Cultural competence has become a ‘buzz’ word in the world of public health and health care. Academic institutions, health care and service providers, and governmental agencies across the country are focusing on developing “cultural competence” as a way to address health disparities and create health equity. Many cultural competence programs are designed to sensitize health providers to the special needs and vulnerabilities of different populations with the goal of providing accessible and appropriate care and services to all. They largely focus on ‘underserved’ populations -- ethnic minority populations most adversely affected by health disparities. Yet, because the concept of culture itself is broad, sometimes the task of developing cultural competence has been a vaguely defined goal with little explicit criteria established for its accomplishment or assessment.
“Actually, the most important part of culture…is that which is hidden and internal but which governs the behavior encounter.” (Hall 1976)
This quote speaks to the unseen yet powerful nature of culture. It is hidden and internal, yet is what helps shape our behaviors and interactions with others. When you are in an environment of a shared culture, where people are mostly acting from a similar set of ideas and beliefs about how the world works, communication and understanding is often easier. Misunderstandings, false assumptions, lack of communication and understandings can arise more easily when people are operating from differing core beliefs.
Training in cultural competence has focused on teaching providers about traditional cultural concepts and practices of the racial and ethnic minority patients/clients/communities they serve in order to identify and prevent health disparities. The idea is if providers are more aware of the cultural background and beliefs of their clients, communication will be easier. Providers can build mutual understandings that improve both delivery of services and patient compliance. While this type of training can certainly be helpful to some extent, sometimes it provides people with “veritable laundry lists of traditional beliefs and practices ostensibly characteristic of particular ethnic groups.” (See article, Beyond Cultural Competence) This approach focuses on the differences and specific ‘traditional beliefs and practices’ of certain groups and can sometimes pit the ‘other’ – namely underserved minority groups - against mainstream or conventional beliefs that remain unnamed and unexplored. The mainstream or conventional beliefs become the norm while the ‘other’ becomes the exotic or esoteric.
To make cultural competence training more effective, two additional factors must be present: 1) awareness of the dynamic, ever changing quality of culture and that it is neither a blueprint for behavior nor a static identity; and 2) the practice of cultural humility. As Linda Hunt, an Associate Professor of Anthropology at Michigan State University, states in an essay on cultural competence:
“Culture does not determine behavior, but rather affords group members a repertoire of ideas and possible actions, providing the framework through which they understand themselves, their environment, and their experiences…Culture is ever changing and always being revised within the dynamic context of its enactment.
…Individuals choose between various cultural options, and in our multicultural society, many times choose widely between the options offered by a variety of cultural traditions. It is not possible to predict the beliefs and behaviors of individuals based on their race, ethnicity, or national origin.”
This description addresses culture’s dynamic nature and approaches it more as a ‘repertoire of ideas and possible actions’ that people can choose from to form their own understanding of themselves and their world. In this sense, there is no way to ultimately predict a person’s beliefs or behaviors.
In addition, the ‘various cultural options’ Hunt speaks of refers to more than our ethnic cultures. Throughout the day, many of us move between several cultures, often without thinking about it. For example, our home/family culture often differs from our workplace culture, school culture, social club culture, religious organization culture, etc. Our personal culture is shaped not only by our ethnicity and skin color, but also by our class, age, experiences, physical abilities, gender, language(s), religion, politics, education, sexual orientation, socio-economic status, and residential status.
With so many factors to consider, how does one move forward with developing cultural competence without being overwhelmed with the complexity and the dangers of stereotyping, or reifying the culture of others? Practicing “cultural humility” is the key. Dr. Melanie Tervalon and Jann Murray-Garcia describe cultural humility as a lifelong process of self-reflection and self-critique. The starting point for such an approach is not an examination of the client’s belief system, but rather having health care/service providers give careful consideration to their assumptions and beliefs that are embedded in their own understandings and goals of their encounter with the client. Training for cultural competency, with its emphasis on promoting understanding of the client with her/his ‘own culture’, has often neglected consideration of the providers' worldview. In practicing cultural humility, rather than learning to identify and respond to sets of culturally specific traits, the culturally competent provider develops and practices a process of self-awareness and reflection.
Providers are encouraged to develop a respectful partnership with each client through client-focused interviewing, exploring similarities and differences between her/his own and each client's priorities, goals, and capacities. In this model, the most serious barrier to culturally appropriate care is not a lack of knowledge of the details of any given cultural orientation, but the providers' failure to develop self-awareness and a respectful attitude toward diverse points of view.
Effectively exploring cultural issues in the client/provider encounter should begin with recognition that "cultural difference" refers to a relationship between two perspectives. It involves self-awareness and an awareness and acceptance of the other person and any differences in the contrasting cultures. Culturally competent providers develop skills for exploring the existence and importance of differences in the basic assumptions, expectations, and goals they and their clients bring to any interaction. This kind of reflexive attentiveness can be useful and should be used in any encounter, not just with people who are perceived to be culturally "other."
Developing cultural knowledge, skills in understanding cross-cultural interactions, and an awareness and acceptance of the dynamic variety of people and populations we work with are all crucial components of cultural competence. And adding in the lifelong self-reflection process of cultural humility is key to improving care. Therefore, as Dr. Tervalon and Dr. Murray-Garcias state in their paper, Cultural Humility versus Cultural Competence, “Cultural competence….is best defined not as a discrete end point but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves.”
Some exercises in self reflection
Below are a few helpful exercises regarding awareness of our own culture and self awareness presented by Anthropologist Dr. Margie Akin at a recent California Health Advocates Senior Medicare Patrol conference. These can be answered on your own, or discussed with staff/colleagues.
- Identify your own cultural and family beliefs and values.
- Define your own personal culture/identity: ethnicity, age, experience, education, socio-economic status, gender, sexual orientation, religion…
- Are you aware of your personal biases and assumptions about people with different values than yours?
- Challenge yourself in identifying your own values as the “norm.”
- Describe a time when you became aware of being different from other people.
Some useful resources…
- National Standards on Culturally and Linguistically Appropriate Services (CLAS) – These 14 CLAS standards are primarily directed at health care organizations; however, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served.
The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations as follows. View the link above for more information.
- Office of Minority Health Cultural Competency web page – This web page has links to basic information on cultural competence; guides and resources; a list of the national CLAS standards; policies, initiatives and laws; reports; and training tools.
- The National Center for Cultural Competence (NCCC) maintains a database of a wide range of resources on cultural and linguistic competence (e.g. demographic information, policies, practices, articles, books, research initiatives and findings, curricula, multimedia materials and web sites, etc.). The NCCC uses specific review criteria for the inclusion of these resources. As part of the NCCC's web-based technical assistance, a selected searchable bibliography of these resources is made available online.
- The California Endowment has a section of their website dedicated to information on Culturally Competent Health Systems. This section includes a long list of excellent publications on the topic.