Mexican-Americans' Perceptions of Culturally Competent Care:" Peer Journal Review

One of the most important goals of any health care provider is insuring the highest level of safe and effective care for their patients. In previous years, the role of cultural influences on patient care, as well as on provider service, has been largely ignored.

Today, however, most researchers and health care workers fully recognize the immense influence culture can exert on the success, or the failure, of health care.

In response to this reality, Maria R. Warda's work, "Mexican-Americans' Perceptions of Culturally Competent Care," published in the Western Journal of Nursing Research, addresses the practical question of just what constitutes "culturally competent care," specifically as it relates to Mexican-Americans. In particular, Warda notes that the four main areas of cultural care as defined by "the Hispanic literature on cultural care" (Warda, 2000, p. 203), are "family, spirituality, communication, and health beliefs and practices." Thus, according to Warda, the main research question to be considered is paraphrased, "What are the specific traits, beliefs, and practices that make up the four identified components of culture that most impact health care for Mexican-Americans?"

In introducing the reader to the central question of her work, Maria Warda clearly sets up the significance of the problem discussed. She writes:

Although the literature abounds with author's discussions of the need for nurses and other health care providers to deliver safe and optimal care to patients of diverse ethnic groups, little work has focused on defining and measuring the dimensions of culturally competent care (203).

She continues, "The purpose of this research was to identify culturally competent concepts from the perspective of Mexican-Americans (203)."

Clearly, according to Warda, the problem lies not in the identification of the problem, or even in the acceptance of the merit of understanding the role of culture as a component of delivering "safe and optimal care to patients of diverse ethnic groups." Instead, Warda is concerned with the "dearth" of concrete information on the exact specifics of the cultural components involved. Obviously, without concrete "field knowledge" of these cultural components, the knowledge of their existence in and of itself, is quite useless.

Of course, in any work of research, it is imperative for the author to have a sense of just "what he or she is doing" and why. In this case, Warda is particularly clear. She states, "Health care providers must collaborate with representatives from diverse client groups to develop culturally congruent interventions that consider variability in traditions, customs, and values (203)." Not only does the author make it abundantly clear that she intends to satisfy a portion of this need (in this case, dealing with the Mexican-American cultural community), but she specifically intends to gain the relevant information by interviewing a "focus group," from which she can gain specific information on the factors involved.

An additional component of a good research project involves the "consistency between the aim of a research study, the research questions, the chosen methods, and the personal philosophy of the researcher (Proctor, 1998)." Warda clearly states the aim of the study, the research question, as well as a statement of their intended research methods, "focus group interviews, built around [the four cultural areas in question]...were used to explore the subjective perceptions of Mexican-Americans regarding the indicators of culturally competent care (203)." Therefore, the component that remains to be examined is the author's congruity or lack of congruity between the research method (and its goals) and the philosophical basis of the research method.

In considering this question, it is apparent that Warda's use of a focus group to provide "subjective" perceptual data concerning culturally appropriate care, is strongly rooted in the Post-positive philosophy -- a method that is clearly rooted in the best philosophical basis for any study on human culture. This is simply because of the highly subjective and variable nature of human cultural difference -- a subject matter that, because of its inherent subjectivity and variability, naturally lends itself to a Post-positive research philosophy in which "reality is not a rigid thing, instead it is a creation of those individuals involved in the research (Hughes 1994)." Further, research on the nature of research philosophy suggests that cultural studies are among the topics most likely to be suited to a research method based on a Post-positive philosophical method:

among the various factors that influence reality construction,

Culture, gender, and cultural beliefs are the most significant. They recognize the intricate relationship between individual behavior, attitudes, external structures and socio-cultural issues (Proctor, 1998).

Unfortunately, Warda fails to accomplish the most crucial goal of the practice -- to provide a clear view of the supporting (as well as contradictory) literature surrounding the chosen research question. According to the University of Toronto, a literature review must "...be organized and related directly to the thesis or research question you are developing, identify areas of controversy, and formulate questions that need further research (Toronto)."
To be accurate, Warda does begin her literature review citing a theoretical study establishing the importance of understanding the "unique health care needs...of racial/ethnic groups" (Porter and Villarruel, 1993). She also ends her review with two other relevant studies, citing the "lack of culturally competent care" (De La Rosa, 1989; Jaurbe, 1995). However, most of the works referenced in the middle of the review are either empirical studies on the economic or the linguistic components of insufficient health care among Hispanics; (Trevino, Moyer, Valdez & Stroup-Benham, 1991; Franks, Clancy, & Gold, 1993; Ruiz, 1993; Spector, 1991; Juarbe, 1995; Todd, Samoroo, & Hoffman, 1993; Zambrana, All, Dorrington, Wachsman, & Hodge, 1994; Cornelius & Altman, 1995; Ginzberg, 1991; Marin, Marin, Padilla, De La Rocha, & Fay, 1981; Radecki & Bernstein, 1986; Suarez, 1992).

Although there is room for oppositional views in the literature review, the Works Cited do not give this impression. Instead, the review presents as a hasty construction of the formal research study protocol, more in the spirit of "filling space" than giving a sense of the breadth and substance of the current literary discourse on the subject matter at hand. In short, the relationship of the Mexican-American study to previous research is unclear in consideration of the majority of the studies cited. Again, to be fair, Warda did include a few references to studies directly related to the topic of culture as it relates to the quality of health care (Porter and Villarruel, 1993; U.S. Census, 1992; Perez-Stable Napoles-Springer, & Miramotes, 1997; and De La Rosa, 1989; Juarbe, 1995). However, it is not merely the comparative quantity of non-culturally-based studies included in the review to truly relevant articles that gives one pause -- on the contrary -- there is no rule concerning the amount of research cited in the review, as long as it is representative of the current level of discourse. Yet, one cannot help but feel that the works listed, on some level, detract from the perceived value of the research study at hand -- casting unfortunate doubt on the importance of cultural variables where there exist strong competing linguistic and economic factors as well.

To be sure, Warda does allude to the need for research into the "components of culturally competent care (205)," by restating her goal at the conclusion of the literature review. However she does not specifically describe the lack of relevant literature in the review itself. Indeed, she could have improved on the section by not only identifying the relevance of the research at hand (and re-stating the fact of the "dearth" of information on this aspect), but also by noting the existence (or, as the case may be, the non-existence) of studies considering the aspects that hold the greatest challenge for Hispanic's seeking health care -- economic, linguistic, or cultural.

Unfortunately, this she does not do.

The specific theoretical framework of the study that emerged from the data gathered was labeled, "Valuation-disregard paradox: Patterns of health care experiences (209)." This information was divided into two categories, "Congruent health care experiences," or those that result in an "enabling" influence -- "valuing, personalismo, system supports, and cultural comprehension, and "Incongruent health care experiences," that result in "hindering" -- "discounting, systems barriers, and blaming (210)." Thus, Warda constructs a theoretical framework for the projected outcome of the individual/health care system interaction where the "self-organization" that represents the "total-self" of the individual, "the personal and cultural self," enters the health care experience, and, depending on the culturally sensitive treatment, is transformed by either a "congruent" or "incongruent" experience. The final result is a "self-system" interaction, whereby the individual is "enabled" or "hindered (214).

Further, an important aspect in the theoretical schema developed for the study is the author's addition of "personal barriers" to healthcare in addition to the cultural components at issue. These include economic considerations, lack of knowledge, and linguistic barriers. However, much like the literature review, Warda fails to make a solid connection between these factors and the topic in question…