Beyond Cultural Competence: The Jar of Life

South Africa. Beyond our gold, diamonds, Springboks Rugby team and sunny beaches, we are known for our diversity. Not only does our multiculturalism have a rich history, we also have an amazing and unique dynamic that exists between the different cultures that make up our rainbow nation.

As we move into the third decade of democracy, this dynamic is now beginning to make its way into the healthcare sector, raising questions about what it means for healthcare providers to be 'culturally competent' and whether we need to start moving beyond competence, into a 'critical consciousness' in which culture is not restricted to a set of characteristics, but is viewed as more fluid, ever-changing and differing from person to person.


In 1999, Dr Jerome Hanley, a clinical child psychologist, published a paper entitled "Beyond the Tip of the Iceberg: Five steps towards Cultural Competence".
In it, he described a continuum developed by James Mason that moves towards the achievement of cultural competence, which he described as "the ability to work across cultures in a way that acknowledges and respects the culture of the person or organization being served" (Hanley, 1999)

The five steps along the continuum include:

• Cultural Destructiveness: lying at the most negative end of the continuum, this represents the attitudes, practices and policies that cause damage to cultures, and the individuals within these cultures. An example of this would include the infamous Tuskegee Syphilis study, which brought many ethical and racial issues to the forefront. 

• Cultural Incapacity: this occurs when the health care system unintentionally lacks the capacity to assist a particular community or minority group. For example, not having an isiZulu translator to convey important information to the patient, which can result in misunderstandings, lack of informed consent or non-compliance to treatment.

• Cultural Blindness: this refers to the provision of services with the intention of being completely unbiased, or in other words, working on the 'melting pot' theory that everyone is the same, and that culture makes no difference to provision of services. An example would be the belief that all patients should be treated equally, regardless of different cultural backgrounds and expectations

• Cultural pre-competence: Falling on the positive end of the spectrum, this represents efforts to recognise the differences between people of different cultures, and make attempts to take these into consideration when planning treatment or interacting with these people. For example, this would include using appropriate music or décor that would be relevant to the individual

• Cultural Competence: This refers to accepting and respecting the cultural differences between individuals, as well as actively working towards assessing our own cultural awareness and working towards improving our knowledge and awareness of cultural practices of different populations. This also includes building resources and cultural models that can assist with providing service to individuals of a particular culture.

 (Hanley, 1999)

According to Dr Henley,  there are three important factors that a person needs in order to build cultural competence:
1. Self-knowledge or deep thought, which allows a person to begin understanding their own viewpoints and perspectives and introspect deeply.
One lesson that OT has taught me is the importance of reflection, as it highlights innate perspectives that colour how we see the world around us. Our experiences often determine the way we relate to people of other cultures, therefore it becomes important to be aware of these potential biases, especially within the South African context.

2. Experience: Immersing yourself in a culture is the best way to understand it.
A Sierra Leone proverb that Henley uses to explain the importance of immersion: "a paddle here, a paddle there, -the canoe stays still," indicates that it takes much more than superficial efforts to truly understand a different culture.
This has never been more true than in South Africa, where there are subtle nuances between cultures in different regions, and where the more you experience a culture, the more layers and depth of each culture become evident.

3. Active efforts towards positive change
Change in behaviour is necessary, as simply being aware of the cultural background of another but not using this knowledge to actively improve healthcare provision is of no use.

However, a 2009 article by Kumagai and Lypson proposes the idea that we need to start moving beyond the current idea of cultural competence, which, they argue, restricts the idea of culture to something that can be characterised, categorised and learnt, undermining its complexity (Kumagai, Lypson, 2009).

They state that cultural competence
"is not a static requirement to be checked off some list but is something beyond the somewhat rigid categories of knowledge, skills, and attitudes: the continuous critical refinement and fostering of a type of thinking and knowing—a critical consciousness— of the self, others, and the world" (Kumagai, Lypson, 2009). 

They assert that the way in which culture is addressed in higher education needs to move away from compartmentalised teaching aimed at gathering information about other cultures, as this tends to put everyone of a certain culture into one neat basket, risking over-generalisation. (Kumagai, Lypson, 2009). 

Instead they promote a move towards integrating the development of a 'critical consciousness' into learning, training students to view each individual through a 'conscientized' lens, taking into account the various factors that interplay within the person and their context.(Kumagai, Lypson, 2009). 

Within the OT course, I feel that our learning pushes us towards development of a critical consciousness, as we are trained to look at each client from various angles, whether cultural, medical or functional. In addition, we place greater emphasis on the person's own interpretation of their culture rather than on the characteristics they would be expected to have, given their ethnicity and area of origin.
However, the responsibility lies with us to ensure that we do not approach clients with preconceived notions based on our own knowledge bases and let these beliefs cloud the true cultural expression of the client.
  

Henley, J (1999). "Beyond the Tip of the Iceberg: Five steps towards Cultural Competence". Retrieved from: http://aacu.org/sites/default/files/files/hips/Beyondthetipoftheiceberg.pdf

 

Kumagai, A.K., Lypson, M.L (2009). Beyond Cultural Competence: Critical Consciousness, Social Justice and Multicultural Education. Academic Medicine, 84 (6).