7 Ways Cultural Competency Increases Health Equity

Why is cultural competence necessary in healthcare?

As the makeup of this country changes, cultural sensitivity and competency in healthcare should be a fundamental strategy to curb health inequities for every healthcare organization.

There’s no doubt ignorance and/or lack of acknowledgment of culture is one factor that leads to health inequities. It also contributes to other health equity considerations such as health disparities and health literacy gaps. When a practitioner considers culture, they gain the ability to make progress towards health equity more quickly.

The business case for cultural competency is strong. The Office of Minority Health published National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care.

Below are 7 reasons to “embrace cultural.” Besides being the right thing to do and make social, moral, and ethical sense, there are also financial considerations.

1. To help eliminate health disparities and achieve health equity.
2. To respond to demographic changes and reflect the diversity of the community.
3. To improve the quality of care.
4. To position your organization well in the marketplace.
5. To help meet regulatory, legislative, and accreditation mandates.
6. To decrease the risk of a liability/malpractice case.
7. To improve the cost-effectiveness of care.

1. Health inequities

Census data from 2018 shows over 67 million (nearly 22 percent of the population) people speak a language other than English at home, and the numbers continue to rise.

People with language barriers or limited English go to the doctor less and get fewer preventive services even after controlling for literacy, health status, health insurance, regular source of care, and economic conditions.

That means a patient may not get immunizations, regular checkups, and routine cancer screenings.

Cultural health inequity transcends language and ethnic differences. For example, there can be cultural differences for people of different sexual orientations.

Data indicates lesbians are less likely to get preventive cancer screenings like a mammogram or Pap test, have health insurance coverage, or have had a checkup in the past year compared to heterosexual women.

When preventive services are not done in a timely manner, chronic conditions, cancer, and other diseases may be caught late. This can lead to increased healthcare costs and different health outcomes.

There’s already a difference in health outcomes when one compares white Americans and BIPOC (Black, Indigenous peoples, and people of color) populations and white Americans. This pre-existing state of affairs will worsen if the healthcare system does not recognize the importance and get up to speed relative to gaps in provider cultural sensitivity and competency issues.

Furthermore, by the year 2030, the population is expected to increase more by international migration than natural increase related to birth rates.

According to Census data, the population of people who are two or more races is expected to be the fastest-growing racial or ethnic group for the next few decades. This year, the Federal government expects the majority of children to identify with a race other than non-Hispanic White.

Data shows health outcomes are poorer for people of color. For example, infant mortality is more than two times higher for an African American child than non-Hispanic white, and maternal mortality is 3 – 4 times greater. While infant death rates are down, the gap between black and white babies is widening.

Researchers believe an infant’s entire environment contributes to the gap and may harken back several generations due to the impact of epigenetics. According to social policy researcher, Martha Hargraves, of the University of Texas, the problem should be viewed in a medical, socio-economic, and empowerment context.

The same conditions also contribute to the gap between black and white adults for several other health conditions and causes of death. Racial and ethnic minorities shoulder a disproportionate burden of chronic illness and higher death rates for certain conditions.

The trend is clear – this nation is becoming more diverse. Is the health system ready? All signs point to a long, circuitous, and rocky road to health equity.

The longer we delay transformational change, the further behind we get in creating a system which is better for all of us. Health inequity very often reflects systemic issues that jeopardize the care of all populations and increase the likelihood of poor outcomes for all of us, not just “those people.”

2. Healthcare quality improvements

When a provider and patient have different cultural backgrounds and beliefs and perhaps speak a different primary language, it can lead to lower quality of care.

A paper in the journal, Quality Management in Health Care, points to the potential for diagnostic errors, missed screening opportunities, failure to understand and take into account varied responses to medicine, harmful drug interactions from the combined use of Western and cultural or homeopathic remedies, and the inability of the patient to follow treatment guidelines and recommendations.

There’s potential for improved healthcare outcomes when culture is front of mind in every patient interaction.

Health outcomes can improve when you have doctors who can speak the language of patients, empathize with them, relate to them, and understand their cultural beliefs.

Practitioners can also provide better care when they’re knowledgeable about disparities and understand the cultural context of a patient.

For example, non-Hispanic black women are three to four times more likely to die before, during, or after childbirth. These pregnancy-related, life-threatening complications impact black women no matter their socio-economic status. For instance, tennis superstar Serena Williams, someone obviously in tune to her body, had to advocate strenously on her behalf and demand the care needed to save her life after childbirth.

The Council on Patient Safety in Women’s Health Care and the Alliance for Innovation in Maternal Health (AIM Program) found maternal disparities can improve with cultural competency and clinician understanding of the disparity.

A woman should not have to fear death from not being taken seriously while in a care setting. There should be an understanding of potential complications and the potential for drastically different outcomes for patients of diverse backgrounds.

3. Diversity in leadership positions

When underrepresented groups are on staff, gaps in quality of care improve because there’s better context, understanding, knowledge-sharing, and sensitivity to culture, ethnicity, and race.

Healthcare organizations should aim to hire a workforce that’s representative of the community as a whole. It establishes trust, improves health equity, and lowers cost.

Diversity is important from the top down.

McKinsey and Company found overall, across all industries, gender and ethnic diversity correlated to profitability. However, such diversity is often low on executive teams.

Ten percent of graduates in the U.S. are black, yet only 4 percent hold senior executive positions. This leadership gap is also common for Latinx and Asian Americans, as well as women of all races.

Their survey shows gender, ethnic, and cultural diversity allow a company to attract the best talent, improve the customer experience and employee satisfaction, and put the organization in a better decision-making position.

Diversity from the top down is one of the best ways to improve cultural awareness in a healthcare organization and should be reflected in  the makeup of  both board members and C-suite leadership positions.

The American Hospital Association’s Diversity and Cultural Proficiency Assessment Tool for Leaders points to success stories like Northwestern Memorial Hospital. In downtown Chicago, Northwestern Memorial Hospital made diversity a priority, as those who are people of color make up 50 percent of its service area and 27 percent of patients.

In three years, they diversified senior management positions by 25 percent. Underrepresented groups are now 5 percent of the medical staff and 48 percent of the hospital workforce.

The hospital made strides by changing the culture, the look of the hospital workforce, external communications, recruitment, training, and accountability measures. Diversity initiatives are part of the entire health ecosystem, including the procurement area. They also reward employee “loyalty” to diversity.

4. Improve your market positioning

Fourth, cultural sensitivity positions your business organization well in the marketplace for today and tomorrow. With changing demographics well documented and expected to continue to trend upward, the healthcare system needs to adapt and more accurately reflect the changing demographics of many communities.

The National Center for Cultural Competence indicates that delivery systems that focus on culture can help recruitment, and retention, and as well as improve both patient access to care as well as patient satisfaction. When an organization is seen as a leader in the community and markets itself as such, it’s positioned well for the future.

Contra Costa Health Services in California created a Remote Video/Voice Medical Interpretation program. Soon after implementation, they served twice as many patients and for significantly lower costs.

The Georgetown University Health Policy Institute points to studies showing African Americans and other underrepresented groups report lower satisfaction with care. African Americans, Latinos, and Asian Americans are more likely than Whites to believe their care would be better if their ethnicity or race differed.

Without patient satisfaction and community trust, a healthcare organization may not be the provider of choice for many patients. The entire healthcare journey needs to be considered – from proactive community outreach and collaboration to an empathic, comprehensive, coordinated approach to care plus adequate access to follow-up and preventive care, in addition to treatment of acute and chronic conditions.

Community health centers can bridge this gap and prove impactful in neighborhoods throughout a city. Staff should represent the makeup of that neighborhood. And rural areas present their own challenges, including access to care, broadband coverage to enable digital delivery methodologies, and lack of coverage or insufficient health insurance coverage, especially if located in a state which did not take advantage of an opportunity to expand Medicaid.

Minorities are underrepresented in healthcare. It’s shown that when doctors and patients have the same racial or ethnic background, patient trust and satisfaction often improve.

5. Regulatory guidelines

Next, legislative, regulatory, and accreditation mandates are always changing and evolving. The Affordable Care Act (ACA) addresses cultural and linguistically appropriate services.

There are guidelines to follow for those who serve Medicare and Medicaid patients, as well as legislation such as Title VI of the 1964 Civil Rights Act. It lays the foundation for regulatory compliance, stating that nobody should be excluded, denied benefits, or subject to discrimination under programs or activities that get financial assistance from the Federal government.

6. Healthcare lawsuits

A study in the Journal of the American Medical Association found patients who frequently sue complained most about communication. Doctors who were never sued were described as concerned, accessible, and willing to communicate.

If there’s a cultural difference, and communication suffers, the risk of a problem or misunderstanding increases substantially.

The Office of Minority Health highlights a cultural competence healthcare example. A first responder in Florida misinterpreted the word “intoxicado” in its Blueprint for Advancing and Sustaining CLAS Policy and Practice. The first responder thought it meant “intoxicated.” However, it means “feeling sick to the stomach.”

This language barrier and misunderstanding led to a delay in diagnosing the patient and a potentially preventable case of quadriplegia. It led to a $71 million malpractice ruling.

In the same report, the Office of Minority Health reported the HHS Health Resources and Service Administration (HRSA) also found practitioners can be liable under tort principles for lack of cultural and linguistic competency. The provider can be presumed negligent if the patient can’t follow guidelines because they conflict with their beliefs, and the provider didn’t identify or accommodate those beliefs.

If the clinician treats the patient based on miscommunication, the healthcare organization may face increased civil liability because they didn’t provide a needed interpreter.

7. Cost of care

Next, the cost-effectiveness of treatment goes up when the cultural competence of the healthcare system increases.

The authors of Quality Management in Health Care point out the association between language barriers and higher diagnostic test rates. Doctors order more tests when there’s a communication issue. Professional interpreters (not family translators) can help ease this healthcare cost.