CULTURE AS A COMPONENT OF COMPETENCE IN HEALTH …



Guiding Principles for Cultural Competency

Improved cultural competency on the part of providers and healthcare organizations is an important component of any approach to mitigating disparities in health access and outcomes among minorities and other underserved populations. “Disparities in access to quality care extend beyond race and gender to segments of the population that are often marginalized. For example, HIV-infected injection drug users are less likely to receive antiretroviral therapy than non-drug users are. It follows that disparities in access to quality HIV care are related to disparities in survival, which have been reflected in AIDS mortality data for some time.” (U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2002, p. 2)

“Eliminating disparities in health outcomes is a challenge. No single solution will remedy the problem because the problem has no single cause. The many barriers separating individuals from quality care include lack of health information; co-morbidity involving other serious health problems, such as addiction and mental illness; attitudes about accessing healthcare; shortage of healthcare providers; and poverty.” (U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2002, p. 2)

“Cultural competency is also a factor. Cultural differences between providers and clients affect the provider-client relationship.  How clients feel about the quality of that relationship is directly linked to client satisfaction, adherence, and subsequent health outcomes. If the cultural differences between clients and providers are not recognized, explored, and reflected in the medical encounter, client health outcomes may suffer.” (U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2002, p. 2)

The Guiding Principles for Cultural Competency serve as a tool for assisting AETC faculty, providers, and administrators in addressing health disparities and cultural competency within their healthcare setting.

Core components of the Guiding Principles for Cultural Competency

1. Cultural identities influence our thoughts, behaviors, and ways of life. Each individual can identify with many cultural groups.

2. Cultures are always changing. HIV education and training should reflect this. It is not enough to learn about a particular cultural group through a single training activity. The process of becoming culturally competent, or culturally fluent, is on-going and involves the development of knowledge, skills, and awareness.

3. The development of culturally appropriate training materials and capacity building programs

for HIV minority and minority-serving providers should include an expanded view of cross-cultural competence and issues that apply within and across cultures.

4. Training programs must be designed to help providers develop competencies and skills

needed for intercultural understanding, and expand on ways to achieve cultural fluency especially as knowledge evolves in the areas of health literacy and linguistic competency.

5. Healthcare providers need to gain a better understanding of general cultural starting points for

approaching, learning about, and interacting within different cultures.

6. Providing education, training tools, and technical assistance to AETCs will assist in

developing skills for cultural fluency and will increase capacity to provide the best culturally appropriate healthcare to clients with HIV/AIDS.

Terminology. Cultural competency implies that the individual can achieve a state of competence. “To be culturally competent doesn't mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and are willing to accept, that there are many ways of viewing the world” (Galbraith, 2000). In fact, many understand cultural competence as a journey rather than a destination. Other terms may convey a better understanding of the evolutionary and non-linear process of working in multicultural settings:

• Cultural sensitivity

• Cultural awareness

• Cultural openness

• Cultural humility

• Cultural fluency

Common concepts and themes in definitions. Culture and competence are both broad and inclusive terms. The definitions that we have examined share a number of important themes:

▪ Respect for cultural variation in the individual and community.

▪ Knowledge/awareness of personal cultural values, beliefs, and practices; cultural variations; and ways to become more culturally aware.

▪ Attitudes that are open, willing to consider differences, eager to learn about cultural variation, able to forego ethnocentric judgment, and convinced that culture makes a difference in the ability to provide quality healthcare.

▪ Skills that support cultural interactions: communication, sharing, comprehension, integration, assessment, intervention, evaluation, and change.

▪ Levels of cultural interactions: individual, social (dyad, family, community), and structural (agency, system, political, government) levels.

Framework for culture. People define cultural constructs within the context of their own life histories, growth, and current situations. A working framework for competence in the care of HIV-infected clients must take the following areas of cultural concern into account for each individual:

▪ Demographics: race, ethnicity, gender, age, generation

▪ Communication: language(s), literacy (reading, speaking, health)

▪ Education level: functional as well as actual

▪ Economic status of the individual and the environment in which s/he functions

▪ Occupation/means of support: work status, current means of income (legal? illegal? borderline?), labor, profession

▪ Geography: current residence, community/neighborhood, place of birth, legal status, travel, nationality, etc.

▪ Environment and situational context: safety of communities in which the individual spends a significant amount of time; risks related to violence, fear of violence, or coercion; communities of risk (i.e., drug/alcohol use, anonymous sex)

▪ Personal relationships: family, friends, partnerships, sex, drugs, etc.

▪ Health (physical, emotional, mental): norms, beliefs, practices, preferred providers, taboos; definitions of health, disease/sick role, disability, and care; HIV and other disease diagnoses, treatments, achievements; perceptions (developed over time) of efficacy, value, and disparity/discrimination in relationships with various healthcare systems and providers

▪ Gender and sex: gender, gender roles, transitions, sexual orientation, sexual intercourse

▪ Community affiliations: religious, political, service, social, etc.

▪ Culture-specific definitions: spirituality, art, ethics, value, locus of control, power

▪ Individual experiences: development over time that has lead the individual to accept, reject, and/or modify cultural components that were imparted to him/her as a child; life experiences that have expanded, challenged, realigned, or reinforced early cultural influences; individual constellation of factors that make up her/his cultural orientation

▪ Culture comfort: has the individual integrated a personal set of cultural influences into his/her life? how do those beliefs and practices intersect with health practices and self-acceptance? can the individual function within larger social systems (family, community, social structures)? is the individual in a state of cognitive dissonance, discord, or discomfort with/between the values of personal, familial, and/or social cultures?

Framework for cultural interactions when caring for people infected with HIV. We all develop (learn, practice, accept) cultural influences that can never be the same as those of any other individual or group of individuals. We often choose to interact with others who have similar values, experiences, and cultural influences to our own, but when we move out into larger social networks (especially for healthcare), we confront people who live in dissimilar cultures and who are in

positions of power as gatekeepers to care, medications, and treatment services. Each individual in the healthcare relationship has considerations related to culture that must be acknowledged and honored.

Providers. Healthcare providers possess knowledge and skills that were developed in a process of professional education. They have their own language, expectations, and professional cultures. They also have responsibilities:

▪ To develop skills to assess individual client cultures and to work with the client to integrate components of that culture into a care and treatment plan that the client can accept.

▪ To be open to learning about the ways of others and willing to see past stereotypes when working with individuals and families.

▪ To suspend judgment, especially in the assessment phases of care.

▪ To remember that individuals are unique even within groups: some Hispanics do not speak Spanish, some women are not mothers, some Catholics use birth control, and some college-educated people use alternative/traditional healthcare practices.

▪ To adopt an attitude of service to the client and the community.

▪ To explore, understand, and honor their own cultural definitions and values.

▪ To constantly compare personal culture(s) within the context of professional obligations.

▪ To deal with any dissonance that occurs between cultures by “honoring and setting aside” or by making personally acceptable changes and developing methods of dealing with larger culture clashes and ethical dilemmas that can occur in cross-cultural settings.

▪ To accept responsibility as the power broker in healthcare situations to address healthcare in a holistic manner that includes culture.

Client. The client also has obligations:

▪ To share the components of her/his culture that will impact on the ability to seek care, to participate in the process of developing a healthcare plan, and to implement care prescriptions.

▪ To seek care from providers who understand his/her culture.

▪ To teach providers who are open to these discussions.

Unfortunately, many clients feel that they are in a “one down” position in ANY healthcare setting, especially if they are poor, do not understand healthcare systems, have cultural constraints against disagreeing with authority figures, or already suffer from discrimination by virtue of race, ethnicity, gender, status, or diagnosis (especially HIV, drug use, mental health problems, and STDs). Because of this, the provider’s responsibility to honor various cultures is imperative.

Structure/Context: Healthcare takes place within a social setting: it may be a dyad (rare in modern Western systems) or in the arena of a clinical space that requires interactions with many different service providers. Healthcare can be improved in institutions that accept obligations to make culture an important component of care by:

▪ Expecting that care will be provided in a culturally sensitive manner

▪ Integrating culturally appropriate frameworks and policies into all aspects of operation

▪ Educating staff about general guides to cultural awareness as well as the specific cultural traditions of their clients

▪ Providing information in the language(s) of the patient – including forms, brochures, patient education, signage, etc.

▪ Hiring staff who understand and communicate in more than one language; making sure skilled translators are available

Definitions of cultural competence.

▪ The "ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences." (Cooper & Roter, 2002, p. 554)

▪ The ability of systems [and individuals] to provide care to clients with diverse values, beliefs, and behaviors, including tailoring delivery to meet clients' social, cultural, and linguistic needs. “The goal of cultural competence is to create a health care system and workforce that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency." (Betancourt, Green, Carillo, & Park, 2005, p. 499)

▪ “A set of behaviors, attitudes and policies of a system, agency or individual that enables that system, agency, or individual to function effectively in trans-cultural interactions . . . to a person or program’s ability to honor and respect the cultural differences (beliefs, interpersonal styles, attitudes and behaviors) of individuals and families who are clients, staff administering programs, and staff providing service at state and local levels. In doing so, it incorporates values at the levels of policy, administration, and practice.” (National Maternal and Child Health Center on Cultural Competency, 1995, p. 21)

▪ “A program’s ability to honor and respect beliefs, interpersonal styles, attitudes, and behaviors of families who are clients, as well as the multicultural staff who are providing services. It incorporates these values at levels of policy, administration, and practice.” Cultural competency is viewed as a continuum, not as a one-time goal. “Competency implies skills which helps to translate beliefs, attitudes, and orientation in action and behavior in the daily interaction with children and families.” (Texas Department of Health & National Maternal and Child Health Center on Cultural Competency , 1996)

Concluding Remarks

Enactment of these principles can be achieved by using other tools developed by the AETC Cultural Competence and Multicultural Care Workgroup such as: 1) Addressing Health Literacy in HIV Care and Treatment: A Collection of Case Studies, 2) Cultural Competency Organizational Self Assessment (OSA) Question Bank, and 3) population-based resource lists. These tools and resources, as well as others, can be obtained from the AETC website at .

Acknowledgements

This tool was developed by the AIDS Education and Training Centers (AETC) Cultural Competence and Multicultural Care Workgroup (Leader: Ronald Lessard, BA, NMAETC). Collaborating members include Nicholas Alvarado, MPH (Pacific AETC), Mary Annese, MPA (Northwest AETC), Dorcas Baker, RN, BSN, ACRN (PA/MidAtlanitc AETC), Magda Barini-Garcia, MD, MPH (HRSA HAB), Daria Boccher-Lattimore, DrPH (NY/NJ AETC), Lucy Bradley-Springer, PhD, RN, ACRN, FAAN (Mountain Plains AETC), Yolanda Cavalier, MPH (HRSA HAB), Fransing Daisy, PhD (Northwest AETC), I. Jean Davis, PhD, DC, PA (NMAETC), Durrell Fox, BS (New England AETC), Allen Funnyé, MD, FACP (NMAETC), Ben Hakmatnia (NMAETC), Erica Hayes (NMAETC), Cheryl Hamill, BSN, MN (Delta Region AETC), Melissa Laurie (NY/NJ AETC), Eloise Lopez, RN, BSN (Delta Region AETC), Sylvia Moreno (Texas/Oklahoma AETC), Eric Noel, BA (MATEC), Ruben Ortiz (NMAETC), Tonia Poteat, MMSc, PA-C (SEATEC), Kelly Rand, MA (NY/NJ AETC), L’laina Rash, MEd, CHES (MATEC), Dion Richetti, DC (NY/NJ AETC), Makeva Rhoden, MPH (HRSA HAB), Diana Travieso Palow, MPH, MS, RN (Florida/Caribbean AETC), Richard Vezina, MPH (AETC NEC), Amanda Wilkins (MATEC), Rochelle Williams (NMAETC), and Brenda Woods-Francis, MPH, RD (HRSA HAB). The workgroup efforts were coordinated by the AETC National Resource Center (Jamie Steiger, BSW, Managing Editor, Andrea Norberg, MS, RN, and Supriya Modey, MPH, MBBS).

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