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Finding Common Ground: Implementing Culturally Competent Care in Denmark

Abstract

In many ways, the universal health care system in Denmark addresses the needs of its patients. The system has not, however, adequately adapted to the changing concerns of the country's increasingly diverse population of ethnic minorities. There is one model of culturally competent care, espoused by community health centers in the United States, serves as a template for addressing this problem. In particular, the Ryan-NENA Community Health Center on the Lower East Side of New York City illustrates how healthcare professionals can provide for the different needs of immigrant communities in a culturally competent manner. We propose that this model be implemented in Denmark, to ensure that ethnic minorities have equal access to the healthcare system and to maximize their ability to become more active and integrated members of society. 

The Issue 

Denmark's demographics have shifted significantly in the last several decades, as ethnic minorities have become an increasing presence in a largely homogenous society. Immigrants currently comprise 9.5 percent of the population,  while in 1980 they made up just one percent.  In comparison with the United States, which has experienced substantial flows of immigration throughout its history, this phenomenon in Denmark is relatively new. As a result, institutions such as healthcare find themselves unequipped to deal with a more diverse population, with different health needs. A cyclical relationship develops between a lack of culturally competent healthcare for ethnic minorities and their detrimental health outcomes as compared to the native Danish population. Most health institutions in Denmark do not record data based on ethnicity, so it is difficult to assess the overall health disparities between native-born Danes and non-Western immigrants. However, a study found that the latter group has higher rates of type 2 diabetes, asthma, and skeletal muscle disease.  Ethnic minorities also use the emergency room more often than the native Danish population. This finding not only points to a potentially higher level of health problems; it also suggests that immigrants may have a more limited knowledge of the Danish healthcare system, and face barriers to seeking primary care that include language, fear of discrimination, and an unsatisfactory quality of care.  
Often, Danish institutions place the onus of integration on immigrant groups, explaining their shortcomings with reference to their limited Danish language skills and low educational level. The National Board of Health in Denmark, for example, found that these factors contributed to communication problems between doctors and patients who belonged to ethnic minority groups. This gap can, in turn, negatively impact the quality of treatment.  Our argument, however, goes beyond these explanations to focus on the importance of healthcare professionals' ability to meet the specific needs of their diverse patient population. Studies find that most of their cultural knowledge has been obtained on an ad hoc basis from the media or through contact with patients, as opposed to courses, colleagues, or books and journals. The absence of institutionalized training in this area leads to a lack of cultural understanding, and the perpetuation of stereotypes and misinformation. As a result, “approximately 60% of all three professional groups (physicians, nurses, and nurse assistants) [in Denmark] had experienced 'immigrant' patients having not understood advice and counseling, and 40% felt that they could not fulfill the needs of the 'immigrant' patients.”  
It seems that the deeper underlying issue here relates to the position and recognition of immigrants and ethnic minorities in Danish society. On the one hand, the nation strives to treat ethnic minorities equally when compared with Danes, including access to the state-run healthcare system. On the other hand, this effort to treat all people equally translates into a minimal support for multicultural policies or specially designed programs to meet the more specific needs of certain populations.  The potential health consequences of such an inadequate level of cultural sensitivity should provide an incentive to promote cultural awareness among healthcare providers in order to better serve their increasingly diverse set of patients.

Culturally Competent Care in the United States

The idea of culturally competent care, first developed by community health centers in the United States during the 1960s, can provide the Danish healthcare system with a model of how to address these challenges. Affectionately referred to as the ‘Nation of Immigrants’, the United States has a long history of dealing with a diverse population. The country is comprised of rapidly growing ethnic minorities which are poised to surpass the non-Hispanic White population by 2042.  While this contributes invaluably to the richness of American culture, it also presents a challenge in making healthcare accessible to each of its citizens. The stark inequalities with respect to health care among minority populations in the United States  demonstrates that thus far, this challenge has not been successfully addressed.
At the same time, these persistent disparities in institutionalized healthcare have necessitated a refinement of the model of culturally competent care, which remains an essential part of healthcare education today. Cultural competency training teaches providers to be knowledgeable and sensitive to the various values, beliefs, and attitudes rooted in a patient’s ethnic, cultural, or religious background.   This perspective involves an analysis of how patient interactions with providers possibly play a role in the social marginalization of minority groups, and an investigation into how providers can address these inadequacies in care. It also challenges providers to become perceptive about their own assumptions, and develop humility and respect for cultural differences. This helps the burden of adaptation to be spread evenly between patients, healthcare providers and institutions. Conversely, culturally incompetent care can result in decreased patient trust and compliance, the absence of informed consent, and potentially irreparable medical errors at the clinical level. Even further, it can negatively impact a community’s perception of allopathic healthcare, foster isolationism, and generate health inequalities at the macro-level.
Community health centers such as the Ryan-NENA in New York City serve as an example of how a cultural competency model is applied in a community health setting.  Ryan-NENA addresses the multicultural needs of its Lower East Side community members by maintaining an almost entirely bilingual staff, and requiring that providers complete cultural competence training. It utilizes an extensive language bank network and conducts ongoing community needs assessments.   Moreover, as a non-profit organization and federally recognized community health center, Ryan-NENA is subject to several federal, state, and city audits. This official level of scrutiny requires the center to regularly evaluate the health of those it treats against national standards and goals, such as the Healthy Families 2010 benchmarks, and efficiently adapt their approach to meet these objectives. For instance, the Lower East Side area served by Ryan-NENA may have a lower childhood immunization rate than the New York or United States population.  A needs assessment reveals a particularly isolated community with barriers to accessing primary care, which can be remedied with an outreach effort through partnerships with local leaders and active community members. Such a system, by enabling both healthcare providers and the delivery system to straightforwardly respond to the needs of an ethnically diverse group of people, addresses some of the difficulties associated with integration and forges a genuine bridge between Western and non-Western cultures in the United States. 

Implementation in Denmark

In contrast to the United States, Denmark has a robust healthcare system which is significantly more accessible to its members. However, there remains a need for culturally competent care within this system as well. The American model, if applied within the Danish healthcare system, would improve the quality of care for minority populations and decrease or even prevent the health disparities discussed above. Any effort at implementation necessitates an assessment of how culturally competent care will function within the Danish context.
Sundhesstyrelsen, the National Board of Health, has recognized this need, and is demonstrating a basic receptiveness and readiness to promote cultural competence among its healthcare providers at all levels of care. For instance, it has already begun providing cultural mediators to address the health disparities that exist between minority and non-minority populations. Some experts have suggested that this approach would not even necessarily require additional resources from the Danish government, because the health savings resulting from the reduced number of medical errors with this system would offset the cost. Odense Universitets Hospital and Bispebjerg and Glostrup Hospital have recently begun to shift their focus to this area. However, we feel that cultural competence training should begin at the university level; in this case, one’s proficiency could be continuously updated through continual medical educational credits (CMEs). Meanwhile, methods to assess the implementation and effectiveness of that training should be measured through needs assessments designed to hold the healthcare system accountable to the communities it serves. If all of these elements are in place, the goal would be a systemic implementation of culturally competent care; initially in Copenhagen’s most ethnically diverse district, Nørrebro, and later, at primary, secondary, and tertiary levels of care.
Although the National Board of Health has indicated its readiness, receptivity, and availability of resources for the project, the increasing anti-immigrant sentiment among Danes may challenge policies specifically catering to ethnic minorities. Nativist parties such as the Danish People’s Party are likely to resist, and argue that ethnic minorities should be treated on an entirely equal footing compared to native Danes. Additionally, they might claim that the cultural competence model would deter the assimilation of immigrants, since by forcing the Danish healthcare system to adapt it would take away immigrants' responsibility to integrate into society.
Nevertheless, making the healthcare system more culturally competent coincides with the goal of leveling the playing field between ethnic minorities and native Danes. Without this element, ethnic minorities’ access and quality of healthcare remains inferior. Ultimately, adapting the healthcare system to a variety of cultures and languages will facilitate a bridging of the present communication gap between immigrant patients and providers. This, in turn, can only promote social justice and minority rights as it decreases the disadvantages these minorities currently experience in the area of health, and eases the integration of immigrants into Danish society.

References

“Statistics Denmark - Immigrants and their descendants and foreign nationals,” Statistics Denmark, http://www.dst.dk/HomeUK/Statistics/focus_on/focus_on_show.aspx?sci=565 (accessed August 1, 2009).
Hedetoft, Ulf, “Denmark: Integrating Immigrants into a Homogeneous Welfare State,” Migration Information Source, http://www.migrationinformation.org/profiles/display.cfm?ID=485 (accessed August 1, 2009).
Folmann, N, “Ethnic Minorities in Denmark – health and health services use,” European Journal of Public Health 2007 17 (Suppl 2): 110. http://eurpub.oxfordjournals.org (accessed August 1, 2009).
Norredam, Marie et al., “Emergency room utilization in Copenhagen: a comparison of immigrant groups and Danish-born residents,” Scandinavian Journal of Public Health, Vol. 32, No. 1, 53-59 (2004), http://sjp.sagepub.com/cgi/content/abstract/32/1/53 (accessed August 1, 2009).
“Patienter med anden etnisk baggrund er en udfordring for sundhedspersonale,” Sundhedsstyrelsen, 4 Juli 2008, http://sst.dk/Nyhedscenter/Nyheder/2008/kulturelle_mediatorer_resume_juli2008.aspx (accessed August 1, 2009). 
Michaelson, J.J.; Krasnik, A.; Nielsen, A.S.; Norredam, M.; Torres, A.M. Scandinavian Journal of Public Health 2004; 32: 287–295. 
Hedetoft, Ulf, “Denmark: Integrating Immigrants into a Homogeneous Welfare State,” Migration Information Source, http://www.migrationinformation.org/profiles/display.cfm?ID=485 (accessed August 1, 2009).
U.S. Census Bureau. http://www.census.gov/population/www/projections/2008projections.html (accessed August 1, 2009).
Nelson, Alan R., et al., “Unequal Treatments: What Health Care System Administrators Need to Know About Racial and Ethnic Disparities in Healthcare,” Institute of Medicine, March 2002.
     
“Introduction to Culturally Competent Care,” Santa Clara University, http://www.scu.edu/ethics/practicing/focusareas/medical/culturally-competent-care/introduction.html (accessed August 1, 2009).
“William F. Ryan Community Health Center,” http://www.ryancenter.org (accessed August 2, 2009).
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