As part of the discussion of racism and discrimination, notions of mainstream bias and the stereotyping of cultural groups in healthcare need consideration. The history of working with diverse cultural groups in healthcare in High Income Countries has numerous examples of stereotyping of specific cultural groups leading to interventions that are often inadequate or inappropriate 38 , The very concepts of normality and abnormality in Western therapeutic approaches are embedded in cultural constructions that cannot be easily generalized across cultures Of particular concern here is the overdiagnosis of particular cultural groups with particular mental disorders as in the case of the overdiagnosis of schizophrenia in African American communities 19 , Coping and resilience are other areas of consideration in the context of cultural diversity and mental health.
Coping styles refer to the ways in which people cope with both everyday as well and more extreme stressors in their lives, including mental health related stressors.
The US Surgeon General [ 19 , p. Different cultures may place stressful events differently as normative, or something that most people in that culture will experience, such as coming-of-age rituals.
Further they will allocate social resources differently, leading to diverse experiences of these stressors. And finally, they may assess stressors differently, such as in terms of breaking of taboos or other cultural norms p. This diversity in terms of dealing with stressors can be both a protective factor and a risk factor. Hechanova and Waelde 14 suggest that, in collectivist cultures, healing is a product of interdependence and that the health of the group is at least as important to the individual as his or her own health.
Closely associated with coping, resilience is the ability to do well despite facing adversity, and is often discussed in the context of traits and characteristics of individuals. Kirmayer et al. They go on to suggest that, in the context of the Aboriginal Peoples of Canada, resilience is embedded in cultural values, renewed cultural identity, revitalized collective history, language, culture, spirituality, healing, and collective action.
As discussed earlier, collectivist cultures can play a key role as both a protective factor and a risk factor in issues of mental health. In many cultural groups, the family can be very involved in all aspects of a person's life Family factors such as supportive extended families and strong sibling relationships can act as protective factors in mental health, while perceptions of stigma, severe marital discord, breaking of norms and other such factors can be major risk factors 19 , Which would suggest that interventions that include cultural renewal and community and family support systems can be very useful in some or most cultural groups.
Cultural impacts on the therapeutic relationship are a significant factor to be considered in working with diverse cultures in mental health. The cultural context of the client and the practitioner are both central to the therapeutic relationship, a relationship that cannot work without careful consideration of the implications of cultural diversity.
Ideally, both the therapist and the client would be from the same culture and some of the pitfalls can be avoided In practice, there is a strong likelihood that therapists would be working with clients from cultures very different from their own and making assessments without linguistic, conceptual and normative equivalence, which could lead to many errors in service provision decision Some of the issues of overdiagnosis of certain cultural groups with particular mental disorders as mentioned earlier may find its roots with this lack of equivalence in assessment Still further considerations involve the concept of culture as language Language is central to any culture and to cultural understanding, and yet in HICs such as Australia the therapist and the client may not even share the same language.
While many High Income Countries have policies in place to ensure that appropriate interpreters are used in such circumstances, an endemic problem of non-utilization of interpreters continues Society as a patient is a term that Marsella 45 uses to point out that not all problems are located within the individual, and that the patient's well-being or lack thereof is often a product of the impacts of the external environment.
This is particularly the case with migrants and refugees or Indigenous populations in HICs who may experience racism, discrimination, and attendant marginalization 30 , Marsella goes on to argue for mental health professionals who work across cultures to take up the roles of social activists and challenge some of the societal contexts that are impacting on their clients This societal context also involves globalization and the rapid change of systems and cultures.
Globalization is not a new process but the last years has seen a rapid increase in global networks, increased velocity of global flows and increased depth of global interconnectedness The loss of social networks as protective factors can be very significant in terms of increasing levels of distress in culturally diverse communities such as refugees and migrants in HICs Traditional healers and healing systems are being replaced by Western systems that can suffer from inadequate resourcing and may be culturally inappropriate All of which points to the need for ways forward that build on these diminishing resources and strengthen the capacity of individuals and communities toward better mental health outcomes.
Some possible future directions are discussed in the next section. Mainstream mental health systems are increasingly acknowledging the intersection of cultural diversity. As an example, the provision of the cultural formulation interview in the DSM-5 is a positive step especially as it seeks to explore cultural identity, conceptualization of illness, psychosocial stressors, vulnerability, and resilience as well as the cultural features of the relationship between the clinician and the patient However, this is just one tool in the larger picture and cannot mean anything without more radical changes in systems and practices.
Much of the literature in the field points to the need for holistic health services that incorporate the total context in which health and illness are experienced 12 , 44 , Some suggestions involve the integration of mental health services with primary health care as a way of getting past some of the stigma and discrimination issues 19 , As Ng et al.
More recent approaches such as the biopsychosocial and the recovery approaches in mental health or renewed calls for medical pluralism also offer new opportunities to work with people in a more holistic way 55 , Fernando [ 11 , p. Marsella 45 argues that community-based ethno-cultural services are a positive resource in the community that can provide an essential function in working with mental health issues in diverse cultural groups.
Further, he argues that the development of a strong social support and community-based network must be intrinsic to the process. In the context of working with refugees in the UK, Tribe [ 1 , p. These positive resources, including especially traditional healing practices and systems can be involved in the provision of mental health services through collaborations, partnerships, and community-based health systems. An example here is the Muthuswamy healing temple in India where research conducted by the National Institute of Mental Health and Neurological Sciences NIMHANS , India concluded that people with mental health issues staying at the temple showed significant reduction in psychiatric rating scale scores.
Similarly, Gone 33 points to the widespread use of talking circles, pipe ceremonies, sweat lodges and other culturally specific practices in the federal Indian Health Service in the United States to argue for a renewed focus on participation in traditional cultural practices, and attendant possibilities of spiritual transformations, shifts in collective identity and meaning making.
Boksa et al. Mahony and Donnelly 44 also point out that spiritual and traditional healing practices can prove very useful in terms of promoting immigrant women's mental health. Another way forward is to go beyond cultural competence frameworks and practice toward developing cultural partnerships. Quite a few authors point to cultural competence as the most commonly used framework of practice in working with issues of mental health in culturally diverse settings 58 — While the cultural competence framework has proved useful in terms of working across cultures, it suffers from a few significant flaws.
Firstly, cultural competence frameworks approach culture from a purportedly value-neutral position, thereby ignoring the differences in power and the nature of historical and present-day oppression experienced by cultural groups In circumstances where some cultural groups can be marginalized, as in the context of the issues of historical dispossession, racism, stereotyping, stigmatization, and power differentials, it becomes extremely important to work toward more equitable ways of engaging with communities 61 — And finally, cultural competence draws on static notions of cultures that are not based on the reality of the constantly changing and transforming nature of cultures 61 , These issues point toward the need for developing partnerships that are more equitable and that realign power relationships between service providers and individuals.
The focus must be to move from traditional relationships built in power relationships to more interdependent and synergistic relationships 64 , A range of partnerships could be useful toward developing more effective mental health systems. They could include cultural partnerships between mental health providers and diverse cultural communities. It would certainly add to the nature of these partnerships if the providers also followed a deliberate policy of hiring workers of diverse backgrounds, and especially those from the communities that the service users come from.
Murray and Skull 66 suggest that these forms of partnerships between refugee groups and health service providers have been shown to be more effective in terms of responding to health and other needs of the refugees than traditional top-down approaches.
Finally, the relationship between the therapist and the client could be viewed as a cultural partnership, very much in line with the recovery approach, where the client would be an active participant in the process.
In this article, some of the key considerations of working with diverse cultures in mental health have been explored and the point made that there can be severe repercussions on individuals and communities if systems and processes are not in place to enable mental health providers to work effectively across cultures. Each of these considerations in turn provides opportunities for new ways of engaging across cultures that can empower all parties involved rather than disempower and marginalize some groups while empowering others.
Rather than approach the considerations from a deficit approach, where each of these is a problem, they can provide new avenues for developing integrated and holistic approaches toward working with mental health. A few of these avenues have been discussed in the paper, and some of these are already beginning to make inroads into mainstream mental health services, such as the emphasis on integrative services and the recovery approach.
Others, which have been delineated in greater detail in this paper, such as working with positive resources in the community and cultural partnerships, are those where very small one-off projects have been embarked on and where arguably there is much more opportunity for broad based research and practice. The author confirms being the sole contributor of this work and approved it for publication. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The reviewer BM and handling Editor declared their shared affiliation. National Center for Biotechnology Information , U. Journal List Front Public Health v. Front Public Health. Published online Jun Author information Article notes Copyright and License information Disclaimer. Received Sep 4; Accepted May The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice.
No use, distribution or reproduction is permitted which does not comply with these terms. This article has been cited by other articles in PMC. Abstract The purpose of this paper is to explore some of the key considerations that lie at the intersection of cultural diversity and mental health.
Keywords: culture, cultural diversity, mental health, mental illness, cultural partnerships. Introduction Culture is a broad and vexed term that can be defined in a range of ways, depending on the field of study and the perspective of the person using the term. Key considerations Hechanova and Waeldle 14 suggest that there are five key components of diverse cultures that have implications for mental health professionals.
Ways forward Mainstream mental health systems are increasingly acknowledging the intersection of cultural diversity.
Conclusion In this article, some of the key considerations of working with diverse cultures in mental health have been explored and the point made that there can be severe repercussions on individuals and communities if systems and processes are not in place to enable mental health providers to work effectively across cultures. Author contributions The author confirms being the sole contributor of this work and approved it for publication. Conflict of interest statement The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References 1. Tribe R. The mental health needs of refugees and asylum seekers. Mental Health Rev. Giddens A. Cambridge: Polity Press; Bean R. Canberra: Department of Immigration and Multicultural Affairs; Does diversity hurt democracy?
J Democr. Haque A. Mental health concepts in Southeast Asia: diagnostic considerations and treatment implications. There are numerous assessment tools available for evaluating cultural competence in clinical, training, and organizational settings.
These tools are not specific to behavioral health treatment. Though more work is needed in developing empirically supported instruments to measure cultural competence, there is a wealth of multicultural counseling and healthcare assessment tools that can provide guidance in identifying areas for improvement of cultural competence. This appendix examines three resource areas: counselor self-assessment tools, guidelines and assessment tools to implement and evaluate culturally responsive services within treatment programs and organizations, and forms addressing client satisfaction with and feedback about culturally responsive services.
Though not an exhaustive review of available tools, this appendix does provide samples of tools that are within the public domain. This item self-report instrument assesses perceived ability to perform various counselor behaviors in individual counseling with a racially diverse client population.
For additional information on psychometric properties and scoring, refer to Sheu and Lent Download PDF 77K. Acad Med. The TSET consists of 83 items, conceptually based on the literature of transcultural nursing, ordered into three subscales: 1 Cognitive knowledge, consisting of 25 items ; 2 Practical interview, consisting of 28 items ; and 3 Affective Values, attitudes and beliefs, consisting of 30 items. It is an assessment tool adapted from the transcultural self-efficacy tool TSET.
The CCCET can be used for multiple formative and summative evaluation purposes to guide individual, course, curricular, and employee educational program innovations and teaching-learning strategies.
The CCCET contains three subscales measuring different dimensions of cultural competence clinical behaviors: a the extent of culturally specific care Subscale 1 ; b cultural assessment Subscale 2 ; and c culturally sensitive and professionally appropriate attitudes, values, or beliefs including awareness, acceptance, recognition, appreciation, and advocacy necessary for providing culturally sensitive professional nursing care Subscale 3.
The subscales contain 25 items, 28 items, and 30 items, respectively. The reliability coefficients provided evidence for internal consistency. Citation: Jeffreys, M. Evaluating Cultural Competence in the Clinical Practicum. Nursing Education Perspectives, 34 2 Citation: Tucker, C. Journal of the National Medical Association , 99 6 , As defined by Karnik and Dogra , p. The questionnaire measures four factors: 1 patient and health professional behaviors, 2 self-assessments, 3 self-awareness, and 4 cultural influence.
The Cronbach alpha was measured as 0. This behavioral assessment of cultural competence may provide a method for providing feedback aimed at professional development in the area of cultural competence for students, clinicians, faculty, and programs. Citation: Hammer, M. Measuring intercultural competence: The Intercultural Development Inventory.
International Journal of Intercultural Relations 27 4 , The CCAI measures the 4 variables of emotional resistance, flexibility and openness, perceptual acuity, and personal autonomy. Intercultural Press — The aim of this grant was to rethink ways cultural diversity is taught in pre-health education.
The project included an interdisciplinary model for teaching pre-health undergraduate students pre-medicine, pre-nursing, pre-life sciences about the intersections of race, gender, health, and ethnicity. For more information contact Dr. Piontek at mpiontek umich.
These two measurements are combined to produce four dimensions that represent different intercultural learning orientations: proactive, protective, attentive, and adaptive.
They provide an annotated bibliography of each assessment tool as well as a direct link to obtaining a copy of each tool. Developed by authors Suarez-Balcazar,Taylor-Ritzler, Pertillo, Rodakowski, Garcia-Ramirez and Willis, the CAI-UIC measures perceived levels of cultural competence based on an extensive literature review, feedback from experts, and a synthesis of prevalent instruments and conceptual models of cultural competence available in the literature.
The validation study was conducted with a random sample of practitioners. The citation for the psychometric testing of this tools is: Suarez-Balcazar, F. Journal of Rehabilitation , 77, Gilbert provides a list of organizational and healthcare professional cultural assessment tools. The subscale a coefficients ranged from. Citation: Nichols-English, G. This report provides a brief overview of the concept of cultural competence with an emphasis on useful tools and resources.
It is designed to examine all components of a curriculum, including the following areas: where culturally competent care is currently taught, educational elements that have been previously unrecognized, where gaps in the curriculum exist, and planned and unplanned redundancies. For more information about the tool contact Dr. Ella Cleveland at ecleveland aamc. Citation: Lucas, T. Health Psychology , 27 2 , It was validated for content, analyzed for reliability, and field and pilot tested.
Results indicated that the CDAQ has favorable psychometric properties. Journal of Cultural Diversity ,14 3 This project is aimed to contribute to the methodology and state-of-the-art of cultural competence assessment. The product — An Organizational Cultural Competence Assessment Profile — builds upon previous work in the field, such as the National Standards for Culturally and Linguistically Appropriate Services CLAS , and serves as a future building block that advances the conceptualization and practical understanding of how to assess cultural competence at the organizational level.
The project was implemented through a contract with The Lewin Group, Inc. Citation: Thom, D. BMC Med Educ. Questions were grouped into themes that became the six modules in this Question Bank.
Thematic categories are intended to reflect AETC foci and activities. It is stated to be particularly useful in a residency setting to teach the next generation of orthopaedists. Contact Dr.
Ramon at ramon jimenez. Participants respond utilizing a 6-point Likert-type scale, the scale ranges from 1 strongly disagree to 6 strongly agree. Total score which encompasses all three subscales can range from 20 to with higher scores representing more color-blind racial attitudes. Citation: Neville, H. Journal of Counseling Psychology , 47, The purpose of this report was to identify and review the most relevant assessment tools for the set of organizational cultural competency standards and to make recommendations regarding the future evaluation of organizational cultural competence.
The CCCI is administered via a structured interview. In the field test family members were asked to rate service coordinators by responding to items grouped into four subscales: respect for cultural differences, community and family involvement, appropriateness of assessment and treatment options, and agency services and structure.
The research team continues gathering data and refining the CCCI. They are seeking collaborations with communities or organizations that are interested in using the instrument and that are willing to share data so psychometric properties of the scale can be further investigated.
For more information, contact Sara Hudson Scholle, Ph. The first portion, Section A, asks participants to describe a visit with their current doctor or other health care provider in the last 12 months in which a decision was made about their health care. Section B asks subjects if the experience they described involved a routine health care visit or an emergency.
Section C then includes 28 procedural justice items, which focus on the three facets of procedural justice: Trust, Impartiality, and Participation. Participants would be asked to reflect on the experience they described in Section A while answering these questions. After the procedural justice items, participants were asked to answer eight distributive justice items while focusing on their health care experience. In addition, the scores on each scale range from Citation: Fondacaro, M.
Social Justice Research , 18 1 , The ODCS has internal consistence reliabilities in the present study ranging from. Citation: Pascarella, E. Journal of Higher Education , 67 2 , The score is derived from a rubric comprised of three main constructs awareness, knowledge, and skills and four rating categories Proficient, Competent, Beginner, and Novice. To address the primary objective, the results of a Delphi survey of 19 diversity or cultural competence experts in the field were analyzed.
Fourteen institutions, for a total of student responses, served as the sample to test the relationships with cultural competence and the independent variables. The results also demonstrate evidence for a negative relationship between cultural competence and color blind racial attitudes, and a positive relationship between cultural competence and Lifetime Experience with Discrimination. Citation: Cram, Bridgette E.
Hammer Ph. A short version of ASK contains 24 items for self-assessment and practice use. A series of internal consistency reliability tests were performed to examine the reliability.
The instrument was validated using factor analyses. Citation: Leung, P. Children and Youth Services Review , 35, In addition, the RHS has shown initial evidence of construct validity. It was found to correlate with empathy and forgiveness of an offender and positive relationship characteristics with a parent, such as closeness and positive and negative affect. This scale has also been used successfully at a self-report measure.
Citations: Davis, D. Hook, J. Relational humility: Conceptualizing and measuring humility as a personality judgment. Humility: Review of measurement strategies and conceptualization as a personality judgment. Journal of Positive Psychology, 5 , The QDI assesses the cognitive component of attitudes directed toward racial minority groups and women and the affective component of attitudes as related to interpersonal comfort in interactions with racially diverse persons.
Citation: Ponterotto, J. Educational and Psychological Measurement , 55 6 , Useful from an organization and an individual perspective. The assessment report also provides coaching tips and development planning templates.
Based on Low. Journal of Public Health Medicine , 26 4 The IRC has scales for intercultural sensitivity, intercultural communication, intercultural relationship building, conflict management, leadership and tolerance for ambiguity.
The instrument has been developed and tested over a period of more than three years. Van der Zee and Brinkmann, The components of this instrument are substantial knowledge, perceptual understanding and intercultural communication. Citation: Narayan, M. Cultural assessment and care planning. Home HealthCare Nurse , 21 9 , — It measures tolerance for ambiguity, behavioural flexibility, communicative awareness, knowledge discovery, respect for otherness and empathy.
INCA, The authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care.
The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C3 Instrument.
Citation: Haidet, P. Academic Medicine , 80 1 , Citation: Bacon, J. Becker, Cookston, J. Journal of Nursing Education , 42, The Cronbach alpha for the 3 factors ranged from. More positive scores higher EFURMS Scores were associated with older faculty who had been teaching longer and had more experience teaching underrepresented minority students.
Citation: Moreau, P. Dissertation: University of Massachusetts Medical School. Graduate School of Nursing Dissertations. Possible scores range from , with higher score indicating that students perceived greater integration of cultural competence in their nursing program. Citation: Godfrey, S. Current Psychology , 19, Citation: Jo, M. Marketing Letters , 8, This monograph compares organizational assessment instruments through the following questions: For what type of organization was the instrument developed?
How were the instruments developed? How do the authors define cultural competence? What domains do the authors use as categories of analysis?
Duanying Cai of Chiang Mai University. The tool consists of 29 items including five dimensions: cultural awareness, cultural respect, cultural knowledge, cultural understanding and cultural skills. The validity was also tested by the developer. Completion time for this questionnaire was approximately 10 min. Citation: Cai, D. Developing a cultural competence inventory for nurses in China. International Nursing Review. The total score ranges from zero to Higher total NCCS scores indicate a higher level of cultural competence.
Citation: Perng, S. Construct validation of the nurse cultural competence scale: a hierarchy of abilities. J Clin Nurs , 21 11—12 ,— The nurses self-report their perceived level as novice, advanced beginner, competent, or proficient to expert by marking what they believed best described their level of cultural competence in nursing care. This method of using a rating based on the concepts of novice to expert has been successfully used by other researchers.
With permission from the authors, 44 statements were extracted and modified from the two tools in order to support development of the survey. The survey is comprised of seven sections that addressed the following: cross-cultural interactions, cultural awareness of self, seeking and sharing knowledge, global and domestic awareness, cross-cultural communication, international and multicultural experiences, and clinical perspectives.
The survey was structured on a 5-point Likert scale, ranging from strongly disagree 1 , disagree 2 , neutral 3 , agree 4 , and strongly agree 5. In order to measure frequency of behaviors, a 5-point Likert scale ranged from never 1 , sometimes 2 , neutral 3 , usually 4 , and often 5. The overall reliability level of the combined subscales was.
J Clin Nurs , Earle Waugh and Dr. Jean Triscott to help health care professionals evaluate their own cultural knowledge, awareness, sensitivity, behaviors, and cultural confidence. Citation: Waugh, EH. Szafran O. Canada: Brush Education, Inc. This measure contains nine elements that assess the person's daily life, followed by a follow-up question about what the person believes was the reason for that daily discrimination.
This measure also presents a short version of five elements. It takes five to ten minutes to administer. Williams and colleagues have also developed other assessment tools measuring discrimination and is available at Everyday Discrimination Scale David R. Williams harvard.
Citation: Williams, D. Journal of Health Psychology, 2 3 , Citation: Echeverri, M. American Journal of Pharmaceutical Education , 74
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