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Cultural competence: A critical factor in child health policy
CHILD HEALTH POLICY Column Editor: Stephanie L. Ferguson, PhD, RN
Cultural Competence: A Critical Factor in Child Health Policy Josepha Campinha-Bacote, PhD, RN, CS, CTN RIME, POVERTY, lack of education, lack of health insurance, and access to health care are just a few risk factors that effect children's physical and emotional health. Several of these risk factors are far more common among specific ethnic and cultural groups. However, there is a paucity of nursing literature that examines cultural issues in child health policy. This article will address information regarding cultural competence and child health, and make recommendations regarding a culturally competent model of policy development for child health issues.
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CULTURAL COMPETENCEAND CHILD HEALTH The health of a nation is largely determined by the health of its children and their families. Zimmerman (1997) states "the children of the United States can be considered in crisis because of inadequate health services" (p. 716). Policy makers have become concerned about the health care of children. Child advocacy groups, like the Children Defense Fund, have spoken out regarding the direct provision of healthcare services (Natapoff & Wieczorek, 1990). Using universally accepted indices such as infant morbidity and mortality, and prenatal care to measure maternal and child health, the United States ranks below many of the other industrialized developed countries (Zimmerman, (1997). When we look at specific ethnic populations, these statistics reflect a drastic negative trend. For example, among our African American population, the infant mortality rate is higher than in developing countries (Zimmerman, 1997). Policies addressing these concerns are beginning
From Transcultural C.A.R.E., Cinncinati, OH. Address reprint requests to Josepha Campinha-Bacote, PhD, RN, CS, CTN, 11108 Huntwicke Place, Cincinnati, 0H45241. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-001253.00/0 260
to emerge. However, the question remains are these policies culturally relevant to meet the needs and concerns of our ethnically/culturally diverse children and their families?
A CULTURALLYCOMPETENT MODEL OF POLICY DEVELOPMENT Cultural competence can be defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in crosscultural situations: (Cross, Bazron, Dennis, & Isaacs, 1989, p. iv.). The Culturally Competent Model of Policy Development (Figure 1, Campinha-Bacote (1997) is a conceptual model that views cultural awareness, cultural knowledge, cultural skill, and cultural encounters as components of cultural competence. In this model cultural competence is viewed as a process, and not an endpoint, in which one continually strives to achieve the ability to effectively work within the context of an individual, family, or community from a diverse cultural/ethnic background (Campinha-Bacote, 1994). Each component of this model will be discussed and examples of application to policy development will be provided. Cultural awareness is the deliberate and cognitive process in which one becomes appreciative and sensitive to the values, life ways, practices, and problem-solving strategies of an individual's cultural background (Campinha-Bacote, 1994). During this process one must closely examine their own personal beliefs, values, and cultural attitudes. "The United States is a heterogeneously populated country and absolute standards may not be accepted as universals . . . nurses need to know that there are many competing beliefs and many ways of analyzing ethical dilemmas" (Wolahan & Smith, 1990, p. 75). Journal of Pediatric Nursing, Vol 12, No 4 (August), 1997
CULTURALCOMPETENCE IN CHILD HEALTH POUCY
Figure 1. The CulturallyCompetent Model of Policy Development. Reprinted with permission from TransCutural C.A.R.E. (CampinhaBacote, 1994)
Seeking cultural awareness is necessary, for an individual has a tendency to be ethnocentric regarding one's own values (Campinha-Bacote, 1997). This ethnocentric perspective can result in a policy that reflects cultural imposition. As defined by Leininger (1978), cultural imposition is the tendency of an individual to impose his/her values, beliefs, and patterns of behavior upon another culture. Borkan and Neher's (1991) Developmental Model of Ethnosensitivity is a helpful tool that allows one to assess their level of cultural sensitivity. However, one must move beyond cultural sensitivity and awareness and obtain cultural knowledge. Cultural knowledge is the process in which one seeks out and obtains a sound foundation concerning different cultural/ethnic groups (CampinhaBacote, 1994). The goal of cultural knowledge in policy development and implementation is to become knowledgeable of specific health care variables that might effect health outcomes. Specific factors to consider are the ethnic/cultural group's health practices, high risk behaviors, hereditary and genetic diseases, health conditions, reasons for migration, health seeking behaviors, self-medicating practices, dietary practices, pregnancy and childbearing practices, perceptions of barriers to health care, perceptions of healthcare providers, variations in drug metabolism, occupation, and biological variations. The component of cultural knowledge is similar to Walker, Richmond and Buka's (1984) component of "securing a knowledge base" in developing public policy. Securing a culturally relevant knowledge base can be considered a culturally competent approach in the development of child health policy. However, to obtain cultural knowledge one must acquire cultural skill. Cultural skill is the process of learning how to directly access an individual's values, beliefs, and practices to formulate a culturally sensitive policy (Campinha-Bacote, 1994). To accomplish this, one must be skillful in a variety of culturally relevant
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research methodologies. Culturally sensitive research will provide data on the current health status of ethnically diverse children and their families, as well as the effectiveness of intervention programs in this target populations. Several authors have provided guidelines to direct research on ethnically diverse populations (Porter & Villarruel, 1993; Rogler, 1989; Campinha-Bacote & Padgett, 1995; Jones, 1992; Stanfield, 1993; Schulman, 1995). Finally, seeking cultural encounters with diverse populations will assist one in creating culturally relevant ways of thinking. Face-to-face encounters will allow one to validate, negate, or modify existing knowledge about specific cultural groups. These interactions will also contribute in the development of health outcome measures that are culturally relevant. The component of cultural encounters can assist one in developing a "political will" and "a clear social strategy." As defined by Walker, Richmond, and Buka (1984) political will refers to the process of generating resources to carry out the policies and programs: while social strategy refers to the plan by which one applies their knowledge base and political will. Cultural encounters can be used as a tool in developing culturally sensitive public policy. One can use cultural encounters as a political forum to generate cultural resources as well as a resource in planning how they will apply the knowledge in a culturally responsive manner. CONCLUSION
Cultural competence is a critical factor in child health policy. Cultural issues must be examined and addressed during policy formulation, implementation, and evaluation. The Culturally Competent Model of Policy Development, with its focus on cultural awareness, cultural knowledge, cultural skill, and cultural encounters has the potential to assist health care professionals and policy makers in developing strategies that will enhance cultural competence in child health policy.
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REFERENCES Borkan, J., & Neher, J. (1991). A developmental model of ethnosensitivity in family practice training. Family Medicine, 23(3), 212-217. Campinha-Bacote, J. (1997). Understanding the Influence of Culture, In J. Haber, B. Krainovich, A. McMahon & P. Price-Hoskins (Eds.), Comprehensive Psychiatric Nursing, Fifth Edition, pp. 76-90. St. Louis: Mosby-Year Books. Campinha-Bacote, J. (1994). The Process of Cultural Competence in Health Care: A Culturally Competent Model Of Care (2nd Edition). Cincinnati, OH: Perfect Printing Press. Campinlaa-Bacote, J. & Padgett, J. (1995). Cultural competence: A critical factor in nursing research. Journal of Cultural Diversity, 2(I), 31-34. Cross, T.L., Bazron, B., Dennis, K.W., & Isaac, M.R. (1989). Toward a Culturally Competent System of Care. Monograph produced by the CASSP Technical Assistance Center, George Washington University Child Development Center, Washington, DC. Jones, E., & Kay, M. (1992). Instrumentation in cross-cultural research. Nursing Research, 41, 186-188. Leininger, M. (1978). Transcultural Nursing: Theories, Concepts and Practices. NY: John Wiley & Sons.
Natapoff, J.N., & Wieczorek, R.R. (1990). Maternal-Child Health Policy: A Nursing Perspective. NY: Springer Publishing. Porter, C.P., & Villatxue|, A.M. (1993). Nursing research with African American and Hispanic people: Guidelines for action. Nursing Outlook, 41, 59-67. Rogler LH (1989): The meaning of culturally sensitive research in mental health. Am J Psychiatry 146, 296-303. Schulman, K.A., Rubenstein, L.E., Chesley, EE., & Eisenburg, J.M. (1995). The roles of race and socioeconomic factors in health services research. Health Services Research, 30, 179-195. Stanfield, J.H. & Dennis, R.M. (1993). Race and Ethnicity in Research Methods. Newbury Park: Sage Publications. Walker, H.M., Richmond, J.B., & Buka, S.L. (1984). Summary and recommendations for next steps. Monitoring Child Health in the U.S. Cambridge, MA: Harvard Press, pp. 199-227. Wolahan, C., & Smith, E. (1990). Ethics: Issues and Policies. In J.N. Natapoff & R.R. Wieczorek (Eds.), Maternal-Child Health Policy: A Nursing Perspective. NY: Springer Publishing. Zimmerman, M. (1997). Infants and Children, In J. Haber, B. Krainovich-Miller, A. McMahon, & P. Price-Hoskins (Eds.), Comprehensive Psychiatric Nursing, Fifth Edition, pp. 716-738. St. Louis: Mosby-Year Books.
Cultural Competence: A Critical Factor in Child Health Policy Josepha Campinha-Bacote, PhD, RN, CS, CTN RIME, POVERTY, lack of education, lack of health insurance, and access to health care are just a few risk factors that effect children's physical and emotional health. Several of these risk factors are far more common among specific ethnic and cultural groups. However, there is a paucity of nursing literature that examines cultural issues in child health policy. This article will address information regarding cultural competence and child health, and make recommendations regarding a culturally competent model of policy development for child health issues.
C
CULTURAL COMPETENCEAND CHILD HEALTH The health of a nation is largely determined by the health of its children and their families. Zimmerman (1997) states "the children of the United States can be considered in crisis because of inadequate health services" (p. 716). Policy makers have become concerned about the health care of children. Child advocacy groups, like the Children Defense Fund, have spoken out regarding the direct provision of healthcare services (Natapoff & Wieczorek, 1990). Using universally accepted indices such as infant morbidity and mortality, and prenatal care to measure maternal and child health, the United States ranks below many of the other industrialized developed countries (Zimmerman, (1997). When we look at specific ethnic populations, these statistics reflect a drastic negative trend. For example, among our African American population, the infant mortality rate is higher than in developing countries (Zimmerman, 1997). Policies addressing these concerns are beginning
From Transcultural C.A.R.E., Cinncinati, OH. Address reprint requests to Josepha Campinha-Bacote, PhD, RN, CS, CTN, 11108 Huntwicke Place, Cincinnati, 0H45241. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-001253.00/0 260
to emerge. However, the question remains are these policies culturally relevant to meet the needs and concerns of our ethnically/culturally diverse children and their families?
A CULTURALLYCOMPETENT MODEL OF POLICY DEVELOPMENT Cultural competence can be defined as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in crosscultural situations: (Cross, Bazron, Dennis, & Isaacs, 1989, p. iv.). The Culturally Competent Model of Policy Development (Figure 1, Campinha-Bacote (1997) is a conceptual model that views cultural awareness, cultural knowledge, cultural skill, and cultural encounters as components of cultural competence. In this model cultural competence is viewed as a process, and not an endpoint, in which one continually strives to achieve the ability to effectively work within the context of an individual, family, or community from a diverse cultural/ethnic background (Campinha-Bacote, 1994). Each component of this model will be discussed and examples of application to policy development will be provided. Cultural awareness is the deliberate and cognitive process in which one becomes appreciative and sensitive to the values, life ways, practices, and problem-solving strategies of an individual's cultural background (Campinha-Bacote, 1994). During this process one must closely examine their own personal beliefs, values, and cultural attitudes. "The United States is a heterogeneously populated country and absolute standards may not be accepted as universals . . . nurses need to know that there are many competing beliefs and many ways of analyzing ethical dilemmas" (Wolahan & Smith, 1990, p. 75). Journal of Pediatric Nursing, Vol 12, No 4 (August), 1997
CULTURALCOMPETENCE IN CHILD HEALTH POUCY
Figure 1. The CulturallyCompetent Model of Policy Development. Reprinted with permission from TransCutural C.A.R.E. (CampinhaBacote, 1994)
Seeking cultural awareness is necessary, for an individual has a tendency to be ethnocentric regarding one's own values (Campinha-Bacote, 1997). This ethnocentric perspective can result in a policy that reflects cultural imposition. As defined by Leininger (1978), cultural imposition is the tendency of an individual to impose his/her values, beliefs, and patterns of behavior upon another culture. Borkan and Neher's (1991) Developmental Model of Ethnosensitivity is a helpful tool that allows one to assess their level of cultural sensitivity. However, one must move beyond cultural sensitivity and awareness and obtain cultural knowledge. Cultural knowledge is the process in which one seeks out and obtains a sound foundation concerning different cultural/ethnic groups (CampinhaBacote, 1994). The goal of cultural knowledge in policy development and implementation is to become knowledgeable of specific health care variables that might effect health outcomes. Specific factors to consider are the ethnic/cultural group's health practices, high risk behaviors, hereditary and genetic diseases, health conditions, reasons for migration, health seeking behaviors, self-medicating practices, dietary practices, pregnancy and childbearing practices, perceptions of barriers to health care, perceptions of healthcare providers, variations in drug metabolism, occupation, and biological variations. The component of cultural knowledge is similar to Walker, Richmond and Buka's (1984) component of "securing a knowledge base" in developing public policy. Securing a culturally relevant knowledge base can be considered a culturally competent approach in the development of child health policy. However, to obtain cultural knowledge one must acquire cultural skill. Cultural skill is the process of learning how to directly access an individual's values, beliefs, and practices to formulate a culturally sensitive policy (Campinha-Bacote, 1994). To accomplish this, one must be skillful in a variety of culturally relevant
261
Cultural Competence
i
research methodologies. Culturally sensitive research will provide data on the current health status of ethnically diverse children and their families, as well as the effectiveness of intervention programs in this target populations. Several authors have provided guidelines to direct research on ethnically diverse populations (Porter & Villarruel, 1993; Rogler, 1989; Campinha-Bacote & Padgett, 1995; Jones, 1992; Stanfield, 1993; Schulman, 1995). Finally, seeking cultural encounters with diverse populations will assist one in creating culturally relevant ways of thinking. Face-to-face encounters will allow one to validate, negate, or modify existing knowledge about specific cultural groups. These interactions will also contribute in the development of health outcome measures that are culturally relevant. The component of cultural encounters can assist one in developing a "political will" and "a clear social strategy." As defined by Walker, Richmond, and Buka (1984) political will refers to the process of generating resources to carry out the policies and programs: while social strategy refers to the plan by which one applies their knowledge base and political will. Cultural encounters can be used as a tool in developing culturally sensitive public policy. One can use cultural encounters as a political forum to generate cultural resources as well as a resource in planning how they will apply the knowledge in a culturally responsive manner. CONCLUSION
Cultural competence is a critical factor in child health policy. Cultural issues must be examined and addressed during policy formulation, implementation, and evaluation. The Culturally Competent Model of Policy Development, with its focus on cultural awareness, cultural knowledge, cultural skill, and cultural encounters has the potential to assist health care professionals and policy makers in developing strategies that will enhance cultural competence in child health policy.
262
JOSEPHA CAMPINHA-BACOTF
REFERENCES Borkan, J., & Neher, J. (1991). A developmental model of ethnosensitivity in family practice training. Family Medicine, 23(3), 212-217. Campinha-Bacote, J. (1997). Understanding the Influence of Culture, In J. Haber, B. Krainovich, A. McMahon & P. Price-Hoskins (Eds.), Comprehensive Psychiatric Nursing, Fifth Edition, pp. 76-90. St. Louis: Mosby-Year Books. Campinha-Bacote, J. (1994). The Process of Cultural Competence in Health Care: A Culturally Competent Model Of Care (2nd Edition). Cincinnati, OH: Perfect Printing Press. Campinlaa-Bacote, J. & Padgett, J. (1995). Cultural competence: A critical factor in nursing research. Journal of Cultural Diversity, 2(I), 31-34. Cross, T.L., Bazron, B., Dennis, K.W., & Isaac, M.R. (1989). Toward a Culturally Competent System of Care. Monograph produced by the CASSP Technical Assistance Center, George Washington University Child Development Center, Washington, DC. Jones, E., & Kay, M. (1992). Instrumentation in cross-cultural research. Nursing Research, 41, 186-188. Leininger, M. (1978). Transcultural Nursing: Theories, Concepts and Practices. NY: John Wiley & Sons.
Natapoff, J.N., & Wieczorek, R.R. (1990). Maternal-Child Health Policy: A Nursing Perspective. NY: Springer Publishing. Porter, C.P., & Villatxue|, A.M. (1993). Nursing research with African American and Hispanic people: Guidelines for action. Nursing Outlook, 41, 59-67. Rogler LH (1989): The meaning of culturally sensitive research in mental health. Am J Psychiatry 146, 296-303. Schulman, K.A., Rubenstein, L.E., Chesley, EE., & Eisenburg, J.M. (1995). The roles of race and socioeconomic factors in health services research. Health Services Research, 30, 179-195. Stanfield, J.H. & Dennis, R.M. (1993). Race and Ethnicity in Research Methods. Newbury Park: Sage Publications. Walker, H.M., Richmond, J.B., & Buka, S.L. (1984). Summary and recommendations for next steps. Monitoring Child Health in the U.S. Cambridge, MA: Harvard Press, pp. 199-227. Wolahan, C., & Smith, E. (1990). Ethics: Issues and Policies. In J.N. Natapoff & R.R. Wieczorek (Eds.), Maternal-Child Health Policy: A Nursing Perspective. NY: Springer Publishing. Zimmerman, M. (1997). Infants and Children, In J. Haber, B. Krainovich-Miller, A. McMahon, & P. Price-Hoskins (Eds.), Comprehensive Psychiatric Nursing, Fifth Edition, pp. 716-738. St. Louis: Mosby-Year Books.