University of New Mexico UNM Digital Repository Sociology ETDs Electronic Theses and Dissertations Summer 7-31-2017 A Sociological Analysis of the Cultural Competence Construct: Essays on the Conceptualization, Operationalization, and Implementation of Cultural Competence in the U.S. Medical Profession Cirila Estela Vasquez Guzman University of New Mexico Follow this and additional works at: https://digitalrepository.unm.edu/soc_etds Part of the Sociology Commons Recommended Citation Vasquez Guzman, Cirila Estela. "A Sociological Analysis of the Cultural Competence Construct: Essays on the Conceptualization, Operationalization, and Implementation of Cultural Competence in the U.S. Medical Profession." (2017). https://digitalrepository.unm.edu/soc_etds/76 This Dissertation is brought to you for free and open access by the Electronic Theses and Dissertations at UNM Digital Repository. It has been accepted for inclusion in Sociology ETDs by an authorized administrator of UNM Digital Repository. For more information, please contact [email protected]. Cirila Estela Vasquez Guzman Candidate Sociology Department This dissertation is approved, and it is acceptable in quality and form for publication: Approved by the Dissertation Committee: Dr. Kristin Barker, Chairperson Dr. Nancy Lopez Dr. Jessica Goodkind Dr. Andrew Sussman A SOCIOLOGICAL ANALYSIS OF THE CULTURAL COMPETENCE CONSTRUCT: ESSAYS ON THE CONCEPTUALIZATION, OPERATIONALIZATION, AND IMPLEMENTATION OF CULTURAL COMPETENCE IN THE U.S. MEDICAL PROFESSION By Cirila Estela Vasquez Guzman B.A., Sociology, Whitman College, 2010 M.A., Sociology, University of New Mexico, 2013 DISSERTATION Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Sociology The University of New Mexico Albuquerque, New Mexico December, 2017 ©2017, Cirila Estela Vasquez Guzman iii DEDICATION I dedicated this dissertation to my mother, Elena Guzman. As an immigrant, Spanish speaking woman, single parent, she is my biggest hero and role model. This is for you. iv ACKNOWLEDGEMENTS As a first-generation, immigrant, English as a Second Language, undocumented, Latina woman, my educational achievements would not have been without the support of my mentors and family. I dedicate my dissertation to my family, whose struggles, tears, and love kept me alive and fighting every day. Without my family’s support, I would not be where I am today. No one in my entire family history had gone to college. My mother, Aurora, barely finished an elementary-level education, while my father, Sebastian, nearly completed a high school-level education in Mexico. My parents worked two to three jobs in order to provide my brother and me opportunities they never had. I have childhood memories of my brother Pablo and me helping them clean office buildings and throw newspapers at five in the morning. I also remember seeing the hard labor that went into working in the fields. Pablo is now at Stanford University finishing his PhD in mechanical engineering, and it is an honor to be completing my PhD in Sociology at the University of New Mexico. I thank my family for always telling me to keep fighting no matter how hard things got. A very special thank you goes out to my mom, Aurora Elena Guzman for her daily phone calls, texts, and messages of encouragement that keep me going. I would also like to thank my dissertation committee. My chair and advisor Dr. Kristin Barker, was critical in giving me feedback to take my work to that next level of rigor and clarity. My time with her was valuable and always insightful, pushing my dissertation in ways I did not foresee. I would like to thank my committee members, Dr. Jessica Goodkind, Dr. Andrew Sussman, and Dr. Nancy Lopez, all of whom provided valuable feedback on my chapters. I would like to give a very special thank you to Dr. Andrew Sussman. He was the v most involved in my dissertation process. Coffee time, lunches, and general meetings with him always lifted up my spirits and got me moving in the right direction. Without his unlimited time and support, completing this dissertation would not have been possible. I would further like to thank a special mentor of mine, Dr. Robert Valdez, who guided me throughout my graduate career from day one. He was also critical to my dissertation process from the proposal stage all the way to the very end. Dr. Valdez, the former director of the Robert Wood Johnson Foundation Center for Health Policy, is the reason why I chose the University of New Mexico. His support and time was critical to my success as a student and as a person. It is imperative that I acknowledge all the foundations that gave me financial and emotional support. I would like to thank Dr. Gabriel Sanchez, current director of the RWJF Center for Health Policy, for the travel money to conduct my interviews, access to a tape recorder, as well as payment for writing support by Dr. Jane Jones. The center has been instrumental to my graduate career in many ways too numerous to list. In addition, thank you to Dr. Adriana Ramirez and the Andrew W. Mellon Foundation for their fellowship, which provided structure and financial support towards completing my degree. The Graduate Resource Center, formerly led by Dr. Lawrence Roybal and currently by Dr. Stephanie Sanchez, was also critical to my success throughout my graduate time at the University of New Mexico. I took part in writing groups, workshops, and writing camps within a community of other students of color pursuing their PhDs in a range of disciplines. They propelled me one-step closer each time to completing my dissertation. In addition, most importantly, I would like to thank my husband, Andrew Lee Breidenbach. He stood by my side through the ups and downs and never left my side. His vi patience and time in reviewing every page, every sentence, and every word I wrote was incredible. I have no words to thank him for his love and support. Being able to fall in love and strengthen our relationship during our graduate program has added light to the many moments of darkness and frustration. I would like to thank Drew for his unconditional love and support throughout this process. I could always talk to him on ends about my dissertation; I could always show him sections and he would be willing to review it; and I could always be vulnerable with him, sharing weaknesses and successes. Thank you to my love. C. Estela Vasquez Guzman vii A SOCIOLOGICAL ANALYSIS OF THE CULTURAL COMPETENCE CONSTRUCT: ESSAYS ON THE CONCEPTUALIZATION, OPERATIONALIZATION, AND IMPLEMENTATION OF CULTURAL COMPETENCE IN THE U.S. MEDICAL PROFESSION By CIRILA ESTELA VASQUEZ GUZMAN B.A., Sociology, Whitman College, 2010 M.A., Sociology, University of New Mexico, 2013 Ph.D., Sociology, University of New Mexico, 2017 ABSTRACT PURPOSE: At the turn of the 21st century, the concept of cultural competence in medicine became a strategy to address cultural diversity and widening health and healthcare inequities. Cultural competence combines the tenets of patient-centered care, with an emphasis on the social and cultural factors that affect the quality of medical services, treatment decisions, and health outcomes. Substantively, this dissertation answers core questions about the parameters of cultural competence in medicine. Theoretically, it considers the jurisdictional terrain of the medical profession and its changing nature concerning the adoption of cultural competence. The overarching research question is how, why, and with what consequence did the medical profession integrate cultural competence? METHODS: I analyzed the conceptualization, operationalization, and implementation of cultural competence. I conducted semi-structured interviews with 14 key policy actors from four major organizations concerned with U.S. medical education to examine the viii conceptualization of the cultural competence mandate passed in 2000. Using discourse analysis, I analyzed 89 articles published in the Journal of the American Medical Association (JAMA) to assess the diverse operationalization of cultural competence within the medical profession. Moreover, I conducted a comparative case study analysis on data from a larger NIH-founded research team studying biased decision-making using mixed-methods to assess the implementation of cultural competence. We conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 students at 15 diverse public and private medicals schools. We also led focus groups with an additional 196 third and fourth year medical students. These three empirical chapters provide a cross-sectional snapshot of the medical profession’s legal, workplace, and professionalization jurisdictional claim to cultural competence. RESULTS: The first empirical chapter demonstrates that the conceptualization of cultural competence is a moving target. Cultural competence was conceptualized as being integral to the identity of the 21st century provider, but the standards, mission, approach, and policy effect has expanded. In the second study, three themes capture the tensions with implementing cultural competence into the practice of medicine. Culturally competent providers provide appropriate health information and make culturally-appropriate medical decisions, but such practices are constrained by the biomedical structure and culture of medicine. Finally, in the third chapter the implementation of cultural competence varies widely among the fifteen medical schools. Three themes capture the manner in which schools incorporated cultural