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

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The Culture, Diversity and Equity Project: Literature Review Culture The term ‘culture’ in cultural competence is meant to “direct attention to the role that culture plays in shaping human behavior”, in particular, health related behaviours, practices and perceptions (Hernandez et al.,1998; citing Cross et al., 1989). Definitions of culture in the cultural competence literature vary surprisingly little, most relying on classical modern anthropological conceptions of culture which foreground ethnic and racial forms of cultural difference. Cross et al.’s (1989) definition of culture, which remains the most widely cited in the literature, is exemplary in this respect. They define culture as “the integrated pattern of human behavior that includes thoughts, communication styles, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious or social group” (1989, p.13). The CLAS (Culturally and Linguistically Appropriate Service) standards developed by the Office of Minority Health employ an almost identical definition. 11 Other definitions of culture contained in the literature include: • “The learned, shared and transmitted values, beliefs, norms and life practices of a particular group of people” (Leininger & McFarland, 2002; cited in Jirwe et al., 2006) • “The structure of behaviors, ideas, attitudes, values, habits, beliefs, customs, language, rituals, ceremonies, and practices of a particular group of people that provides them with a general design for living and patterns for interpreting behavior” (US DHHS, 2001). • “An integrated pattern of learned beliefs and behaviors that can be shared among groups [that] includes thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and customs” (Betancourt, 2002). • “The unique characteristics that all of us possess that distinguish us as individuals and identify us as belonging to a group or groups” (The GTA Diversity and LHINS Working Group, 2008a). More often than not, despite references to groups in general in such definitions, non-ethnic and intra-ethnic forms of cultural difference go unexamined in cultural competence frameworks. Betancourt’s (2002) work is exceptional in this respect, to the extent that it regards culture as being “shaped by multiple influences, including race, ethnicity, nationality, language, and gender” as well as “extend[ing] to socioeconomic status, physical and mental ability, sexual orientation, and occupation, among other factors” (ibid.). Competence Competence is defined by the US DHHS as “having the knowledge, skills, and abilities to be effective in a particular area” (2001, p.2) or having attained a level of mastery (US DHHS, 2001, p. 3). In cross-cultural situations, competence implies “having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities” (OMH, 2001 [CLAS Standards]; Adapted from Cross, 1989). The International Council of Nurses defines competence as “a level of performance, which demonstrates effective application of knowledge, skills, attitudes and judgements” (ICN, 2005). Key Components of Cultural Competence The literature contains numerous portraits of what a culturally competent health care setting looks like and how it functions. In one of the few systematic reviews of the cultural competence literature, Anderson et al. (2003) conclude that a culturally competent healthcare setting should include an appropriate mix of: 11 Culture is defined in the CLAS standards as “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Office of Minority Health, 2001). 38
The Culture, Diversity and Equity Project: Literature Review • A culturally diverse staff that reflects the community(ies) served; • Providers or translators who speak the clients’ language(s); • Training for providers about the culture and language of the people they serve; • Signage and instructional literature in the clients’ language(s) and consistent with their cultural norms; and • Culturally specific healthcare settings. More locally, in the context of the LHINs, the GTA Diversity and LHINs Working Group contend: • A local health integration network (LHIN) that is culturally competent establishes diversity as a corporate strategic priority; reflects the principles of diversity, equity and inclusion in its organizational culture; mirrors the community’s diversity in its governance and staffing; and cultivates inclusive relationships with communities. • Indicators of success for a diverse and culturally competent LHIN include commitment from the top, clarity on what needs to be changed; process internally managed, knowledge-based, and supported by training; commitment reflected in policies and procedures; goals action-oriented and measurable; resources targeted; and built-in accountability in action plan (2008a). Other key components of cultural competence are elaborated in the cultural competence frameworks discussed below. B. Cultural Competence Frameworks Cultural competence frameworks can be broken down into two main kinds: individual core competency-defined frameworks, and intervention-area/level/domain defined frameworks. Whereas the former are generally oriented towards individual health practitioners, outlining the core individual-level competencies comprising ‘cultural competency’, intervention-area/level/domain frameworks are generally oriented towards organizations and systemlevel players, outlining the key domains, areas and levels for health care organizational/system cultural competence intervention. The latter intervention frameworks can be further subdivided between those that are thematically organized and those that are organized by domains for culturally competent intervention I. Individual Competency-Defined Frameworks Sue et al. (1996) Tripartite Framework D. W. Sue, Ivey and Pederson (1996) developed the most widely cited cultural competence conceptual framework for outlining the specific nature of knowledge and skills required to become culturally competent at the individual health practitioner/counsellor level. Their conceptual scheme includes three general competency areas, defined more specifically in the context of counsellor-client relations: • Cultural awareness and beliefs, which pertains to “[p]rovider’s sensitivity to her or his personal values and biases and how these may influence perceptions of the client, client’s problem, and the counselling relationship”. • Cultural knowledge, which pertains to [c]ounsellor’s knowledge of the client’s culture, worldview, and expectations for the counselling relationship”; and • Cultural skills, which relates to “[c]ounsellor’s ability to intervene in a manner that is culturally sensitive and relevant” (Sue, 2006). This tripartite framework informs the American Psychological Association’s Multicultural Guidelines (2003) and numerous other cultural competency training modules and standards of culturally competent care (see Part III on Training and Haarmans, 2004 for more detailed elaboration of competencies within this tripartite framework). 39
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REFERENCES ACAS [Advisory Conciliat
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