I. Policy and Overview: Why Cultural Competence?

Policy

The Minnesota Department of Human Services (DHS) encourages health and human services providers and organizations to demonstrate their ability to serve diverse populations before they serve individuals from diverse cultures. The organization and its personnel are always accountable for culturally appropriate services.

DHS is committed to meeting the needs of Minnesotans in all their diversity. The department has dedicated itself to providing services, programs and policies that are appropriate and accessible to our customers, who encompass a broad range of human differences such as ability and disability, age, educational level, ethnicity, gender, geographic origin, race, religion, sexual orientation, socio-economic class, and values. If DHS is going to make that vision a reality, we must encourage all health and human services organizations to enhance their abilities to provide culturally competent services. (Former Commissioner Linda Anderson, Oct. 2002)

DHS recognizes that significant disparities exist between the outcomes experienced by minorities and American Indians and those experienced by the general population and is committed to overcoming those disparities. [1] (Commissioner Kevin Goodno, January 9, 2003)

Health and human services organizations can enhance their cultural competence with:

  • • culturally competent personnel – providers, paraprofessionals, and administrators with appropriate skills, knowledge, and attitudes
  • • culturally competent services – interventions and treatments proven effective with individuals from the diverse communities likely to be served
  • • culturally competent organizations – policies, administrative procedures, and management practices designed to ensure access to culturally appropriate services and competent personnel.
  • Professionals need to constantly improve their skills and increase their knowledge. Organizations hire and train culturally skilled and knowledgeable people. They anticipate which cultural communities they are likely to serve and then develop the competence to serve them appropriately. When an organization finds that it lacks a professional skilled in the culture or language of a client in the waiting room, it is incumbent upon the organization to consult with, or refer to, someone who possesses that skill. Prior to calling upon consultants or making referrals, the organization needs to have established relationships with them.

    In an emergency, meet immediate needs. Make a referral for culturally appropriate follow-up.

    Why cultural competence?

    The reason to become more culturally competent is to provide better services. A health or social services organization cannot be clinically or programmatically competent unless it is culturally competent.

    One cannot fully achieve cultural competence but one must strive toward greater cultural competence. These Guidelines are designed to help organizations and professionals move toward that goal.

    Culture influences one’s behavior and family practices. Culture influences an individual’s health and mental health beliefs, practices, behaviors, and even the outcomes of interventions. Health behavior depends on how one understands the cause of illness. In mental health and medicine, research indicates that culturally-appropriate service improves diagnostic accuracy, increases adherence to recommended treatment, and reduces inappropriate emergency room and psychiatric hospital use.

    A professional strives for cultural competence to become a better clinician, social worker, or teacher; to provide more effective health, mental health, or social services; and to make services equally accessible to each of the diverse groups that the organization serves.

    For a social worker or a clinician to accurately determine an individual’s needs and to appropriately plan how to address those needs, the professional first needs to understand how clients’ culture affects them and what cultural strengths might be exerted upon those needs. While all people share common basic needs, there are vast differences in how people of various cultures go about meeting those needs. [2]

    Ultimately, cultural competence is a personal pursuit. The interpersonal relationship between the service professional and the client is what most determines whether services are appropriate. The first step toward achieving cultural competence is accepting the reality that openness to long-term, ongoing, and persistent development is required. The culturally skilled professional is one who is in the process of actively developing and practicing strategies and skills in working with culturally different clients. [3]

    An individual professional cannot be culturally competent alone. It requires organizational commitment. Management creates the service delivery structure and environment where cultural competence is possible.

    The more that health and human services systems move away from “one-size-fits-all” institutional services and, instead, focus on individualized and family-centered service, the more that organizations will have to address issues of cultural competence. [4] Culturally competent practice improves access and quality of service for individuals of diverse populations.

    Striving for cultural competence is a long-term developmental process. It is a process in which an organization can measure its progress according to its achievement of specific developmental tasks. One of the most powerful conceptualizations of this is Terry Cross’s Cultural Competence Continuum [5] which envisions a variety of ways that a person may respond to cultural differences on the path to competence:

  • • cultural destructiveness
  • • cultural incapacity
  • • cultural blindness\cultural pre-competence
  • • cultural competence; and
  • • cultural proficiency.
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    What is cultural competence?

    Cultural competence is a journey; not a destination that one can ever fully attain.

    Cultural competence or culturally competent means the ability and the will to respond to the unique needs of an individual client or family that arise from the client’s culture and the ability to use the person’s cultural strengths as resources or tools to assist with the treatment, intervention or helping process. For the organization, cultural competence means the ability to provide equal and meaningful access and equal quality to individuals from each cultural and linguistic population served, based on an understanding of each population’s distinct needs. For the professional, the ability to use the client’s culture as a resource will depend, in part, upon knowledge of specific cultures and their histories, skills in cross-cultural and culturally-specific practices, and the ability to communicate effectively. (Cultural competence has been defined in a variety of ways. See Appendix E for other definitions.)

    Cultural competence indicates the ability to work across cultures; to appropriately serve clients of cultures different from one’s own. Since individuals and organizations are not, by nature, culturally competent [6], they take active steps to change behavior. They:

  • • learn what the client’s culture believes about family, health, and mental health, cultural values, and patterns of family dysfunction, disease incidence and prevalence
  • • learn skills and behaviors to provide appropriate service for diverse populations.
  • • learn to effectively exchange information, perception, instruction, and preferences about the client’s presenting problem or condition and related history.
  • In this document, culturally competent indicates the ability to work across multiple cultures and is, therefore, distinct from culturally specific which refers to capability with one particular culture.

    Being of a cultural minority does not, itself, make a person culturally competent. For example, an African American psychologist may be competent to provide culturally-specific services to African American clients but would not be culturally competent unless she has demonstrated success in treating clients of at least one other culture.

    Becoming more culturally competent requires not only learning more about others’ cultures, but also about one’s own culture, as a point of reference in trying to understand the more subtle effects of culture on behaviors and beliefs.

    No individual can be deeply familiar with all of the cultural beliefs that affect health and behavior in Minnesota’s heterogeneous society. It may be that an individual cannot become an expert in even one non-native culture. For this reason, these Guidelines eschew the notion of being culturally competent in favor of the notion of pursuing cultural competence. To develop increased cultural competence, every provider can acknowledge a culture’s profound effect on health and social outcomes and can be willing to learn more about this powerful interaction.

    Cultural competence does not mean treating all members of a cultural group in the same manner. Too much emphasis on gaining pedantic knowledge of a particular non-native culture could encourage stereotyping because it may distract even a well-meaning learner from the client’s individualized response to his or her culture. Cultural competence is a subset of individualized care in the sense that it is the ability to provide individualized care that accounts for the influences and benefits of the client’s culture. Thus, an organization that gains the skills in cultural competence, consequently increases its ability to serve all diversity, including those who are racial and ethnic minorities.

    Who can receive culturally appropriate service?

    Everyone has a culture. Should everyone get culturally competent service?

    The practical standard is that extraordinary effort will be directed toward any cultural group:

  • • whose understanding of health, mental health, illness, or disability is sufficiently different from the mainstream to create a risk of sub optimal service as a result;
  • • whose family customs, social patterns, child-rearing practices, and religious values are sufficiently different from the mainstream to create a risk of inaccurately assessing family functioning;
  • • whose primary language is not English or whose means of communication is sufficiently different from mainstream as to risk misunderstanding essential elements of the clinical or professional interaction; or
  • • whose history of experiencing war or ethnic, racial, social, or class-related discrimination is likely to have produced trauma or stressors beyond the norm.
  • Civil rights guidelines [7] require agencies receiving federal health and human services funds to augment services or supports when cultural or linguistic factors have contributed to a client’s condition or have a bearing on his or her capacity to effectively participate in the agency’s services.

    Legal requirements apply to linguistic competence. Each health and human services organization that receives federal dollars, directly or indirectly, must translate written materials where a significant number or percentage of the population eligible to be served or likely to be directly affected by the program needs services or information in a language other than English in order to communicate effectively. Oral interpretation services must be of sufficient quantity and quality to meet the needs of all clients with limited English proficiency. (See Sections 17.3 and 17.4)

    The next question often is this: How much cultural competence is enough? Does a person need culturally competent care when he comes into the doctor’s office with a broken arm? Or is it important only in culturally “loaded” situations like mental health therapy, termination of parental rights determinations, or end-of-life situations?

    The answer is this: Cultural competence is necessary in all client encounters. “The ability to construct culturally competent relationships with patients throughout their lives is key to managing these more loaded situations with less panic, fear, and distress.” [8] Because everyone has a cultural identify, cultural competence must be applied to everyone.” [9]

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    Individualized services and cultural competence

    Enhancing an organization’s cultural competence consequently enhances its ability to provide individualized care. The skills and administrative structures necessary to provide culturally appropriate services are those required to provide individualized services.

    Psychological assessment practice, for example, is shifting toward an emphasis on individual differences within social contexts. This new assessment perspective expands the concept of individual differences by adding dimensions based on culture and gender. [10]

    Any mainstream intervention will work extremely well for a small segment of racial/ethnic-minority clients, produce mediocre results for a large segment, and extremely bad results for another small segment. [11] Thus, interventions need to be based not on the client’s cultural group but, rather upon the nature of the individual client whose individuality is partly a manifestation of his or her culture.

    Any assumption that members of an ethnic group are influenced in the same way by cultural beliefs is false. Considerable intragroup diversity exists among ethnic groups. Human services professionals consider the cultural context of an individual’s life when deciding upon a service strategy, but failure to recognize a client’s unique response to his or her own culture may result in miscommunication and missed opportunities to provide services that clients need.

    Who should implement these guidelines?

    These guidelines apply to all organizations and agencies that receive grant funds from, or that are under contract with, the Minnesota Department of Human Services, including county social services organizations and their vendors or contractors, managed care organizations and their provider networks, and community-based organizations. Health care providers may be more familiar with the national CLAS standards for cultural competence. The CLAS standards are consistent with the Guidelines but the Guidelines go further to support direct case work by agency staff. These guidelines are not a mandate except as noted. They are an educational tool that helps to answer the question: How do we become more culturally competent?

    DHS encourages county social service agencies to develop and implement cultural and linguistic competence plans. These Guidelines will complement counties’ Limited English Proficiency Plans. (See DHS Bulletin #00-89-4, December 28, 2000).

    DHS’s 2001-2002 health plan contracts for Medical Assistance, General Assistance Medical Care, and MinnesotaCare services required health plans to develop cultural and linguistic competence plans.

    Why does cultural and linguistic competence matter to your organization?

    The business and ethical cases for cultural competence are both powerful. In business terms, activities necessary to develop competence in serving diverse populations could be labeled "emerging market development."

    Minnesota’s demographics are changing rapidly. The changing populations present new market opportunities for health care products and social services. New customers bring more and different demands. If organizations are to succeed under these new market conditions, they will conduct market research, differentiate products to the diverse populations, create partnerships with cutting edge vendors and entrepreneurs, train workers in the new technologies, and listen to customers’ feedback.

    In government, changing demographics demands greater efficiencies in the use of limited public dollars. Those dollars must buy more effective services for a greater number of people.

    Cultural and linguistic competence are relevant to health and human services organizations because of: demographics, health disparities, access barriers, quality of services, legal and accreditation mandates, liability and fiscal efficiency, competition, and out-of-home placement costs.

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    A. DEMOGRAPHICS

    Minnesota’s county officials can no longer say: “We don’t need to worry about diversity because we don’t have any minorities here.” According to the 2000 Census, 80 of Minnesota’s 87 counties count at least 100 individuals in one or more of the four major racial/ethnic minority groups, Black, American Indian, Asian, and Latino. [12] Thirty-nine counties have racial/ethnic minority populations of at least 5 percent. [13]

    Minnesota is experiencing record-breaking growth of ethnically and linguistically diverse populations. The 2000 Census tells us that Minnesota’s minority population doubled in the last decade (1990 to 2000). Minnesota is one of three states ranked in the top ten in rate of growth of three major minority groups: Blacks, Hispanics and Asians. In the entire metro area, minorities represent one of every six residents, while in Minneapolis and St. Paul more than one of every three residents belongs to a racial/ethnic minority group.

    This growth represents the immigration of new Americans, as well as the resettlement of ethnic minority populations from other parts of the United States. New Americans in Minnesota speak upwards of eighty different languages in their homes, [14] have limited English proficiency and often do not understand the intricacies of child protection law as it pertains to culturally different child rearing and disciplinary practices.

    B. DISPARITY

    Service outcomes are worse for diverse populations than for the general population. Minnesota leads the nation in the disproportionate numbers of African American and American Indian children involved in the child welfare system. They receive fewer services and experience less favorable outcomes.

    African American and American Indian children are five times more likely to be in out-of-home placement than their White counterparts. They are more likely to experience multiple placements. They stay in placement longer and are less likely to be reunified with their parents. (DHS Bulletin #01-68-01, March 1, 2001).

    The experience of African American and American Indian children in the juvenile justice system is perhaps even more disparate. The U.S. Department of Justice found that the custody rate for White juveniles in Minnesota was 155 per 100,000, while the rate for African American and American Indian youths was 1,690 per 100,000, a rate ten times greater.

    According to the University of Minnesota Center for Urban and Regional Affairs, Minnesota has the highest concentration of inner-city African American poverty in the United States. The Center for Disease Control reports that Minnesota has the highest African American teen pregnancy rate in the country. Similarly, life expectancy for American Indians is dramatically worse than that for their White neighbors. The census also reveals that Minnesota is the fifth most racially segregated state in the union in terms of housing and neighborhood settlement patterns.

    Minnesota is one of the healthiest states for White people. Diverse populations have much poorer health outcomes.[15] The infant mortality rate in the metropolitan area is four times greater for Indian and Black infants than for White infants. [16]

    While 18 percent of Minnesota children under age 18 are listed in the 2000 Census as non-White or Hispanic, racial and ethnic minority children make up:

  • • 20 percent of children with emotional and behavioral disorders in special education;
  • • 24 percent of children born with low birth weight; [17]
  • • 27 percent of low birth weight babies; [18]
  • • 38 percent of children born to teenage mothers. [19]
  • • 45 percent of children in mental health residential treatment facilities;
  • • 45 percent of children found to be abused or neglected after being reported to county officials; [20]
  • • 55 percent of children in the corrections system;
  • The disparity in public service use by children and families is also complicated by culturally-specific health problems,[21] which may not receive appropriate treatment. The adjustment problems of deaf and hard-of-hearing children, for example, are only beginning to be commonly recognized, as are racial and ethnic differences in metabolizing some common psychotropic drugs. Further, behaviors which reflect cultural practices may be inappropriately pathologized by practitioners. Children and families seeking or in need of help instead experience misunderstanding and prejudice, and are likely to receive services that are ineffective or even harmful.[22] These practice issues are potent reminders that culture “affects everything we think and do from how we treat our aging relatives, to when and how we recognize a child’s transition into adulthood, to what we do when we feel sick.”[23] Providers risk doing harm when they fail to recognize and fix the causes of disparities.

    “Over-representation of adolescents of color in the juvenile justice system result from decisions made very early on regarding the need to remove children from their homes; decisions that are based in some large part on the family’s color or race.”[24]

    Some disparities are positive. Many cultural practices contribute to the health of a community, ranging from traditional diets that are low in fat, to emotionally and financially supportive bonds among extended families, or religious practices from which followers draw strength.[25] Such positive disparities, if they are understood by practitioners, could be used in the healing process.

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    C. ACCESS BARRIERS

    Health and human services organizations will provide meaningful access to services they provide for individuals in all cultural and linguistic groups. “Access” refers to the client’s ability to get needed services. For persons with limited English proficiency, meaningful access means effective communication between the organization and the client. []26

    Barriers include the inability to communicate with professionals and support staff in the organization; the inability of the organization to accurately determine a client’s needs; failure to obtain authorization for necessary treatment or services; unavailability of needed services; inability of the organization to provide services in a manner that is effective; excessive distance and lack of transportation to services; inability of professionals to establish rapport conducive to effective services or treatment; inability to pay for needed services. [27]

    D. QUALITY OF SERVICES

    For social workers, psychologists, doctors, nurses, teachers, and other professionals, developing a relationship of mutual trust and confidence with a client is not merely “Minnesota Nice.” These professionals provide vitally important services whose very nature requires the establishment of a close relationship with the client; a relationship that is based on empathy, confidence and mutual trust. Such intimate relationships depend heavily on the free flow of communication between professional and client. This essential exchange of information is difficult when the two parties involved speak different languages or come from different cultures. Competency in dealing with diverse populations is crucial and lack of it has especially adverse consequences. [28]

    Culture influences the accuracy of assessment and the effectiveness of services or treatment. If social workers, therapists, doctors, and teachers are ignorant of the client’s culture, they may make incorrect assumptions about what is causing a problem[29] and provide inappropriate services.

    When children are the clients, parents play a crucial role in service and case planning and outcomes. Providers must be able to understand the family’s values and utilize the family’s cultural strengths. The family is an important source of insight into the child’s problems and ideas for service and case planning. Families can help to identify culture-related needs when the professional is skilled in interviewing across cultures. Families and other community members can identify culturally normal and appropriate responses and behaviors and thus help the professional to distinguish culturally atypical or injurious responses from responses which simply are dissimilar from responses that are appropriate in the mainstream culture. Further, the family must be a partner in services if they are to succeed. Often, the provider or case manager’s competence in the family’s culture can be the factor that determines whether the organization and the family are working together—or against each other.

    E. LEGAL AND ACCREDITATION MANDATES

    Cultural and linguistic competence are required by state and federal law. (See Appendix A.)

    State and federal agencies increasingly rely on private accreditation to set standards and monitor compliance. Both the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), which accredits hospitals and other health care institutions, and the National Committee for Quality Assurance (NCQA), which accredits managed care organizations and behavioral health managed care organizations, have issued standards that require cultural and linguistic competence in health care.

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    F. LIABILITY AND FISCAL EFFICIENCY

    Providers may be liable under malpractice laws and rules for claims that their failure to bridge communication gaps breached professional standards of service. Further, they may be liable for damages resulting from treatment in the absence of informed consent. [30]

    Ineffective services and treatments exacerbate a client’s problems, requiring a higher level of care. Ineffective services and treatments carry high costs for the organization, for taxpayers, and for society as a whole. Pursuing cultural competence enhances service effectiveness, which will either save money or allow the organization to increase its capacity to serve more clients.

    G. COMPETITION IN THE FUNDING ARENA OR MARKETPLACE

    State health care and social services purchasers and private funders have an increasing commitment to doing business with partners who provide equal access and quality to diverse populations. Provision of publicly-financed health and mental health care is increasingly delegated to the private, non-profit sector. Organizations that can improve outcomes for diverse populations, provide equal access to services, and increase client satisfaction will have the competitive edge.

    Among the quickest ways for a mainstream organization to increase its capacity to serve diverse clients is to implement a partnership with an existing culturally-specific, community-based provider.

    Incremental approach and coalition building

    Striving toward cultural competence is a developmental process. It may be viewed as a goal toward which professionals, agencies, and systems can strive.[31] Guidelines outlined in Section II envision an incremental approach toward cultural competence, based on a sustained series of specific, achievable actions with realistic time lines. Organizations implement these guidelines over time according to a plan they develop for themselves.

    Building internal-external coalitions helps to develop internal support for cultural competence efforts and promotes the organization’s successes to clients and the community. The following coalition building principles may be useful: [32]

  • • Clients and parents are the best advocates for system change. As constituents and customers, they can get attention where professionals may be ignored.
  • • All stakeholders are included, especially those who are likely to resist.
  • • Anecdotes (personal stories) and data are both necessary to make a convincing case.
  • • Dialogues, not training sessions, will be most helpful in learning about people’s issues and their perceptions of the organization’s services. Find out why individuals within the organization might feel pursuing cultural competence could be difficult. Encourage discussion about racism and class, organizational costs, and political realities.
  • • No single leader speaks for an entire community. Get participation from several respected community leaders.
  • • Goals are real and meaningful. Be clear about what you want to accomplish.
  • • Goals address both equity and social justice as well as the system’s self-interests, such as the reputation, financial benefits of cultural competence.
  • • Resistance is to be expected—so prepare your responses and pick your battles.
  • • Small victories create momentum.
  • A culture is not monolithic

    To say that culture alone explains everything is as dangerous as saying culture counts for nothing.[33] Individuals within any particular ethnic or cultural group are different from one another. Values, opinions, and family practices differ. Diversity trainers often say the difference among individuals within a cultural group are greater than the difference between cultural groups. An organization must respond to an individual whose individuality is formed, in part, by the person’s culture.

    Further, organizations engaged in cultural competence planning need to recognize that clients’ reactions to their efforts will differ. For example, one study looking at parents of children with severe emotional disturbances found African American parents split almost evenly over the desirability of programs targeted at specific racial or ethnic groups. While some parents were dissatisfied because providers failed to understand that norms of behavior could differ among communities, other parents felt that minority children should receive exactly the same treatment as anyone else.[34] (See Appendix C.)

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    Culture is not just race and ethnicity

    Organizations must be careful not to view culture only as race or ethnicity. Many groups, such as the poor, homeless, disabled, gay/lesbian/bisexual/transgender, and immigrants/refugees exhibit distinct cultural characteristics, which may present special service delivery issues. Those who are deaf not only often use a distinct language but also manifest a “deaf culture.” Poverty imposes demands that can manifest as distinct worldviews that are cultural in nature. While socio-economic status is independent of race/ethnicity, it has culture-like characteristics for its members and engenders culture-like responses from others. For example, a study of parents describing how families had been treated by child-serving agencies found that low-income parents of all races were almost three-times more likely than others to describe experiences in which they felt they were not treated with respect by service providers. [35]

    Sovereignty of American Indian tribes

    Sovereignty of American Indian tribes is recognized by the State of Minnesota.[36] State policy says: “When undertaking to formulate policies that directly affect Indian tribes and their members, the State and its agencies must recognize the unique government-to-government relationships between the State and Indian tribes and whenever feasible consult with the governments of the affected Indian tribe or tribes regarding a State action or proposed action anticipated to directly affect an Indian tribe.”

    Health and human services organizations and programs must acknowledge tribal sovereignty as follows:

    Health and mental health care providers must recognize the right of American Indian people—living on or off the reservation—to receive publicly funded services from Indian Health Services (IHS) facilities and tribal clinics operated under Public Law 93-638 (the so-called “Section 638" clinics and providers). Minnesota Health Care Programs must cover these services. [This includes Medical Assistance (MA fee-for-service and the Prepaid Medical Assistance Programs, including County Based Purchasing; Minnesota Senior Health Options, and Minnesota Disability Health Options); MinnesotaCare; and General Assistance Medical Care.] Additionally, when an IHS or 638 clinic provider refers an American Indian enrollee to a managed care organization provider, the managed care organization shall not require the enrollee to see a primary care provider prior to the referral; however, the referred provider may determine that the service is not medically necessary or not covered.

    Child welfare agencies engaged in child custody, foster care placement, and termination-of-parental-rights cases and other child welfare cases must comply with the Tribal/State Indian Child Welfare Agreement, which was authorized by the Legislature and executed between DHS and several tribes and bands June 18, 1998. (See the Agreement at 99-68-11.pdf

    The Tribal/State Agreement is based on the federal Indian Child Welfare Act (ICWA), which authorizes states and Indian tribes to enter into agreements concerning the care and custody of Indian children and jurisdiction over child custody proceedings involving such children.[37] “The trust responsibility of the federal government and the status of tribes as sovereign governments together provide the basis for treating Indian children differently from non-Indian children for child welfare purposes,” according to the Agreement. “Pursuant to the sovereign status of tribal governments, in their parens patriae capacity, tribes have substantial legal authority to determine the welfare of their members or individuals eligible for membership...Included under the tribe’s authority are decisions regarding the type of care received by Indian children who require placement away from the home of their parent(s) or Indian custodian(s). The parens patriae interest of tribes includes any placement of Indian children made by the local social services agencies and child placement agencies licensed by DHS.”

    Contracts with tribes. A state agency or local subdivision contracting with a tribe for any reason “may not require an Indian tribe or band to deny its sovereignty as a requirement or condition of a contract with an agency.” (Minnesota Statutes, Section 16C.05, Subdivision 7) This restriction is pertinent to all health and human service organizations and their individual cases. In addition, tribes are granted Sovereign immunity which means that a tribe or band that has entered into any type of contract (including a grant) with the state is immune from a lawsuit in state court to enforce the terms of the contract unless the tribe or band has waived its sovereign immunity or agreed to permit an arbitrator's decision to be enforced in state court.

    In general, “states have no power to limit the tribes’ sovereign powers...State civil regulatory laws do not apply to American Indians on reservations. A state has authority to act within the reservation only to the extent that Congress explicitly authorizes it to act....Thus, even though a reservation is located within the boundaries of a state, and the state has some responsibilities to the members of the tribe, the state may exercise few of its normal powers of regulation and taxation within that reservation,” according to the Minnesota Senate Counsel. [38]

    The U.S. Congress found in Public Law 103-413 that:

  • • the tribal right of self-government flows from the inherent sovereignty of Indian tribes and nations;
  • • the United States recognizes a special government-to-government relationship with Indian tribes, including the right of the tribes to self-governance as reflected in the Constitution, treaties, and Federal statutes, and the course of dealings of the United States with Indian tribes. [39]
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    Is cultural competence aimed at the provider or the administration?

    Both. View your organization and its products as a whole. Make no distinction between your organization and the vendors or providers with whom you contract to perform your work. Both the providers who perform services and the organizations that provide access through service authorization, client intake, payments and billing will pursue cultural competency.

    When you pursue cultural competency, what can you expect?

    Those who pursue personal and organizational cultural competency can expect both personal discomfort and institutional resistance.

    The individual who is accustomed to a monocultural environment is likely to experience discomfort when interacting with people significantly different from themselves. This is true for the client as well as the professional. Nervousness and insecurity is driven by fear of offending and a fundamental lack of understanding of the other’s culture. Overcoming such discomfort requires a sustained effort. [40]

    For the organization, cultural competency is complicated. Discussions within the organization will be difficult and sometimes frustrating. This may be true even if all participants support the concept of cultural competence. Expect that some of those who oppose it will be less than forthright in their opposition.

    Resistance takes many forms. To illustrate the thinking of those who resist cultural competence, their statements are quoted; these were written responses to a 1999 DHS document that proposed to mandate cultural competence standards for a health care program:

    “It’s an unfunded mandate. We’re not getting paid for this.”

    “There are higher priorities. Our system lacks the basic services.”

    “These requirements are prescriptive and administratively burdensome.”

    “This is special treatment for a small group of people.”

    “These are ‘best practices’– Cadillac services. We can only afford the basics.”

    “This is a rural area. We don’t have any minorities here.”

    “These standards exceed current service standards.”

    “Our staff has already been trained in diversity and sensitivity.”

    “How do you know we’re not (already) culturally competent?”

    “There aren’t any minority professionals. Minorities never apply.”

    “Our services are available to everyone.”

    “How do we operationalize this?”

    “There is some value in having these requirements as a straw man for negotiations.”

    Social and economic factors

    Commentators in both the social work and health fields draw connections from social and economic factors to outcomes for persons from diverse cultures.

    A person’s health, for example, is said to be a product of social and economic environment as well as a product of service system competence, and individual factors (such as genes, beliefs, coping skills, and behavior). Socio-economic factors affecting health include income, education, housing, employment and working conditions, environmental health, crime, and cohesiveness of communities.

    Achieving a vision in which all Minnesotans have an equal opportunity to enjoy good health, “is bigger than our systems of public health and health care,” according to A Call To Action: Advancing Health Through Social and Economic Change, Minnesota Health Improvement Partnership, July 2001.[41] “All individuals, systems, and institutions in the community share responsibility for–and reap the rewards of– improved health.”

    Because social and economic factors are largely beyond the control of the individual health and human services organizations who are the audience of these guidelines, such factors are beyond the scope of this document. Social and economic factors, however, merit the reader’s attention. For a comprehensive description, please see: http://www.health.state.mn.us/divs/chs/mhip/schaction.pdf

    These “How to” Guidelines build on national standards

    These Guidelines are the next generation. They address the “how to” questions that ensue from the rich legacy of work that has gone before it. These Guidelines build on and are consistent with national standards for health care, mental health care, child welfare, and language assistance. The Minnesota Department of Human Services is particularly indebted to:

    The CLAS standards, properly entitled the National Standards on Culturally and Linguistically Appropriate Services in Health Care (December 22, 2000), Office of Minority Health, U.S. Department of Health and Human Services, published in the Federal Register, Vol. 65, No. 247, pp. 80877. (See Appendix G for 14 CLAS Standards.)

    The WICHE standards, properly entitled Cultural Competence Standards in Managed Care Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic Groups, Western Interstate Commission for Higher Education Mental Health Program; the Managed Care and Workforce Training Initiative of the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services; and the University of Pennsylvania School of Medicine.

    OCR Guidance, properly entitled the Office of Civil Rights Policy Guidance on the Prohibition Against National Origin Discrimination As It Affects Persons with Limited English Proficiency, (Federal Register, Vol. 65, No. 169, Aug 30, 2000, pp. 52762 through 52774).

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