Cultural competence in health care : challenging inequalities, involving institutions

Cultural competence has been recommended as a strategy to reduce health inequalities among migrants but, so far, the effects on health care remain sparse. Cultural competence neglects the roles played by the institutional and political levels on the attitudes of health professionals. This thesis aims at challenging the health inequities experienced by migrants in involving the health professionals and the institutions at the meso and the macro levels. We investigated three main research questions. To what extent do culturally competent interventions contribute to the reduction of health inequalities and to the improvement of quality of care? How cultural competence is implemented and diffused in the health services in Belgium? We conducted the COMETH study, a quantitative empirical study with a social network analysis design. What are the best practices and political recommendations for improving equity in health for migrants beyond cultural competence? Firstly, when the intervention aims at reducing health inequalities, universal interventions are more adapted, while improving quality of care requires specific interventions. Secondly, the sense of responsibility of health professionals towards cultural competence is influenced by the context surrounding the health services. Thirdly, cultural competence spreads in health services through effects of leadership, particularly the role-modelling, rather than through interpersonal relationships. Fourthly, there is a low level of commitment towards cultural competence among health professionals. The responsibility to adapt is put on the individuals or patients rather than on the institutions and the policymakers. Finally, the concept of cultural competence is discussed in the Belgian health system.