Section
II: Conceptualizing Cultural
Competence and Identifying
Critical Domains
I.
Conceptualizing Cultural Competence and identifying
critical Domains
Based
on the literature review, this section reports on the current
state of the field in conceptualizing cultural competence
and identifies key domains or areas for measuring cultural
competence. This
section also provides a synthesis of the literature that
provides a basis for each of the domains identified by the
project team. A full annotation of the articles reviewed for this analysis
can be found in the bibliography at the end of this document.
A.
Approaches to conceptualizing cultural competence
Many
health care professionals agree that cultural competence
is a critical factor in providing relevant services to the
nation’s growing culturally and ethnically diverse patient
population.
An extensive body of literature exists that describes
the evolution of cultural competence in the context of health
care.
The following discussion primarily focuses on this
body of work, recognizing that literature outside of the
health care sphere (e.g., social marketing, anthropology,
communication and media, etc.) could also enhance the understanding
of cultural competence in health care.
While many articles addressing the concept of cultural
competence were reviewed, the project team identified five
central works.
The authors of these five works are Cross, T.L.,
Bazron, B.J., and Isaacs, M.R, Campinha-Bacote, J.,
Carballeira, N., Leininger, M., Davidhizar, R., and Giger,
J.N. These works were chosen as seminal literature because
of their scope and substance, their frequent citation in
the literature, and the consensus validation of their ideas
and perspectives in works of many other authors.
The
literature provides health care professionals with several
definitions of cultural competence and numerous methods
for providing culturally competent care.
For the purpose of this review, we use the definition
of cultural competence set forth by Cross, T.L., Bazron,
B.J., Dennis, K.W., Isaac, M.R., and Campinha-Bacote, J.
Cultural competence is “a
set of congruent behaviors, 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.”
The
literature on cultural competence approaches the issue of
competence in two ways: theoretical and methodological.
For example, Cross, et al. and Campinha-Bacote offer
a theoretical approach in which cultural competence is seen
as a process or continuum whereby an individual’s view of
other cultures transforms from destructive or unaware to
proficient.
Cross, et al. define a set of factors that
must be present in order to progress along the continuum.
There are six possible points along this continuum:
1.
Cultural destructiveness,
2.
Cultural incapacity,
3.
Cultural blindness,
4.
Cultural pre-competence,
5.
Cultural competence, and
6.
Cultural proficiency.
Furthermore,
Cross, et al. describe several conditions that must exist
in order for professionals to move along this continuum.
Professionals must: value diversity, understand their
cultural biases, be conscious of the dynamics that occur
when cultures interact, internalize cultural knowledge,
and develop adaptations to diversity.
Each of these conditions set by Cross, et al. must
function at every level of the health care system in order
for that system to provide culturally competent care.
Similar
to Cross, et al., Campinha-Bacote views cultural competence
as a process, not an endpoint, in which health professionals
continually strive to work within the cultural context of
the patient.
The process requires health care providers “to see
themselves as becoming culturally competent rather than
being culturally competent.”
Although Campinha-Bacote does not define points in
this process of becoming, the author does outline five components
of cultural competence similar to the five essential elements
presented by Cross, et al.
The five components of competence include:
1.
Cultural awareness,
2.
Cultural knowledge,
3.
Cultural skill,
4.
Cultural encounters, and
5.
Cultural desire.
Health
care providers can work on any one of these constructs to
improve the balance of all five, but eventually all five
constructs must be experienced and addressed.
Campinha-Bacote explains that the intersection of
these constructs represents the process of cultural competence,
and as the area of intersection becomes bigger, health care
providers will internalize cultural competence at a deeper
level and provide higher quality care.
Authors
such as Carballeira, Leininger,
and Davidhizar and Giger offer
a more methodologically driven
approach that focuses on the methods
a professional might use in order
to become culturally competent
and provide culturally competent
care.4,
,
These authors typically assume that cultural competence is a
goal that can be reached when
a skill set is learned with the
proper training.
D-link
Specifically
Carballeira depicts the interaction between a provider and
a client as a cross-cultural exchange of attitudes.7
The author suggests that in a health care setting,
the patient simply reacts to the provider’s “cultural attitude.”
Similar to the Cross, et al. and Campinha-Bacote
continuum models, Carballeira proposes that the provider’s
cultural attitude falls within a range: superiority, incapacity,
universality, and sensitivity, to competence.
Additionally, Carballeira explores the patient’s
reaction to the provider where the client’s reaction ranges
from resistance to accommodation to adaptation.
The author suggests the use of the LIVE & LEARN
model which presents providers with a practical, phased
approach to cross cultural service delivery that respects
client centrality, avoids stereotyping, and leads to the
adoption of mutually acceptable objectives and measures
for changed behavior.
In this model, the acronym “LIVE” stands for Like,
Inquire, Visit, and Experience,
while “LEARN” stands for Listen,
Evaluate, Acknowledge, Recommend,
and Negotiate.
Leininger’s
Sunrise Model provides a method for assessing patients in
order to provide comprehensive and culturally sensitive
care.
Leininger believes that the Western medical model
fails to explore cultural patterns of illness.
The Sunrise Model suggests that the world view and
social structure of the client are important areas to investigate
and can be explored using seven dimensions:
1.
Cultural values and lifeways,
2.
Religious, philosophical, and spiritual beliefs,
3.
Economic factors,
4.
Educational factors,
5.
Technological factors,
6.
Kinship and social ties, and
7.
Political and legal factors.
Health
care professionals must develop the skills, knowledge, and
patience to explore and validate what the patient says and
does. Once
information is obtained for each of the dimensions, health
care professionals can guide patient treatment and interventions.
According to this Sunrise Model, providers should base their
selection of a treatment approach or combination of approaches
on information gathered from the assessment. Leininger suggests
that this guidance can occur in a variety of ways: cultural
care preservation and/or maintenance, cultural care accommodation
and/or negotiation, and cultural care repatterning and/or
restructuring.
Davidhizar
and Giger also present a transcultural assessment model
to assist health care professionals in assessing patients
from diverse cultures that focuses on six factors:
1.
Communication,
2.
Space,
3.
Time,
4.
Social organization,
5.
Environmental control, and
6.
Biological variations.
According
to Davidhizar and Giger, health care professionals should
receive training on how to use these factors to assess the
health beliefs and practices that may have a significant
impact on how an individual responds to treatment and patient
education. Using
this assessment model will assist health care professionals
in providing care that is sensitive and tailored to the
needs of culturally diverse individuals.
The various
approaches to conceptualizing cultural competence identified
in the literature stress the importance of viewing cultural
competence as a dynamic process involving continual progression
and involvement of all levels of the health care system.
The literature identifies essential elements and conditions
that must be present in the health care system in order
to support cultural competence. These essential elements
will provide a basis for identifying domains for measuring
cultural competence, as discussed in the Section II. B of
this report.
B.
Critical domains for measuring
cultural competence
D-link
The
conceptual literature discussed in the previous section
and other literature reviewed later in this document suggest
that cultural competence in health care settings must be
evidenced or manifested in a broad range of spheres or areas.
The project team has preliminarily identified nine
such areas that are potentially important to the development
of a measurement profile for cultural competence in health
care settings. These areas are referred to here as domains,
and include:
1.
Values and attitudes,
2.
Cultural sensitivity,
3.
Communication,
4.
Policies and procedures,
5.
Training and staff development,
6.
Facility characteristics, capacity, and infrastructure,
7.
Intervention and treatment model features,
8.
Family and community participation, and
9.
Monitoring, evaluation and research.
Within
these global domains, many specific subjects or topic
areas were identified as characterizing the domain and
forming the particular focus or substantive content for
which indicators and measures might be identified and developed.
These topic areas are discussed in Section II. C
of this report. In
this section of the report, the nine domains are defined
with regard to providers’/health care organizations’ cultural
competence and discussed with respect to the domains’ linkage
to the key conceptual literature.
Domain
1: Values and
attitudes
Values
and attitudes refer to the set of beliefs and mindsets possessed
by providers, administrative staff, health care organizations
and others involved in service delivery.
The discussion of values and attitudes in the conceptual
literature is intertwined with discussions of cultural sensitivity
(see below). The
conceptual literature emphasizes training, assessment, and
cultural encounters in order for providers to increase the
awareness of the values and attitudes they bring to the
consumer-provider interaction.
Cultural encounters also increase providers’ ability
to understand those that consumers bring with regard to
health, medical treatment, and authority.
In other words, provider values and attitudes toward
other cultures can change through cross-cultural interactions
with clients and by developing knowledge about and adaptation
to this diversity.
Leininger’s theory requires health care professionals
to evaluate, acknowledge, and develop respect for the cultural
differences. This
can be accomplished through active listening, open-ended
questions, and a nonjudgmental attitude toward the differences
that are encountered.
Carballeira stresses the importance of the provider’s
“cultural attitude” and describes a range of attitudes,
from “superiority” to “competence.”
At the “competence” level, the provider can respect
client centrality, avoid stereotyping, and adopt mutually
acceptable objectives and measures for changed behavior.
Domain
2: Cultural
sensitivity
Cultural
sensitivity generally refers to heightened awareness and
complements several other domains, most notably communication.
While values and attitudes refer to the beliefs held by health care professionals,
cultural sensitivity refers to heightened knowledge of the
needs of the client. Often, cultural sensitivity
manifests itself in a provider’s ability to accurately interpret
and respond to non-verbal or other cultural cues or in the
way in which health care organizations provide information
to their clients. This sensitivity can lead to the behavioral
adaptations needed for cultural competence. For
example, Cross, et al. and Campinha-Bacote both view cultural
competence as a continuum.
As a person moves along the continuum, their values
and attitudes undergo a transformation from a state of ignorance
to one of competence.
However it is also possible for an individual to
be culturally aware, and not change behaviors to become
culturally competent.
Domain
3: Communication
Communication
encompasses a wide range of activities, both oral and written,
that describe the flow and exchange of information among
those involved in the provision and receipt of care, including
interpersonal exchanges and exchanges between individuals
and organizations.
Cultural factors affect the consumer-provider communication. Cultural competence leads to actions creating concordance in
communication styles and increasing the availability and
accessibility of language services (e.g., interpretation
and translation) to improve communication.
Improved communication can lead to increased consumer
satisfaction as well as an improved understanding of and
compliance with diagnoses and treatment regimens. From a
conceptual perspective, Davidhizar
and Giger focus heavily on communication as a key tool for
improving cultural competence in their theory of transcultural
assessment. Providers
must assess the patient’s communication style to learn about
cultural-specific cues that are used.
For example, an understanding of these communication
cues can assist the provider in explaining procedures and
instructions.
Domain
4: Policies
and procedures
Policies
and procedures refer to the programmatic and planning vehicles
through which organizations can facilitate the provision
of culturally competent care.
Specifically, this includes mechanisms, such as conflict
resolution processes and hiring procedures, as well as other
devices that operate primarily in managed care settings,
such as the breadth of provider networks and types of incentive
systems. Cross, et al.
discuss policies and procedures in the context of their
continuum of care.
As an agency or professional moves toward cultural
competence, they begin to understand the interplay between
policy and practice and are committed to policies that enhance
services to diverse clientele.
Those that are culturally blind (a mid-point along
the continuum) may believe that they are implementing culturally
competent policies when, in fact, their policies may be
discriminatory and ultimately restrict access to services.
When an agency or professional reaches cultural proficiency,
policies are flexible and culturally impartial.
Domain
5: Training
and staff development
Training
and staff development concentrates on how to provide health
care professionals the knowledge and skills required to
supply culturally competent care.
An understanding of providers’ individual skill and
knowledge level represents a starting point from which to
develop programs and curricula to develop cultural competence
among health care providers and other staff in health care
settings. Conceptually, the literature often presents training and professional
development in the context of interventions and treatment.
However, the domain also addresses the training that
happens in academic institutions. Campinha-Bacote,
Carballeira, Leininger and Davidhizar and Giger agree that
health professionals should be trained to collect relevant
cultural data when conducting health histories and assessments.
Although training and staff development potentially
constitutes a topic area within policies and procedures,
numerous training efforts profiled in the literature as
well as the conceptual emphasis on its importance led to
its categorization as a separate domain.
Domain
6: Facility characteristics, capacity, and infrastructure
Facility
characteristics, capacity, and infrastructure refer to issues
related to the access and availability of care and the environment
in which it is provided, including location, hours of operation,
physical resources, and information systems.
Often, these issues influence consumers’ experiences
in a health care delivery setting and can hamper their capacity
to access it. Cross,
et al. address this issue when discussing the influence
of an organization’s infrastructure on its ability to be
culturally competent.
An organization in seeking to become culturally competent
can address the needs of different cultures by developing
service models that are adapted to the cultural-specific
needs of the population.
Domain
7: Intervention and treatment model features
Interventions
and treatment model features focus on aspects of patient
evaluation, diagnosis, treatment, and referral services.
These can include how traditional healing beliefs
interrelate with the Western medical model, ethnopharmacology,
inclusive decision-making, care
coordination, and, in a managed care context, health benefit
design. Conceptually,
Campinha-Bacote, Carballeira, Leininger and Davidhizar and
Giger discuss how culturally competent evaluation of consumers
can assist providers in planning interventions and treatments. Basing diagnoses on a cultural assessment that is sensitive
to the cultural needs and beliefs of the patient and sharing
it with consumers in a culturally sensitive manner can contribute
to consumers’ increased understanding of diagnoses and treatment.
This increased understanding is a step towards improving
compliance with a treatment regimen and addressing consumers’
health concerns. To
truly address issues of intervention and treatment providers
must understand the epidemiological profile of the client
base.
Domain
8: Family and
community participation
Family
and community participation refers to family centered, family
focused, and family-oriented care that recognizes the important
role of the family and the larger community in the provision
of health care. Community
participation in assessments and community outreach efforts
represent means for providers to develop an understanding
of consumers’ cultural backgrounds and support structures
and to include these perspectives into policy planning and
development and other activities. The extent to which the
health care system considers and incorporates input from
a broader unit than the direct client influences the degree
to which consumers and providers engage in culturally competent
discourse. Both
Leininger and Davidhizar and Giger stress that a cultural
assessment of a patient should explore the social organization
or kinship and social ties of the patient.
This includes involving the family and/or community
members when appropriate.
Domain
9: Monitoring,
evaluation and research
Efforts
to become culturally competent include monitoring and evaluating
current efforts in order to assess the extent to which cultural
competence is present, is maintained, and contributes to
desired results with respect to health and health care.
The spectrum of efforts includes assessing organizations,
services, and consumer needs and satisfaction. In addition
to evaluation and monitoring, organizations and individuals
can pursue research activities designed to create and disseminate
new knowledge on cultural competence.
From a conceptual perspective, Campinha-Bacote suggests
that providers should research and obtain a sound educational
foundation about the various world views of different cultures.
Developing a knowledge base helps build cultural
awareness which can result in cultural competence.
Exhibit
I
provides a summary of the ideas related to the domains as
found in the key conceptual literature and demonstrates
the degree of congruence within the field.
It also portrays to some extent the degree of overlap
among the nine domains.
As noted earlier, these nine domains represent the
broad spheres or areas in which cultural competence should
be evidenced or manifested in culturally competent health
care settings. Within these domains, specific topics or
subjects further characterize the domains and provide clues
to what might be included in a measurement profile. In Section
II. C of the report and in Attachment 3, the domains and topic areas are discussed in light of
a review of an extensive and wide-ranging set of documents
and publications. (See Annotated Bibliography.)
D-link
C.
Topic areas addressed by
the critical domains of cultural
competence
Having
examined the domains and their grounding in the conceptual
literature, this section presents a synthesis of the remaining
literature-based evidence supporting each domain.
It highlights specific behaviors, activities, and
issues that address the question of cultural competence.
Domain
1: Values and
attitudes
The
beliefs and mindsets of organizations, professionals, and
consumers influence direct care encounters, shaping the
interaction between the consumer and the provider, the provider’s
delivery of care, and the way in which consumers perceive
care.
These
values can manifest themselves at different levels. At the individual level, the literature discusses the importance
of acknowledging and respecting other cultures and the role
of culture in health care.
One particular topic area of emphasis is that of
provider diversity.
Beyond the individual consumer and provider, the
literature highlights the importance of incorporating principles
related to cultural competence in organizational missions,
visions, and goals.
This represents an area of overlap with the domain
of policies and procedures.
Awareness
and acceptance of culture and its impact on how care is
delivered and received is an essential element in a culturally
competent program ,
,
,
,
,
,
,
,
and applies to both consumers and providers.
Cultural perceptions influence when a symptom is
defined as a health problem and the severity of the problem
and whether to seek advice.
-
Behui,
et al. argue that consumers’ unique sets of beliefs
about the causation of their change in function and
emotional experience influences their determination
of who they perceive to be appropriate healers.
-
Perez-Stable,
et al. discuss how the cultural concept of fatalismo
(fatalism) in Latino culture may lead some Latinos to
be less likely to change behavior to reduce risk or
seek care.
Providers
who are aware of cultural beliefs also have more effective
communication with consumers,14 highlighting the interconnectedness of the domains of cultural
competence.
-
Oomen
and Owen examine how to identify and treat Type II diabetes
among Latinas and recommend that understanding consumers’
perceptions of diabetes and its treatment would lead
to a more culturally sensitive method of diagnoses and
treatment.
-
Crandall,
et al. discuss the importance of socially responsible
values in the provider workforce by examining attitudes
of medical students and how they change.
Awareness
and acceptance can take various forms, from acknowledgment
to respect. Identification and recognition of the differences
between cultures and how they shape interactions represents
a first step towards accommodating and adapting care to
respect those differences.
Carballeira posits that shifts in cultural attitudes
of providers and consumers can lead to improved results,
and includes elements of that shift in the “LIVE & LEARN”
model. In this
model, changes in consumers’ reactions would shift from
resistance-accommodation-adaptation while changes in providers’
reactions would progress along a continuum of superiority-incapacity-universality-sensitivity-competence.7
Ultimately, conveying respect during encounters where differences
of values exist remains challenging because manifestations
of respect depend on culturally-specific norms of interaction. Furthermore,
the impact of cultural value differences is not limited
to race and ethnicity alone but extends to socioeconomic
status and power dynamics that differ by race and ethnicity.25
In
addition to awareness, acknowledgment, respect, and acceptance
of cultural values and differences, several articles discuss
the need to emphasize the value of diversity and other values
that promote healthy outcomes for underrepresented groups.
17,
25
Instilling a positive view of diversity differs from,
but can co-exist with, targeted recruitment and retention
efforts by health care organizations discussed under the
policies and procedure domain. Promoting diversity as a value becomes important as these efforts
require time and resources to progress.
At
an organizational level, the literature stresses the importance
of creating mission and vision statements that articulate
an organization’s principles and rationale related to providing
culturally competent health care services. These goals and
objectives can also manifest themselves in program announcements,
policies, and requests for proposals.
Domain
2: Cultural
sensitivity
Cultural
sensitivity generally refers to heightened awareness and
complements several other domains, most notably communication.
Lister defines cultural sensitivity as regard for
a consumer’s beliefs, values, and practices within a cultural
context and awareness of how a provider’s background may
influence professional practice.16
Cultural sensitivity also refers to some of the less readily
quantifiable aspects of care with regard to culture. For instance, Hennessy and Friesen discovered that Mexican-Americans
were highly concerned with the “caring” with which service
was delivered, more than the technical proficiency of the
care.
Non-verbal
communication, visual representation, and non-translated
culturally-sensitive materials are examples derived from
the literature of cultural sensitivity related to communication.
9,
,
,
Though these topic areas also align with the domain
of communication, their evolution from a finely tuned understanding
of culture-specific needs and preferences beyond language
needs merits their inclusion here.
-
Salimbene
discusses how providers and consumers use a “cultural
filter” to process a host of information, including
facial expressions, body language, and behavior, in
provider-consumer interaction.15
-
Wright,
et al. study similar issues about non-verbal communication
in relation to critical care patients making end-of-life
decisions across a range of racial and ethnic groups.
They observe how non-verbal cues are often critical
in decision-making and how misunderstandings of these
cues can lead to decisions around which little agreement
exists.
-
Yancey
and Waldlen describe the success of using Spanish-language
videotapes in increasing breast and cervical cancer
screening among Latinas and African-American women.
These videotapes included relevant cultural dynamics,
varied production elements with entertainment value
(e.g., music), information comprehensible to an audience
with little formal education, and a minimally didactic
presentation.
-
Guidry,
et al. analyze culturally sensitive printed cancer education
materials targeted at African Americans, gauge their
educational value
and discuss the need for cultural sensitivity to encompass
the culture-specific needs and preferences of those
populations for whom English is the primary language
of communication.
Domain
3: Communication
Communication
encompasses a wide range of activities that describe the
flow and exchange of information among those involved in
the provision and receipt of care.
This focuses primarily on interpersonal exchanges
between consumers and individual providers and the exchange
that occurs between consumers and health care delivery organizations.
The literature discusses a number of concerns regarding
communication and how cultural factors may affect the consumer-provider
communication,
including issues related to communication style, language
services available to consumers, and language-concordant
capacity of providers.
Consumers
and providers each possess independent styles of communication.
There is evidence that having a sufficient number
of administrative and provider staff competent in negotiating
the communication styles of racial and ethnic groups seeking
services can help minimize the need for interpreters and
other language services.10
Peer education and testimonials are other mechanisms to communicate
across different styles.
-
In
studying how to increase breast and cervical cancer
screening rates for African-American, Latina, Chinese,
and Vietnamese women, Pasick, et al. discuss the importance
of peer education and testimonials.
Specifically, they examine different videos and
printed brochures employed by a variety of clinics to
determine the preferences of specific populations in
terms of what information is important for them, how
that information should be crafted into a message, and
the different media preferences of the various populations.
-
DiClemente
and Wingwood conducted the first randomized controlled
trial of community-based HIV sexual risk reduction for
economically disadvantaged young adult African American
women and found that those who participated in peer
education sessions on a variety of topics demonstrated
significant improvement in some risk factors relative
to their control group counterparts.
Open
communication between the provider, consumer, and the consumer’s
family is also critical to gaining understanding between
providers and consumers with different communication styles.
-
Oomen
and Owen, in examining how to identify and treat Type
II diabetes among Latinas, suggest that providers ask
direct questions on follow up visits regarding treatment
adherence, barriers to compliance, and possible solutions.21
Language
services for those consumers with limited English proficiency
or for whom English is not the primary language is of growing
importance in making treatment decisions and ensuring appropriate
care. ,
These include the provision and appropriate use of interpreters
and translated materials, for educational and administrative
purposes. The
Culturally and Linguistically Appropriate Services (CLAS)
standards stress the importance of interpreters in consumers’
interactions with the health care delivery system.,
The availability of interpreter services that is
timely and of high quality is often a concern, and standards
for this vary.,
Family and friends are not adequate substitutes for
trained interpreters who demonstrate bilingual proficiency
and receive training that includes the skills and ethics
of interpreting and knowledge in both the terms and concepts
relevant to clinical or non-clinical encounters.
-
Baker,
et al. examine the use of interpreters in emergency
departments, assessing how often they are used and who
usually interprets and studies consumer and provider
perceptions of the appropriateness of their use based
on respective language capabilities.
They find that regardless of provider competence
in the consumer’s language of preference, consumers
tend to prefer the use of interpreters, except when
the consumer is more comfortable in English than another
language.
-
Randall-David
and Pasick, et al. discuss some of the difficulties
in selecting an interpreter and stress that providers
require training and knowledge in order to work with
one effectively. ,
In
addition to oral language services, the presence of translated
materials helps meet the needs of limited English proficiency
consumers. ,
Translated materials can include patient education resources
and administrative paper work, including consent forms,
and should be translated into primary language of communities
served. ,
,
,
,
