_____________________________________________________________ Cultural Competence: An Overview
DISCRIMINATION Discrimination has traditionally been viewed as the outcome of prejudice [7]. It encompasses overt or hidden actions, behav- iors, or practices of members in a dominant group against members of a subordinate group [8]. Discrimination has also been further categorized as lifetime, which consists of major discreet discriminatory events, or everyday, which is subtle, continual, and part of day-to-day life and can have a cumulate effect on individuals [9]. DIVERSITY Diversity “encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics” [10]. Diversity is often incorrectly conceptual- ized into singular dimensions as opposed to multiple and intersecting diversity factors [11]. INTERSECTIONALITY Intersectionality is a term to describe the multiple facets of identity, including race, gender, sexual orientation, religion, sex, and age. These facets are not mutually exclusive, and the meanings that are ascribed to these identities are inter-related and interact to create a whole [12]. This term also encompasses the ways that different types and systems of oppression intersect and affect individuals. PREJUDICE Prejudice is a generally negative feeling, attitude, or stereotype against members of a group [13]. It is important not to equate prejudice and racism, although the two concepts are related. All humans have prejudices, but not all individuals are racist. The popular definition is that “prejudice plus power equals racism” [13]. Prejudice stems from the process of ascribing every member of a group with the same attributes [14]. RACISM Racism is the “systematic subordination of members of tar- geted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power” [15]. Racism is perpetuated and reinforced by social values, norms, and institutions. There is some controversy regarding whether unconscious (implicit) racism exists. Experts assert that images embedded in our unconscious are the result of socialization and personal observations, and negative attributes may be unconsciously applied to racial minority groups [16]. These implicit attributes affect individuals’ thoughts and behaviors without a conscious awareness. Structural racism refers to the laws, policies, and institutional norms and ideologies that systematically reinforce inequities, resulting in differential access to services such as health care, education, employment, and housing for racial and ethnic minorities [17; 18].
INTRODUCTION Culturally competent care has been defined as “care that takes into account issues related to diversity, marginalization, and vulnerability due to culture, race, gender, and sexual orienta- tion” [1]. A culturally competent person is someone who is aware of how being different from the norm can be marginaliz- ing and how this marginalization may affect seeking or receiving health care [1]. To be effective cross-culturally with any diverse group, healthcare professionals must have awareness, sensitiv- ity, and knowledge about the culture involved, enhanced by the use of cross-cultural communication skills [2; 3]. Healthcare professionals are accustomed to working to pro- mote the healthy physical and psychosocial development and well-being of individuals within the context of the greater community. For years, these same professionals have been iden- tifying at-risk populations and developing programs or making referrals to resources to promote the health and safety of at-risk groups. But, because of general assumptions, persistent stereo- types, and implicit and explicit biases, culture-related healthcare disparities persist [2]. In the increasingly diverse landscape of the United States, assessing and addressing culture-related bar- riers to care are a necessary part of health care. This includes seeking to improve one’s cultural competence and identifying blind spots and biases.
DEFINITIONS
CULTURAL COMPETENCE In healthcare, cultural competence is broadly defined as practi- tioners’ knowledge of and ability to apply cultural information and appreciation of a different group’s cultural and belief systems to their work [4]. It is a dynamic process, meaning that there is no endpoint to the journey to becoming cultur- ally aware, sensitive, and competent. Some have argued that cultural curiosity is a vital aspect of this approach. CULTURAL HUMILITY Cultural humility refers to an attitude of humbleness, acknowl- edging one’s limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others’ cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [5]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique [6].
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