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1.6 Cultural Competency of Health Professionals
1.6.1 Definitions
The area of cultural competence in general suffers from a lack of
agreed upon definition, and what constitutes a culturally competent health
professional is similarly unclear. This does not mean that the area is
not well traversed; on the contrary, definitions, resources, training
programs, curricula, and purveyors of all the above abound. The main challenge
for anyone seeking to attain cultural competence is trying to determine
what to be trained in and who should do the training.
Not even the term "cultural competence" is universally accepted.
Experts speak of cultural awareness, cultural diversity, cultural sensitivity,
and other concepts. Terry Cross has done some of the pioneering
work in this area, and many other academics and professionals have built
on this work or developed their own definitions and explanations. The
HRSA Bureau of Primary Health Care has also compiled a list of
cultural competence definitions that it makes available to HRSA grantees.
1.6.2 Curricula and Training Programs
In academic settings, cultural competence training ranges from semester-long
courses to discrete components that are part of a broader course outline.
Robert Like, M.D., faculty member at the University of Medicine
& Dentistry of New Jersey-RWJ Medical School, helped develop curriculum
guidelines for teaching culturally sensitive and competent health care
to family medicine residents and other health professions students. Based
on ten years of development by members of the Society of Teachers of Family
Medicine (STFM), these guidelines are intended to inform both the teaching
and practice of primary health care delivery to culturally diverse populations.
These guidelines have been widely praised, and are possibly the first
formally adopted by a health professions organization.
Noel Chrisman, Ph.D., University of Washington-Seattle, started
a cross-cultural nursing track at the School of Nursing in 1974, and similar
programs exist at the University of Miami, the University of California-San
Francisco, and the University of Utah. Many other health professions training
programs across the country have specialized coursework in this area or
faculty who are conducting research or teaching on cross cultural health
issues. Elena Rios, M.D., of the HHS Office of Women's Health,
is currently surveying medical schools for information on their curricula
or programs, and the Association of American Medical Colleges is
developing cultural competence curricula guidelines for medical schools.
Outside academic settings, continuing education courses and courses
designed for organizations and staff range from a few hours to a few days.
There are hundreds of consultants and trainers teaching cultural competence
to health professionals. Their credentials range from no formal training
to previous experience in human resources diversity training to doctoral
level research and academic training experience in cross cultural issues
(ie. medical anthropology, transcultural psychology, intercultural relations).
Each trainer develops his/her own content and teaching approach, and both
content and approach vary widely. For example, a common method of teaching
cultural competence is to provide a general overview of the role of culture
in health service delivery, and then to spend time focusing on the health
beliefs and behaviors of specific ethnic groups. While this has the effect
of increasing general knowledge about an ethnic population, it can lead
to facile stereotyping if improperly conducted or understood. It has been
suggested that teaching a more universal skills approach to cultural competence
allows practitioners to use general questioning and medical history-taking
techniques on any individual from any ethnic background--a more useful
approach for health facilities that see a wide diversity of clientele.
(See Kleinman, Bloch in Appendix 7). This skill could be combined
with intensive education about specific ethnic groups.
Given the absence of any standardized curriculum elements or evaluative
measures for content or quality, it is impossible to discern the relative
quality of one training program over another, and this is an issue that
must be addressed if we ever expect to truly assess individual or organizational
competence, especially if participation in training becomes one marker
of competence.
Persuading staff and organizations to undertake cultural competence
training can also be problematic. For example, health professionals would
prefer not to sit for long cultural competence training sessions unless
they are required by credentialing bodies or the organizations they work
for. When they do, they are often frustrated, attempting to practice new
skills in what may still be a culturally incompetent organization. And
organizations are often reluctant to take time for organization-wide training,
either because of the cost, the disruption, or the reality it forces them
to face about their institutions that staff training might not completely
address.
Some examples of cultural competence educational programs that have
received praise include training providing by the Cross Cultural Health
Program in Seattle, WA (Appendix 8) ; the Proyecto Informar
curriculum and train-the-trainer module developed by the National
Coalition for Hispanic Health and Human Services Organizations; the
train-the-trainer cultural competence training offered by the HHS Maternal
and Child Health National Center For Cultural Competence; and cultural
competence training for managed care organizations developed by Robert
Like, M.D., Harvard Pilgrim Health Care has designed its own
2.5-3 day program for health professionals and staff that will be piloted
in April 1998.
Conferences and workshops on cultural competence topics are another
way that skills, resources and training are conveyed. They include meetings
designed for: specific clinical settings (e.g.- immunization programs,
managed care organizations); specific ethnic group health characteristics
and issues (e.g.- Hmong cultural profiles and conference by the Center
for Cross Cultural Health in Minnesota); and health status/condition
specific topics (e.g.- ethno-geriatric medicine (Stanford University
Geriatric Education Center), maternal and child health, HIV).
1.6.3 Attitude/Skills Assessments, Tools, Resources
A subset of many cultural competence training programs are tools
for individuals to assess their own cultural competence or the competencies
of staff. So many of these tools have been developed that they have been
reviewed and catalogued by a number of researchers and projects (ie.,
Judge Baker Children's Center, Mathematica Policy Research, Inc.),
although they are not rated against each other. One tool, developed by
Miguel Tirado, Ph.D., was based on extensive research with Chinese
and Latino patients and physicians, although it has been suggested that
the tool is too long for widespread use. Also, a variety of books,
tools and other resources exist to assist health professionals to assess
and manage the cultural issues raised by their clients. These include
books, textbooks, monographs, and reference tools on cross cultural health
care (ie., Lipson, Pedersen, Purnell); cultural profiles developed by
Ethnomed, Center for Cross Cultural Health in Minnesota, COSSMHO, and
a myriad of others developed by community based and national ethnic advocacy
organizations.
It is often difficult and time-consuming to find appropriate tools
for particular circumstances or organizations. Information about resources
is usually spread by word-of-mouth, and individual organizations often
promote their own tools and approaches, making objectivity or independent
analysis is difficult to come by.
Summary Recommendations for 1.6
- Support consensus development and adoption of cultural competence
definitions and corresponding competencies for health professionals,
including curriculum elements. Promote to providers, provider organizations,
health professions associations, health professions educators, and cultural
competence trainers.
- Assist with the development and implementation of cultural competence
course modules or courses into the health professions curricula. Promote
to health professions educators, administrators, and state agencies
overseeing health professions education and certification.
- Support placement of health professions students and prospective students
in internships at health facilities expert in serving multicultural
populations. Include a didactic cross cultural health education component.
- Consider certification of cultural competence trainers.
- Support synthesis of the critical elements and techniques of cultural
competence training programs.
- Disseminate information about model training programs.
- Support cultural competence training and development of cultural profiles
and resources materials for health professionals, especially on topics
related to the needs of recent newcomer groups.
- Promote health professional and provider organization interaction
with local ethnic communities to learn more about community needs and
health issues (ie. ethnic community clinical advisory boards or ethnic/cross
cultural grand rounds).
- Support research and consensus development on whether widespread cultural
competence assessment of health professionals is desirable and whether
such testing, as a part of certification and accreditation, is feasible.
Contacts, Resources, References
1.6
Robert C. Like, MD
UMDNJ RWJ Medical School
Family Medicine
1 Robert Wood Johnson Place
New Brunswick, NJ 08903-0019
732-235-7662
Like@UMDNJ.EDU
Melissa Welch, MD
University of California, San Francisco
School of Medicine
400 Parnassus Avenue
San Francisco, CA 94143-0320
415-502-4212
melissa_welch@ucsfdgim.ucsf.edu
Elena Rios M.D.
National Hispanic Medical Association
1700 17th St., N.W.
Washington, D.C. 20009
202-265-4297
Deborah Danoff, MD, Asst. VP
AAMC-Medical Education Div.
2450 N Street, NW
Washington, DC 20037
202-828-0982
Center for Cross Cultural Health
410 Church St, SE, Suite W227
Minneapolis, MN 55455
612-624-6930
http://www.umn.edu/ccch/
Francesca Gany
NY Task Force on Immigrant Health
NYU School of Medicine
New York, NY 10016
212-263-8783
GANY@IS.NYU.EDU
Miguel Tirado, PhD
California State University-Monterey Bay
100 Campus Center
Seaside, CA 93955
408-582-3967
Mary Thorngren
COSSMHO
1501 -16th Street, NW
Washington, DC 20036-1401
622-5090
Transcultural Health Care: A Culturally Competent Approach, by Larry
Pumell. Philadelphia, PA: F.A. Davis Company, 1997.
Pocket Guide to Cultural Assessment, by Elaine Geissler, 1994, Mosby.
Counseling across cultures, fourth edition. Pedersen, P., Draguns, J.,
Lonner, W. & Trimble, J. E. (Eds.). Thousand Oaks, CA: Sage.(1996)
Culture & Nursing Care: A Pocket Guide. Juliene Lipson et al. UCSF
Nursing Press,1996,
Cultural Diversity in Health and Illness, by Ruth Spector, 1991, Appleton
& Lange.
Transcultural Nursing: Concepts, Theories, Research, and Practices, by
Madeleine Leininger, 1995, McGraw Hill and Greydon Press.
A Practical Guide for the Assessment of Cultural Competence in Children's
Mental Health Organizations, by Monica Roizner, Ed.D., Judge Baker Children's
Center,1996
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