Before embarking on a discussion about cultural competence it is essential that we share an understanding of the meaning of ‘culture’. This is no easy task as Alan Barnard and Jonathon Spencer point out in their review of the history of this term from an anthropological standpoint: they note that it is almost impossible to create a hard and fast definition given the many and opposing ideas over two centuries of debate (Barnard and Spencer, 1996). They comment that within anthropology culture is seen as “plural and relativistic” meaning that there are many cultures in the world and a person is the product of her culture, shaped and influenced by the environment surrounding her (Barnard and Spencer, 1996, p136). Too often, though, culture is described as “integrated patterns of human behaviour” that include “language, thoughts, communications, action, customs, beliefs, values” (Anderson et al., 2003, p68), frequently reduced to “a catalogue of ideas and practices” (Baumann, 1999, p25) said to define cultural groups. Loong Wong comments that this perspective on culture predominates in the fields of business and management (Wong, 2010), a point that is pertinent to this research project. The drawback of this narrower perspective is that these attributes are determined by the dominant majority and serve to define culture as bounded and closed, unchanging and static (Prato, 2009), fixed at a particular point in time (Carpenter-Song et al., 2007; Fontefrancesco, 2012) thus essentialising groups of people within society (Lyshaug, 2004; Galeotti, 2009). As well as essentialising cultures, this bounded view places one culture in an inferior position to another (Fontefrancesco, 2012). Giroux adds his support for a shift away from the idea of culture as a list of attributes when he talks of “unity-in- difference” which can only be achieved if society rejects “essentialising” and “separatist” language that deems some cultures “tolerable” to others (Giroux, 2000, p338).
Not only is the static, trait-based approach deterministic, but it is consistent with society’s understanding of culture (Street, 1993) as can be seen in news reporting. For example, in Canada a cab driver acquitted of a crime was subject to vilification and abuse which his lawyer described as a "grotesque stereotype'' based on the man’s “Arab race and Muslim
religion” which people understood to “mean he is prone to sexually assault a vulnerable woman” (Tutton, 2017). In Australia, recent news reported tensions in Victoria’s Venus Bay where local residents described seasonal Chinese tourists digging for shellfish as “Asians” and “ethnics” who had a “culture to take everything” but without contributing
to the local economy. An anthropologist studying this situation described the comments as based on “longstanding ingrained stereotypes we have about Asian people in Australia” (Pepper, 2017).
Another short-coming of this trait-based approach is that it does not acknowledge diversity within as well as between cultures, such as religious affiliation, gender identity, sexual orientation, or health status, which operate to produce sub-cultures within cultures (Hess and Billingsley, 2007; Racher and Annis, 2007). Neither does this approach make allowances for the way in which people change (Carpenter-Song et al., 2007) under the influence of time, environmental factors, relationships, migration and so on. Arguing for greater recognition of the differences between individuals within cultures Mohamad Alkadry says that no two people have the same lived experience and hence could not really be said to have the same culture. For example, individuals may share an identity, such as black American, and this may shape their experiences but, he contends, this is not the same as sharing a culture (Alkadry, 2005). Similarly, David Napier and colleagues suggest that just because groups of people share an attribute (eg a country of birth) does not mean that all people in the group necessarily share the same beliefs (Napier et al., 2014). John Capitman adds strength to this view when he argues that membership in a social group changes over time, resulting in changes in a person’s social relationships over time (Capitman, 2002). Capitman (2002) cites an example of a person who shifts from young and able today to older and disabled at some future point. Accompanying this change in situation is a change in the way society views the individual. The common thread in all of these views is that culture is something that is given meaning through interactions between people and therefore can be expressed as “always contextual” (Laird, 2000, p107). This means that each of us displays a culture depending on the situation in which we find ourselves. For example, I would respond to people differently in situations where I act as mother, daughter, student, school board member and so on. In other words I “dance an attitude” (Laird 2000, p103) according to the situation. In some instances the idea of race is substituted for that of culture, along with the implication that all people of a particular race must share the same culture and therefore the same values and ideals (Carpenter-Song et al., 2007; Alexander and Stivers, 2010). However, many authors have argued that the concept of race is a difficult one that has transitioned from its, now largely discredited, biological basis meaning people who share
physical characteristics to a social basis, that is people who share a common ancestry (Bhopal, 2004; Ford and Kelly, 2005). Regardless of this apparent re-definition, these authors caution that biology still underpins the meaning of “race” and the term should be used sparingly. In agreeing, I would argue that using race or common ancestry to define culture simply brings us right back to the bounded, fixed notion of culture. Health policy officers need to be aware of this to avoid falling into the same trap.
The Lancet Commission on Culture and Health (Napier et al, 2014) recognised the many assumptions in traditional definitions of culture. The authors argue that this does not account for what is taken “for granted”, and recommended a definition of culture that acknowledges this dimension
“The shared, overt and covert understandings that constitute conventions and practices, and the ideas, symbols, and concrete artifacts that sustain conventions and practices, and make them meaningful.” (Napier et al., 2014, p1610)
Taking a different approach, Michele Fontefrancesco has mapped the change in anthropological thinking away from the basic list of attributes to consideration of culture as a “fluid, changeable, positional reality”, de-emphasising culture as bounded in favour of recognising a series of relationships or networks within which individuals operate (Fontefrancesco, 2012, p60). She says that culture should be thought of as:
“knowledge in motion, where people are places of contact, creation, propagation of knowledge towards other individuals that, in their turn, are also places of contact, creation and propagation of knowledge towards other individuals” (Fontefrancesco, 2012, p61-62)
Others also argue for an understanding of culture that is relational and “meaning-centred”, such as Brian Street who notes that “culture is an active process of meaning making and context over definition, including its own definition” (Street, 1993, p25) and Elizabeth Carpenter-Song and colleagues who offer their understanding of culture as
“a dynamic process of shared meanings, located in and emerging from interactions between individuals” (Carpenter-Song et al., 2007,
p1364).
Joan Laird also takes the approach that culture is “not measurable or generalizable” but is “an individual and social construction, constantly evolving”, “constantly in motion, changing in meanings and definitions” (Laird, 2000, p103-107).
Noting that culture should not be essentialised (Roseberry, 1992), and the general agreement with Fontefrancesco’s view that culture should be recognised as fluid (Phillips, 2007; Delanty, 2011), Ruth Dean goes on to argue that the changeable nature of culture occurs because the definition or construction of culture is dependent on the changing social and political context within which culture is considered and defined (Dean, 2001). In this situation, Adital Ben-Ari and Roni Strier suggest that constantly shifting views about culture put people from CALD backgrounds into the category of being “unknowable” because, they say, we can never pigeon-hole a person into a specific cultural category for all time (Ben-Ari and Strier, 2010, p2164). For this reason, Anne Phillips recommends that people should be seen as “agents” and not “captives of culture” (Phillips, 2007, p176). Both Laird and Alexander and Stivers also add a focus on the individual. Laird (2000), echoing Gadamer’s (1989) comments on prejudice, argues that the individual should shift focus away from herself as the centre and be more open minded about the beliefs and experiences of others. Alexander and Stivers propose that viewing people first and foremost as “citizens”, sharing “values to which they are committed”, will help to break down perceived barriers based on pre-conceived notions of culture and may lead to less stereotyping (Alexander and Stivers, 2010, p587). This is akin to Robert Young’s “postcolonial challenge” to “see all people as human beings” (Young, 2012, p39) and is a view that requires health policy officers to demonstrate considerable self- awareness about their own backgrounds and the organisational structures and processes that serve to categorise and label individuals.
One last point about how culture is viewed. Phillips believes that the term “culture” has become code for “non-Western” or “minority” groups (Phillips, 2007, p29). William Roseberry agrees, arguing that consideration of culture is usually based on Western or Euro-centric assumptions about what constitutes culture, cautioning against this attitude in favour of challenging such assumptions (Roseberry, 1992). Anderson and her colleagues apply this criticism specifically to healthcare, warning that “Western science” is “the norm against which the Other is assessed and culture is ‘read’” thus culture is never “neutral” (Anderson et al., 2007, p297).
Roseberry suggests that we need to rethink “cultural production and understanding” (Roseberry, 1992, p846) in a way that identifies not only different ways of doing things (social, domestic and political) but questions the links between Western and non-Western
cultures that result in a (non-Western) culture being described as Other. Roseberry (1992, p846) also notes the need to challenge assumptions about Western history in the context of “intercultural contrasts and connections”. This means that we must consider more carefully the potential impact of history in one society on the progress and history of another, a point which is consistent with a critical multicultural perspective. Roseberry (1992) goes on to say that any consideration of society must take into account power imbalances and the ways in which a colonised culture responds to Western intrusion. For this thesis I chose to adopt the flexible understanding of culture expressed by Carpenter-Song et al (2007). This approach fits within a critical multicultural framework because it affords the opportunity to identify the contradictions between the essentialist list of attributes and the actual lived experience of individuals. With this knowledge we can refuse to accept the bounded, Western or Euro-centric descriptions of culture in favour of greater reflection about people as humans, shaped by their histories and with many alternative ways of generating knowledge and responding to society. By taking this position, I accept Roseberry’s (1992) challenge to move away from Western or Euro- centric assumptions about what constitutes culture.
3.1.1 The meaning of health policy making
Before moving away from discussion of the nature of culture I want to emphasise a specific point. Napier et al (2014), Fontefrancesco (2012) and Carpenter-Song et al (2007) all argue that culture is about making meaning. In the health policy context, when policies are enacted they become part of the fabric of society that add to the meaning of health in that society. Health policy officers therefore create meaning in society through the policies they develop and implement. I have already shown, in Chapter 1, that understandings of health in society vary and mismatches between those understandings can cause difficulties for both policy maker and citizen. Developing health policy therefore places a responsibility on the shoulders of health policy makers to ensure that the meaning they are creating is understood by citizens in the way that policy makers intended. The problems identified in those earlier examples show that this is not always happening. My research explores the role of cultural competence in citizen engagement as a means to support the development of health policy that is meaningful to citizens.