_____________________________________________________________ Cultural Competence: An Overview
Experts have recommended that a structural or critical theoreti- cal perspective be integrated into core competencies in health- care education to teach students about implicit bias, racism, and health disparities [32]. This includes [32]: • Values/ethics: The ethical duty for health profession- als to partner and collaborate to advocate for the elimination of policies that promote the perpetuation of implicit bias, racism, and health disparities among marginalized populations. • Roles/responsibilities: One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one’s own position in this structure. • Interprofessional communication: Ongoing discussions of implicit bias, perspective taking, and counter- stereotypical dialogues should be woven into day-to-day practice with colleagues from diverse disciplines. • Teams/teamwork: Health professionals should develop meaningful contacts with marginalized communities in order to better understand whom they are serving. Adopting approaches from the fields of education, gender studies, sociology, psychology, and race/ethnic studies can help build curricula that represent a variety of disciplines [33]. Students can learn about and discuss implicit bias and its impact, not simply from a health outcomes perspective but holistically. Skills in problem-solving, communication, leader- ship, and teamwork should be included [33].
• Safe housing, transportation, and neighborhoods • Racism, discrimination, and violence • Education, job opportunities, and income • Access to nutritious foods and physical activity oppor- tunities • Polluted air and water • Language and literacy skills Social determinants of health also contribute to wide health disparities and inequities. For example, people who lack access to grocery stores with healthy foods are less likely to have good nutrition, which raises the risk of heart disease, diabetes, and obesity and lowers life expectancy compared with those who have easier access to healthy foods [34]. Promoting healthy choices will not eliminate these and other health disparities. Instead, public health organizations and their partners must take action to improve the conditions in people’s environments. Healthcare providers play a role by identifying factors affecting the health of their patients, providing resources (when appropriate), and advocating for healthy environments.
BARRIERS TO PROVIDING CARE
Culturally diverse patients experience a variety of barriers when seeking health and mental health care, including: • Immigration status • Lower socioeconomic status • Language barriers • Cultural differences • Lack of or poor health insurance coverage • Fear of or experiences with provider discrimination • Mistrust of healthcare systems Such obstacles can interfere with or prevent access to treatment and services, compromise appropriate referrals, affect compli- ance with recommendations, and result in poor outcomes. Culturally competent providers build and maintain rich refer- ral resources to meet patients’ assorted needs. Encountering discrimination when seeking health or mental health services is a barrier to optimal care and contributor to poorer outcomes in under-represented groups. Some providers will not treat patients because of moral objections, which can affect all groups, but particularly those who are gender and/or sexual minorities, religious minorities, and/or immigrants. In fact, in 2016, Mississippi and Tennessee passed laws allowing health providers to refuse to provide services if doing so would violate their religious beliefs [35]. However, it is important to remember that providers are obligated to act within their profession’s code of ethics and to ensure patients receive the best possible care.
SOCIAL DETERMINANTS OF HEALTH
Social determinants of health are the conditions in the environ- ments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. Healthy People 2030 groups social determinants of health into five categories [34]: • Economic stability
• Education access and quality • Health care access and quality • Social and community context • Neighborhood and built environment
These factors have a major impact on people’s health, well- being, and quality of life. Examples of social determinants of health include [34]:
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