Stephane M Shepherd: Cultural awareness training for health professionals can have unintended consequences

The overpoliticisation of simple medical encounters may do more harm than good

Cultural awareness training for health professionals is now commonplace across the Anglosphere. It emerged in response to prevailing cross cultural health disparities, which are thought to persist—in part—because of the cross cultural inexperience of medical staff [1].

Yet despite the aspirational intent of this exercise and the traction it has gained, cultural awareness training is in many ways inadequate and unverified. Indeed, systematic reviews demonstrate that this kind of training has limited to moderate effects [2,3,4,5].

The rationale behind cultural awareness training is that health professionals may be ignorant of the belief systems, world views, experiential realities, histories, norms, and traditions of various multicultural patients and, as a result, such patients may feel excluded, ignored, discriminated against, or misunderstood during their healthcare interactions [6].

Topics that you might cover in a cultural awareness workshop include: historical circumstances, pre- and post- migratory stressors, social taboos/stigmas, experiences of discrimination/racism, parenting styles and family arrangements, religious/spiritual practices, and community hierarchies. This method is often termed the “museum” approach, which sees health professionals exposed briefly to a myriad of cultural artefacts and traditions.

Instinctively, it seems obvious that the advantages of this approach might include the fostering of empathy and tolerance, the improved detection of culturally unique behavioural cues and symptom reporting styles, the avoidance of social transgressions, and perhaps a better understanding of how historical/environmental circumstances might underpin current challenges for individuals from that group. In turn, patients may feel more comfortable and therefore perhaps more likely to engage and/or adhere to treatment.

Yet cultural awareness workshops can also have several unintended consequences. A workshop attendee is in danger of absorbing only stereotypes and superficial information in the brief timeframe a workshop affords [7]. The catalogue of cultural norms and practices they learn about during this time may give the professional a preconceived notion of how a patient may conduct themselves before they have even interacted with them. This could overstate the importance of culture—or the relevance of cultural dynamics to a patient’s life or as it pertains to their health. The professional might unthinkingly view culture as central to the problem or attribute any clinical misunderstanding to cultural differences.

Moreover, when workshops describe a set of circumscribed cultural norms and practices, this may unintentionally undervalue or underplay the heterogeneity of individuals within a cultural group. The danger is that this allows professionals to accept an exoticised or traditionalised view, which may not reflect the current reality of how many patients from that cultural group live.

Workshop attendees may also be led to believe that they, as health professionals, are a homogenous group bereft of cross cultural know-how whose presence in a clinical interaction is naturally one of privilege. Relative privilege should not necessarily mean that a professional is incapable of treating disadvantaged or minority patients suitably. Nor should it mean that a clinician’s extensive skillset is automatically unserviceable or even hazardous because they have been involuntarily—and in many cases unfairly—saddled with a “culturally incompetent” group label. Untenable scenarios can unfold where clinical expertise is reluctantly or softly administered to patients from specific cultural groups to avoid any possible situation where a patient may be uncomfortable with a perceived power imbalance. Again, there is a danger that every service misunderstanding or patient grievance is automatically assumed to be a symptom of structural discrimination.

Cultural awareness workshops have also been criticised for perpetuating a sense of “otherness” [8]. By emphasising “differences,” this training primes those who attend to view cultural minorities as wholly distinct, non-mainstream, or even non-conformist—perhaps prompting a disinclination to intuitively sympathise or support supplementary arrangements for the “outgroup.” For attendees who already hold prejudices towards the culture in question, a workshop inundated with information on disparities, injustice, and oppression may unintentionally consolidate a view of helplessness, dependency, or confirm a downtrodden stereotype. Furthermore, workshops that accentuate white guilt or which are delivered in a confrontational manner may only serve to alienate—rather than educate—those who could benefit from better cultural understanding.

Some level of cultural knowledge for health professionals is probably necessary. However, organisations should prioritise local cultural issues that are relevant to an organisation’s catchment area. And it would be better for training to focus on the values of openness, non-judgment, and responsiveness. A commitment to these values arguably fosters a greater eagerness to accommodate cultural knowledge rather than the reverse.

Moreover, improving cross cultural clinical interactions should not be the sole responsibility of health providers and professionals. Community narratives that promote a distrust for health professionals—although justified in some cases—may only serve to perpetuate poor relationships, and are unhelpful in bridging divides and altering misconceptions that all “outgroup” clinicians are culturally unaware or perhaps even racist.

It is a laudable objective to improve the cross cultural service delivery of health providers and professionals. We should care about health disparities and the factors that prompt these gaps must be addressed. Yet the overpoliticisation of simple medical encounters may not be the panacea to this predicament and, in fact, may do more harm than good.

Stephane M Shepherd is a visiting professor at the Department of Mental Health (Moore Center for the Prevention of Child Sexual Abuse), Bloomberg School of Public Health, Johns Hopkins University. He is also a senior lecturer at the Centre for Forensic Behavioural Science, Swinburne University of Technology, Australia. His research focuses on cross cultural issues in justice health and forensic mental health. He is Australia’s inaugural Fulbright scholar in cultural competence.

Competing interests: None declared.


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