Culture and the notion of cultural competence

There is a tendency in clinical practice to imagine that ‘culture’ is a concept that separates ‘us’ from ‘them’. That is, we tend to understand culture as a construct that explains differences between two groups. In Australia the groupings most commonly recognised are ‘us’, ‘Westerners’, who are different from ‘them’, meaning anyone else who does not fit into this dominant cultural category. A secondary grouping that is also considered is that of ‘us’ as healthcare professionals, placed in juxtaposition to ‘them’, those who are patients or clients (Tilburt & Geller 2007). This latter distinction is often implicit—clinical reality is rarely explicitly discussed as a cultural construct, nor is it often acknowledged that the biomedical approach is culture specific and value laden (Kleinman et al 1978, Hahn & Kleinman 1983).

To understand culture as a dichotomy in this way is simplistic and misleading. Everyone lives within and is a product of ‘culture’. In simple terms, culture refers to a system of ideas and beliefs, including values and ideals, which are held in common by a community of people with a system of shared meanings (Chur-Hansen et al 2006). Culture is heterogeneous: an individual functions within and is shaped by a number of subcultural identities. For example, gender, sexuality, religion and religiosity, marital status, age, level of education and employment (or lack of employment) are all examples of subcultural groupings. Within these subcultures, while common ideas and beliefs will be apparent, there will be individual variations. Similarly, in the healthcare professions, while the biomedical model could be arguably seen as the dominant cultural framework, there are a number of differences in understanding and approach, both within medicine and its various specialities, and between and within the different healthcare professions themselves, such as dentistry, medicine, nursing, physiotherapy and psychology. In addition, existing alongside recognised Western healthcare professions are those practitioners who also contribute to subcultural understandings about illness and disease, and offer treatment including, for example, traditional healers, religious leaders and alternative and complementary medicine providers.

With complexities around cultural and subcultural differences in communities, along with differences on an individual level, health professional students and practising clinicians are faced with a complex challenge. It is not appropriate to assume that dominant cultural categories (such as ‘Western’ and ‘biomedical model’ approaches to healthcare) must take priority, and that therefore proficiency in these will be sufficient. To operate on this level is ethnocentric, or as Kleinman et al (1978 p 251) term it, ‘medicocentric’—the belief that one’s own cultural understandings are superior to all others (Keesing & Strathern 1998). However, it is also unrealistic to imagine that any one person can have a working knowledge and understanding of every possible cultural and subcultural perspective. Clinicians and undergraduate students and trainees need to demonstrate an ability to work with people from a variety of different backgrounds, including eliciting their narratives about what they think is wrong and what they think needs to happen next. Thus healthcare practitioners need to demonstrate ‘cultural competence’, which has been defined by Anderson et al (2003) as including the capacity to identify, understand, and respect the values and beliefs of others (p 74). More specifically, Carpenter-Song et al (2007) explain cultural competence as the application of specific techniques and skills by an individual in the context of clinical encounters, and the promotion of organisational practices to meet the needs of diverse populations (p 1363).

There are a number of models of cultural competency for training healthcare professionals. Carpenter-Song et al (2007) have summarised the shortcomings identified by medical anthropologists who have critiqued these models. Criticisms include presenting culture as static; treating culture as a variable; conflating culture with race and ethnicity; failing to acknowledge diversity within groups; inadvertently placing blame on a patient’s culture; emphasising cultural differences and thereby obscuring structural power imbalances; and finally, failing to recognise biomedicine as a cultural system itself (p 1363). In addition to addressing these concerns in any cultural competency model, the premise of medical anthropologists is that biomedical culture must be modified to be culturally appropriate to the patient, and that it is this approach that can facilitate the cultural competency of practitioners (Dein 2004).

Explanatory models of illness

Arthur Kleinman is Professor of Medical Anthropology in Social Medicine and Professor of Psychiatry, Harvard Medical School (Online. Available: http//www.fas.harvard.edu/9 Jan 2009). His seminal work in medical anthropology on explanatory models has been influential in medical education (in behavioural sciences curricula) and in the training and clinical practice of psychiatrists. First published in the 1970s, it is only recently that other health professional training programs have incorporated this concept into curricula or clinical practice. There is very little in the published literature about explanatory models outside of medicine. However, for an example in dentistry see Nations and de Araujo Soares Nuto (2002), in epidemiology see Weiss (2001), in nursing see McSweeny et al (1997), and in physiotherapy see Hunt (2007).

Kleinman and his colleagues (Kleinman et al 1978, Kleinman 1980, 1988a, 1988b) note that patient and clinician explanatory models share five common issues: aetiology, onset of symptoms, pathophysiology, course of illness (including type of sick role—acute, chronic, impaired—and severity of disorder), and treatment. Patient explanatory models reflect social class, cultural beliefs, education, occupation, religious affiliation and past experiences with illness and with healthcare. Kleinman et al (1978, p 256) state:

To utilise the explanatory model concept in clinical practice it is necessary to elicit the patient’s explanatory model in a systematic way, showing genuine interest and respect. The patient is the expert as it is they who are experiencing this illness, and thus they are asked to explain what is happening, from their perspective, to the healthcare practitioner.

Kleinman et al (1978) suggest the following questions: (1) What do you think has caused your problem?; (2) Why do you think it started when it did?; (3) What do you think your sickness does to you? How does it work?; (4) How severe is your sickness? Will it have a short or long course?; (5) What kind of treatment do you think you should receive?; (6) What are the most important results you hope to receive from this treatment?; (7) What are the chief problems your sickness has caused for you?; (8) What do you fear most about your sickness? (p 256).

In negotiations between the patient and the healthcare professional’s explanatory model, discrepancies are identified and discussed. Some discrepancies can be recognised but need not be changed, for example, if a person is willing to take medication but also wishes to consult a fortune-teller, the healthcare professional should respect this. Where the patient is unwilling to accept the biomedical treatment for their problem, the healthcare professional needs to negotiate, to try and find a mutually agreeable compromise. Kleinman et al (1978) consider the negotiation stage to be perhaps the single most important step in building trust, promoting adherence and increasing patient satisfaction. On a practitioner level, this process can be seen as facilitating reflexive practice, a personal and professional quality that is valued in current health professional education pedagogy (Tilburt & Geller 2007).

The concept of explanatory models of illness and their role in cultural competency has been applauded because it is practically relevant; it is not simply a theory (Phillips 1985). Furthermore, the concept is able to manage the physical reductionism and Cartesianism of biomedicine: the explanatory model concept does this, as it juxtaposes the medical model with the patient’s—both are considered valid (Phillips 1985). It addresses the concerns outlined by Carpenter-Song et al (2007). That is, it can accommodate change over time, take into account irrational beliefs and hidden meanings, accept diversity between and among groups, because in the clinical setting it focuses on the individual rather than any one particular group, and recognises that the healthcare professions are a culture unto themselves and this must be taken into account in clinical practice (Kleinman 1981). Discussing explanatory models facilitates communication, and this, it has been proposed, is instrumental in improving disparities in healthcare (Ashton et al 2003).

However, while it is generally accepted that the explanatory model concept is a useful one in the demonstration of cultural competence, there are some limitations to its use that have been discussed in the literature. It has been argued that people’s explanatory models can be vague, have multiple levels of meaning, change frequently, and blur ideas and experience (Rajaram & Rashidi 1998). Eliciting and understanding them may not be straightforward. It has also been noted that explanatory models are fluid (Williams & Healy 2001), dynamic, and evolve over time as contact with biomedicine influences affects understandings of illness (Schreiber & Hartrick 2002). Thus the explanatory model offered by a particular patient at one time may not be the same one offered at a later date. This is not necessarily problematic, as long as the healthcare practitioner is cognisant of this, and reviews the patient’s explanatory models accordingly. Williams and Healy (2001) suggest that explanatory models might be more properly called ‘explanatory maps’ to reflect their unstable nature. McSweeny et al (1997), from the perspective of nursing research and practice, document several limitations to the approach. They call for more research into the utility of using the concept of explanatory models for improving patient outcomes, as to date there is a dearth of evidence to show that cultural competency training of any type has an impact on health outcomes, a point also made by Betancourt (2003).

In a review of culturally competent healthcare systems, including a review of cultural competency training for healthcare providers by Anderson et al (2003), the efficacy of training could not be reported because so few studies have evaluated outcomes pre- and post-training, or compared different training interventions. The issue of the amount of time needed to elicit and explore a person’s explanatory model in the clinical setting has also been underscored by McSweeny et al (1997): they suggest the approach is possibly more advantageous when multiple encounters with a patient are feasible. Additional time facilitates trust and rapport, so the individual is more comfortable in disclosing their thoughts about their illness. Lloyd et al (1998) have developed a Short Explanatory Model Interview (SEMI), which is brief, standardised and validated, in an attempt to address the issue of time limitations, particularly where the elicitation of the explanatory model from a group of patients is undertaken for the purpose of research. McSweeny et al (1997) further note that the negotiation phase between the patient and healthcare professional’s explanatory models assumes an equality of power that rarely exists, and with which the patient might not be comfortable, if the negotiation phase were offered. This is an issue which needs to be considered on a case-by-case basis, and will in itself require a level of cultural competency in making a judgement about the patient’s preferred role in the clinical encounter. An important point to be made about the use of explanatory models in clinical practice is that elicitation, understanding and negotiation all require considerable skill on the part of the clinician, and these skills must be taught. We therefore turn our attention to the concept of explanatory models and cultural competency training in health professional curricula.