miss a critical
component in the development of the profession in the twenty-first century.

Beingtulturollq
lompetentin
l|enlth
Educotion:
flFocus
for]'|ethod
Selection
In order to provide culturally appropriate servicesto diverse populations, sev-
eral competency areasshould be addressed.First, it is imperative that a health
educator become aware of diversity and his or her role in ensuring that diversity
issuesare addressedin the professionalsetting. Next, being culturally competent
results in health educators going the extra mile to ensure that their workplaces
and the servicesthey provide are inclusive of the diverseneedsof the population
being served.Last, building skills in creating an inclusive environment, using in-
clusive language,understanding culture, establishingdiscussionguidelines, de-
veloping facilitation skills, choosing materials that reflect diverse peoples and
viewpoints, and diversifying teaching techniques and learning styles will in-
creasethe health educator'sability to meet the needs of others. Although these
are not easy tasks, this section provides further ideas about how to incorporate
each into one'spersonal and professionalinteractions.

Heighten Personal Awareness

Before developing and implementing programs for diverse populations, health
educators must first understand their own belief systems regarding issues of
diversity (e.g., race, ethnicity, religion, gender,sexual orientation, age,ability).
The first step in this process involves becoming familiar with personal biases.
Health educators need to be in touch with their personal biasesso that they do
not disrupt servicesand educationprovided in cross-culturalor transcultural (i.e.,
experienceswith others different from oneself) settings. People have had differ-
ent experiencesand they naturally brinqpiases to interactions with others who
 Being cultura[y Gompetent in Hearth
Education:A Focus for Method serection
35

rtfrfr'ridttions
I
new heahh educarorwirh the local
5r,]:, i Over the next several weeks, Katie
neatthdepartment,was askedto give ob_
a talk to tained a lot of backgroundinformarion
a local high school group abour smoking pre_ for
ner presentation.She felt comfortable
This particularcommuniryhigh s.[ool with
:.lrion smokrng prevention messages, but still un-
had a diversestudentpopulalion,with
manv easyas to her abiiity to deliver the
Latino.Spanish-speaking yourh. Althoueh she informa_
l j o n w i r h i n l h e c o n r e x ro f r h e g r o u p .
telt confidenrin the subject *urr"l. ro She
b""or._ o e c r c e c ls h e n e e d e d t o [ u r t h e r
sented.she realizedshehad very limited knowl_ research
smoking prevention programs
ed-ge ol. and past interactionwilh, those and mes_
o[ sagesin the literature targetingyouth
ditleringerhnicbackgroundsfrom hersel[. in gen_
She e-rat,and would ask the htgh school
y1nr.9 lo makesurerhe informationpresenred erouu
il she could alrend a couple of its
netpedlhe young peoplebur did not rn""iingr.
alienate ere she would listen to itre group,
them becauseof her lack of knowledge f observe
about and inrerview
rnemas borha populationand individuals_ wiling
ff;; ;[t:.tions,

differfrom themselves.previoussocial
experiencesand poriticalinteractions,
well as rhe communicarion and probrem-solving as
capabiritiesof individuars,af-
fectinteractionswith othersand may
readto stereot)?ingor misunderstanding.6
with an understandingof personarbiases,
heartheducatorshave a clearerun-
derstandingof their limitations in
communrcating with target populations.
Health educatorsalso must exhibit professionalism,
separatingtheir personar
biasesfrom their profrusionarinteractions,
especiallyas they are calredon more
frequently to work with diverse popurations.
itrr, ,, a difficult task, and one that
should be carefully analyzed,prio. to
programmrng at any level.
Along with careful evaluarion of perlonal
biases, lisiening, ,,i,$i""ri"r::r.
watching'reading'and parricipatingare
importantin becominsa cul- -ai,,;,. ir-
turally
competent
professional.
Health
educarors
*" l;,h?;;, _#ffiffiffi*I
,,.i,"our,ras
about other cultures when they immerse
themselvesin those cul_
tures'Learning about other cultures a group
can be accomplishedby at, ioentirier canincrude
tending cultural events, such as pride
Day, Cinco de Mayo, individuars from arl

L#il:,1"3i:fj;:TffiX[11"T_T'*ffix,]
ji::*jfl"n*ruim
abouttopicson differentcurtures;bein!
involvedin neighborhood urarionsof peopre
activitiesin the community; and reading
materialso., urrJf.o* o.o_ are in greatestneed
pteof different curtural backgrounds, or hearth-rerated
serv-
especialrythor. ;;;;;;;;_
ifiedbythepeopIeaboutwhomthematerialis,*.,u",'.Establishing@w
relationshipswith peoplefrom different
culturesis perhapsthe most
beneficialway to learn about other cukures.
Thesererationshipswil allow freedis_
cussionand provide opportunities to listen
and learn f.om othe, poins ofview
fir
ll'
36 Chapter 2: Promoting Health Educationin a Multicultural Society

Transfer Personal Knowledge into Professional Settings

The resulting knowledge associatedwith becoming awareof personal biasesand
learning about other cultures should be transferred into professional practice and
the workplace. At a broader professional level, the following strategiescan en-
hance a health educator'sability to understand diversiry and help ensure that it
is incorporated into professional practice and workplace interactions:6
r Determine whether current expertise addressesboth regional and world-
wide diversity and responsibility for human and international interactions.
r Determine whether programs enhance people'sskills and knowledge
about the diverse world around them so that people better understand
themselves and the values of other cultures.
r Determine whether materials, curricula, services, and resourcesbenefit all
target populations. Materials should reflect gender, racial, and other cul-
tural differences (e.g., gender-neutral language).
r Determine whether an action plan has been developed relating to special
information for underserved populations, such as migrant farm workers,
immigrants, homeless persons, and people with differing sexual
orientation.
r Determine whether plans incorporating Healthy People 2010 into prog-
ramming have also included the needs of diverse populations.e
r Tailor an evaluation mechanism to suit the needs of the particular organi-
zation that measuresthe extent to which the health education workplace
is meeting its responsibilities of responding to the diversity of its clientele,
with input from the population or populations being served.
The process of becoming culturally competent is not a single-time inter-
vention, but one that needs constant reevaluation and reappraisal both at the
individual and the organizational levels. A culturally competent health educa-
tor is in a position to determine the extent of the cultural competence of the
professional setting, assessand document the strengths and weaknessesof the
organization, and focus on areasfor improvement in both the workplace and
programming.

Greate an Inclusive Environment

Creating an educational environment inclusive of the diversity among par-
ticipants can be one of the greatest challenges in health education program-
ming. In doing so, several areasof concern should be addressed,including
(1) the use of languageand verbiage,(2) understanding the targetpopulation
culture, (3) discussionguidelines, (4) facilitation skills, (5) use of ma'terials,and
(6) teaching techniques and learning styles. These ideas will help to infuse
 Beingculturally Gompetent in Hearth Education:
A Focus for Method serection 37

fl
Upon completing her researchregardingLatino
utilized heakh departmenrseMces.Shelound
youth,Katie discoveredthat youths ofrJn rhrive
thar although the healrhdepanmentwas often
in educationalenvironmentsthat facilitateco_
emparheticto peoplewith diverseculturesand
operationrather than competition and that
backgrounds,they did not have specificre_
allowfor groupwork. Rs far as ,-"f.i"- "L_ sourcesavailableto youti about smoking.and
ventionmessages,
therewerea few ideai,bur that the pamphles that wereavailable*."* r"_
not many rargeredat Hispanic youth. She de_
ally directedto white popularions. Shedecided
cidedthat she would incorporaiegroup activ_
to [urther explore the resourcesin the com_
ity into the presentat_ion
after consulting with munity in order to developa resourcelist. Thaf
the youth group.
way. when young people utilized heahh
Upon inteMewing l-atino youths lrom rhe de_
. partment seryices,rhe providerscould have
high schoolgroup, she discoveredrhat very few a
referral sheet for existing resourcesupon re_
couldidentifyseMcesor resourcesavailableto
quest.Shealso decided to reviserhe smoking
them for smoking prevenrion.She decided to
prevention informarion availablero LatinJ
exptoreher own agency's
exptore agency'sabiliry
abiliry to meet
meerLatino
Latino youth to make it more appropriate,attractive,
youth needsand irs responseio youth as they
and applicablero rhem.

culture into the educationarenvironment and

wiil help ensurethat method se_
lectionhas taken culture into account.

Use Inclusive Language

Health educators need to consider the importance
of inclusive language when
presenting informationto individualsand community
groups.Lanjuageis one
of the most important methods for communicating,
yet can be the hardestto
changefor inclusiveness.Both orar and written
communication must be crearry
understoodby diverse populations. Strategiesfor
ensuring inclusivenessincrude
oral and written communication that rs gender
neutrar (e.g.,using words such
aspartner and spohesperson), in the appropriat" language,arrd ut ih" appropri_
ate literacy level. Reading-lever-anarysis
programs and learner verificatron pro_
ceduresshould be used with written -ut"riulr-.
Membersof the targetcommumty
shouldbe involved in developingmaterialsin different
languages.iruJutio., urrd
retranslarionshould be carried our to ensure
that the upp.lp.Lr. message', con-
veyed.Picturesand words conveying health messages
should be used as much as
possibleand where appropriate. Iflanguage issues
are not considered,health ed-
ucatorsrisk not connecting with the targetpopulation
at the most basic level.
Understand the Target population Culture
Another areaof challengeis becoming aware
of the culture, beliefs (especialry
healthbeliefs),and varuesof the targei popuration.
It is very difficult for some_
one living outside the cultural parametersof
a community to understand that
38 Ghapter 2: promoting Hearth Educationin
a Murticurturarsociety

population'sculture if it has nor been personaily

experienced.culture in itserf
is diverse,and generalizationsfrom past
experienceswilr not necessarilyhold
true for any particurar targetpopuration
or herp a health educatorwith a cur-
rent program or event. Even when the
health educator is properly prepared,
cross-culturarinteraction may include participants,previous
"*p"ri".r.", thut
may impede the educational process.Although
this may be frustrating, the
health educator should remain motivated
unJ i.rt.."rr.i r., th" partrcipants,
points of view. If needed, community
resources and. organizatiins that are
culture-specificcan be utilized for troubleshooting
problematic areas.
Establish Discussion Guidelines
discussionguiderines(e.g.,for use with focus
-"r*p groups or crasses)shourd
be determinedand statedat the beginning
ofany program or event,and should
be maintained by the faciritator anJg.o.rp"m"-bers.
Discussionsamong groups
should be sensitiveto diversity Guidelines
for inclusivenessmay include any
or all of the fo'owing: (r) respecting the
confidentiarity of ati
commentsand actions, (2) being sensitive farticipants,
to different p"rsorralexperiencesof
group members, (3) being sensitiveto
different revelsof expertise'amongthe
group, (4) avoiding assumprionsabout
the curtural o. "th.ri. backgroundsof
other group members, (5) allowing privacy (i.e.,
the right to pu* i' any dis_
cussion or acdvity), and (6) other guiderines
rhat the gro.,p d""rr* important
in order to facilitate toleranceand respect
for eachperson,spoint of view.
Develop Facilitation Skills
Health educatorsshould be facilitatorsofacceptance
and respectin any setting.
Good faciritation skills require negotiation,
the ability to d"ul with contro_
versy being approachableand open, and being
objective and impartiar. Ifproper
facilitation occurs, a hearth educator .u.,
b""u role model for inclusiveness.
Choose Materials Wisely
Efforts should be made to serectpieces
from many perspectiveswhen deter-
mining which materials to include in programming.
For insrance,articresby
women and people of color can culturarize
a curriculum. By remembering
there is diversity among participants, health
educatorswil utirize materialsfrom
more than one viewpoint. It may also be
necessarywhile preparing curricura
to use focus group discussionsto determine
what teachingmaterialsand meth-
ods are appropriateand acceptablefor
the population at hand.
Diversify Teaching Techniques and
Learning Styles
It is alwayseasiestto teachhow one prefers
to be taughi, but this may not reach
all participants. Education should include
various methods (e.g., lectures,
small groups, role plays, computer exercises)
to be inclusive of the various
 Tips and Techniques for Incorporating Culturat Gompetence 39

rt$fl'rittilsns
I
Feelingmore preparedlor her presentation
because she had learnedmore about her tar-
get popularion and its culture. Katie began
to garher materials for the presenlation.
Aithoughshe prided herselIjn her abiliry ro
adaptto differentpresentations,she knew if
shewas to be truly effecrivewith her group
she would need to ensureshe was attentive
t o c u l t u r a l c o n s i d e r a t i o n sS
. he thought a
I e a r n i n ge n v i r o n m e n t w i t h g r o u p a c t i v i t y
a n d c u l t u r a l l y a p p r o p r i a t em a t e r i a l sw e r e
crucial (i.e.,materialscorrectlytranslatedinto
Spanishthat were appealingto the group).
fhese ideas,although somewhateasyto in-
tuse into rhe presentation,might make all rhe
dilferencein helping her populationrelarero
her and connect with her smoking preven-
tion messages.

learningstyles among participants. Becauselearnersmay be visual, tactile, or

audio oriented, a variety of teaching methods should be incorporated to ac-
commodatedifferent preferences.values clarification exercisesare also ben_
eficialin heightening cultural sensitivity becausethey help further participant
awarenessof personal values, while allowing others to state their values. As
statedby Noreen clark, dean of the school of public Health at rhe Unrversity
o[ Michigan:ro

As a societywe hayeto get agreementson what is important, what

we vqlue. . . .It's not a mqtterof your valuesbeingbetterthan mine.. .
it\ a matter of creatinga societywhereboth our valuescoexist.

onnl
Prnclice
As health educatorsattempt to positively changethemselvesand the environ-
ments in which they work, they should be aware of a few issuesthat will aid
in the processof establishingmulticultural competencein the heart of profes-
sionalpractice.

Take Small Steps Toward Ghange

Becominga culturally competenthealth educatorwill take time. old habits are
hard to break, so effort must be made to institute changeover time. It is im-
portant to remain oneselfthroughout the process,as humannessin the effort
of trying to be cuhurally sensitiveis an admirablequality. peoplewill be aware
of a fake persona anyway,sotruthfulness is the best policy Additionally, as small
stepsare taken toward inclusiveness,a trust in others must be established.
Eachclient or participant is a unique individual, so careshould be taken ro not
40 Chapter 2: Promoting Health Educationin a Multicultural Society

j:'":':-'r;i;::i;-q;:!-!"t;j
g- dlsx;{! !';;:-..;"'!J-;: Gharacteristicsof a MulticulturallyGompetent
Health Educator
r Acquiresknowledge and groupsof peopledifferentthan
aboutindividuals
oneself
I Participates in culturalevents
a Emoathizes for humankind
I Competentin processand contentareasof healtheducation
t discussionaboutthe importanceof cultureamongvarying
Facilitates
and groups
individuals
I Providesa safe environmentfor exploring the meaningof culture
T Providesan inclusiveenvironment
I Speaksin gender-neutrallanguage
I Promotesnot onlytolerance,but acceptance
I Strivesto reducehealthdisoarities
I Empowers diversepopulation
to helpthemselves
I Modelsthe importanceof diversityin personaland professional settings
I Includesculturalconsiderationsin all programmingand activities

judge based on past experiences.With each successfulventure at attaining

cultural sensitivity, the health educator will become more culturally competent
(seeTable 2-I for traits of a culturally competent health educator).

Infuse Cultural lssues into Facilitation

Although the information presented in Table 2-l will help equip the health
educator with facilitation skills, other tips are also important.6 Cultural dif-
ferences can be brought into the discussion through a planned activity re-
garding a health topic. For example, special remediesfor dealing with common
illnessesmight be discussed,or ethnic or more readily availableor obtainable
foods might be evaluatedfor nutritional content. By providing these types of
opportunities, health educators are encouraging expression of, and accept-
ance for, differencesin culture, food or other preferences,and socioeconomic
class, while allowing for exchange of ideas and even the fostering of rela-
tionships between people in a nonthreatening environment. Participantsmay
disagreeon a concept being presented.As the facilitator, the health educator
should be careful to not support or oppose one view. By being open in dis-
cussions,the health educator establishesa climate of caring and acceptance.
Inclusive languageand use of variety in exampleswill also improve facilita-
tion skills.
 Overcoming Challenges to Becoming Multiculturally Competent 41,

Know Limits
Health educatorsmay find at times that their personal values intrude in pro-
fessionalsettings. If this is a continual problem, then refer clients to another
competentprofessionalwho is better able to deal with the issue. This is nor
to say the health educator should avoid all potential clients that causeinrer-
nal struggle, becausecontinued effort at working with others may help the
health educator sort through conflicting personal values and professional
oblisations.

0vercomi
[hall sloBecomin
There are many challengesto becoming a multiculturally competent profes-
sionaland ensuring a multiculturally competentworkplace.Both personaland
professionalbarriers, aswell as outside opposition, may impede a well-intended
effort.This section includes ideasfor reducing barriers and lesseningcommu-
nity resistance.

ReducePersonal Barriers
Perhapsthe biggest barrier to attaining cultural competenceat the personal
ievel is a lack of awareness.Getting beyond one'sparadigm and life focus is
difficult, and occurs best when awarenessis first heightened.Awarenessat a
global level encouragessharing of wealth, prosperity,and economic develop-
ment among all U.S. cirizens. It is a difficult process,as expressedin the fol-
Iowing sentiments:11

Simplyput, at q time when the econonryis weahandmatry politicians

are employing old strategiesof blaming minoritiesfor gettingmore
than theirfair share, it is not dfficult to understandthe resistance
that many peopleexpresstowardstextsand progrqms,that, in their
minds,merely "rewrite" history.For thesepeople,all this tqlk about
multiculturalismis little more than an attemptto creqtea narratiye
that ma'l?esthem lessthan heroicby virtue of achnowledgingthe sig-
niJicanceof others,otherswho havebeenoppressed and who haye
beenhithertoyiewednot as importantbut rqther as problematic.
Becauseof this, educatorscqnnotunderestimate the importanceof
the reevaluationof the statusof indiyiduals qnd groups of people;
many will be compelledto seetheir own significancechallenged,if
not threatenedwith erasure,as othersgain a new placein both texts
and the nqtion.
r*
l'
Ghapter 2: Prcmoting Health Educationin a Multicultural Society

Health educators should adhere to the Code of Ethics for the Health
Education Professionwhen dealing with personalbarriers.l2Article I! Section l,
specifically addressesthe need to be sensitive to social and cultural diversity.
By following the code of ethics, health educators will ensure they are abiding
by professional expectations rather than personal beliefs when conflict arises.
Reviewing literature in related disciplines may also help a health educator in-
creasecultural awareness.Health educators should avail themselvesof the var-
ious opportunities that present themselvesto becomemore educatedon cultural
awarenessand the provision of culturally appropriate care, such as attending
conferencesand spnposia and reading the growing body of literature available.
The reader is referred to Marin and colleaguesl and Buckner6 for more infor-
mation on the importance of cultural diversity in health education program-
ming. Finally, the health educator can combat personal resistanceby referring
to several organizations and resourcesthat can help professionalsbecome more
culturally aware and competent (see Table 2-2 and the Additional Resources
list).

Lessen Professional Barriers

In the health education field, the greatest barriers to multiculturalism con-
fronting health educators are a lack of research,of available health education
programming specifically targeting diverse populations, and of preprofessional

ffi ^-- rsininlien:Pr-o-lnelins

lllllipsl$rel.ltpelthE{rtp$rtis:*
AmericanAssociationfor HealthEducation
19OOAssociationDrive,Reston,VA20191-1599
1-800-321-O789
(Specifically,
two publicationsexist: Culturalawarenessand sensitivity:
Guidelinesfor health educators, and Culturalawarenessand sensitivity:
Resourcesfor health educators.\

AmericanPublicHealthAssociation
1015 15th Street NW,washington,Dc 2o0o5
202-789-5600
(APHAhas specificcaucusesto addressdiversityissues.)

AmericanSchoolHealthAssociation
7263 State Route43 or PO Box 708. Kent. OH 44240
330-678-1601

Societyfor PublicHealthEducation
1015 15th Street NW Suite 410, Washington,DC,20005
20240&9804
 overcoming chailenges to Becoming Murticurturailycompetent

training. Much of the researchin health-relatedfields has predominantly used

white malesas the point of reference.Additionally,researchhas shown that tra,
ditional health education approachesare not as effective with underserved
groupsof people aswith the resr of the popularion.r Few professionallytrained
healtheducatorshavereceivededucationregardingmulticultural issuesbecause
few programs nationwide have incorporated a multicultural emphasis into
their coursecontent. Thesebarriersmay affecta health educator'sability to ef-
fectivelywork with the many diverse target populations for which programs
aredesigned.
Even in a profession in which most individuals consider themselves
open-minded, the road to cultural competencehas been slow. Many organi-
zationsand agenciesstill face barriers that impede their ability to effectively
incorporate culture into programming, method selection, and material de-
velopment.At the institutional level, health education agenciescan avoid bar-
riersby (1) being awareand acceptingof cultural differencesand similarities;
(2) having the ability for cultural self-assessment(i.e., for assessinghow cul-
turally comperentthe orga.ization is); (3) having the required awareness,un-
derstanding,and knowledge of target populations; (4) deveioping skills rhat
facilitatediversity; and (5) being sensitiveto dynamics inherenr with cultural
interaction.l
To improve the status of researchregardingmulticultural issuesin heaith
education,more researchersneed to seecultural diversity as important. For in-
stance,one study found that only 78 titles of 774 articlesthat appearedin
prominent health educationjournals over a four-yearperiod alluded to a mul-
ticultural emphasis.13 More researchprojects will need to be specific to rarger
populationsand must be run by adequatelytrained health educators.To avoid
barriersto multiculturalism, professionalresearchshould adhereto a number
of guidelines,including the following:1
I Demographicinformation must be collectedon all targetpopulations.
r Bettermeans of reaching underservedpopulations through interventions
must be developedand implemented.
r Peereducation must be utilized.
I Studiesneed to include not only health probremsbut also social
and
contextual indicators of their incidence and prevalence.
r Evaluation componentsshould addressboth processas well
as impact
indicators.
Approachesthat are more useful than traditionar health education programs
in helping underservedpopulations include peer education,Iay health workers
(e.g.,family members,significant others in the communities),interaction
with
44 Ghapter 2: Promoting Health Educationin a Multicultural Society

health care providers, self-help groups, and school-basedinterventions. When

implementing any of these approaches,cultural issuesshould be addressedby
taking into account the values,expectancies,norn$, beliefs,and behavioralpref,
erencesof the target group.l
Along with a multicultural focus, a mindset of advocacymust be instilled
in professionally prepared health educators, since they will be in positions to
work with people (e.g., administrators,legislators)who have a profound im-
pact on other groups'causes. Colleges and universities training future health
educators should incorporate skill building and training in areas of commu-
nity organization and empowerment, advocacy,volunteerism, and diversity in
order to preparestudents for the realities of changing demographics.Developing
culturally sensitive programs will increase the level of culturally competent
health educators.

Plan for and Dissipate Community Resistance

Community resistancemay also be a barrier to incorporating cultural diversity
at the agencylevel, especiallywhen dealing with multicultural issuesthat ignite
debates among those with different value systems. For example, inclusion of
a gay and lesbian youth support program in a school district may initiate con-
fioversy because of differing belief systems among educators, administrators,
parents, and students. Religious values and lack of information about an issue
may also contribute to the resistance.
It is important to be able to handle community opposition to multicultural
programming. Opposition to multicultural programming may even include the
target population itself. For example, Native American populations who have
had negative past experienceswith health education programs may not be sup-
portive of additional programming. Finding out why the target population or
populations feel as they do, and making sure that the program is developed in-
corporating their perspectives,will increasethe likelihood of program success.
Overcoming community opposition can be accomplished by developing
relationships with key individuals associatedwith the target population. These
key individuals and groups will provide insight into community norms, values,
and belief systems.By believing in what the agencyis trying to accomplish,
they will help the health educator createa successful plan to reduce or elim-
inate opposition.
Whenever possible and appropriate, broad-basedcoalitions or partnerships
concerning a particular health issue should be developed.By beginning with a
common point of interest (i.e., the health issue), individuals will focus on the issue
at hand rather than individual biasesabout the target population. For example,
if a coalition is organized to promote sexual abstinence,including abstinence
 Expected Outcomes 45

amonggay youth, the group should focus on the issueat hand insteadof per-
sonalviews about homosexuality.
It is alwaysbetter for a program to work with the opposition than to exclude
them.By finding a common concept for agreement(e.g.,reducing risks for a spe-
cific disease),barriers such as conflicting values and personal stereotypeswill
begin to break down. An attempt ar working together shows empathy and con-
cem on the health educator'spart. once the opposition is heard, they may be sat-
isfied and no longer be a threat to the program. Some groups, however, will
refuseto agreewith other positions and will not be willing to compromise.when
this occurs, partnerships will not likely work for either party involved.

txpected
0utcomes
By following the suggestionsdescribed previously, health educators can expect
to enhancetheir cultural competenc;zThis, in turn, will lead to more cultur-
ally competentinstitutions, organizations,programs,and research.By includ-
ing the target populations throughout program development, materials and
resourceswill be inclusive of their point to view and more likely to be utilized
in the future.

qtfr'ribtilons
4
After the presentationabout smoking pre-
vention, many of the young people stayed to
ask Katie furt-herquestions-Her preparation
had paid off. By carefully selecting merhods
for the presentarion that incoryoraled the
unique cultural considerationsof the youth
group. her messages were well received.
Besidesimparting information on an impor-
tant risk factor for disease prevention to a
group ofyoung people,she alsohad increased
her comfon level regardingdifferent popula-
tions. The youth knew she was open and re-
spectful, and in turn, they encouragedher
continued involvement in the health lecture
seriesat rheir group meerings.Indirectly, she
had also establisheda rrusring bond between
the health deparrment and a group of tradi-
ti onally disenfranchisedyouth.

Another outcome is mutual trust and respectbetween groups that tradi-

tionally have had turbulent relationships.Many minority groups distrust the
more dominant, or majority, populations (i.e., those populations with power
in the social structure) and their services.Ensuring cultural diversity in pro-
gramming can build relationshipswith mutual understanding.The power of
reestablishingtrust relationshipsis not to be underestimatedin the context of
relationshipsbetween individuals and the institutions representedby other
individuals.
 Society

A iery importaht outcome of obtainingcultural

competence at the indi_
vidual and professional levels is the developmenr of health education
pro-
grams' including method selection, that are embracedby the community
to the
extent that they are institutionalizedby the target population. The target
pop-
ulation is more likely to take ownership becauseit has been empowered
and
involved in the process.
The goal of all the aforementioned is to pave the way for the elimination
of disparitiesin health outcomesacrosspopulations within the united
states.
clearly, barriers to continuous, quality care are very important reasonsfor
the
continued disparities in health status and outcomes of members of
under-
served populations. Thus, at the personal,professional,and community
lev-
els, greater awarenessof diversity issuesmust be achieved, paving the
way for
new directions in programming for diverse populations. The goal of multicul-
tural diversity can best be summarized by the following:ro

we (health educators)have to begin with deveropingan awareness

and hnowledgeof culture which irnpliesa non-jud,gmentalacceptance
of the worth of all ethnic groups-a wilingness to seepeopleas much
as human beingsas membersof a particular grory. . . . The
final stage
is to be able to perform a specific tashwhile tahingculture into
accountsuch that the outcomeis better than it would have beenhad
the role of the clientbculture not beenconsidered.

[onclusion
Society demographics are changing, which directly affectsrhe practice of health
educators. New strategiesneed to be inclusive of cultural diversity and should
be implemented by culturally competent health educarors.The health
educa-
tion profession must continue to examine its professional preparation pro-
grams, research,literature, programming and curricula, methods, and
evaluation
strategies to ensure the inclusion of cultural diversity. As stated by Buckner:6

The reality . . . of the 2lst cantury leayesus no alternatiyesbut to be

prepared,to be innovative,to be progressive,to be
Jlenble qnd to dare
to meet the challengeof buildingbndges our [crients] into the
for
next century.

The goal of attaining a multiculturally competent profession begins with

eachindividual health educator.By eachindividual examining his or her own
bi-
ases,beliefs, and values and determining how these transfer into the profes_
sional setting, alternative,he or she can devisemore inclusive ideasand activities
if needed. once every health educator is responsive to the diverse needs
of his
 Conclusion 47

or her targetpopulations, workplaces can then be transformedinto respectful

and inclusive semings.Above all, the health education professioncan be re-
sponsive to Birckner's challenges6to be at the forefront of meeting the needs
of our ever-changingAmerican population.

culture: similar ideas,beliefs,values,and perceptionsamongpeopleof a particular

group.
disparity: The vast differencesthat exist betweenpopulationsin terms of accessto
services,morbidityand mortalitystatistics,availabilityof resources,and the like.
inclusive language: using languagethat does not leaveout a particulargroupor
population.Forexample,referringto the top positionin a localagencyas the chair-
person rather than chairman.
majority: The groupthat holdsthe powerin a population.This may or may not mean
theyhavethe greatestnumberof individuals in the community (e.g.,whitemen hold
the powerin Americanpoliticalarenas,althoughthey may not accountfor the most
peoplein the community).
minority: A government-invented word usedto categorizepeople.This term is often
seenas inferring"lesserthan" or somehowinferior;therefore,its use is on the decline.
underserved: Populationsthat do not havethe same amountof services,re-
sources,and so forth neededto deal with individualand communitvhealthissues
compared with otherpopulations.

REFERENCES

1. Marin, G., Burhannsstipanov,L., Connell, C. M., Gielen,A. C., Helitzer-Allen,

D., Lorig, K., Morisky, D. E., Tenney,M., & Thomas,S. (1995). A research
agendafor health education among underserved populations. Health Educahon
Quarterly,22, 346-363.
2. Federal InteragencyForum on Aging-Relatedstatistics.older Americans
2000: Key indicators of w ell-being. Available: http://www.agingsrats.gov/
chartbook2000/population.html.AccessedI0/ 6/ Ol.
3. Greenberg,J.S., Bruess,C. E., & Haffner, D. \M (2000). Exploringthe dimen_
sionsof human sexuality. Sudbury, MA: Jones and Bartlett.
4. Redican,K., Stewart,S. H.,Johnson, L. E., & Frazee,A. M. (1994). profes_
sional preparation in cultural awarenessand sensitivity in health education:
A national stlrvey.Journal of Health Educdtion,25,2I5_2I7.
5. National Alliance of Black School Educators.( l9B4). SavingtheAfncan_
Amencan child. Author.
6. Buckner, w P, Jr. (1994) . Promoting multicultural sensitivity among educa-
tors. In P cortese & K. Middleron (Eds.), The comprehensiteschoolhealth
challenge:Vol.2 (pp. 661-686). SanraCruz, CA: ETR Associates.
 48 Ghapter 2: Promoting Health Educationin a Multicultural Society

7. Staddon,D. T. (1992). Multiculturalresourcemanual.Mt. Pleasant,MI:

Central Michigan University Printing Services.
8. MacDonald,J. L., Thompson, P R., & DeSouza,H. (f998). Multicultural
health education: An emerging reality in Canada. Hygiene,7, 12-16.
9. U.S. Department of Health and Human Services.(2000). Healthy people2010.
Washington, DC: Author.
10. Clark, N. M. (f994). Health educatorsand the future: Lead, follow, or ger out
of the way.I ournal of Health Education, 25, 136-14I .
II. Scapp,R. (1993). Feeling the weight of the world (studies) on my shoulders.
The Social Studies,84,67-70.
12. Coalition of National Health Organizations. (2000). The Code of Ethics
for the Health Education Profession.Journal of Health Education,31,216-218.
13. Brookins-Fisher,J., & Rieckmann, T. (1996). The presenceof multicultural-
ism in titles ofselected health education iournal articles. TheHealthEducatox
28.3-7.

A D D I T I O N A TR E S O U R C E S

Print
Banks, J. A. (1997). Teachingstrateglesfor ethnicstudies(6th ed.). Needham Heighs,
MA: Allyn & Bacon.
Banks,J. A., & McGee-Banks,C. A. (1997). Multicultural education:Issuesandper-
spectires(3rd ed.). Needham Heights, MA: Alllm & Bacon.
Brainard, J. M. (1996). Cultural diyersity in the health classroom.New York: Glencoe.
Downes, N. J. (1997). Ethnic Americansfor the health professional(2nd ed.).
Dubuque, IA: KendalVHunt.
Doyle, E. I. (f 995). In the rough:A teachingstrategiesdirectoryfor cultural di,versity
inhealth education.Denton, TX: TexasWoman's University.
Gordon, A., & Williams-Brown, K. (1996). Guidingyoung children in a diyerse so-
ciety. Needham Heights, MA: Allyn & Bacon.
Sebastian,J.G.,&Bushy A.(1999).SpecialpopulationsinthecontnunityGaithersburg,
MD: Aspen Publishers.
Simmons, R., Bennett, E., Ling Schwartz, M., Tung Sharify, D., & Short, E. (2002).
Health education and cultural diversity in the health care seuing: Tips for the
practitioner. Health Promotion Practice, 3 ( I ), 8- I 1.
Spector,R. E. (1996). Culturaldiyersityinhealthandillness(4th ed.). Stamford,CT:
Appleton & Lange.
U.S. Department of Health and Human Services,SubstanceAbuse and Mental
Health Services Administration, Center for Mental Health Services. (2001).
Cultural competencestandardsinmanagedmentalhealth care semices:Four un-
d.erseryedlund.errepresented
raciallethnic groups.Washington, DC: Author.

I
 Conclusion 49

Internet
cDC on the Move against Health Disparities. Available: http://www.kaisernetwork
orglhealth_casr/hcast_index.cfm?display=detail&hc=5 2.
The Center for Researchon Ethnicity, Culture and Health. Available:
sph.umich. edu,/crech,/.
Crosscultural Health care program. Available: http://www.xculture.org/index.cfm.
House,J. s.' & williams, D. R. Undersrandingand reducing socioeconomic
and
raciaverhnic disparities in health. Available: http://books.nap.edu/books/
0309071755/htmV82.html#pagerop.
Midwest Latino Health. Available: http://www.uic.edu/jaddams/mlhrc/mlhrc.html.
National Heart, Lung, and Blood Institute strategic plan to Address Health Dis-
parities. Available: http://www.nhlbi.nih.gov/resources/docs/plandisp.htm.
Native American cancer Research.Available: http://members.aol.com,/natamcan/.
s;.'rnposiumon Diversity in Health professions.Available: http://ww-uziom.edu/IoM/
IOMHome/nsf/Pages/nickens+symposium.