Th 246867

Finding our footing in the ocean

May 1, 2007
with the help of intercultural training programs

with the help of intercultural training programs

by Toni S. Adams, RDH, BA

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We live in an ocean of culture. We are surrounded by difference, including many conflicting beliefs, values, and attitudes that we often do not even recognize. Even worse, that lack of knowledge can lower the quality of care we give our patients. Certainly we do not mean for that to happen, but a profusion of health-care research verifies that it does.

I have confirmed and reconfirmed this fact during my seven years of academic study into the nexus of communication, culture, and health care. That is why I agree with many authorities that all health-care providers need to learn more about culture and intercultural communication so we can better understand and care for our patients. My purpose here is to outline the various arguments in favor of the need of intercultural communication training for dental hygienists.

Culture is not innate but learned, passed on from generation to generation, and it becomes deeply ingrained. It frames our lives and gives us rules to live by. We assume we all have the same rules and judge others based on that assumption. But we are wrong. We can see differences in manners and dress and taste; we cannot see the deep-seated beliefs and values that underlie those obvious differences. It is like trying to play bridge when some of the players assume you are playing pinochle, or rummy, or Crazy 8s, or poker. It is like trying to play the flute with music written for the trombone or the drums. Many of the elements are the same but crucial details differ. Culture profoundly influences how patients experience illness and how we practice as health-care providers, so it is important to understand that they and we may be using different sets of rules.

We need only look around to realize that the world is changing. People travel more, move more, and immigrate more easily than ever before. In the United States, minority groups are the fastest growing segments of our population. One in 10 U.S. residents was born outside the country. More than one in four of us are of African-American, Hispanic, or Asian/non-Hispanic descent - a proportion that is estimated to increase to one in three by the year 2020, and to more than one in two by 2050. “Minorities” became the “majority” in California in 1999. Almost 47 million U.S. residents, 18 percent of the population, speak a language other than English at home, and 21 million, or 8 percent, are limited in English proficiency. All of this difference contributes to more than just a lack of understanding.

Minority groups suffer a disproportionate number of health problems compared to the majority. “All ethnic minority populations in the United States lag behind European Americans (whites) on almost every health indicator, including health-care coverage, access to care, and life expectancy, while surpassing whites in almost all acute and chronic disease rates.”1

Minority people also suffer excessively from dental diseases and lack of resources to receive care. “Blacks, Hispanics, and American Indians/Alaska Natives have the poorest oral health of any population group in the United States.”2 These disparities can be related in part to the providers’ lack of cultural knowledge and intercultural communication competence.

African-American lung cancer patients trusted their physicians less than white patients did, mostly due to receiving less supportive and informative communication from the doctors. Ethnically diverse type 2 diabetes patients who felt that they received quality communication from their physicians were healthier according to physiological measures compared to those who sensed that they received poor communication. Several dental hygiene scholars have concluded that dental hygienists need to learn how to deliver patient education in a culturally sensitive manner. These findings are compounded by other research that showed that health providers consider themselves to be better communicators than their patients think they are.

Such disparities happen in part due to interpersonal barriers between health-care providers and their minority patients. In dentistry, some of these barriers that can result from the health-care provider’s lack of intercultural knowledge and/or poor communication skills include: patient distrust, fear, cultural isolation, and lack of value of dental care, therefore perception of need.

Fear is a huge barrier to seeking dental care even among people who grew up in this country; imagine how that fear is compounded for newcomers. International exchange students in American universities listed fear as the dominant obstacle to seeking any kind of health care. Other researchers found that 85 percent of all dental hygiene patients experience some degree of fear.

Taken together, lack of understanding, appreciation for, and communication of cultural differences in health encounters results in “patient dissatisfaction, poor adherence, and poorer health outcomes.”3 A number of sources have suggested that improved communication and intercultural communication knowledge and skill could help overcome these barriers to health care. These include U.S. government agencies and reports along with the nursing, medical, dental, and dental hygiene communities.

Medical profession bridges cultural gaps

Both Healthy People 2010, a report of national U.S. health goals, and the Surgeon General’s Report on Oral Health in America that was issued in 2003 call for the need of intercultural communication competence among oral health-care providers and staff. In 2001, the Office of Minority Health, a division of the U.S. Department of Health and Human Services, in an effort to synthesize the most relevant and effective approaches, issued National Standards for Culturally and Linguistically Appropriate Services in Health Care, better known as the CLAS Standards.

All entities (schools, clinics, etc.) that receive government funding must adhere to these standards, and others, including dental professionals, are also urged to follow them. One of the CLAS standards mandates intercultural communication training for health-care providers and supporting staffs.

The nursing profession has been a leader in this field. Madeline Leininger, an RN with a PhD in anthropology, began to write about intercultural health issues in the 1950s, introduced the then-new concept of “transcultural nursing,” and authored the first known textbook on the topic in 1978. She also founded the Transcultural Nursing Society in 1975 and the Journal of Transcultural Nursing in 1989.

In the medical field, communication became one of six required competencies identified in 2003, and is thus included on the Medical Board Examination that all graduating medical students must pass in order to become licensed medical doctors.

Additionally, the American Medical Association and the Accreditation Council for Graduate Medical Education require medical education programs to produce physicians who display “sensitivity to patients of diverse backgrounds” (Section V, Part D, Line 5).4

Other allied health professions have not been so well studied but, according to various scholars, such topics are rarely taught. Mercado Galvis5 asserted that practicing dental professionals are deficient in intercultural communication competence.

Kalkwarf6 called for dental faculty to become culturally competent so they can pass the knowledge on to staff and students and, ultimately, to practicing dentists. The validity of this request seems to have been confirmed by recent research showing that empathic ability declined significantly in dental students as they progressed through their training programs.

Furthermore, the American Dental Association scheduled three “Workshops on Diversity in Dentistry” in three different parts of the country in 2005 and 2006, but the entire series was ultimately cancelled due to a lack of interest. I found this particularly perplexing because I think this topic is fascinating!

ADHA begins cultural diversity policy

The leadership of the American Dental Hygienists’ Association recently confirmed the need of intercultural communication competence among its members at their 83rd Annual Session in Orlando, Fla., in June 2006. According to the ADHA Web site, the importance of cultural competence was mentioned in drafts of both the Clinical Practice Guidelines and the Curriculum for the Advanced Dental Hygiene Practitioner. Additionally, Proposed Resolution 10 that is currently under review states, “The ADHA does not currently have a policy statement on cultural diversity. Knowledge of cultural diversity is vital at all levels of dental practice. Knowledge about cultures and their impact on interactions with health care is essential for dental hygienists practicing in a clinical setting, education, research, or administration.”7

According to my own recent research, very few dental hygienists have received any intercultural communication instruction in their educational programs until the last five years or so. Even then, that training has been limited, confirming what I have read in the dental hygiene literature. Fitch emphasized that dental hygiene training and practice must focus on patient-centeredness, intercultural communication competence, as well as an understanding of basic cultural concepts. She also called for the inclusion of cultural and intercultural communication knowledge and skills in all dental hygiene course content.8

Some of the most compelling reasons to follow this advice come from recent changes in state laws. California, New Jersey, and Washington have passed laws that are now in various stages of implementation. California Assembly Bill 1195, that took effect on July 1, 2006, requires all continuing medical education, unless exempt, to include cultural and linguistic competence materials in their curricula. New Jersey Senate Bill 144 requires cultural competence training as a condition of medical licensure. Washington Senate Bill 6194 requires that courses in multicultural health in basic education and continuing education be instituted by July 1, 2008, for all health professionals licensed in that state. That includes us! Other similar legislation has been introduced in Arizona, Illinois, and New York. New York’s proposal specifically mentions dental hygienists. These are not recommendations or even policies; they are laws. If it is happening in medicine, it is just a matter of time before it happens in dentistry. If it is happening in a few states, it is just a matter of time before it spreads to other states.

Aside from many substantial ethical and legal reasons to study diversity, I have found that learning about this topic is just so darn interesting and personally enriching. I have encountered many “ah-ha” moments regarding past and current experiences and in the process have come to understand myself better too. We have much to gain both personally and professionally from learning more about each other.

The conclusions are clear. The ocean of diversity that we live in has become the norm in this world. Knowledge can help us find our footing in that ocean but we have had little opportunity to study the principles of diversity. Minority patients suffer from a disproportionate amount of dental problems in part due to dental professionals’ lack of cultural knowledge. Enhanced knowledge, training, and experience can improve intercultural communication competence. Neither our patients nor we are likely to change our deeply ingrained cultural learning, even if we try. So the best we can do is endeavor to understand one another.

We have been challenged, and in some cases required, to expand our knowledge, so we must address this topic in order to provide better care for our diverse patients. I have studied these issues for more than seven years and have developed a passion for the subject. I will be sharing some of my learning at RDH Magazine’s Under One Roof Conference Aug. 2 through 4 in Washington, D.C. Please join me.

Selected references (full list available upon request)

1 Kagawa-Singer M, Kassim-Lakha S. A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Academic Medicine 2003; 78(6):577-587.

2 Milgrom P, Garcia RI, Ismail A, et al. Improving America’s access to care: The National Institute of Dental and Craniofacial Research addresses oral health disparities. Journal of the American Dental Association 2004; 135: 1389-1396.

3 Betancourt JR. Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Academic Medicine 2003; 78(6):560-569.

4 The Accreditation Council for Graduate Medical Education (July 1, 2004). General competencies: Minimal program requirement language. Retrieved on Oct. 25, 2005, from

5 Mercado Galvis DL. Clinical contexts for diversity and intercultural competence. Journal of Dental Education 1995; 59(12):1103-1106.

6 Kalkwarf KL. Creating multicultural dental schools and the responsibility of leadership. Journal of Dental Education 1995; 59(12):1107-1110.

7 The American Dental Hygienists’ Association: ADHA (2006b). Retrieved Aug. 30, 2006, from the American Dental Hygienists’ Association Web site:

8 Fitch P. Cultural competence and dental hygiene care delivery: Integrating cultural care into the dental hygiene process of care. The Journal of Dental Hygiene 2004; 78(1):11-21.

Toni Adams, RDH, BA, combines 26 years of clinical dental hygiene experience with more than seven years of study and research in the communication field. Her writing and speaking bring the two disciplines together to present dental professionals with unique, interesting, and helpful information. In addition to speaking to dental professionals, Toni has taught public speaking at the university level, has presented scholarly papers at national communication conferences, is now writing a communication handbook for dental hygienists, and is close to earning a Master of Arts degree in communication studies. She welcomes comments and questions at [email protected];