Transcript CULTURAL COMPETENCES IN HEALTH SETTINGS

CULTURAL COMPETENCES
IN HEALTH SETTINGS
by Lena Dominelli
University of Durham
For ESRC Seminar 19 July 2006
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.
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
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
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
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
Critique of CCA
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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
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
Critical ‘Race’ Theory
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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
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.