Noura A. Abouammoh

2.5 Cultural competence and patient-centred care

The literature review identified some opponents to the concept of cultural competence. For example, Dreher and MacNaughton (2002) argued that cultural competence is a fallacy. They declared that although individuals are considered “carriers” of their cultural traditions, the notion of cultural competence assumes that all patients from the same culture have the same belief system, whilst in reality, people differ in their level of adherence to cultural traditions. Unlike in the public health area where decisions and interventions are applied to communities in which the behaviours of the majority should be considered, health care services in clinics are dispensed to individuals, thus it is of great importance to appreciate the differences between people of the same cultural background (Dreher and MacNaughton, 2002). The authors, therefore, assume that cultural competence at the patient-provider level is merely another name for patient-centred care.

Cultural competence, in its essence, is about communication. Patient-centred care is a model of communication in this context (Stewart, 2001). Stewart et al. (2001) noted that:

“Patients want patient-centred care which (a) explores patients’ main reasons for the visit, concerns, and need for information; (b) seeks an integrated understanding of patients’ worlds – that is, their whole person, emotional needs, and life issues; (c) finds common ground on what the patient’s problem is and mutually agrees on management; (d) enhances prevention and health promotion; and (e) enhances the continuing relationship between the patient and the doctor“ (p. 445)

Evidence suggests that patient-centredness has a positive impact on the quality of care (Kinmonth et al., 1998, Stewart, 1995). However, it should be noted that, like cultural competence, different interconnected components play major roles in structuring the interaction process between patients and physicians, as shown in figure 2.2 (Aita et al., 2005).

Figure 2.2 Patient-centred interaction model (Aita et al., 2005).


The concepts of patient-centeredness and cultural competence are overlapped (Beach et al., 2006). Figure 2.3 shows features in which both concepts overlap at the interpersonal level.
• Curbs obstructive behaviour such as using technical language, frequent interruptions, or false reassurance

• Understands transference and counter transference

• Understands the stages and functions of a medical interview

• Attends to health promotion and disease prevention

• Attends to physical comfort

Patient-Centred Care

• Understands and is interested in the patient as a unique person

• Uses a biopsychosocial model

• Explores and respects patient beliefs, values, meaning of illness, preferences, and needs

• Builds rapport and trust

• Finds common ground

• Is aware of own biases and assumptions

• Maintains and is able to convey unconditional positive regard

• Allows involvement of friends or family when desired

• Provides information and education tailored to patient level of understanding

Cultural Competence

• Understands the meaning of culture

• Is knowledgeable about different cultures

• Works with local community

• Appreciates diversity

• Is aware of health disparities and discrimination affecting minority groups

• Effectively uses interpreter services when needed
Figure 2.3 Overlap between patient-centred care and cultural competence at the interpersonal level (Beach et al., 2006)
Both concepts are better applied under a culturally competent system, which can be characterized by: workforce diversity reflecting patient population; availability of language assistance; ongoing staff training to deliver culturally and linguistically competent service, and satisfaction of performance data by race/ethnicity (Beach et al., 2006).

Saha et al. (2008) argued that although cultural competence and patient-centred care overlap in many elements and have the same overall aim of improving health care quality, they differ in terms of the aspects of quality which they emphasize. The primary aim of cultural competence is to reduce inequalities in healthcare while the aim of patient-centred care is to provide individualized care (Saha et al., 2008). Additionally, some of the developers of the cultural competence models, for example Orque (1983) and Purnell (2000), warned against practicing unconscious cultural competence, which may overlook individual differences.

2.6 Summary

In summary, culturally competent care can only be developed through training, experience, guidance and self-evaluation. Additionally, the concept of cultural competence in health care has to be applied not only on a professional level, but also on an administrative level. The need for culturally competent care was recognised more than five decades ago. Since then, more attention has been given to the application of the concept of cultural competence through the development of its models, and clearer ideas concerning practicality were added to the notion of cultural competence. Cultural competence is a complex concept required to successfully meet the needs of patients of different cultural backgrounds from that of health care providers. Cultural competence can be learned and requires continuous reflection by health care providers. It can be understood that cultural competence is not a communication technique that one can master, rather, it is a way of thinking about, understanding and interacting with people (Dunn, 2002). Furthermore, the main focus of cultural competence models and frameworks is to avoid ethnocentric assessment in order to provide care that is responsive to the recipients’ perspectives. Last but not least, cultural competence and patient-centred care are two complex concepts that overlap in many components, yet differ in terms of the aspect of quality which they emphasize.

The concept and models of cultural competence were recognised and developed based on the common picture of local health care providers caring for a culturally diverse population however, it seems logical to assume that the notion of cultural competence in health care could be applied to international health care providers caring for local patients.