CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review Each of these ‘directions’ are elaborated and fleshed out with prospective actionable initiatives and existing good practice examples in Gardner’s (2008a) Discussion Paper, which provides a comprehensive and concrete series of recommendations for action planning over the short, medium and long term in the LHINs context. 6 Ontario Health Quality Council Equity Framework Rachlis (2007; 2008) has consistently advocated for Ontario governmental health bodies (MOHLTC, LHINS) to adopt the Ontario Health Quality Council’s (OHQC) 7 equity framework in order “to operationalize its policy work on health equity” (Rachlis, 2008). This framework is elaborated in the OHQC’s second (2007) Report, which promotes a three-pronged approach to developing a more equitable health system: 1. Improve the accessibility of the health system through outreach, location, physical design, opening hours, and other policies. 2. Improve the patient-centeredness of the system by providing culturally competent care, interpretation services, and assisting patients and families surmount social and economic barriers to care. 3. Cooperate with other sectors to improve population health. Rachlis recommends broadening or fleshing out this framework further to include anti-racism/anti-oppression issues and approaches (2007). While the first and second intervention themes of this framework for action are pre-occupied with healthcare equity, that is reducing health inequities in and through healthcare services, the third framework theme retains a broader concern with population health and health status beyond the healthcare system (hence the call for intersectoral cooperation, and this framework’s characterisation, here, as a ‘health equity in healthcare’ framework). 6 Created by the Ontario government in March 2006, Local Health Integrated Networks are “14 not-for-profit corporations who work with local health providers and community members to determine the health service priorities of [14 designated] regions. As Local Health Integration Networks (LHINs), [the Ontario LHINs] plan, integrate and fund local health services [in their region], including: Hospitals Community Care Access Centres Community Support Services Long-term Care Mental Health and Addictions Services Community Health Centres. (http://www.lhins.on.ca/; retrieved January 5, 2009). 7 The Ontario Health Quality Council (OHQC) is an independent agency funded by the Government of Ontario, established in September 2005, under The Commitment to the Future of Medicare Act, 2004. The Council is an Operational Service Agency that reports to the Minister of Health and Long-Term Care. Section 4 of the Act sets out its mandate as: “to monitor and report to the people of Ontario on: 1. access to publicly funded health services; 2. health human resources in publicly funded health services; 3. consumer and population health status; and 4. health system outcomes; and 5. to support continuous quality improvement (http://www.ohqc.ca/en/mandate.ph). Section 5 of the Act further requires the Council to deliver a yearly report to the Minister on the state of the health system in Ontario, and any other reports required by the Minister. Since its inception in 2005, the Council has published three reports on Ontario's health system (entitled QMonitor). 34
The Culture, Diversity and Equity Project: Literature Review 2.3 HEALTHCARE EQUITY FRAMEWORKS Healthcare Equity frameworks, as conceived here, begin and end with healthcare disparities that have their roots and remedies within the healthcare system. Distinguished by their more narrow focus on healthcare inequities, such approaches can be further subdivided between those that consider structural socio-economic factors in healthcare disparities (e.g. OHQC, 2007), and those that focus more narrowly on the role of culture (most often focusing on ethno-racial dimensions of culture) in explaining and remedying healthcare inequities. A majority of cultural competence frameworks discussed in the literature may be situated in this latter camp. A. Cultural Competence – An Overview American health agencies, service providers and professional organizations have been addressing issues of culture in healthcare services since the 1970s and 1980s as part of a broader effort to reduce health disparities (Betancourt et al., 2002; APA 2003). ‘Culture-centred’ approaches to healthcare have increasingly come to challenge and displace (albeit still dominant) ‘culture-blind’ approaches based on standardized (‘cookie cutter’) services for all, regardless of colour, culture or class (see Figure 2.1 for genealogical map of cultural competence in this respect). Proponents of ‘culture-centred’ approaches argue that such ‘culture-blind’ approaches, while sometimes wellintended, wittingly or unwittingly privilege dominant cultural norms and health practices in health care settings in ways ignoring and/or minimizing the specific healthcare needs and concerns of cultural minorities with deleterious consequences for their health outcomes (APA, 2003). The first generation of ‘culture-centered’ approaches to health emphasized the importance of increasing ‘cultural awareness’ and ‘cultural sensitivity’ among healthcare practitioners. Whereas cultural awareness has been defined as “being conscious of one’s own cultural background and how it relates to our behaviours, thoughts and emotions” (Sue et al., 1998), cultural sensitivity has been defined as “the recognition of personal attitudes, values, beliefs, and practices within one’s own culture and insight into the effect of self on others” (Schim et al., 2005; italics mine). 8 Cultural competence approaches and frameworks, while incorporating such insights, are widely represented as an advance over this earlier focus on attitudes and awareness due to their more ‘action-oriented’ emphasis on ‘competence’ defined in terms of required skills and behaviours (Hernandez et al., 1998; Chestang, 1998). The Ontario Ministry of Children and Youth Services (2005) Achieving Cultural Competency toolkit conveys this distinguishing feature of cultural competence: The term ‘cultural sensitivity’ implies that diversity work is just about people being nice to one another. While having good interpersonal skills is certainly positive, cultural competency involves much more than that. Cultural competency is a professional skill that enables staff and organizations to serve their clients effectively and competently. Beyond simply treating diverse clients with sensitivity, culturally competent organizations actively identify and remove any barriers that prevent them from accessing and participating in the organization’s programs and services. Despite the abovementioned need to examine organizational-level service barriers often mentioned in the cultural competence literature, a majority of this literature continues to focus primarily on individual-level cultural competencies. However, there is a growing body of research on the institutional and systemic dimensions of cultural competency (Cross et al.,’s 1989 being among the first; see for instance Smedley, 2008; Chrisman, 2007; Dreachslin et al., 2007; California Endowment, 2007; Conviser, 2007; Pyles & Kim’s, 2006; Cashin et al., 2006; Beach et al., 2006; Hayes-Bautista, 2003; Anderson et al., 2003; Chin, 2002). 8 Hernandez et al. further add to this definition of cultural sensitivity, “the ability to empathize and identify with the emotional expressions, values and beliefs of someone from a different cultural group” (1998, p.13). 35
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