Cultural competence in substance use treatment for migrants and ethnic minorities : what’s the problem represented to be?

Introduction: Larger exposure to social determinants of detrimental mental health and problem use as well as disparities in substance use treatment (SUT) between migrants and ethnic minorities (MEM) and non-MEM counterparts have been extensively documented around the world. These disparities include access, referral, diagnosis, waiting times, retention rates and presence, and are found across the treatment spectrum. Since the turn of the century cultural competence (CC) has gained influence in SUT theory and practice as an effective way to overcome them. Nevertheless, it remains unclear how CC is related to these disparities. This paper aims to understand (1) the nature and origin of CC in SUT, (2) the premises of CC argumentation in SUT, (3) how the components of CC theory are questioned, (4) to what degree CC SUT outcomes correspond with these premises, and finally (5) what is left unquestioned in the CC literature.Methods: We carried out a literature review (2007–2017) focused on CC SUT targeted at MEM. The literature search located 41 meta, narrative, systematic, conceptual, historical and other reviews of models and components of CC in SUT, as well as user and provider perspectives on these. We applied Bacchi’s “What’s the problem represented to be?” approach (2009), analysing how the “problems” relating to disparities in SUT for MEM are represented, the underpinning presumptions of CC, how these presumptions are questioned and what is left unquestioned. The identified CC presuppositions are categorised following an ecosocial perspective (micro, meso, macro).Results: Most of the identified studies build on Cross et al.’s (1989) definition of CC. (1) USA studies mainly describe individual and organizational CC and culturally adapted interventions. Researchers from mainly Australia, Canada and New Zealand describe culture-based intervention strategies for ‘indigenous’ populations. Very few European Union (EU) studies were located. (2) Presuppositions that argue for CC and culture-based approaches are mainly located at the macro level (disparities in [mental] health, dominant [professional] cultures, increasing diversity in society and the right to health); meso and micro level arguments are described extensively, but to a lesser degree. (3) Issues that are questioned include CC’s limitations, culturalizing and stereotyping effects, “the universalist stance” and conceptual vagueness. (4) Most outcome indicators focus on workforce (meso) and intervention (micro) and not the system level. (5) Themes that have not been questioned include high rates of incarceration of MEM groups, prevalence rates as presuppositions, the lack of accessibility to SUT as a component of CC, not comparing provider to user perspectives in outcome studies and the use of prevention literature in arguing for CC in SUT.Discussion: CC relies largely on the underlying and often unproblematised assumptions of what ‘culture’ is. Also, many of its presuppositions are in line with social recovery movement argumentation. Although most studies that argue for CC SUT do so from a health inequality perspective only some identify how components of CC work to reduce these disparities. Future research should focus on how the identified components both individually and conjointly address specific SUT disparities, how they are applied in SUT practice and whether they are in line with SUT needs and perspectives of service users with varying MEM backgrounds. Lastly, the lack of monitoring and the proliferation of derived CC concepts in the EU should be further examined.

Jaar van publicatie:2018