The author Jemaima Tiatia wishes to acknowledge the contributions of and thank those who provided advice and peer review: Metua Faasisila, Dr Peggy Fairbairn-Dunlop, Dr Monique Faleafa, Lita Foliaki, Dr Siale Foliaki, Nite Fuamatu, Pefi Kingi, Dr Jean Mitaera and the Ministry of Health’s Pacific Innovations and Capability and Pacific Policy and Strategy teams.
Citation: Tiatia J. 2008. Pacific Cultural Competencies: A literature review.
Wellington: Ministry of Health.
Published in February 2008
by the Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 978-0-478-31702-2 (Print)
ISBN 978-0-478-31703-9 (Online)
This document is available on the Ministry of Health’s website:
Talofa lava, Malo e lelei, Kia Orana, Taloha Ni, Fakalofa Lahi Atu, Ni Sa Bula Vinaka, Talofa, Kia Ora, Greetings Recent Ministry of Health sponsored research about the contribution of health care to health gains is showing that, in contrast to other population groups, Pacific peoples have benefited least. This clearly suggests that concerns about inequalities in access and exposure to health services (including health promotion and disease prevention programmes) are well founded and that health services need to be more responsive.
In Aotearoa / New Zealand there is a growing awareness that cultural competence is a key tool to making health services more responsive to Pacific peoples, Māori and other groups. Some organisations (including District Health Boards and other regulatory bodies) have already begun thinking about what Pacific cultural competence means. Likewise many Pacific health services have for many years already interpreted and implemented culturally competent Pacific practice in their work places.
This report Pacific Cultural Competencies: A Literature Review was undertaken by Dr Jemaima Tiatia (Hibiscus Research Ltd) and includes the input of leading Pacific cultural competence experts. The report contributes to the exciting and evolving thinking in the area of Pacific cultural competence, by providing an overview of the literature to date. It also provides practical recommendations for taking Pacific cultural competence forward.
Increasing cultural competency is a shared responsibility that requires partnerships across a wide range of sectors – including health, social services, education, justice and research – using systematic and sustainable approaches.
Towards this end, I hope that you will find this report valuable in your own journey towards achieving culturally competent Pacific health care.
‘I consider New Zealand a Pacific nation. We are of the Pacific – the vast ocean binds and connects us all.’
Luamanuvao Winnie Laban
‘The ocean is our sea of islands. One thing we all have in common is the ocean, the same sea washes the shores of all islands and also the coastline of Australia and New Zealand.’
Executive Summary vii
1 Overview 1
Review limitations 2
2 Definitions 3
Culture and cultural competency 3
Other related terms 4
3 Why the Need for Pacific Cultural Competencies? 6
New Zealand’s Pacific population in brief 6
Pacific peoples’ health status in brief 7
The need for Pacific cultural competencies 8
Some Pacific initiatives 9
4 Conceptualising Cultural Competency 13
Conceptualising Pacific cultural competency 14
Traditional healing 18
Individual and organisational cultural competence 19
Individual cultural competence 19
Organisational cultural competence 21
5 Cultural Competence Measures and Mechanisms for Achievement 22
6 The Role of Pacific Cultural Competence in Service Quality 31
7 Recommendations 33
Organisations and services 33
Content of cultural competence programmes 33
Measures of cultural competence 33
Research/investigations needed 34
Other considerations 34
Table 1: Key themes of the Waitemata DHB Pacific Cultural Competency Project 17
Table 2: Individual Pacific cultural competence constructs 20
Table 3: Mason’s five progressive steps for measuring cultural competence 23
Table 4: Core elements of the BESAFE model 24
Table 5: Summary of culturally competent services 26
Table 6: Measures of organisational Pacific competency 29
Figure 1: Mason’s continuum of cultural competence 23
Figure 2: Leininger’s Sunrise Model 25
As part of Goal 2 of the Pacific Health and Disability Workforce Development Plan, objective 2.1 is to ‘define and develop cultural competence’. This objective notes the importance of cultural competence in the delivery of health and disability services to Pacific peoples by Pacific, mainstream and other (Māori) providers.
This report provides an overview of the literature on Pacific cultural competence in health care, focusing on the following key areas:
relevant definitions of Pacific cultural competence, cultural competence and other related concepts
studies that provide a rationale for, and outline the benefits of, different Pacific cultural competence approaches
studies relating to individual and organisational cultural competence
competence measures and mechanisms for achievement
the role of Pacific cultural competence in service quality
analysis and recommendations from the literature review on actions to take in the New Zealand setting to address Pacific cultural competence issues for the health and disability sector.
Cultural competence is the capacity of a health system to improve health and wellbeing by integrating cultural practices and concepts into health service delivery. Generally it is considered a behavioural approach and functions on the principle that behavioural changes can only be achieved first and foremost by changes in attitude. The capacity to affect attitudes and behaviours is influenced by many factors, including leadership in the field, access to information, goodwill, informed decision-making, a learning environment, best-quality practices, and organisational processes and procedures.
Although there is no universally accepted single definition of cultural competence, most definitions have a common element, which requires an adjustment or acknowledgement of one’s own culture in order to understand the culture of clients, patients, working colleagues or communities. This is achieved by recognising and respecting the culture of the person, family, community and/or organisation being served.
Pacific cultural competence is a relatively recent concept with very little development, resulting in few clear definitions and limited buy-in. There are, however, working definitions, including the ability to understand and appropriately apply cultural values and practices that underpin Pacific peoples’ world views and perspectives on health. A pertinent definition also includes the ability to integrate or acknowledge Pacific values, principles, structures, attitudes and practices in the care and delivery of service to Pacific clients, their families and communities.
Seeking clear definitions for Pacific peoples alone is rather complex, for within Pacific communities themselves, there are diversities. For instance, Pacific peoples occupy different social positions, hold various places of status and encompass a range of backgrounds and experiences. Cultural competence should include all these diverse dimensions.
Culturally competent attitudes and aptitudes are critical for all marginalised sub-groups, whether gender groups (male, female, trans-gender, fa’afafine); age groups (elderly, adolescent, children); sexual-preference groups (gay, heterosexual, lesbian, bisexual); place of birth (island-born or raised, New Zealand-born or raised, and multi-ethnic); people with disabilities; or religious groups.
There is substantial evidence to suggest that cultural competence is imperative. However, there is little evidence on which approaches and techniques are effective and how and when to implement them appropriately. In addition, the development of suitable cultural competence measures is hampered by a lack of clarity on the meaning of cultural competence in the first instance. So although there is no universal understanding of what culturally competent care is, the challenge lies in identifying ways of measuring or evaluating appropriate care and cultural competence training, defining successful programmes, and creating innovative methods for assessing a construct that is continually evolving at multiple levels within a service community.
An important issue for Pacific peoples is that cultural competencies lack rigorous evaluation. As a result, it is uncertain what actually works to improve outcomes. It must also be said that criteria for what a culturally appropriate service entails need to be established and must be clearly defined in order to develop cultural competencies or best practices within the context of continuous quality (Kirk et al 2002).
Cultural competence is achievable within health care if leadership and workforce development are supported. At present, in health care there are community assessments, mechanisms for community and client feedback, and implementation of systems for ethnic and language preference data collection. There are also quality measures developed for diverse client populations; culturally and linguistically appropriate health education resources, materials and health promotion activities; and appropriate secondary interventions. It is important to acknowledge recent initiatives that could complement and further contribute to cultural competence developments.
Pacific cultural competence should be considered integral to the definition of quality of care if we are to move towards quality outcomes. It could be included in accreditation tools, regulatory criteria and national surveys. Quality indicators are required to identify, define, track, evaluate and improve culturally competent practices and services. The implication seems to be that little is known about the feasibility and efficacy of Pacific cultural competencies. For Pacific peoples, the issue is that cultural competencies lack rigorous evaluation, which means the most effective approaches for improving outcomes are uncertain. Increased research and study are recommended for achieving sound outcomes in cultural competence.
Increasing cultural competency is a shared responsibility, requiring partnerships across a wide range of sectors – including health, social services, education, justice and research – using systematic and sustainable approaches. Pacific cultural competencies are fundamental to the delivery of health and disability services for Pacific peoples by Pacific, mainstream and other (Māori) providers. Pacific communities should be encouraged and supported to develop more effective and innovative models of health care delivery and service to appropriately meet their health needs.
Cultural competence is a subset of individualised care, in the sense that it is the ability to provide individualised care that accounts for the influences and benefits of the client’s culture. An organisation that gains skills in cultural competence increases its ability to serve all diversity.