Rethinking cultural competence
TL;DR: This issue of Transcultural Psychiatry presents papers from the McGill Advanced study Institute in Cultural Psychiatry on ‘‘Rethinking Cultural Competence from International Perspectives,’’ which was held in Montreal, April 27 and 28, 2010, and shows how conceptual analysis and critique of cultural competence can point toward ways to improve the cultural responsiveness, appropriateness and effectiveness of clinical services, and in doing so contribute to reducing health disparities.
Abstract: In recent years, cultural competence has become a popular term for a variety ofstrategies to address the challenge of cultural diversity in mental health services.This issue of Transcultural Psychiatry presents papers from the McGill AdvancedStudy Institute in Cultural Psychiatry on ‘‘Rethinking Cultural Competencefrom International Perspectives,’’ which was held in Montreal, April 27and 28, 2010. Selected papers from the meeting have been supplemented withother contributions to the journal that fit the theme. Taken together, thesepapers show how conceptual analysis and critique of cultural competence canpoint toward ways to improve the cultural responsiveness, appropriateness andeffectiveness of clinical services, and in doing so contribute to reducinghealth disparities.Cultural diversity poses challenges to mental health services for many reasons.Culture influences the experience, expression, course and outcome of mentalhealth problems, help-seeking and the response to health promotion, preventionor treatment interventions. The clinical encounter is shaped by differencesbetween patient and clinician in social position and power, which are associatedwith differences in cultural knowledge and identity, language, religion and otheraspects of cultural identity. Specific ethnocultural or racialized groups may sufferhealth disparities and social disadvantage as a result of the meanings and mater-ial consequences of their socially constructed identities. In some instances, cul-tural processes may create or constitute unique social and psychological problemsor predicaments that deserve clinical attention. In culturally diverse societies,the dominant culture, which is expressed through social institutions, includingthe health care system, regulates what sorts of problems are recognized and whatkinds of social or cultural differences are viewed as worthy of attention.A large literature shows the importance of social determinants of healthincluding social status, employment, education, wealth and social support
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01 May 2014
TL;DR: The publication of Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice marks a watershed in the treatment of Indigenous mental health issues.
Abstract: Editors: Nola Purdie, Pat Dudgeon and Roz Walker Foreword by Tom Calma ‘Designed for practitioners and mental health workers, as well as students training to be mental health workers, I am confident that the publication of Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice marks a watershed in the treatment of Indigenous mental health issues.’ Tom Calma Aboriginal and Torres Strait Islander Social Justice Commissioner
570 citations
TL;DR: A definition for cultural safety is proposed that is more fit for purpose in achieving health equity, and the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development are clarified.
Abstract: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.
391 citations
TL;DR: Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.
Abstract: AIMS: This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees. METHODS: We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed. RESULTS: Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored. CONCLUSIONS: Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria. Language: en
281 citations
Cites background from "Rethinking cultural competence"
...Clinical assessment will be more accurate and appropriate when it integrates questions on the local modes of expressing distress and understanding symptoms (Nasir & Abdul-Haq, 2008; Kirmayer, 2012)....
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...DE, Kirmayer LJ (2015). DSM-5® Handbook on the Cultural Formulation Interview....
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TL;DR: Attention to the nature of clinical evidence and to the importance of cultural context in illness and healing can help both EBP and CC move beyond their current limitations and contribute to the evolution of mental health services that respond effectively to cultural diversity.
238 citations
Cites background from "Rethinking cultural competence"
...without changes at other levels including the structure of health care systems and institutions and the models of intervention themselves (Alegria et al., 2010; Bhui, Ascoli, & Nuamh, 2012; Kirmayer, 2012)....
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...An added critique of cultural competence comes from the concern that focusing on practitioners’ skills serves to further accentuate the power imbalance in the clinical encounter (Kirmayer, 2012)....
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...…may be insufficient to change clinicians actual behavior or improve the quality of services without changes at other levels including the structure of health care systems and institutions and the models of intervention themselves (Alegria et al., 2010; Bhui, Ascoli, & Nuamh, 2012; Kirmayer, 2012)....
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Book•
02 Nov 2002
TL;DR: In this article, a panel of experts documents this evidence and explores how persons of color experience the health care environment, examining how disparities in treatment may arise in health care systems and looking at aspects of the clinical encounter that may contribute to such disparities.
Abstract: Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients’ and providers’ attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider–patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.
6,185 citations
Book•
05 Mar 2009TL;DR: The "The Spirit Level" as mentioned in this paper is a study of social and environmental problems in a more equal and unequal society, and it is shown that many of these problems are more likely to occur in a less equal society.
Abstract: Large inequalities of income in a society have often been regarded as divisive and corrosive, and it is common knowledge that in rich societies the poor have shorter lives and suffer more from almost every social problem. This groundbreaking book, based on thirty years' research, demonstrates that more unequal societies are bad for almost everyone within them - the well-off as well as the poor. The remarkable data the book lays out and the measures it uses are like a spirit level which we can hold up to compare the conditions of different societies. The differences revealed, even between rich market democracies, are striking.Almost every modern social and environmental problem - ill-health, lack of community life, violence, drugs, obesity, mental illness, long working hours, big prison populations - is more likely to occur in a less equal society. The book goes to the heart of the apparent contrast between the material success and social failings of many modern societies. "The Spirit Level" does not simply provide a key to diagnosing our ills. It tells us how to shift the balance from self-interested 'consumerism' to a friendlier and more collaborative society. It shows a way out of the social and environmental problems which beset us and opens up a major new approach to improving the real quality of life, not just for the poor but for everyone. It is, in its conclusion, an optimistic book, which should revitalise politics and provide a new way of thinking about how we organise human communities.
2,387 citations
Additional excerpts
...Email: laurence.kirmayer@mcgill.ca (Wilkinson & Pickett, 2009)....
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TL;DR: Cultural humility is proposed as a more suitable goal in multicultural medical education that incorporates a lifelong commitment to self-evaluation and self-critique and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.
Abstract: Researchers and program developers in medical education presently face the challenge of implementing and evaluating curricula that teach medical students and house staff how to effectively and respect- fully deliver health care to the increasingly diverse populations of the United States. Inherent in this challenge is clearly defining educational and training outcomes consistent with this imperative. The traditional notion of competence in clinical training as a detached mastery of a theoretically finite body of knowledge may not be appropriate for this area of physician education. Cultural humility is proposed as a more suitable goal in multicultural medical education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partner- ships with communities on behalf of individuals and defined populations.
2,277 citations
"Rethinking cultural competence" refers background in this paper
...Various alternative approaches to addressing cultural diversity have been proposed, including the constructs of cultural safety (Papps & Ramsden, 1996) and cultural humility (Tervalon & Murray-Garcia, 1998)....
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Book•
01 Jan 2003
TL;DR: In this article, Fraser and Honneth set out to advance the discussion in political philosophy regarding the increasingly polarized political positions of redistribution or recognition, or more simply, class politics versus identity politics.
Abstract: In this debate political philosophers Fraser and Honneth set out to advance the discussion in political philosophy regarding the increasingly polarized political positions of redistribution or recognition, or more simply, class politics versus identity politics.
1,966 citations
"Rethinking cultural competence" refers background in this paper
...Recognition of cultural diversity coupled with analysis of the structural sources of inequality offers us the best way to understand and redress the inequities and injustices that are ignored, or even aggravated, by culturally-blind health care (Fraser & Honneth, 2003)....
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TL;DR: A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of racial/ethnic disparities in health and improve care for all Americans.
Abstract: OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care.
METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers.
RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care.
CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.
1,709 citations
"Rethinking cultural competence" refers background in this paper
...‘‘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 et al., 2003, p. v)....
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