the-lancet---culture-and-health.pdf

Colleagues 48 think of competence as a means to

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colleagues 48 think of competence as a means to address organisational, structural, and clinical barriers to health- care access and provision faced both by physicians and those who seek their help. Although cultural competence training has roots going back to the 1960s, it almost never figures in the training of public health organisation employees, and has only been formally integrated into medical education since the 1970s, arguably in response to calls for new medical models that address the shifting demographics caused by migration. 49,50 In most training, however, it is not present, even if the view prevails that cultural competence can improve clinical outcomes by addressing the needs of those who are different from whatever dominant sociocultural groups provide care. Cultural competence and diversity are vaguely defined, poorly understood, and prone to being affected by political rather than educational motives. 51 Conventional understanding of cultural competence that emphasises recognition of racial, ethnic, and linguistic identities shifts clinical meaning away from socioeconomic factors and standard clinical diagnoses. Cultural competence is surely far more than a vague umbrella term that encompasses training in cultural sensitivity, multi- culturalism, and cross-culturalism. 52 Research into diverse health views of speakers of non- native languages has furthered understanding of just how wide ranging health needs are around the world. This research seeks to prevent medicalisation of ethnic groups on the mistaken assumption that because they might fare less well clinically they are less willing to comply with and adhere to treatment regimens. 53,54 Substantial scope exists for further research into these areas, particularly for studies that critically explore how ethnic origin and language proficiency can be rightly or wrongly held responsible for clinical non-adherence. 55 The need for this research is especially clear when health-care providers consult in multiethnic communities, where the need for translation is essential. 56,57 Language mediates most experiences of health-care services for
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The Lancet Commissions 1614 www.thelancet.com Vol 384 November 1, 2014 patients. 58 These services include not only face-to-face consultations with health-care practitioners, but also language-specific medical leaflets, health-related tele- vision programmes, and, increasingly, health advice on diagnostic websites and online discussions. However, intercultural health communication is not only about language translation, but also situated beliefs and practices about causation, local views on what constitutes effective provision of health care, and attitudes about agency and advocacy. 59 It is also about understanding communities of care and how they function at a local level to ameliorate uptake and overuse of expensive services. In one north London community (Tottenham and North Middlesex) studied for this Commission, more than 50% of the community health organisations functioning in 2010 were shut down as a
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