Introduction
The importance of cultural competency
Over the last 50 years, increased non-European immigration, globalization, changing sexual norms, and the aging of the American population have resulted in a much more culturally diverse country with respect to race, ethnicity, age, religion, sexual identity and orientation, and beliefs about illness and health. As a result, health care providers are likely to encounter patients who will be culturally different from them. These cultural differences affect both patients’ and providers’ health beliefs, practices, and behaviors and influence their expectations of each other. Lack of awareness about cultural differences can make it difficult to achieve high-quality care. Miscommunication may result, and the provider may fail to understand why the patient does not follow instructions. For example, why the patient takes a smaller dose of a prescribed medicine (because of a belief that Western medicine is “too strong”); or why the family, rather than the patient, makes important decisions about the patient’s health care (because major decisions are made by the family as a group in the patient’s culture). Likewise, the patient may reject the provider (and the entire U.S. medical system) even before any one-on-one interaction occurs because of nonverbal cues that do not fit expectations.
Thus in the context of the provider-patient relationship, cultural competence refers to the health care provider’s ability to work effectively with individuals from different cultural and ethnic backgrounds. Despite our similarities, fundamental differences among people arise from nationality, ethnicity, and culture, as well as from family background and individual experiences. Cultural competency refers to the ability to understand the language, culture, and behaviors of other individuals and groups, and to make appropriate recommendations. It also includes an awareness of one’s own cultural influences as well as personal biases and prejudices. Cultural competency has been described as a “set of congruent behaviors, attitudes, and policies that come together in a system, agency or profession that enables that system, agency or profession to work effectively in cross-cultural situations” (1). This definition of cultural competency identifies systems, agencies, or professions as potential points of intervention. However, other definitions of cultural competency primarily address individuals within systems and pay less attention to other factors associated with social inequity.
Although varying definitions of culture exist, what is common to these definitions is the view that culture is a set of shared values, beliefs, patterns, and communication styles that characterize the social life of a group or society (1–11). Importantly, culture is not a static entity but rather a fluid and ever-changing set of values, knowledge, and beliefs and a learned behavior. By acknowledging, recognizing, and accounting for cultural issues, health care providers can deliver effective and appropriate care for patients in a variety of inpatient and outpatient settings.
Cultural sensitivity, which is a necessary component of cultural competence, means that health care professionals make an effort to be aware of the potential and actual cultural factors that affect their interactions with patients. It also means that they are willing to design and implement culturally relevant and specific programs and materials and to make related recommendations. The terms cultural competence and culturally effective health care are sometimes used synonymously.
Cultural competence has implications beyond the individual provider-patient relationship. Despite steady improvements in the overall health of the U.S. population, racial and ethnic minorities as a whole continue to experience disproportionately higher morbidity and mortality rates than nonminorities. For example, African Americans and Hispanic Americans (and to a less well-documented extent, Native American, Alaska Natives, Asian Americans, Native Hawaiians, and other Pacific Islanders) receive less medical care in general and fewer intensive care procedures compared to white patients (12–14). This pattern has been found in the use of hightechnology interventions, such as angioplasty and coronary artery bypass surgery, and for medical and surgical procedures as well as the treatment of chronic conditions, such as diabetes. Men have higher prevalence of coronary heart disease, yet women die at higher rates. African American women have lower prevalence of breast cancer, yet die at higher rates. The reasons for these racial and ethnic disparities are complex and include multiple interconnected social and economic factors (12–15). In contributing to the elimination of these disparities, health professional students and providers must understand the underlying forces driving and maintaining these health disparities.
Differences in access to health care and differences in the quality of care received unquestionably contribute to health disparities. Timely use of personal health services to achieve the best health outcomes or health care access can be measured by (a) entry into the health care system, (b) structural barriers (e.g., transportation, ability to schedule appointments, and specialist referrals), (c) patient perceptions (e.g., patient-provider communication and relationships, cultural competency, health literacy, and health information), and (d) health care utilization (i.e., routine, acute, and chronic care, and avoidable hospital admissions).
While explanatory models for health disparities acknowledge the role of socioeconomic factors, they often include “culture” as a separate but related underlying factor (16–17). Freeman suggests that “poverty is reflected through the prism of culture…culture may augment or diminish poverty’s expected effects” (16). Poverty or social and economic location within a society, combined with geopolitical context, shapes a racial, ethnic, or cultural group’s access to social resources such as health care access and quality. Several views have been proposed on the role of culture in explaining health disparities. Some consider culture as a central or a significant predictor of health; some view it as having some role that is not yet clear, and others view it as a contextual variable that may promote or enhance the use of health services (18–25).
Although the National Healthcare Disparities Report does not specifically mention the role of bias and stereotyping, racial and ethnic bias and stereotyping by health care providers are thought to make significant contributions to health care disparities (12–14). Cultural competency training at all levels of professional education can play an important role in addressing racial and ethnic bias and stereotyping by health care providers.
Cultural competence is now recognized by various governmental and accreditation agencies as essential for improving patients’ health status and access to health care and for eliminating disparities in health care delivery. Health care system interventions to increase cultural competence can include programs to recruit and retain staff who reflect the cultural diversity of the community, use of interpreter services or bilingual providers, cultural competency training for health care providers, use of linguistically and culturally appropriate health education materials, and culturally specific health care settings (23). Health may be improved through these approaches because patients gain trust and confidence in accessing health care, and health care providers increase their ability to understand and treat a culturally diverse clientele. The effectiveness of these interventions can be assessed through intermediate outcomes and health outcomes. Examples of professional, governmental, and accrediting organizations recognizing the importance of cultural competency include the following:
(1) Association of American Medical Colleges (AAMC) Liaison Committee on Medical Education (LCME). Standards for accreditation of medical education programs leading to a medical degree in the U.S. and Canada require that medical students and faculty demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments (26). Medical schools are now required to document development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are being achieved. Medical school instruction must stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. Clinical instruction is to include demographic influences on health care quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. Most importantly, self-awareness among students regarding any personal biases in their approach to health care delivery is to be addressed. The AAMC’s recently published Tool for Assessing Cultural Competence Training (TACCT) is a comprehensive guide of objectives for the development of cultural competency and health disparities curriculum for undergraduate and graduate medical education (27, 28) and is shown in the introduction and Appendix 3.
(2) Accreditation Council for Graduate Medical Education (ACGME). In 1999, ACGME identified six core competencies for physicians: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (29). The fourth competency requires interpersonal and communication skills resulting in effective information exchange and collaboration with patients, their families, and other health professionals. The fifth competency, professionalism, includes “sensitivity to a diverse patient population.” Health care organizations and health professional training programs are therefore beginning to develop cultural competence initiatives. Many organizations are getting social and legal pressures to do this from different segments of the population.
(3) The Department of Health and Human Services’ Office of Minority Health. In 2001, the Office of Minority Health released the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) to guide health care organizations and individual providers in providing culturally effective health care (30).
(4) State Cultural Competency Training requirements. In 2005, New Jersey became the first state to require cultural competency training for physicians as a condition of licensure. More recently, Washington, California, New Mexico, and Maryland have passed legislation mandating or strongly recommending cultural competency training. A number of states are considering similar legislation (see http://www.thinkculturalhealth.org/cc_legislation.asp for a current update).
Individuals working with different ethnic and cultural groups can become more culturally competent by advancing through three main stages: developing awareness, acquiring knowledge, and developing and maintaining cross-cultural communication and negotiation skills. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals is self-instructional, with case vignettes and questions, followed by case discussions. Twenty-five cases are presented in the areas of general medicine, cardiology, pulmonary medicine, hematology/oncology, neurology, pediatrics, endocrinology, and obstetrics and gynecology. Learners will not only gain knowledge, but have direct insight into real-life scenarios that have occurred in clinical settings.
The cases focus on how age, gender, socioeconomic position, race/ethnicity, sexual orientation, immigrant status, language, religious and spiritual practices, and folk beliefs and practices can affect the doctor-patient relationship. For example, the age of the patient may influence how the patient uses his/her time with the physician and/or how the patient is perceived by the physician (Case 21). Patients who are very young or very old may require the assistance of others in obtaining information and providing care (Case 10). The doctor-patient relationship may be negatively affected when the physician makes superficial judgments about patients based on stereotypes of a racial, ethnic, or socioeconomic (Cases 2, 11, 24, 25). A lack of patient empowerment, as a response to perceived higher status of the physician, may pose a barrier to building rapport, and result in an inability to question the physician’s recommendations, or an overly trusting, dependent patient. A patient’s perceptions of entitlement (i.e., deserving of special treatment), and whether the patient is rich or poor, can also negatively affect the doctor-patient relationship.
Ability to pay is considered the leading barrier to accessing health care. Financial constraints may result in poor health care due to lack of preventive care and/or later presentation for care. A patient may lack a primary care physician, be unable to pay for appropriate diagnostic tests and treatments (e.g., prescription medications), and/or depend on unreliable or expensive sources of transportation (Case2). The daily experience with poverty, partner violence, drug use, poor housing, prostitution, and toxic environments impact not only the access to care, but also the patient’s ability to prevent disease and its complications.
A patient’s health literacy, associated either with low educational attainment or with a lack of understanding of health issues, can negatively affect the patient’s ability to understand a diagnosis or participate as an active partner in developing and carrying out a treatment plan (Case9). Health literacy can be unassociated with overall literacy and should be explored with all patients. Lack of reliable information (whether due to lack of money to pay for it, or lack of education to know whether and how to use it) can lead to an inability to understand or put into action the information provided. Individuals without ready access to a computer, or education or knowledge on how to use resources available at a library, may find it difficult to obtain needed information about self-care, illness, treatment, and resources.
Patients of the opposite gender as their physician may not feel comfortable discussing issues related to sexuality or sexual dysfunction. Gender discordance between the patient and the provider may affect the physician’s ability to take a sensitive and thorough sexual history, and patients may prefer the same gender for OB/GYN and urology providers (Cases 4, 13). Gender bias in diagnosis and treatment may result in underconsideration of heart disease with females, overuse of cardiac catheterization with males, or presumption of males as perpetrators of partner violence and abuse (Cases 17, 21).
Stigma and the potential for discrimination serve as obstacles for lesbians and gays seeking appropriate health care (Cases 8, 12). Screening for interpartner violence with gay and lesbian patients is often overlooked and unattended. Establishing comfort and trust between the patient and the physician (i.e., the physician conveys and the patient feels that it is safe to disclose sexual orientation and sexual practices) is key to good doctor–patient communication.
Individual worldviews and belief systems (i.e., the meaning and significance of illness) of patients and physicians are shaped by the cultures in which they were raised and currently reside (Cases 3, 5, 7,13,15,20,22). Issues of trust/distrust due to historic racism (e.g., Tuskegee Study) and intergroup conflicts can negatively affect the doctor-patient relationship (Cases 1, 16). Racism on the part of the patient or physician may diminish the physician’s ability to gather and/or interpret information about the patient and assure effective treatment and management (Cases1,19). For example, a young black man or woman presenting to the emergency department with pain while in a sickle cell crisis may be presumed to be a drug seeker (Case 22). Communication and interpersonal styles of communication that differ by culture may contribute to misunderstanding, misdiagnosis, or failure to develop rapport (Cases 7, 23). Values and traditions that conflict with mainstream “American” practices (e.g., female genital mutilation, objecting to an evaluation by provider of the opposite gender due to social norms, providing proof of virginity, seeking alternative therapies, and using euphemism to describe a terminal diagnosis) may affect the doctor–patient relationship.
Some of the meaning and significance of illness is shaped by the religious or spiritual traditions in which patients or their physicians are raised and/or currently practice (e.g., how a patient and family respond to death and dying) (Cases 10, 14, 17). Patient values and traditions stemming from religious/spiritual beliefs may conflict with those of their physician or health care system (e.g., end-of life decisions, abortion, organ donation, and therapeutic practices such as use of blood products). Physician comfort and willingness to cooperate with certain patient practices can enhance the ability of the physician to establish rapport and build trust with the patient (e.g., patient’s unwillingness to disrobe for physical examination, or patient’s request to participate in or condone religious/spiritual practices such as asking the physician to pray with them) (Case 25). Some beliefs or practices may require or prohibit certain behaviors that can affect the patient’s health or treatment (e.g., the challenge for diabetics of fasting during the Muslim holiday of Ramadan) (Case 4).
Verbal and nonverbal language differences between patients (and their families) and caregivers can diminish their ability to acquire accurate and timely information and provide care. Professional medical interpretation is needed in all places of care delivery since patients who speak English as a second language may not fully comprehend interviews or instructions in English (Cases 6, 10, 11, 23). Nonverbal language is also culturally based communication: assumptions cannot be made regarding the meanings attached to familiar actions (e.g., proximity, body language, gestures, and eye contact) (Case 22).
Patients may question the competence of foreign-born (immigrant) physicians or other health care providers due to pronounced accents, differences in cultures, and educational systems perceived as inferior (Case 19). The doctor–patient relationship may also be challenged by the expectations and experiences an immigrant patient brings to the encounter, and by the level of understanding and comfort the immigrant has of American culture (e.g., patients ’lack of empowerment in the country of origin and concerns for safety especially with health care providers) (Cases 6, 22). The reason for immigration (e.g., economic opportunity or refugee status) and immigrant status may play important roles in the ability to access needed services. Immigrants who are living with undocumented family members, or who are undocumented themselves, delay presentation of symptoms and use fewer medical services (Case 23). Many immigrants work for smaller employers who do not provide paid leaves to attend medical appointments. Employment as seasonal workers can also prevent continuity of care and/or compliance with treatment. Given these issues, it is not surprising that the average lifespan of a male immigrant agricultural worker is 47 years as compared to a comparable white male.
In summary, health professionals in training and practice have been and will continue to be challenged to take care of patients and their families from many different ethnic and cultural groups who may live in the U.S. on a full- or part-time basis. Developing skills in cultural competency is an evolving process and it takes time, experience, and a commitment to listening and respecting patients and, above all, appreciating their perspective. It is our hope that Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals will help with this process. Developed by a multidisciplinary team of medical educators experienced in cultural competency and health disparities education of medical students, physicians, and other health care professionals, this book of cases is the first of its kind.
Olivia Carter-Pokras, PhD
University of Maryland School of Public Health
College Park, MD, USA
Horace DeLisser, MD
University of Pennsylvania School of Medicine
Philadelphia, PA, USA
1. Cross T., Bazron B., Dennis K., Isaacs M. Towards a Culturally Competent System of Care, vol I. Georgetown University Child Development Center, CASSP Technical Assistance Center, Washington, DC, 1998.
2. Geertz C. The Interpretation of Cultures: Selected Essays. New York, Basic Books, 1973.
3. Merriam-Webster I. Merriam-Webster’s Medical Desk Dictionary. MerriamWebster Inc, Springfield, Mass, 2005.
4. Stedman T.L. Stedman’s Medical Dictionary. Lippincott Williams & Wilkins, Philadelphia, 2006.
5. American Psychological Association. Guidelines on Multicultural Education, Training, Research Practice and Organizational Change for Psychologists. American Psychological Association, Washington, DC, 2002.
6. VandenBos G.R. APA Dictionary of Psychology. American Psychological Association, Washington, DC, 2007.
7. Last J.M. A Dictionary of Public Health. Oxford University Press, Oxford, 2007.
8. Giddens A. Sociology, 2nd edn. Polity Press, Oxford, 1993.
9. Schaefer R.T. Sociology: A Brief Introduction, 4th edn. McGraw-Hill, New York, 2002.
10. Johnson A.G. The Blackwell Dictionary of Sociology: A User’s Guide to Sociological Language. Blackwell Publishers, Malden, Mass, 2000.
11. Winthrop R.H. Dictionary of Concepts in Cultural Anthropology. Greenwood Press, New York, 1991.
12. Physicians for Human Rights. The Right to Equal Treatment: An Action Plan to End Racial and Ethnic Disparities in Clinical Diagnosis and Treatment in the United States. Physicians for Human Rights, Cambridge, Mass, 2003.
13. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC, 2003.
14. Agency for Healthcare Research and Quality. National Healthcare Disparities Report. Agency for Healthcare Research and Quality, Washington, DC, 2006.
15. Carter-Pokras O., Baquet C. What is a health disparity? Public Health Rep 2002;117:426–32.
16. Freeman H. Commentary on the meaning of race in science and society. Cancer Epidemiol Biomarkers Prev 2003;12:232S–36S.
17. Brunner E., Marmot M. Social organization, stress, and health. In: Marmot M. & Wilkinson R.G., eds. Social Determinants of Health. Oxford University Press, New York, 1999.
18. Brach C., Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev 2000;57:181–2 (suppl 1).
19. Johnson R.L., Somnath S., Arbelaez J., Beach M.C., Cooper L.A. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19:101–10.
20. Organista K.C. Solving Latino Psychosocial and Health Problems. John Wiley & Sons, Inc, Hoboken, NJ, 2007.
21. Collins F.S. What we do and don’t know about “race,” “ethnicity” genetics and health at the dawn of the genome era. Nat Genet 2004;36(11): S13–15.
22. Viruell-Fuentes E.A. Beyond acculturation: immigration, discrimination, and health research among Mexicans in the United States. Soc Sci Med 2007;65:1524–35.
23. Anderson L.M., Scrimshaw S.C., Fullilove M.T., Fielding J.E., Normand J. Culturally competent healthcare systems: a systematic review. Am J Prev Med 2003;24(3S):68–79.
24. Betancourt J.R., Green A.R., Carrillo E. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. The Commonwealth Fund, New York, 2002.
25. Freimuth V., Quinn S. The contributions of health communication to eliminating health disparities. Am J Pub Health 2004;94(12): 2053–5.
26. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Association of American Medical Colleges, Washington, DC.
27. Association of American Medical Colleges. Tool for Assessing Cultural Competence Training (TACCT). Washington, DC. Available at: http://www.aamc.org/meded/tacct/start.htm.
28. Lie D.A., Boker J., Crandall S., DeGannes CN., Elliott D., MD, Henderson P., Kodjo C., and Seng L. Revising the Tool for Assessing Cultural Competence Training (TACCT) for curriculum evaluation: Findings derived from seven US schools and expert consensus.’ Med Educ Online. 2008;13:11. Available at http://www.med-ed-online.org
29. Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. General Competencies: Minimum Program Requirements Language, 1999. Available at: http://www.acgme.org.
30. Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards). U.S. Department of Health and Human Services, Washington, DC, 2001. Available at: http://www.omhrc.gov.