America is becoming more diverse each year. The U.S. Census projects by 2060, the foreign-born population will exceed levels not seen since 1890. It has always been the case that having respect for and a real understanding of a patient as a whole person, as well as his/her culture, results in a better patient-physician relationship imbued with trust, an experience which includes shared decision-making which leads to greater adherence to a care plan, and better health outcomes. And studies have shown the negative impact of care delivered without cultural sensitivity, competency, and humility (“CCH”), especially for those with chronic conditions.
Culture, competency, and humility (CCH)
Achieving CCH is challenging at both the individual practitioner and health system levels. It requires intentional and recurring education and training. It is not a one-and-done, especially given the topics may not have ever been mentioned during medical education and clinical training programs.
Difficult though it may be, it is more important than ever as the population evolves and becomes more engaged consumers of health-care, as care becomes more complicated and technology-dependent, and as the world becomes more racially, ethnically, and gender diverse and, in the U.S., as the “majority” population becomes less so as time passes.
As reimbursement methodologies evolve to an increasingly value-based approach, CCH will be critical to attaining quality, cost-effective care. CCH and the other elements of health equity – health (il)literacy, health disparities, and social determinants of health (SDOH) – are key factors to be addressed if one’s goal is outstanding health outcomes and sustainable patient activation.
Culture impacts one’s beliefs, behaviors, and values. There may be culturally different values, practices, customs, styles of communication, interactions, and roles and relationships.
What is culture?
The Office of Minority Health defines culture as “the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics. Culture is dynamic, and individuals may identify with multiple cultures over the course of their lifetimes.”
Cultural elements include, but are not limited to:
- Cognitive ability or limitations
- Country of origin
- Degree of acculturation
- Family and household composition
- Gender identity
- Health practices, including the use of traditional healer techniques.
- Military affiliation
- Occupational group
- Perception of family and community
- Perception of health and well-being and related practices
- Perceptions/beliefs regarding nutrition
- Physical abilities or limitations
- Political beliefs
- Racial or ethnic group
- Religions and spiritual beliefs, traditions, and practices
- Sexual orientation
- Socio-economic status
As this country becomes more diverse, culture becomes an even more critical consideration for every patient interaction.
What is cultural competence?
This is a problem for the practitioner and health system to fix, not the patient.
Any one of these cultural elements can influence healthcare decisions by the patient and the provider.
For example, culture may impact:
- when a patient seeks care
- access to care
- treatment options
- health beliefs and health practices
These cultural factors may impact a person’s ability to identify symptoms of an illness, the point at which a person gets care, expectations of that treatment, and the ability to understand the treatment.
Cultural competency is the ability of healthcare providers to function effectively, even when there are cultural differences. By addressing this need, an organization breaks down communication barriers to ensure the patient achieves the best possible health outcomes. However, many sectors of the healthcare system struggle with cultural competence.
In the U.S., without a diverse staff or a practice setup to provide care for patients who are not fluent in English, a practitioner may be even less able to relate to the patient who does not look like him or her. A lack of curiosity, thirst for knowledge, lifelong learning, and respect for others and resistance to the possibility of more than one way to deliver care and treat patients, and poor listening and communication skills can result not only in poor quality care but actual threat to life and limb.
Bias, stereotypes, prejudice, the “isms” – racism, sexism – and their kin – homophobia, xenophobia, misogyny, and religious intolerance – may drive decisions in the diagnosis and treatment of the patient. These behaviors and thought systems can lead to patient distrust, malpractice, and can cost lives.
The National Center for Cultural Competence points out it’s difficult for healthcare providers to acknowledge and accept their biases and their differential treatment of patients because their job is to help others. So, these biases are often minimized, avoided, and sometimes rejected. However, unconscious (and explicit) bias exists.
Interventions and resources can prove helpful in recognizing and changing practitioner behavior, so health equity is a priority.
When patient-centered care is truly the focus, a patient’s individual life experiences and overall healthcare journey are a priority. It’s more than just collecting data to identify social determinants of health (SDOH). Cultural humility requires a practitioner to be open-minded about someone else’s cultural beliefs. The Robert Wood Johnson Foundation advises that cultural humility requires practitioners to look beyond their frame of reference and acknowledge the patient has both agency and authority over their own experiences.
Once again, this may be challenging for healthcare providers because it requires accepting the reality of unconscious (and sometimes not so unconscious) bias. With cultural competency, a provider is respectful and responsive to different beliefs.
Doctors are treating patients, not just their disease. They have an identity, a background, and an existence outside the doctor’s office. Certain aspects of their lives impact their interest in treatment, the type of treatment they may prefer or the one that may be the best fit for all they are, including the practicalities of the day-to-day, the degree of understanding of the risks and benefits of a given recommendation or set of options, and both acceptance of as well as adherence to a treatment plan, just to name a few.
The authors of “Cultural humility: treating the patient, not the illness” point out that humility is an ongoing process. It requires self-reflection and self-critique. It’s not just their culture that influences them, but their individual beliefs. Once again, this may be challenging for healthcare providers because cultural humility requires accepting the reality of unconscious (and sometimes not so unconscious) bias. Cultural humility is a prerequisite to cultural competency. It means a provider is respectful and responsive to different beliefs and takes steps to make accommodations unless they would result in unsound or ineffective medical practices.
These outside factors, concerns, and beliefs can impact the prognosis and effectiveness of treatment. Having the humility to understand their role in patient care can change both healthcare experiences and outcomes.
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.
- To help eliminate health disparities and achieve health equity.
- To respond to demographic changes and reflect the diversity of the community.
- To improve the quality of care.
- To position your organization well in the marketplace.
- To help meet regulatory, legislative, and accreditation mandates.
- To decrease the risk of a liability/malpractice case.
- 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.
Cultural sensitivity, competence, and humility build trust, which in turn increases the likelihood of delivery of preventive care services, which can catch diseases earlier and reduce long-term costs.
Strategies for cultural competence in healthcare
You have to start somewhere. If diversity and cultural sensitivity are not an embedded part of your strategy now, it needs to be incorporated immediately.
The American Hospital Association’s Diversity and Cultural Proficiency Assessment Tool for Leaders helps organizations evaluate ensure cultural proficiency and that you’re as diverse as the community you serve.
This can help health systems assess where they are and where they need to go as an organization.
There are several areas to focus:
- A diverse workforce from the top-down that reflects the community it serves.
- Interpreter services available for patients for all healthcare-related interactions, whether in-person or on the phone.
- Making all written communications available in multiple languages.
- Understanding of socioeconomic conditions within the community.
- Work with traditional healers.
- Community health centers that make healthcare more accessible, improve patient satisfaction, and holistically address patient needs.
- Collect meaningful data and analyze it to identify medical errors and health inequities in care due to culture or literacy.
- Training staff to identify unconscious and other biases and providing training tools.
- An organizational cultural shift that focuses on the person, not the disease.
For a detailed blueprint, adapt a “Think Cultural Health” mentality and implement the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
What is your organization doing to improve cultural competency?
As a physician, healthcare executive at a Fortune 100 company, and integrative health practitioner, Z. Colette Edwards, MD, MBA knows the unique value of a holistic, whole-person approach to health and well-being. She also understands the challenges health inequities can present. Known as “The Insight Doctor,” she offers guidance and powerful tools that prepare your body, mind, and spirit for menopause, stress, and inflammatory bowel disease. Lastly, Dr. Edwards coaches individuals in the development of self-advocacy and health system navigation skills.