A multi-level examination of cultural competence in community health: an organisational case study

© 2016 Dr. Mandy TruongIt is widely recognised both within Australia and internationally that consideration of cultural issues in health care is important in meeting the health needs of culturally and linguistically diverse groups. Increasing cultural competence depends on a multi-dimensional approach that addresses individual, professional, organisational, and systemic competence. Knowledge about organisational best practice related to cultural competence is still emerging and there is a strong need for further research. Accordingly, the purpose of this PhD study is to address several gaps in the evidence base by contributing a deeper understanding of cultural competence and to provide evidence and guidelines to inform organisational cultural competence assessments. First, it aims to further our understanding of cultural competence within the community health context. Second, it aims to examine the outcomes and implications of conducting an organisational cultural competence assessment at a community health service. And, third, to evaluate the utility of an organisational assessment tool. The conceptual framework underpinning this research consists of several interdisciplinary frameworks and models, namely: the social ecological model, health promotion principles, cultural competence frameworks and Andersen’s behavioural model of health service use. Several frameworks and models were used in respect to the different aspects of the research. This PhD study adopts a qualitative approach to explore cultural competence within a community health service from client/carer, provider and organisational perspectives using semi-structured interviews and process evaluation. Findings of this study indicate that participants considered the practice of providing culturally competent health services to be multi-dimensional and multi-level. Most staff participants viewed cultural competence as being an important aspect of their work; however, they also identified that at times there were challenges in providing culturally competent care. Decisions made by clients/carer participants to use health care services are based on multiple factors, of which culture may be one. Client/carer participants were more likely to identify other non-culturally related potential barriers to service use such as: long waiting lists, lack of knowledge of services available, language and communication difficulties, and procedural issues such as making appointments. From study findings, a conceptual model was developed encompassing key issues impacting health service utilisation for culturally and linguistically diverse groups to inform design of interventions and/or further research to improve cultural competence within health care settings. Study findings also highlighted that the implementation of an organisational assessment of cultural competence at a community health service was a highly complex undertaking. Factors such as leadership, staff engagement, organisational inertia, organisational culture and resourcing were viewed as potential barriers or facilitators to the implementation of a cultural competence assessment tool and subsequent organisational efforts to improve cultural competence. Consideration of organisational factors, such as those highlighted by study findings, can inform the implementation of future organisational cultural competence assessments. Additionally, findings regarding the evaluation of a cultural competence assessment tool indicated that despite the challenges and limitations of the tool, it was found to be an important mechanism to facilitate organisational reflexivity. In particular, it enabled identification of organisational strengths and gaps to provide an impetus for action to improve organisational cultural competence. The findings can be used to inform the future development and refinement of such tools to improve their effectiveness, accuracy and relevance