"Certain Circumstances" Issues in Equity and Responsiveness in Access to Health Care in Canada

Part IV Toward Cultural Competence

Document 1

Introduction to Cultural Competence in Pediatric Health Care

November 2000
This is an abridged version of the original report.

Introduction

For years, Canadians have looked with pride to their health care system, as a national symbol of our collective values. There is room for improvement, however, in the provision of Canadian health care. For example, culture can play a significant role in the accessibility of health care and as a result it is essential for health care providers to demonstrate cultural competence. In order to fulfill the principles of the Canada Health Act and satisfy the health care requirements of a diverse nation, the meaning and relevance of cultural competence in health care must be addressed.

The Canada Health Act is the framework for health care in Canada. This pivotal piece of legislation stresses the importance of access to health care for all citizens. As such, one of the five principles of the Canada Health Act is the principle of accessibility. Within the context of the Canada Health Act, this principle refers to financial barriers to health. However, the specific text does not fully embody the true meaning of accessibility to health care for Canadians. Other barriers such as the geographic distribution of the population, a lack of specialized health care providers and a lack of interpreters may also create a barrier to access. Further barriers are often the result of cultural differences that give rise to ineffective communication and misunderstandings. Limited communication often results in limited assessment and thus, limited treatment.

Communication is an essential aspect of health care. In turn, cultural competence is an important aspect of communication. In order to receive appropriate treatment of the highest quality, it is necessary for clients from all cultural backgrounds and linguistic profiles to be able to voice their individual needs, within their specific context, to a health care provider. When information has been successfully communicated by the client and understood by the health care provider, there is greater likelihood that the client will be able to access and receive the necessary care.

In a health care setting, culture can influence communication through everything from language used and emotional responses to eye contact and touching. Culture encompasses many elements such as beliefs, attitudes, values, verbal communication and non-verbal communication ^a. Culture may be influenced by a number of factors such as location, race, ethnicity and religion. Less obvious, but equally important influencers of culture are factors such as disability or sexual orientation. For instance, the hearing impaired have a unique culture, in that they possess their own language with non-verbal cues, which are specific to that group. Gay, lesbian, bi-sexual and two-spirit individuals are another example of a population that must be treated with cultural competence.

If health care providers are not competent in addressing cultural differences, this may limit their clients' access to optimal care. A competent individual is someone who has "requisite or adequate ability or qualities" ^b . In other words, a competent health care provider requires a combination of skills, knowledge, attitude and judgement to effect a positive outcome in health care. Cultural competence is defined as the "provision of health care that responds effectively to the needs of patients and their families, recognizing the racial, cultural, linguistic, educational and socio-economic backgrounds within the community ^c."

There are four elements to cultural competence ^d:

• self-awareness and awareness of one's personal value system;
• understanding of the term culture and its place in a health care setting;
• sensitivity to the cultural issues of each individual client;
• comprehension and ability in using specific methods to deal with cultural issues.

Cultural competence also requires a firm understanding of one's own culture. By combining these elements, health care providers help to bridge the gap between themselves and their clients. Increased closeness in terms of understanding and mutual respect will serve to increase the client's access to the best possible care.

In light of the diversity of the population, the application of cultural competence in health care relationships holds particular relevance in Canada. Demographic figures gathered by Statistics Canada provide evidence of the non-homogenous nature of the Canadian population and thus reinforce the necessity of a culturally competent health care system. Canada is a country with citizens from various cultural backgrounds. The 1996 census conducted by Statistics Canada identified the ethnic diversity of the Canadian population. Of those reporting only a single ethnic origin, approximately two-thirds of respondents claimed to be of European origin and nearly one-third simply claimed to be of Canadian origin. Of the respondents reporting more than one ethnic origin, the most common origins were Asian, Aboriginal, Caribbean, Arabian and African.

Canada also has a sizeable immigrant population. The total number of immigrants between 1961 and 1996 was 4,971,070 ^e . The ethnic composition of the immigrant population has been dynamic over the years. In 1957 the top ten source countries of immigrants were European; whereas, in 1997, eight of the top ten were non-European ^f . Furthermore, in 1999, the top three regions of origin were Asia and Pacific (51%), Europe and the United Kingdom (21%) and Africa and the Middle East (18%) ^g.

Another factor, inextricably intertwined with culture is language. In her report, Language Barriers in Access to Health Care, Sarah Bowen recognizes that language is not the only cultural barrier in access to health care; however, language is the basis for further understanding ^h. When the client and the health care provider can communicate on a basic level, this provides a foundation for a more positive health care interaction. The importance of language runs deeper than the necessity for health care providers to be able to work in one of Canada's two languages (French or English). The 1996 census showed that of the population reporting one mother tongue, 16.3% identified neither French nor English as that language. The three most common mother tongues reported, besides English (60.1%) and French (23.6%), were Chinese (2.5%), Italian (1.7%) and German (1.6%) ⁱ. The remaining 10% spoke several miscellaneous languages.

Given these statistics, it is clear that Canadians are not a culturally homogenous group. The Canada Health Act stresses the principle of access for all citizens. An understanding of the concept and application of appropriate knowledge, skills and judgement is pivotal to the care of culturally diverse clients. The application of cultural competence is essential if health care providers are to provide a high level of access to quality care within an effective and efficient health care system.

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^a The Southwest Regional Center for Drug Free Schools. 1992. Cultural Sensitivity Position Paper. http://www.occe.ou.edu/swrc/culpos.html

^b Merriam-Webster. 2001. Merriam-Webster's Collegiate Dictionary, http://www.m-w.com/home.htm

^c Masi, R. 2000. Report of Proceedings of the National Workshop on Current Practices and Strategies in Pediatric Health, p.8.

^d American Association of Medical Colleges. 2000. Cultural Competency,

^e Statistics Canada. 1996. Immigrant Population by Place of Birth and Period of Immigration, 1996 Census, Canada

^f Kessel G. 1998. The Canadian Immigration System

^g Citizenship and Immigration Canada. 1999. Facts and Figures 1999: Immigration Overview

^h Bowen, S. 2000, Language Barriers in Accessing Health Care, p.2.

ⁱ Statistics Canada. 1996. Population by Mother Tongue, 1996, Census