Associate Professor of Sociology, Department of Behavioral Sciences, Winston-Salem State University, Winston-Salem, NC 27110, USAUnited States
Associate Professor of Gerontology, Department of Behavioral Sciences, Winston-Salem State University, Winston-Salem, NC 27110, USA The Institute of Healthcare’s Triple Aim Initiative (TAI) identifies the improvement of patients’ experience as one of three key components necessary for optimizing the American health care and cost-delivery systems.
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The Institute of Healthcare’s Triple Aim Initiative (TAI) identifies the improvement of patients’ experience as one of three key components necessary for optimizing the American health care and cost-delivery systems. Widely adopted today, the TAI’s focus on patient-centered care also implicitly embeds the idea of care that is culturally-sensitive.
Editorial Product or Process: Cultural Competence or * *Corresponding author Cultural Humility?
Cecile N. Yancu, PhD Associate Professor of Sociology Department of Behavioral Sciences Winston-Salem State University 1* Cecile N. Yancu, PhD ; Deborah F. Farmer, PhD Winston-Salem, NC 27110, USA E-mail: yancuc@wssu.edu 1Associate Professor of Sociology, Department of Behavioral Sciences, Winston-Salem State University, Winston-Salem, NC 27110, USA Volume 3 : Issue 1 2 Associate Professor of Gerontology, Department of Behavioral Sciences, Winston-Salem Article Ref. #: 1000PMHCOJ3e005 State University, Winston-Salem, NC 27110, USA Article History rd Received: April 3rd, 2017 The Institute of Healthcare’s Triple Aim Initiative (TAI) identifies the improvement th Accepted: April 6th, 2017 of patients’ experience as one of three key components necessary for optimizing the American th Published: April 6th, 2017 health care and cost-delivery systems.1 Widely adopted today, the TAI’s focus on patient-cen- tered care2 also implicitly embeds the idea of care that is culturally-sensitive. Perhaps nowhere in the health-care delivery system is this emphasis on patient-centered, culturally sensitive, care Citation more important than for those addressing life-limiting illness or for frail elders who are coping Yancu CN, Farmer DF. Product or process: Cultural competence or with the advanced stages of multiple chronic conditions.4 cultural humility? Palliat Med Hosp Care Open J. 2017; 3(1): e1-e4.
These two patient populations have been the target of numerous studies in cross-cul- doi: 10.17140/PMHCOJ-3-e005 tural research, much of which has shown that dialogue surrounding palliative care and hospice is eased when caregivers, both clinical and laypersons, are culturally sensitive.5 Cultural sensi- tivity supports the development of trust and rapport with patients.6 The crucial question is how cultural sensitivity can best be achieved when working with a diverse patient population. The purpose of this editorial is to provide insight into the meaning of culture and to examine two leading methods for acquiring some degree of cultural sensitivity: cultural competence and cultural humility.
Culture is an umbrella term that subsumes within it values, beliefs, customs, rituals, practices and behaviors. In short, culture is a combination of the material and non-material components of human society that is as fluid as it is diverse. Over millennia, humans have learned to adapt culture as a tool for survival in a resource-challenged, often volatile environ- ment. Seen from an evolutionary perspective, culture empowers individuals to work together in relatively cohesive social groups. Over time and generations, culture enables us to communi- cate with each other in meaningful ways that facilitate the development of substantive survival strategies and transmit this useful knowledge to progeny.7 As human environments vary widely so, too, do adaptive behavioral strategies.8 Culture plays a salient role in health. Culture determines how we distinguish health 9 10 status from sickness and configures the patient experience.9 It influences diagnosis10 by con- touring the way that we legitimate symptoms and separate objective disease from subjective distress.11 In effect, culture influences all facets of the illness experience. However, the land- scape of cultural diversity is broad, encompassing human characteristics ranging from, but not limited to, race/ethnicity, gender identity, sexual identity and orientation, socio-economic sta- tus, urban/rural, age/generation and religion. Nonetheless, whether motivated by the morality of social justice as in UNESCO’s (2001) Universal Declaration on Cultural Diversity12 or the Copyright efficiency of best practices demands,13 clinicians and service providers are increasingly called ©2017 Yancu CN. This is an open on to master an understanding of cultural diversity in order to improve care, especially for un- access article distributed under the 14 derserved groups.
Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, Cultural diversity embodies the idea that all societies generate a catalogue of distinc- distribution, and reproduction in tive differences that separate groups from one another often leading to social stratification. In any medium, provided the original practice, cultural diversity is manifested in a broad range of ever-changing behaviors, beliefs, work is properly cited.
rituals, restrictions, traditions, norms, institutions, and relationships that form the basis of cul- tural knowledge. This makes cultural mastery something akin to ties, improving access to better care,23 increasing health literacy trying to grab onto a cloud.
and, in general, promoting health equity.24 The problem is that much of the recent work done to address health inequities has The issue of the frequent collision of social and politi- focused on increasing cultural competence among providers as cal worlds also complicates cultural understanding. Gender pro- if this could somehow empower at-risk groups to overcome de- vides a salient example. Gender, long conceptualized as a binary cade’s worth of social disadvantages that are at least partially social construct is used to attach social roles and behaviors to responsible for poor health outcomes.24 Additionally, despite de- a binary concept of sexual identity. Social order runs smoothly cades of theorizing about and researching cultural competence when people behave in a way that supports a match of gender to certification, there is a lack of consensus about its key compo- sex; a mismatch between gender and sexual identity challenges nents.25 Adding cultural humility, a process of openness, col- the existing social and political order. Although the notion of a laboration, and self-reflection rather than a presumption of com- third gender is socially unremarkable in some societies, such as petency,26 to cultural competence could be uniquely beneficial.
the Hijra of Southeast Asia, in the U.S. the gender/sexual iden- tity mismatch has shifted into the clinical realm. Earlier versions Cultural humility provides a distinctive approach to ex- of the diagnostic and statistical manual (DSM) identified gender ploring, understanding, and appreciating the differences among identity disorder (GID) as a condition in which one is at odds us. Cultural humility begins with self-examination of one’s own with the gender identity assigned at birth. The 2013 version ac- cultural beliefs and practices with the goal of developing re- knowledged a conceptual diagnostic shift and destigmatized the spectful relationships.20 It “involves the ability to maintain an condition by changing the classification from GID to Gender interpersonal stance that is other-oriented (or open to the other) Dysphoria.16 Now, four years later, social dialogue about gender in relation to aspects of cultural identity that are most impor- has shifted to conversations about gender diversity, the concept tant to the client”.26 Cultural humility has both an intrapersonal, that gender exists on a spectrum idea rather than being binary.17 self-reflective dimension and an interpersonal dimension that Thus, in a span of less than ten years, a person who was born includes respect for others, lack of superiority, and a focus on with female genitalia but self-identified as predominately male others rather than self.26 Cultural humility is a lifelong process; has “transitioned” from having a psychiatric disorder to being the goal is the process, not the end product.19 gender-non-conformist.
Sociologically speaking, cultural humility shuns eth- Such shifts in cultural ideas leave clinicians and service nocentrism in favor of a culturally relativistic approach to oth- providers with major challenges when working with patients/cli- ers. It is rooted in the belief that one culture may not impose its ents from diverse cultural backgrounds. Nonetheless, patient- or value system on other cultures; this may be considered part of client-centered care depends on respecting the values, practices, professionalism.27 The other-focused nature of cultural humility and beliefs that matter most to individuals and their families, requires the practice of cultural sensitivity, seeking out, perceiv- particularly near the end-of-life. Although, a universal approach ing, and striving to understand cultural information provided by to addressing cultural differences would be ideal, culture’s very the other person.26 Biases may be explicit to the individual and complexity makes this strategy nearly impossible. Two com- to others or implicit and unrecognized by the interacting indi- monly used approaches to bridge the cultural sensitivity gap are viduals.28 Ideally, self-reflection enables people to make their cultural competence and cultural humility.
implicit biases explicit, acknowledge them and take them into account when working with others.
Competence is often used interchangeably with terms such as skill, proficiency, and expertise. Cultural competence Essential to the cultural humility perspective is the idea is conceptualized as having four elements: cultural awareness, that we are all members of multiple, intersecting cultures, not 18 29 knowledge, attitudes, and skills.18 The concept implies a de- just one culture related to our race or ethnicity.29 Our multiple lineated product and suggests a mastery of something, in this identities and perspectives encompass a myriad of factors such case, of a theoretically finite body of knowledge.19 The under- as gender, social position, and geographical location that affect lying idea is that awareness and understanding of the cultural the way we view the world and influence the ways in which we backgrounds and beliefs of others facilitates communication.20 interact and communicate meaningfully with others. The prac- In contrast, cultural humility is a dynamic process that includes tice of cultural humility puts us in the potentially uncomfortable self-reflection, personal critique, and growth.22 On the plus side, position of being learners, rather than experts, about cultures competence is more easily standardized, taught, and implement- other than our own. Communication and understanding occur ed than cultural humility; however, the danger is that it can lead more easily among people who have shared cultural ideas and 18,21 to essentialism or stereotyping. Using a sociological frame- beliefs about how the world works; it is more difficult to acquire work that focuses on the reality of human cultural diversity, cul- among people who do not have shared core beliefs.20 tural humility (process) better serves patient-centered, culturally sensitive care when used in tandem with competency (product).
Thus, cultural humility may complement, rather than Cultural competence has long been viewed as the cornerstone of replace, cultural competence.29 To interact effectively with an fostering cross-cultural communication, reducing health dispari- increasingly diverse population, we need both process (cultural humility) and product (cultural competence), awareness and 386. doi: 10.1080/10401334.2015.1077127 openness to other world views combined with some knowledge about other cultures and ways of thinking to know what to look 7. Mace R, Jordan FM. Macro-evolutionary studies of cultural for, what questions to ask. Beginning with self-reflection of our diversity: A review of empirical studies of cultural transmission own attitudes, beliefs, and practices, we must then learn as much and cultural adaptation. Philos Trans R Soc Lond B Biol Sci.
as possible about the beliefs, values and behavioral practices of 2011; 366(1563): 402-411. doi: 10.1098/rstb.2010.0238 the cultures/groups with which we interact. Cultural knowledge, such as concepts of personal space, how people like to be ap- 8. Brown GR, Dickins TE, Sear R, Laland KN. Evolution- proached, and whether direct eye contact is desired or consid- ary accounts of human behavioural diversity. Philos Trans R ered disrespectful, can facilitate positive and productive initial Soc Lond B Biol Sci. 2011; 366(1563): 313-324. doi: 10.1098/ interactions. The initiator should be aware of subtle signs like rstb.2010.0267 body language and adjust the communication and interaction style accordingly. This demands sensitivity that depends upon 9. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: willingness to acknowledge we must be perpetual learners with Clinical lessons from anthropologic and cross-cultural research.
our reach always exceeding our grasp. Throughout this process, Ann Intern Med. 1978; 88(2): 251-258. doi: 10.7326/0003-4819- we must be mindful that we are all members of multiple cultures 88-2-251 and interlocking identities that are continuously influenced by factors such as racial/ethnic identity, gender, age, cohort, family 10. Rounsaville BJ, Alarcón RD, Andrews G, Jackson JS, Ken- composition, socio-economic status, living situation, education- dell RE, Kendler K. Basic nomenclature issues for DSM-V. In: al level, and life experiences.
Kupfer DJ, First MB, Regier DA, eds. A Research Agenda for DSM-V. Arlington, VA, USA: American Psychiatric Associa- CONFLICTS OF INTEREST tion; 2002: 1-29.
The authors declare that they have no conflicts of interest.
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