Article
Community engagement in healthcare

The Australian Health Care Standards Council (AHCSC) has established standards for cultural competency in health care. These standards, based on community engagement principles, ensure staff cultural competency in both assessment and management to achieve optimal outcomes in health services delivery for citizens.

Conceptual Model of Consumer Engagement in Health Care
http://www.uq.edu.au/health

The term culture “implies the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group”. The term competence “implies having the capacity to function effectively” (Goode, 1995).

Culture is a vital factor for consensus building and to understand how people respond to each other. Therefore, service planning and service learning for the benefit of the people need to be based on shared values, traditions and norms. These shared attributes include the ethnic and racial background; language; gender, socio-economic and educational status; sexual orientation; physical capacity; age; personality; spirituality and religion; regional perspectives; and new immigrant socialisation.

What is cultural competence?
Cultural competence is thus a set of shared values, behaviors, attitudes, and practices within a system, organisation, program or among individuals which enables them to work effectively together. Cultural competence is a life-long process. It involves ongoing examination of one’s own attitudes and values, acquisition of new knowledge, and appreciation of cultural differences and similarities within, among, and between groups. It involves raising one’s individual intellectual level to respect another person’s point of view and interpersonal style.

At a systems level—organisational or program—cultural competence requires a comprehensive and coordinated plan for:

1. policy making;
2. infrastructure building;
3. program administration and evaluation;
4. delivery of services and enabling supports; and
5. the individual.
Ref: Centre for Culture & Health http://cch.med.unsw.edu.au/cch.nsf

A culturally competent system reflects and responds to the communities it serves through its administrative policies and procedures, hiring practices, training and professional development, and the active participation of community members (consumers). Self-assessment, culturally-based needs assessments, and the active incorporation of findings from these assessments into practice—all are essential elements of culturally competent systems.

Why is cultural competence important?
Effective programs acknowledge and incorporate the culture of the people they serve. Culturally competent health services are more effective with the cultural groups receiving the services. Culture shapes how people experience their world, interpret their environment, live with their families, choose their lifestyle, work, play and reside in their community.

Cultural competency is best achieved when organisations and people work closely with knowledgeable persons from the community to develop health care services that reflect the shared values, traditions and customs of the people they serve. Cultural competency adds value to service delivery system and assures quality.

Cultural competency in the health care industry
The one area where all must be treated on equal terms is in the health care field. Health care workers have a reputation for being caring and understanding people. Because of this they are aware how people from different beliefs and customs need to be considered in the hospital setting. Different religious traditions have led to certain practices and behaviour. These need to be respected.

To assume that because patients are in a Western hospital they can shed millennia of cultural inheritance to conform with different cultural perspectives is to misunderstand the value of cultural practice. For some it may adversely affect the progress or response to treatment. It is not a case of either assimilation or multiculturalism. It is a marriage of the two. The health care provider and patient must seek to learn from each other, each being prepared to not only live as neighbours but also to respect areas of habit or cultural emphasis in the interests of harmonious co-operation.

Within this context there can be issues of socio-religious concern, which are of importance no matter the country of origin or religion of the people involved. Offers of assistance to seek out the appropriate religious person for the patient in no way must be given the appearance of interference or cause embarrassment.

Culturally competent health care providers collaborate with culturally knowledgeable community members at every phase of program operation—design, implementation, and evaluation — administrators, providers, staff and clients work to enhance program integrity and clarify communication. The result is strong and sound interventions, leading to improved health outcomes.

In essence, a culturally competent health industry needs to incorporate the following critical factors into service delivery in caring for diverse populations:

1. Health-related cultural factors
2. The incidence and prevalence of diseases in a given population
3. Research findings and treatment outcomes specific to that population.

Multicultural pain management
Despite significant advances in areas of medicine, many studies of pain management, including investigation of elderly cancer patients, indicate that pain remains poorly managed and under-treated for many patients (Bernabei R et al, 1998). Unrelieved pain has been associated with undesirable outcomes such as delays in postoperative recovery. Thus, healthcare providers need a better understanding of pain management.

One of the most challenging aspects of pain management is the understanding of a person’s culture and how it affects response to pain. Religious beliefs, cultural influences and diverse personal attitudes toward pain and suffering impact a person's response to pain.

Demographics of pain
Paediatric patients often are under-treated for pain because they cannot effectively communicate the level of pain they are experiencing. It is usually by age 4 that most children can point to the part of their body causing them pain or identify it on a drawing. While children's coping skills and developmental levels vary widely their body language can provide clues to pain they are experiencing. For example, a child lying on his side in bed, with his knees pulled up toward his chest, might have abdominal pain.

Elderly patients face unique issues regarding pain management. For example, the desire to be a "good patient" often makes some hesitant to mention their pain; some may fear the addiction potential or side effects of narcotics and decline pain medication, preferring to "tough it out."

Pain management for the elderly should focus on the different types of pain they suffer, for example, arthritis, osteoporosis, diabetes-related neuropathy and angina. Further, pain from different conditions of arthritis may vary throughout the day and depend on activity levels and the interaction of multiple medications. All these types of pain may need to be addressed by different interventions.

Cancer-related pain is a specialised area of pain management. Some people may become apprehensive about increasing medication doses in case they cause side effects worse than the pain itself and prolong hospitalisation and hasten death. In some cultures, pain may be interpreted as a test of one's faith, and the foregoing of pain medication may be viewed as a sign of personal strength and fortitude. As a result, healthcare professionals acknowledge and respect the patient's choices in pain management.

Patient education is important to ensure patients receive sufficient pain control to optimize recovery. Some patients may hesitant to ask for medications which state "as needed" for fear of appearing weak. Similarly, education of health providers and families of patients need briefing about cancer pain management which is paramount to not only reduce suffering, but also to promote healing and assure quality of care.

Quality of care
Pain is a complex phenomenon. A person's response is shaped by their individual life experiences. While it is understood that healthcare providers cannot know everything about a person's culture, they need to be aware of external influences on pain experience, including the effects of personal or cultural and religious beliefs. The healthcare provider accepts that the patient's pain is unique and that no two people will respond to pain in precisely the same manner.

The effective management of pain is multifaceted. Open lines of communication facilitate acknowledgement and respect an individual’s choice of treatment. It may be to decline modern pain medication, or ask for alternative or traditional treatment options, such as, acupuncture, massage, imagery, meditation, music therapy, relaxation therapy, yoga or herbs and even biofeedback.

As a general rule, the healthcare industry will have served its purpose by maximising patient comfort and minimizing poor outcomes. For this, all factors influencing quality of care need to be considered, including the willingness to understand the uniqueness of an individual’s desires and to respect the treatment choices. In these circumstances, it is appropriate to offer support and spiritual companionship and promote a sense of trust and acceptance.

References

• Bernabei R et al, 1998. Management of pain in elderly patients with cancer. JAMA, 279(23), 1877-1882.
• Breast Cancer Network Australia, http://www.bcna.org.au
• Joint Commission report on pain management, 1999. Joint Commission on American Health Organisations (JCAHO), http://www.jcaho.org
• National Coalition for Cancer Survivorship. (2004). Pain and the elderly. http://www.canceradvocacy.org/resources/essential/pain/elderly
• The Australian Council for Safety and Quality in Health Care (Council): Partnerships for Health in Action: Promoting Consumer and Community Involvement in Health Care Improvement. http://www.safetyandquality.org/consumrept0705.pdf
• Sullivan-Tevault M, 2004. Department of Pain Management, Veterans Affairs Medical Centre, Bay Pines, Florida, http://www.va.gov/