Refining the concept of cultural competence: building on decades of progress

While it is recognised that a patient’s cultural background may be significant in clinical encounters, lack of clarity about the concept of culture can distort its impact.2,4,20-22 Anthropology, the discipline from which the term “culture” originated, offers many definitions but most make reference to a system of shared meanings or guidelines that are inherited and provide a lens through which to view the world. Contemporary anthropologists stress variations that exist across cultures with respect to beliefs, practices, norms, behaviours and expectations. Helman, for example, notes that culture is “an increasingly fluid concept, which in most societies is undergoing a constant process of change and adaptation”.20 Social scientists stress that cultures are complex, heterogeneous and dynamic, and intricately connected to the social context of people’s lives.2,4,21,22

So how does this understanding of culture differ from its usage in medical settings? Critiques from social scientists suggest that culture is often conflated with race and ethnicity, resulting in reification of existing racial categories.4 Central to this criticism is the failure to recognise diversity within cultures and the concomitant reductionism whereby culture is identified as a variable associated with essential differences between groups. Culture is viewed as a “risk factor” and cultural attributes as potential sources of the problem. Kirmayer noted that culture has been framed in terms of “ethnoracial blocs” which “conflate language, geographic origin, ethnicity and race” and “do not capture the diversity of society and the rapidly growing numbers of people who define themselves in hybrid ways that cut across these categories or escape them entirely”.21 Cultural competence literature tends to associate culture with group membership and shared beliefs and values that influence behaviour in health care settings.21 Not only does this approach underestimate cultural diversity within groups, but the process of “essentialising” culture removes individuals from their complex social worlds in which the structural and material determinants of inequality may be as powerful as cultural influences on health inequity. In an attempt to provide more conceptual clarity around cultural competence, Lo and Stacey coined the term “hybrid habitus” which interprets patients’ cultures as “the broad, less than fully conscious cultural orientations that shape a patient’s sense-making in clinical settings . . . [and] in turn, are shaped by surrounding, intersecting structural forces”.22 These forces may include socioeconomic status, gender, language and experiences of racism, all of which can interact with cultural orientations and influence the clinical encounter. This deeper understanding of culture in all its complexity has practical implications in health care settings. A patient’s culture is not reduced to stereotypical attributes, but rather understood as comprising layers of meaning that extend beyond values, beliefs and practices and are shaped by and in turn shape social structures.

However, any examination of the meaning and use of “culture” needs to consider the culture of medicine itself to assess its role in reproducing or addressing health inequities.

In the US, Good and colleagues questioned why disparities in health care continue to exist despite the introduction of cultural competence training in health professional programs.23 They suggested the need for a critical analysis of the culture of medicine where the “social processes within our complex medical institutions” are explored, including the presence of institutional racism, power imbalances and the role of professional socialisation. Taylor reinforces this, noting that cultural competence strategies have an overemphasis on the patient’s culture with scant attention paid to the culture of biomedicine.24 Institutional and professional medical culture is characterised by expert language and efficiency in clinical decision making based on legitimate medical knowledge. Taylor suggests that “it is confidence in the truth of medical knowledge that underwrites physicians’ special power to alleviate suffering”. Medical knowledge is thus not seen as a cultural product but as “real” knowledge which leads her to describe medicine as “perceiving itself to be a ‘culture of no culture’ ”.24 While some may disagree with this, it has consequences for the development of cultural competence curricula that “go beyond focusing on ‘other’ cultural groups, and attend to cultural dimensions of medicine itself”. Central to this discussion is the potential mismatch between professional medical socialisation, institutional practices and cultural competence strategies. Indeed, clinicians sometimes can be at odds with institutional directives and feel constrained by administrative practices that may compromise patient care.

Despite cultural competence training becoming commonplace in medical programs in Australia and elsewhere, few studies have focused on the culture of medicine itself. As Good et al note “rarely do students have the time or the formal sanction to critically analyze the profession and institutions of care to examine how treatment choices, quality of care and research practices are shaped; or how medical culture may produce processes that evolve into institutional racism . . . in clinical practice”.23 Kleinman and Benson go further, suggesting that the culture of biomedicine is “key to the transmission of stigma, the incorporation and maintenance of racial bias in institutions, and the development of health disparities across minority groups”.2 Implementing a more expansive notion of cultural competence that incorporates greater critical analysis of biomedicine has potential for less discordance between institutional culture and strategies aimed to improve culturally informed care.

Finally, critiques of cultural competence by social scientists and others have drawn attention to inadequate measures of the concept and the scarcity of outcomes-based research that links cultural competence strategies to better health.25-30 A study of quantitative measures of cultural competence found many hidden assumptions in survey questions designed to assess the impact of educational interventions, including the notion that frequent contact or immersion experiences necessarily enhance competence.29 Much depends on the kinds of interactions and the quality of the experiences, with contact alone not necessarily fostering insight. Recent studies also have found a lack of rigorous evaluation of cultural competence measurement tools, with few instruments having been validated. Chun noted that cultural competence training is often viewed as “unscientific” due to inadequate measurement techniques that can undermine implementation efforts.27 This is reinforced by findings of a review of the methodological rigour of studies evaluating cultural competence, which found a consistent lack of rigour, the consequence of which “limits the evidence for the impact of cultural competence training on minority health care quality”.26 In addition to rigorous instrument evaluation, qualitative methods, including observations, interviews and reflective journals should supplement traditional survey techniques when determining the effectiveness of cultural competence training.29

The first systematic review of studies assessing whether educational interventions to improve cultural competence were linked to improvements in health outcomes concluded that where an association was established, it tended to be in a positive direction.28 However, the authors identified many methodological limitations of existing studies and drew attention to the overall paucity of high-quality research, concluding that the evidence was not robust. Looking ahead, they noted that “subjective constructs such as patient trust and the quality of the patient experience using validated measures have emerged as outcomes of intrinsic value that should also be considered in the cause-effect dynamic”.28 Inherent in cultural competence measurement issues is the question of who decides whether a health professional has achieved cultural competence; arguably, the patient as the recipient of services is best positioned to make this judgement. The authors noted that because educational interventions are often removed from clinical outcomes, other measures such as enhanced trust between patient and practitioner and a high degree of satisfaction with a clinical encounter are worthy outcomes in health care settings and may also contribute to improved levels of utilisation.28