Rethinking health care cultures in community services: Towards an operational five-criteria framework.

Calls for cultural change in health services often remain confined to managerial or ethical discourse, lacking critical depth and operational clarity. This article develops the concept of health care cultures (HCCs) as an analytical category in its own right: dynamic configurations of power, knowledge and practice that actively shape how care is conceived, delivered and governed. Drawing on a Gramscian framework, feminist care theory, and the literature on structural competency, I conceptualise HCCs as sites of tension between hegemonic and subaltern forms of knowledge and practice. This reframing has direct implications for how community health and mental health services are analysed, evaluated and transformed: it moves beyond treating culture as a background variable to be managed, or as a property of patients and professional encounters, to examining how the institutional organisation of care itself produces and reproduces inequalities. On this theoretical basis and drawing on three research projects conducted in Brazil and Spain, I propose a five-criteria framework for analysing and transforming HCCs: structural competency, community participation, recognition of experiential knowledge of illness, shared and supported decision-making and the safeguarding of users' rights. These criteria are interdependent rather than parallel. Structural competency provides the conditions of possibility for the other four, which together constitute a way of asking what kind of institution a community health service is and what kind it might become.