Ethnicity and Health Health Article

ETHNICITY AND HEALTH

The issue of cultural sensitivity is central to ethnicity and health, and to developing health-promotion and disease-prevention programs for different racial and ethnic populations. This article provides definitions and a conceptual framework for understanding cultural sensitivity and the rationale for tailoring health-promotion programs for different cultural groups. Most of the examples provided relate to African Americans and Hispanic/Latino populations. Nonetheless, the principles discussed are applicable to other racial, ethnic, and sociodemographic subpopulations.

CULTURAL SENSITIVITY

Cultural sensitivity goes by many names, including cultural competence, culturally appropriate, culturally consistent, multicultural, cultural diversity, cultural pluralism, cultural tailoring, and cultural targeting. Although definitions and distinctions for these terms have been offered, the terminology has no accepted standards. In response to this need, the following definitions are proposed:

Cultural Sensitivity. The extent to which ethnic and cultural characteristics, experiences, norms, values, behavioral patterns, and beliefs of a target population, as well as relevant historical, political, environmental, and social forces, are incorporated in the design, delivery, and evaluation of targeted health-promotion materials and programs.

Cultural Competence. The capacity of individuals to exercise interpersonal cultural sensitivity. "Culturally competent" refers to practitioners, whereas "culturally sensitive" relates more to intervention programs, materials, and messages.

Multicultural. Incorporating and appreciating perspectives of multiple racial and ethnic groups without assumptions of superiority or inferiority. In this sense, culturally competent individuals and culturally sensitive interventions are implicitly multicultural. Cultural pluralism is a synonym.

Cultural Tailoring. The process of creating culturally sensitive interventions; often involving the adaptation of existing programs, materials, and messages to racial/ethnic subpopulations.

Culture-Based. This term refers to programs and messages that use culture, ethnicity, history, and core values to motivate behavior change.

Ethnic Identity (EI). Ethnic identity involves the extent to which individuals identify with and gravitate to their own racial or ethnic group. Ethnic identity includes elements such as racial and ethnic pride, affinity for group culture (e.g., food, media, and language), attitudes toward majority culture, involvement with group members, experience with and attitudes regarding racism, attitudes toward intermarriage, and the importance placed upon preserving one's culture and aiding others of like background. For immigrant groups, ethnic identity includes aspects of acculturation (i.e., adoption of values and practices of the host country).

Cultural sensitivity can be conceptualized in terms of two primary dimensions: "surface structure" and "deep structure." Surface structure involves matching intervention materials and messages to characteristics of a target population. For audiovisual materials, this may involve using people, places, language, music, and foods familiar to, and preferred by, the target audience. Surface structure includes identifying the channels (e.g., media) and settings (e.g., churches, schools) that are most appropriate for delivery of messages and programs. It also entails understanding characteristics of the behavior in question. Surface structure refers to the extent to which interventions correspond to the needs of the target population and to how well interventions fit within the culture, experience, and behavioral patterns of the population.

The second dimension of cultural sensitivity, deep structure, reflects how cultural, social, psychologic, environmental, and historical factors influence health behaviors in different populations. This includes understanding how members of the target population perceive the cause, course, and treatment of illnesses; as well as perceptions regarding the determinants of specific health behaviors. Specifically, this involves appreciation for how religion, family, society, economics, and the government—both in perception and in fact— influence the target behavior. Among many African Americans, for example, there is a belief that the U.S. government may be covertly encouraging the spread of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), guns, and drugs in their communities. Some Hispanics feel that certain illnesses are a punishment from God or the result of the "evil eye." Messages that incorporate, though not necessarily accept or refute these beliefs, will likely enhance program acceptance and effectiveness.

Core cultural values for African Americans include: communalism, religion and spiritualism, expressiveness, respect for verbal communication skills, connections to ancestors and history, commitment to family, and intuition and experience rather than empiricism. African-American culture is also characterized by a unique sense of time, rhythm, and communication style. The use of oral communication (i.e., interpersonal vs. print interventions), as well as stories, religious/spiritual themes, and historical references to convey messages in health-promotion programs for African Americans can improve the success level of programs. For Hispanics, core cultural values include familismo (importance of family), respecto (respect for elders), dignidad (the value of self-worth), caridad (the value of rituals and ceremonies), fatalism, and simpatía (the importance of positive social interactions). The novella format (i.e., the use of stories) may be a particularly effective mechanism to convey these concepts to motivate health behavior change among Hispanic populations.

Whereas surface structure generally increases the receptivity, comprehension, or acceptance of messages, deep structure conveys salience: Surface structure establishes feasibility, whereas deep structure determines program impact.