BY Ruwan Laknath Jayakody
In order to minimise disparities in access to and the delivery of healthcare, many Western countries have implemented cultural competence in healthcare facilities, and therefore, culturally competent physicians should be in possession of the skills needed to provide high-quality, holistic care to multicultural societies.
This observation citing O. Handtke, B. Schilgen, and M. Mösko’s “Culturally competent health care – A scoping review of strategies implemented in health care organisations and a model of culturally competent healthcare provision” was made in an editorial on “Culturally competent physician: A need of the day” which was authored by the Sri Jayewardenepura University’s Medical Sciences Faculty’s Professor of Pharmacology, C. Wanigatunge, and published in Journal of the Ceylon College of Physicians 52(1) in June 2021.
As Greek physician Aelius/Claudius Galen noted: “Science and medicine must be practised in the context of human desires and needs. To provide holistic care, a physician must understand the human being, his society, and the environment.”
Culture, as explained in J.R. Betancourt’s “Cultural competence – Marginal or mainstream movement”, is a pattern of learned beliefs, values, and behaviours that are shared within a group and includes language, styles of communication, practices, customs, and views on roles and relationships. M. Chandratilake, Y.G.S.W. Jayarathne and D. Karunarathne’s “Cultural beliefs and practices of the Sri Lankan public as experienced by clinicians” notes that each culture has its own core beliefs and practices which are influenced by societal norms, religious beliefs, personal experiences, and the practices related to traditional medicine, which in turn influence health and medical practices.
“Healthcare services in any country are accessed by culturally and linguistically diverse patients whose beliefs influence healthcare-seeking behaviours and adherence to its practices. Beliefs of cautiousness result in patients being extra careful beyond medical advice (e.g. avoidance of head baths during illnesses) while beliefs of contradiction may result in patients not complying with instructions (e.g. reluctance to use inhalers in the belief that the use of inhalers makes one dependent on them),“ Wanigatunge elaborated.
“In a system where alternative practices play a significant role, belief in alternatives could lead to patients having no faith in medical advice from an allopathic system and make them go looking for alternatives (e.g. those with epilepsy or mental illnesses trying exorcism in the belief that these are illnesses due to the influence of supernatural beings or going behind faith healers for cures for cancers or incurable diseases). Being culturally competent would help healthcare providers give better advice to patients and ensure greater compliance to such advice while reducing the disparities in accessing healthcare.”
In J.R. Betancourt, A.R. Green, J.E. Carrillo, and O. Ananeh-Firempong the Second’s “Defining cultural competence: A practical framework for addressing racial and ethnic disparities in health care”, cultural competence is defined as the ability of healthcare service providers and organisations to effectively deliver healthcare services that meet the social, cultural, and linguistic needs of patients.
“The goal of cultural competence in healthcare is to reduce health-related disparities and to provide optimal care to patients regardless of their race, gender, ethnic background, native languages that are spoken, and religious or cultural beliefs,” Wanigatunge added.
T.L. Cross, B.J. Bazron, K.W. Dennis, and M.R. Isaacs’s “Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed” mentioned that a culturally competent health system recognises and accepts the importance of cultural diversity at every level, assesses the cross-cultural relations, stays vigilant towards any changes and developments resulting from cultural diversity, broadens cultural knowledge, and adapts services to meet the needs that are culturally unique.
As R.C.L. Like, T.J. Barrett and J. Moon pointed out in their “Educating physicians to provide culturally competent, patient-centred care”, in order to provide culturally sensitive patient-centric care, physicians should treat each patient as an individual whilst recognising and respecting his/her beliefs, values and care-seeking behaviours. The failure to do so, according to Betancourt et al., could lead to mistrust, dissatisfaction, and decreased adherence, resulting in turn in poorer health outcomes.
“The concept of cultural competence gained importance with the recognition of the poorer health status and disparities in healthcare delivery to ethnic minorities and migrants in developed countries. Despite the absence of migrants, being culturally competent is also important for developing countries with their multi-ethnic and multi-religious communities and traditional medical systems that exist parallel to the allopathic system. The traditional systems in these countries play an important role in healthcare delivery and influence the health-seeking behaviour of the people,“ Wanigatunge observed.
In a particular suburban Sri Lankan population, per P. Senanayake, B. De Silva, A. Madumanthi, N. Madushani, K. Wijerathne, S. Sivayogan, and C.A. Wanigatunge’s “Healthcare-related behaviour among residents of a selected Medical Officer of Health area”, Ayurvedic health care was the preferred initial treatment for most, following fractures. “The influence of traditional systems was also amply demonstrated during the Covid-19 pandemic where people were extremely receptive to advice and treatment modalities originating from these systems despite the lack of evidence for efficacy or safety,” Wanigatunge further observed.
“Physicians in such countries would belong to cultures at variance with the values of the allopathic system that they have learnt and practised, which could in turn lead to conflicts. When faced with culture-related concepts, practitioners of the allopathic system may consider them unimportant or unscientific and ignore the patient’s beliefs if it does not fit with the bio-medical model. Alternatively, these beliefs may be entertained based on culturally biased thinking. However, neither will achieve the desired outcomes,“ Wanigatunge maintained.
“The modern Western medical system originated in the West and has values and norms which may at times be different to those in countries that practise the system. For example, the Western concept of autonomy where the individual takes his/her own decisions is not perceived in the same manner in other countries where the family plays a significant role in decision-making,” Wanigatunge mentioned.
According to Betancourt, this is widely encountered in caring for patients with malignancies where the family is against divulging the true nature of the illness to the patient. “The physician then faces a dilemma as their learning and practices are different to that of their patient’s expectations and values. Understanding and working with such issues will provide an ethically accepted compromise to inform the patient in a manner that is acceptable to the family,” Wanigatunge opined.
Wanigatunge pointed out that being able to communicate in the patient’s own language is important for effective communication. As Betancourt puts it, patients may present their symptoms differently from how physicians hear them or have learnt of them from textbooks. “Words may have regional nuances – for example, a single Sinhala word “hathiya” is used by patients to describe shortness of breath, wheezing or even chest tightness, and therefore, if not properly understood and explored by the physician, it can lead to a wrong diagnosis and management. The issues with language can be made worse if the physician is practising in a region where the primary language is not their own. Using interpreters – which in many instances is whoever is around that speaks the patient’s native language – results in information being lost in translation between the patient and their healthcare provider,” Wanigatunge further explained. Betancourt pointed out that while language competence is important, cultural competence is not merely the language skills needed to address language-related barriers.
“When faced with issues that are culturally diverse, physicians need to explore and reflect upon these issues from the patient’s point of view. It is equally important to express the physician’s own views, negotiate reality, and advocate appropriately. Such mutual understanding of issues will help the patient to be a partner in decision-making and illness management,” Wanigatunge emphasised.
“While healthcare professionals need to learn about the tolerance of others’ beliefs, it would be reasonable to encourage patients to also be culturally sensitive and be aware that not all healthcare providers are equally competent in diverse cultures. Patients should also try their best to communicate their concerns relating to their beliefs, values, and other cultural factors that might affect care and treatment, to their physicians and other healthcare providers. A bi-directional dialogue without preconceived ideas or prejudices is essential in order to improve the outcomes in clinical encounters,“ Wanigatunge also added.
“Cultural competence can be taught and implemented during clinical training and will provide physicians with the knowledge and skills needed to address cross-cultural issues in the clinical practice,” Wanigatunge noted. Per the Association of American Medical Colleges’ “Cultural competence education”, the US Liaison Committee on Medical Education added a standard for medical school education programmes to include cultural competency education within their curricula.
While this would, as A.G. Mainous, Z. Xie, S. Yadav, M. Williams, A.V. Blue, and Y. Hong put it in “Physician cultural competency training and impact on behaviour: Evidence from the 2016 National Ambulatory Medical Care Survey”, necessitate a rethinking of teaching and learning activities, it is possible to seamlessly integrate cultural competence training into medical education at different levels. Such training, as Betancourt elaborated, should include methods for eliciting the patient’s understanding of the illness and their condition. “Exploring the patient’s beliefs would provide the physician with an opportunity to educate the patient while avoiding costly investigations and medicines. An interactive, case-based discussion that highlights cultural issues related to patient management would be an ideal method for teaching cultural competence,” Wanigatunge recommended.
Local academic highlights importance of culturally competent physicians
29 Jul 2022
Local academic highlights importance of culturally competent physicians
29 Jul 2022