**7.1. Organizational level**

Cultural competence of health interventions is largely determined by leadership within organizations as well as discharge of a myriad of functions carried out by individual members of the healthcare team. The degree to which the makeup of major establishments reflect the different groups that make up the target population will influence how culturally adequate the policies, procedures, and decisions made will be. Available evidence suggests that inequalities of representation at strategic, management, and operational levels within the health organization result in poor acceptability and access to health services.

Inadequate minority representation in governance, administrative, and clinical leadership roles causes healthcare systems to be disconnected from the minority communities they serve.

## **7.2. Case study 1 (a transgression of the principle)**

Mr. Audu Bako had just discovered he was HIV positive. It came to him as a shock; despite the fact that he had four wives and several other "mistresses" and never practiced safe sex, he had never thought that this dreaded disease would catch up with him. After all, none of his friends had it. He would never divulge his condition to anyone, not even his wives. If his neighbors or coworkers discovered his secret, he would become a laughing stock of the community. He would lose his respect, people would keep their distance from him, even avoid him completely.

He had been referred to an HIV clinic at the big hospital at the center of town. He was not comfortable going there. He would have preferred a place at the outskirts of town or even another town where he was unknown. He cautiously approached the entrance to the clinic which he identified with the large signboard outside it. As he made to enter, he saw his landlord Chief Alfred Nwosu stepping out of the clinic with a polythene bag in his hand, glancing cautiously in either direction as he made to exit the clinic. Audu swiftly changed his direction and hurried away before he was spotted. He walked back to the car park and drove his car away hurriedly. He never came back.

What went wrong? The clinic was located separately from other clinics in the hospital making it easy to identify its clients. In African countries like Nigeria, HIV is still associated with a lot of prejudice against the victim as most people associate it with sexual promiscuity, even blaming patients for their condition. Audu would rather take his chances elsewhere than be seen at the clinic, than to be labeled one of "them."

## **7.3. Case study 2 (a transgression of the principle)**

Dr. Sanjay Patel sat down in his consulting room at the large hospital in Calgary, Alberta, where he worked as an Obs/Gyn consultant providing family planning services. His last client for the day was a middle-aged woman of Asian descent. Her file indicated she was 42 years old and that her name was Mrs. Fei hung Zhao. It also indicated a bad obstetric history and the fact that she already had five children. Three minutes into the interaction, it dawned on Dr. Patel that his client's understanding of English was quite poor. Further enquiry revealed that there was no member of staff who could speak any Chinese. He tried to get across to her with some basic words and a lot of sign language. She refused the hormonal contraception (as an injection or IUCD) which was ideal for women of her age but preferred oral pills. He tried his best to instruct her on how to take them and asked her to return in a month with a family member. Fei hung returned 5 months later; she was 3 months pregnant.

What went wrong? The Mandarin community comprises about 3% of the Canadian population. It is a conservative society and as such Fei hung was not comfortable discussing birth control with a man, especially one of a different race. Not one member of the Chinese community worked in the hospital. The language barrier ensured that she did not understand most of Dr. Patel's attempt to educate her and her rejection of hormonal contraception was because she felt it would make her fat. She misunderstood the directions on how to take her pills and when to return. By the time she got pregnant, she was shocked and disappointed; she really felt she had done all the right things.
