Sign up for alerts

Spring 2008 | Vol 11 No 3

Focus

Making a world of difference

Why cultural competence is a need, not a luxury

By Rani Srivastava

Canadian society is becoming increasingly diverse. Data from the 2006 census show that one in five Canadians are “foreign born,” and this population is increasing at about 14 per cent, nearly four times the rate in the Canadian-born population. Since the definition of foreign-born does not include non-permanent resident ssuch as students, individuals with work permits or refugee claimants, the actual proportion of foreign-born persons in Canada is likely higher. Ontario continues to be a preferred destination for more than half of newcomers, and large urban centres such as Toronto, Montreal and Vancouver are home to nearly 70 per cent of recent immigrants. Although immigration is a major contributor to our cultural landscape, it is not the only factor. The 2006 census shows that the number of people who identify as Aboriginal is increasing and has surpassed the one million mark. Given these demographics, it seems obvious that health care agencies need to respond to a culturally diverse population. But that is easier said than done.

Culture is intimately connected to health care. It influences how people experience and report symptoms, which remedies they seek and how. Misdiagnosis and miscommunication can occur when clinicians fail to recognize diverse ways of expressing distress. This is particularly true in mental health, where the clinician is often the diagnostic as well as the therapeutic instrument, with little objective assessment data from other sources such as blood tests or x-rays. Clinicians often struggle to determine whether behaviours deemed inappropriate in mainstream society really do reflect illness or whether they reflect cultural needs or traditions.

The overall goal of cultural competence is to improve the quality of care and help reduce or eliminate health disparities

Over the years, two key issues have emerged from discussions around understanding and responding to cultural issues in health care. First, culture plays a pivotal role in health and illness; second, the culture of clinicians and the health care system affects diagnosis, treatment and access to services. This means that cultural competence needs to be practised not just at the level of the individual care provider but also at the level of the organization and the broader health care system. We must recognize that our health systems – and the education system that trains health care providers – are built on a western, biomedical model of health beliefs and health care delivery. As a result, health care providers have little formal training around how to understand and incorporate the range of health beliefs and cultural paradigms that exist in our complex, multicultural society.

Cultural competence is as complex a concept as the society it reflects. Cultural competence is the ability of health care providers to work effectively in cross-cultural situations. While older terms such as “cultural sensitivity” and “cultural awareness” referred to an appreciation of and respect for cultural differences, “cultural competence” takes the concept one step further to include the ability to ultimately put this knowledge and skill into action.

The essential role of cultural competence in good health care has been reinforced through increasing evidence of health disparities. Studies have documented disparities in access to health care, as well as health care quality and health outcomes for racial and ethnic minorities across a wide range of clinical specialties. The 1988 Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees found that within the mental health arena not only do minorities have less access to mental health services, they are less likely to receive the needed services, often receive a poorer quality of mental health care and are often underrepresented in mental health research.

Increasing diversity and these growing health disparities have made the need for cultural competence an urgent call to action. The overall goal of cultural competence is to improve the quality of care and help reduce or eliminate health disparities. This is done by improving access to care and building trust and engagement with diverse clients and communities. Cultural competence includes valuing cultural diversity, being aware of one’s own personal and professional biases, understanding the dynamics associated with “difference,” learning about different cultures and cultural issues and adapting one’s approach to care to fit the needs of individuals and communities. Being culturally competent does not mean knowing everything about every culture or needing to abandon one’s own cultural identity; instead, it involves a willingness to accept the idea that there are many ways of viewing and approaching the world.

But acceptance and action are slow to come. Why is there more talk than action in providing culturally competent care? Part of the answer may lie in the fact that current conceptions of culturally competent care challenge health care providers to examine their own personal and professional biases, rather than merely learn about cultural differences. Self-awareness is recognized as a critical attribute, but self-awareness can be hard to acquire and old ways of working can be hard to change. We must also acknowledge that awareness and intentions do not result in change without purposeful action. When it comes to cultural competence, action must occur at all levels of the health care system. To achieve the changes necessary in clinical care, policy-makers and educators need to rethink the standards for quality in a multicultural society. Organizations need to develop strategies to infuse the policy and standards in day-to-day services.

In the meantime, we cannot wait for someone else to take action. Gandhi said, “Each one of us must be the change we want to see in the world.” Indeed, the first steps in the journey toward cultural competence are paved with the commitment to making a difference and acting on it – something each of us can do.

Rani Srivastava is the deputy chief of Nursing Practice at the Centre for Addiction and Mental Health in Toronto. She is also the editor of  and a contributing author in The Healthcare Professional’s Guide to Clinical Cultural Competence.