Noura A. Abouammoh

1.6 Summary

Eating habits and sedentary lifestyle adopted by most Saudi people have contributed to the increasing prevalence of T2DM, which is reaching epidemic proportions in SA. Patients with T2DM are mostly followed by IMGs who constitute around 80% of primary health care physicians.

The employment of large numbers of IMGs is needed in SA to cover health care service demands, yet this situation may have implications in terms of the quality of communication between doctors and patients, as they do not share the same cultural and/or linguistic background, and therefore may have an impact on the quality of the care delivered.

Chapter 2

History, definitions and models of cultural competence

2.0 Introduction

The compelling need for cultural competence has been recognized due to the current and projected change in the demographic makeup in most parts of the world (Kodjo, 2009, Papadopoulos et al., 2004). For example, the Office of National Statistics in the UK announced that migrants to the UK significantly increased from 154,000 to 212,000 in a period of 12 months, from 2012 to 2013. This change led to the existence of cross-cultural encounters in most fields, and the medical field is one example.

In multi-cultural communities it is probable that physicians from the local community have to deal with patients from another community who come from a different culture and may bring different health related beliefs, values and behaviours, than that of the physicians’ (Betancourt, 2004). This has led organizations and providers to acknowledge the importance of delivering culturally competent care to immigrant patients to overcome cultural barriers in the clinical encounter.

This chapter analyses the concept of cultural competence, its origin and definitions, as well as providing a historical overview of the various theoretical models.

2.1 Search strategy

In order to identify models of cultural competence, the researcher identified one bibliographic paper on a cultural competence model (Shen, 2004) using Google Scholar and used the ‘pearl growing’ technique to identify further relevant papers in this field. This technique involved retrieving reference lists and citations from the Shen (2004) paper and other related papers and following them up to grow the body of included literature. Information about the history and definitions of cultural competence were gathered from the identified papers and from a scope search in Google Scholar. Using the search terms ‘cultural competence’, ‘history of cultural competence in healthcare’ helped in achieving the aim of this search, which was to gather background information about cultural competence in healthcare. The search continued until no more significant materials could be found.

2.2 The origin of cultural competence

Madeleine Leininger, a nurse based in the US in the 1950s, and the founder of culture care theory, was the first to realize, the need for culture care to be incorporated into the holistic view of patients’ state. Leininger was the first to note that nursing care was uni-culturally focused, while the nation was rapidly becoming multicultural, and that health care provision for refugees, immigrants and minority ethnic groups could no longer be ignored. She believed that it is one of the patients’ rights to have their values, beliefs and needs met by their caregivers (Leininger, 1995).

She believed that the relationship between health professionals and patients should be built with a focus on achieving health and well-being. However, in order to achieve this, health care professionals should be aware of and provide culturally sensitive care to the culturally diverse population (Leininger, 1995).

Leininger presented the concept of culturally competent care as a pioneer in the belief that peoples’ health and care related beliefs and practices are significantly influenced by their cultures. Its goal is to assist and support people from minority ethnic groups to maintain and improve their health and well-being (Leininger, 1995). She recognised that the concept of “care” has different meanings in different cultures and can only be determined by examining peoples’ norms, beliefs, values and life practices that are learned, shared and handed down (Leininger, 1995).

In the mid 1950s, Leininger recognized that interpreting care, delivered by health care professionals, as culturally sensitive or not, is also complicated by the fact that, not only concepts of care, but health and illness states are also strongly influenced by culture.

Additionally, Leninger (1995) advised health care professionals not to judge patients from other cultures as ignorant or lacking modern medical knowledge as they may be simply accustomed to another form of medical knowledge for example, traditional medicine, which can be described as different rather than wrong. She also explained that the care provided by professionals who adapt their care according to patients’ expectations is more effective than that of professionals who expect patients to make all the adjustments.

Further research led Leininger to develop a Cultural Diversity and Universality Theory (CDUT) (Leininger, 1995). This theory focuses on differences, or “diversities” and commonalities, or “universalities” of care practices transculturally. It has practical features that are depicted by the Sunrise model (Figure 2.1) (Leininger, 2002).

Figure 2.1 Sunrise model (Leininger, 2002)

The Sunrise model describes the interrelationship of CDUT and presents culturally based factors influencing health, well-being and illness that nurses should think about when dealing with patients from different cultures. She preferred to think about this model as a cognitive map, rather than a theoretical model, that assists health care professionals to build the knowledge necessary to deliver culturally congruent care.

Leininger defined culture as:

“The learned, shared, and transmitted knowledge of values, beliefs, norms, and life ways of a particular group that guides an individual or group in their thinking, decisions, and actions in patterned ways” (Leininger, 1995, p.9)

Therefore, the theory made it challenging for health care providers to decide the dimensions in peoples’ culture that influence their health and shape their expectations of care. In the Sunrise model, which encompasses the practical features of the theory, these dimensions were identified and they are: technological factors; religious and philosophical factors; kinship and social factors; cultural values, beliefs and lifeways; political and legal factors; economic factors, and educational factors. All these factors, according to Leininger, are not independent but interrelated (Leininger, 1995).

The CDUT assumes that individuals’ experiences of indigenous care, or professional care shape the concept of care in different cultures and it is essential for health care providers to have a knowledge base about individuals’ expectations, that stems from their experiences, to gather information concerning differences and similarities in regards to health beliefs and practices (Leininger, 1995).

After acquiring information on peoples’ worldview and care expectations, health care professionals are expected to use one of the following three modalities with an aim to guide decisions and actions that best fit the situation. The modalities are: 1) Cultural care preservation and/or maintenance; (2) cultural care accommodation and/or negotiation; and, (3) cultural care patterning or restructuring (Leininger, 1995).

Leninger (1995) directed special attention to the role of religion in individuals’ health. She explained that religion, like culture, strongly influences peoples’ beliefs, interpretations and responses. For example, religion may propose teachings that discourage, or encourage, unhealthy behaviours such as smoking and alcohol abuse. According to her, religion can also be considered as a type of medicine. She suggested for example, that religious people, because of optimism related to their religious belief, may be less prone to the adverse health impact of psychological or emotional stresses. If practitioners are of a different belief system to their patients, misunderstanding can be expected. Therefore, practitioners should not only be aware of the different religion-related health belief systems, but should also understand these and take them into account in their discussions with their patients.

In general, it is important for healthcare providers to acknowledge differences and similarities between their culture and that of their patients, including all the cultural elements noted earlier, and to be sensitive to sub-cultural differences.