Cultural Competence: An Overview _____________________________________________________________
practitioners to move assessment and practice away from a pathology-oriented model and instead acknowledge the com- plex transactions of the individual’s movement within, among, and between various systems [95]. Practitioners who engage in culturally sensitive assessment nonjudgmentally obtain information related to the patient’s cultural beliefs, overall perspective, and specific health beliefs [96]. They also allow the patient to control the timing [97]. The goal is to avoid the tendency to misinterpret health concerns of ethnic minority patients. Panos and Panos have developed a qualitative culturally sensitive assessment process that focuses on several domains [96]. Each domain includes several questions a practitioner may address in order to ensure that he or she is providing culturally responsive care. Alternatively, Kleinman suggests that the practitioner ask the patient what he or she thinks is the nature of the problem. He highlights the following types of questions that may be posed to the patient [98]: • Why has the illness/problem affected you? • Why has the illness had its onset now? • What course do you think the illness will follow? • How does the illness affect you? • What do you think is the best or appropriate treatment? What treatment do you want? • What do you fear most about the illness and its treatment? Similar to Kleinman’s culturally sensitive assessment questions, Galanti has proposed the 4 Cs of Culture [99]: • What do you call the problem? • What do you think caused it? • How do you cope with the problem? • What questions or concerns do you have about the problem or treatment? Pachter proposed a dynamic model that involves several tiers and transactions, similar to Panos and Panos’ model [100]. The first component of Pachter’s model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional must be willing to acknowledge that they do not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups they come in contact with. Reading and becoming familiar with medical anthropology is a good first step. The second component emphasizes the need for specifically tailored assessment [100]. Pachter advocates the notion that there is tremendous diversity within groups. Often, there are many intersecting variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the patient and the professional [100]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. The professional
might recommend a combination of alternative and Western treatments. Beckerman and Corbett further recommend that recently immigrated families be assessed for [101]: • Coping and adaptation strengths • Issues of loss and adaptation • The structure of the family in terms of boundaries and hierarchies after immigration • Specific emotional needs • Acculturative stress and conflict for each family member Practitioners should seek to understand the sociopolitical context of the origin country. A migration narrative is also recommended, whereby an individual provides a story of their migration history. Asking about how long the family has been in the United States, who immigrated first, who was left behind, and what support networks are lacking gives the practitioner an overview of the individual’s present situ- ation. The theme of loss is very important to explore. Types of losses may include family and friends left behind, social status, social identity, financial resources, and familiarity. For refugees and newly immigrated individuals and families, assessment of basic needs (e.g., food, housing, transportation) is necessary [102; 103]. Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of ques- tioning. Practitioners should work to recognize that there are a host of factors that contribute to patients’ multiple identities (e.g., race, gender, socioeconomic status, religion) [36; 37; 82].
A WELCOMING AND SAFE ENVIRONMENT
Improving access to care can be facilitated, in part, by provid- ing a welcoming environment. The basis of establishing a safe and welcoming environment for all patients is security, which begins with inclusive practice and good clinician-patient rap- port. Shared respect is critical to a patient’s feeling of psycho- logical well-being. Security can also be fostered by a positive and safe physical setting. For patients who are acutely ill, both the illness experience and treatment process can produce trauma. This is particularly true if involuntary detainment or hospitalization is necessary, but exposure to other individu- als’ narratives of experienced trauma or observing atypical behaviors from individuals presenting as violent, disorganized, or harmful to themselves can also be traumatic. As such, care environments should be controlled in a way to minimize traumatic stress responses. Providers should keep this in mind when structuring the environment (e.g., lighting, arrangement of space), creating processes (e.g., layout of appointments or care systems, forms), and providing staff guidance (e.g., non- verbal communication, intonation, communication patterns).
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