Culture defines us.1 Although our genetic makeup, which is largely nonmodifiable and affects our physical state of being, social determinants of health are also of great influence. Determinants of health describe the factors that affect the health of individuals. At the core of each person are their inherited traits as well as the choices that they make about their lifestyles (eg, diet, exercise, leisure activities). Their health is further marked by their exposure to healthy or risky behaviors based on the places where they live, work, worship, or go during the day and their built environment (eg, sidewalks, exposure to clean air, policies for healthy choices).2 Basically, our socioeconomic status, race and ethnicity, gender, age, and communities (environments), as part of our cultures, shape us.3
Consider the following brief descriptions of three individuals and the determinants of health that influence them. Patient 1 is a 42-year-old bilingual Vietnamese American, Buddhist woman living on the West Coast whose family immigrated to the United States 35 years ago. Her lifestyle choices include a vegetarian diet, gardening, and daily meditation. She lives in a suburban community with her husband and three children, drives a hybrid electric/gas car to her work as a school teacher, and purchases food from a local farmer’s market. She has health insurance and her city public policy includes no indoor smoking in public places and state policies include special low-emission requirements on vehicles. Weekend activities with the family include sports and dance for the kids along with others from the community center that serves a number of Asian-American families.
Patient 2 is a 27-year-old single African American, Muslim upper-middle-class man living in a major city in the Eastern Coast of the United States. Having just finished his graduate school degree, he lives in a high-rise apartment and walks or rides the subway to his work at a major corporation. In his leisure time, he enjoys reading and going to major sporting events with his college friends who come from diverse backgrounds. During the week, he also frequents the local mosque and community events that are supported by his neighborhood.
Patient 3 is a 55-year-old European American, Protestant middle class man living in the Midwest. His family moved from the rural South 2 years ago for a new full-time job. Due to recent economic changes in the community, he now has to work three part-time jobs (two in food industry and one in construction) so that he can help support his wife who is undergoing breast cancer treatment. As a result of his high work demands, he is not able to shop for groceries or exercise and so the couple often eats away from the home or they prepare quick and processed meals at home. He notices that he has gained about 10 pounds (4.5 kg) in the past 6 months and has difficulty sleeping. The family also has not had time to connect with their church or other friends due to his work and doctor appointments for his wife.
Can healthcare professionals assume that these three patients have the same healthcare beliefs, values, and approach to healthcare? While each of the patients described above will have a unique health situation, social determinants will influence their exposure to healthy conditions and their cultural backgrounds will also shape their health beliefs and behaviors.4
What is culture? Culture can be defined as “the learned and shared beliefs, feelings, and knowledge that individuals and/or groups use to guide their behavior and define their reality as they interact with the world.”5,6,7 However, to interact more effectively with individuals from different cultural backgrounds, providers should develop cultural and linguistic competencies.
Social Determinants of Health.
Cultural competency may be described as the attitudes, knowledge, skills, and values that an individual has and uses in working effectively in a cross-cultural environment.8,9 At an organizational level, cultural competency can be demonstrated by an organization having a defined set of values and principles (mission), policies, and structures for service delivery that incorporate community input and enable individuals in the organization to work effectively within cultures and cross-culturally.8,10
Linguistic competency is linked to cultural competency. It describes the “capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences” (eg, persons of limited English proficiency [LEP], those who have low literacy skills, individuals with different hearing or sight abilities).10
The environments we live in—our communities—also define our health.3,4,11 Research suggests that while we should address health at the individual level, providers and policymakers must also understand and address healthcare at the community and population level.12,13 But what creates a community? Communities may be defined as organized groups of people with a shared identity that may exist around racial and ethnic groups, socioeconomic position, religion, age, gender, language, as well as other cultural ties.14 Communities can also cut across these variables. Community competency encompasses cultural competency; however, it also recognizes the unique role of communities as a type of culture.14 Within a community competency framework, clinicians will understand that at the core of a community are history, context, geography, and culture.14 For example, given similar socioeconomic and educational backgrounds, an adolescent male raised in Chicago, Illinois, whose family is from Puerto Rico would have a different life experience (ie, a different community or environmental influence) than an adolescent male of a similar family background being raised in Greenville, South Carolina.
History helps describe the collective consciousness of a community. For example, a community’s recent history may include the devastation of a flood or tornado. Political history can affect a refugee population’s experience and the history of slavery in the United States affects multiple communities. The history of a community is not always considered in social determinants of health models, but understanding the history can enhance evaluating the social determinants of health. Context acknowledges the present situation of a community such as the quality of education, housing, or healthcare. Geography helps to distinguish differences between a male of Islamic religion and Somali descent who is raised in Philadelphia, Pennsylvania, from one who is raised in St. Paul, Minnesota.
What is the difference between cultural and community competency? Cultural competency helps clinicians understand the individual; thus, “culturally competent care can be considered patient-centered care.”14,15 Community competency provides a broader context for clinicians to work with individuals and families, as it incorporates the influence of the population and environment on the individual. Although this chapter focuses on cultural competency and care of individuals, acknowledging the influence of community on individuals is significant.
Healthcare providers should strive toward cultural competency in the context of social determinants of health and community history to improve care and access unique resources for patients and communities from diverse cultures and backgrounds. This skill is increasingly important to healthcare practice as our society becomes more and more diverse. The healthcare provider tries to negotiate an approach to treatment that is respectful of patient beliefs, while integrating an effective course of therapy in a manner consistent with the patient’s beliefs and understanding. This approach does not devalue the patient’s cultural and community beliefs. As a result, better treatment adherence can occur.16,17 The negotiation between provider and patient is the art of patient care and is a skill that requires continual practice.
A culturally competent approach to care incorporates—at all levels—the importance of culture, the assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to culturally unique needs of the patient.8,16,17,18 In short, there is respectful acknowledgment of the patient’s belief system. A culturally competent approach to care includes a set of behaviors and attitudes that enable a healthcare provider to work effectively in cross-cultural situations with humility, sensitivity, and cultural awareness.
Reasons for Cultural Competency
Changes in demographics, health disparities, patient safety, and healthcare workforce shortages are among the reasons for needing cultural and linguistic competency in healthcare.16,17 In this section, the situation as it exists in the United States is detailed. The central concepts would be similar for other countries around the world, even though some of the specifics would vary.
The United States is diverse.19 Approximately 40% of the population identifies as African American, Hispanic, Asian, American Indian, being of another race that is not white, or as coming from two or more races.19 The United States is aging, with 14.5% of the population reported as being 65 years of age or older.19 Furthermore, people have diverse religions, languages, and countries of origin. Nearly 84% of adults in the United States report identifying with a particular faith or religious group.20 More than 300 distinct languages are spoken in American homes.21 The three patients described in the beginning of the chapter highlight some of the diversity that might be encountered throughout our United States.
Regrettably, health disparities generally occur in populations who have systematically experienced a social, economic, or environmental disadvantage in society. While disparities are often linked to differences in race and cultural backgrounds, they also exist among groups based on religion, physical disability, sexual orientation, and age, among other characteristics. Health disparities refer to gaps in the quality of health and healthcare and can include differences in rates of disease or illness, access to healthcare, or general health outcomes.22 One of the overarching goals of Healthy People 2020 (Table e2-1), which frames the national health agenda, is to eliminate health disparities that exist in our population and achieve health equity.23
TABLE e2-1Overarching Goals of Healthy People 2020 ||Download (.pdf) TABLE e2-1 Overarching Goals of Healthy People 2020
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Achieve health equity, eliminate disparities, and improve the health of all groups
Create social and physical environments that promote good health for all
Promote quality of life, healthy development, and healthy behaviors across all life stages
Health disparities may vary based on the population and the health outcome measured. For example, adults in the United States who are African American experience higher mortality rates of heart disease compared to non-Hispanic whites.24 Diabetes prevalence rates are greater among adults with lower household incomes, Hispanics, and African Americans than among Asians and non-Hispanic whites. Suicide rates are higher among men than women, with elevated rates found in American Indian/Alaska Native as well as Lesbian, Gay, Bisexual, and Transgender (LGBT) populations.25 Smoking prevalence is higher among adults who have not graduated from high school when compared with adults with a college degree. These statistics and others like them underscore the need for improvements in the quality of healthcare for minorities.
A healthcare provider’s cultural competency can help to address health disparities in their communities and empower patients from minority groups to improve their health.26,27 By understanding the needs of underserved patients and by identifying the unique resources available within these populations, the healthcare provider can positively impact patient’s healthcare experience. For example, a healthcare provider who understands the importance of community support in a Latino patient seeking healthcare can include a key community member (eg, a promotora or lay health worker) as an active member during treatment and posttreatment care.28,29 By working within the patient’s cultural needs and expectations, the provider can use otherwise overlooked support systems (eg, family, neighborhood friends, and religious ties) in a community with fewer or overtaxed resources. Using cultural competency skills to better identify cultural and community assets in minority and underserved populations allows the provider to go beyond basic awareness of and sensitivity to cultural differences to increase a patient’s adherence with treatment and positively impact patient health outcomes.30 Additionally, the provider’s ability to empower patients through cultural competency will facilitate the development of trusting patient/community/provider relationships.31
Culture and language may also play a role in patient safety.32 Errors and adverse events can occur because of differences in language between healthcare providers and patients, ineffective use of an interpreter, or inadequate translation of written material related to health. Poor judgment or lack of adherence to a treatment plan can occur because of discordance in a patient’s cultural health belief system. Cultural “incongruences” among patients and providers may lead to making judgments about a patient’s decision to use complementary and alternative medicine (CAM) or casting stereotypes based on personal biases about healthcare.15
While some areas of the country may have a surplus of providers, there are still shortages in healthcare providers across disciplines as well as lack of diversity among providers, which contributes to health disparities.33 More than 54 million Americans live in areas that are designated by the Health Resources and Services Administration (HRSA) as primary care health professional shortage areas.34
To meet the healthcare needs of a multicultural society, there is a compelling need to equip current and new providers with the skills to provide a culturally competent approach to care. The education and recruitment of a culturally diverse workforce can lead to greater provider-patient concordance (ie, ability for a patient to consult with a provider of similar cultural or linguistic background).34,35
Given the dynamic shifts in demographics in the United States and contrasts in health equity across cultures, healthcare providers cannot ignore the effects of culture on healthcare. If the healthcare system does not acknowledge and address cultural influences in patient care, patient safety can be compromised. Opportunities exist for educating providers and recruiting a more diverse workforce to care for society.