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DRAFT CULTURAL COMPETENCE IN COMMUNITY HEALTH NURSING
Noel J. Chrisman, PhD, MPH
CULTURE AND COMMUNITY
When community health work is carried out with the community rather than on
families, agencies, or community members, cultural competence takes on even more
importance than is otherwise true. In this chapter, cultural competence is defined as
professional attitudes, practice skills, and system savvy for working cross culturally
(Chrisman and Zimmer 2000). Community health skills do not work or do not work well
unless both the community health worker and the sponsoring agency are culturally
competent; that is, both individuals and groups can work effectively with specific
cultures and across a variety of cultures. This chapter will examine what cultural
competence is at both individual and institutional levels and show how such competence
is essential in community work. Examples will be provided to help illuminate the
concepts and theories related to culturally competent community work. You are
encouraged to add your own examples and to think about how they are similar to or
different from the examples found here. You should also collect as many examples as
you can from your colleagues because we do not know the right answers for community
work—all of us are still learning. It is the examples that help to instill techniques in our
practices. But it is the set of theories, both practice theory and cultural theory, that allows
us to integrate and expand the meanings of these experiences.
The approach that I prefer to use in community work is Community Based
Participatory Research (CBPR) (Israel et al., 1998, Israel et al., 2001), but there are
others. A fundamental model for many types of community work was introduced by Jack
Rothman in the 1970s (Rothman 1995; see figure 1). CBPR goes beyond Rothman’s
typology. The approach involves a collaborative partnership in a cyclical, iterative
process in which communities of identity (as opposed to simply aggregates of people, see
below) play a lead role in: (a) identifying community strengths and resources; )b)
selecting priority issues to address; (c) collecting, interpreting, and translating research
findings in ways that will benefit the community; and (d) emphasizing the reciprocal
transfer of knowledge, skills, capacity and power (Israel et al., 2000
It is important to briefly review what Israel and her colleagues mean by these
principles. A collaborative partnership is one in which partners are equal and jointly
control all phases of the research project. It is a cyclical iterative process in contrast to
many standard linear research approaches in which assessment leads to priorities which
lead to action which lead to evaluation. As depicted in Figure 2, the model of
Community Partnership Research, stages are cycled through again and again and not
necessarily in order. Community of identity is a key concept in community work
because so much of public health science is based on populations and these are frequently
confused with communities. A population is an aggregate of people who share a
common attribute, but who do not necessarily interact among themselves. In contrast,
Israel and her colleagues (2000) discuss that identities in family, neighborhood, and
community are socially constructed through social interaction. “Community is
characterized by a sense of identification and emotional connection to other members,
common symbol systems, shared values and norms, mutual—although not necessarily
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equal—influence, common interests, and commitment to meeting shared needs” (Israel et
al., 2000, p. 5). When community health practitioners attempt to mobilize a population,
they frequently discover that there are not enough or strong enough bonds among
members to sustain working together.
The collaborative (a) works with community strengths and resources. Not only
does this approach avoid the demeaning attitude of some community researchers who
refer only to problems (McKnight 1995), it also will identify those issues on which
community members are likely to spend their time. (b) The collaborative also selects the
priorities. This contrasts strongly with much academic research in which university
scientists acquire grant funding to work on a particular disease in spite of what
community members may think needs work. By being fully involved with the entire
research process (c), the collaborative is able to avoid such common pitfalls in
community work as lack of access to the population or misunderstanding what people
have been saying. Finally, (d) the transfer of knowledge, skills, capacity and power
ensures that community members and community health professionals alike benefit from
the community research process.
Why is it called research? Israel and her colleagues use this term because they
carry out research along with their community interventions. Such research is necessary
so population-based community health workers can begin to specify the methods,
techniques, and theoretical perspectives that will be successful in the use of community
dynamics to improve and promote the health of populations. In addition, most of the
reports of community projects to be found in the literature are paid for by research funds
and the teams carrying out the community work are committed to a process of discovery,
to identify how CBPR works.
The crucial importance of cultural competence is salient in this description of
CBPR. All the basic elements are powerfully influenced by cultural factors. For
example, maintaining a partnership requires recognizing each partner’s wants and needs
as well as culturally approved ways to interact, such as maintaining the culturally
appropriate distance between people having a conversation (Hall 1959) or recognizing
the meanings of tones of voice. We have mentioned the importance of assets and
resources for CBPR, but it is also essential to recognize that these are culturally
influenced. An outsider might see just a coffee shop, whereas the cultural insider
recognizes it as the “office” of a community leader. In addition, community resources
may not be equally accessible to all groups in an area if the resource (laundromat, library,
park) is believed to be the “turf” of one or another ethnic group (Suttles, 1968).
Community meanings and priorities also affect the process of translating and presenting
assessment findings to the community. In some cases, an epidemiological assessment
that teenage pregnancy is not a problem is ignored by a morally outraged community.
Cultural competence (discussed in more detail later in the chapter) is not just a
narrowly constructed skill such as monitoring blood pressure or a complex set of skills
such as patient counseling, it is a whole set of attitudes and capabilities that must be part
of practice with individuals, families, groups, and communities. The essence of cultural
competence is knowledge, attitudes, and skills that allow practitioners to understand the
culture as well as the ability to translate that understanding into community health
programs that fulfill both the need for health promotion/disease prevention and
community members’ needs to maintain cultural practices. Although part of cultural
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competence requires heightened awareness of differences and an ability to relate to
people from a different culture (Vance 1999; Wenger 1999) it goes beyond these
significant attributes to the realm of action. Cultural competence involves acting in ways
that will promote people’s cultural goals as well as their health. Campinha Bacote (1999)
states that cultural competence is not an endpoint; instead it is a journey characterized by
constant learning—from our mistakes and from theoretical and methodological advances
reported in the literature.
One reason that cultural competence is seen as a journey and is oriented toward
discovering fluid and flexible cultural patterns is because of the nature of culture itself.
There are a number of definitions of culture found in the literature and used in this
chapter. One, for example, is that “culture is a learned, shared, and symbolically
transmitted design for living” (Chrisman 1991, p. 45). Culture is a design, a set of
guideposts or expectations, not a hard and fast group of rules. Thus, there is a great deal
of variation in people’s behavior even when they and others believe they share the same
culture. In addition, culture is constantly recreated through interactions among its
members. By holding oneself and others to cultural expectations, each of us contributes
to the continuity of those expectations. Community activities are influenced by an
elusive and complex cultural design. Thus, community workers experience patterns or
tendencies in behavior rather than a parade of particular customs.
Doctors and nurses who work with patients in primary care or in hospitals usually
understand cultural competence as their knowledge of specific health beliefs and
practices characteristic of American ethnic groups and patients who arrive from other
countries (e.g., the medical web site, Ethnomed; or Giger and Davidhizar, 2004). Thus,
they want to know the kinds of religious practices, food habits, and folk remedies used by
a particular ethnic or immigrant group so they can work with or around these
characteristics. This probably derives from their experience of culture as the behaviors
that impede their provision of care. In part this is the result of the degree to which
European American cultural patterns are embedded in the practice of western
biomedicine, the dominant medical practice found in the United States. Ethnocentrism
(the belief that the ways of life found in my culture are correct, see below) may lead
clinicians to judge cultural specifics as odd, and usually “wrong.” With these beliefs,
they are prevented from learning that people from other cultures are likely to view their
lives in a very different way from the clinicians (see Fadiman 1997 for an example of
conflicts in beliefs and practices among patients and practitioners).
CULTURE
We have been using the concept of culture without having examined it. Now,
let’s look at this complex and confusing concept and its relationships with health and
community. The last two to three decades have seen a great deal of attention to this
century-old anthropological concept. Fewer people nowadays automatically think that
culture means to go to the opera or ballet; or that culture is the set of bacteria growing in
a petri dish. With a rapidly diversifying population, more attention to immigrant and
refugee groups, and the legacy of the civil rights and women’s movements, the notion of
culture is meaningful to a majority of American citizens. Yet now it means too many
things. One of the damaging things it means to many Americans is “culture is the odd
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beliefs and behaviors of those other people.” For example, some European Americans
state that they have no culture; they are “American,” as if there were no American
culture. This approach is not only incorrect; it is detrimental. It implies that these others
from different cultures are somehow inferior; after all, the standard must be European
American.
Another damaging perspective arises from health care providers (and many other
Americans) who argue that culture includes aspects of our diverse American society such
as “race,” class, gender, age, disabilities, and the like. This position confuses the
professional anthropological view of culture as a set of perspectives, experiences, or rules
with the notion of personal and group differences that may be based on a variety of
human characteristics. Moreover, “race,” class, gender, and the like tend to be viewed as
qualities of the individual, whereas culture is necessarily interactive and collective. It
only exists in the company of people in relationships.
Culture is defined variably by many authors. A number of these are included in
the chapter. I tend to use a simple definition: Culture is a learned, shared, symbolically
transmitted design for living (Chrisman 1991, p. 45). This definition can be used in both
individual and community-level practice. Culture is learned; we cannot decide on the
basis of a person’s appearance that he or she has a certain culture. Probably more
important is that the conditions under which one’s culture is learned affect how culture is
constructed for that person or group. For example, men learn a somewhat different
version of the culture than women. This is where race, class, gender, sexual orientation
and the like fit in. Because of discrimination, population subgroups are exposed to the
culture differently and thus carry a different version from some other people. This also
means that what was learned can be changed.
Culture is shared; when we are curious about whether an activity or set of beliefs
is cultural, we can find out whether others in the same group have these same beliefs and
behaviors. Just as important is that when culture is shared, we will know that our
culturally appropriate activities and messages will be interpreted in roughly the same
way. This is significant when designing and implementing community-level
interventions that will be understood and acted upon by community members.
Finally culture is symbolically transmitted. Use of symbols is an essential
human characteristic. As college students learn in basic English courses, symbols are
words or objects that stand for something else, usually something much more complex
than the symbol itself. For example, for decades, the symbol for a nurse was a starchy
white cap. For many people it still is. That symbol (like the doctor’s white coat) conveys
professionalism, science, and caring, among other qualities. Culture can be defined in
terms of symbols (see the Geertz definition in the box). This means that much can be
communicated through a symbol, including feelings and beliefs. Language is the primary
cultural transmission mechanism, but non-verbal communication is also important. The
implication of this last feature is that if we are working in an ethnic community in which
a language other than our own is spoken, we will need to learn as much of that language
as possible. It also means that we should learn central features of body expression as
modes of communication. A famous example concerns the Thai; for them, it is offensive
while sitting on the floor to face the soles of your feet toward others. Another example
concerns the reactions of white people to the loud and animated speech of many African
Americans. And in like measure, African Americans are sometimes put off by the quiet
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withdrawal of whites in a stressful situation. Knowledge of these subtle but powerful
means of communication is crucial in community organizing because fragile relationships
may not survive unintended meanings. Part of individual cultural competence is an
attitude of open discovery and acceptance and the practice skill to interact in such
contexts. Equally important is working together to identify these cultural barriers and to
discover ways to work around them. Instituting such a dialogue (i.e., negotiation as
discussed below) is one way to build trust.
Culture is:
• A system of symbols which acts to
• Establish powerful moods and motivations
•
•
•
in humans by
Formulating conceptions of a general order
of existence and
Clothing these conceptions with such an
aura of factuality that
The moods and motivations seem uniquely
realistic.
Geertz, 1973
It is very important to distinguish between the definition of culture as a
phenomenon and the existence of many different specific cultures. The same word,
“culture,” is used for both. Particular cultures are the historically constructed designs for
living associated with a society or group; Thai culture, Mexican culture, and the like. For
specific cultures, the community practitioner will want to know as much as possible
about the values, beliefs, customs, and other patterns likely to be associated with that
culture. The general definition of culture should be brought to mind when behavior
around you is odd and you are looking for an explanation. The concept of culture should
be one of the explanations available to you as you work in a community. Americans in
general tend to think psychologically so we ascribe odd behavior to mental aberrations.
A psychological intervention to solve an essentially intrapersonal problem is logical and
likely to be successful. However, if the issue is cultural and therefore interpersonal,
individual approaches will be undermined once the person goes back to his or her family
and culture. The beliefs and behaviors are normal in that context and there is no reason
for change. Once you think that culture is implicated (vs. poor mental health or bad
manners), then to intervene you should know more about the specific culture. What are
the values and beliefs that seem to be promoting the odd behavior you are watching?
Here the concept of cultural relativism is important. Cultural relativism is the
ability to observe and listen to indications of culturally patterned beliefs and
behaviors from the perspective of that culture, not one’s own (Chrisman 1991).
Cultural relativism aids community health workers to reduce their ethnocentrism and that
in turn facilitates an accurate view of the person’s or community’s cultural context. Once
the cultural context is known, it is possible to deal with the problem by including the
values and beliefs of that culture in your work with the family or community. For
example, a community worker could experience rejection as a number of Chinese elders
refuse to have their blood taken during a diabetes screening program in their
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neighborhood. If this action is taken to be a mental aberration or an indication of
grumpiness, the clinician would miss the opportunity to assess further. With an accurate
and culturally appropriate assessment, he or she would discover that many older Chinese
immigrants believe that they have a fixed amount of blood and each loss reduces energy
and ultimately life.
As you assess for values and beliefs (see below for a discussion of these terms) of
the community with which you are working, you discover more detail about the beliefs or
behaviors that you once thought odd. More important, however, is that you learn the
basic building blocks for constructing a culturally appropriate intervention. Since all
health promotion and disease prevention projects aim to affect behavior (and sometimes
beliefs and attitudes), the approach must always be cultural. Remember that beliefs and
behaviors are part of the design for living. Knowing the community’s culture (or set of
cultures if the community is diverse) increases your flexibility and creativity. You have
many more options for design than current culture-bound designs in community health.
Race, Culture and Ethnicity
For some Americans, the idea of culture is confused with “race.” Although
anthropologists have written and lectured for a century that “race” and culture are
separate phenomena, many Americans still adhere to the idea. After all, they might
argue, it makes common sense (but common sense is always culture-bound) because
people who are identified as belonging to a particular “race” frequently believe and
behave in similar ways. There is always a great deal of within-group variation, but
stereotypes sometimes ring true. The difficulty is that culture refers to learned behavior
and “race” is believed to be biological. Recent recognition by medical scientists of what
has been known for decades by biologists and anthropologists is that “race” is not a
scientific biological category; that is, it is not based on specific genes, the basic building
blocks of life. “Race” in the United States is a culturally constructed mixture of skin
color, facial contours, and hair texture. (These ideas will be discussed in more detail
below.) The reason that “race” is included within quotation marks is to highlight its
contested meaning in American culture (see Williams, Lavizzo-Mourey, & Warren 1994
for a good discussion).
“Race” and culture may be distinguished by example. People of the same race
may have extraordinarily different cultures. For example, the United States is home to
many different groups of people referred to in the 2000 census as “Asian.” These include
Chinese Americans and Japanese Americans who have been in the U.S. for more than a
century, Koreans with a shorter history, and a large heterogeneous group of Southeast
Asians (e.g., Hmong, Vietnamese, Lao, Mien, and Thai) who are recent immigrants and
refugees, having arrived in the last three decades. There are massive cultural and
linguistic differences among these groups who carry the same outdated “racial” label.
Americans base their judgments of “race” on skin color and other physical
characteristics. Behavior is the result of a large number of forces and is only related to
skin color because of social and political patterns of discrimination that have existed for
centuries in the United States.
This difference between “race” and culture makes a difference in community
health projects too. A significant problem can arise when practitioners believe that
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members of the same “race” have community relationships with each other and share a
common culture. This judgment is frequently the consequence of confusing population
(people who share a common characteristic) with community (people who share common
values and interaction patterns). CBPR projects must build on existing community ties
and if these are not present, the task of mobilizing the community is made more difficult.
Moreover, people place different meanings on health promotion and disease prevention
activities. Assuming that when people look similar (i.e., share the same “race” based on
color) they will share cultural meanings is dangerous.
One example can be taken from a community-based secondary prevention project
involving diabetes in Seattle Washington. The funding agency (Centers for Disease
Control and Prevention, CDC) required that “racial” groups had to be the target of the
REACH 2010 intervention (Racial and Ethnic Approaches to Community Health). The
Seattle project was aimed at African Americans, Latinos, and Asian Americans and
Pacific Islanders. Agencies for each of the three “racial” groups received the same
amount of money to carry out the intervention. The agency serving the Asians spent
much more money for materials and personnel than was spent by the African American
group because of cultural and linguistic differences within their target population.
Survey instruments had to be translated into five languages; five group facilitators who
spoke the appropriate language had to be hired; five types of group interaction styles had
to be accommodated. The Latino agency dealt with only one language (with its attendant
costs for translation and appropriate personnel), but still had group members from a
variety of Latin American cultures.
Another area of confusion is “race” and ethnicity. Ethnicity is a concept that
refers to a group’s beliefs in common heritage, values, and identity. An ethnic group
may distinguish its boundaries from other groups with markers such as food, ceremony,
dress, and housing decorations or style (Nash 1989), all of which imply beliefs and
behaviors. In contrast, race is supposed to be a biological concept. That is, Americans
think of race as having to do with biology. If we think in terms of biological science, this
would mean that genes are involved. In fact, serious work in the life sciences over the
last two decades has shown that “race” is much more involved with outward physical
characteristics—known as phenotype—such as skin color. Phenotype is the physical
expression of an organism’s genotype—the complement of genes inherited from one’s
parents and broadly shared within a population. A biological judgment about who
belongs to which population must be based on genotype since that is what is inherited
and also transmitted to the next generation. Phenotype varies because of a wide variety
of environmental factors and is not inherited. Work in the field of genetics over the last
decade has clearly shown that it is impossible to show consistent genetic differences
between what we have always called “racial” groups. In other words, it is not possible to
distinguish races biologically, only culturally and socially.
Thus, in contrast to what we imply about “race” as a demographic category that is
constantly used in health statistics, “race” is a cultural phenomenon. Racial
categorizations depend on the opinions of the people who designate “race” and these
categories are impossible to measure using biological science. Nonetheless, “race” and
ethnicity can be used as categories on which community interventions may be based. It is
essential to avoid assuming that “race” implies an existing social organization that can be
mobilized. Of course there may be numerous organizations that serve members of a
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“race,” but it is not because of their physical characteristics; it is because they feel a sense
of belonging together—i.e., ethnicity.
There are other indicators of cultural differences within the United States that are
like ethnicity, but based on different foundations. For example, religion provides people
with a sense of their common values and the feeling of belonging together. Religion may
cross ethnic groups; e.g., European Americans may be Protestant, Catholic, or Jewish. It
is very important to avoid linking an ethnic group such as Latinos with a church such as
the Catholic Church since the generalization does not always hold true. The same is true
for Middle Eastern ethnic groups and Islam. Certainly large proportions conform to the
expectation but some do not. There are many ways that Americans are similar and
different (see figure 3 about diversity and difference). Some of these elements of
difference more easily allow for interacting groups; e.g., ethnicity, religion, or sexual
orientation. Others do not necessarily easily provide for group formation; e.g., gender,
age, or personality. Obviously any of these differences can be the foundation for a group.
But some will require another social characteristic. For example, gender is a powerful
organizer, but it is too general. Thus, education might cross-cut gender as in University
Women’s Clubs; or social class might cross-cut sexual orientation with relatively affluent
gay men and their sense of identity as part of a gay movement or membership in ‘Act up’
or other activist groups. The same is true for race and ethnicity to some extent.
Thus, it is essential to carry out a careful assessment to confirm the degree to
which particular cultural characteristics actually contribute to group behavior. Basing
programs on stereotypes (e.g., that all Latinos are Catholic; that all men who have sex
with men are members of the gay pride movement; that the Black population is a
community) is dangerous. The community health practitioner should document group
patterns so that programs are based on the group’s experienced reality. This helps
support group ownership of a project.
This does not mean that we ought to be purists about “race,” ethnicity and other
group characteristics in our work; the categories are real enough in everyday life. The
implications have to do with community organizing. Do not assume that a racial group
includes people who share a common culture. Remember that black Americans may be
members of a variety of different cultures just as there is an incredible variety of cultures
lumped with the term “Asian” or “Latino.” In addition, differences in social class cross
cut each racial group, further complicating the picture as we attempt to organize people
around common cultural values. Cultural competence requires that we know that such
variations exist and that we are able to learn how to work within these cultures without
assuming culture from “race” or, to put it another way, without assuming behavior from
color. Moreover, racism—discrimination based on purported racial categories
(Barbee 1993)—is an intensely damaging aspect of community. Racist attitudes and
behaviors of people within the organization for whom the practitioner works and among
community members involved in a community health project can be very damaging. For
example, if the community worker staffing a coalition of African American harbors racial
ill will toward that population, coalition members are sure to sense it and it will take a
great deal of time and energy for the person to slowly build the trust necessary to work
with the coalition. Importantly, the worker will probably become less racist through this
essential process of working closely with people. Nothing reduces stereotypes and
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discriminatory feelings better than consistent interaction, particularly eating together (as
is done with most successful coalitions).
“Race” and racism are significant issues for all health practitioners, but especially
for those who work in the community. Given the underlying principle within nursing, for
example, to work for social justice, all nurses are or should be concerned with these
topics. Nursing stands for providing high quality care to all patients and communities
and this particularly includes those who are excluded in many other aspects of life—
mostly poor people and people of color. In addition, discrimination and poverty are
significant societal-level factors that have systematic and widespread effects on the health
of the public (the ‘social determinants of health’).
CULTURAL CONCEPTS AND COMMUNITY PRACTICE
Next we will begin to use the culture concept and its components as a tool to
design and carry out community health projects. Three component concepts within
culture are custom, belief, and value (Chrisman and Zimmer 2000). Customs are
behavioral regularities related to the continuity of social relationships that contribute
meaning to life. Beliefs are “propositions accepted as true” (Goodenough 1963).
Values are cultural standards that are used to judge the worth of one’s own or others’
attitudes, beliefs, and behaviors (Chrisman 1991). These three concepts provide a
beginning understanding of factors that influence whether and how a community health
project is carried out. In all cases, the culturally appropriate community assessment
needs to include as much information about these cultural factors as possible (see below
for a discussion of the assessment process).
Customs
Customs are like habits in that they occur over and over again. However, in
contrast to habits that have mostly individual meaning, customs are meaningful for the
whole cultural group (given lots of human variation of course). A custom is a shared
behavior pattern that contributes to the persistence of social relationships. Customs
include dietary practices (both the foods and the cuisine), religious observances (that may
be more subtle than a typical western observer might notice), styles of interaction (e.g.,
loudness and softness of voice, distancing, warmth, aloofness, and touch), and family
structure (such as an extended versus a nuclear family). The community practitioner will
want to assess for customs relevant to the planned project and work with community
members so the customs are included in the intervention plan. For example, a number of
studies have pointed out that Latinos in parts of the U.S. tend to believe that a diabetic
diet does not fit their cultural preferences. Family members state that the food is for
Anglos and that it is too expensive (e.g., Hunt et al., 2000). Moreover, the recipes and
menus available in standard interventions have not been aimed at these cultural groups.
Certainly, these practices are changing—e.g., the American Diabetes Association (ADA)
prepares materials in Spanish aimed at Latino eaters. An approach more in keeping with
CBPR and with culturally appropriate activities is to work with representatives of that
population to adapt the ADA materials to the particular community with which one is
working. This process encourages a more intimate, familistic, interaction style that might
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be more familiar to Latinos and allows for local variation in practice and taste to be taken
into account.
This same process should be used with other customs as well. For example,
interaction styles vary across cultures and can be a significant source of conflict when
they are not known and respected. The more boisterous demeanor of people from some
American subcultures may put off European Americans, while the reticence of others
may lead community workers to believe that they are not interested in the project. This
becomes a particular problem when the community health professionals from one ethnic
group (including European Americans) are seen to be overbearing and uncaring,
potentially reinforcing the stereotypes held by members of another ethnic group about
those health care practitioners. These seemingly minor, nearly invisible, problems can
stop a promising project. For example, in one case, an African American practitioner
working with a primarily Asian population was reported to be insensitive and overly
focused on bureaucracy. This person had a great deal of difficulty working with
community members. In Miami, there is a great deal of conflict between Cuban health
care providers and Haitian patients, and African American health care providers with
Haitian and Cuban patients. There is also conflict between health care providers of the
groups. Much has to do with health beliefs, but a greater part is due to social, economic,
and racial factors. Naturally, European American nurses and other practitioners find
themselves in these situations frequently. Cultural competence techniques discussed
below help reduce these tensions a great deal.
Beliefs
Beliefs also need to be included in the assessment. Remember that these are
“propositions accepted as true.” Frequently biomedical health care providers will
evaluate community beliefs in terms of their congruence with the professional beliefs of
physicians and nurses; and usually the community beliefs are seen as wrong. (Note that
this is ethnocentrism.) People act on their own beliefs more frequently than those learned
from clinical personnel who are believed to repeat what they have learned in school and
who have not taken the time to understand the community’s cultural perspectives. A key
example of this is related to the health beliefs and practices of a community. In
Honduras, a community health team worked to introduce oral rehydration therapy (ORT)
to the villagers in a rural area (Kendall et al., 1983). They knew from both clinical and
epidemiological studies that these solutions of salts and water would prevent unnecessary
deaths from diarrhea. When they explained to the villagers that this treatment would save
children’s lives, the practitioners were surprised to learn that diarrhea was believed to be
normal and a necessary step in the development of young children. Since these
community health practitioners had done an adequate assessment, they knew to simply
shift gears and talk about the ORT in a different way.
An extremely common complex of beliefs that occurs in the U.S. as well as
around the world involves the supernatural in everyday life (whether a monolithic God,
multiple gods, spirits, or simply supernatural forces). These beliefs sometimes are
expressed as the belief that only God can prevent some kinds of deaths and people will
defer to God’s Will. This is sometimes referred to as “fatalism.” Fatalism provides a
particularly good example of how cultural approaches may lead us astray. Members of
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many cultures explain bad events, including bad medical events, by saying that it is the
will of God. Researchers working with multicultural populations have only now begun to
look to fatalism as an explanation for why people do not adopt new behaviors that might
allow for early discovery of diseases such as cancer and heart disease. Fatalism has
become a “variable” with measurable attributes. One of the problems with this is that
occasionally, the belief that an event is the will of God arises from teachings of the local
church or family experience rather than a widespread and shared cultural pattern. It is
also clear that there are many other reasons for rejecting a health promotion behavior in
addition to fatalism. Community health researchers and practitioners will not know
which explanation fits until they talk with the families. If we plan that a cultural trait like
fatalism will be part of the repertoire of a particular cultural group without confirming the
assumption, we are guilty of stereotyping—of applying the generalization to a particular
group without assessing. Not only is this offensive to the community; it also leads
community health practitioners to create inappropriate programs.
Beliefs in the supernatural can also be extremely helpful in designing a
community project. This is especially true for working with faith-based organizations
such as churches. Members of a church have both social and spiritual bonds with each
other. They are accustomed to gathering together for prayer, for social events, and for
personal or family growth. More and more community and public health interventions
over the last two decades have chosen the church as the location for a program. For
example, Deborah Erwin has been working with African American women in churches
for a number of years. She has found that church members are very effective in
delivering breast and cervical cancer screening messages to other members (Erwin 2002).
Another example is a series of projects in North Carolina in which churches across the
state have partnered with university researchers to promote a diet composed of at least
five fruits and vegetables per day. One project developed a special cookbook aimed at
rural African Americans that is used in conjunction with menu discussions, food
demonstrations, and support groups within the churches. (e.g., Campbell et al. 1999)
Values
Finally, community programs must fit with the people’s values, their standards for
judging good and bad. The values involved with family life, for example, are an essential
element in community health interventions. Believing that the best kind of family is one
that includes only the parents and children (or a variant of that) implies very different
family participation in community projects than when the valued family includes
grandparents and varieties of other relatives. This has implications for which family
members might need to be taught about health promotion actions. Moreover, there are
usually values concerning the appropriate behaviors of family members. For example,
frequently, women are seen to be in charge of the household, whereas men should take
the more public roles. It is important to remember that this division of labor does not
always mean that women are subordinate, though frequently it does. Immigrant women
and girls, in particular, may hesitate to participate in community events without the
husband’s and father’s permission. This means that the project must be careful to work
closely with the men even when the topic of the project is of more concern to women. In
the partnership with the Yakama Indian Nation, Chrisman and Strickland found that
12
husbands and brothers were equally as concerned with cervical cancer as their wives and
sisters (Chrisman et al., 1999).
Concepts such as beliefs, values, and customs are the theoretical way to
understand how to work with communities. How can we make this come alive for you as
a community practitioner? One of the central ways to make this happen is to trust your
‘gut instincts’. Most of us notice when things are going wrong around us and try to come
up with an explanation. It is important that culture be considered as one explanation for
why things are not working well in the community project. Of course, there are many
other reasons: (a) there could be a power struggle between agencies or people; (b)
someone may be having a psychological problem; or (c) you and your project could very
well have stepped on some toes in a political arena. When you feel that something is
going on, you should to do a more thorough assessment and rule out the alternative
explanations until you find one that is satisfactory—including cultural differences. That
is not the end of the process of understanding, however. Now you have a hypothesis that
needs to be tested. Your assessment must include discussions with participants in your
project to discover whether you are on the right track.
Values are extremely difficult to discover during the culturally appropriate
community assessment process. That is because values are deep seated within the
individual’s sense of self as part of the community. It is nearly impossible to ask people
to articulate what their values are. Instead, values may be surmised from the choices
people make. It is also possible to use a paper and pencil values clarification exercise.
One way to listen for values during the assessment process is to start with an old, but
useful set of value orientations suggested in the literature long ago (Kluckhohn 1976
[1953]). Table 1 shows these five value orientations and the variations that might be
expected across cultures.
Two of these value orientations can be used as examples for community health
projects. One is a culture’s orientation toward time. Some groups are said to be “futureoriented,” which means that behaviors are valued for their likely outcomes in the future.
Investing money for later use rather than to spend it now on something extravagant or
impractical is a common example. In health, eating a healthy diet and exercising
regularly to promote a healthier future is important in health promotion and disease
prevention. Another orientation is “past-oriented.” Cultures with this orientation value
behaviors that were important in the past: ‘we have always done it this way and it is the
best way’. For example, some Native American tribes have been promoting a return to a
more traditional diet to counteract the negative consequences of the high sugar and
carbohydrate diets that have become prevalent. Finally, there is a “present-orientation.”
This perspective values ‘living for the moment’, and allows for spontaneous expressions
of behavior.
It is essential that community health nurses and others recognize that these three
perspectives do not occur in a pure form; there are always mixtures in communities and
in people’s behaviors and these shift and change over time. A future-orientation is more
characteristic of mainstream American culture than the other two. Thus, a European
American community health nurse with a future orientation may well become very
frustrated with community members who do not want to adopt immunizations because
they do not fit with what the ancestors did or because it is inconvenient at this point in
time. Similarly, a Native American practitioner who values the past for her people may
13
hesitate to introduce some kinds of community projects that do not reflect the past. One
health educator, Annie Wauneka (1990 [1962]) who is a member of the Navajo Indian
Nation was asked by the tribal council to work with the tribe to design plans to convince
members to treat and prevent tuberculosis properly. Wauneka began by finding out what
medicine men said caused the disease. She also discovered what beliefs existed in
western medicine. Armed with this information, she developed a plan that cast western
medical ideas in traditional Navajo terms so that infected tribal members could feel
comfortable with the new information.
A second value orientation is a culture’s conception of the relationship between
humans and the natural world (and don’t forget that sometimes a culture’s view of the
natural world include what European Americans might think of as the supernatural). The
three central orientations in this value complex include a harmonious relationship, a
subordinate one, and a relationship in which humans are superior to nature. A central
theme in American culture is that humans can dominate nature. Western medicine is
heavily invested in this perspective in that medicine intends to “beat” nature through
organ transplants or hormonal alterations and many more examples. Those cultures who
feel they are dominated by nature do not see that they have much power to change their
natural system and instead may plead with their version of the supernatural for help. This
orientation may also be related to the concept of “fatalism,” the belief that what happens
to people is the Will of God or is meant to be, certainly not something over which family
members have some control. As with all cultural patterns discussed in this chapter,
fatalism can be overstated. There might be circumstances when families would take
more control of the situation.
The orientation toward nature as a harmonious relationship is widespread
throughout world cultures and is certainly found among many American Indian tribes and
among a variety of American ethnic groups originating in Asia. Among some Asian
cultures, the harmony is seen in their medical systems in which balances among humans
and the supernatural, the natural world, and internal temperatures promote health. Some
Native Americans explain sickness by referring to inharmonious relationships with the
natural world; e.g., when the earth has been mistreated in some way.
Since American mainstream culture has a strong influence on both medicine and
community level health promotion and disease prevention ideas, the notion that humans
dominate nature pervades these programs. Deborah Erwin, whose Witness Project was
mentioned above, has come to grips with this contrast in beliefs. She knows that many
southern African American women believe that having cancer is a death sentence; there
is nothing that can be done. To counteract this belief, she asks African American cancer
survivors to witness to church congregations. This approach uses a typical activity in
southern churches—witnessing—as the mechanism to suggest that at least in this case,
women were able to surmount the cancer. Dr. Erwin explicitly addresses the general
belief that nothing can be done with a culturally approved practice that does not threaten
the general orientation, but does promote a new view among women churchgoers.
Differences in values, beliefs and customs can cause real trouble when planning
health projects for communities (rather than with communities). First, presuming that we
know and accept that community involvement is necessary, how do we approach
communities that are not white and/or middle class and who may not share the same
culture? It is important that community health practitioners ask the questions since most
14
people do not. Many professionals do not think to ask whether culture might make a
difference. Through ethnocentrism and sometimes racism, culture can blind the health
professional (including community health nurses) to significant differences. A related
problem, discussed with international data by Stone (1989), is that not all cultures view
citizen participation the way mainstream Americans do—as a democratic process in
which each person should participate. Some cultures are much more hierarchical than the
U.S. and people on the bottom expect to do as ordered by people on the top.
CULTURAL COMPETENCE
Attitudes
Cultural competence is defined above as professional attitudes, practice skills,
and system savvy for cross-cultural situations (Chrisman and Zimmer 2000). These
attributes are appropriate for the care of individual patients, for communities, and for
populations. Professional attitudes in this definition are not the “professionalism” of the
hospital in which hierarchy and expertise have a tendency to erode personal relationships.
Instead, culturally competent community health professionals should have a positive
attitude toward flexibility and the desire to reduce one’s ethnocentrism. Ethnocentrism is
the key word here. It means that a person believes that only his or her culture has the
correct views or answers, that other cultures are wrong; or worse, that they are bad or
pathological in some way (Chrisman 1991). Community health nurses and other health
care providers confront ethnocentrism every day, whether it is their own or of that of
other professionals, or of the patient and family. In many ways, ethnocentrism is useful
to all human beings because it prevents us from having to question whether the culture in
which we were raised is comprised of the only right and correct ways of life. However,
when the clinician or community health practitioner works with people from another
culture, this attitude is very damaging. If, during an assessment, the nurse or physician
hears a custom that is “wrong,” he or she might overlook it or dismiss it or, worse, react
overtly and negatively. This negative reaction signals the client that it is better not to
disclose personal facts to the clinician. In a maternal child home visit example, a nurse’s
ethnocentrism occurred at a crucial time. The public health nurse and the interpreter
made a visit to a new mother who had limited English abilities and had lived in the
United States for only a short time. When the nurse discovered that the baby slept with
the mother consistently, she blew up. Luckily the interpreter was able to calm things
down, but there can be a great deal of damage when a professional nurse declares that the
person is a bad mother—particularly when the mother was doing what had always been
required in her culture to be a “good mother.”
Anthropologists learned a century ago that imposing one’s own cultural values on
the beliefs and behaviors of another society was inaccurate and misleading science
(Friedl 1976). The antidote was cultural relativism, the ability to observe and listen to
indications of culturally patterned beliefs and behaviors from the perspective of that
culture, not one’s own (Chrisman 1991). This liberating point of view allows a much
more valid community assessment because community members’ statements can be
listened to accurately by reducing the overlay of one’s own belief system. Once data are
gathered, however, decisions about what to do next need to be made with one’s
professional knowledge and skills in the forefront (that is, you must be professionally
15
ethnocentric). If the community health nurse had listened openly and warmly (the
practice implication of cultural relativism), she could have learned that the practice was
centuries old and that it was meaningful to the relationship of mother and child. Later,
the nurse could have checked the biomedical literature to discover the relative benefits
and deficits of the practice as confirmed by research. If the practice is, on balance,
positive, she can leave it alone and support the mother’s good mothering skills. If, on the
other hand, the literature findings show more harm than good, the nurse can offer
alternative options, but options that come from the mother’s culture rather than the
nurse’s culture. This set of practices is part of the negotiation discussed below.
A significant reason to nurture one’s positive attitude toward flexibility and
cultural relativism is that community health workers have so much less control over
patient and family activities in the community than clinicians in hospital or clinic
settings. The young mother in the story could very well have forbidden the nurse to
return, reducing her abilities to receive care later if necessary, but salvaging her pride and
cultural knowledge. Moreover, she can tell her story to others from her immigrant group,
perhaps leading to general distrust of health care providers. If this happens and the
community health nurse is instituting a community program, it could be scuttled by just
one mistake. Luckily, most people are more forgiving than that and will allow for second
or third chances, especially when the service is valued. Another reason that forgiveness
may occur is that the agency or its personnel might have exercised cultural relativism in
the past and so have built up some credit in the form of trust. Note that cultural
relativism as part of cultural competence is not the extreme view of accepting all beliefs
and behaviors of all people. There are unhealthy practices in all cultures, including ours
(e.g., an excess of high fat and low fiber foods that are easy to purchase). The
community health practitioner will want to ensure that he or she does not “go native.”
Practice Skills
Professional Clinical Skills
The second element of cultural competence is practice skills. The first priority
practice skill is one’s professional abilities as a community health professional. After all,
clients consult individual and family oriented clinicians because they need the services.
Community health workers, whether at the group or community/population level, may be
welcomed because they bring needed services or health promotion/disease prevention
advice. We should not forget, however, that such advice is frequently not particularly
clear to recipients who do not have the same faith in the preventive powers of medicine
as European Americans do. When the health professional is an expert in his or her
community health practice, he or she can spend more time developing cultural
competence. These skills grow simultaneously with other skills, but cultural competence
is a journey not an endpoint; they should always be expanding (Campinha Bacote 1999).
Cultural Competence Skills
The second set of practice skills includes those of cultural competence. These
skills consist of (a) cultural assessment, (b) cultural negotiation, (c) interpreter use, (d)
family and social network assessment, and (e) community partnership building and
maintenance. All of the skills are founded on a basic distinction in anthropological
theory—emic and etic descriptions and understandings (Tripp-Reimer 1984; see the
derived illness-disease distinction in Chrisman and Zimmer 2000). These terms were
16
adapted from the linguistic concepts of phonemic and phonetic analysis. An etic
description and analysis focuses on specific measurement methods that have been agreed
upon by scientists. The emic level refers to the ways in which the culture in question has
constructed the phenomenon. The reason this is so important is that community health
nurses and other health practitioners tend to view the world in terms of their scientific
categories (etic viewpoints). This leads them to overlook or even reject the particular
cultural meanings of behavior or belief.
The ability to maintain and use both emic and etic analytical skills can be
illustrated with the planning process for a large multiethnic diabetes project. Analysis of
census and epidemiological data led the planning team to know that diabetes is a growing
problem for each of the racial/ethnic groups to be involved in the project. These are etic
data. Disease rates are measured and computed similarly for all diseases and all
populations. Observing these rates over time produces conclusions concerning the degree
to which a public health problem exists. This CBPR project did not stop at that point as a
top-down “social planning” intervention would. The next step was to gather emic data:
the voices of the people. The ethnic agencies involved in the planning held town
meetings for seven ethnic groups, each held in the native language of the group. People
who had diabetes and their families along with other community members were invited to
talk about their needs from their perspectives. Ultimately, the design of the project
included organizing small groups led by community members so that individuals and
their families could learn more about how to take care of themselves or their family
members. Without the etic (epidemiological) data, the public health scientists would
have had less confidence that this was a good plan. And without the emic (community
voices at the town meetings) data the project would risk providing a service the
populations did not desire.
Cultural competence depends on the community health worker’s ability to assess
and work with both community cultural categories and those of the nursing and public
health professions. This chapter briefly considers a range of cultural competence skills,
but the growing and maturing nurse will augment these with practice emerging from
experience and from the advances in our understanding of the attitudes and skills of
cultural competence.
System Savvy
Third is the critical competency of system savvy. For nurses and other providers
who work at the individual and family level, the ability to understand and change the
system is neither well taught nor well supported. Yet, without working at the system
level, the clinician and client are doomed to understandings and interventions that may
not last past the shift change or may not affect the behaviors of other members of the
health care team. What was so carefully achieved can be lost. At the community level,
system is nearly the whole arena of practice. Successful community projects must attend
to what Warren (Warren 1988) refers to as vertical, or more and less inclusive (nested),
relationships among systems and super- or sub-systems (Thompson and Kinne 1990).
These invisible and seemingly unimportant relationships are powerful. Super-system
factors affecting a neighborhood, such as municipal government, the police, or welfare
system, can have potent effects on a community project. For example, a well-planned
mammography campaign may flounder because the city health department reduces
funding for their mammography program just as the community organizing has prepared
17
residents to desire this important screening. Similarly, subsystem factors such as
interethnic conflict, struggles for power in an elementary school, or the closure of a park
can affect a project aimed at children’s oral health.
Community health practitioners must also be aware of and work with what
Warren (1988) calls the horizontal community: the integrative (or dysfunctional) ties
among community members themselves. When interpersonal social ties, relationships
among community institutions, and communication patterns are open and stable, a
community is better able to respond to the organizational messages of the community
health practitioner. Part of the community assessment process should be designed to
discover the degree to which these horizontal ties will be helpful in planning and
implementing community processes.
System savvy is important for discovering the nature of both the vertical and
horizontal aspects of community through the community assessment. The community
health worker should be particularly alert to cultural patterns that signal more and less
distant social ties (horizontal integration) that are unfamiliar. For example, it will take
sophisticated data gathering and analysis to determine whether the factional disputes that
have been described for some American Indian reservations are as disruptive as they
appear to non-Indians. In any event, the practitioner must know enough about all factions
to work with them all in a community project.
In addition, system savvy is related to cultural processes that, because they are not
ethnic, may not seem cultural. Interorganizational relationships are an essential part of
community health projects and they take a great deal of work to maintain. One important
organizational structure for community projects is the coalition (Goodman et al., 1996).
The essence of a coalition is that people join together based on a limited number of
common problems that they can solve more easily together than apart. This means that
much of the mission of an agency or the personal commitments of a community volunteer
may not be satisfied by coalition participation. Thus, the coalition must consistently
focus on what is held in common in order to maintain commitment. The coalition
facilitator must know about agency culture or the cultural demands of neighborhoods or
membership groups in order to help these to mesh. For example, one agency may be very
oriented toward its grass roots members and come to the table frequently with new
program desires. Another agency with similar grass roots involvement and support may
have adopted a long-term plan. These differences need to be worked out among coalition
members.
When agencies and their members are from different ethnic or other cultural
groups, the kinds of issues driving coalition participation are similar to those outlined
above, but because they are cultural and related to their basic identities, the feelings about
issues will probably be much deeper. That is because values, beliefs, attitudes, customs,
and the like are not just overt behaviors; they arise from the depths of feeling that culture
engenders. The definition adapted from Geertz expresses the depth of cultural meanings
and implies that the world is experienced differently by different cultural groups. When
there are differing views of the world at the table—different conceptions of the basic
elements of life itself—disagreements over the subject matter are not minor. Handling
varying perspectives at the coalition table takes great flexibility and openness, plus the
ability to negotiate in culturally appropriate ways. These same attitudes and skills are
used in other ways in community health projects.
18
CULTURE-SENSITIVE CARE
Cultural competence demands alterations in the ways we think about and perceive
the world, the ways we practice, and how we define and work with systems. An effective
approach for practicing cultural competence is culture-sensitive care (Chrisman 1986;
Chrisman and Zimmer 2000). Just as light-sensitive eyes react instantly, adaptively, and
productively to light, so the culturally competent person reacts to the cultural elements of
the community situation. Culture-sensitive care is a set of principles: knowledge,
mutual respect, and negotiation. Principles are preferable to laundry lists of cultural traits
because of the wide range of individual and family variation within cultural groups. The
list, or a cookbook (or recipe) approach, is too unreliable. A cookbook approach is one in
which a list of cultural characteristics supposedly exhibited by a cultural group is
memorized by health care providers as if they were as consistently true as physiological
information. For example, many Latinos retain some portion of traditional beliefs in the
‘hot’ and ‘cold’ properties of plant and animal foods and ways of preparing them. (One
analogy to this belief set is the linguistic practice of categorizing some nouns as
masculine and others as feminine in European languages.) This belief system includes
ideas that hot or cold properties can cause illness and that illnesses can be treated by
adding the opposite quality. For example, an ear infection might be characterized as ‘hot’
and thus would be treated with something ‘cold’ such as a vegetable (see Clark 1970).
The difference between this information and that included within physiology is that
human behavior and belief is much more inconsistent than physiological activities so the
information can not be generalized to all Latinos.
By using the principles, the community health worker has the flexibility to
recognize cultural patterns and to work creatively within them. Each of the three will be
examined in turn.
Knowledge
Knowledge is the important groundwork of all practice, not just culturally
competent care. One kind of knowledge was mentioned above—knowledge of varying
traits for different cultural groups. Why require knowledge when many cross cultural
experts believe that recipes are misleading? It is very helpful to have a sense of the
generalizations that you and others have made about a group. These are not considered
predictions to be applied to each individual, but can be very helpful in community
planning. For example, if your community coalition is working toward nutrition
interventions for Latinos, it is very helpful to have a sense of what kinds of food they eat
currently. It is impressive to the group you are assessing if you can indicate that you
thought they might mention the hot and cold qualities of foods. Clearly many Latinos do
not use that categorization system, and even neighbors disagree on which foods are hot
and cold, but just knowing that foods may be categorized in this way is an important start
on working with people’s diets. The essential point is to refrain from stereotyping. Keep
the generalizations in mind so you can react positively if you hear a particular practice;
be open to the possibility that a folk practice will need to be included in the intervention.
Just do not act on the generalizations until after you have evidence that they apply in a
particular case.
19
A second essential type of knowledge is knowledge of your practice. As
mentioned above, the practitioner should be comfortable in his or her practice to do the
best possible job of culturally appropriate community work. In fact, it is difficult for
novice clinicians to engage in much more than rudimentary cultural competence because
they should focus on ensuring that their practice is safe. But a second aspect of practice
knowledge relates to culturally competent practice, remembering that it is a journey.
Culturally competent professionals are always learning new or adjusted principles, new
information about various ethnic and other cultural groups, or new techniques.
The third and most important kind of knowledge is self-knowledge. In
community work where practice lies in working with groups and larger social units, the
practitioner is the instrument of change. If you do not know your strengths and
weaknesses, likes and dislikes, and opinions, you are an uncalibrated instrument. When
working with multicultural populations, one’s own biases will not only become visible,
but may also disrupt the course of the community project. For example, even though the
principal scientist on a project was a person of color, he was unable to see that his
western scientific perspective blinded him to the cultural inappropriateness of a written
questionnaire early in the project. Moreover, he rarely visited the community to get to
know people. In another project, the multicultural evaluation team agreed on a
questionnaire and how to administer it. Nonetheless, a number of items were
incomprehensible to participants because of cultural differences with European American
science that were largely invisible to the European American scientists. In a third case, a
person from one group acted in a discriminatory fashion toward a member of another
group during a meeting. The person did not recognize the existence of a bias. This
action reduced people’s confidence for a number of months until the problem was
straightened out. Similarly, knowing that you have biases about a particular cultural
group can heighten your consciousness during interactions with members of that group
and you are less likely to make such a mistake.
Interpersonal cultural, “racial,” or class-based mistakes, however, are nearly
impossible to prevent completely. The best one can hope for is that you can build up
enough “credit” through culturally competent actions that people will allow you the
occasional mistake. Note that this implies that you are personally involved over longer
periods of time than is usual in individual level practice or in community projects that are
delivered with little or no participation from the population receiving the intervention.
Nonetheless, this style of practice is uniquely rewarding because not only are rich
interpersonal relationships formed, but also it is possible to achieve much more with a
longer time frame.
Mutual Respect
The second principle of culture-sensitive care is mutual respect, the practice of
respecting community members and the goal to elicit their respect of you. Respect is
a crucial aspect of cross-cultural care at the individual, family, and community levels.
One definition is:
Respect is an attitude toward others that is grounded theoretically in an
acceptance of shared participation in a common moral community, or, at least,
of a common humanity. The need for respect to be nurtured (in education) and
required (in practice) typically arises from students' and practitioners'
20
challenging encounters with difference, e.g., of beliefs, rituals, speech, symbols,
power status, gender, ethnicity, or sexual orientation. A respectful attitude
values the core of humanity in the 'other' without necessarily admiring or even
approving of the beliefs or other differences as noted. Actions arising from
respect are sometimes known as basic courtesies (Lenburg, Lipson, Demi,
Blaney, Stern, Schultz, & Gage, 1995, p. 37).
Respect is one of those key attitudes similar to your commitment to reduce
ethnocentrism and to know your own biases. It is a fundamental attitude underlying your
practice of cultural relativism in that learning to judge people’s beliefs and actions in
their context contributes to your greater understanding and enhances respect. Clients of
health practitioners or members of the community board facilitated by community health
workers tend to be closely attuned to the reactions of these professionals; in part because
the health care interaction is somewhat mysterious and there is frequently a large power
imbalance. Thus, even small indications of a lack of respect, perhaps arising from
ethnocentrism or racism, are noticed and can have an effect. Remembering to respect the
client and community at all times can help reduce problems in the future. In community
work, the stakes are simultaneously higher and lower in comparison to individual level
clinical practice. The stakes are lower in the sense that community members are not sick
and not as vulnerable as those in the hospital or clinic; thus, the clinician is unable to do
as much harm. In addition, community members may be vulnerable to the higher power
of the community health practitioner, but they too have power. The practitioner stays in
the community with the permission of community members so an offending clinician
who has shown disrespect can simply be avoided.
The stakes are also higher in community settings. This is so because of the reduced
power differential mentioned above. If someone on the community health team is
consistently disrespectful and is not reassigned or educated by the team, the project may
not be allowed to stay in the community. In this case, a project can be lost through lack
of respect of people or of valued cultural patterns. One source of such disrespect derives
from unwillingness on the part of health care providers to recognize and value the
contributions that can be made by community members. This is a long-standing problem
(Kone et al 2000; Sullivan et al., 2001) and is only now being remedied through CBPR
approaches. Some books, chapters, and articles are clear that the knowledge of
community members must be included in the creation, implementation, and evaluation of
a community health project. This is an inherently cultural process. Frequently such lack
of respect arises from the privileged position of the community health nurse or other
member of the community health team. These professionals have been strongly
socialized to believe that their way of carrying out a project is the only right and good
way (notice the professional ethnocentrism) and that this way of doing things is backed
up by decades of scientific research. Of course, the research does exist, but in most
cases, it was not informed by a culturally appropriate design. Respect for community
members (and for co-workers) tends to ameliorate these problems.
The culture-sensitive care quality, however, is mutual respect. How is that different?
The point here is that being respectful—producing respect—is essential, but not
sufficient. As the community health professional, your goal is to work with community
members over the long run and to create and sustain health promotion and disease
prevention projects. Frequently, these projects use volunteers from the community.
21
There are a number of ways to keep volunteers involved, and maintaining their respect is
one. So, a key aspect of mutual respect is that the community health practitioner needs to
elicit the respect of community members. This is accomplished first by showing respect.
People find it easier to respect those who respect them. But the worker should go farther.
Showing a real interest in community and community members’ needs, desires, and
assets is one way to elicit respect. Another way is to involve them in decision-making
and in carrying out plans. The essence of Community-Based Participatory Research
(CBPR) is community involvement and participation in the whole project and mutual
respect is a fundamental building block in this process.
Negotiation
The final element of culture-sensitive care is negotiation. In individual or family
clinical care, negotiation is used when the patient and clinician have conflicting or
contrasting beliefs or practices (Chrisman and Zimmer 2000). The same is true at the
community level. In both clinical and community practice, however, health care
providers should always use the basics of negotiation. There are four steps (Chrisman
and Zimmer 2000):
♦ Listen carefully to the positions articulated by community members. Use a valuing
and culturally appropriate way to ask for clarification. That is, you should listen
positively with respect and comment very briefly on those parts of the conversation
with which you particularly agree.
♦ Present your thoughts based on your professional knowledge and your own
experience. The reason for your own experience is to provide a greater personal
connection with the community members.
♦ Compare the two (or more) views. This means to discuss the consequences of all the
perspectives so that a decision can be made that will solve the most problems with the
fewest deficits. The most difficult part of this process is to avoid relying only on the
power of professionalism or western science. These will simply make the discussion
one about power rather than about problem solving.
♦ Compromise. This is the crucial step. The community health practitioner and
community members or coalition should agree to the final plan, hopefully one that
will contain elements from all the suggestions. It is worthwhile to take the time to
come to a consensus. On a number of occasions, decisions have been rushed and the
coalition has revisited the issue again and again. In addition, hard feelings may be
engendered. Sometimes people resign from the board or coalition over such
problems.
If the community health worker and community body (committee, coalition, or board)
are committed to sharing power and valuing all perspectives, the negotiation process is
almost automatic. All parties at the table will feel free to voice their opinions. A great
deal of knowledge will be available to the board based on the culturally appropriate
community assessment carried out initially. Trust will have been built up over time
through numerous such problem-solving interactions. The community health
professional must remember that early in the history of any community project, trust
cannot be assumed. This contrasts with the typical thoughts of the individual level
clinician who simply expects to be trusted.
22
ORGANIZATIONAL CULTURAL COMPETENCE
A feature of cultural competence in community health work that is often
overlooked is organizational cultural competence, the ability of an organization to
support culturally competent actions at the individual and organizational levels (see
Chrisman and Schultz 1997). It is not enough for you to be personally culturally
competent; you work with a community and with a team. If the organization with which
you work is not competent as an organization, you run the risk of failing because of the
actions of others. In the example mentioned above about the community health nurse
who disvalued the new mother who followed her customs, the organization lost
credibility. That affects your abilities to perform.
Organizational cultural competence is convincingly strengthened by the
publication in 2000 by the Culturally and Linguistically Appropriate Services (CLAS)
standards. A two year national effort led by the Office of Minority Health of the
Department of Health and Human Services of the federal government went in to
developing a set of 14 standards designed to highlight, maintain, and promote adequate
means for health care organizations to serve the nation’s multicultural and multifaceted
population. Table 2 lists all the standards.
For those of us who work in Community-Based Participatory Research, these
standards are almost self-evident because work in CBPR would not occur without
following these guidelines. For example, the first embodies the essence of what has been
written in this chapter thus far.
The first standard states that
“Health care organizations should ensure that patients/consumers receive from all
staff members effective, understandable and respectful care that is provided in a
manner compatible with their cultural health beliefs and practices and preferred
language.”
The fifth standard states the obvious in community work. Community members would
not be able to engage in health promotion/disease prevention activities without translated
materials.
“Health care organizations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to
receive language assistance services.”
Organizational cultural competence as outlined in this chapter includes (1) a multicultural
mission and goals statement, (2) diversity in hiring and promotion, (3) valuing and
managing diversity, and (4) permeable boundaries with the community.
Multicultural Mission and Goals
The multicultural mission and goals are very important even though they seem
distant from planning culturally competent projects within communities. Such a
mission/goals statement is one that explicitly states that the organization stands for
23
working in positive ways with a diverse clientele. Goals may include such actions as
active recruitment, retention, and promotion processes to increase workforce diversity;
creating an advisory board with diverse membership and with power sharing; and support
of policies designed to reduce racism and cultural ignorance. You have already seen that
the organization itself can affect your performance negatively in the community. It can
also be a positive influence. When a multicultural mission is in place, employees and
clients alike can work within the organization to promote the behaviors embodied in the
mission. In addition, if top-level decisions have been made that disadvantage one or
more cultural groups, employees and clients can work to change these decisions based on
the agreed upon mission.
As an example, here is the Mission Statement for the Seattle King County
REACH 2010 project, a multicultural health promotion/disease prevention project
(secondary prevention) funded by the Centers for Disease Control and Prevention
focused on Diabetes:
The mission of the REACH 2010 Coalition is to reduce diabetes health disparities
experienced by communities of color. Through strong partnerships, the Coalition
supports the empowerment of individuals, families, and communities, and creates
sustainable long-term approaches to prevention and control of diabetes by
utilizing all appropriate community resources in King County.
This mission statement explicitly states that communities of color are the groups with
whom the project will work and that this work will be carried out through strong
partnerships.
Diversity in Hiring, Promotion, and Retention
A diverse workforce (see CLAS standard 2) does not ensure a culturally
competent organization, but it is a strong contributor. Just as educational institutions
have recognized that student learning is expanded with a diverse student body, so have
organizations learned of the positive outcomes of a diverse workforce. These include
better relationships with underserved communities because community members can see
people who look and sound somewhat like they do. Community members might be more
likely to trust such organizational members, a trust that might extend to other staff as
well. Importantly, diversity among staff creates a conduit for information to flow from
the community toward the organization. In addition, with a voice at the table, staff whose
background reflects that of the people and agencies with whom the organization works
are able to make suggestions from a stronger knowledge base than might be expected
from a less diverse staff. There is more creativity in the organization.
Valuing and Managing Diversity
Valuing and managing diversity are attitudes and skills possessed by organization
members that contribute strongly to the whole (see CLAS standard 3). Valuing diversity
is a characteristic of a staff that has learned to recognize differences and to work
productively within a diverse environment. They are able to communicate with each
other in ways that are not offensive, to reduce their racism and other forms of
discrimination, and to understand themselves and see how their own experiences are
24
similar to and different from those of other staff. The process of achieving an
organization whose staff values their diversity is a productive one (Chrisman1998).
Workshops lasting four to five hours are the beginning step for staff to talk with each
other in a controlled environment. Such discussions need to include the entire staff so
that all have the experience in common. Follow-up workshops and events are also
important to “keep the ball rolling.” These can include presentations, additional
workshops, films with ensuing discussions, and field trips.
Managing diversity is a similar set of skills for the people in the organization
who manage the diverse workforce (Thomas 1990). The ability to manage a
heterogeneous set of employees requires all the skills of any manager: monitoring and
counseling, allocating tasks and supporting their completion, resolving conflicts,
providing leadership, and the like. One difference, however, is that additional
communication skills are needed. The manager should learn ways to communicate that
are related to the myriad ways employees are able to listen. For example, quiet
persuasion may be effective with one group or assertive demanding may work better with
others. Flexibility is probably the key attitude and skill. When managing a diverse
workforce, it is essential to remember that the bottom line is the ability to achieve the
goals of the organization.
Traditional organizations tend to have a set of customs for culturally
homogeneous managers and workers. Over time, these are recognized as the ‘way we do
things around here’ (Frost et al., 1991). With a diverse workforce these tacit European
American cultural patterns may no longer work. For example, one situation that has
become more common in the last decade or two is contrasting religious holidays. When
Americans believed that the U.S. was a “melting pot,” people from all religions had to
observe holidays such as Christmas and Easter because their businesses were closed
down. In addition, they had to use vacation days for their own religious holidays. Now
there is greater recognition of the problem and innovative solutions proposed.
Conceiving of the work unit as an interdependent team is one way. People can recognize
multiple ways of reaching the same ends. People from one religion or other group can
trade workdays with those from another. Such multicultural teamwork is promoted by
celebrating diversity activities such as ethnic food potluck lunches.
Permeable Boundaries with the Community
The organizations we have been discussing are those that facilitate health
promotion and disease prevention activities in community settings and with community
members. All the characteristics discussed to this point are designed to make the
organization responsive to the community in a number of different ways. This final
characteristic nicely ties these other activities together. The notion behind permeable
boundaries is that community events and participants are invited into organizational
space and organization members attend community events. Spatial barriers to knowledge
about organization and community are removed or reduced. A major Latino health
organization in the Pacific Northwest behaves this way. They sponsor a parade and fair
for Fiestas Patrias, Mexico’s Independence Day, on the grounds of the organization.
Latinos from around the region attend the event. In addition, the organization attends
events in the community. For example, the local park and recreation center has a
25
midsummer celebration at which the Latino organization regularly has a booth. In
addition, the dental clinic assists with an annual dental screening at the local elementary
school. Permeable boundaries underlie the creation of working relationships and reduce
the sense of distance and mistrust between organization and community.
Cultural Competence Continuum
A useful tool for examining cultural competence on the individual or
organizational level is Terry Cross’s Cultural Competence Continuum (see Figure 4).
This six-category chart lays out a set of positions that people might take toward the
‘other’, toward groups other than one’s own. Each category is described with examples
of how an individual might perceive and/or discuss members of other groups. These
categories—that include cultural destructiveness, cultural incapacity, cultural blindness,
cultural pre-competence, cultural competence, and cultural proficiency—may be used by
managers and community health professionals working with individuals to help a
community health team or organization to assess their current position on the chart and
what steps might be taken to move toward cultural proficiency. Culturally competent
managers have told me that as part of their monitoring function, they know to listen to
employee conversations to pick up comments reflecting one or another of the categories.
Most of the very best organizations with which I have worked are at the cultural precompetence level. That is, they believe they are doing the best they can by having
limited outreach projects, by being “sensitive” to the desires of multicultural populations,
and by hiring minority staff. This chapter has already discussed the principles needed to
achieve cultural competence at the organizational level. We did not, however, address
cultural proficiency. This is the challenge for all of us—in practice and in universities
alike. The next two decades will be a time of testing our resolve to make these advances.
CULTURALLY COMPETENT PRACTICE WITH COMMUNITIES
How do all these recommendations about cultural competence fit with the real
work of Community-Based Participatory Research? First, let’s examine the theoretical
model I use for my CBPR work, the Interlocking Community Partnership Model (see
Figure 5). The four puzzle pieces surrounding the community assessment and evaluation
element are concepts that have been in the community change literature for decades;
rarely, however, have these been considered in the context of community culture. The
arrows demonstrate the activities that take place to achieve the next element of the model.
Felt Needs
The notion of felt needs derives from the work of Kurt Lewin and refers to
building any project on what the community members believe they need; or, more
pragmatically, what they are willing to work on (see Nyswander 1956; Goodenough
1963). When felt needs are not taken into account, it is difficult to achieve much interest
and commitment on the part of community members (e.g., Minkler 1990). This element
of the model is crucial for cross-cultural work. Too frequently, community health
practitioners assume that a program designed for one group will work for another. For
26
example, programs for mammograms may not be very effective with single ChineseAmerican women since there is a belief in that culture that single women need no
attention to their sexual attributes (Mo 1992). These women might not feel any desire
whatsoever for such a service.
In addition, collecting and documenting the community’s felt needs can identify
significant culture-specific areas that may not have been previously seen as relevant by
community health practitioners. For example, researchers in Seattle are finding that
women’s sewing circles are very popular with immigrant women from Southeast Asia,
Latin America, and East Africa. In their simplest form, such sewing circles are informal
groups of women who sew together and talk. An early version of Seattle’s experience
occurred when Hmong women began weaving cloth for sale. Currently, in the early
2000s, the women’s sewing group is a central feature among a variety of groups. For
example, the Horn of Africa project combines women’s sewing groups with learning
English and with increasing parenting skills, essential aspects of adaptation to a new
country. In South Park, a small immigrant neighborhood in the south part of Seattle,
Southwest Youth and Family Services has been providing women’s groups for Spanish
speakers who had reported feeling detached from each other in the neighborhood.
Other projects have been integrated with the circles among other immigrant
groups, such as mental health and domestic violence discussions. A similar approach
was used with women of the Yakama Indian Nation in the early nineties (Chrisman et al.,
1999). June Strickland and I listened to women’s desires for help with appropriate menus
for diabetic family members. Two Yakama women who worked with the project
designed workshops to be presented across the reservation. These workshops included
learning native crafts, health education about cancer (the subject of our project) and other
health issues, food, and childcare. We were much more successful by taking felt needs
into account—even though they were not narrowly relevant to our goals.
Participation
When the intervention team mobilizes and involves a community around its own
felt needs (the first action arrow of the model), there is likely to be more participation),
which is a central element in the current thinking about community health projects.
Participation, in the sense of involvement and ownership rather than simply acceding to
the will of an agency (cf. Rifkin et al., 1988; Woelk, 1992), occurs as people and
organizations recognize that others share their same felt needs. This recognition is the
result of community organizers bringing community assessment data back to community
members and organizations so they can visualize the extent of shared goals, and by
providing the organizational mechanisms that allow people to join together. This
requires identification and mobilization of groups and organizations. Choosing
opportunities for community members to participate together is another area where
culture makes a difference. For example, in the REACH 2010 community based project
in Seattle (one of 24 CDC-funded REACH sites), each of the ethnic groups carried out
town meetings (designed to collect felt needs) in a different way. The lead agency for
African Americans had a party with door prizes, food, and information about diabetes
(the subject of the REACH grant). The lead agency for Asian Americans and Pacific
Islander Americans provided Asian food, interpreters for each of the language groups
27
(five languages are included now), and Asian clinicians to provide health education. The
Latino agency had a party with food and a salsa band. Each agency knew its own
population well and planned accordingly. These style differences contributed to a feeling
of comfort among the people who attended, the comfort of being with others who are like
them. The central planning activity—discovering the stated needs of people with
diabetes—was similar across groups in that all broke into small groups and reported back
to the larger group or to the planners.
Empowerment
When the community health practitioner has achieved involvement and then
participation in the community project, the stage is set to make another milestone. If the
project is set up so there is success, community members will begin to feel as if they are
competent, and their personal as well as community-level self efficacy will be enhanced.
They will begin to feel empowered (Wallerstein 1992). This outcome is especially likely
when community members have been part of the planning team and suggestions are more
likely to be culturally appropriate for the community. This action arrow (success) refers
to the need for the facilitator to carefully assess the strengths and weaknesses of the
group so that projects are set up that can be successful (Minkler, 1990). For example,
when Seattle Partners for Healthy Communities (an Urban Research Center funded by the
CDC) began in 1995, the first project was a set of interviews with community members,
agency representatives, and university researchers to discover that what worked well and
what worked poorly in previous Seattle community projects (Kone et al., 2000; Sullivan
et al., 2001). This project engaged 85 leaders in community work in the project and was
the foundation for a set of principles that has guided the project in the intervening years
(Chrisman et al., 2002). The first intervention project was aimed at African American
elders to help them decide to receive influenza and pneumonia vaccine (Krieger et al.,
2000). This project succeeded in two ways: African American elders volunteered to
work on the project, increasing community ownership. Secondly, the research showed
significant increases in the numbers of people immunized. With this strong foundation,
Seattle Partners continues as a major community force in the city and has carried out
about twelve additional projects.
Community Competence
Finally, if the community organizer has an involved, participating, and
empowered group, the community can move toward community competence
(Goeppinger and Baglioni, 1985). In essence, this means that the community has the
ability to identify its internal needs, articulate them to an outside world in a way that
there will be positive responses, and that they have the social support and technical skills
to join together and improve the community. The key set of action items includes
capacity building activities such as English as a Second Language (ESL) classes,
leadership classes, parenting classes, citizenship classes, and the like
Assessment and Evaluation
28
All of these fundamental concepts of community organizing and community
building are glued together by the central piece—continuing community assessment and
evaluation. In a community project that is carried out with multicultural populations, a
variety of qualitative research methods are the most useful, at least in the beginning
(Chrisman et al., 2002). This is because community health professionals do not yet know
all the significant variables with which to create quantitative instruments. In addition,
there is a great deal of variation across communities and cultures. This intense and
engaged process of data gathering serves also to identify key cultural issues of interest to
the population and community members who may want to participate.
Community assessment and evaluation, seemingly at different ends of a healthplanning continuum, are both research projects. They may be carried out together,
particularly since some of the questions are the same: what do the people want?
(assessment), did they get it? (evaluation). Moreover, both are means of communicating
with the community. When a project starts and the facilitator wants to enhance
community involvement, one of the ways to accomplish this is to report demographic and
epidemiological findings back to the community (as long as this is not done in terms of
the “needs” of the community). Two typical ways for this to be accomplished are town
meetings and newspaper or other mass media announcements. Clearly the community
practitioner will work closely with community members to discover which media are
considered appropriate for particular kinds of messages and what the messages ought to
be disseminated. For example, in a program in Seattle, an African American agency used
an ethnic newspaper, radio station, churches, and beauty shops; and the Asian and Pacific
Islander agency used the newspaper and many local businesses. A side benefit is that
participants in these businesses may decide to become involved in the project in other
ways. These same two communication mechanisms are essential for communication with
the community about how the project is going (feedback from the evaluation).
Naturally, the community assessment is much more complex than simply
gathering secondary census and epidemiological data. Qualitative methods such as
interviews, participant-observation, focus groups, and document analysis are necessary to
flesh out the richness of life in the community. In addition, the community assessment
should focus on assets as well as needs (McKnight 1995) and should be oriented toward
inviting community members to participate in the project. The qualitative data gathering
approaches are also likely to be much more responsive to community cultural patterns
than the more quantitative ones because people are encouraged to say what they want to
say in their own ways. The CHN may require an interpreter to understand the language,
but should certainly sit down with others from the cultural subgroup in order to put their
comments in the context of their everyday lives.
A focus group is a good example of a qualitative technique that is helpful for
involving community members and for discovering and highlighting cultural patterns
relevant to the project. It is essential to recognize, however, that there are significant
cultural influences on the conduct of such groups (Strickland 1999). How the group is
formed requires knowledge of whether men and women should be joined, of how age and
status will affect people’s comments, and of what topics are simply not discussed in a
public forum. The moderator of the focus group should be alert for members who
demonstrate particular interest in the subjects of the focus group discussion. This person
can be approached later to find out if he or she would like to be on the planning or some
29
other committee. Motivation is heightened through culturally appropriate questions. For
example, the moderator (who should be hired from the same group as the members, but
this is not a hard and fast rule), should ask about how participants perceive and
experience the subjects under consideration by the group. This lays out the cultural
issues and allows comments that expand both the depth and breadth of group, as well as
investigator, understanding of the issue.
Interviews and document analysis are similarly important. Interviews provide a
somewhat private time (since some may want family members present) for community
members to discuss their lives with the community health practitioner. These findings
can later be tested in the more interactive focus groups. Documents produced in the
community—e.g., newspapers, brochures, flyers, books, and electronic media
presentations—provide a powerful picture of what the community thinks of itself. The
practitioner learns what kinds of expressions are used and about what; hot community
topics are likely to appear in these sources; and the community health worker can
demonstrate his or her interest in and knowledge about the community to others once
these documents have been examined.
Interlocking Community Partnership Model
The Interlocking Community Partnership Model (Figure 5) is a template for
action. Each of the elements in the model is a well-accepted concept within books and
articles about community work. The model serves two purposes. It reminds community
workers of the kinds of knowledge and activities that should be part of a community
project, especially Community-Based Participatory Research. Second, it ties goals such
as felt needs or empowerment together with concrete guides for planning events or
programs. Beyond its basic properties, however, it is a construct that easily allows
cultural knowledge and skills to be integrated with community work.
CONCLUSION
Community health is a difficult area in which to work. Many community health
practitioners use the traditional top-down (“social planning” in Rothman’s terms [1995])
approach in which community members have no voice in the project. Under these
circumstances, cultural beliefs, values, customs, patterns of interaction, and the like, seem
as if they are simply barriers to the community health practitioner’s population health
goals. And they are barriers; more and more underserved populations across the United
States refuse to go along with these interventions. In contrast, use of a participatory
approach opens the community worker to the many cultural influences that are present in
any community change project. This addition is not always welcomed by the staff, but
can be a key factor in success—as long as success is measured in terms of a positive
change in population health status and in communities with greater capacity to partner
with public health and other community health institutions. There are very clear-cut
stresses and strains working in partnerships in which more than one cultural group is at
the table. However, there are personal benefits from being able to interact with a much
broader range of people than is allowed people in some other professions. In addition,
the community health projects are more likely to work better.
30
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33
Figure 1 Types of Community Organizing
Population Health
Social Planning:
Top-Down
Locality
Development:
partners
Social Action:
Bottom-Up
Rothman 1995
Noel Chrisman, University of Washington, 2001
Figure 2
Community
Partnership Research
Community
Assessment
Evaluation,
Feedback Loop
Sustain
Involve Community,
Set Priorities
Implement
Program
Noel Chrisman, University of Washington, 1996
Culture, Involvement,
Capacity Building,
Shared Power
34
Figure 3 Human Diveristy
Diversity is about our
Differences
•Age, Gender, Personality
•Sexual Orientation
•Race/Ethnicity, Religion
•Physical/Mental Abilities
•Urban/Rural, Region
•Social/Political Class
•Migration/Generation
Figure 4
35
Cultural Competence Continuum
Cultural
Cultural
destructiveness incapacity
Cultural
blindness
Cultural preprecompetence
culture seen as a
problem
not interested in
serving people
who are different
color/culture
doesn’t make a
difference
“blame the
victim”
everyone is the
same
recognizes there’s view distinct
developing
a problem
differences
research,
among
minorities
technology, and a
piecemeal
practice base
without
acceptance and
discrimination in
hiring
“doors open to
everyone”
1940’s-1950’s
useful for only
the most
assimilated
outreach projects
if you’re not like
the dominant
culture,
something is
wrong with you
seek advice from
a variety of
hire minority staff groups
tries to break
down culture
(example:
Japanese
internment)
Cultural
competence
organizational
change
sensitivity
change may get
blocked by
outreach efforts
ask “what can we
do”
ignores cultural
strengths
danger of false
sense of security
fosters
assimilation
tokenism
Cultural
proficiency
respect for
individuals and
their cultural
identity
hire bi-lingual
employees
willing to
monitor, evaluate
and modify
institutionalize
changes
Terry Cross, adapted by C/C Health Care Program
Figure 5: Community Partnership: Interlocking Dynamics
Community Partnership:
Interlocking Dynamics
Community
Competence
Felt Needs
Participation
capacity building
mobilization
Community
Assessment and
Evaluation
Empowerment
success
Noel Chrisman., 1997
36
Table 1 Value Orientations
Human value orientation toward:
Time
Social relationships
Relationships with nature
Personality types
Innate predisposition
Variants
Past, present, future
Lineal, collateral, individual
Superordinate, subordinate, harmonious
Being, being-in-becoming, doing
Evil, neither evil nor good, good
Table 2
CLAS Standards:
1. Health care organizations should ensure that patients/consumers receive from all
staff members effective, understandable and respectful care that is provided in a
manner compatible with their cultural health beliefs and practices and preferred
language.
2. Health care organizations should implement strategies to recruit, retain, and
promote at all levels of the organization a diverse staff and leadership that are
representative of the demographic characteristics of the service area.
3. Health care organizations should ensure that staff at all levels and across all
disciplines receive ongoing education and training in culturally and linguistically
appropriate service delivery.
4. Health care organizations must offer and provide language assistance services,
including bilingual staff and interpreter services, at no cost to each
patient/consumer with limited English proficiency at all points of contact, in a
timely manner during all hours of operation.*
5. Health care organizations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to
receive language assistance services.*
6. Health care organizations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters and
bilingual staff. Family and friends should not be used to provide interpretations
services (except on request by the patient/consumer).*
7. Health care organizations must make available easily understood patient-related
materials and post signage in the languages of the commonly encountered groups
and/or groups represented in the service area.*
8. Health care organizations should develop, implement, and promote a written
strategic plan that outlines clear goals, policies, operational plans and
management accountability/oversight mechanisms to provide culturally and
linguistically appropriate services.
9. Health care organizations should conduct initial and ongoing organizational selfassessments of CLAS-related activities and are encouraged to integrate cultural
and linguistic competence-related measures into their internal audits, performance
improvement programs, patient satisfaction assessments, and outcomes-based
evaluations.
10. Health care organizations should ensure that data on the individual
patient’s/consumer’s race, ethnicity, and spoken and written language are
37
collected in health records, integrated into the organization’s management
information systems, and periodically updated.
11. Health care organizations should maintain a current demographic, cultural, and
epidemiological profile of the community as well as a needs assessment to
accurately plan for and implement services that respond to the cultural and
linguistic characteristics of the service area.
12. Health care organizations should develop participatory, collaborative partnerships
with communities and utilize a variety of formal and informal mechanisms to
facilitate community and patient/consumer involvement in designing and
implementing CLAS-related activities.
13. Health care organizations should ensure that conflict and grievance resolution
processes are culturally and linguistically sensitive and capable of identifying,
preventing, and resolving cross-cultural conflicts or complaints by
patients/consumers.
14. Health care organizations are encouraged to regularly make available to the public
information about their progress and successful innovations in implementing the
CLAS standards and to provide public notice in their communities about the
availability of this information.
* Indicates that the standard is a current federal requirement for all recipients of federal
funds.