CULTURAL COMPETENCES IN HEALTH SETTINGS

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CULTURAL COMPETENCES IN HEALTH SETTINGS

• by Lena Dominelli
• University of Durham
• For ESRC Seminar 19 July 2006

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Cultural Competence

• Definition
• Cultural competence is the capacity to be aware
  of, have respect for and work effectively with
  people from different ethnic, cultural,
  political, economic and religious backgrounds
  than ones own while being aware of how ones own
  culture influences perceptions of and
  interactions with others. This also requires an
  understanding of the significance of differences
  within groups and between them.

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Aims of Culturally Competent Approaches (CCA) are
to

• Be respectful of and responsive to the cultural
  and linguistic needs of service users
• Reduce racial and ethnic disparities in health
• Improve the quality of health care (different
  meanings)
• Make health care more efficient and effective
• Find out the implications of ethnicity and race
  for managing disease
• Produce innovative health services
• Improve training for medical and health care
  personnel
• Standardise education and training
• Meet the needs of diverse patient groupings
• Equalise health care delivery throughout the
  country

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Claims of Defenders of CCA

• Cultural competence seems to be evolving from a
  marginal to a mainstream health care policy issue
  and as a potential strategy to improve quality
  and address disparities (Betancourt et al.,
  2005)
• Different cultural attitudes are seen as
  significant in making health care provisions more
  relevant to patients
• Cultural sensitivity is being driven by ethnic
  minority practitioners and service users
• Cultural sensitivity requires a commitment from
  health care professionals to understand and be
  responsive to the different attitudes, values,
  verbal cues and body language of those with
  different cultural heritages (Goldsmith, 2000)
• Cultural sensitivity focuses on action and
  communication in clinical settings to produce
  best possible clinical outcome
• Cultural sensitivity considers organisational
  change in asking practitioners to represent the
  communities they serve and provide services that
  meet their needs

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Culturally Competent Workforce

• Represents the communities its serves
• Involves bicultural/bilingual individuals who
  link ethnic communities to health care
  organisations
• Improves communication between patients and
  health professionals
• Seeks to overcome barriers that prevent ethnic
  minorities from using services
• Seeks to increase an organisations cultural
  competence
• Offers information, referral, counselling,
  advocacy and health education, transportation,
  and outreach
• Includes culturally competent interpreters
  speak another language(s), understand nuances in
  language and culture, learn specialised
  vocabularies and concepts, and operate ethically
• Follows ethical standards and norms

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Problematising the CCA

• Assumes expert knowledge supersedes that held by
  service users
• Visualises identity as fixed and unitary
• Biologises race and ethnicity
• Assumes one intervention or type of service suits
  everyone
• Assumes a toolkit applicable to all situations
  can be developed
• Tries to manage rather than understand and deal
  with the significance of culture and its meaning
  for individuals, groups or communities

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Critique of CCA

• Assumes Western medicine provides the appropriate
  benchmarks, e.g., Latinos are forthcoming about
  their symptoms, Chinese people are circumspect
  and may withhold information (Goldsmith, 2000)
• Assumes Western medicine is the basis for
  assessing inconsistencies between information
  given by patients and medical diagnosis
• Rigidities in CCA may exacerbate poor use of
  scarce resources by seeking to give a superior
  experience without added expense or capital
  investment (Goldsmith, 2000)
• Outreach and preventative health care cannot be
  provided on the cheap
• Focusing primarily on language barriers ignores
  power inequalities between patients and health
  professionals even if it recognises the
  importance of gender, age, tone of voice or
  physical gestures in transcultural interactions
• Emphasises a doctors capacity to self-assess
  gaps in knowledge and training needs when s/he
  might not know what they are missing
• Cultural competence is seen as a cure-all for
  many health inequalities that are rooted in
  structural considerations rather than in personal
  inadequacies amongst health professionals,
  important as these may be
• Meeting unique needs requires an individualised
  service that is contextualised within broader
  social relations, but is not necessarily cheap
• May produce segregated health services that
  ghettoise services for ethnic minorities
• Minority employees may find cultural competence
  is required only of them
• Cultural stereotypes may deny individuals the
  health care they need and oppress individuals
  seeking to escape them
• Culturally competent practitioners cannot
  criticise inappropriate aspects of culture,
  especially those that violate human rights, e.g.,
  FGM

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National Standards on Culturally and
Linguistically Appropriate Services (CLAS)

• CLAS consists of 14 standards. Approval for them
  is being sought from health care providers across
  the USA
• The standards cover all aspects of service
  provision from access to delivery
• The standards cover recruitment and retention of
  staff, including staff development issues
• The standards cover organisational culture
  including that of not charging for language and
  interpretation services
• The standards cover information collection and
  storage
• The standards cover grievance procedures
• The standards call for publicly available
  information on implementation of CLAS standards

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Critical Race Theory

• Seeks to replace CCA by encouraging practitioners
  to know themselves
• Awareness of ones own racism, prejudices, values
  devaluing others and action directed against
  those who are different
• Encourages respectful but reflexive contact
  amongst those who are different
• Requires awareness of how culture can be used to
  avoid change
• Challenges unitary notions of identity and
  questions a practitioners potential to learn all
  there is to know about culture
• Does not assume that racial/ethnic matching
  automatically leads to closer understanding and
  collaboration between practitioners and service
  users
• Acknowledges the importance of context and that
  we are all ethnic minorities with specific
  cultures that are tailored by individuals to suit
  their own specific needs and ideas even though
  some are more valued than others
• Requires ethnic minority groupings to become
  involved in service design, construction and
  delivery
• Promotes ethnic minority groupings strengths and
  resiliency without losing sight of problematic
  behaviours
• Roots its analyses in structural inequalities and
  argues for social justice, human rights and
  active citizenship as the bases for service
  provision while simultaneously focusing on
  personal change and understandings of the self
• Integrates cultural awareness throughout the
  educational curriculum
• Involves practitioners in taking risks and
  acknowledging the relevance of historical
  legacies in their relationships with service
  users, e.g., mistrust

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References

• Betancourt, J R, Green, A R, Carrillo, E and
  Park, E R (2005) Cultural Competence and Health
  Care Disparities Key Perspectives and Trends
  in Health Affairs, 24(2), March/April, pp.
  499-405.
• Dominelli, L (2004) Culturally Competent Social
  Work A Way Towards International Anti-Racist
  Social Work? in Guttierez, L, Zuniga, M and Lum,
  D (eds) Education for Multicultural Social Work
  Practice. (Alexandria, VA. Council on Social
  Work Education, 2004) pp. 281-294.
• Goldsmith, O (2000) Culturally Competent Health
  care in The Permanente Journal, 4(1), Winter,
  pp. 1-7.
• Lum, D (2000) Culturally Competent Practice A
  Framework for Understanding Diverse Groups and
  Justice Issues. Pacific Grove, CA Brooks/Cole.
  2nd Edition, 2003.