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Enhancing the Development of
Cross Cultural Communication
ASPE 2005
Ms. Marilyn Guenther
Dr. Mark Fitzgerald
Dr. Marilyn Lantz
University of Michigan School of Dentistry
Introduction
• What is cultural competence?
• What is “culture”?
• Why is cultural competence important for oral
health care providers?
• How can we best provide educational programs
to develop cultural competence?
• Why use Standardized Patient Instructors in
these educational programs?
Why cultural competence?
• Improve health outcomes
• Increase quality of life for every patient
• Increase access to care for minority
populations
• Reduce oral health disparities
Kagawa-Singer, M. and Kassim-Lakha, S. 2003.
Academic Medicine 78:577-587.
What is cultural competence?
• Acknowledgement of the importance of
culture in people’s lives
• Respect for cultural differences
• Minimization of any negative consequences
of cultural differences
Paasche-Orlow, M. 2004 Academic Medicine 79:347-350.
What is cultural competence?
A matter of basic ethics:
Culturally competent care is a moral good
that emerges from an ethical commitment to
patient autonomy and justice.
Paasche-Orlow, M. 2004. Academic
Medicine 79:347-350.
What is “culture”?
• Dynamic, responsive coherent systems of
beliefs, values, and lifestyles that have
developed within particular geographic
locations, using technology and economic
resources; cultures evolve as needed to
adapt to changing environmental
conditions.
Kagawa-Singer, M. and Kassim-Lakha, S. 2003.
Academic Medicine 78:577-587.
What is “culture”?
Seven nested elements including:
environment, economy, technology,
religion/world view, language, social
structure, and belief and values.
Hammond, P. An Introduction to
Cultural and Social Anthropology.
New York: McMillan, 1978.
What is “culture”?
• An integrated pattern of learned beliefs and behaviors
that can be shared among groups and include
thoughts, styles of communicating, ways of
interacting, views of roles and relationships, values,
practices, and customs. Culture explains how we
explain and value our world, and provides us with the
lens through which we find meaning. We are all
influenced by and belong to, multiple cultures that
include, but go beyond, race and ethnicity.
Betancourt, JR. 2003. Academic Medicine 78:560-569.
Surbone, A. 2004. Annals of Oncology 15:697-699.
What is the role of “culture”?
• The purpose of culture is to teach its
members what to do to survive, how to
do it, and why they should persevere in
the face of adversity.
Kagawa-Singer, M. and Kassim-Lakha, S. 2003.
Academic Medicine 78:577-587.
Cultural competence and
oral health care
• Culture is fundamental to the development
and management of disease in every
population.
 Disease is a process; illness is what the patient
experiences
 Culture influences beliefs about the cause of
disease, how illness is experienced, what
treatments are appropriate, how treatments
should be provided, who should provide
treatment, etc.
Cultural competence and
oral health care
• Not taking culture into account in the
patient-dentist interaction can result in
significant miscommunication
• Miscommunication can result in under/non
utilization of care, poor compliance,
increased oral health disparities, poor
quality of life, poor treatment and health
outcomes
The conundrum – the Individual
• Culture is not “all defining”
• Variations on cultural themes exist within
subgroups as well as among individuals
• Individuals are unique, and each develops his or
her own interpretations of cultural “guidelines.”
• Seeing individuals only as members of their
“culture” stereotypes them
• Ideal - treat patients as individuals; maintain a
constant awareness of the potential impact of
culture
The Conundrum cont’d
Toward Resolution
• In reality, all patient-dentist interactions are
cross-cultural in some sense.
• The interaction between patient and dentist is
not about group differences; it is about
individual preferences
• Therefore, all dentists should develop, refine,
and enhance their cultural competence across
their professional lifetimes.
How we think about designing
educational programs to develop
cultural competence
Cross-cultural education –
a framework
Three conceptual approaches
 Awareness/Sensitivity Approach - attitudes
 Multicultural/Categorical Approach knowledge
 Cross-cultural Approach – skills and tools
Betancourt, JR. 2003. Academic Medicine 78:560-569.
Cross-cultural education –
a framework
• Awareness/Sensitivity Approach
• Primary focus is on provider attitudes
 Goal is to increase provider awareness of the impact of
sociocultural factors on individual patient’s health
values, beliefs, and behaviors and ultimately on the
quality of care and outcomes
 Students explore and reflect on culture, racism, sexism,
classism, etc. – discussed in terms of impact on dentistpatient interaction and clinical decision-making
Cross-cultural education –
a framework
 Significant overlap with professionalism
curriculum here
 Attitudes central to professionalism – curiosity,
respect, empathy, humility, sensitivity, and
awareness, are all required to fully consider all
of the outside influences on the patient, and
form the foundation for cross-cultural care
Cross-cultural education –
a framework
 Students must understand the feeling of being
“different,” and must develop an understanding of their
own “culture,” biases, and tendency to stereotype
 Students learn an appreciation for diverse health
values, beliefs, and behaviors
• This approach is primarily used during the
first two years of dental school
Cross-cultural education –
a framework
• Multicultural/Categorical Approach
• Primary focus is on increasing provider
knowledge of cross-cultural issues**
 *older approach of teaching unifying cultural
characteristics of cultural groups (patients of
culture x believe y.. and behave like z…) – lead
to stereotyping
 *new focus is on methods of community
assessment and evidence-based factors, e.g.
Cross-cultural education –
a framework
 ethnopharmacology
 historical factors that might shape health
behaviors
 disease incidence/prevalence among groups
• This approach is used throughout the four
years of dental school
Cross-cultural education –
a framework
• Cross-cultural approach
• The primary focus is on developing tools and skills
for providers
 Uses process oriented instruction to meld interviewing
and communication skills with sociocultural and
ethnographic tools to:
 Elicit patient’s explanatory model
(patient’s concept of illness)
 Assess patient’s social context
Cross-cultural education –
a framework
- Strategies for provider-patient negotiation
and facilitation of participatory decision-making
• This is a practical approach for the clinical years
of the DDS program.
• Standardized Patient Instructors (SPIs) are
particularly useful for teaching and assessing the
cross-cultural approach.
Why are SPIs particularly effective for
teaching cross-cultural skills?
• They provide reasonable consistency across role
portrayal, student assessment, and
feedback/discussion
• Standardization assures consistency, yet
reasonable variability can also be achieved – this is
important to avoid stereotyping (SPIs retain
certain aspects of their own identity with the role)
• A range of experiences can be assured for all
students
Why are SPIs particularly effective for
teaching cross-cultural skills?
• Students can practice their new and developing
skills in cross-cultural communication and receive
immediate feedback on their performance in a
“safe” environment
• Students can become sensitized to the need to
perform a RISK assessment (Kagawa-Singer, M. and
Kassim-Lakha, S. 2003) at each patient encounter
R
I
S
K
Provider’s
Culture
Provider
Provider’s
Cultural
Concept
of Health
-
Resources of patient and family
Individual identity and acculturation
Skills available for adaptation to disease
Knowledge about ethnic group
1
2
4
Negotiated Objectives
To Optimize Health
Patient’s
Patient’s
Culture
Culture
3
Patient
Patient’s
Cultural
Concept
of Health
Measurable
Practice Outcomes
Practitioner Behaviors,
Attitudes and Values
Behavior Change:
i integrity
m well-being
Client/Patient Behaviors,
Attitudes and Values
A note of caution –
challenge for dental education
• Be aware that dental students are in the
process of learning and reacting to the
culture of their schools and their
profession.
• Their identities are quite complex. They
are in a period of moral clarification and
adjustment.
Dental
Student’s
Identity
Natal Culture
Student
Subgroup
Culture of
Profession
Gender
Culture
Dental
School
Culture
A note of caution • Cultural competence curricula will force many
students to wrestle with the deep-seated ethical
tension between their own emergent ethical
commitments and ethical relativity.
• We need to make sure that we do not force
students to embrace the full spectrum of cultural
relativity.
• The task is to help them clarify how dentists may
maintain their own values and concurrently
pursue the values of cultural competence.
Questions?