**7.5. Case study 3 (an observance of the cultural competence principle)**

Dr. Teta Greene stood in front of a gathering of 120 members of the Freetown branch of the Sande society, a fraternity of Liberian women. Her mission in that community was to start a campaign against the dehumanizing practice of female genital mutilation which had caused untold hardship for many years. When it was time for her address them, Dr. Greene introduced herself and two men who had accompanied her. After a brief introduction, both men proceeded to address the women for the next 30 minutes. By the end of the talk, many women were in tears. Dr. Greene asked women who were willing to help stop the practice among their children, families, and community to raise their hands. More than half of the group raised their hands and gave their names as a sign of commitment. How did she get that kind of response?

Dr. Greene knew that genital mutilation is a ritual for admission into the Sande fraternity so the entire audience had experienced it and were suffering from its various complications. The first speaker was an elderly public school headmaster who was well respected in the community and whose mother had been mutilated as a child. The second speaker was a Catholic priest who was well respected in the predominantly Catholic community. Both men spoke about the dangers of the practice and how the same women subjected to it were its strongest promoters. The message was right, the messengers were ideal, and therefore the required change was achieved.

## **7.6. Case 4 (an observance of the principle)**

The acceptance of family planning in Egypt had been very low for centuries, and as a result, contraceptive prevalence rates were poor and maternal mortality high. However, in the late 1930s, the Grand Mufti, considered the highest authority as far as the interpretation of the Quran was concerned, issued a document endorsing contraception. He stated that contraception was in no way against the tenets of Islam. This led to the establishment of family planning clinics across the country and positive changes in fertility indices [32]. What brought about this change? In many countries, especially in Africa and the Middle East, the most influential voices are those of religious leaders. Where a health service goes against religious beliefs, wide acceptance is almost impossible even when other cultural factors are taken into consideration. Ensuring that the health "product" is supported by religious institutions is fundamentally strategic in these societies.

Based on the illustrations above, it needs to be clearly stated that cultural competence is required at several critical points within the healthcare delivery process. For ease of understanding, these have been divided into three; organizational, structural, and clinical interventions:

**Cultural competence at organizational levels:** interventions deployed at this point must ensure a reasonable level of diversity in the composition of leadership and personnel of a healthcare organization to ensure that it is representative of its target population.

**Cultural competence at structural levels:** this requires efforts to ensure that healthcare delivery processes and activities are designed in such a way that they guarantee reasonable levels of access to quality care for all subgroups within the population that system serves [26].

**Cultural competence at clinical levels:** interventions required here are steps taken to improve the capacity of a healthcare practitioner to recognize, understand, and harness cultural peculiarities of individual patients in the provision of health-related information and care.
