Is Cultural Competence the Answer to Health Disparities?

The whole issue of the May-June 2008 Journal of Professional Nursing is devoted to cultural competency in nursing education, and largely contains work from faculty at The University of Pennsylvania. It is a very interesting read, as the authors describe their journey to being more culturally competent, aware, and diverse as a school. I whole-heartedly support this kind of movement in nursing education, but continue to get the sense that cultural competency is somehow tied to better patient outcomes (not necessarily from this special issue of JPN, but in general).

Drevdahl and colleages¹ provided a very good review of the assumption that cultural competency is the answer to health disparities. Their conclusions, which are supported by the available data, are that little evidence exists that cultural competency (either the training or being "competent" itself) are effective means at reducing health disparities. Certainly, there has been an increasing focus on cultural competency in the last 10 years, but little has changed with health disparities.

Recent work^3-6 has illustrated just how poor the current situation is. Essentially, cultural competency has not been shown to improve patient outcomes when the data are considered in whole. A recent publication in nursing, however, continues to link the two issues.⁷

Certainly a lack of awareness of issues surrounding appropriate culturally-sensitive care could lead to unequal treatment for some persons, but disparities still exist on many fronts. ^8-10 The source of these disparities is more than individuals, and so nursing's focus on the individual and on cultural competence will be insufficient to address the problems. More attention must be paid the social, structural, and political forces in our society that perpetuate inequality on all fronts. Specifically, greater attention needs to be paid to the antecedents of poor health, such as poverty, low-quality educational systems, and crime.

These are all nursing problems because they are public health problems. Viewing them as such puts the problems back in the lap of nursing.

1. Drevdahl D, Canales M, Dorcy K. Of goldfish tanks and moonlight tricks: Can cultural competency ameliorate health disparities? Adv Nur Science. 2008;31(1):13-27.

2. Beach M, Price E, Gary T, et al. Cultural competence: A systematic review of health care provider educational interventions. Med Care. 2005;43(4):356-373.

3. Capell J, Veenstra G, Dean E. Cultural competence in healthcare: Critical analysis of the construct, its assessment and implications. J Theory Construct Test. 2007;11(1):30-37.

4. Jones M, Cason C, Bond M. Cultural attitudes, knowledge, and skills of a health workforce. J Transcult Nurs. 2004;15(4):283-290.

5. Price EG, Beach MC, Gary TL, et al. A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Acad Med. 2005;80(6):578-586.

6. Scrimshaw SC, Fullilove MT, Fielding JE, Normand J, Anderson LM. Culturally competent healthcare systems: A systematic review. Amer J Prev Med. 2003;24(Suppl3):68-79.

7. Giger J, Davidhizar R, Purnell L, et al. American Academy of Nursing Expert Panel report: Developing cultural competence to eliminate health disparities in ethnic minorities and other vulnerable populations. J Transcult Nurs. 2007;18(2):95-102.

8. Blendon RJ, Buhr T, Cassidy EF, et al. Disparities in health: perspectives of a multi-ethnic, multi-racial America. Health Aff (Millwood). 2007;26(5):1437-1447.

9. Snowden LR. Bias in mental health assessment and intervention: Theory and evidence. Amer J Pub Health. 2003;93(2):239-243.

10. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare Managed Care. New Eng J Med. 353(7):692-700.