Specifically, the paper will address the following:

• What is cultural competence?
• Why is cultural competence important in the context of healthcare?
• How is cultural competence developed?
• How can cultural competence be measured?
• What needs to happen to progress the cultural competence agenda in health?

WHAT IS ‘CULTURAL COMPETENCE’?

History of the term

The term ‘cultural competence’ first emerged in the 1980s in the USA in response to the need for human services providers across a range of disciplines (education, social work, health and welfare) to better meet the needs of an increasingly multicultural population. In the context of healthcare provision, there was growing evidence that people from non-dominant cultural groups (ethnic and racial minorities) continued to experience significantly poorer health outcomes
than people from the majority/dominant culture (Betancourt et al 2003; Brach & Fraser 2002). The concept of ‘cultural competence’ has since been taken up in a number of other English-speaking countries, particularly those with significant
immigrant and indigenous populations. A vast amount of literature about cultural competence has been generated, most of it emanating from the USA and Canada, with a substantial amount being generated in the UK, Europe and also in New Zealand (1). There is now also a growing body of work being produced to respond to Australasian contexts, some of it
addressing the relationship between ‘cultural respect’ and working with Aboriginal peoples.

Many definitions

A review of the literature indicates that while there is no one universally accepted definition of ‘cultural competence’, many definitions share key elements. These elements include: valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent in cross-cultural interactions, institutionalising the importance of cultural knowledge and making adaptations to service delivery that reflect cultural understanding (Goode 1995). In addition,cultural competence may be viewed as both a way to improve access and equity and a business strategy to enhance cost effectiveness. The following definition by Cross et al (1989) remains one of
the most frequently cited and succinct definitions:

Cultural competence is a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or those professionals to work effectively in
cross-cultural situations (Cross et al 1989).

Different levels

As the above definition indicates, cultural competence has a number of components and ideally operates concurrently on
different levels.

At the systems, organisational or program level, a coordinated and comprehensive plan needs to be in place to support the efforts of individuals. Such a plan includes strategies to address policymaking, infrastructure building, workforce development, program administration and evaluation, and service delivery.

Cultural competence is much more than awareness of cultural differences, as it focuses on the capacity of
the health system to improve health and wellbeing by integrating culture into the delivery of health services (NHMRC 2005) .

At the individual level, cultural competence may be regarded as:

The ability to identify and challenge one’s cultural assumptions, one’s values and beliefs. It is about developing empathy and connected knowledge, the ability to see the world through another’s eyes, or, at the very least, to recognise that others may view the world through different cultural lenses (Fitzgerald 2000).

Distinction between ‘competence’ and ‘competency’

There is a tendency in the literature to use the terms ‘competence’ and ‘competency’ interchangeably. However, it
is important not to conflate their meanings as the political and educational differences are profound (Smith 2005).

‘Competence’ refers to a broad global capacity; it is an outcome that describes what someone can do (Tight 1996).
‘Competency’ is a much more narrow concept that is used to label specific skills and abilities that are observable and
assessable (Smith 2005).

Currently in Australia, Competency-Based Training (CBT) is very popular in the Vocational Education & Training (VET)
arena and continues to enjoy strong support at a national level from both industry and government. This has led some in the ‘cultural competence movement’ to align themselves with CBT. Some argue that this is a useful strategy to gain ‘legitimacy’ and help put diversity issues on the training agenda. Others, however, warn that there are risks in uncritical acceptance of CBT as this can lead to reducing human attributes to discrete activities that can be objectively and (some would say) mechanistically measured. While it may be that some aspects of cultural competence can be broken down into such discrete and observable skills (and there may be value in assessing these), many would argue that it is highly debatable that values and attitudes may be so measured2. Proponents of CBT, however, might argue that, as behaviour tends to refl ect attitudes, and behaviour can be observed, then it is possible to infer attitude change from behaviour change.

Nevertheless, given the unresolved nature of such debates, it may be prudent to adopt the more global term ‘competence’ when referring to the attributes required to deliver services that are respectful and responsive to the beliefs and practices of culturally and linguistically diverse (CALD) client populations.

Difference between ‘competence’ and ‘awareness’

Is ‘cultural competence’ just a newer version of ‘cultural awareness’ or ‘cultural sensitivity’? How is it different? It is argued that ‘competence’ implies both action and accountability and in this sense potentially takes the notion of cultural responsiveness further along the continuum of change. It is possible to be aware of and even sensitive to cultural difference without necessarily doing anything about this, that is without changing practice. The practice aspect of cultural competence adds an important skills component to the domains of knowledge and awareness. A third important aspect of cultural competence is the notion of reciprocity. This emphasises that the development of cultural competence involves a two-way learning process between health service provider and consumer.

WHY IS CULTURAL COMPETENCE IMPORTANT IN THE HEALTHCARE CONTEXT?

Changing demographics, increasing workforce diversity and disparities in health access and outcomes

Australia’s population comprises people with over 200 different ancestries. Over 200 languages are spoken and over 100
religions are observed. Almost one-quarter of the population (22%) were born overseas and approximately 15% speak a
language other than English at home (ABS 2001). In addition to this diversity is the diversity within Australia’s indigenous
population who at the last census made up 2.4% of Australia’s population (ABS 2001). As one of the most culturally diverse societies in the world, it is therefore incumbent on Australian healthcare systems and providers to respond in ways that ensure that this diversity is effectively accommodated in order to promote and sustain the health of Australian society now and into the future (Johnstone & Kanitsaki 2005). Moreover, the increasing diversity that is refl ected both internally in the health workforce and externally in health consumer populations has clear implications for effective ‘diversity management’3. A healthcare organisation that is ‘culturally competent’ is able to provide culturally responsive services and at the same time reap the benefits of ‘productive diversity’ (4). Indeed, the development of cultural competence has been identified as an effective access and equity strategy as well as a quality improvement process that is linked to improved health consumer outcomes (Betancourt et al 2003; Brach & Fraser 2002; DHFS & AIHW 1998).

Benefits of cultural competence in healthcare

Specifically, the benefits of delivering culturally competent healthcare include:

• Improved access and equity for all groups in the population
• Improved consumer ‘health literacy’ and reduced delays in seeking healthcare and treatment
• Improved communication and understanding of meanings between health consumers and providers, resulting in:

• better compliance with recommended treatment
• clearer expectations
• reduced medication errors and adverse events
• improved attendance at ‘follow-up’ appointments
• reduced preventable hospitalisation rates
• improved consumer satisfaction

• Improved patient safety and quality assurance
• Improved ‘public image’ of a health service
• Good business practice and better use of resources.

Conversely, it follows that there are substantial risks that are likely to incur costs if healthcare provision is culturally incompetent.

The influence of ‘culture’

It is well established that cultural beliefs shape understandings of and responses to health and illness (Kleinman et al 1978; Angel & Thoits 1987; Kirmayer & Young 1998; Fadiman 1997). It is important that healthcare providers remember that culture also shapes the clinical encounter and that healthcare services in Australia are generally provided according to a ‘Western’ (5) biomedical paradigm. For many client groups, this approach does not fit with their belief systems. When there is a ‘mismatch’ between belief systems, health outcomes are likely to be poorer. The tendency of the health system (or more specifically medicine) to represent itself as a ‘culture of no culture’ thus results in a culture-blind and ethnocentric approach. This effectively creates an exclusionary system (Kagawa-Singer & Kassim-Lakha 2003).

The impacts of colonisation, migration and refugee experiences

The impacts on individuals of the legacies of colonisation, experiences of migration and refugee resettlement vary depending on a range of social, economic and environmental determinants. The resulting diversity of intersecting needs challenges the health system to be truly responsive to the heterogeneity in our population. Failure to meet the challenges has significant negative health outcomes for some groups of people.

Aboriginal & Torres Strait Islander people

It is well-documented that the health status of Aboriginal and Torres Strait Islander people is substantially poorer than that of non-Indigenous Australians. Disadvantage across a range of socio-economic factors impacts negatively on the health of Aboriginal and Torres Strait Islander people. Both morbidity and mortality rates are higher, with Indigenous people more likely to experience disability and reduced quality of life due to ill-health. Life expectancy of Indigenous Australians is estimated to be approximately twenty years lower than for other Australians (ABS & AIHW 2003). In applying the principles of cultural competence to working with Indigenous people, their unique historical context must be taken into account and interventions tailored accordingly. In recognition of this, the Australian Health Ministers’ Advisory Council (AHMAC) commissioned its Standing Committee on Aboriginal and Torres Strait Islander Health (SCATSIH) to develop the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health (AHMAC 2004).

Immigrants

Health requirements for immigration ensure that people immigrating to Australia generally enjoy good health on arrival. However, despite an initial ‘healthy migrant effect’, this relative advantage tends to decrease, as length of residence increases (AIHW 2002; Young 1992). Some evidence suggests that mortality and morbidity rates from certain diseases are increasing for some migrant groups. For example, cervical cancer mortality rates among women born in Asia are higher than among Australian-born women generally, possibly partly due to lower participation rates in pap smear screening (AIHW 2004). Proportionately, more overseas-born people than Australian-born also report having diabetes, with mortality rates also being higher for those born in some parts of Europe and Asia (AIHW 2004). Hospitalisation rates for tuberculosis, cataract removal, gastritis, duodenitis, kidney and ureter calculus are also higher among people born is some parts of Europe and in Asia (AIHW 2004). Moreover, some groups continue to experience problems in dealing with the Australian health care system and, as a result, many health services may still under-utilised by CALD groups. This leads some commentators to the conclusion that “there is mounting evidence that the ‘positive’ health inequalities in migrant groups…are now converting (or have already converted) to ‘negative’ health inequalities” (Johnstone & Kanitsaki 2005:25) (6). However, given the heterogeneity both within and between groups, it is difficult and inadvisable to draw conclusions about the health of immigrants in general.

Refugees and asylum-seekers

While most refugees are healthy on arrival into Australia (like other migrants, having undergone screening for serious conditions), many new arrivals are at heightened risk for a number of health conditions that are refl ective of their experiences and sometimes of their region of origin. These health issues include poor dental health, undetected or poorly managed chronic diseases, infectious diseases, malnutrition, under-immunisation, physical and psychological consequences of torture (including sexual violence) and armed confl ict (Smith 2003). Evidence also suggests that newly arrived refugees are also more likely to rate their own health as either ‘fair’ or ‘poor’ (NSW Health 2004). While refugees and other humanitarian entrants who are permanent residents are eligible for Medicare (7), they face a number of barriers in accessing healthcare. These include language barriers, financial constraints, limited trust of health service providers, lack of familiarity with the Australian healthcare system and culturally incongruent service delivery.

Legislative and policy context

Legislative frameworks operate at both federal and state levels to regulate multicultural and human rights in Australian jurisdictions. (8)

In addition, public policy at the national level affirms access and equity principles in The Charter of Public Service in a Culturally Diverse Society (DIMA 1998), by emphasising that cultural diversity considerations should be incorporated into the strategic planning, policy development, budgeting and reporting processes of service delivery. The key statement of Australia’s multicultural policy, Multicultural Australia: United in Diversity (May 2003), similarly promotes acceptance and
respect for our cultural diversity and supports the rights of all Australians to maintain and celebrate, within the law, their culture, language and religion. Four principles underpin multicultural policy.

These are:

• Responsibilities of all – to support Australia’s basic democratic structures
  

• Respect for each person – to express their own culture and beliefs, subject to the law
• Fairness for each person – in relation to equality oftreatment and opportunity
• Benefits for all – in terms of ‘productive diversity’, that is, the cultural, social and economic dividends arisingfrom the diversity of our population.
  

At the state level, in NSW, the Charter of Principles for a Culturally Diverse Society (1993) reiterates the obligations to improve service delivery to a culturally diverse society. These responsibilities are articulated in the NSW Community Relations and Principles of Multiculturalism Act 2000 which outlines a number of principles that public sector agencies are required to observe. These principles echo those at the federal level and constitute the policy of the state of NSW in relation to cultural diversity. (9)

In the context of NSW Health, the most current key policy documents at the time of writing are Strategic Directions for Health 2000-2005 and NSW Health and Equity Statement: In All Fairness (2004). In the former document, “Fairer Access” is noted as one of the key goals and in the latter, “Cultural Diversity” is named as one of the key underpinning principles. A recently released consultation document, Fit for the Future, outlines NSW Health’s broad directions for the next two decades. ”Respect for individuals and communities” and “access and equity” are two of the core values espoused in the document (NSW Health 2006).

It is beyond the scope of this paper to comprehensively detail the evolution of multicultural and human rights public policy and legislation and its effects on healthcare in Australia. However, evidence suggests that, despite over thirty years of multicultural policies and programs and notwithstanding policy and legislative frameworks, Australia’s healthcare system is still not as responsive as it needs to be to the cultural diversity of the populations that it purports to serve (Johnstone & Kanitsaki 2005).

HOW CAN CULTURAL COMPETENCE BE DEVELOPED IN HEALTH SERVICES?

As noted, the concept of cultural competence is gaining popularity in Australia. However, a focus on conceptualising, at the expense of operationalising, has resulted in some confusion regarding how the notion translates from theory into practice.

Support from the top vital

In the absence of a clear framework for implementation and endorsed standards for practice, policy statements are likely to remain in the realm of rhetoric. Therefore, first and foremost, a commitment to operationalise cultural competence must be evident in the leadership of an organisation and embedded in key performance indicators. Such commitment must not only take the form of unambiguous statements that ‘good practice’ is ‘culturally competent practice’ and ‘quality healthcare’ is ‘culturally competent healthcare’, but such statements must be backed with allocation of resources to implement and evaluate initiatives. Without ‘diversity champions’ at the most senior levels, efforts at the individual level are unlikely to create or sustain substantial systemic change (Cope & Kalantzis 1997; Gardenswartz & Rowe 2002; Dowd 2002).

Combination of strategies at different levels

The process of becoming culturally competent in healthcare requires multi-level strategies and involves both ‘top-down’ and ‘bottom-up’ change management strategies. Reciprocal learning between health service providers and culturally and linguistically diverse consumers is also integral to fostering a culturally competent health system (NHMRC 2005; Procter 2003).

At the organisational and systemic levels, this occurs in relation to the development of policy and guidelines, implementation frameworks and guidelines and workforce development plans. It may require re-examination of mission statements, protocols and procedures, data collection, administrative practices, staff recruitment and retention, staff orientation and professional development opportunities, interpreting and translating processes, research tools, community partnerships, health promotion activities, complaints mechanisms, client satisfaction surveys, capacity building and participatory action research involving consumer consultants (Goode 1995; Betancourt et al 2003). Valuing workforce diversity and fostering culturally inclusive workplaces are fundamental to organisational cultural competence strategies.

At the individual/clinical level, health professionals and clinicians need to be aware of their own attitudes, values, biases and preferences, as well as be prepared to acquire new skills and knowledge. The process of individual cultural competence development may be facilitated by organisational education and training initiatives. It should be noted, however, that ‘training’ ought not to be viewed as the only avenue for individual learning. Other opportunities to develop cultural competence include working with cultural brokers/mediators/ consultants and mentoring programs.

Education & training: what works?

Despite its limitations, staff training and professional development remain a popular cultural competence intervention and so it is worthwhile examining the options that are available.

‘Integrated’ or ‘modular’ training?
Very often, such training is provided in the form of ‘standalone’ modules/workshops/seminars variously called ‘Working with Diversity’, ‘Cultural Awareness’ or ‘Cross-cultural Communication’. The time allocated to such sessions varies enormously, as does the content, format and quality. While the intention of this sort of training may be to enhance practice, the context in which it is delivered may well limit its effectiveness. If it is offered as optional, the audience is invariably ‘the converted’. If it is mandatory (as is frequently the case after a ‘critical incident’ occurs), then participants are often unreceptive and it is perceived as punitive. Neither scenario augurs well for organisational change.

Another option in relation to cultural competence training is integrating diversity issues into ‘mainstream’ courses for health workers, at the undergraduate (pre-service) level as well as in the context of continuing professional development. Many commentators voice a strong preference for the ‘integrated’ approach over the ‘modular’ approach. However, few specify how to ensure that this occurs. While such an enterprise may well yield more far-reaching and sustainable results than ‘addon’ courses, the lack of a coherent educational framework and rigorous evaluation processes severely hamper efforts (Beach et al, 2005; Anderson et al, 2003). Furthermore, there are varying interpretations of ‘integration’. In some contexts, it implies a longitudinal threading of diversity issues throughout the entire curriculum, while in others, a ‘session’ inserted into a longer program is deemed ‘integrated’. Moreover, a truly integrated approach to curriculum development poses a longterm challenge and is therefore often less appealing to those who would prefer to opt for the apparently quick-fix solution of mandating all staff members to attend ‘diversity training’ (also known as ‘the sheep-dip approach’).

Key features/elements of effective training

Much is still contested in the field of cultural competence learning and teaching. However, despite the absence of a solid evidence base in relation to what training approaches are most effective, there is emerging from the literature a picture of what might constitute ‘good practice’.

• Trainers – the training must be delivered by trainers who demonstrate a level of cultural competence themselves. Thismay seem self-evident, but it is worth articulating what thismight mean. In addition to a good knowledge of diversity issues, a number of other criteria have been proposed forselecting suitable trainers. These include demonstrating important personal attributes such as self-awareness andpsychological adaptability, empathy and responsiveness,freedom from ethnocentricity and an ability to act as an agent of change. In addition, the literature frequently notes such important trainer characteristics as commitment to the principles of adult education, good process competence, familiarity with the routines and procedures of the health facility in which the participants work (vital for credibility) and strong facilitation skills to manage diverse opinions and sometimes emotionally volatile situations (Anand 1999; Gilbert 2003). Some commentators note that a mixed ethnicity and mixed gender training team has benefits, but also potential drawbacks (Anand 1999).
• Content – A broad, inclusive understanding of ‘culture’ as complex, dynamic and fl uid is necessary to underpin the content. Such an understanding encompasses the range of dimensions of human diversity and look beyond narrow
  definitions of ‘culture’ that relate only to birthplace, language and ethnicity. Connected to this idea is that cultural competence is not about knowing everything there is to know about this or that particular cultural / linguistic group. Indeed the pursuit of such an unrealistic goal invariably leads to stereotyping.

The three interrelated learning domains of awareness, knowledge and skills are frequently proposed as the basis for an appropriate framework for cultural competence training (Gunn 1995).

• Awareness – The starting point for effective cultural competence training must be self-examination, rather than a  focus on ‘the other’, as this can only perpetuate an ‘us and them’ way of thinking which is precisely what is to be avoided. This includes encouraging participants to become aware of their own internalised beliefs and biases (including those deriving from their organisational and professional culture) and how these might impact on interactions with client/patients.
  

• Knowledge – In terms of equipping learners with the necessary knowledge base, trainers need to contextualise their  training within the relevant policy and legislative frameworks. Training frequently risks becoming merely information provision, as participants often request guidance on how to work with specific ethnocultural groups and the temptation is to offer up lists of cultural traits or masses of culturally specific information. However, the most effective training will resist taking this route of least resistance.10 While this may result in some disgruntled participants who feel as if their needs are not being met, it is important to remember that it is often in this space of discomfort and confusion that important self-refl ection takes place and ‘transformative’ adult learning results (Mezirow 1995; Merriam & Caffarella 1999).
  

• Skills – skills development in the areas of cross-cultural communication, including, but not limited to, knowing when and how to work with professional interpreters, conflict resolution, negotiation of explanatory models and critical thinking are typically cited in the literature as integral to effective cultural competence training (Carillo et al, 1999).
• Format/Techniques – Consistent with adult education theory, good cultural competence training will involve a range of techniques to accommodate the diversity of adult learning styles, acknowledge prior learning experiences (good and bad) and be tailored to meet the specific needs of the participants. The approach taken and the balance of activities addressing each of the learning domains (affective, cognitive, psychomotor) will obviously vary depending on a number of factors, including the time available. However, evidence suggests that practical and experiential activities
  yield the best results when facilitated skilfully. (11)
• Context – the most effective training programs are embedded in an overall organisational plan to develop cultural competence. It is important to remember that, despite its popularity as a potential panacea for all that is lacking in health service provision, training is not the answer to the problems. Well-targeted and effectively facilitated, it can be  a valuable strategy to assist in the process of long-term organisational change. Most importantly, developing cultural competence should be seen as an ongoing and incremental ` and not a one-off event. Therefore, learning opportunities should be regularly scheduled and any one session/workshop/course/seminar on its own should be seen as simply a step in the process of developing what some prefer to call ‘cultural humility’ (Tervalon & Murray-Garcia 1998).
  

HOW CAN CULTURAL COMPETENCE BE MEASURED?

No explicit criteria for cultural competence assessment and lack of evaluation

Despite its widespread popularity as a goal to strive towards, no explicit criteria have yet been established to assess the achievement of cultural competence. Agreement across the different healthcare professions in relation to the measurement of cultural competence is conspicuously lacking (Johnstone & Kanitsaki 2005). The difficulties inherent in conducting cultural competence evaluation (because of the lack of appropriate tools and resources) are compounded by reluctance on the part of many health service providers to participate in meaningful evaluation and data-collection activities (Diversity Rx 2002 cited in Johnstone & Kanitsaki 2005).

Perhaps another reason for the scarcity of rigorous evaluation studies may be the lack of agreement as to the meaning of the term ‘culture’ (Hunt 2001). If we understand ‘culture’ in its broadest possible sense, as suggested, it is dynamic and complex, encompassing the full range of dimensions of human diversity (e.g. gender, sexual preference, age, (dis)ability, socioeconomic status etc.). The term ‘competence’, however, has been well defined by educators (particularly in the VET sector, as previously noted) and so, perhaps in an effort to ‘pin down’ the slippery and elusive concept of ‘culture’ and attach some ‘measurables’, it has been linked, by some, to the Competency Based Training (CBT) movement. However, the end result may well be a ‘dangerous liaison’ that tends towards representing culture as a decontextualised set of traits or cultural characteristics that can be ‘known’. This approach runs the grave risk of promoting stereotyping and runs counter to notions of individual client/patient-centred intervention.

Clearly the challenge in cultural competence evaluation lies in finding the right balance between maintaining the fluidity of the core concepts and meeting the demands for ‘hard’ measurement of effectiveness. Importantly, research is needed that explores the impact of cultural competence interventions on the ‘end-users’; we need to know more about what strategies have the most beneficial impacts on health consumer outcomes.

Various tools/instruments to assess competence at the individual level

One approach to assessment has been the development of a number of tools or instruments for individual practitioners/clinicians to assess their own cultural competence. For this to be most effective, scrupulous honesty on the part of the individual is called for. To encourage such honesty, the results of such self-assessments are often not collated or fed into ‘the system’, but are intended to encourage self-refl ection and to give the individual some ‘baseline data’ about their own cultural competence. However, it is worth noting that the collation and analysis of a critical mass of such individual self-assessments may well provide a ‘barometer reading’ of the cultural competence of an organisation. Embedded in such tools is the notion that there are a number of personal characteristics or attributes that a culturally competent individual demonstrates and which, presumably those who are not yet competent, can develop.12 Other possible ways of measuring individual cultural competence include clinical case file audits and the incorporation of cultural competence into staff orientation and performance management processes. However, in the absence of agreed practice standards, the value of such assessment tools is questionable.

In addition to individual checklists, there are a number of models (mainly developed in the USA) that provide useful practical frameworks for implementing and assessing cultural competence at both the individual and the organisational level. Most of these are based on a developmental continuum approach. (13)

Standards to assess competence at the organisational level

Perhaps the most useful way of assessing organisational cultural competence is by measuring performance against a set of agreed standards. This approach was formally adopted in 2001 in the US through the publication of National Standards for Culturally and Linguistically Appropriate Services in Health Care issued by the Office of Minority Health, US Department of Health & Human Services. The fourteen standards are grouped according to three themes. These are ‘Culturally Competent Care’ (Standards 1-3), ‘Language Access Services’ (Standards 4-7) and ‘Organisational Supports for Cultural Competence’ (Standards 8-14). Within this framework, the standards vary in terms of their stringency and enforceability. Only the four standards that relate to Language Access Services are mandated for services receiving Federal funds. The remaining standards are either recommended guidelines or recommendations for voluntary adoption by healthcare organisations.

In Australia, there is currently no equivalent standards framework for health services at the National level14. At the State level, in NSW, the Ethnic Affairs Priority Statement (EAPS) Standards framework arguably goes some way towards encouraging systemic cultural competence. A project to embed cultural diversity into the health services accreditation system is currently being undertaken by the Australian Council on Healthcare Standards (ACHS) and Quality Management Services (QMS), in partnership with South Eastern Sydney & Illawarra Area Health Service and NSW Health. Some organisations have developed their own cultural competence standards15 and some professional groups have developed competence standards that incorporate cultural issues (16). There are, however, persistent gaps in the system and a lack of consistency across the range of healthcare service providers.

WHAT NEEDS TO HAPPEN TO PROGRESS THE CULTURAL COMPETENCE AGENDA IN HEALTH?

To date, efforts to advance the cultural competence agenda in Australian healthcare have been piecemeal and have suffered from a lack of coordination. However, change in this respect may be on the horizon.

The National Health & Medical Research Council (NHMRC) has recently released a document titled Cultural Competency in Health – a guide for policy, partnerships and participation. This is a comprehensive document, aimed at high-level policymakers, that describes a model with national application. Such a document has the potential to lead the way forward for the development of cultural competence in Australian healthcare – if it can galvanise action to make cultural issues “core business at every level of the health system” (NHMRC 2005:1).

Identified areas for action include:

• National collaboration on a framework for culturally competent health practice
• Addressing gaps in research to strengthen the evidence base in relation to what interventions are most effective
• Development of accountability mechanisms and performance indicators
• Identification of core competencies and processes for addressing these in education and training
• Improved data collection, reporting and sharing
• Development of a range of ‘hands-on’ resources and toolkits.

CONCLUSION

The DHI urges all those involved in the provision of healthcare – governments, funding bodies, policymakers, managers, researchers and practitioners – to engage in ongoing discussions, with each other and with health consumers from diverse communities, to contribute to coordinated action for change. The development of a truly culturally competent healthcare system is a long-term goal that involves a multifaceted, multilevel approach. The sustained commitment of all stakeholders in this process is needed if this goal is to be realised for the benefit of all Australians.

About the Author

Sarah Stewart

Coordinator, Workforce Development Education & Training
Diversity Health Institute
Sydney West Area Health Service
Ph: 9840 3764 • Fax: 9840 3755
Email: Sarah_Stewart at wsahs.nsw.gov.au