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Internet Citation: Research Protocol: Improving Cultural Competence to Reduce Health Disparities for Priority Populations. Content last reviewed December 2019. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
Social determinants of health, such as working and living conditions and quality healthcare access, aren’t the same for everyone. Health inequities pose a serious challenge to the healthcare community, but healthcare providers have a powerful tool at their disposal: cultural competence. Cultural competence in health care addresses the disparities that people of racially and culturally diverse backgrounds often experience. It can ensure all patients get the care they need to live healthier lives. What Is Cultural Competence in Health Care?Cultural competence in health care means delivering effective, quality care to patients who have diverse beliefs, attitudes, values, and behaviors. This practice requires systems that can personalize health care according to cultural and linguistic differences. It also requires understanding the potential impact that cultural differences can have on healthcare delivery. For example, race, socioeconomics, health literacy, and other factors can influence:
While cultural competence in health care initially referred to meeting the needs of people from distinctive ethnic and racial groups, it now also refers to meeting the needs of people with disabilities, those from diverse socioeconomic backgrounds, and members of the LGBTQ community. The Need for Cultural Competence in Health CareDifferences between healthcare providers and patients can affect communication. This can, in turn, impact both clinicians’ and patients’ decisions with regard to treatment. For example, a clinician may misinterpret a patient’s silence as a lack of interest in receiving care. As a result, the clinician may not order a diagnostic test, when in fact the patient’s response reflected their notion of respectful behavior. When healthcare providers fail to recognize the differences between them and their patients, they may inadvertently deliver lower-quality care. Cultivating skills that improve cross-cultural communication can play an important role in delivering equitable care. Additionally, building teams with healthcare professionals who reflect the diversity of the patient populations served can also improve cross-cultural communication. Diverse teams have a wider cultural knowledge base that they can share with one another. This makes them likely to respond with empathy to the unique cultural needs of patients. Language accessibility is also key. Language barriers keep patients from accurately describing their symptoms and providers from explaining diagnoses. Language barriers can also create unsafe and inappropriate situations in other ways. For instance, clinicians may rely on children to serve as interpreters, putting young people in the position of telling a parent they have cancer. As another example, clinicians may rely on abusive spouses to interpret for their battered partners. Both situations pose significant problems. Combining Cultural Competence with Cultural HumilityHealthcare providers strive to develop a multicultural orientation to deliver culturally sensitive care and improve communication. However, even when healthcare professionals have a meaningful understanding of a culture, they still can’t predict the behaviors and attitudes of their patients simply based on their cultural backgrounds. That’s because people are unique, and their behavior and beliefs might not always reflect those of their cultures. Given this, healthcare professionals must focus on building cultural competence and cultural humility. Cultural humility recognizes the limits of people’s knowledge of others. It also acknowledges that even people who have cultivated their cultural awareness can still have unintentional, unconscious biases about cultures other than their own. Cultural humility involves an ongoing process of self-evaluation. Through exploration of and reflecting on their own beliefs and behaviors, healthcare professionals can improve their awareness of implicit biases and foster an approach to patients characterized by openness and curiosity about each new patient. Goals of Cultural Competence in Health CareCultural competence aims to break down barriers that get in the way of patients’ receiving the care they need. It also strives to ensure improved understanding between patients and their providers. The growing diversity in the U.S. population demands that the healthcare community expand its ability to address patient needs. Cultural competence offers a pathway and a framework to reach the goal of better health for all patients. Culturally and linguistically appropriate services, or CLAS, respond to individual preferences and needs of each patient. They also help improve health outcomes and decrease health disparities. According to the U.S. Department of Health and Human Services Office of Minority Health, the principal standard of CLAS involves delivering equitable care that is:
Importance of Cultural Competence in Health CareCultural competence significantly benefits healthcare organizations and patients alike. It results in more patient participation and engagement, fostering respect and improved understanding, which can lead to:
Improved Patient OutcomesCultural competence improves communication, which keeps patients safer. Clear communication allows healthcare providers to collect accurate medical information. It also encourages active dialogues in which patients and providers can ask questions, correct misunderstandings, and build trust. Studies have shown that the absence of culturally competent care can lead to preventable mistakes and adverse events. For example, a recent study in Hospital Pediatrics that examined patient safety in hospitals across the U.S. suggests that patients lacking English language proficiency experience more adverse safety events during hospitalization than fluent English language speakers. The events they experience tend to be more severe as well. Examples of Improved Patient OutcomesOn the flip side, the use of culturally competent strategies can lead to marked improvements in health outcomes. A Plos One study reviewing culturally competent strategies found numerous examples of interventions that made noteworthy differences. For example, after a medical center introduced a bilingual Russian internist to help resolve language barriers, Russian-speaking patients with diabetes experienced significant reductions in their blood pressure and cholesterol. In another example, an in-patient psychiatric unit that incorporated Spanish language proverbs into therapy sessions found increased participation, improved motivation, and greater willingness to explore emotional topics among Spanish-speaking patients. Improved Patient ExperiencesHealthcare environments that show an awareness of and respect for differences create more satisfying experiences for patients. When providers adjust treatments to meet patient needs and preferences, patients notice, and their overall experience improves. The Plos One review found that Black men rated providers’ behaviors and attitudes significantly higher after the clinic gave its providers cultural competence training. Another recent study published in the Journal of Sport Rehabilitation found cultural competence positively affects how patients experience health care. In addition to raising patient satisfaction, it increases the likelihood that patients will follow medical advice. The more culturally competent patients find their providers to be, the better their experiences. The study also indicated that patients treated by providers who could speak their language felt more satisfied as well. If a healthcare provider uses medical jargon unfamiliar to a patient or makes assumptions about a patient because they use public health insurance, the patient may likely feel frustrated. Conversely, if clinicians show nonjudgmental openness in response to differences, actively listen, and make efforts to verify patients have understood them, their patients are more likely to feel satisfied with their care. Examples of Cultural Competence in Health CareThe following examples of cultural competence in health care illustrate ways that healthcare organizations address cultural differences when providing care even when obstacles and differences in perspectives exist. Consider the following situations: A pregnant farm laborer from Mexico arrives at an emergency room in medical distress. Doctors discover the patient’s placenta has separated from the uterine wall, making an urgent C-section necessary. The patient responds “yes” to all questions, though it appears they have little understanding. After the C-section, doctors admit the newborn to the NICU because the baby is premature and has respiratory distress syndrome. The patient, their husband, and their mother, all indigenous, speak only a smattering of Spanish and no English. Spanish-speaking staff members try to get a clear history about the mother and explain the baby’s condition to the family, but communication is a challenge. As the baby’s condition becomes tenuous, the family wants to bring in a traditional healer to cleanse the baby of its illness. Culturally Competent ResponsesIn this case, delivering culturally competent care requires securing an interpreter who speaks the patient’s native language. Only then can the healthcare providers take a thorough medical history of the patient, learn about potential exposure to pesticides through their work, and give the patient the opportunity to fully understand the medical conditions of both the mother and the baby. Additionally, with an interpreter in place, healthcare providers can explain their medical perspective and engage the patient and their family in a conversation to understand their cultural perspectives and preferences in receiving care. Such a conversation gives the family a chance to express its desire to bring a traditional healer, as well as any other desires or concerns. Once the medical team has better information and back-and-forth communication, it can recommend culturally appropriate care and negotiate a plan of action that everyone agrees on. Adapting to a New Patient PopulationA local hospital experiences an influx of ultra-orthodox Jewish patients as a newly established Hasidic community nearby grows. The hospital staff has little knowledge of the customs or traditions of this growing segment of the facility’s patient population. However, the staff has already encountered:
Culturally Competent ResponsesThe hospital invites representatives from the Hasidic community to meet with administrators and staff members to openly discuss traditions and customs potentially relevant to their health care. The hospital also asks the community representatives to explain their community’s specific needs. In this way, the hospital gets ideas and suggestions about established solutions the community already has for dealing with customs, such as not using electricity on Shabbat. The hospital also learns of other customs, such as no physical contact between members of different genders. Based on the conversations, the hospital proposes policies and procedures that can better serve the needs of the Hasidic patient population. It then discusses those policies and procedures with the community representatives to ensure the proposals are appropriate. Respecting a Patient’s ChoicesA severely ill 80-year-old patient learns that one of their heart valves has stopped working. To survive, they need surgery to replace the valve. The patient has a history of excessive bleeding. This will require doctors to perform blood transfusions during the surgery. The patient is a devout Jehovah’s Witness. According to their religious beliefs and interpretations, the Bible does not allow any type of blood transfusion, so the patient refuses the surgery. Culturally Competent ResponsesThe patient’s medical team engages the patient, their family, and trusted members within the patient’s religious community in discussions about the nature of the surgery and the risk that the patient might not survive without it. After the patient gets all the information and seems to understand all the risks, the medical team respects their choice to forgo the operation. To meet the needs of all patients, organizations must learn how to improve cultural competence in health care. They can begin by implementing strategies that develop and improve cultural competence among healthcare teams. Promoting awareness and education plays a key role in improving cultural competence in health care. To develop cultural competence, healthcare professionals need to identify their beliefs and build an awareness of their culture. This gives them a basis to improve their cross-cultural awareness. Cross-cultural awareness makes healthcare providers more open to unfamiliar attitudes, practices, or behaviors. It also improves collaboration with patients and helps them respond with flexibility. Benefits of cross-cultural awareness include:
How can healthcare organizations best promote the cross-cultural awareness and other skills needed for culturally competent health care? Cultural Competence TrainingCultural competence training teaches healthcare providers intercultural communication skills and helps trainees respond to cultural differences with greater agility. Additionally, cultural competence training can help organizations uncover organizational policies or practices that act as barriers to different communities. Then, they can adjust them to ensure they meet the needs of diverse patients. Accessibility Leads to Improved Cultural Competence in Health CareCultural competence in health care demands accessibility. Accessibility means ensuring that language, culture, race, and other such factors don’t become barriers to patients’ receiving quality care. How can healthcare organizations make health care more accessible? Build Knowledge About the Local CommunityHealthcare organizations should learn about the populations they serve. Collecting and analyzing demographic data and sending targeted surveys to specific communities builds important knowledge about local communities, which puts them in a much better position to meet patient needs and ensure accessibility. In this way, a hospital may learn it needs interpreters in Korean or Farsi, or it may discover a large segment of the population requires Halal dietary options for hospital stays. Surveys and community engagement can uncover other key information that enables healthcare organizations to become more accessible. For instance, community engagement may clarify the need for staff members familiar with Nepalese culture or the need to bolster a diabetes outreach program. Recruit and Retain Diverse Team MembersRecruiting and retaining team members who accurately reflect the populations they serve gives healthcare organizations a clear advantage in their efforts to deliver culturally competent health care. When patients encounter team members who look like them, speak their language, and share their culture, they tend to feel more welcome. Healthcare providers who share cultural similarities with their patients often have a greater capacity to communicate with them, understand their perspectives, and anticipate their needs. Diverse team members can also share their insights with their colleagues, deepening everyone’s capacity to deliver culturally competent care. Barriers to Cultural Competence in Health CarePromoting cultural competence can present challenges. Some of the barriers to cultural competence in health care include: Adequate Knowledge of an Organization’s Cultural CompetenceTo successfully address cultural competence, healthcare organizations need to first gauge their current performance. This involves answering questions such as:
Without knowing where disparities exist, leadership can’t properly channel its energy and resources. As such, healthcare organizations that value cultural competence must collect data about their patients’ races, language preferences, sexual orientations, ethnicities, etc., as well as track disparities. Patient surveys can also offer insight into an organization’s level of cultural competence. With the right information, healthcare organizations can target areas to improve. As an example, data might reveal an organization serves a larger number of patients from the LGBTQ community than previously realized. This gives leadership the opportunity to make sure it has enough healthcare providers with specialized knowledge in LGBTQ health care. Putting Cultural Competence Into ActionTo put cultural competence into action, healthcare organizations must create an institutional framework that:
Cultural competence demands an ongoing commitment and multipronged approach. Healthcare organizations must build an infrastructure that supports activities and protocols that ensure culturally competent practices. Additionally, organizations must weather pushback from staff members who may perceive cultural competence as limited to racial and ethnic diversity and already consider themselves culturally competent. In such cases, healthcare organizations can implement educational programs that broaden definitions of cultural competence. Limited Resources to Support Cultural CompetenceRealizing cultural competence in health care takes resources. Organizations must invest time, money, and leadership into developing the infrastructure required to make cultural competence more than just a value. This means budgeting for, among other things:
Though prioritizing cultural competence comes with a price tag, it ultimately offers an essential return on investment. Healthcare administrators have an instrumental role to play in promoting cultural competence in health care. Their expert knowledge in organizational behavior, financial management, and information systems and analysis empowers them to build the infrastructures needed to support culturally competent systems. Explore how Tulane University’s Online Master of Health Administration equips graduates with the skills needed to develop culturally competent systems capable of meeting the needs of diverse communities. SourcesAgency for Healthcare Research and Quality, “Cultural Competence and Patient Safety” American Hospital Association, “Becoming a Culturally Competent HealthCare Organization” County Health Rankings, “Cultural Competence Training for Health Care Professionals” Every Nurse, “Seven Steps to Become a More Culturally Sensitive Nurse” Focus, “Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients” Harvard Public Health Review, “The Importance of Effective Communication in Healthcare Practice” Hospital Pediatrics, “Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children” Journal of Sport Rehabilitation, “Does Having a Culturally Competent Health Care Provider Affect the Patients’ Experience or Satisfaction? A Critically Appraised Topic” Med City News, “The Need for Cultural Competence in Healthcare” Minority Nurse, “5 Ways to Improve Cultural Competence in Nursing Care” Plos One, “Culturally Competent Healthcare –A Scoping Review of Strategies Implemented in Healthcare Organizations and a Model of Culturally Competent Healthcare Provision” Quality Interactions, “Cultural Awareness in Healthcare: A Checklist” The Society for Diversity, “Benefits of Having Cultural Diversity in a Healthcare Organization” U.S. Department of Health and Human Services, The National CLAS Standards U.S. Department of Health and Human Services, National Culturally and Linguistically Appropriate Services Standards U.S. Department of Health and Human Services, What Is CLAS? |
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