Building cultural competency

By Wayne Wenske, Senior Marketing Coordinator, and Cassidy Penn, M.Ed.

Editor’s note: the definition of “minority group” used in this article is consistent with that of the U.S. Office of Management and Budget (OMB - 15 Directive) and includes American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, and Native Hawaiian or other Pacific Islander.

In 2015, the U.S. Census Bureau released a report that analyzed the nation’s population looking toward the year 2060. Details in this report, named “Projections of the Size and Composition of the U.S. Population: 2014 to 2060,” include the following:

• The U.S. population is expected to grow from 310 million in 2014 to 400 million in 2051 and 417 million in 2060.
• By 2020, more than half of all children are expected to be part of a minority race or ethnic group.
• The minority population is projected to rise to 56 percent of the total in 2060, compared with 38 percent in 2014.
• By 2044, the US is projected to become a plurality nation. Meaning, no race or ethnic group is projected to have greater than a 50 percent share of the nation’s total.¹

What does this mean for health care? These statistics suggest that health care professionals will increasingly need to recognize and work with cultural differences to deliver quality health care. This ability is often referred to as “cultural competency.”

This article will introduce the concepts of cultural competency and health disparities and biases that may come from treating patients of different backgrounds. Also discussed will be methods to help you improve the cultural competency of your practice. 

What is cultural competency?

According to a 2002 report by the Commonwealth Fund, cultural competency in health care “describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or English proficiency.”²

The U.S. Department of Health and Human Services (HHS) defines cultural competency as “the level of knowledge-based skills required to provide effective clinical care to patients from a particular ethnic or racial group.” However, religion, age, generation, economic class, disability, gender, sexual orientation, and other traits may also define a cultural identity.³

The Association of American Medical Colleges (AAMC) further defines cultural competency as a “set of congruent behaviors, knowledge, attitudes, and policies” that come together to enable effective work in cross-cultural situations. “Culture” is defined by the AAMC as “integrated patterns of human behavior,” including language, customs, beliefs, and institutions of racial, ethnic, social or religious groups, while “‘competence’ implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities.”⁴

Battling cultural bias

Cultural competency is not merely about being respectful of a person’s cultural background, religious beliefs, or language proficiency, it is also about ensuring that cultural bias does not affect your personal interactions.

Having a cultural bias is assuming that one’s own culture is accepted as “normal” and shared by everyone. For example, a cultural bias may be that Americans typically eat such foods as eggs, bacon, cereal, and toast for breakfast. But what about the people in America who eat noodles for breakfast? Or tortillas? Or hummus? Or any of the other myriad foods eaten for breakfast all over the world? Are they not normal?

Awareness of cultural differences can go a long way toward battling cultural bias. In the health care environment, cultural biases can lead to poor communication, a lack of understanding, and patients withdrawing from their physicians. Even worse, cultural bias can also lead to incorrect diagnosis and treatment, and lack of continuity of care. On the other hand, patients who feel their doctor is respectful of their background are more likely to be compliant with treatment.

Some of the following scenarios can be the result of cultural bias:

• Patients may avoid seeking medical treatment for fear of being misunderstood or having their beliefs disrespected.
• The physician’s lack of knowledge about cultural home remedies may lead to harmful drug interactions.
• Not providing translation services can lead to poor communication between patient and provider, leading to missed symptoms and possible wrong diagnosis. 
• Language barriers can limit patient understanding of treatment plans.
• Providers who are not familiar with the unique health concerns among various minority groups may miss opportunities for screening and diagnosis.

Take action to build a more culturally competent practice

What can you do to make your practice more culturally competent? The National Institutes of Health (NIH) has published a list of National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards). These standards are intended to “advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health care organizations to implement culturally and linguistically appropriate services.” The NIH further states that “adoption of these Standards will help advance better health and health care in the United States.” ⁵

See the sidebar (at the end of this article) to read the NAS standards.

Consider taking the following actions to increase the cultural competency of your practice:

• Provide interpreter services for patients who are hearing disabled. This is required of all medical practices and hospitals per the Americans with Disabilities Act (ADA). According to the ADA, physicians are required to make auxiliary aids and services available to the disabled, including qualified interpreters for the hearing impaired.⁷ Create a list of interpreter or translation services in your area, and explore partnerships with other health care professionals.²
• Begin by being more formal with patients born in another culture. Culture often determines roles for polite, caring behavior ²
• Do not be insulted if the patient does not look you in the eye or ask questions.²
• Recruit and maintain bilingual staff members who are fluent in the language most appropriate to your patients. Advertise job opportunities in targeted foreign language and minority health professional association job boards and other media.⁸
• Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials.
• Provide staff training to increase cultural awareness, knowledge, and skills. Engage staff in dialogue about meeting the needs of diverse populations. Provide opportunities for CLAS training, including regular in-services, brown bag lunch series, and orientation materials for new employees.⁷
• Include family and community members in health care decision making. In many cultures, medical decisions are made by the immediate or extended family.²

Respecting cultural attitudes towards modesty

A key tip to remember when treating any patient, especially a patient of faith, is to respect the patient’s modesty. Knock before entering a room and wait for verbal confirmation to enter.

If you are a male doctor treating a Muslim female, offer to have her husband present or a female staff member. If a hospital gown is required for examination, provide one that is long, secures completely in both front and back and has long sleeves. If this cannot be provided, offer for the patient to use his or her own gown.  It is also a sign of respect to limit direct eye contact and to not touch the person while speaking and never without cause and explanation.

Conclusion

Cultural competency in health care practice should not be viewed as an inconvenience or added effort to an already busy practice. Small, specific actions can be applied to every patient, to show your understanding and sensitivity to patients of different cultures. Ensuring that your patient’s individual cultural or religious beliefs are respected and valued will go a long way toward building trust. Greater trust and communication have demonstrated better health outcomes, diagnoses, and patient compliance to treatment—all of which will reduce possible exposure to risk. 

Additional resources

Read more about cultural competency at the following websites:

• National Center for Cultural Competence: http://nccc.georgetown.edu
• Religious Beliefs and Healthcare Decisions: http://www.advocatehealth.com/beliefs
• U.S. Department of Health & Human Services, A Physician’s Practical Guide to Culturally Competent Care: https://cccm.thinkculturalhealth.hhs.gov

Sidebar: National CLAS Standards

Principal Standard

1) Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce

2) Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.

3) Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

4) Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance

5) Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

6) Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally, and in writing.

7) Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

8) Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability

9) Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.

10) Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.

11) Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

12) Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

13) Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

14) Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

15) Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.⁶

Sources:

¹ Colby, Sandra L. and Ortman, Jennifer M., Projections of the Size and Composition of the U.S. Population: 2014 to 2060. United States Census Bureau. U.S. Department of Commerce. Issued March 2015. Available at  http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf. Accessed July 19, 2016.

² Betancourt, Joseph R., et al. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. The Commonwealth Fund. October 2002. Available at http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf. Accessed August 2, 2016.

³ U.S. Department of Health and Human Services. Health Resources and Services Administration, Bureau of Health Professions. Definitions of Cultural Competence. Curricula Enhancement Module Series. National Center for Cultural Competence, Center for Child and Human Development, Georgetown University. Available at http://www.nccccurricula.info/culturalcompetence.html. Accessed August 2, 20016.

⁴

Cultural Competence Education. Association of American Medical Colleges. Available at https://www.aamc.org/download/54338/data/. Accessed July 18, 2016.

⁵ Cultural Respect. National Institutes of Health, U.S. Department of Health & Human Services. Available at https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect. Accessed July 19, 2016.

⁶ National CLAS Standards. Office of Minority Health, U.S. Department of Health and Human Service. Updated June 17, 2016. Available at: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53. Accessed July 19, 2016.

⁷ Treating and accommodating patients under the Americans with Disabilities Act, part one. The Reporter, TMLT, 2016. Available at http://resources.tmlt.org.s3.amazonaws.com/PDFs/Reporter/2016_Quarter_2.pdf. Accessed July 19, 2016.

⁸ National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Office of Minority Health, U.S. Department of Health & Human Services. April 2013. Available at https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf. Accessed July 19, 2016.

This article was originally published in the Reporter Quarter 3 2016.