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

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The Culture, Diversity and Equity Project: Literature Review Towards a definition of Cultural Competence Definitions of cultural competence vary in regards to (1) the extent to which they include levels of analyses beyond the individual level (e.g. considering agency and system-levels of analysis and practice); (2) whether they describe cultural competency in static or dynamic terms (as an ongoing process); and (3) the scope of diversity groups and cultural practices considered or implied under the umbrella of cultural competence. The most widely cited and adapted definition of cultural competence is that of Cross et al. (1989), who define cultural competence as “a set of congruent behaviors, attitudes and policies that come together in a system or agency or among professionals that enables that system, agency, or professionals to work effectively in crosscultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989). 9 Notably, this definition informs the (2001) National Standards for Culturally and Linguistically Appropriate Services (CLAS) issued by the US Department of Health and Human Services’ Office of Minority Health. Other definitions of cultural competence addressing agency/system-levels of analysis include the following: • The ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, 2002). • “The ability of organizations and systems to function and perform effectively in cross-cultural situations” (Vancouver Ethnocultural Advisory Committee of Ministry for Children and Families, 1998; GTA Diversity and LHINS Working Group, 2008a). • “Behaviors, attitudes, and policies that can come together on a continuum: that will ensure that a system agency, program or individual can function effectively and appropriately in diverse cultural interactions and settings” (US Department of Health and Human Services, 2002). • “Ongoing commitment or institutionalization of appropriate practices and policies for diverse populations” (Brach and Fraser, 2000). • “The ability to demonstrate skills and knowledge which enable a person to work effectively across cultures; the ability to provide mental health treatment within the cultural framework of the consumer; the ability to provide effective services to people of a specific cultural background, including one different from the provider” (Substance Abuse and Mental Health Services Administration, 1997, p.27).10 Michael Goh (2005) describes the Substance Abuse and Mental Health Services Administration’s definition as ‘the most comprehensive definition of cultural competence’ to date. Another comprehensive definition of cultural competence is offered by the Cultural competence workgroup for the projects for assistance in transition from homelessness. They define cultural competence as: an ongoing and evolving process that comprises knowledge attainment and the development of behaviors, attitudes, policies, and practices that come together in a system of care enabling agencies, programs, and individuals to increase access to services and to develop or adapt services that are appropriate to specific cultural needs (2002, Report of the Cultural Competence Workgroup for the Projects for Assistance in Transition from Homelessness). 9 The original 75 page monograph published by the Child and Adolescent Service System Program (CASSP) National Technical Assistance Center at the Georgetown University Child Development Center was entitled Towards A Culturally Competent System of Care, Volume I: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally. Cross et al.’s (1989) definition also informs a recent (2005a) Canadian study by Olavarria et al. entitled Standards of Organizational Cultural Competence for Community Health and Social Service Organizations. 10 Michael Goh (2005) describes the Substance Abuse and Mental Health Services Administration’s definition as ‘the most comprehensive definition of cultural competence’ to date. 36
The Culture, Diversity and Equity Project: Literature Review This definition has the benefit of explicitly foregrounding the multiple necessary levels of cultural competence praxis while also accounting for the ongoing, always-in-process nature of becoming culturally competent. The definition, moreover, informs the (2008) Supportive Housing and Diversity (SHAD) Toolkit and report on culturally competent best practice for supportive housing provision. A minority of cultural competence frameworks and definitions have tried to expand the meaning of cultural competence to more directly address issues and inequities of power. The American College of Health Association’s definition of cultural competence is exemplary in this respect (albeit remaining restricted to an individual-level of analysis). According to the ACHA: The term "cultural competency" refers to a long-term, developmental process that moves beyond "cultural awareness" (the knowledge about a particular group primarily gained through media resources and workshops) and "cultural sensitivity" (knowledge as well as some level of direct experience with a cultural group other than one's own). Cultural competency is an engaging, life-long journey of expanding your horizons, thinking critically about power and oppression, and behaving appropriately. Culturally competent individuals have a mixture of beliefs/attitudes, knowledge/experience, and skills that help them to establish trust/rapport and communicate effectively with others (Retrieved 29-01-2009 from http://www.acha.org/about_acha/culture_comp_alist.cfm; emphasis mine). This definition also depicts cultural competence as an ongoing process and continuum rather than destination that can be finally achieved or arrived at once and for all (Anand, 1999; see also Rosenjack Burchum, 2002; Campinha- Bacote, 1999). The literature contains several organizational developmental models of cultural competence outlining the evolutionary stages along this continuum (see Jordan, 1998; Wong, 2007; Anand, 1999). The cultural competence continuum model of Cross et al. (1989) remains the most formative among these. Another comprehensive definition of cultural competence, in terms of the scope of diversity groups mentioned, is the Child Welfare League of America’s definition which defines cultural competence as the “ability of individuals and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic backgrounds, sexual orientations, and faiths and religions, in a manner that recognizes, affirms, and values the worth of individuals, families and communities, and protects and preserves the dignity of each” (cited in Ontario Ministry of Children and Youth Services 2005 Achieving Cultural Competency). This definition is clearly articulated within a human rights moral-political idiom and a larger social service context. It is also distinguishable from most other cultural competence definitions and approaches by its attention to non-ethno-racial dimensions of cultural difference. In the clinical and nursing literatures, cultural competence is primarily defined in terms of individual competencies, attitudes, skills and behaviours (see Campinha-Bacote, 1999; Leininger, 1999; also see Haarmans, 2004 for summary of this literature). Jirwe et al. (2006), in this respect, describe cultural competence as “the multi-cultural knowledge base that nurses need, together with the ability to apply such knowledge in practice”. Bush (2000) likewise defines cultural competency as a “respect for, and understanding of, diverse ethnic and cultural groups, their histories, traditions, beliefs, and value systems” in the provision and delivery of services. Leong (1998) further distinguishes between cultural competence and “cross-cultural competence”, defining cultural competence as “[t]o be able to adapt and function effectively in one’s [own] culture.” (p.3; cited in Haarmans 2004). Leong makes the argument that what is really at issue in much of the cultural competence literature is “cross-cultural competence, i.e., the knowledge and skills to relate and communicate effectively with someone from another culture different from your own” (ibid.). Other theorists and scholars have argued that all encounters are cross-cultural in nature, due to the multiple axes of culture and difference (e.g. race, gender, class, sexual orientation, religion, differential abilities etc.) that culturally separate persons from one another in general, and the differing insights and aptitudes of clinicians and clients, in specific, owing to the formal training and education of the former (Dolhun, Munoz & Grumbach, 2003; APA, 2002; Tsang & George, 1998; Sue, 2001). Such training, critics suggest, amounts to a distinctive form of enculturation in itself. 37
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