Cultural Sensitivity and Competence for Primary Care in Oral Health

It is being increasingly recognized that the effective delivery of health care to diversified populations, needs to take into account the cultural and sociodemographic characteristics of those who need care. These factors account for major disparities in the health status of these populations¹. This applies to oral health as well given the high prevalence of oral disease especially among poor, low-income minority populations. In addition, oral disease "may have a significant impact on general health (while) some poor general health conditions also may affect oral health status"².

In the health care context, providers need to "understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounters" as a way of correcting inequities in the delivery of care, improving outcomes, efficiency and patient satisfaction³. When, why, and how, patients go for care as well as their response to it including follow-up, and its outcome are also influenced by their experiences in the setting where care is provided.

The problem becomes more challenging when care is provided to low income persons of different cultural backgrounds and languages than those of the providers. Cultural competency skills facilitate access to health care providers and organizations, enabling them to understand and respond effectively to the needs of their patients. ⁵

Yet, there is no professional consensus on how this problem can best be addressed although in recent years, cultural sensitivity, cultural competence and language proficiency have been identified as skills necessary for reducing health disparities⁶ while also improving access, outcomes, efficiency and patient satisfaction.

Programs for Reducing Barriers to Access

In an effort to redress this problem both private and governmental research and service delivery programs have been implementing actions for eliminating sociocultural and language barriers that block access to quality health care⁸. The main targets are populations at higher risk, i.e., poor, minority group members and immigrants with limited English proficiency (LEPs) and different and diverse cultural orientations ⁹.

These programs are being implemented at a time of rapid structural changes in the health care delivery systems i.e., rapid diffusion of new technologies, complex methods of capital development, third party payments and insurance schemes, and reorganization of services that include changes in the sites or locations where services are provided, shifting familiar points of access to care, transportation, and the social environment of clinical sites. In addition, consumers are being exposed to multiple sources of information and misinformation, from direct marketing¹⁰ of services, personnel, and products and through traditional health beliefs and practices, self-prescribing, (and also the dispensation of specific prescriptions on demand,) sharing of prescriptions, and indiscriminate use of OTC medicines, etc¹¹.

Some Working Definitions

Culture     This refers to the learned, conventional social understandings, and the norms of behavior of a community or society and its products. Both clinicians and patients are guided by the respective cultural norms of their social groups and communities of reference, but neither individual practitioners nor patients can be appropriately described or understood as members of racial, ethnic or cultural groups.¹²

City dwellers are exposed to diverse influences of belief systems, norms, values and standards of behavior which may become part of their cultural systems¹³. These factors, and their status and roles as individuals within their families and in their communities, are among the key factors that modify their traditional cultures into subcultures of the larger society.¹⁴ The ways of life and cultural orientations of these populations are, in turn, functions of their social standing as conditioned by their education, occupation, religious beliefs, ethnoracial social characteristics, migration, and acculturation.

Cultural Competence   In health care, cultural competence refers to the knowledge base and skills of providers "...to recognize and respond to health related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy (in) an environment in which consumers feel comfortable discussing their cultural beliefs and practices in the context of negotiating treatment options"¹⁵.

How patients categorize their health conditions, the process of care and their response to advice and satisfaction with care are influenced by their socioculturally based beliefs and practices.

Cultural Sensitivity   That aspect of cultural competence that comes from a provider's demeanor and empathy for patients of different cultural backgrounds and life conditions than theirs. Cultural sensitivity is expressed by respect and consideration for those who have different health related value systems, beliefs and norms than those of providers.

Ethnocentrism and Stereotyping   These are the opposites to cultural competence and cultural sensitivity.

Ethnocentric behavior is a bias or prejudice manifested by considering one's own cultural orientation as superior and those who do not conform with it and its values as being ignorant, morally wrong and inferior; e.g. considering that a patient not knowing English has a handicap or disability or admonishing them because "English is the language of this country".

Stereotyping is the bias or prejudice that assumes that all members of an ethnic, national or racial group share the same norms of behaviors and belief systems. These behaviors are not conducive to the trust on which the doctor patient relationship is based.

REFERENCES

1. USDHHS, CDC, Healthy People 2010:Understanding and Improving112000, (1-4).

2. USDHHS, Centers for Disease Control, Healthy people 2010, "Oral Health", 21-3.

3. USDHHS, Office of Minority Health, "National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care", Op. CIT., 80873.

4. See Beaglehole, R., and Bonita, R. "Reinvigorating Public Health", The Lancet. September, 2000 (787f).

5. DHHS, Federal Office of Minority Health, 2000:

6. HRSA,BPHC Cultural Competence: A Journey) Office of Minority Health, AHCPR, Resources for Cross Cultural Health care, Assuring Competence in Health care: Developing National Standards and an Outcomes-Focused Research Agenda", Diversity Rx &HRSA, BPC

7. USDHHS, Office of Minority Health, "National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care", QpJ;;i!.,80873.

8. U.S.DHHS, Public Health Service, Health Resources and Services Administration, Council on Graduate Medical Education, Twelfth Report, Minorities in Medicine, May, 1998, xiii, and Clinton, W.J., Executive Order 13166 of August 11, 2000, "Improving Access to Services for Persons with Limited English Proficiency, Presidential Documents, Federal Register, vol. 65, No.159, August 16, 2000, (50121-50125}.

9. Sheldon, G.F. "Professionalism, Managed Care and the Human Rights Movement", Health Network & Alliance Sourcebook, N.Y. Faulkner and Gray,2,000 (18-35); USDHHS, Office of Minority Health, "National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care", Federal Register. 12.22.2000, (80865-80879).

10. USDHHS, PHS, HRSA, Council on Graduate Medical Education, Twelfth Report. Minorities in Medicine, May 1998, xiii, and Clinton, W. J. Executive Order 13166, August 2000, Improving Access to Services for Persons with Limited English proficiency" Presidential Documents. Federal register, vol. 65, no.159, August 16, 2000 (50121-50125

11. Kleinman, A., "Explanatory Models in Health care Relationships: A Conceptual frame for Research and Family-Based Health care Activities in Relation to Folk and Professional Forms of Clinical Care", Stoekle, J.D. (ed) Encounters Between Patients and Doctors: An Anthology. Cambridge University Press, 1987, (273-283) and Clark, M. "Biomedicine, Meet Ethnomedicine", Health Care Forum Journal, May/June, 1995 (20-29).

12. Cochran, C. E., Mayer, L.C., Carr, T.R., Cayer, N.J. American Public Policy: An Introduction. New York: St. Martin's, (4th edition), 1993 (259).

13. Huff, R. M. and Kline, M. V. "The Cultural Framework", pp. 483 ~, in Huff and Kline, Promoting Health in Multicultural Populations: A Handbook for Practitioners. Thousand Oaks: Sage, 1999, (481-499).

14. Huff, R.M. and Kline, M.V. "The Cultural Framework", pp. 483 et seq., in Huff and Kline, Promoting Health in Multicultural Populations: A Handbook for Practitioners. Thousand Oaks: Sage, 1999, (481-499).

Federal Register, 12/22/00, p. 80874.