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Cultural Competency in Healthcare: A Clinical Review and Video Vignettes From the National Medical Association

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Introduction to Cultural Competency

Definition

Cultural competence in healthcare refers to the capacity to provide effective medical care to persons of varied backgrounds through use of appropriate knowledge, skills, attitudes, and behaviors:

  • Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups; and

  • Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.[1]

Developing cultural competence allows a practitioner to understand, communicate with, and effectively interact with people across cultures. Developing a culturally competent approach to provision of healthcare requires a patient-centered approach that will affect care given to individuals of any community, including those defined by gender, sexual orientation, and disability. Cultural competence includes 4 components:

  • Awareness of one's own cultural worldview;

  • Attitude toward cultural differences;

  • Knowledge of different cultural practices and worldviews; and

  • Cross-cultural skills.[2]

This series on cultural competency will explore these components in 3 modules.

Examining bias. The first module focuses on strategies to reduce provider bias in patient interactions and medical decision making through provider self-examination of bias and its effects. It discusses and demonstrates how healthcare providers can recognize and effectively address the perspective that they bring to the patient-provider interaction.

Patient-provider communication. The second module discusses development of the provider's communication skills and attitudes necessary for placing the needs of the patient at the center of the healthcare interaction within the context of cultural differences. The core of both cultural competency and patient-centered care emphasizes unconditional respect for the patient as an individual, in which a rapport is developed through consideration of the patient's beliefs, values, and meaning of illness.[3]

Addressing language barriers. The third and final module discusses the skills needed for cross-cultural communication by highlighting evidence-based methods of addressing language barriers within the provider-patient encounter.

Rationale for Cultural Competence

The literature continues to provide evidence that a culturally competent clinician is a clinically competent clinician. Therefore, a major rationale for incorporating a culturally competent approach into healthcare is to improve health outcomes. Nowhere is the need for improved health outcomes greater than in communities with healthcare disparities.

It is expected that groups currently experiencing poorer health indexes in the United States will have the largest proportional increase in the country's changing demographic.[4] For example, about 1 in 10 Americans are foreign-born, and over 28.5 million households speak a primary language other than English. So-called minorities will comprise almost half of the US population within 50 years, whereas non-Hispanic whites will experience a negative growth rate by 2035.[5] This rapid change in population patterns necessitates a serious evaluation of how minority populations access and receive quality, cost-effective healthcare, taking into account the sociocultural background of patients, their families, and the environments in which they live.

The extent of healthcare disparities within the United States is considerable. Minorities have lower life expectancy, fewer years of healthy life, and more deaths -- many due to preventable illnesses. Life expectancy for African Americans is 5-10 years less than the national average, and these persons can expect 10-12 fewer years of healthy life. Mortality rates for minorities are higher for all leading causes of death, including cardiovascular disease, stroke, cancer, diabetes, hypertension, chronic kidney disease, and HIV/AIDS. In addition, several studies have demonstrated disparities in the quality of healthcare received by minorities, including lower screening rates, fewer prescriptions -- including for pain medications and beta-blockers -- and fewer referrals for specialized procedures, such as cardiac catheterization and renal transplantation.

Causes of disparities in health and healthcare are multifactorial (Table 1). It is commonly agreed that sociocultural, genetic, and economic factors, as well as factors within the healthcare delivery system, contribute to the poorer health indexes in minority populations.[4] Sources of these contributory factors can be divided into (1) systems of care, (2) patients and their communities, and (3) healthcare providers themselves:

  • Systems of care: Systems of care on both the federal and state levels contribute to disparities in healthcare access for minority patients. These systems issues include differences in health insurance coverage and policies, location of health facilities, poor availability of transportation, and linguistic barriers navigating systems of care. However, in well over 175 studies, when many non-healthcare-related factors were controlled for (socioeconomic status, insurance status, access to care, stage of disease, comorbid condition, and age), significant racial/ethnic disparities in health and healthcare remained.[6]

  • Patient and communities: Patients in minority communities may have lifestyles that promote certain illnesses and contribute to disease progression. Similarly, some patients from minority communities may not be as compliant with medical and follow-up care, taking into account varied levels of health literacy, lack of trust in the healthcare system, and adherence to alternative forms of medical treatment. Evidence shows that minority patients are more likely to refuse recommended services, adhere to poor treatment regimens, and delay seeking medical care. However, most studies have shown that these contributory factors from patients and communities are not a major source of observed disparities.

  • Healthcare providers: It is important to note that physicians and other providers contribute to disparate care through unconscious differences in clinical decision making, which are influenced by their cultural worldviews and can only be addressed through self-examination of bias, stereotyping, and clinical uncertainty in working with patients of different backgrounds.

Table 1. Study Findings Supporting Need for Cultural Competence Training to Address Health Disparities

Citation Study Design Findings Conclusion
Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002;287:1288-1294. Reviewed the 1998 Health Plan Employer Data and Information Set (HEDIS) for 4 measures of performance during 1997 (all patients in data set enrolled in Medicare managed care programs)

Limitation: did not control directly for income and level of education (used ZIP code and 1990 census data as estimate)

After adjusting for socioeconomic factors (age, sex, Medicaid insurance, income, education, and rural vs urban residence), significant disparities remained for:
  • Rates of breast cancer screening

  • Use of beta-blocker after myocardial infarction

  • Follow-up after hospitalization for medical illness for minority patients
Disparities in healthcare not solely due to socioeconomic factors:
  • Future studies needed to control for income directly
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, et al. Racial differences in the use of revascularization procedures after coronary angiography. JAMA. 1993;269:2642-2646. Examined referral rates for cardiac revascularization among Medicare enrollees over a 10-year period

Limitations:

Investigators did not consider severity of stenosis as a potential cause of disparity in cardiac catheterization

Unable to determine whether disparity was due to underutilization of an indicated procedure in minority patients or overuse of a nonindicated study in others

After adjusting for age, sex, region, Medicaid eligibility, principal diagnosis, 6 relevant comorbid diagnoses (CHF, DM, CRF, PVD, CVD, and COPD), and hospital characteristics:
  • Significant disparities remained in rates of referral of African-American patients for cardiac revascularization
Disparities in healthcare not solely due to socioeconomic factors or access to care:
  • Future studies needed to examine effect of severity of illness
Peterson ED, Shaw LK, DeLong ER, et al. Racial variation in the use of coronary revascularization procedures. N Engl J Med. 1997;336:480-486. Examined referral rates for cardiac revascularization in Duke program from 1984 to 1992.

Limitation: no information on patient preference; hence, could not determine whether patients in this study declined bypass surgery or if bypass surgery was not offered by the provider

After adjusting for severity of disease:
  • Blacks were significantly less likely to undergo revascularization procedures

After adjusting for potential benefit of procedure:
  • Significant disparity in revascularization remained

After 5-year follow-up:
  • Disparity in revascularization rates had a negative impact on patient survival
Revascularization procedures underutilized in blacks even when a clear survival benefit was evident:
  • Future studies needed to examine effect of patient preference
Ayanian JZ, Cleary PD, Weissman JS, et al. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med. 1999;341:1661-1669. Examined effect of patient preference on referral rates for renal transplantation
  • Multiregional study across 4 regions in the United States

  • Included both for-profit, and not-for-profit facilities

  • Controlled directly for income in patient interviews
Among patients indicating a preference for receiving a renal transplantation over dialysis:
  • Significantly lower referral rates for renal transplantation were found in black patients
Patient preference did not appear to be the cause of racial disparities in rates of renal transplantation
  • Future studies needed to examine effect of clinicians' role
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999;340:618-626. Physicians viewed videotaped encounters of standardized patients of different gender and race portraying a scripted case of chest pain
  • Chest pain script the same for all patients
Among standardized patients portraying the same scripted case of chest pain:
  • African-American women were referred less often for cardiac catheterization than their white counterparts (P < .01)
Patient race and gender affect physicians' medical decision making
Weisse CS, Sorum PC, Sanders KN, Syat BL. Do gender and race affect decisions about pain management. J Gen Intern Med. 2001;16:211-217. Physicians evaluated medical vignettes with patients of different race and gender presenting with pain
  • Physicians asked to recommend pain management
  • Male physicians prescribed higher doses of pain medications to white vs black patients

  • Female physicians prescribed higher doses of pain medication to black vs white patients
Patient race and gender affect physician's medical decision making
CHF = congestive heart failure; CRF = chronic renal failure; COPD = chronic obstructive pulmonary disease; CVD = cardiovascular disease; DM = diabetes mellitus; PVD = peripheral vascular disease

As indicated by medication compliance and patient satisfaction, evidence supports that a culturally competent approach to healthcare yields positive results by improving access to, utilization of, and quality of care and disparate medical decision making.[7] Betancourt and colleagues[4] identified 3 levels at which sociocultural barriers to effective healthcare occur. Consequently, 3 levels of cultural competency interventions are needed to address these barriers[4]:

  • Clinical (provider-patient encounter): Interventions include equipping individual clinicians with the skills to effectively provide care to diverse patient populations.

  • Organizational (leadership/workforce): Interventions required involve recruiting a diverse healthcare workforce and leadership cadre that better represents the diversity of the community that it serves. For minority patients, racial concordance between patients and healthcare providers is associated with greater patient satisfaction and higher self-rated quality of care.[8] Because a diverse leadership cadre has specialized knowledge of the community it serves, it has the best potential to put systems of care (see below) in place that will optimally serve the community.

  • Structural (processes of care): Interventions involve developing processes of care that facilitate access for underrepresented communities and cultures. Examples include access to language interpretation services and setting convenient hours of service.

Using this categorization, it is possible to demonstrate culturally competent healthcare provided within organizations as well as by individual providers (Table 2).

Table 2. Demonstrating Cultural Competence Within Organizations and Interpersonal Communication

Demonstrating Cultural Competence Within Healthcare Organizations
1. Diverse workforce reflecting patient population
2. Healthcare facilities convenient to community
3. Language assistance available for patients with limited English proficiency
4. Ongoing staff training regarding delivery of culturally and linguistically appropriate services
5. Quality of care tracked across racial, ethnic, and cultural subgroups
6. Community included in setting priorities and planning, delivery, and coordination of care
 
Demonstrating Cultural Competence Within Provider-Patient Interpersonal Communication
1. Explores and respects patient beliefs, values, meaning of illness, preferences, and needs
2. Builds rapport and trust
3. Establishes common ground
4. Is aware of own biases or assumptions
5. Maintains and is able to convey unconditional positive regard
6. Is knowledgeable about different cultures
7. Is aware of health disparities and discrimination affecting minority groups
8. Effectively uses interpreter services when needed