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Step 3 - Design

Design

Cultural competence in:

Cultural competence in design

Outcome indicators are not necessarily the best - choosing indicators relevant to culture and context

Indicators of the health of both Indigenous and culturally diverse groups need to be relevant to the culture and the context. As noted by Bauert et al. (Bauert et al. 2003) indicators of Indigenous health in common use in Australia, Canada and New Zealand range from central indicators (such as the age-standardised rate ratios for Aboriginal people) to secondary indicators (such as change in the prevalence and incidence of chronic diseases, like diabetes, in Aboriginal communities). Existing indicators emphasise outcomes rather than opportunities for early intervention, such as early childhood development and youth resilience. Bauert et al. suggest additional indicators that more closely reflect community knowledge models and values.

Avoiding errors in epidemiological studies of ethnicity

The integration of universalist and culturally relativist approaches, and their methodologies, is required to generate a truly international epidemiology (Patel 2001). Raj Bhopal (Bhopal 1997) sets out the four errors in epidemiological studies of ethnicity

‘Inventing ethnic groups–A study labelled a group as Urdus on the basis of the language spoken, thus inventing an ethnic group

Not comparing like with like–Inner city populations are different from whole population samples, but studies of ethnicity and health continue to focus on them for convenience–as in the recent Health Education Authority survey, in which the comparison population was not an inner city sample7

Lumping groups together–A paper on smoking and drinking habits in British residents born in the Indian subcontinent did not describe sex and regional variations, creating the impression that smoking and drinking were unimportant in the "Asian" population. Among populations of Indian origin, however, smoking and drinking are important problems in some subgroups. Heterogeneity in the prevalence of disease and risk factors has even been shown among different Hindu castes in one city in Tanzania Yet journals still publish comparisons as crude as white and non-white.

Not adjusting for confounding factors–Inferences can change radically once interacting and confounding factors are accounted for: Lillie-Blanton et al challenged the observation that crack smoking was commoner in African Americans and Hispanic Americans and showed that once social and cultural factors were accounted for there were no differences.’  

Recognition of diversity and uniqueness of individuals within groups

There exist “within-group variability and individual differences among ethnic groups that may influence children’s mental health and responsiveness to treatment. Such factors include ethnic identification, acculturation, language, education, socioeconomic status, regional variation, and personal and familial immigration history” (Fisher, Hoagwood, Boyce, Duster, Frank, Grisso, Levine, Macklin, Spencer, Takanishi, Trimble, & Zayas 2002;Fisher & Wallace 2000).

In response to the US Public Health Service projects promoting attention to the disparities in the outcomes of mental health treatments, the American Psychological Association, National Institute of Mental Health among others convened a group to guide decision making for research specific to ethnic minority children and youth. ‘Instead of thinking about identity as an accomplished fact – an independent, unproblematic variable in research – postmodernism encourages investigators to explore the processes, never complete, which shape identity’ (Pfefer, 1998).