Cultural Competence: Can it be Taught?

Cultural Competence:Can it be Taught? Barbara W. Sugland, M.P.H., Sc.D. Maternal & Child Health Institute: Addressing Health Disparities St. Paul, Minnesota June 27, 2002

Keynote Overview • What is Cultural Competence? • Culture vs. Race/Ethnicity • Competence vs. Sensitivity • Stages of Cultural Competence

Keynote Overview • Why is it Important? • Increased Ethnic Diversity; • Ethnic Disparities in Health; • Providers’ Background Different From Patient

Keynote Overview • How to Achieve it? • Organizational Transformation • Personal Transformation

What is Cultural Competence? Cultural Competence A set of congruent practices, skills, attitudes, policies and structures, which come together in a system, agency, or among professionals, which enable that system, agency or professionals to work effectively in cross-cultural situations. Cross, T.L., Bazron, B.J., Dennis, K.W., Isaac, M.R. (1999)

What is Cultural Competence? Cultural Competence • Congruence across aspects of service delivery; • Aspects of service include: • Practices, skills, attitudes (Individual); • Practices, policies, structures (Organization)

Culture vs. Race/Ethnicity Culture • Shared values, beliefs, traditions, norms, customs, folklore, art, history of a group of people • A foundation – “grounds” you • Passed on from generation to generation;

Culture vs. Race/Ethnicity Culture • Dynamic & evolving; • Shapes attitudes & values; • Shapes styles and modes of communication; • Shapes notions about health & illness; • Shapes health-seeking behavior.

Culture vs. Race/Ethnicity Race • Historically ascribed to groups of individuals categorized as biologically distinct. • Modern Times – “race” is a social construction • Physical, behavioral and cultural differences incorrectly ascribed to race;

Culture vs. Race/Ethnicity Ethnicity • A subgroup that shares common ancestry, geography, history, language or culture;

Sensitivity vs. Competence Cultural Sensitivity • Heightened awareness of cultural differences • Increased ability to interpret and respond to non-verbal or cultural cues • Willingness and ability to adapt behavior

Sensitivity vs. Competence Cultural Competence • Incorporate plans, policies & practices to respond to differences • Cultural sensitivity is necessary but insufficient for achieving competence

Stages of Cultural Competence Cultural Proficiency Cultural Competence Cultural Pre-Competence Cultural Blindness Cultural Incapacity Cultural Destructiveness

Stages of Cultural Competence • Destructiveness-- actively working to destroy or diminish well-being • Incapacity -- not actively seeking to destroy, but not actively working to improve well-being • Blindness-- unbiased treatment is the most effective treatment

Stages of Cultural Competence • Pre-Competence -- Belief, desire & commitment, not clear on how to move forward • Competence-- Belief, desire & commitment + structure, systems & policies in place • Advanced Competence -- Competence + Vocal advocates for competent care

Progressing Toward Cultural Competence • Conditions for Progress (Individual) • Awareness • Knowledge • Skill • Practice (cultural encounters) • Personal will

Progress Toward Cultural Competence • Conditions for Progress (Organizational) • Mission & values support competence • Policies promote it • Programs and services reflect it • Hiring strategies facilitate diversity and competence • Mechanisms of accountability to reward & sanction

Models of Competence LIVE & LEARN (Carballeira, 1997) • LIVE -- Like, Inquire, Visit, and Experience • LEARN -- Listen, Evaluate, Acknowledge, Recommend, and Negotiate

Models of Cultural Competence • Sunrise (Leininger, 1993,1999) • Stresses world view and social structure of client • Several dimensions – Cultural, religious & spiritual, economic, educational, technological, kinship & social, political/legal • Providers must explore and validate what the patient says and does

Why is Cultural Competence Important? • Ethnic Disparities in Health • Rates of disease & morbidity higher among racial/ethnic subgroups • Some improvements – gains modest and uneven

Why is Cultural Competence Important? • Increased Ethnic Diversity • Non-whites ~ 31% of US Population • Increase of 25% since 1990 • Density of Ethnic Populations • Providers’ Background Different From Patient

Why is Cultural Competence Important • Context for Understanding and Responding to Differences • Guidance for How to Connect with Patients; • Framework for Enhancing Quality of Care

Achieving Cultural Competence • Achieving Competence Requires: • Organizational Transformation • Philosophy • Structure, practices, protocols • Partnership & collaboration • Personal Transformation • Notions about self relative to others • Capacity (skills and proficiency) • Courage

Achieving Cultural Competence • Practices of Successful Organizations: • Define Culture Broadly • Beyond ethnicity, heritage, language • Shared attributes (gender, sexual orientation) • Shared life experiences (violence, homelessness)

Achieving Cultural Competence • Practices of Successful Organizations: • Value client’s cultural beliefs • Genuine concern and respect • Ability to learn about needs and challenges of community • Willing to understand clients’ life experiences

Achieving Cultural Competence • Practices of Successful Organizations: • Recognize Communication is Complex • Communication is more than shared language • Language differs across cultures • Linguistic variation within cultures • Cultural variation within language • Variation in literacy for all groups

Achieving Cultural Competence • Practices of Successful Organizations: • Facilitate Exchange between Provider and Community • Create a “learning loop” • Active Community Involvement • Community Advisory Boards • Community Volunteers, Lay Workers

Achieving Cultural Competence • Practices of Successful Organizations: • Collaborate with Other Agencies • Health & Educational Institutions • Health & Social Service • Health & CBO’s

Achieving Cultural Competence • Practices of Successful Organizations: • Institutionalized Cultural Competence • Mission & values support competence • Hiring and job descriptions stipulate it • Ongoing staff training & development • Services & outreach reflect it • Mechanism for accountability and feedback

Achieving Cultural Competence • Personal Transformation • Know and Understand Culture (broadly) • Value Diversity • Seek Opportunities to Experience Culture

Achieving Cultural Competence • Personal Transformation • Self-reflection and Self-examination • Styles, Attitudes & Behaviors • Limitations • Biases

Achieving Cultural Competence • Start small, identify “winnable battles” • Organizational • Agency mission, staff retreats, workshops • Anonymous feedback from clients • Anonymous feedback from staff • Personal • Attend diversity or healing racism workshop • Ask clients and colleagues for feedback • Clients and colleagues from different backgrounds

Achieving Cultural Competence • Organizational • Identify partners and establish partnerships • Explore ways to collaborate and support • Personal • Partner with colleagues • Broaden network of co-workers and contacts • Increase exposure to diverse groups

Achieving Cultural Competence • Lobby for change; • Funding to deliver & sustain competence • Flexibility in service delivery strategies • Staff training and continuing education • Professional memberships • Academic institutions and training centers • Research, Public Policy & Advocacy • Organizations

Cultural Competence: Can it be Taught?