Cultural Congruence

by Howard M. Notgarnie, RDH, MA

Technology enables mobility -- virtual mobility through cyberspace and real mobility through transportation -- allowing a mix of cultures within a community. As a result, dental hygienists and the colleagues with whom we work need a wider range of skills and resources to communicate effectively with our clients. Good communication is especially important in our very frequent role as educators, but it is also important when offering and explaining treatment which has a better chance of acceptance by a client who understands the treatment and its value.

Charles, Gafney, Whelan, and O’Brien identify a disassociation between theory and research regarding cultural competence. In making treatment decisions, modern theories of practice stress the role of the client, yet most research points to a lack of cultural sensitivity in regard to clinical aids for client decision-making. What should be determined are variations in language meaning and cultural desire to participate in clinical decision-making. Research should also determine which clinical aids are useful to a given culture.¹

Critics of cultural competence may point to a recent interview study in which health professionals caring for migrant farm workers were focusing on cultural characteristics to interact with their clients, while the workers were more concerned with barriers related to their immigration.²

“Health-Seeking Behavior”

However, there are strong arguments in favor of health professionals developing cultural competence. A concrete example of how culture can affect health care is a recent study showing, contrary to previous reports on socioeconomic status, that when “sociocultural and psychosocial factors” are removed, African-Americans have the same health-seeking behavior as the “majority population.” The above sociocultural and psychosocial factors include “poverty, racism, prejudice . . . discrimination . . . perceived health status, the lack of personal efficacy in contributing to decisions about health care, feelings of helplessness, and the lack of trust in the health care providers.”

Urban African-Americans tend to experience less respect from their providers and less opportunity to participate actively in their health care than other ethnic groups. This neglect results in different treatment plans offered by providers who are often skeptical about success. Furthermore, differences in culture frequently breed subtle discrepancies in meaning between a health professional and client due to differences in their culture. Prejudices may lead the professional to offer different diagnoses, treatments, prognoses, or even the way in which they say it due to their negative stereotypes of clients.³

While it is reasonable for a client to prefer an alternate treatment because of that client’s culture, it is not reasonable to withhold information or options because of something the clinician perceives in the client’s culture. Instead, practitioners need to consider a client’s culture when communicating and offering opportunities for a client to participate in his or her care.

Schim, Doorenbos, and Nagesh describe cultural competence on a developmental scale. Cultural competence includes not only ethnic, but also socioeconomic, gender, sexual orientation, and other situations in which diversity might lead to a different view of treatment options. Cultural competence develops cultural congruence - mutual humility and respect between provider and client. This competence gives a framework for the provider and client to be able to negotiate a treatment plan.

The cultural congruence of a client-provider interaction lies on a gradient. Three markers in this gradient are cultural awareness, cultural sensitivity, and cultural competence. The first is knowledge that variation exists. A culturally aware person is able to recognize patterns and understand variation that leads to particular choices. A culturally sensitive health professional recognizes “personal attitudes, values, beliefs, and practices” and uses communication skills to tune the message to the client. A culturally competent individual applies knowledge, experience, and attitude to each situation.

Anyone learning to be culturally competent aims to improve his or her ability to address client needs within personal situations. People with higher education tend to have greater cultural competence, but it is unknown whether this trend is due to curriculum or exposure to variables related to being educated.⁴

Alternative Medicine and Asians

An example of how lack of cultural sensitivity can lead to adverse outcomes is evident in a recent study that shows Asians and Asian-Americans tend to have a higher rate of dissatisfaction and lower rates of insurance. They also seek health care more than other ethnic groups. Much of any cultural insensitivity is due to a lack of understanding or addressing Asian forms of complementary and alternative medicine (CAM) during consultation and treatment. Another reason for cultural insensitivity is linguistic isolation, where a household has no members fluent in the language generally used in the community.

The lack of response to ethnic-specific needs in the health-care system results in reduced access to care and reduced expectations on the part of the potential clients, who are then less likely to seek health care. There was also an association of recent use of CAM with urgency of need of care. However, less than 10 percent of practitioners have ever discussed CAM with their clients.

The aforementioned study found that satisfaction with care increased when there was discussion of CAM. Satisfaction was evident in client perceptions of thoroughness, quality, and capabilities of their practitioner, the respect with which they felt they were treated, and the likelihood that they would recommend the clinic to others. As the study population increased their adaptation to the culture they were in, they continued to use CAM, using both “conventional” and CAM for their health care needs. However, frequent use of CAM therapies is associated with lower levels of self-perceived health.⁵

Elderly Minorities

Another study describes ethnocentrism as a factor in misdiagnosis as well as underutilization of health care and social services. Toofany (2006) reports in the United Kingdom that, although there are environmental, hereditary, and lifestyle factors involved, older minorities tend to have a greater number of chronic illnesses and report themselves to be in poorer health than do those of European descent in part due to discrimination, language barriers, and lack of access to care. Elderly ethnic minorities often face socioeconomic conditions that put them at higher risk of mental illness, yet mental illness is underdiagnosed due to the ethnocentricity of the diagnostic tests. Minorities may not use primary care and public health as much as needed due to their sense of institutional ethnocentricity. Hospitals accentuate this disenfranchisement with their intimidating and condescending air.

Assessing client’s needs in a cultural context includes considering:

• family support
• financial status
• religious practices
• dietary preferences
• health beliefs
• disease pattern
• alternative healing practices

Yet health professional education does not provide the needed training for most health professionals to address the needs of most minorities. Health professionals can improve their chances of providing culturally competent care by having interpreters, food, and information available in a wide enough range to meet the needs of all ethnic groups. Culturally competent services lead to a higher rate of acceptance of those services by their clients.⁶

Dental Hygiene’s Cultural Competence

The Oncology Nursing Society’s (ONS) concern for inclusiveness and diversity might be a useful insight for the dental hygiene profession to consider. Their guidelines for education “to enhance cultural competence” are:

• promoting cultural self-awareness
• disseminating cultural knowledge
• developing cultural skill-building
• facilitating cultural encounters

The ONS believes improving cultural understanding and diversity will benefit the organization, its members, and their clients.⁷ The same is true for dental hygiene. We are often the first or only clinician a client sees during an office visit, and we are usually the primary educators in an office. Furthermore, most of our work can be done without the stress of urgent need. In these conditions, cultural competence can be especially useful, not only for obtaining a client’s consent for a particular procedure, but also for developing a lasting, positive relationship that leads clients to seek the prevention and early intervention we promote.

The United States Department of Health and Human Services Office of Minority Health offers information and continuing education on cultural competency, which is available and free to all health professionals at http://www.thinkculturalhealth.org.

About the Author

Howard M. Notgarnie, RDH, MA, practices dental hygiene in Colorado, and has eight years’ experience in official positions in dental hygiene associations at the state and local levels.

References

1. Charles, C., Gafni, A., Whelan, T., & O’Brien, M. A. (2006, November). Cultural influences on the physician-patient encounter: The case of shared treatment decision-making. Patient Education & Counseling, 63(3), 262-267.

2. Johnston, M. E., & Herzig, R. M. (2006, November), The interpretation of “culture”: Diverging perspectives on medical provision in rural Montana. Social Science & Medicine, 63(9), 2500-2511.

3. Hewins-Maroney, B., Schumaker, A., & Williams, E. (2005, Summer). Health seeking behaviors of African Americans: Implications for health administration. Journal of Health and Human Services Administration, 28(1), 68-95.

4. Schim, S. M., Doorenbos, A. Z., & Nagesh, B. N. (2006, September/October). Cultural competence among hospice nurses. Journal of Hospice and Palliative Nursing, 8(5), 302-307.

5. Ahn, A. C., Ngo-Metzger, Q., Legedza, A. T. R., Massagli, M. P., Clarridge, B. R., & Phillips, R. S. (2006, February). Complementary and alternative medical therapy use among Chinese and Vietnamese Americans: prevalence, associated factors, and effects of patient-clinician communication. American Journal of Public Health, 96(2), 647-653.

6. Toofany, S. (2006, August). Cultural competencies. Nursing Older People, 18(7), 14-18.

7. Decker, G. M. (2006, November). ONS multicultural diversity statement. ONS News, 21(11), 15.

The Journal of Community Psychology Recommends Personal Development Strategies That Can Lead to Improved Cultural Competence:

• Self-Awareness and Stimulus Value: The clinician must understand how the culture has molded him/herself in order to be comfortable with clients having a different background. Conversely, the clinician needs to understand how one’s own characteristics may benefit or hinder clients’ acceptance of the clinician.
• Cultural Assessment: The clinician should understand where clients come from, how that affects their perception of care, and how well they have been acculturated to their current society.
• Pre-Therapy Intervention: A clinician or other personnel should provide an orientation for clients of the clinic and the services the clinic offers.
• Hypothesis Formation and Testing: The clinician may frequently decide that a client’s culture modifies treatment acceptance or effectiveness and may have to investigate further into clients’ lifestyles.
• Attend To Credibility Concerns: A client from a culture not familiar with our services will have more difficulty looking at the clinician as credible. Providing the client with a recognizable benefit of care will improve credibility in clients’ minds.
• Understand Discomfort and Resistance: Clinicians and clients are often uncomfortable with each other due to differences in their value systems. Addressing these differences will promote understanding of oneself and one’s client that can help to overcome resistance to care.
• Understanding Client’s Perspective: The clinician needs to know three things from the client’s perspective - How does the client perceive the condition to be treated? What would the resolution be in that client’s culture? What is the desired achievement?
• Strategy: Culture may influence how a treatment plan is carried out.
• Evaluation: When considering the effectiveness of treatment, the clinician should determine not only the improvements to health, but improvements in the relationship with the client.
• Willingness To Consult: No clinician can expect to be proficient in every culture, there is no shame in seeking help when needed.