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TUFH 40TH ANNIVERSARY SPECIAL PAPERS: PRACTICAL ADVICE PAPER
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 146-149

An innovative educational strategy to addressing cultural competence in healthcare for quilombola women


1 Santos Dumont Institute, Macaíba-RN; Health Sciences Center, Federal University of Rio Grande do Norte, Natal-RN, Brazil
2 Santos Dumont Institute, Macaíba-RN, Natal-RN, Brazil
3 Health Sciences Center, Federal University of Rio Grande do Norte, Natal-RN, Brazil
4 Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte, Caicó-RN, Brazil

Date of Web Publication18-Apr-2020

Correspondence Address:
Reginaldo Antonio de Oliveira Freitas-Junior
Centro de Educação e Pesquisa em Saúde Anita Garibaldi, Rodovia RN 160, no 2010, Distrito Jundiaí, Macaíba-RN
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_255_19

  Abstract 


Background: The Quilombola community is made up of descendants of enslaved Africans. These people represent an ethnic minority group within the Brazilian Black population with worse health indicators including higher rates of maternal mortality. Context: The Brazilian National Guidelines for education of health professionals state that cultural competence and education of ethnic-racial relations need to be reinforced. Activities: An action research initiative was developed with the main goal of contributing to the development of cultural competence, interprofessional education, and collaborative work as well as improving the maternal and child indicators of the Quilombola community. An elective module for undergraduate health courses with the subject “Cultural Competence in Health Care for Quilombola Women” was implemented. Data on health-related needs identification, students' perceptions about interactions with the community, and competencies necessary to work with the Quilombola community were considered. Outcomes: Our educational strategy reinforces the importance of considering the processes that influence the health care of this population. The reflective capacity and communication skills emerged as the most important attitudinal and psychomotor components, respectively. Future Directions: Sustainability comes from partnerships established between the Quilombola community and the university to institutionalize educational and research strategies. This project contributes to reducing health inequities and deconstructing racism in the training of future health professionals. Conclusions: The creation of links, the building of trust between users and health staff, and the ability to reflect, with emphasis on communication, were shown as the main components of culturally competent behavior in maternal health care in the studied Quilombola population.

Keywords: African continental ancestry group, cultural competency, culturally competent care, health equity, health services accessibility, professional education


How to cite this article:
Oliveira Freitas-Junior RA, Damasio Santos CA, Lisboa LL, Oliveira Freitas AK, Azevedo GD. An innovative educational strategy to addressing cultural competence in healthcare for quilombola women. Educ Health 2019;32:146-9

How to cite this URL:
Oliveira Freitas-Junior RA, Damasio Santos CA, Lisboa LL, Oliveira Freitas AK, Azevedo GD. An innovative educational strategy to addressing cultural competence in healthcare for quilombola women. Educ Health [serial online] 2019 [cited 2020 Jun 4];32:146-9. Available from: http://www.educationforhealth.net/text.asp?2019/32/3/146/282876




  Background Top


International literature reveals significant health inequalities between White and Black people, as well as between men and women, explaining synergistic interaction among social, racial, and gender-based inequalities.[1] Systematic reviews have shown significant association between self-reported racism and illness among people of minority groups.[2],[3] Discrimination related to race/ethnicity is also associated with worse patient-reported experiences of care.[4]

The concept of cultural competence emerged in health professions education from recognition of and advocacy concerning cultural and linguistic barriers to health care. Cultural competence is the ability to interact effectively with people of different cultures. “Culture” is a term that goes beyond just race or ethnicity. It can also refer to characteristics such as age, gender, sexual orientation, disability, religion, income level, education, geographical location, or profession.[5]

The Quilombola community, made up of descendants of enslaved Africans, represents an ethnic minority group within the Brazilian Black population, who are still fighting for equal rights related to the ownership of their lands and expansion of full citizenship for obtaining equity in health care.[6] In Brazil, Black women have worse health indicators than Whites, including higher rates of maternal mortality.[7] As a historically persecuted and excluded group, Quilombola people face greater difficulties in accessing public health due to both deeply ingrained social inequalities and the geographical locations of their communities, which are predominantly rural and remote.[6]

Context

The Brazilian National Guidelines for education of health professionals establish that the fundamental contents must be related to the whole health–disease process of the citizen, the family, and the community. Schools should include transversal themes in their curricula in order to address knowledge, experiences, and systematized reflections on human rights, social responsibility, education of ethnic-racial relations, and history of Afro-Brazilian and indigenous culture.[8] Despite this, the Afro-descendant populations are still neglected in health professions education.

Part of this problem stems from the relative invisibility of these population groups to health schools, whose traditional curricula disregard their specific health needs, resulting in the poor ability of teachers and students to cope with the multicultural context.


  Activities (What Was Done) Top


The “Barriguda” project has been developed with the largest Quilombola remnant community from Rio Grande do Norte State (Brazil), named “Capoeira dos Negros,” in the municipality of Macaíba. This community is located in a rural area and is composed of about 300 families and 1500 inhabitants, with limited access to health care. The project was implemented with the main goal of contributing to the development of cultural competence, interprofessional education, and collaborative work as well as improving the maternal and child health indicators of the Quilombola community.

In order to define the action plan to be implemented and identify the maternal health needs of this population, an action research initiative was developed following a framework devised by Thiollent.[9] To identify health-related needs, we conducted focus groups with Quilombola women (n = 17), community leaders (n = 3), and professionals and health managers (n = 9). We also analyzed reports obtained from public audiences, visits to the community, and services involved with maternal health care in the community of Capoeiras.

Accordingly, a community-based antenatal care service was implemented with the participation of undergraduate students and a multiprofessional team (physician, nurse, physiotherapist, psychologist, social worker, and residents of obstetrics and gynecology). The meetings are held weekly and include health education actions using soft technologies, such as group dynamics, as well as artistic and cultural activities that respect the values, traditions, knowledge, and local culture.

The “Barriguda Project,” named by the pregnant women of the community, refers to the way in which they refer to the Baobab, a tree revered by the Quilombola culture as a symbol of the location of their ancestors. In addition, in the local culture, “Barriguda” is also a caring name of referring to a pregnant woman.

The partnership with the Federal University of Rio Grande do Norte led to the creation of an elective module for undergraduate health courses with the subject “Cultural Competence in Health Care for Quilombola Women.” It is the first discipline in Brazil to address the study of cultural competence with Quilombola remnant populations.

For this article, we analyzed data from the focus groups conducted in the first phases concerning health-related needs identification and data regarding students' perceptions about their interactions with the community and the competencies necessary to work with the Quilombola community. A total of 24 participants from the following undergraduate courses were included: medicine (n = 8), physiotherapy (n = 11), dentistry (n = 2), nutrition (n = 1), psychology (n = 1), and journalism (n = 1). The data were recorded in audio, transcribed, analyzed, and codified. Data analysis was performed using the categorical thematic content analysis technique.[10] The project was approved by the Institutional Ethics Committee (protocol number 1.360.679/2015), and all participants signed a written informed consent.

Outcomes (what was learned)

The Barriguda Project gave birth to an innovative educational strategy to address cultural competence in an educational setting for the health professions in Brazil. Our educational strategy reinforces the importance of approaching the processes that influence health care of the Quilombola population. With regard to the attitudinal component, the project identified the need to stimulate the reflective capacity of students over the various values of health, beliefs, and behaviors. We have learned that it is also necessary to stimulate reflection on their own sociocultural baggage as well as the racist elements of Brazilian society and the consequent marginalization of Afro-descendant communities. Skill development was focused on the communication and understanding of social determinants, cultural, behavioral, psychological, ecological, ethical, and legal issues, at the individual and collective levels.

It should be noted that in the Quilombola women's feedback, the category of “building trust” was more prevalent than categories related to “good living conditions” and “access to health technologies.” From the students' perspective, developing competence in reflexive ability was more evident than properly acquiring knowledge about provision of care for the Quilombola population. The results obtained in the setting of a rural community, geographically isolated and notably vulnerable, show that social and economic considerations reinforce the importance of cultural competence for the improvement of health-care quality.

Cultural competence means being respectful and responsive to the health beliefs and practices of diverse population groups. Developing cultural competence is an evolving, dynamic process that takes time and occurs along a continuum. The focus of cultural competence has been expanded by this project to include health-care systems and all racial and ethnic minority populations experiencing health-care disparities.

This requires being concerned with the training of professionals capable of interacting effectively with individuals and populations that are culturally different. It expands the curricular dimension of the egress profile desired by the schools to achieve an effective health system that is inclusive, democratic, and equitable. Thus, the process of building health systems that can provide culturally competent care in the face of shortages of culturally competent health professionals is challenging.

Cultural competence cannot be expected to come simply from the students' innate characteristics of personality, character, availability, or otherness. Culturally competent care demands knowledge, skills, and attitudes that are developed with strategies that are intentionally planned and include activities in the settings where teachers, students, and diverse communities can interact effectively.


  Future Directions (Sustainability) Top


This project works because it is focused on building trust with a population that is usually neglected and invisible to the Brazilian health system. It is relevant to the educational context because it addresses the current principles of education related to integrated learning, interprofessional and collaborative work, and community-based education. Most importantly, this project contributes to reducing health inequities and deconstructing racism in the training of future health professionals.

We believe that some strategies need to be augmented in order to strengthen the sustainability of the project. These include divulgation of results in scientific events and publications in indexed journals in order to stimulate replication of the project in other neglected communities. Some advances need to be celebrated. In 2017, the project was one of the six winners of the competition “Innovation Laboratory on Social Participation in Integral Care to Women's Health,” being a successful case in the area of vulnerability and equity in women's lives and health. With this award, sponsored by the Pan American Health Organization, the project was validated by the National Health Council and the Brazilian Ministry of Health for replication in other neglected communities.[11]

It is also necessary to strengthen partnerships with universities and research centers in order to stimulate research about improving cultural competence to reduce health disparities. A significant challenge remains regarding evaluation of how cultural competence can contribute to reshaping education as proposed by the UNESCO: learning to know, learning to do, learning to be, and learning to live together.[12]


  Conclusions Top


The creation of links and building trust between users and health-care staff and the ability to reflect, with emphasis on communication, were shown as the main needs for culturally competent behavior in maternal health care in the studied Quilombola population. Creating opportunities for students to understand the health situation of Quilombola population's experience and interprofessional work have been shown to be effective in enhancing the development of cultural competencies in health training. The centrality of interpersonal relations immersed in the environments in which the health–disease process has its determinants is an essential condition as a catalyst for the development of cultural competence.

In the challenge of training health professionals skilled in working effectively with ethnically diverse populations, results show that it is fundamental that students have the knowledge of processes that influence health and care of the population minorities, as well as experiences related to diversity in their undergraduate curricula. This is the teaching–learning process happening in the real world through quality interactions between the learner and the person he or she needs to learn to value, respect, and care for.

Financial support and sponsorship

This study was financially supported by the Ministry of Education, Brazil and Federal University of Rio Grande do Norte.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report – United States; 2013. Available from: www.cdc.gov/minorityhealth/CHDIReport.html. [Last retrieved on 2018 Oct 13].  Back to cited text no. 1
    
2.
Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006;35:888-901.  Back to cited text no. 2
    
3.
Williams DR, Mohammed SA. Discrimination and racial disparities in health: Evidence and needed research. J Behav Med 2009;32:20-47.  Back to cited text no. 3
    
4.
Weech-Maldonado R, Hall A, Bryant T, Jenkins KA, Elliott MN. The relationship between perceived discrimination and patient experiences with health care. Med Care 2012;50:S62-8.  Back to cited text no. 4
    
5.
Goode TD, Dunne MC, Bronheim S. The Evidence Base for Cultural and Linguistic Competency in Health Care. New York: Commonwealth Fund; 2006.  Back to cited text no. 5
    
6.
Freitas-Júnior RA, Santos CA, Lisboa LL, Freitas AK, Garcia VL, Azevedo GD. Incorporating Cultural Competence for Maternal Healthcare in the Quilombola Population into Health Profession Training. Rev Bras Educ Med 2018; 42:100-09.  Back to cited text no. 6
    
7.
Leal MD, Gama SG, Pereira AP, Pacheco VE, Carmo CN, Santos RV. The color of pain: Racial iniquities in prenatal care and childbirth in Brazil. Cad Saúde Pública 2017;33 Suppl 1:e00078816.  Back to cited text no. 7
    
8.
Brazil. Ministry of Education. National Curriculum Guidelines for the Undergraduate Degree in Medicine. Resolution CNE/CES 3/2014. Available from: http://www.fmb.unesp.br/Home/Graduacao/resolucao-dcn-2014.pdf. [Last retrieved on 2018 Oct 14].  Back to cited text no. 8
    
9.
Thiollent M. The Action Research Methodology. 18th ed. São Paulo: Editora Cortez; 2011.  Back to cited text no. 9
    
10.
Bardin L. Content Analysys. 1st 3 ed. São Paulo: Edições 70; 2011.  Back to cited text no. 10
    
11.
Brazil. Ministry of Health. PAHO and the National Health Council award innovative experiences in women's health care. Available from: https://apsredes.org/opas-e-conselho-nacional-de-saude-premiam-experiencias-inovadoras-na-atencao-saude-das-mulheres/. [Last retrieved on 2018 Oct 14].  Back to cited text no. 11
    
12.
UNESCO. The Four Pillars of Learning. Available from: http://www.unesco.org/new/en/education/networks/global-networks/aspnet/about-us/strategy/the-four-pillars-of-learning/. [Last retrieved on 2018 Oct 14].  Back to cited text no. 12
    




 

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