CULTURAL COMPETENCES IN HEALTH SETTINGS

1. CULTURAL COMPETENCES IN HEALTH SETTINGS by Lena Dominelli University of Durham For ESRC Seminar 19 July 2006

2. 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 one’s own while being aware of how one’s own culture influences perceptions of and interactions with others. This also requires an understanding of the significance of differences within groups and between them.

3. 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

4. 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

5. 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 organisation’s 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

6. 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

7. 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 doctor’s 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

8. 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

9. Critical ‘Race’ Theory • Seeks to replace CCA by encouraging practitioners to ‘know themselves’ • Awareness of one’s 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 practitioner’s 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 grouping’s 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

10. 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.