Introduction

Issues of inequality and inequity in healthcare are growing throughout the world. To fully understand these issues, it is also necessary to understand these concepts:

1. cultural awareness
2. cultural humility
3. cultural competency. 

Cultural differences and language are two main issues that may create barriers that prevent public health workers from helping community members. Language and culture can prove to be obstacles for building relationships within a community. This is why it is essential that public health professionals are aware of the cultural differences that exist between them and those they serve. Public health professionals must also be able to demonstrate empathy, or feelings, and use their cultural understanding when working with individuals from different backgrounds.

Culture

Culture refers to integrated patterns of human behavior including the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

Cultural Identity, Cultural Awareness, and Cultural Humility  

Cultural identity: Cultural identity refers to a specific culture to which a person belongs. Cultural groups may be formed through common threads such as language, nationality, ethnicity, race, age, education, economic status, gender, or religion. A person’s cultural identity can be understood as that individual belonging to one or more of these groups. For those who are outside of a particular culture, the first and best way to understand a person’s cultural identity is through their language. Language is culture. Language is the way that people express their culture. While it may not be possible to become fluent in a second language, any effort to understand how an individual expresses their culture through their language can help break down barriers to understanding. In addition to language, cultural traditions are shared through storytelling, music, song, dance, or art. Learning about these cultural expressions can also help a person gain an appreciation for other cultures. For example, reading a novel or other text written by someone with a different cultural background, even in translation, can help build an understanding of the way that person views the world.

Cultural awareness: Cultural awareness is the recognition of the distinctions between one's own culture and other cultures. It also means understanding those differences. It is the process of conducting a self-examination of one’s own biases against other cultures and the in-depth exploration of one’s cultural and professional background. Cultural awareness is considered one of the most important factors for improving the effectiveness and quality of public health in a diverse population. Cultural awareness education needs to be part of every public health care worker's training to increase the quality of health in a community.

Cultural humility: Cultural humility means not considering your own culture or identity as better than or superior to someone else’s. Cultural humility encourages you to respect the points of view and differing opinions of others. 
Cultural humility also requires that you examine your own personal beliefs. You need to be aware of your own personal biases or attitudes that may cause you to look at the world in ways that may cause you to judge someone or an idea or value unfairly. You need to keep an open mind and desire to learn more about other people's cultures, beliefs, and values.

Ways You Can Practice Cultural Humility:  

• Understand your own culture.
• Know that you can explore different values without losing your own.
• Be open to exploring others’ cultural identities and asking questions when you need to have them explained.
• Express curiosity and interest in others’ beliefs and values.
• Commit to learning and growing from your communication with individuals whose beliefs and values differ from yours.
• Learn about other cultures–you can read books about different cultures or learn by talking with someone from that culture.
• Do not forget: There is always more to learn to increase your cultural humility..
  

Bias

Bias consists of attitudes, behaviors, and actions that lean in favor of or against one person or group compared to another. Biases are typically considered to be unfair or unethical. Many times, people are unaware of their biases. Still, biases can affect how we interact and respond to each other, especially in situations in which you are working with someone with a different cultural background. We should try to be aware of and overcome these personal biases. As we are taught in 2 Nephi 26:33 (“2 Nephi Chapter 26, Verse 33,” n.d.):
“…he denieth none that come unto him, black and white, bond and free, male and female; and he remembereth the heathen; and all are alike unto God, both Jew and Gentile.” (Emphasis added)

Stereotypes are discriminatory views of a group that are unfair. Stereotypes often associate negative characteristics generally with an entire group. Individuals are generally aware of the stereotypes they have for others. For example, someone may have a general belief that people from a certain region of the world are more intelligent or that wealthy people are not kind. Another stereotype is that only a particular gender can do specific jobs.  Stereotypes are conscious decisions about others, while biases are more unconscious. Both can interfere with a person’s ability to be objective.  

Implicit Bias  

Implicit bias is attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. It is a form of bias that occurs automatically and unintentionally, and nevertheless affects our judgments, decisions, and behaviors. Implicit bias may present a barrier to recruiting and retaining a diverse scientific workforce.

One of the most important things public healthcare workers can do is examine their implicit biases and work on developing more cultural humility. Some of these issues may be related to language barriers, different values, customs, or other cultural differences. Limiting biases improves healthcare workers’ effectiveness in interacting with diverse cultural communities.

Implicit bias can be lessened when people use strategies including:

• Focus on seeing people as individuals.
• Work on consciously changing your own stereotypes.
• Take time to pause and reflect.
• Adjust your perspective.
• Increase your exposure to other cultures.
• Practice mindfulness and enjoy what is happening now instead of past or future events. 

As you become aware of your biases, you can also get rid of them. As your biases go away, you will improve your cultural awareness and humility. Your cultural competence and leadership skills will also improve. 

Cultural and Linguistic Competence

Cultural and linguistic competence is a set of similar behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. Cultural competence allows everyone to communicate effectively in situations involving people from different cultures.

The goal of cultural and linguistic competence in public health is to provide services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication. Culturally competent services should be employed by all members of an organization at every point of contact. An example of a culturally and linguistically competent company would be a restaurant that provides menus to its customers in English and Spanish. 

Cultural Competence

Have you ever thought about what makes other people different from you? What makes them similar? Are there differences in how you treat people who are different compared to those who are similar? Do you have any preconceived attitudes toward other groups of people?  

Cultural competence means having a broad definition and understanding of culture with clear efforts to understand community needs. It Includes competency training for all of the people in the organization.

Cultural competency involves having humility, respect, openness, knowledge, and love for others despite differences.

We learned earlier that culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. (Centers for Disease Control and Prevention, 2021)

Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.   

"Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes." (Centers for Disease Control and Prevention, 2021)

Cultural competence means more than just being sensitive to the needs of others, it means making policy changes and implementing practices to provide for all no matter the culture, language, or race.

Principles of cultural competence include:

1. Define culture broadly.
2. Value clients cultural beliefs.
3. Recognize complexity in language interpretation.
4. Facilitate learning between providers and communities.
5. Involve the community in defining and addressing service needs.
6. Collaborate with other agencies.
7. Professionalize staff hiring and training.
8. Institutionalize cultural competence.

The importance of cultural competency, including culturally and linguistically appropriate resources and tools, cannot be exaggerated or overemphasized. Cultural competence is the ability to "deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients" (U.S. Department of Health & Human Services, 2021)

Culturally competent organizations:

• Have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally.
• Have the capacity to
  • Value diversity
  • Conduct self-assessment
  • Manage the dynamics of difference
  • Acquire and institutionalize cultural knowledge
  • Adapt to diversity and the cultural contexts of the communities they serve
  • Incorporate the above in all aspects of policy-making, administration, practice, service delivery, and systematically involve consumers, key stakeholders, and communities. 

When public health workers practice cultural competency, they can increase the quality of services and improve the outcomes for all members of society.
       

For example, an investigation as to why some women don't come to the health center for prenatal classes finds that women only want to come in when their partner is off work or older children can interpret for them. The primary reason for their reluctance is language barriers. By practicing cultural competency, the health center can make these classes later in the day when partners are off work or children are home from school. They could also provide an interpreter or teach the prenatal class in other languages.

How do you know if Cultural Competence is working?

Improved quality of care is an indicator that cultural competence is working. As in the previous example, more women coming to the prenatal classes and improvements in prenatal care would be indicators that the cultural competency measures are working. 

Health Literacy

Personal health literacy is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Public health professionals should be aware that the people they serve will have differing levels of understanding of health issues.

Reasons that people have low health literacy may include:

• Low educational levels.
• Cultural barriers, such as a belief that a particular illness can be cured in a culturally traditional way such as through the use of a ritual. 

Barriers to educating members of the community to improve their health literacy may include:

• Using words patients do not understand. Public health professionals should attempt to avoid clinical medical language and instead use a level of language that will allow the client to better understand.
• Limited language proficiency of the public health provider in the native language of the client.

At the organizational level, leadership is needed to ensure that regardless of the level of health literacy, each patient or client should be treated with respect and kindness, as a fellow child of God. Health literacy instruction is necessary, and individuals should be taught with patience and understanding.

Culturally Competent Leadership

Three leadership principles shared by former BYU-Idaho president Kim B. Clark can be useful in understanding the role that culturally competent leadership plays in public health. Clark identified three leadership principles learned from the life of Jesus Christ. Those principles are:

1. Lead by example
2. Lead with vision
3. Lead with love 

(Clark, K. B., 2007)

Leaders in the public health field will show by their own example that they are sensitive to cultural differences. For example, a newcomer from Korea may require services. A culturally competent leader will set the example by asking the individual to teach them a bit of Korean, showing that they are willing to meet them where they are, even in their own language. Numerous tools are now available to translate spoken language into almost any other language imaginable. These are very useful, but making the extra effort to learn even a little of a client’s language shows that you truly care about them.

Visionary leaders in public health will always be looking for ways to improve the cultural competency of themselves and their staff. They will be aware of new and emerging technologies that can assist. They will arrange for professional development to help their staff be more culturally aware. Most importantly, they will be able to express their vision to their staff. They will share their vision in a way that employees and volunteers can share it, and become enthusiastic about pursuing and achieving it. A visionary leader will make their own vision everyone’s vision.

Leading with love is the most important of the three leadership principles shared by President Clark. Love, empathy, and compassion are at the very heart of public health service. Everything in public health is grounded by a desire to help others, to educate, and to serve.

Adaptive Leadership

We have discussed three gospel-based principles of leadership. There are numerous leadership styles and approaches. One that is important to public health is adaptive leadership. Adaptive leadership means that a leader must be able to adapt to sometimes very rapidly changing circumstances. The following are principles of adaptive leadership that make it different from other kinds of leadership:

• Being smart about feelings. Adaptive leaders pay attention to how others feel. They know that change can be hard, but if they show empathy, it can help build trust and make everyone feel better.
• Being fair. Adaptive leaders have to be honest, even if it's not always easy to hear. They have to give everyone the facts so that changes can be understood and accepted.
• Learning and trying new things. Adaptive leaders like to try new things, like new strategies or processes, if it will help the company do better. They also encourage others to reach their full potential.
• Character. Character means being a good person. Adaptive leaders have to earn respect from the people they lead. They have to be honest and open, and be okay with admitting when they are wrong. They also have to be comfortable with new and different ideas.

Adaptive leaders also understand how to help people share ideas and work together. They direct, encourage, inspire, and motivate others. A good leader avoids debate and uses discussion and dialogue to build teams committed to achieving common goals.

Debate assumes that there is a right and a wrong answer and that two sides are against each other, creating a closed-minded attitude. In debate, one listens to the others to find faults or flaws in their ideas.

Discussion assumes that everyone is equal and that all contributions should be considered. Sometimes discussions can result in people sharing their perspectives more than listening to the thoughts of others. Discussions should have the goal of increasing clarity and understanding of an issue.

Dialogue occurs when two or more people work together to find a common understanding. Exploring differences is encouraged. People listen to each other without judgment and trust that others are also listening to them. In dialogue, a conversation remains open-ended, and finding common solutions is the goal.

When conversing with others, a good leader also avoids criticism and focuses on feedback. Criticism is negative, it focuses on mistakes or weakness, and it implies that the other person is the problem. Feedback is positive, it inspires, it focuses on what is wanted and what can be achieved.

Adaptive Challenges

Some of the most significant challenges leaders face are those referred to as adaptive challenges.

Adaptive challenges are situations where the problem is hard to identify, and the solutions are unknown. These challenges are tied to patterns of behavior, dynamics, or relationships that have to be understood before improvements can be made. They usually require changes in the attitudes, beliefs, and behaviors of those involved.

An adaptive challenge differs from a technical challenge. Technical challenges are usually easy to identify, have easy solutions, can be solved by an expert, and require just a few changes. People are generally compliant to these solutions.

An example of a technical challenge is a problem with the company's computer program. With the help of an expert, the problem is usually easy to identify and can be easily solved with a few changes. The employees are generally happy to agree to the changes.

Adaptive challenges are difficult to figure out. Instead of an expert, these challenges require those involved to solve the problem, which may require experimentation and take a long time to implement. The changes may be significant, and many, and people might resist making these changes.

Examples of adaptive challenges include populations that have concerns with issues like; homelessness, sexually transmitted infections, suicide, malnutrition, poverty, and domestic violence. These are complex issues that require many groups, resources, and even legislators working together, as well as individual behavior change to solve these problems. These issues are not easy to solve and individuals may resist changing their behaviors.

Summary

No matter where you are in the world, as a public health worker you will be faced with situations that require cultural competence. There will certainly be many circumstances in which you will be working with people who do not share your own cultural background and beliefs. The world is becoming more and more connected, while at the same time more and more diverse. The better you can understand and adapt to the cultural needs of your clients, the more you will be able to serve them. As a leader, you will be better equipped to adapt to the specific needs of your coworkers and clients when you demonstrate cultural competence. Adaptive leaders also have vision, love and lead by example.

References

2 Nephi Chapter 26, Verse 33. (n.d.). In The Book of Mormon. https://www.churchofjesuschrist.org/study/scriptures/bofm/2-ne/26?lang=eng

Centers for Disease Control and Prevention. (2021, September 10). Cultural Competence In Health And Human Services. National Prevention Information Network. https://npin.cdc.gov/pages/cultural-competence#what

Clark, K. B. (2007, December 14). Leadership with a Small “L.” https://www2.byui.edu/Presentations/transcripts/graduation/2007_12_14_clark.htm

U.S. Department of Health & Human Services. (2021, July 7). Cultural Respect. National Institutes of Health. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect