The need for people to effectively deal with cultural differences is widely recognized in the concepts of cultural awareness, sensitivity, and competence, which involve knowledge of intercultural skills necessary to manage cultural differences effectively. Cultural aware- ness involves an understanding of the importance of cultural differences. Cultural sensi- tivity goes beyond awareness to provide an appropriate response to cultural differences:
for instance, knowing that people from some cultures do not like to look directly into another’s eyes. Cultural competence refers to having further capabilities to deal with dif- ferences effectively, generally implying the ability to function effectively in the context of everyday life of a culture. Cultural responsiveness falls between sensitivity and compe- tence; in nursing care, it is conceptualized as the ability to respond to a patient’s care needs in a way that is congruent with the patient’s cultural expectations. Cultural profi ciency involves the ability to transfer cultural knowledge and skills to others, providing others with the skills to effectively manage cultural differences. Cultural competence involves personal, interpersonal, and organizational skills, including behaviors, attitudes, and poli- cies that enable people to work effectively with the various cultural groups they serve.
Cultural competence has several major dimensions:
Knowledge of the general dynamics of culture and of cross-cultural relations Skills in intercultural adaptation and relations
Specialty-specifi c skills for professional relations
Culture-specifi c knowledge of behaviors and beliefs of specifi c groups
The ability to deal effectively with cultural issues in clinical settings can be conceptu- alized as three major factors: capacity level, specialty area, and specifi c cultural groups (Castro, 1998). There is a range of cultural capacity levels such as awareness, sensitivity, and competence. An individual’s cultural competency varies across different ethnic groups as well as specialty areas (e.g., mediation, assessment, treatment, research, community intervention, policy formation). An individual’s cultural capacities can even differ across segments of a specifi c ethnic group. One may be culturally profi cient in relations with elderly Mexican Americans but lack understanding of and empathy for younger Mexican Americans or monolingual Spanish-speaking Mexican immigrants.
Cultural competence in clinical care also involves professional attitudes and clinical skills, combining them with a knowledge of cultural systems and their effects on behavior and opportunities (Chrisman and Zimmer, 2000). The professional attitudes necessary for effective cross-cultural clinical relations begin with an awareness and acknowledgment of the effects of culture on one’s self and clinical practice, combined with the knowledge of how to adapt to these infl uences in self and others in the context of intercultural relations.
These include the ability to adapt to the effects of prejudice, ethnocentrism, cognitive attri- bution, culture shock, transference, and discrimination. A culturally skilled clinician can respond to the feelings of discrimination and prejudice that clients may harbor, pre- venting these normal but nonproductive intercultural dynamics from impeding clinical care. These reactions can be countered with skills that include anthropological approaches
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discussed below that facilitate the understanding of clients’ cultures and their health behav- iors and beliefs.
Clinical skills depend on intercultural abilities for carrying out culturally competent assessments. Cultural competency is embodied in the elicitation of the explanatory model to obtain clients’ concerns, enabling the negotiation of an acceptable treatment plan that incorporates both clients’ and providers’ perspectives. This general cultural competence involves knowledge of the ways culture in general affects intergroup interactions and an ability to apply cultural knowledge, cultural resources (translators, interpreters), and intercultural skills to resolve the diffi culties presented by cultural differences. General cultural competency includes an awareness of the dynamics of cross-cultural interactions and the ability to adopt perspectives that facilitate those interactions, including cultural awareness, cultural relativism , confl ict resolution, and cross-cultural negotiation.
Specifi c cultural competencies refer to abilities in relating to particular cultures (e.g., Mexican Americans or Hmong immigrants; see Winkelman 1998, 2006a). Specifi c cul- tural competencies require a long time to develop and are generally beyond the reach of providers unless they are native members of that culture or spend long periods engaged with the culture in both the clinic and everyday life. Providers are more likely to learn how to incorporate aspects of cultural knowledge into culturally aware, sensitive, or responsive care than to develop true cultural competency.
Even achieving culturally responsive care requires a development of cultural compe- tency (Culhane-Pera et al., 2003). Providers require knowledge of cultural beliefs, values, and attitudes for an appropriate understanding of patients. Acquiring cultural competence involves several major areas of development (see Hogan-Garcia, 2003; Chrisman and Zimmer, 2000):
Self-awareness of personal cultural features and level of personal cultural competency development
Personal and interpersonal skills for managing the dynamics of intercultural relations Knowledge of cultural systems and specifi c cultures
To facilitate that learning and development, the next sections describe
1. The general levels of cultural competence that were assessed in Chapter One 2. A range of skills for intercultural adaptation. Chapter Four provides additional
models for understanding culture and psychocultural development.
Levels of Cross-Cultural Competence
Cross-cultural effectiveness ranges from a dislike and misunderstanding of out-groups through varying levels of appreciation of the nature and signifi cance of cultural differ- ences. This learning may culminate in multicultural competencies and bicultural identities (Bennett, 1993; Bandlamudi, 1994; Winkelman, 1999, 2001c). These involve increasing degrees of awareness of cultural infl uences on the self and the abilities to adapt effectively to cultural differences. The following categories explain the scales presented in Chapter One in Self-Assessment 1.4. Cross-Cultural Development.
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Ethnocentrism People begin in an ethnocentric condition, ignorant of the relation of cul- ture to behavior and self, lacking competency in understanding cross-cultural issues, and lacking appreciation of the effects of historical and contemporary racism. An exaggerated sense of cultural superiority impairs relations with other groups and limits awareness of cultural differences. Attitudes may be characterized by a belief that other people behave differently because they are stupid or inferior. Bennett (1993) considers the purest form of ethnocentrism to involve denial and ignorance of differences, normally maintained through separation from others who are different. The ethnocentrism phase suffers from a lack of awareness of cultural differences and their relevance. Others are unrefl ectively evaluated from one’s own cultural perspective. One’s cultural perspective is not recog- nized as such; rather, it is seen as a universally valid system of evaluation. For instance, a physician might believe that only biomedicine is established as effective in treating diseases and dismiss the possibility that other ethnomedical systems have general effec- tiveness and validity.
Universalism Universalism involves minimization, a perspective that rejects fundamental differences across cultures and, instead, emphasizes human similarities. Cultural differ- ences are trivialized, manifested in the idea that “everybody’s basically the same” and that you should “treat everybody the same.” This perspective is naïve regarding the importance of cultural differences, ignorant to the fact that one’s perspectives about human universal- ity and sameness are based in one’s own cultural assumptions. In the minimization stage, people often assume that being one’s “natural self” and expressing genuineness can achieve success in intercultural relations. This attitude emphasizes the appropriateness of one’s own cultural behavior in intercultural contexts, an ethnocentrism that reduces the ability to recognize and incorporate an understanding of cultural differences. The minimization pro- cess may be manifested in a physical universalism, where human physical and biological commonalities are emphasized while the culturally unique aspects that direct behavior are ignored or discounted. In transcendental universalism, despite behavioral differences, one believes that all humans conform to some single transcendental principle. This is often embodied in religious universalism in which a single god is believed to have created all humans and demands their adherence to the associated religion. Universalistic perspec- tives in biomedicine include ideas of standard dosages by body weight or normal ranges of weight or laboratory results.
Cultural Awareness and Acceptance Awareness of the importance of cultural differences and knowledge of their infl uences on behavior are the beginning of intercultural adapta- tion and effectiveness. This awareness includes self-awareness of cultural values and how they affect one’s behavior. Awareness of cultural infl uences on beliefs, behavior, and inter- personal relations helps reduce cross-cultural misunderstandings and provides a basis for developing appropriate approaches to culturally different others. For instance, knowing that most Hispanics have two last names can provide an understanding of why a person might give a last name that is different from that given on the previous visit if you only ask for one of them or ask for the mother’s versus the father’s last name. Such awareness can facilitate record keeping.
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Adaptation (Cultural Sensitivity) Cultural sensitivity involves the ability to accommo- date to cultural differences through appropriate adaptations. Adaptation involves making appropriate adjustments for interactions with people from other cultures by adjusting behavior and communication to cultural differences. This development of cultural sensi- tivity is acquired through using knowledge about differences to direct the development of new kinds of behavior and communications in relationships with members of other cultures, leading to culturally appropriate behaviors. Cultural sensitivity leads to ques- tioning one’s own assumptions and replacing them with assumptions from other cultures to appropriately interpret their members’ behaviors. Cultural sensitivity recognizes both specifi c cultural characteristics and intracultural (within-group) differences. Empathy develops as one learns how to view reality from the other person’s perspective, a conse- quence of the intentional shift of interpretative and evaluative frameworks. The abandon- ment of one’s habitual cultural frames of reference enables the recognition of many valid cultural forms and behaviors, creating a philosophical commitment to accept many dif- ferent cultural defi nitions and constructions of reality (pluralism). General intercultural sensitivity engages a commitment to maintain positive attitudes toward all cultural differ- ences and an attitude of learning to adapt to them constructively.
Cultural Competence Cultural competence involves an ability to work effectively with clients from a cultural group based on an understanding of cultural values, beliefs, and behaviors. Culturally competent individuals are capable of using knowledge of cultural patterns to understand priorities, communicate empathy and acceptance, be responsive to individual and community needs, and work effectively with cultural groups to develop culturally relevant interventions. Cultural competence includes the ability to use cultur- ally relevant communication skills, motivational strategies, and organizational approaches (Castro, 1998). Cultural competence generally implicates a personal bicultural develop- ment as one acquires the ability to identify with and relate effectively to another cultural group based on their expectations and perspectives. Cultural competence generally devel- ops through relationships with members of other cultures that produce personal growth, leading to a transformation of self-identifi cation.
Marginalization and Biculturalism Biculturalism involves developments where an individual has internalized two or more different cultures’ expectations. This may or may not involve the ability to function effectively in those different cultures. Some bicultural persons are marginalized, feeling a lack of identity and acceptance in either cultural group. Some are intermediaries, functioning effectively in two cultural groups but keeping those cultural lives separate. Bicultural people have skills and perspectives that allow them to adapt effectively to people from different cultural groups and mediate effectively between the cultures.
Integration Integration involves transcending the limitations of the previous cultural self, producing a new identity that incorporates the other culture. Integration produces a person who defi nes his or her identity in relationship to specifi c cultural contexts. Contextual evaluation emerges as a skill for managing choice in the problematic contexts produced by ethnorelativism, to shift cultural context in evaluating situations using a variety of cultural
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perspectives. The evaluation of context is key to decisions about whether a certain behavior is moral. Personal identity is also contextual, shifting as a function of the situation, the context created by others, and personal goals. Constructive marginality may provide a subsequent stage of development, one where the individual attempts to suspend the use of cultural frames of reference. This person constantly questions assumptions and rejects absolute norms of what is right and wrong, operating outside the framework of any specifi c reference group. Bennett (1993) considers constructive marginality a powerful position from which to serve as a mediator without unrefl ective adherence to any reference group and capable of restraining excesses of ethnocentrism and value-based confl ict.
Cultural Profi ciency Cultural profi ciency involves the ability to teach and direct others effectively in their development of culturally sensitive and competent approaches. Cul- tural profi ciency extends cultural competence in a social activist approach that involves the community in developmental projects that enhance health resources. This proactive approach engages the cultural group, health organizations, and the broader community in the design, development, and delivery of culturally relevant services. Cultural profi - ciency uses a “strengths” approach that recognizes community health and helping resources and strengthens them by incorporating them in community health programs.
Individuals and health organizations need to acquire profi ciency to engage in a proactive stance of training and preparation for managing cultural differences.
Organizational Cultural Competence
The Offi ce of Minority Health of the U.S. Department of Health and Human Services has issued National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care (Offi ce of Minority Health, 2000). These indicate areas of organizational competence (also see items 61 through 75 in Self-Assessment 1.4. Cross-Cultural Devel- opment). Principal aspects of organizational cultural and linguistic competence are embodied in the following principles:
Continuing organizational assessment to integrate throughout programs culturally sensitive and linguistically competent services and assessments
Inclusion in client records of pertinent information regarding cultural background and language preference
Provision of understandable health care that is respectful of and compatible with cli- ents’ cultural health beliefs
A culturally diverse staff, representative of the community, at all levels of the organization
Language services needed by the community that are provided by bilingual staff and professional translators
Provision of written materials and signs in the languages used by the local community Educational services that train staff in providing services that are culturally sensitive and linguistically appropriate
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A strategic plan with clear goals and policies that support culturally appropriate services Performance of needs assessments of local communities and engagement of local communities in collaborative partnerships in developing appropriate services Provision of culturally sensitive grievance and confl ict resolution services for clients Provision of information to the public about cultural competency standards of the organization and efforts to implement them
Other aspects of organizational cultural competence are discussed in Chapter Four regarding assessment processes and community involvement and in Chapter Eight regard- ing the activist role of anthropology, an advocacy approach that engages with health and political institutions to change them in ways to enhance the quality of services provided.
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Mikel Hogan
Mikel Hogan, Ph.D., during the late 1970s coordinated a program funded by the California State Department of Education that implemented desegregation plans for twenty-six school districts. From 1982 to 1993, she was fi eld director for the Offi ce of Civil Rights and the Department of Education, which conducted civil rights evaluations of school districts through- out the state. In 1989 she designed and implemented a cultural competence training pro- gram offered as a thirty-four-hour certifi cate program through the Offi ce of Extended Education at California State University, Fullerton (CSUF). Successful graduates received certif- icates in cultural competence training in such work sectors as health, business, education, government, nonprofi t, and human services. Since 1983 she has taught courses in anthropol- ogy and human services, which is an applied bachelor of science degree that integrates theory and practice in the delivery of services. She is currently a professor and chair of the Human Services Department at CSUF. As an applied anthropologist, Hogan has taught courses in human services; medical anthropology; educational anthropology; applied and urban anthro- pology; and race, ethnic, and gender relations for more than twenty years.
Hogan’s work in various applied anthropology projects in education, civil rights, and cul- tural competence provided the fi eld experience that culminated in the publication of Four Skills of Cultural Diversity Competence (Hogan, 2007). Her knowledge of how to implement cultural awareness, understanding, and skills grew to include a direct and highly specifi c problem identifi cation and problem-solving approach to cultural diversity issues in medical (and nonmedical) work organizations.
Her ethnographic research on cultural issues and problems in medical facilities and the intervention programs she designed to address them integrate the lessons of medical anthropol- ogy into the health care delivery system, resulting in better care for everyone. At another level, the data from her research promote the articulation of a theory of effective medical practice.
PRACTITIONER PROFILE
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