Technical Assistance Bulletin

You Can Use Communications Principles To Create Culturally Sensitive and Effective Prevention Materials



September 1994

Prevention messages and materials can contribute to improving the health status of the Nation's racial and ethnic communities. However, to develop viable messages for target audiences, you should understand:

• Principles of health communications

• The culture of the audience that you are trying to reach.

Customizing messages and materials can make your outreach more effective with special populations.

Culture affects how people respond to messages communicated through various channels: mass media, community events, family discussions, and person-to-person encounters. Culture is also intertwined in how alcohol, tobacco, and other drugs are used in various communities.

This bulletin will help you identify some ways to incorporate cultural sensitivity and effectiveness into your communication projects.

Methods of targeting groups for messages and materials are viewed on two dimensions:

• Primary-based on culture and linked to race, ethnicity, language, nationality, and religion

• Secondary-based on additional elements such as age, gender, sexual preference, educational level, occupation, and income.

Experience has shown that there is no magic formula that works for all African Americans, all Asian Americans, all Hispanics, all American Indians. What is clear, however, is that simply substituting multicultural faces for White faces in messages and materials is not effective. Considerable work must be done to create an information flow that is viewed and accepted as part of the culture.

The Role of Culture

Culture is important to all of us. As Americans, we all share elements of a "national" culture -- things like basketball, hot dogs, high school bands playing Sousa marches, and the Fourth of July.

But many Americans also carry the gifts and strengths of other cultural traditions. We are African Americans, Asian Americans, European Americans, American Indians, Hispanics, Creoles, Cajuns, and mixtures of many races and ethnicities. We play soccer, eat tacos, listen to reggae, dance at powwows, and join the parade on the Chinese New Year. Our cultural backgrounds and heritages affect the way we dress, the food we eat, the music we listen to, the festivals we celebrate, and much more.

One of the difficulties in the United States today is defining culture. All too often, culture is seen as identical to race, ethnicity, language, nationality, or religion. While culture draws on all these elements, it is not synonymous with any of them.

Culture incorporates the shared values, traditions, norms, customs, arts, history, folklore, and institutions of a people. Culture shapes how people see their world and structure their community and family life. Culture defines what people value and hold dear.

Of course, some definitions of culture are broader than this. Groups like youth or veterans do share values, traditions, and institutions. However, while treating such groups as distinctive cultures may be useful for some interventions, it is not generally as effective in the development and implementation of communication strategies. This is because the shared values and history that people have based on these linkages tend not to be as powerful as the shared values and history that come from the more classical definition of culture which encompasses social interaction passed down through generations.

Nationality

Culture often corresponds with nationality. However, people living within the same nation may have very different cultures, and people living in neighboring nations may actually share the same culture.

In a nation like the United States, where many groups of different ancestry have come together as citizens, one culture usually becomes the primary culture of the nation. That unifying culture is then modified by the contributions of many other cultures. In this Nation, the primary American culture is English speaking with its roots in Western Europe and Protestant religion. However, this does not mean that American culture is simply transplanted European culture.

While the national culture of the United States has its roots in Western Europe, there have been changes over time, making the national culture more inclusive of non-Europeans. Indeed, much that is distinctive in the culture of this Nation is due to gifts of other cultures that have been incorporated into the national culture. This is true for music, food, styles, of dress, holidays, poetry and other forms of American literature, and the visual arts.

Language

Language often acts as a conveyer of cultural values. However, having the same language does not automatically mean that people share the same culture. For example, Spanish-speaking persons in the Americas represent three distinctive cultures:

• European (Hispanics with ancestry from Span)

• African (many Hispanics from the Caribbean and parts of Central and South America)

• Indian (Hispanics whose ancestors lived in the Americans before the arrival of Columbus).

Similarly, among French-speaking individuals, the cultures of French Canadians, Haitians, and immigrants from France are quite distinctive.

Use of messages and materials in languages other than English can be valuable, but they should be developed and tested with particular care. Often the well-educated leadership of a target audience may prefer English while the majority of the audience may be more receptive to another language. In such cases, you may decide to use a bilingual approach that satisfies the gatekeepers while ensuring that the messages and materials reach their intended audiences.

Sometimes you may need to translate from standard English to whatever hybrid form of the language best reflects the special history and culture of your target populations. This does not mean a heavy-handed use of dialect, slang phrases, and poor grammar. Rather it requires the appropriate use of phrases and word images that have special meaning to target audiences but which may not be noticed at all by others who are not part of the culture. This approach must be pretested carefully with the target audience. It is easy to cross the line and create messages and materials that target the community in a manner that is insensitive, insulting, or unintentionally humorous.

Translations should be handled by professionals who understand the nuances and context of language as well as the formal structure.

A word-for-word translation often misses key elements of the intended message and communicates wrong or confusing information. Fluency in a language other than English (particularly if the language was learned in a classroom setting) does not always provide the insight into the culture necessary for an effective translation.

Cultural Values and Attitudes

When designing targeted prevention messages for various cultures, you may encounter beliefs about alcohol, tobacco, and other drugs that are part of their cultural framework. All cultures have beliefs about health based on folk wisdom, tradition, and custom. These may be old patterns that no longer work or new ways of coping with American culture. When these beliefs run counter to current research and scientific information, or if they conflict with established or changing norms of the national culture, this can present special challenges.

For example, some cultures believe that it is masculine for men to drink and smoke but place sanctions on women for the same behavior. In other cultures, use of alcohol by teenagers may be viewed as a relatively harmless rite of passage and not as an illegal and sometimes dangerous practice. Folk "wisdom" -- such as stories about the so-called amazing curative powers of alcohol or mind-altering drugs for various ailments -- many run counter to scientific facts. New information, like the dangers of using alcohol and cocaine during pregnancy, may be greeted with suspicion.

Culture is interrelated with many of our attitudes and values. These include:

• Whether primary importance is placed on the individual or on the community.

• Generally accepted roles for women, men, and children

• Whether the preferred family structure is nuclear or extended, one generation or multigenerational

• Relative importance of folk wisdom, life experience, "mother wit," and common sense in comparison to formal education and advanced degrees.

• Ways that wealth is measured -- in material goods, like money and property, or in personal relationship, like children, extended family support systems, and friendships

• Whether the society reveres its youth as the promise of the future or its elders as the repositories of wisdom

• How time is used and valued, for example, importance of timeliness

• Whether people are tradition bound or open to experimentation

• Linkage or separation between religious life and/or spirituality and secular life

• Favorite and forbidden foods

• Manner of dress and adornment

• Body language, particularly whether touching or close proximity is permitted in specific situations.

You can incorporate these concepts into your messages and materials in many ways, some of them quite subtle. For example, in many Hispanic culture, a hug is a demonstration of affection while in some East Asian cultures a hug is an invasion of personal body space. Thus how the characters in a television public service announcement interact can be as powerful a cultural message as the actual dialog between them.

Similarly, in many African-American, Asian, and Hispanic cultures, young people lower their eyes when spoken to by adults as a symbol of deference to authority. However, other cultures, particularly those with roots in Western Europe, see lack of eye contact as an indication that the person is being less than truthful. Thus a young person may be directed to "look in my eyes when I'm talking to you" by a White person and told "don't you dare look at me" by an elder of his or her own community.

Additional Ways To Target Audiences

Messages and materials also must respect the variations within cultural groups. Racial and ethnic groups are not monolithic. For example, although much of the recognized "mainstream" culture in the United States is drawn from Western Europe, people of European descent represent a multiplicity of religious backgrounds, national origins, traditions, customs, and folklore.

People within any racial, ethnic, language, nationality, or religious group are not homogeneous even though they may hold many cultural beliefs, practices, and institutions in common. Some of the major areas of difference within groups include:

• Age

• Gender

• Sexual orientation

• Education level

• Occupation

• Geographic area

• Income

• Adherence to folk customs and beliefs

• Presence or lack of disabling condition

• Health status

• Alcohol, tobacco, and other drug beliefs and practices

• Preferred language

• Citizenship, immigrant, or refugee status.

These elements must be taken into account in the design and implementation of culturally specific messages and materials.

For example, teenagers in the United States are often viewed as having a culture of their own that is quite distinctive from that of adults. However, trying to target messages and materials to members of a "youth culture" within the United States, using age parameters only, has often proved unsuccessful. This is because the share values and history of African-American youth are so different from those of youth of European ancestry and youth from other cultures.

These differences among youth of various races and ethnicities include:

• Musical preferences, such as rap, heavy metal, salsa

• Style of dress

• Media choices, including radio stations and magazines

• Importance of religion

• Favorite sports and sports figures

• Dating rituals

• Use of alcohol, tobacco, and other drugs

• Leisure time activities.

As a result, in many communities there is no youth culture that is sufficiently homogeneous across race and ethnicity to stand as an alternate cultural grouping. In these communities, it is often wiser to target first based on classic cultural definitions (race, ethnicity), adding youth as a secondary targeting criterion.

The second level of targeting is often important. For example, use of rap music in a prevention message may be quite effective in reaching young African Americans. However, the same music can alienate older African Americans who often reject this musical form as "noise."

Is There a Role for General Market Messages?

Until quite recently, the preference for many programs was to try to reach everyone with a basic message rather than targeting messages to specific groups. The rationale for this broad-brush approach included:

• The feeling that we all respond to the same elements of American culture in messages and materials

• The belief that a good prevention message could be so powerful that it would reach all groups equally

• The perceived divisiveness of doing separate ("segregated") messages and materials for different groups

• The lack of time, money, and expertise to develop separate, culturally specific campaigns and the risk of omitting some groups entirely.

Some of these arguments still make sense. Generally, even persons with roots in other cultures can understand messages that use the images, symbols, and language of the primary culture of the nation in which they reside. But they may not truly feel the message in the same way that they would if the communication had specific meaning for their own culture. Messages geared toward specific cultural groups are often far more effective than general market messages in changing attitudes regarding problem use of alcohol, tobacco, and other drugs.

Yet this does not mean that there is no longer a place for any general market messages. Some media - such as television and daily newspapers - reach the general public. For these media, broad messages still are important. Still, general market messages should be augmented, whenever possible, with more targeted messages that are much more specific in their reach to designated audiences.

And even when targeted messages are used, cultural sensitivity should still be part of the design of any general market messages. This means that even if you have specific campaigns designed to reach African Americans or Asian Americans, your general market campaigns also should be appropriate for these groups as well as for the majority culture. This does not mean that every general market prevention message requires a "United Nations" approach with each target group represented visually. However, all messages and materials should be inclusive, and none should contain elements that are offensive or inappropriate to any segment of the population.

Important Steps for Developing Culturally Appropriate Messages and Materials

Developing culturally sensitive and effective messages and materials for your prevention programs and projects can be challenging. Some steps that can help, which are adapted from the first three stages of the six-stage ATOD communications process as illustrated in the diagram below are as follows:

• Gather general information on the issue you plan to address. For example, are there particular ways that alcohol, tobacco, or other drugs have historically been used within the culture? Are the rates of use higher or lower than in the general population or skewed differently with respect to age, gender, or socioeconomic status? You should do your homework before you approach the community for help in designing a program.

• Decide what specific issue or problem you will address. Determine your focus: nonuse of alcohol, tobacco, and other drugs for youth or pregnant women? Moderate alcohol use for adults? Community action against illicit drugs? Decreased availability of alcohol and tobacco products for youth? Your ideas should not be set in stone because the community may have its own perspective on the most important problems they face with alcohol, tobacco, and other drugs. However, you should have some starting point for discussion.

• Define and understand your specific target audience. Identify key items such as race, ethnicity, nationality, religious preference, geographic boundaries, age, gender, and cultural preferences. Be as specific as possible. Don't assume that national data can truly describe your population. Involve knowledgeable community leaders in a needs assessment process so that you know exactly whom you are targeting with proposed messages and materials.

  Cultural sensitivity should be a factor in the design of all organizational communications, including speeches and news releases - not just in targeted public service announcements, brochures, and special media campaigns.

  
  
  

  Targeted Media Channels

  Part of your challenge will be to identify media channels that reach various racial, ethnic, and other specialized audiences. Many groups have their own media, particularly newspaper and radio stations. In communities with large concentrations of Hispanics, there may be Spanish - language television networks and programs. African Americans can often be reached through syndicated programs designed for African-American audiences and local public affairs programs. Leaders from the community can help you to identify key media.

  
  
  

  Racial and Ethnic Terms

  Words are very important in the development of culturally sensitive messages and materials. Terms that refer to race and ethnicity often have both overt and hidden meanings. For example, many people of color resent use of the words "minority" and "non-White." Whenever possible, you should use the descriptive term that is preferred by the majority of persons in that specific target group. This may be a nationality-based -- such as "Japanese" or "Lakota" -- or broader term like "persons of color." In some instances, it is preferable to use a combination of accepted terms.

  
  
  
• Identify the channels that can best reach the audience and how those channels actually are used by the audience. Choosing the appropriate channels can be complicated. Although demographics may show that most of the target audience watch general market media such as television and daily newspapers, they may place more credibility in media that are owned or controlled by members of the target audience. It is often a good idea to combine general market and target market media to increase the number of times your message is seen or heard and the number of people who see or hear it. Sometimes interpersonal and community channels such as church bulletins, flyers posted at the corner grocery or laundromat, group meetings, loud speakers on cars or trucks that circle the neighborhood, or printed T-shirts can be quite effective in reaching a specific audience with a prevention message.

• Develop preliminary concepts in concern with people who are representative of your target audience. An effective way to do this is to identify members of the target population who are respected and influential within the community and enlist their help in the planning process. (Remember, these individuals who are best known and have most stature in the larger, mainstream society.) Leaders will vary from one group to another. They may hold formal rank within the religious structure, operate within informal spheres of influence, serve as teachers or counselors, have leadership positions within a youth group or gang, or be elders who are seen as wise men and women. Gaining the support of people who represent your target audience can provide invaluable insight into the needs, beliefs, and customs of the audience.

• Test the preliminary concepts with the intended audience. Even though you involve representatives of the target community in the development of concepts, it is still important to test the concepts in order to check the cultural appropriateness and potential effects on the issue or problem you are addressing. This can be done through use of focus groups, interviews, and questionnaires. It is often advisable to use skilled and knowledgeable individuals who accurately understand the community (and preferably are from the community) to ensure that the information received truly reflects the community's feelings and beliefs. Concept testing allows you to see how messages are received and understood.

• Work in concern with community-based experts to develop or select specific messages and materials that use the pretested concepts. The messages and materials should be those that are most effective and that can be best communicated through the selected communication channels that best reach the target audience. A message that will be carried primarily on non-English radio may be quite different from one that will be primarily print. Furthermore, if a message is designed to be communicated primarily by word of mouth, the basic message would be clear and concise enough so that the prevention concepts do not get lost or confused as part of the spoken process.

• Field test the messages and materials with the intended audience. Even when the preliminary concepts have been tested and the specific messages are designed in concert with representatives of the targeted community, you should pretest the actual messages and materials before a major campaign is launched.

• Make revisions as necessary, based on audience reactions and results. When creating culturally sensitive and effective materials for target populations, it is easy to make mistakes. A second round of pretests can help to correct these. If problems arise, you may find it necessary to go back to the drawing board, make revisions, and pretest the messages and materials again until the truly serve their purpose. This is part of the fine tuning and can prevent misunderstandings.

  Creating culturally sensitive and effective messages and materials is not easy. But the results are well worth the extra effort. Simply striving for inclusiveness in general market messages is not enough -- particularly in trying to change attitudes that lead to problems with alcohol, tobacco, and other drugs among racial and ethnic groups. Only when the people we are trying to reach see themselves and their cultures reflected back in our messages and materials can we expect to see the changes in attitudes and awareness that we seek.

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  Reference/Resources

  The following references and resources can provide background and additional information on communicating with culturally diverse audiences.

  Axelson, J. Counseling and Development in a Multicultural Society. Monterey, CA, Brooks-Cole, 1985.

  Kumabe, K.I., Nishida, C., and Heyworth, D.H. Bridging Ethnocultural Diversity in Social Work and Health. Honolulu, University of Hawaii School of Social Work, 1985.

  National Clearinghouse for Alcohol and Drug Information (NCADI), Box 2345, Rockville, MD 20852, (301) 468-2600 or (800) 729-6686. Provides information the research literature, programs, and educational materials.

  Orlandi, M., Weston, R., and Epstein, L.G., Cultural Competence for Evaluators: A Guide for Alcohol, Tobacco, and Other Drug Abuse Prevention Practitioners Working With Ethnic/Racial Communities. Washington DC, Center for Substance Abuse Prevention (CSAP), Division of Community Prevention and Training/Department of Health and Human Services (DHHS), 1992.

  Putsch, R.. Cross-cultural communications. Journal of the American Medical Association, 1985; 254, 3344-3348.

  Randall-David, E. Strategies for Working With Culturally Diverse Communities and Clients. Washington, DC, Office of Maternal and Child Health (OMCH)/Department of Health and Human Services (DHHS), 1989.

  Glossary of Key Terms

  Culture: The shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, language, nationality, or religious. Cultural Competence: A set of academic and interpersonal skills that allows individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. This requires a willingness and ability to draw on community - based values, traditions, and customs and to work with knowledgeable persons of and from the community in developing targeted interventions, communications, and other supports. Cultural Diversity: Differences in race, ethnicity, language, nationality, or religion among various groups within a community, organization, or nation. A community is said to be culturally diverse if its residents include members of different groups. Cultural Sensitivity: An awareness of the nuances of the one's own and other cultures. Culturally Appropriate: Demonstrating both sensitivity to cultural differences and similarities and effectiveness in using cultural symbols to communicate a message. Ethnic: Belonging to a common group -- often linked by race, nationality, and language -- with a common cultural heritage and/or derivation. General Market Messages: A message intended for a broad audience. Language: The form or pattern of speech -- spoken or written -- used by residents or descendants of a particular nation or geographic area or by any large body of people. Language can be formal or informal and includes dialect, idiomatic speech, and slang. Mainstream: A term that is often used to describe the "general Market." This term usually refers to a broad population that is primarily White and middle class. Multicultural: Designed for or pertaining to two or more distinctive cultures. Nationality: The country where a person lives and/or one that he or she identifies as a homeland. Race: A socially defined population that is derived from distinguishable physical characteristics that are genetically transmitted. Religion: A system of workship, traditions, and belief in a higher power or powers - often called God - that has evolved over time, linking people in a commonality of reverence and devotion. Targeted Message: A message designed to appeal to a specific group or subset of the general market. The target audience can be based on race, ethnicity, age, gender, income level, occupation, health status, behavior, or a combination of these or other factors.

  Please feel free to be a "copy cat" and make all the copies you want. You have our permission!

  
  
  

  Developed and Produced by the CSAP Communications Team. Patricia A. Wright, Ed.D., Managing Editor. Distributed by the National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20852. This bulletin is one in a series developed to assist programs that are working to prevent alcohol, tobacco, and other drug problems. We welcome your suggestions regarding information that may be included in future bulletins. For help in learning about your audience, developing messages and materials, and evaluating communications programs, contact the CSAP Communications Team, 7200 Wisconsin Avenue, Suite 500, Bethesda, MD 20814-4820, (301) 941-8500.