Moving towards Community Cultural Competence

Depósito de Investigación de la Universidad de Sevilla https://idus.us.es/ This is an Accepted Manuscript of an article published by Elsevier in International Journal of Intercultural Relations, available at https://doi.org/10.1016/j.ijintrel.2019.09.002 Under a CC-BY-NC-ND license 1 Community Context in Cultural Competence: Moving towards Community Cultural 1 Competence 2 3 Rocio Garrido, Ph.D. 4 University of Seville 5 Manuel Garcia-Ramirez, Ph.D. 6 University of Seville 7 & Fabricio E. Balcazar, Ph.D. 8 University of Illinois at Chicago 9 10 11 12 Acknowledgements 13 This work was supported by the Ministry of Science and Innovation of the Spanish 14 Government, within the framework of the project entitled “Community Cultural Competence: 15 Competent Professionals in Diverse Communities” [PP2015-4129]. 16 17 18 Declaration of interest: None. 19 20 21 Corresponding author: Rocio Garrido 22 [email protected] 23 Departamento de Psicología Social, Facultad de Psicología. Universidad de Sevilla. 24 C/ Camilo José Cela, s/n. 41007. Sevilla (Spain) 25 2 Abstract 1 Addressing the complex needs of migrants and ethnic minorities is a challenge for host 2 communities, where the cultural competence of service providers is considered an important 3 asset for combating inequities and for encouraging well-being. However, efforts focused on 4 promoting cultural competence have not been very effective in generating real changes to 5 professional practice, organizations and/or communities. Current models of cultural 6 competence are primarily centered on the personal capabilities of professionals and on 7 organizational standards, overlooking their interdependence with community contexts. To 8 address these challenges, this study introduces the community psychology approach and 9 explores the concept of Community Cultural Competence (CCC) as a way of including the 10 community context in cultural competence frameworks and using it to promote migrant and 11 ethnic minority health equity. CCC is defined as a multilevel and multidimensional process of 12 personal development that implies the acquisition of critical awareness, responsiveness to 13 diversity, capacity to act within the organization, and capacity to act within the community. 14 These competences strengthen the effectiveness and influence of providers across different 15 levels or work environments—i.e., intrapersonal, interpersonal, organizational, and 16 community. This paper describes a mixed-method study carried out in southern Spain in three 17 different contexts (i.e., reception, transition and settlement contexts). Data collection involved 18 a questionnaire administered to 525 community service providers. The results were shared in 19 community forums attended by multiple agents, who put forth recommendations for 20 interpreting the results and transferring them to local actions. Major theoretical contributions 21 and suggestions for improving CCC are discussed. 22 Key words: Community Cultural Competence, equity, context, service provider, community 23 psychology, mixed-method. 24 Introduction 25 3 Complex European migration flows have led to a call for responsive health systems 1 (Pottie et al., 2017). This challenge has redirected attention to the cultural competence of health 2 and social care staff, given its positive impact on migrant well-being (Paloma, García-Ramírez, 3 & Camacho, 2014; Rechel, 2011). The concept became popular in the 1960s-1970s, within the 4 framework of the African-American civil rights movement. It was originally developed in order 5 to increase health professionals’ capacity to reduce the cultural gap between them and users from 6 different backgrounds. Cultural competence could be defined as the knowledge, attitudes and 7 abilities that enable providers to work effectively in culturally diverse contexts (Campinha- 8 Bacote, 2002; Sue, Arredondo, & McDavis, 1992). 9 Several authors have pointed out that the traditional conceptualization of cultural 10 competence oversimplifies health users’ needs, often ignoring the complexity of social reality 11 and the impact behind the social determinants of health (Marmot, 2007; Ridley, Baker, & Hill, 12 2001; Weaver, 2008). Essentially, emphasis was placed on ensuring that professionals were 13 trained up and that healthcare services were adapted to meet the medical needs of ethnic 14 minorities in health-related contexts (e.g., medicine, nursing, counselling), yet disregarding a 15 broad, inclusive approach which encompasses the social determinants of health. Ottersen et al. 16 (2014) have argued that “we must acknowledge the need for a global cross-sectoral action and 17 justice in our efforts to address health inequity”. Thus, the present study extends the analysis of 18 cultural competence to include community services as health services. 19 Community services is an umbrella term used to refer to any community-based resource 20 aimed at securing the local population’s well-being and health. This covers health education, 21 the promotion of healthy environments, decent housing conditions, employment and access to 22 a sufficient level of income, safety and protection, spiritual support and citizen engagement. 23 Community services are at the forefront of the response to migrant and minority needs, 24 irrespective of legal status, administrative situation, or length of stay (Permanand, Krasnik, 25 Kluge, & McKee, 2016). Community service providers (hereinafter, providers) play a crucial, 26 4 active role in this response. We use this term to refer to those people who work either 1 contractually or voluntarily in community service settings to improve the health of their users 2 and communities—e.g., health and education staff, NGO volunteers, association leaders, and 3 religious leaders. 4 In response to recent mixed migration flows, many ‘developed’ countries have 5 increased restrictive policies against migrants and other ethnic minorities—with actions like 6 cutting the entitlement for some groups—and have reduced financial support and resources for 7 community services (Ingleby, 2012). This situation along with the effects of austerity policies 8 introduced in many European countries, like Spain, places most migrants and ethnic minorities 9 in a situation of extreme vulnerability. They tend to settle into socially segregated areas which 10 hinder their incorporation into mainstream society—limiting their capacity to learn the 11 language and actively participate in the community—and they often remain unemployed or 12 work under very precarious and unhealthy conditions (Carr, 2010; Hernandez-Plaza, Garcia- 13 Ramirez, Camacho, & Paloma, 2010). 14 According to the IOM (2016), mixed migration flows demand an in-depth analysis of 15 their implications for host societies, which are impelled to adapt their policies, structures and 16 services to diversity in the population, focusing on the reduction of inequities in health 17 (Ingleby, 2012). Providers play a crucial role in addressing these issues by (a) highlighting and 18 advocating for the rights of minorities; (b) empowering minorities and creating opportunities 19 for their sociopolitical participation; (c) building networks and injecting social capital into 20 communities; and (d) ensuring accountability for policy implementation (Bishop, Vicary, 21 Browne, & Guard, 2009). 22 With this in mind, the study aim is to redefine the cultural competence of providers, 23 prioritizing the role played by contextual factors in the analysis of cultural competence, which 24 is key to achieving health equity and guaranteeing the rights of migrants and ethnic minorities 25 (Balcazar, Suarez-Balcazar, Willis, & Alvarado, 2010; Rechel, 2011). 26 5 Theoretical Background: Beyond Cultural Competence 1 Despite the vast literature on cultural competence—see the reviews developed by 2 Balcazar et al. (2009) and Alizadeh and Chavan (2016)—a commonly accepted definition has 3 yet to be established. One of the most popular definitions was proposed by Campinha-Bacote 4 (1999): “a process in which the provider continuously strives to achieve the ability to 5 effectively work within the cultural context of a client/individual, or family or community” (p. 6 203). This process enables people to understand and appreciate differences, to recognize and 7 respect variations that occur within cultural groups, and to adjust their practices to the needs of 8 people from various cultures. 9 Cultural competence has been primarily formed by two concepts: culture and 10 competence. “Culture” is usually linked to ethnicity, nationality or country of origin, 11 categorizing users according to their origin or color. This has been criticized by many authors 12 because of its reductionist nature, which ignores not only the multiple dimensions and diversity 13 of identities that are implicit in every culture, but also the contextual determinants associated 14 with the country of origin (Balcazar et al., 2010; Owiti et al., 2014; Weaver, 2008). On the 15 other hand, “competence” is understood as the trainable capability of providers and 16 organizations, recommending a series of ‘do’s and don’ts’ that define how we respond to 17 migrants and ethnic minorities’ needs (Abe, 2012). 18 Many theoretical frameworks place the responsibility of providing culturally competent 19 service provision upon professionals. Quite a few models have proposed that cultural 20 competence comprises cognitive, affective/attitudinal, and behavioral components. The 21 cognitive component—i.e., knowledge and critical awareness—refers to the way in which 22 people perceive the world, themselves, and service users (Campinha-Bacote, 1999). The 23 affective/attitudinal component refers to feelings and emotional tendencies toward migrants; it 24 includes a sense of cultural humility, cultural sensitivity, and/or ethnocultural empathy 25 (Arasaratnam, 2006; Papadopoulos & Lees, 2002). The behavioral component encompasses 26 6 communication skills, including the appropriate use of translators or making materials and 1 instructions available in the recipient’s preferred language (Kupka & Everett, 2007; 2 Steenbarger, 1993); flexibility and adaptability to cross-cultural situations (Moffit & Wuest, 3 2002; Poole, 1998; Suh, 2004); and effective participation in intercultural encounters 4 (Campinha-Bacotte, 2002; Kupka & Everett, 2007; Overall, 2009). 5 Subsequently, models and guidelines for implementing cultural competence at an 6 organizational level have emerged. A good example is the National Standards for Culturally 7 and Linguistically Appropriate Services (CLAS) in U.S. Health and Health Care, whose 8 principal standard is to “provide effective, equitable, understandable, and respectful quality 9 care and services that are responsive to diverse cultural health beliefs and practices, preferred 10 languages, health literacy, and other communication needs.” (U.S. Department of Health and 11 Human Services, 2013). However, these models have also been a source of criticism. They 12 have not been able to override the “culturalist” concept of earlier models, nor have they delved 13 into the social nature of the health inequities that ethnic minorities experience (Cattacin et al., 14 2013). This limitation becomes more evident as we struggle to see any models striving to 15 incorporate and address the interdependence of professionals and their organizations with the 16 community contexts in which the social reality of their services’ users play out (Balcázar et al., 17 2009; Hernández et al., 2009; Abe, 2012). 18 The community context epitomizes the social reality faced by ethnic minorities, because 19 it is the physical and sociocultural environment which paints a picture of their lives. It 20 determines the rules governing civil coexistence, the chance to share their values and 21 traditions, to rebuild their social networks and social capital, and the opportunities for inclusion 22 in the labor market (Hernandez-Plaza et al., 2010). The community context is also a space that 23 casts light on the public policies important to the lives of its citizens. Migrant persons and 24 those belonging to minority groups with limited political rights are highly dependent on their 25 7 local settings, key determinants when it comes to accessing community-based services that 1 look after and promote their health. 2 A few authors have highlighted the importance of the social context as a core 3 component of cultural competence. According to Overall (2009), the environmental domain 4 encompasses knowledge of the community's languages and dialects, local transportation, home 5 mobility, safety issues, and the housing conditions of service users. Hernandez et al. (2009) 6 also view the community context domain as a central dimension of cultural competence, 7 emphasizing the role that ethnic and racial differences play in service delivery. Although these 8 models contribute significantly to the importance of the social context in cultural competence 9 conceptualizations, more research is needed to address the dynamic interdependence between 10 community contexts and other impactful components. These include access to political leaders, 11 participation in community-based activities, establishing trust, and building familiarity with 12 gatekeepers of migrants and ethnic minority groups. Furthermore, strong empirical support for 13 the community context as a key dimension of cultural competence is warranted. 14 This study aims to build on this direction, proposing and testing the concept of 15 Community Cultural Competence (CCC), considered not only a learning process for 16 developing the capability of providers to reduce the cultural gap, but also as a way of gaining 17 power to facilitate changes toward equity at intrapersonal, interpersonal, organizational, and 18 community levels. This perspective could advance our understanding and transformation of 19 professional practices, as well as those of the organizations, communities, and policies 20 underpinning them (Council of Europe, 2011; Seeleman, Essink-Bot, Stronks, & Ingleby, 21 2015). 22 Community Cultural Competence 23 We define Community Cultural Competence (CCC) as a multilevel and 24 multidimensional process through which providers acquire capacities and create opportunities 25 that allow them to effectively operate across different work contexts (i.e., intrapersonal, 26 8 interpersonal, organizational, and community). CCC is multidimensional because it refers to 1 several distinct but related dimensions treated as a single theoretical concept (Edwards, 2001), 2 and it is multilevel because these dimensions operate across different levels/contexts (Snijders 3 & Bosker, 2011). As Figure 1 illustrates, the CCC model is made up of four dimensions: 4 critical awareness, responsiveness to diversity, capacity to act within the organization and 5 capacity to act within the community. 6 ______________________ 7 Insert Figure 1 about here 8 _______________________ 9 On an intrapersonal level, critical awareness permits providers to gradually decode 10 their own sociocultural background and that of their users, analyzing the differences and 11 respecting them. Similarly, it encourages ethnocultural empathy (Rasoal, Eklund, & Hansen, 12 2011), which enables providers to maintain a willingness to challenge what they know about a 13 user based on generalizations about his or her culture, and to better understand their 14 circumstances. Critical awareness seeks to overcome the limitations of knowledge provision- 15 based models which often stereotype users and misattribute cultural reasons to their problems, 16 instead of acknowledging that they may be linked to social inequality (Napier et al., 2014). 17 Critical awareness helps providers to gain a deep understanding of the health inequities that 18 ethnic minorities experience, so that they can guide users on how to address them at their 19 sociopolitical roots. 20 To be effective on an interpersonal level, providers must develop responsiveness to 21 diversity. This includes cultural sensitivity and communication abilities (i.e., patterns for 22 decoding verbal and nonverbal communication, managing different communication styles, and 23 active listening), thus allowing them to adapt their professional practices to the reality of their 24 users. These skills also enable them to collaborate with other community providers, mediators, 25 and community gatekeepers. Through the development of skills, providers can build new 26 15 organizational and community influence. It seems that the dimensions which had an influence 1 on the work contexts were those that emerge when providers have a direct relationship with 2 users (responsiveness to diversity) or with the community (capacity to act within the 3 community). These results partially support our hypothesis, and highlight the importance of the 4 community-level dimensions. 5 ______________________ 6 Insert Figure 3 about here 7 _______________________ 8 Qualitative phase 9 Method 10 Contexts and Participants 11 The results of the quantitative study were shared at three community forums held across 12 all three contexts where the studies took place, in order to facilitate their interpretation, 13 dissemination and applicability to the local communities (Becker, Harris, McLaughlin, & 14 Nielsen, 2003). A total of 36 community agents participated, 12 in the transition rural context 15 (Huelva), 17 in the settlement urban context (Seville), and 7 in the reception border context 16 (Algeciras). Their roles covered providers, autochthonous and migrant users, political leaders 17 and researchers. They were mainly women (24/36) and their age ranged from 20 to 65 years. 18 Data collection and analysis 19 The community forums followed the same structure in all contexts, following a four- 20 step process, adapted by Becker et al. (2003): (1) welcome and explanation of the common 21 goal; (2) presentation of the CCC concept and the main local results; (3) small groups 22 discussions about the results and development of guidelines for improving the providers’ CCC 23 at a local level; and (4) a common joint selection of the best guidelines and the conclusions. 24 The detailed procedure is presented in the Table 3. 25 ______________________ 26 16 Insert Table 3 about here 1 _______________________ 2 The information collected during the community forums was summarized by the 3 researchers in order to achieve a unique compendium of recommendations, but they always 4 maintained the participants’ structure and words. 5 Community forums’ recommendations for amplifying the impact of CCC and 6 transferring results to local actions 7 The summary of the main suggestions and guidelines for action is presented in Table 8 4—indicating the popularity of the guidelines. In general, community agents highlighted the 9 need to develop critical awareness and to improve cultural humility and flexibility among 10 providers. They pointed out the importance of cultural competence trainings, aimed at 11 identifying the rights and realities of migrant populations, and also to remove their own 12 prejudices and reflect upon structural and institutional racism. At an organizational level, they 13 denounced the shortage of resources and the need to adapt services to the real situation faced 14 by migrants and providers. They asked for more organizational support, such as training 15 courses and extra services (e.g., cultural mediators). Finally, at a community level, they 16 proposed to improve the coordination and community embedding of providers, and to also 17 increase the participation of migrants within their local organizations and the development of 18 their own socio-political agenda. Additionally, the participants recognized the privileged 19 position of the community-based organizations (i.e., NGOs, cultural and citizen associations) 20 regarding the task of identification migrant and ethnic minorities’ needs and addressing them. 21 ______________________ 22 Insert Table 4 about here 23 _______________________ 24 25 26 17 Discussion 1 This article redefines cultural competence of community service providers as a 2 multilevel and multidimensional construct, which includes their organizational and community 3 interdependence. Adopting a community psychology approach and a mixed-method design, we 4 offer empirical support for community cultural competence (CCC), comprising four 5 interconnected dimensions: (a) critical awareness; (b) responsiveness to diversity; (c) capacity 6 to act within the organization; and (d) capacity to act within the community. These results 7 support the nature of cultural competence as a first-order construct, shedding light on their 8 internal structure (Suarez-Balcazar et al., 2014; Abe, 2012). According to Edwards (2001), 9 clarifying the nature of multidimensional constructs is a critical step towards greater theoretical 10 and empirical precision. 11 Moreover, this study shows that some dimensions of providers’ CCC have a positive 12 impact on their influence on the work contexts. At an individual level, responsiveness to 13 diversity can have a positive impact on the providers’ own practice. This coincides with the 14 results obtained in studies on psychological empowerment in workplaces, which showed that 15 improving work skills makes professionals develop greater control of their work, self- 16 determination, and self-efficacy (Laschinger & Leiter, 2006). They also acquire a more 17 positive assessment of their daily work and the impact they can generate in the local 18 community (Conger & Kanungo, 1988). 19 Nevertheless, contrary to what we hypothesized, the structural equation model did not 20 show providers’ critical awareness as having an impact on their practice. This could be 21 explained by drawing on a traditional critique of cultural competence training based on 22 cognitive elements, which maintains that cognitive changes are not usually transferred to 23 behavioral changes (Beach et al., 2005; Weaver, 2008), especially when the contexts of work 24 do not offer support for it (Cattacin et al., 2013). Community forums shed light on this issue. 25 The participants considered critical awareness an indispensable element of CCC, but 26 18 underlined the importance of receiving support from organizations and communities to develop 1 and implement it in their practice. Otherwise, critical awareness could act as a risk factor, 2 leading to burnout among professionals. 3 At an organizational level, the quantitative results also indicated that the capacity to act 4 within the organization had no impact on providers’ influence in their organizations. 5 Information provided during the forums could help us understand these results. Participants 6 noted that organizations do not empower their professionals; some participants even 7 complained that organizations—and the policies that guide them—contribute to alienating 8 them, maintaining the status quo and the inequities that affect migrants. However, some 9 participants indicated that organizations sometimes influence the well-being of providers, 10 which could have a positive impact on their performance. These results are consistent with 11 several studies that have shown how the capacity to act within organizations serve as a 12 protective factor against burnout, anxiety or depression-related symptoms (Bennett, Lowe, 13 Matthews, Dourali, & Tattersall, 2001). Future research should explore these relationships, 14 which may have a mediating effect on the relationship between the capacity to act within 15 organizations and the providers’ organizational influence. 16 Finally, the capacity to act within the community had a positive impact on providers’ 17 influence on both the organization and the community. These results, which were also supported 18 by the forum discussions, underline the importance of working closely with gatekeepers so as to 19 generate more impact on the local contexts (Suarez-Balcazar & Tayler-Ritzler, 2014; Vera & 20 Speight, 2003). Becoming embedded in the community offers providers increased knowledge 21 about the real needs and strengths of the community, and about other resources and possible 22 collaborations they can pursue in order to increase the impact of their actions. By enhancing their 23 capacity to act within the community, providers can exert a greater influence on community 24 leaders, as well as on current and potential users. 25 19 This study has covered different types of community services, which is an innovation in 1 research on cultural competence. It has allowed us to address cultural competence from a 2 social determinants approach, encompassing healthcare, education, socio-occupational 3 services, law enforcement forces, community-based organizations, and faith-based services. 4 During the community forums, participants highlighted the privileged position of the 5 community-based organizations, such as NGOs and citizen associations, into addressing the 6 social determinants of health. Community-based organizations act as a bridge between the 7 population and other entities, helping to enhance community engagement, especially for 8 excluded populations (Wilson, Lavis, & Guta, 2012). In this case, the existence of migrant 9 organizations is an indicator of empowerment (Paloma, García-Ramírez, De la Mata, & 10 AMAL, 2010), because they seek to address their own needs, preserving their culture of origin 11 or religion and/or promoting their social participation. 12 Applications and transferences 13 This study generates some guidelines for designing actions that take into account the 14 community context at different levels and guides cultural competence towards promoting 15 equity, as previously recommended by several authors (e.g., Ivey & Collins, 2003; Nassar- 16 McMillan, 2014; Vera & Speight, 2003). One of the most obvious applications of this model is 17 the development of training programs for providers. We propose that CCC training should be 18 based on capacity-building principles (Suarez-Balcazar & Taylor-Ritzler, 2014). It should 19 focus on reinforcing the strengths and assets of an organization, its professionals and the 20 community where they are located, taking into account their social, historical, economic and 21 political contexts. These training programs can utilize a contextually based approach which 22 promotes empowerment, while enhancing competencies that are absent or low. 23 However, although this CCC model is focused on providers, its nature can allow 24 researchers to anticipate which organizational characteristics should change in order to 25 promote CCC among staff. This issue was discussed at length during the community forums, 26 20 establishing that providers with high CCC levels will be able to bring about change to their 1 organizational structures to achieve: (a) a multicultural mission; (b) greater user accessibility; 2 (c) increased user participation and empowerment; (d) the adaptation of services to the reality 3 of users and providers; and (e) the promotion of changes focused on equity. These findings are 4 in line with studies on equity standards for health and social care for migrants and ethnic 5 minorities (Cattacin et al., 2013; U.S. Department of Health and Human Services, 2013). They 6 also reinforce the proposal put forward by Maton (2008), presenting organizations as 7 empowering community settings. These settings can act as bridges between users and 8 communities, protecting their well-being and empowering them (Paloma et al., 2010). 9 Consequently, there should be a balance between providers’ empowerment and their 10 organizations in order to take advantage of the best characteristics that can have a positive 11 impact on the service users and their communities. 12 Research limitations and directions for future research 13 There are several limitations that should be considered when examining the findings 14 from this study. First, the sampling was not random. However, we followed a strategy based on 15 several steps with an aim to recruit a diverse sample of service providers. Therefore, although 16 the sample was not statistically representative, it can be considered representative of the 17 diversity of contexts in which providers offer services in Andalusia. Furthermore, the target 18 population of providers from the Spanish region of Andalusia may not be representative of 19 other populations (Hughes, Seidman, & Williams 1993). This is a region that boasts a unique 20 cultural history and which attracts a large number of migrants every year because of its 21 location in the southern region of Spain and its proximity to North Africa. Consequently, many 22 service providers have been exposed to migrants (mainly, Africans) for many years, 23 particularly in rural and border areas. This situation could be quite different from other 24 countries and regions, although current migration patterns around most developed countries 25 have increased significantly during the last few years due to war and/or climate change. 26 21 Second, there are limitations associated with the self-administered instrument (Gozu et 1 al., 2007; Shen, 2015), as the respondents may have shown some bias, such as the tendency to 2 overestimate their own cultural competence capacities at baseline. In addition, social 3 desirability control measures (Huang, Liao, & Chang, 1998) were not collected. This decision 4 was taken intentionally during the development phase of the questionnaire, along with 5 community agents, aimed at reducing the number of items and time required to complete the 6 survey. 7 Third, the quantitative survey only included providers at front line level; however 8 policy-makers, managers and other top organizational positions were not included. Although 9 one of our objectives was to prove if competent providers could have a real influence in 10 transforming organizational equity-cultural standards, that limited the scope of our results and 11 thus future researches should include them. This will allow understanding what kind of leaders 12 could promote a better engagement of providers in transforming organizations and also what 13 kind of strategies are more suitable to promote providers as a link between communities and 14 organizations. 15 Lastly but not least, another limitation of this study—shared by the majority of research 16 on cultural competence—is that objective indicators were not included to measure the real 17 impact of CCC. However, the perception of influence on the work contexts was included in the 18 analysis, which, given the limited scope of a cross-sectional study to capture community 19 complexities and organizational changes, may be a suitable approach for exploring the impact 20 of CCC at this level. As suggested by many authors (Alizadeh & Chavan, 2016; Beach et al., 21 2005; Renzaho et al., 2013), future research should include objective variables related to 22 organizational changes (i.e., increased efficiency in the operation of services, increased 23 satisfaction toward services, etc.) and communities (i.e., increased health, equity, and 24 empowerment). These measures could reinforce the perspective of people-in-context (Trickett, 25 22 2009), and could allow researchers to make multilevel analyses that provide a more complete 1 and realistic understanding of the impact behind interventions (Snijders & Bosker, 2011). 2 Conclusions 3 This study reviews the multidimensional and multilevel nature of the cultural 4 competence construct, exploring interdependence between providers, their organizations, and 5 the communities they serve. Our study contributes to breaking down the close link between 6 culture and cultural competence, adopting an equity-driven approach based on the social 7 determinants of health. From this perspective, the conditions of inequity that afflict migrant 8 groups and ethnic minorities call for a focus on competence across all domains that determine 9 the health of these populations, addressing it from different community services—going 10 beyond healthcare services (Society for Community Research and Action, 2016; Sorensen et 11 al., 2019). This perspective is particularly relevant when it comes to tackling the challenges 12 that new and complex migration flows pose, not to mention the humanitarian crises which are 13 breaking out at border areas and in transition and settlement contexts. As Knipper (2016) 14 enounced: “States are obliged to ‘respect, protect and fulfil’ the ‘highest attainable standard of 15 health’ based on the assumption that health depends on determinants beyond the control of the 16 individual (e.g. social, economic, and political)”. Many professionals and organizations are 17 trying to do the best they can, despite the difficulties and frustration they are experiencing 18 because of a lack of resources to cope with the growing demand and because of policies in 19 place that violate the rights of minority groups—e.g., blocking or restricting access to services 20 that rightfully belong to them. To address such inequalities, the inclusion of the community 21 context in the cultural competence equation allows us to frame it as a question of social justice. 22 23 References 1 Abe, J. (2012). A community ecology approach to cultural competence in mental health service 2 delivery: The case of Asian Americans. 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Descriptive Statistics of the items used in the questionnaire Items used to measure CCC Dimensions Items Mean SD Critical awareness CC1. I think it’s important for a provider like me to know how to differentiate between the sociocultural groups that exist in the neighborhood. 3.98 0.92 CC2. We as providers must be effective at promoting services for all people, regardless of their sociopolitical status, ethnicity or background. 4.23 0.81 CC3. I show my appreciation for their cultural norms when I interact with people of another ethnic origin or sociocultural background. 4.06 0.82 CC4. I am sensitive to valuing and respecting the differences between my cultural environment and that of immigrant users or those belonging to ethnic minorities. 4.14 0.74 Responsiveness to diversity HH1. I am competent working with immigrants or persons belonging to ethnic minorities. 4.19 0.70 HH2. I am effective when communicating with immigrants or persons belonging to ethnic minorities. 4.06 0.79 HH3. My cultural sensitivity comes across in the way I work. 4.03 0.79 HH4. I can adapt my work to the needs of immigrants or persons belonging to ethnic minorities. 4.05 0.80 Capacity to act within the organization CAO1. My organization provides me with adequate training to work competently with immigrants or persons belonging to ethnic minorities. 3.26 1.19 CAO2. In my organization I have access to interpreters when the user speaks a language I don’t understand well. 2.92 1.44 CAO3. In my organization I have up-to-date information (demographic, cultural, and epidemiological) about the population I work with. 2.67 1.25 Capacity to act within the community CAC1. I have access to political leaders from whom I can request the necessary resources to develop community-based programs. 2.05 1.11 CAC2. I participate in the community-based activities held in the neighborhood where I work (parties, gatherings, etc.). 2.60 1.24 CAC3. I know most people who work to improve the neighborhood where I work (professionals, community leaders, gatekeepers). 2.69 1.21 Items used to measure Influence on the work contexts Dimensions Items Mean SD Individual influence EI1. The work I do is important to me. 4.60 .61 EI2. I have the specialized skills necessary to carry out my work. 4.37 .62 EI3. I can decide for myself how to do my job. 3.99 .92 Organizational influence EO1. The work I do is important to the running of my organization. 4.19 .80 EO2. I have enough influence over what goes on in my organization. 3.26 1.06 EO3. My work helps to transform my organization. 3.48 1.01 Community influence EC1. My work is important to the running of this neighborhood. 3.81 .97 EC2. I have influence over what goes on in this neighborhood. 2.87 1.09 EC3. My work helps to transform this neighborhood. 3.21 1.07 1 33 Table 2. Descriptive Statistics, Reliability and Correlations Among Community Cultural Competence Dimensions Factors Mean (SD) # ítems Alpha Cronbach Correlations CA RD CAO CAC Critical Awareness (CA) 4.132 (0.610) 4 .715 1 .469** .182** .144** Responsiveness to diversity (RD) 4.076 (0.682) 4 .849 1 .364** .182** Capacity to act within the organization (CAO) 2.976 (1.072) 3 .741 1 .400** Capacity to act within the community (CAC) 2.442 (0.973) 3 .742 1 **p< .001. 1 2 34 Table 3. Four-step process of the community forums Step 1 Participants were welcomed and informed about the objectives of the community forum (giving verbal consent): (1) to offer feedback on the CCC concept; (2) to help the researchers gain a better understanding of the local CCC diagnosis; and (3) to propose guidelines aimed at improving the providers’ CCC on a local level. Step 2 The CCC concept and the main local results were presented by the researchers using simplified graphics and tables. Step 3 In small groups, participants combined this information with their own personal knowledge to reflect upon and discuss the results in order to propose guidelines for improving the providers’ CCC at a local level. Researchers used some structured sets of questions in order to guide the group discussions. By each dimension of the CCC model, two questions were introduced. For instance, below are those relating to critical awareness: (a) What would you highlight from the results presented regarding critical awareness in your working community?, and (b) What lines of action do you think could be developed to improve critical awareness (keep in mind that these actions can take place at different levels: i.e., individual, organizational and community)? Step 4 The groups shared their guidelines and were given an opportunity to explain why some actions are needed and how to implement them. Afterwards, the participants agreed upon 3-5 suggestions for each CCC dimension and conclusions were made. 1 35 Table 4. Recommendations for amplifying the impact of CCC and transferring results to local actions Dimensions Community Forum’s Proposals Critical Awareness • Dismantle and challenge migrants and/or minorities’ stereotypes (**) • Promote dialogue with the user and understanding of his/ her migration situation (**) • Encourage programs to develop critical awareness rather than cultural knowledge (*) • Remember that Spain has been and actually is a migratory nation (*) • Remind providers that they offer a community service and, thus, they should defend principles based on respect and tolerance (*) • Understand the sociopolitical crisis as an opportunity to reconsider issues that did not work in our socioeconomic model and offer more sustainable and responsive alternatives to address the citizens’ needs • Promote awareness of the providers’ role in generating structural changes • Make the leap from the organizations to the policies so as to foster equity Responsiveness to diversity • Collaborate with cultural mediators (**) • Enhance teamwork, not only interdisciplinary and cross-sectional, but also, with community agents (**) • Increase flexibility and adaptability among providers, particularly those who are civil servants (**) Capacity to act within organization • Increase the financial support to develop quality services (**) • Boost training programs in cultural competence and evaluate their impact (*) • Improve the working conditions so that the providers could demonstrate their skills (e.g., increase attention time per patient) (*) • Reduce accessibility barriers for migrants (e.g., hours of operation not consistent with habitual working hours, minimizing bureaucratic procedures) (*) • Sanction racist behaviors • Upgrade the incentive system • Foster organizational values which extend to multiculturalism • Increase the cultural diversity of the personnel • Strengthen service evaluations, revising the quality criteria in a participatory manner— with input from providers and users • Incorporate support to the community and the empowerment of the general public as an indirect objective in all organizations Capacity to act within community • Upgrade the planning of joint actions and coordination of networks (e.g., developing a common agenda for action) (**) • Improve health literacy in the migrant communities, mainly on their rights and proper use of resources (**) • Develop a guided map of the existing recourses in the community by sectors • Create new mobilization platforms and intersectional collaborations, as well as community-based coalitions • Increase recognition and trust for the providers from the community members • Promote the empowerment of the migrant communities, who are sometimes invisible or passive • Generate gatherings to share experiences and promote better practices * Guidelines that were repeated in two forums 1 ** Guidelines that were repeated in all three forums. 2 36 Figure 1. Community Cultural Competence Model and Predicted Relationship 1 2 Critical awareness (intrapersonal level) Responsiveness to diversity (interpersonal level) Community Cultural Competence of service providers Individual Organizational Community Influence in the work contexts Capacity to act within the organization (organizational level) Capacity to act within the community (community level) Influence on the work contexts Community cultural Competence of providers 37 Figure 2. Model of Community Cultural Competence 1 2 3 Note: CA=Critical awareness; RD= Responsiveness to diversity; CAO=Capacity to act within the organization; 4 CAC=Capacity to act within the community. 5 * α<.05 6 **<.01 7 .623 (.072)** .473 (.057)** .519 (.054)** .296 (.056)** .240 (.069)** .204 (.071)* CA DMS CAO CAC Fit Index: χ2(70) = 242.31, p< .01; CFI = .90; RMSEA = .07, 90%int=0.06-0.08 ** ** ** ** ** ** ** ** ** ** ** ** ** ** RD 38 Figure 3. Structural equation model predicting the impact of the CCC dimensions on perceived 1 influence on the work contexts 2 3 Note: CA=Critical awareness; RD= Responsiveness to diversity; CAO=Capacity to act within the organization; 4 CAC=Capacity to act within the community; IND=Influence on the work contexts at individual level; 5 ORG=Influence on the work contexts at organizational level; COM=Influence on the work contexts at community 6 level, 7 * α<.05 8 **<.01 9 CA DMS CAO CAC IND ORG COM -.072 (.115) .070 (.104) .016 (.093) .637 (.124)** .115 (.1116) .095 (.094) .117 (.084) .294 (.070)** .207 (.078)* .156 (.095) -.034 (.099) .021 (.092) FitIndex: Χ2(80) = 536.36, p< .01; CFI = .90; RMSEA = 0.06, 90%int =0.05-0.06 ** ** ** ** ** ** ** ** ** RD