Cultural competence: Developing best practices in dentistry

Between the growing number of non-natives in the United States and subsequent barriers to oral health care, it is imperative that dental care providers develop a set of best practices to meet the needs of people in the unique cultural landscapes in which they practice. In my article in the January issue, “Dental disparities among US immigrants,” we discussed health-care disparities among immigrants, communication barriers, and the struggle to acculturate to the Western mindset of modern medicine.

Why it matters

Culturally sensitive health care is believed to be effective for promoting not only improved systemic health but also oral health among immigrants.¹ Sensitivity awareness can help overcome feelings of powerlessness that immigrants may feel when they don’t belong to the dominant culture.¹ Whether relocation to the US is voluntary or involuntary, immigrants may experience culture shock as they integrate into their new social and cultural frameworks. Uprooted persons often experience a period of bereavement for loss of their known culture, feeling guilt, pain, and sadness, which can lead to problems with self-esteem and mental health. To further complicate the matter, host societies’ attitudes toward immigrants can compound feelings of stress already created by legal concerns, financial hardships, fear of unemployment, poor housing, and a lack of opportunities.

Attitudes, opinions, and beliefs of health-care providers can directly impact those at risk. To improve culturally sensitive care, the dental team can integrate a skill set that includes cultural awareness, appreciation for differences in worldviews, and understanding perceptions in dental-related illnesses.² In short, cultural competency empowers providers to tailor not only dental care to the individual needs of the patient, but also human care.

Five building blocks

Five basic principles are used as building blocks to cultivate optimal care in the dental practice. As one of the nation’s most influential advocates in health care, Dr. Josepha Campinha-Bacote developed the guidelines with the aim of bringing transcultural competence to health care. She believes developing cultural competence continually evolves and should be viewed as a process, not an end result.³

Benchmark cultural competencies

Value diversity (knowledge).
Conduct self-assessment (awareness).
Manage the dynamics of difference (sensitivity).
Acquire and institutionalize cultural knowledge (competency).
Adapt to diversity and the cultural contexts of communities they serve.

As the most basic principle, cultural knowledge is acquiring information about cultural characteristics of other ethnic or cultural groups. Doing so brings cultural awareness, or the idea of being open to different and changing cultural attitudes. Cultural sensitivity acknowledges the difference between cultures but does not assign values to those differences; that is, one is not considered more right or wrong than another. Finally, when all other principles have been brought together to an operational effectiveness that produces better patient outcomes, cultural competence is met.³ It’s important to remind ourselves that cultural competence does not hinge on perfection. An attitude of inclusion, understanding, and patience can prevail over social differences.

Race, ethnicity, and culture

Understanding the distinction between race, ethnicity, and culture is vital in changing perceptions about marginalized groups. Race categorizes humans by biologically distinct physical traits and geographic origin. Physical features related to race can include skin color, facial structure, eye color, hair color, and other physical traits. Some examples of race include Asian, Black, Hispanic, white, Pacific Islander, and Alaskan Native.

Where race is based largely on physical attributes, ethnicity denotes groups that share a common identity such as shared history, traditions, language, nationality, or cultural heritage. A few examples of ethnicity include Jews, Arabs, Irish, Italian, Caribbean, African, and Greek. Ethnicity can be tricky as there are subcategories and cross-cultural influences.

Culture on the other hand, is something that defines a person, and is something we’re taught by other humans. It includes values, beliefs, customs, and behaviors.² Religious symbols, traditions, laws, architectural style, and social expectations are all cultural elements that contribute to self-identity. Whether a culture is sociocentric or egocentric has a profound impact on an individual’s cultural identity.

Communication

Dental care team members can fine-tune intercultural communication to understand the appropriateness of gestures, the meaning of direct and indirect communication, and body language. Providers can gain a general awareness of a culture’s norms, and then explore a patient’s individual beliefs and values. In doing so, it will become apparent that each patient is different even within his or her own cultural context.² An appreciation of varying cultural convictions is crucial to caring for each patient as an individual.

Intercultural communication requires understanding attitudes and perceptions of personal space, physical gestures, eye contact, and communication styles. Direct eye contact is considered disrespectful by some Asian Americans and should not be interpreted as disinterest. In fact, in some Asian cultures, lack of eye contact is a sign of respect, especially in opposite gender patients or those of differing social statuses.

Many Indian-Americans use loud and direct communication, which can come across as rude and overbearing to their American counterparts.⁴ Interrupting or talking over the top of someone is common in many cultures. Interrupting may also stem from not understanding social cues or may be the result of thinking in one’s native tongue, then translating thoughts into spoken language.

Being open-minded when interpreting body language outside of our own cultural confines can prevent misunderstandings. Patients may nod in agreement even if they don’t understand. A language barrier, embarrassment, or respect may prevent some from asking questions. Head wagging by South Asians is often used to communicate, “I hear what you are saying,” as opposed to a form of disagreement. East Asians may smile from embarrassment and may find it difficult to directly refuse a request.⁴

Even with an interpreter, dental professionals should speak directly to the patient, using short sentences with simple terminology. Avoid using a child as an interpreter when possible. Low-touch societies, such as Asians, do best when procedures are explained beforehand. Orthodox Jews and some Islamic sects do not allow opposite-sex touching, so shaking hands should be avoided in these situations, and same-sex providers may be more appropriate for these patients to feel comfortable.⁵

When treating larger populations, dental practitioners must carefully differentiate between cultural and biological traits. A geographic cluster of oral cancer related to a racial trait is much different than the same produced by cultural practices such as the use of smokeless tobacco or dietary habits.⁵

Implementing best practices

The five essential principles of cultural competence can be used as a guideline to define best practices unique to each dental practice and the communities they serve. Adopting a “salad bowl” viewpoint instead of a “melting pot” philosophy forges communities by capitalizing on cultural diversity and acknowledges the valuable contributions of many cultures.⁶

The Partnership for Public Health Law recommends revising office policies and procedures to increase access to immigrants, but also to ensure profitability.⁷ Even small changes within a dental practice can have a positive impact on attracting and retaining immigrant patients.

Review current forms and questionnaires to make sure only necessary and relevant information is requested. For example, an SSN is not necessary for cash payments.
Provide linguistic competency that extends beyond the treatment room to include front office, billing, and treatment coordinators.
Consider publishing forms, questionnaires, and informational material aimed at local populations.
Create an online repository of forms, privacy practices, and materials in multiple languages.
Utilize volunteer opportunities and outreach programs to connect with immigrant communities, easing fears and encouraging care.
Develop consumer-friendly materials that address immigrant fears relating to public charge, reporting, and other myths.
When possible, recruit and retain minority and bicultural staff.
Assess and train staff by conducting an informal survey about perceived beliefs and barriers.
Develop training materials that address concerns and misconceptions. Assign a cultural sensitivity officer, much like you would for OSHA.
Ensure marketing and promotional tools include culture-specific attitudes and values.
Be open to the idea of including family and community members in health-care decision making.
Consider expanding your hours of operation.
Assure patients that information about other family members is not required for treatment purposes, with the exception of minor children needing parent or guardian consent.^7,8

As dental team members unite in their efforts to develop an inclusive environment that welcomes diversity, lives can be transformed. It’s been said that a smile is worth a thousand words, but which words remain the question. To answer that, we must learn to understand the individuals entrusting us with their oral health, but also increase our own self-awareness. Developing a set of best practices that embraces cultural knowledge, sensitivity, and competence will improve quality of care for all patients, including the immigrant populations that bring tradition, diversity, and culture to our neighborhoods and communities.

References

Batalova J, Shymonyak A, Mittelstadt M. Immigration Data Matters. Migration Policy Institute. March 2018. Accessed August 31, 2020. https://www.migrationpolicy.org/research/immigration-data-matters
Crespo E. The importance of oral health in immigrant and refugee children. Children (Basel). 2019;6(9):102. doi:10.3390/children6090102
Spotlight on immigrant women. Institute for Women’s Policy Research. Accessed July 21, 2020. https://statusofwomendata.org/immigrant-women/
Juckett G. Cross-cultural medicine. Am Fam Physician. 2005;72(11):2267-2274.
Hsu WC, Yoon HH, Gavin JR, Wright EE Jr, Cabellero AE, Tenzer P. Building cultural competency for improved diabetes care: introduction and overview. J Fam Pract. 2007;56(9 Suppl):S11-S14.
Building culturally competent organizations. The Community Toolbox. University of Kansas Center for Community Health and Development. https://ctb.ku.edu/en/table-of-contents/culture/cultural-competence/culturally-competent-organizations/main
Ambegaokar S. Opportunities for maximizing revenue and access to care for immigrant populations. National Health Law Program Partnership for Public Health Law. https://www.astho.org/Public-Policy/Public-Health-Law/Access-to-Care-for-Immigrant-Populations-Overview
Guidelines and strategies for cultural competency. Health Network Solutions. Accessed January 31, 2020. https://www.healthnetworksolutions.net/index.php/guidelines-and-strategies-for-cultural-competency

Nichole Jarnagin, BSDH, RDH, has been a dental hygienist for more than 20 years, practicing in both general dentistry and periodontics. She received her bachelor of science degree from Weber State University in Ogden, Utah, and has worked in Wyoming, Utah, and Texas. She currently lives in the Dallas Metroplex and works as a dental hygiene educator.