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Cultural competence - background

    Evolution of the concept since the 1970s

    Cultural awareness

    During the 1970s there was growing attention to cultural awareness, seen as a beginning step toward understanding that there is difference. Many people undergo courses designed to sensitise them to formal ritual and practice rather than the emotional, social, economic and political context in which people exist.

    The term cultural awareness has been ascribed to the cultural training programs developed by Queensland Health, which adopted Hodge’s definition as cited in the Revised Minimum Standards for Aboriginal and Torres Islander Cultural Awareness Training, that being a sensitivity to the similarities and differences that exist between two different cultures, and the use of (this) sensitivity in effective communication with members of another cultural group. (National Rural Faculty - Royal Australian College of General Practitioners 2004).

    Note that cultural awareness seems to be about difference rather than diversity (and which includes similarities as well as differences)

    Cultural respect

    In the Cultural Respect Framework for Aboriginal and Torres Strait Islander health prepared by the Australian Health Minister's Advisory Council (AHMAC) cultural respect is defined as Recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples [p 6]. AHMAC noted that cultural respect can only be achieved when health service providers create an environment in which Aboriginal and Torres Strait Islander peoples can feel culturally safe and where cultural differences are respected. The end result is equity of outcomes for Aboriginal and Torres Strait Islander individuals and communities (National Rural Faculty - Royal Australian College of General Practitioners 2004).

    Cultural sensitivity

    During the 1980s there was attention paid to cultural sensitivity. Cultural sensitivity alerts students to the legitimacy of difference and begins a process of self-exploration as the powerful bearers of their own life experience and realities and the impact this may have on others.

    The Association for the Advancement of Health Education's definition for Cultural sensitivity, is ‘Knowledge that cultural differences (as well as similarities) exist, along with a refusal to assign cultural differences such as values as better or worse, more or less intelligent, right or wrong: they are simply differences. Cultural sensitivity does not imply expert understanding of specific cultural groups but rather a level of awareness and acceptance. (National Rural Faculty - Royal Australian College of General Practitioners 2004)

    Cultural competence

    By the late 1980s, there was a call for a more comprehensive skill based concept that included the system no less than the patients/subjects/informants – ‘us’ as well as ‘them’.

    Models of cultural competency offer a variety of definitions that attempt to capture or expand on five elements considered essential to providing culturally competent health care across cultures (Institute of Medicine Committee on Communication for Behavior Change in the 21st Century 2002):

               Valuing diversity;

               Developing the capacity for self-assessment;

               Raising awareness of dynamics inherent when cultures interact;

               Using organizational processes to institutionalize cultural knowledge; and

               Striving to develop individual and organizational adaptations to diversity.

    Cultural competence is ‘A set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency or those professionals to work effectively in cross-cultural situations’ (Cross et al. 1989).

    ‘A program's ability to honor and respect those beliefs, interpersonal styles, attitudes and behaviors both of families who are clients and the multicultural staff who are providing services.’ (Roberts & And 1990).

    Culturally competent agencies and systems understand, accept and respect cultural differences. They involve people who are reflective of the diverse groups in the community -- in the development of policies, services and programs which are appropriate and relevant to them. A culturally competent organization respects differences and pays attention to the dynamics of difference. They do continuous self-assessment, expand cultural knowledge and resources, and adapt their service models to accommodate needs. Such organizations consult with ethno-cultural communities and are committed to hiring culturally competent employees. They also understand the interplay and influence between policy and practice. (Cross, Bazron, Dennis, & Isaacs 1989).

    At systems, organizational or program level, cultural competence requires comprehensive coordinated plan that includes interventions on levels of (a) Policy making (b) Infra-structure building (c) Program administration and evaluation (d) Delivery of services and enabling supports and (e) The individual

    Mandates that organizations, programs and individuals (a) Value diversity and similarities among all peoples (b) Understand and effectively respond to cultural differences (c) Engage in cultural self-assessment at the individual and organizational levels (d) Make adaptations to the delivery of services and enabling supports and (e) Institutionalize cultural knowledge

    (Denboba 1993;Goode 1995;Maternal and Child Health Bureau (MCHB) 1999).

    The contexts and nuances

    Continuum models of cultural competence

    Cross, et al. define a set of factors that must be present in order to progress along the continuum (Cross 1988). There are six possible points along this continuum:

    1. Cultural destructiveness, leading to

    2. Cultural incapacity, leading to

    3. Cultural blindness - clinicians and health care institutions assume that they are unbiased; however, this assumption is based on an incorrect belief that all people are the same. In this stage, facility policies and practices do not recognize the need for culturally specific approaches to solve problems. This stage may progress to

    4. Cultural pre-competence - recognize weaknesses in the health care delivery system or in their personal cultural knowledge base, and they explore alternatives. They also are committed to responding appropriately to cultural differences. This stage may progress to

    5. Cultural competence, leading to

    6. Cultural proficiency - recognize the need to conduct research, disseminate the results, and develop new approaches that might increase culturally competent practice.

     Campinha-Bacote ( 1991) defines a continuum as:

    1. Cultural awareness, leading to

    2. Cultural knowledge, leading to

    3. Cultural skill, leading to

    4. Cultural encounters, leading to

    5. Cultural desire.

    Cultural competence in health promotion

    Health promotion refers to the process by which individuals, communities and populations are given the tools necessary to improve health outcomes.

    Culturally competent health promotion implies the incorporation of culturally sensitive concepts and practices into health promotion activities. Developing CCHP policies and interventions entails the integration of a multilevel community organization and development approach. Activities associated with this approach include community input into the design, implementation and evaluation of programs and associated activities, a comprehensive understanding of the health issues and needs of the target population, and the provision of health information and education (Resources for Cross Cultural Health Care, U.S.Department of Health and Human Services, & Office of Minority Health and the Agency for Healthcare Research and Quality 2004).


    Cultural competence of the researcher

    Sawyer et al. (Sawyer et al. 1995) report that researcher/participant matching has been used in nursing research as a strategy for the development of culturally competent knowledge. They discuss the complexities inherent in matching and argue that matching as a strategy used to generate culturally competent knowledge is too complex. They propose instead that researchers in every research project reflect on their knowledge of culture, their cultural sensitivity, and the nature of collaboration during every phase of the research. Reflecting on and responding to these questions may facilitate the development of more culturally competent knowledge.

    Cultural humility

    Melanie Tervalon, in a reaction against an over-instrumental focus on operational skills which had crept into the cultural competence movement, signalled cultural humility as ‘A lifelong process of self-reflection and self-critique. Does not require mastery of lists of "different" or peculiar beliefs and behaviours supposedly pertaining to certain groups. 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 failure to develop self-awareness and a respectful attitude toward diverse points of view (Tervalon & Murray-Garcia 1998). Note that this concept does not assume a hierarchy of skills and competencies, but does call for the capacity to change in response to humility. Cultural humility has not been applied outside the English-speaking Western context.

    Cultural safety

    Health researchers in New Zealand are well aware of the concept of cultural safety. Cultural safety, as defined by Eckerman et al is: ‘an environment which is safe for people; where there is no assault, challenge or denial of their identity, or who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience, of learning together with dignity and truly listening’ [p 213]. The focus of this concept is on the experience of the patient or client, whereas the term cultural competency focuses on the health professional's attributes, the recognition of and appropriate response to key cultural features that affect clinical care (National Rural Faculty - Royal Australian College of General Practitioners 2004).

    The effective care of a person/family from another culture by a person who has undertaken a process of reflection on own cultural identity and recognises the impact of the their culture on own practice. Unsafe cultural practice is any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual. From 1992 Nursing Council of New Zealand. … Cultural safety is well beyond cultural awareness and cultural sensitivity. Cultural safety is the experience of the recipient of care. It gives people the power to comment on care leading to reinforcement of positive experiences. It also enables them to be involved in changes in any service experienced as negative.

    Ramsden postulated that cultural safety is achieved in three stages:

    1. Cultural awareness: the understanding that there is difference: also an understanding of the social, economic and political context in which people exist

    2. Cultural sensitivity: legitimising this difference: a process of self-exploration that enables us to see how our own life experiences impact upon others

    3. Cultural safety: safe service, as defined by those who receive the service.

    Ramsden's operational definition of cultural safety, incorporates not only a non-judgemental acknowledgement of cultural differences but also a component of self reflection which enables the health professional to understand how their own behaviour stemming from their own cultural life view impacts on others and how this can be modified to provide a service which is perceived by Indigenous people as being culturally safe and culturally respectful (National Rural Faculty - Royal Australian College of General Practitioners 2004).

    Cultural security

    Indigenous health researchers in Australia are well aware of the concept of cultural security. Security can be defined as: “the capacity of a society to conserve its specific character in spite of changing conditions and real or virtual threats: more precisely, it involves the permanence of traditional schemas of language, culture, associations, identity and national or religious practices, allowing for changes that are judged to be acceptable. This notion of security is rightly seen as a fundamental concern for every society, including for cultural matters, as well as a central question of international relations that must be addressed in present conditions (Tardif 2002).

    Principles of cultural respect, culturally sensitive health services and equity of outcome are central to the definition of cultural security which the Department of Health, Government of Western Australia has articulated as being ‘a commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, views, values and expectations of Aboriginal people. It is a recognition, appreciation and response to the impact of cultural diversity on the utilisation and provision of effective clinical care, public health and health systems administration. Cultural security is about ensuring that the delivery of health services is such that no one person is afforded a less favourable outcome simply because she or he holds a different cultural outlook. (National Rural Faculty - Royal Australian College of General Practitioners 2004).

    Linguistic competence

    The following definition, developed by the National Center for Cultural Competence, provides a foundation for determining linguistic competence in health care, mental health and other human service delivery systems (Goode & Jones 2003). 

    Linguistic competence – the capacity of an organization and its personnel to communicate  effectively, and convey information in a manner that  is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. This may include, but is not limited to, the use of (1) bilingual/bicultural or multilingual/multicultural staff; (2) cultural brokers; (3) foreign language interpretation services including distance technologies; (4) sign language interpretation services; (5) multilingual telecommunication systems;  (6) TTY; (7) assistive technology devices; (8) computer assisted real time translation (CART) or viable real time transcriptions (VRT); (9) print materials in easy to read, low literacy, picture and symbol formats; (10) materials in alternative formats (e.g. audiotape, Braille, enlarged print ); (11) varied approaches to share information with individuals who experience cognitive disabilities; (12) materials developed and tested for specific cultural, ethnic and linguistic groups; (13) translation services including those of: legally binding documents (e.g. consent forms, confidentiality and patient rights statements, release of information, applications), signage, health education materials, public awareness materials and campaigns; and (14) ethnic media in languages other than English (e.g. television, radio, Internet, newspapers, periodicals);

    The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity.

    Traditional medicine

    The WHO General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine (World Health Organization 2000) defines traditional medicine as ‘the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness’.

    Anti-cultural competency