Cultural Competence Module ONE

• Race
  
• Ethnicity
  
• Culture
  
• Cultural Knowledge
  
• Cultural Awareness
  
• Cultural Sensitivity
  
• Cultural Competence
  
• Generalization vs. Stereotype
  
• Continuum of Cultural Competency
  

1. "The concept of race as used by the Census Bureau reflects self-identification by people according to the race or races with which they most closely identify. These categories are sociopolitical constructs and should not be interpreted as being scientific or anthropological in nature." The five categories used by the Census Bureau until 1997 are American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, Hispanic, and White. These categories were treated as if they were mutually exclusive. (Federal Register, 1997, Directive 15, Revisions to the standards for the classification of federal data on race and ethnicity).

   "It has become clear that human populations are not unambiguous, clearly demarcated, biologically distinct groups…. Throughout history whenever different groups have come into contact, they have interbred. The continued sharing of genetic materials has maintained humankind as a single species.… Any attempt to establish lines of division among biological populations is both arbitrary and subjective (American Anthropological Association, 1999). Since 1998, the US Census Bureau has allowed respondents to national surveys to indicate self-identification with one or more groups. In 2000, when respondents to the Census were able to classify themselves as members of more than one race, almost 7 million people (2.4%) did so.

2. The Institute of Medicine advocates the use of ethnic group instead of race to classify the US population in order to divert research attention away from biological determinism and toward a focus on culture and behavior. "Race is a construct of human variability based on perceived differences in biology, physical appearance and behavior." The racial groups used by the federal Office of Management and Budget are not discernable by genetic information nor do they reflect the diversity of the US population. (Smedley et al, 2002).

3. Historical Definition: "…a group of people of common ancestry, distinguished from others by physical characteristics, such as hair type, colour of eyes and skin, stature, etc." Therefore, race usually refers to a biological basis ("WordReference," 2003).

"Socially transmitted beliefs, values, ways of knowing, and patterns of behavior characteristic of a designated population group" (Kleinman and Wood as cited in Drew, 2004, p. 125). Culture includes more than race and ethnicity; it may include a person's gender, religion, socioeconomic status, sexual orientation, age, and background (Drew, p. 125). Therefore, it is complex and may not be static.

"The idea of more effective cross-cultural capabilities is captured in many terms similar to cultural competence. Cultural knowledge, cultural awareness, and cultural sensitivity all convey the idea of improving cross-cultural capacity" (http://cecp.air.org/cultural/Q_howdifferent.htm.)

"Familiarization with selected cultural characteristics, history, values, belief systems, and behaviors of the members of another ethnic group" (Adams, 1995 in http://cecp.air.org/cultural/Q_howdifferent.htm)

"Cultural Awareness means developing sensitivity and understanding of another ethnic group. This usually involves internal changes in terms of attitudes and values. Awareness and sensitivity also refer to the qualities of openness and flexibility that people develop in relation to others. Cultural awareness must be supplemented with cultural knowledge" (Adams, 1995 in http://cecp.air.org/cultural/Q_howdifferent.htm.)

1. Cultural sensitivity is knowing that cultural differences and similarities exist without assigning values, i.e., better or worse, right or wrong, to those cultural differences (National Maternal and Child Health Center of Cultural Competency, 1997).

2. The National Standards for Cultural and Linguistically Appropriate Services (CLAS) (http://www.omhrc.gov/CLAS/indexfinal.htm), issued by the HHS Office of Minority Health, defines cultural sensitivity as "the ability to be appropriately responsive to the attitudes, feelings, circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic or cultural heritage" (Office of Minority Health, 2001).

Cultural competence has many definitions. Most commonly, cultural competence in health care is considered to be the utilization of knowledge about groups of people in organizational policies and procedures in order to increase the quality of health care and thereby improve outcomes. The concept of cultural competence highlights the idea of working effectively with persons in the context of culture. Cultural competence requires more than knowledge and awareness. It requires incorporating that knowledge and awareness as guides to culturally competent healthcare practice. (Adams, 1995 in http://cecp.air.org/cultural/Q_howdifferent.htm).

Definitions in the Compendium of Cultural Competence Initiatives in Health Care (http://www.kff.org/content/2003/6067/6067v6.pdf) (pages 6-7) relate to providing programs or systems of health care. For example, "Cultural competence comprises behaviors, attitudes, and policies that can come together on a continuum that will insure that a system, agency, program, or individual can function effectively and appropriately in diverse cultural interaction and settings. It ensures an understanding, appreciation, and respect of cultural differences and similarities within, among, and between groups. Cultural competency is a goal that a system, agency, program or individual continually aspires to achieve." (US Department of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA) (http://bhpr.hrsa.gov/diversity/cultcomp.htm) as cited in Henry J. Kaiser Family Foundation, 2003, Compendium of Cultural Initiatives in Healthcare).

The terms cultural knowledge, cultural awareness, and cultural sensitivity are often confused with cultural competence. For other clear distinctions, refer to The Center for Effective Collaboration and Practice (http://cecp.air.org/cultural/Q_howdifferent.htm).

The danger in trying to describe an entire cultural group is that it may create the false sense that every member of the group is the same, thereby reinforcing stereotypes. Remember that diversity exists in every group.

"Generalizations are often used to summarize cultural beliefs and practices….They point to common trends, but more information is needed to determine whether a statement is appropriate to an individual" (Mutha et al., 2002, p. 74). Generalizations are also reflected in research findings, where the relevance of the generalization from many cases to a specific situation must be carefully considered. Failing to do so is called the "ecological fallacy."

Stereotypes infer that a person or a group of people fits a particular generalization without regard for individual differences. Using stereotypes inhibits us from exploring whether a characteristic fits a particular individual or group of people. It is important to develop relationships with our patients and communities and to learn how to elicit information in order to build a deeper understanding of them. Therefore, cultural competence includes finding out about each individual in addition to understanding various cultural values/behaviors so we learn not to make assumptions, to be aware of cultural cues, and to ask questions in a culturally sensitive way.

Achieving cultural competence is a continual challenge. Authors note that a health professional may be culturally competent practitioner with one population but not another.

Many models have been used to describe a continuum of cultural competency. As an example, Terry Cross's Organizational Cultural Competency Model (1989) describes the characteristics of cultural destructiveness at one end and advanced competency at the other.

Continuum of Cultural Competency (Obtained from Mutha et al, 2002, and adapted from Cross et al, 1989).

The following activities will help you examine your cultural values and beliefs, how they may influence your behavior, and how you work with individual patients' communities. Think about how your practice is affected by your values and beliefs, as well as those of other classmates.

You will gain maximum benefit from completing this sensitizing activity early in the course.

Explore your place on Cross et al's (1989) cultural competency continuum.
Open this brief questionnaire (Questionnaire I, Cultural Awareness), then print and complete it. Reflect on your pattern of responses and consider where you would place yourself on the cultural competency continuum.

You may find it sensitizing to read or re-read the following references:

• Drew, J. D., (2004). Cultural competence in partnerships with communities. In Anderson, E. T., & J. McFarlane (Eds.). Community as partner (4th ed., pp. 114-135). Philadelphia, PA: J. B. Lippincott.

• Van Ryn, M. & Fu, S. S. (2003). Paved with good intentions: Do public health and human service providers contribute to racial and ethnic disparities in health? American Journal of Public Health, 93, 248-255.

A recent Institute of Medicine report recommended that the health care system pursue several techniques as part of a multi-level strategy to reduce racial and ethnic disparities in medical care.

• Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.) (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington DC: The National Academic Press. Also on the web:
  http://books.nap.edu/books/030908265X/html/index.html

After clicking on the section you want to read, it may be easier to read if you click on printable PDF page on top

A Compendium of Cultural Competence Initiatives in Health Care (http://www.kff.org/uninsured/upload/14365_1.pdf) (2003), sponsored by the Henry J. Kaiser Family Foundation, includes efforts underway in the public and private sector organizations since 1990 to reduce cultural and communication barriers to health care. This resource also includes brief definitions for the major terms, organizational descriptions of initiatives, and a list of experts in the field.

A website by The Henry J. Kaiser Family Foundation and the Robert Wood Johnson foundation, "Help understand why," provides evidence on racial/ethnic differences in cardiac care and recent stories on disparities in health and medical care from the Kaiser Daily Health Policy Report. Click here to explore (http://www.kff.org/whythedifference/).

Values and beliefs affect how people interact with individuals and work in teams. They affect communication styles such as language, degree of directness, facial expression, eye contact, gestures, touch, loudness, pitch, silence, and appropriate subjects of conversation.

What do you know about your own values and beliefs?

Exercise:
Complete the Cultural Values/Styles Questionnaire by the due date in the course pages (Questionnaire II). Please print out a copy of your responses. Your responses will be anonymous. We will post the aggregate data for the class (group) HERE after everyone completes the survey. You will find it helpful to compare your responses to those of the class as a whole.

Email Dr. Goeppinger at jgoeppin@email.unc.edu with no more than a paragraph describing one way in which you are similar to/different from your classmates. Speculate on the reasons why you are similar/different.

Readings:

Reading these additional references may be helpful as you continue to reflect on your experiences.

1. On the Center for Effective Collaborative Practice website (http://cecp.air.org/promisingpractices/Default.htm), you can find three series of monographs on Promising Practices and Children's Mental Health. Please have patience when downloading these large files.

   One of these monographs, Cultural Strengths and Challenges in Implementing a System of Care Model in American Indian Communities (http://cecp.air.org/promisingpractices/2000monographs/vol1.pdf) (Cross et al, 2000), presents the practices of 5 American Indian children's mental health projects that integrate traditional American Indian helping and healing methods with a systems of care model. The authors utilize a relational model that describes mental health as balance among context, mind, body, and spirit. (Scroll down and click on Volume 1 of the 2000 series.)

2. The Diversity Rx website (Fortier, date varies) presents essentials, models and practices, policy, legal issues, and networking but is somewhat difficult to navigate. You can quickly review its content from this link (http://www.diversityrx.org/HTML/MAP.htm) or go directly to the Table of Contents (http://www.diversityrx.org/HTML/TOC.htm).

   To directly access:
   Databases or important summaries and links (http://www.diversityrx.org/HTML/DIVRX.htm)
   Multicultural Health Best Practices Overview (http://www.diversityrx.org/BEST/index.html)
   Community Capacity Building (http://www.diversityrx.org/BEST/3_1.htm)
   Hot Links (http://www.diversityrx.org/HTML/NEHOT.htm)

3. The Community Toolbox (http://ctb.lsi.ukans.edu/)(University of Kansas,2003), created and maintained by the University of Kansas Work Group on Health Promotion and Community Development and AHEC/Community Partners in Amherst, Massachusetts, is mostly a how to website. Look at:

   Community building tools (http://ctb.lsi.ukans.edu/tools/tools.htm)
   
   Part H. Cultural Competence, Spirituality, and the Arts and Community Building (Chapters 27 - 29) (http://ctb.ku.edu/tools/en/part_H.htm)
   

   Chapter 27. Cultural Competence in a Multicultural World (http://ctb.lsi.ukans.edu/tools/EN/chapter_1027.htm)
   Chapter 28. Spirituality and Social Action (http://ctb.ku.edu/tools/en/chapter_1028.htm)
   Chapter 29. The Arts and Community Building: Celebrating, Preserving, and Transforming Community Life (http://ctb.ku.edu/tools/en/chapter_1029.htm)

4. National Center for Cultural Competence, Georgetown University Center for Child and Human Development (1999-2002). http://www.georgetown.edu/research/gucdc/nccc/index.html

5. The Transcultural Nursing website (Fernandez & Fernandez, 2003)(http://www.culturediversity.org/index.html) has interesting case studies (http://www.culturediversity.org/cases.htm). Click on the different ethnic populations on the left tool bar.

Grades will be Pass or Fail.

P - Students read assignments and link to a variety of Web sites. Completion of assignments and exercises indicate thorough preparation and thoughtful reflection.

F - Assignments and exercises will not be done or will be done with minimal preparation and without thought and reflection.

Adams, D.L. (Ed.) (1995) Health issues for women of color: a cultural diversity perspective. Thousand Oaks, CA: SAGE Publications.

Center for Effective Collaboration and Practice (n.d.). How does Cultural
      Competency differ from Cultural Sensitivity/Awareness? Retrieved May 19, 2003 from
      http://cecp.air.org/cultural/Q_howdifferent.htm

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally
      competent system of care. Washington, DC: Georgetown University.

Cross, T., Earle, K., Echo-Hawk Solie, H., & Manness, K. (2000). Cultural
      Strengths and Challenges in Implementing a System of Care Model in
      American Indian Communities. Systems of Care: Promising Practices in
      Children's Mental Health, 2000 Series, Volume 1. Washington, DC: Center
      for Effective Collaboration and Practice, American Institutes for Research.
      Retrieved May 19, 2003 from
       http://cecp.air.org/promisingpractices/2000monographs/vol1.pdf

Drew, J. D. (2000). Cultural competence in partnerships with communities.
      In E. T. Anderson & J. McFarlane (Eds.). Community as partner (pp. 116-136).
      Philadelphia, PA: J. B. Lippincott.

Fernandez, V. & Fernandez, K. (2003). Transcultural Nursing.
      Retrieved May 19, 2003 from
      http://www.culturediversity.org/

Fortier, J. P. (date varies). Diversity Rx. Retrieved May 19, 2003 from
      http://www.diversityrx.org/BEST/index.html

Henry J. Kaiser Family Foundation (2003). Compendium of Cultural
      Competence Initiatives in Health Care. Retrieved May 19, 2003 from
      http://www.kff.org/uninsured/upload/14365_1.pdf

Henry J. Kaiser Family Foundation and The Robert Wood Johnson
      Foundation (2002). Help understand why. Retrieved May 19, 2003 from
      http://www.kff.org/whythedifference/

Mutha, S, Allen, C., & Welch, M. (2002). Toward culturally competent care: A
      toolbox for teaching communication strategies. San Francisco, CA: Center
      for the Health Professions, University of California, San Francisco.

National Center for Cultural Competence, Georgetown University Center for Child
      and Human Development (1999-2002). Retrieved May 19, 2003 from
      http://www.georgetown.edu/research/gucdc/nccc/index.html

Office of Minority Health, Public Health Service; US Department of Health and
      Human Services (2001). Assuring cultural competence in health care:
      Recommendations for national standards and an outcomes-focused
      research agenda. Retrieved May 19, 2003 from
      http://www.omhrc.gov/CLAS/indexfinal.htm

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.) (2002). Unequal treatment:
      Confronting racial and ethnic disparities in health care. Committee on
      Understanding and Eliminating Racial and Ethnic Disparities in Health
      Care. Washington DC: The National Academic Press.
      Also on the web: http://books.nap.edu/books/030908265X/html/index.html

Systems of Care: Promising Practices in Children's Mental Health. Washington,
      DC: Center for Effective Collaboration and Practice, American Institutes
      for Research. Retrieved May 19, 2003 from
      http://cecp.air.org/promisingpractices/Default.htm

University of Kansas (2003) Community tool box: Bringing solutions
      to light. See especially Part H (Cultural Competence, Spirituality,
      and the Arts and Community Building) (http://ctb.ku.edu/tools/en/part_H.htm)
      Chapter 27. Cultural Competence in a Multicultural World
      (http://ctb.lsi.ukans.edu/tools/EN/chapter_1027.htm)
      Retrieved May 19, 2003 from
      http://ctb.lsi.ukans.edu/

Van Ryn, M. & Fu, S. S. (2003). Paved with good intentions: Do public health and
      human service providers contribute to racial and ethnic disparities in
      health? American Journal of Public Health, 93, 248-255.

WordReference.com with Collins Dictionaries (n.d) Uses The Collins English Dictionary(2000).
      HarperCollins Publishers.
      Retrieved May 19, 2003 from WordReference.com
      http://www.wordreference.com/English/definition.asp?en=race