Chapter e3: Cultural Competency

Culture defines us.¹ Although our genetic makeup, that 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 Black 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.”^5–7 However, to interact more effectively with individuals from different cultural backgrounds, providers should develop cultural and linguistic competencies (Fig. e3-1).

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 integrates—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.^8,16–18 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 42% of the population identifies as Black or 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 15.6% 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 e3-1), which frames the national health agenda, is to eliminate health disparities that exist in our population and achieve health equity.²³

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.

Several models are often used in healthcare to describe and understand cultural competency: the Cultural Competence Continuum by Terry Cross, the Purnell Model for Cultural Competence by Larry Purnell, and the Process of Cultural Competence in Delivery of Healthcare Services by Josepha Campinha-Bacote.^36–38 Across these models, a salient theme surfaces—cultural competency is a process rather than an achievement.^10,36–38

In the Cross Cultural Competence Continuum, six stages are described in a stepladder model starting with cultural destructiveness and ascending toward cultural proficiency.³⁷ Cultural destructiveness in healthcare occurs when a person or an organization actively devalues or berates patients or a community based on their cultural background (eg, race, language, and religion). When persons or organizations are willing but unable to support culturally oriented practices, they demonstrate cultural incapacity. Cultural blindness results from an effort to treat every patient or family the same regardless of culture. However, the provider or organization can miss key elements in the patient’s healthcare behavior that are attributable to their culture. Treating patients equally does not necessarily signify that patients should be treated the same. In cultural precompetency, individuals and organizational leaders recognize that culture is influential in healthcare and efforts are made to improve and adapt care related to culture. In this stage, providers and organizations often believe that making a few adjustments or changes in practice or policy to improve care to diverse cultures are sufficient. However, they do not embark on a continuous improvement plan.

Although cultural competency can really never be achieved, individuals and organizations demonstrating traits of cultural competency will value diversity and seek to continuously implement and evaluate new ideas and programs to improve their care to patients and families from different cultures. Those providers and organizations considered to be more culturally proficient will be viewed as leaders at the forefront of cultural competency who are actively educating others or conducting research in the field.

In the Campinha-Bacote model, five constructs with an interdependent relationship describe the providers developing process of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.³⁸ By self-assessment of cultural and professional biases and beliefs, clinicians develop increased cultural awareness. This self-awareness helps clinicians to recognize the risk of imposing personal beliefs in patient care. As clinicians learn more about beliefs and practice, disease epidemiology, and the efficacy and acceptance of therapies that are found in diverse cultures, they expand their cultural knowledge. Providers acquire cultural skills as they learn how to collect subjective information and social histories as well as conduct physical assessments that are relevant to different cultures. The increased opportunity for cultural encounters through directly interacting with individuals and families from diverse groups helps providers to have practical experience with cultural norms and variations as well as language needs. At the intersection of awareness, knowledge, skills, and encounters is cultural desire. When providers want to learn and grow in the process of cultural competency and do not feel obligated to care for diverse cultures, then they expand their cultural desire. Cutting across all of these constructs is a sense of cultural humility in which providers recognize the continuous process of learning.

The Purnell model explores the relationship of family, community, and the global society as they influence the individual person.³⁶ The model further outlines 12 different cultural beliefs and traits that may affect the individual and are often interconnected, such as healthcare practices, spirituality, communication styles, and workforce issues. In this model, Purnell illustrates that healthcare providers and organizational leaders often experience a learning process related to their cultural consciousness. In this continuum, providers may move from being unconsciously incompetent (not aware of lack of competence), consciously incompetent (aware of lack of competence), consciously competent (aware of improving competence) toward unconscious competence. When a provider is unconsciously competent, they have been able to integrate skills, knowledge, and awareness of the varying cultural, familial, and broader community influences on a patient with fluency.

As clinicians use these models and work with new cultures and in new environments, they may feel that they regress and are not as competent. However, if organizations and clinicians recognize that they are on a path of continuous improvement and approach the care of patients and communities with an attitude of humility and sensitivity to potential opportunities and barriers in care, they will be taking great strides toward providing a positive healthcare environment for their patients and the communities they serve.

Legal and regulatory issues surrounding cultural competency include understanding and interpreting Title VI of the Civil Rights Act and accreditation standards for healthcare organizations. Title VI “prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance.”^39,40 In 2000, under Executive Order 13166 of Title VI, federal agencies became required to evaluate and develop services for persons with LEP and meaningful access to these services.^40,41

The 2013 enhanced National CLAS Standards (Culturally and Linguistically Appropriate Services) provide a framework for health and healthcare organizations to promote health equity and quality for diverse populations.⁴² The Standards open with an overarching principle to “Provide Effective, Equitable, Understandable, and Respectful Quality Care and Services.” Fourteen standards grouped in three themes follow, including: (a) Governance, Leadership and Workforce (Standards 2-4); (b) Communication and Language Assistance (Standards 5-8); and (c) Engagement, Continuous Improvement, and Accountability (Standards 9-15). State and national policies have provided particular emphasis on access to language services including interpreters (Table e3-2).⁴¹ Challenges persist to appropriately use, certify, and reimburse professional interpreters with a growing number of states also requiring cultural competency training for health professionals.

The Joint Commission, the primary national accrediting body for healthcare organizations and programs, supports CLAS standards through requirements for effective communication, cultural competence, and patient-oriented care.⁴³ This roadmap highlights the importance of integrating culturally competent care across the organizational and professional structure from admission to dismissal.

Recognizing that improved patient safety occurs when providing appropriate language services and obtaining informed consent with well-translated and easily understandable forms. The Joint Commission has recommendations based on cultural and linguistic competency.^32,43 Considerations include collecting patient-level demographic data to report outcomes to better understand patterns in health disparities. HRSA has also developed indicators of cultural competence in healthcare organizations. The incorporation of cultural competency into Joint Commission and HRSA guidelines gives organizations and healthcare leaders further rationale to move toward more culturally competent care.

The Joint Commission emphasizes leadership involvement and ongoing staff education related to cultural competency. Further, more than 30 states in the United States have passed legislation requiring healthcare professionals to complete training in cultural competency or multiculturalism and/or have state-sponsored implementation activities.^42,44

The healthcare system must work to engage patients and their communities.³ There are definite trends from stakeholders in managed care, government, and academe to incorporate cultural competence for the purpose of improving quality of care and in some cases as a business imperative.⁴⁵ Independent of the legal and regulatory requirements, the ultimate goal of a healthcare provider is to improve patient outcomes including understanding the culture and language of patients.

How do patients experience and understand their own health? According to medical sociologists, patients may enter the healthcare setting with a different explanation of their illness than the explanation found in the Western biomedical model (WBM). This model proposes that there is a pathophysiologic or etiologic reason for disease. In many cultures, the source and meaning of illness may be attributed to a variety of other causes such as spiritual or religious influences or to retribution for previous deeds.⁴⁶ The term disease, from the view of Western medicine, is the result of a physiologic process. However, in most of the world cultures, the concept of illness is intimately related to the spiritual or religious aspects of their respective society. The clash of cultures can sometimes cause confusion in the patient and/or the provider about the true effects of a treatment or illness. This conflict can cause unfortunate outcomes on many levels. In an effort to help identify cultural differences in a clinical setting, providers can ask patients questions to help elucidate the previous unforeseen differences.

One of the most studied and widely used clinical models is the Patient Explanatory Model (PEM). It includes eight questions to evaluate a patient’s explanation of disease (Table e3-3).⁴⁷ The model may best be used when clinicians sense discordance with the patient relating to adherence to a treatment plan or to the overall visit (see the Clinical Presentation box for an example of how to use the PEM).⁴⁸

Complementary and alternative medicine is defined as any practice for the prevention and treatment of disease that is not usual conventional medicine.⁴⁹ Classified under CAM are a broad range of practices that are grouped under four categories: biologically based practices, energy medicine, manipulative and body-based practices, and mind-body medicine. Specific examples of CAM may include dietary supplements, vitamins, herbal preparations, homeopathy, special teas, acupuncture, massage therapy, magnet therapy, spiritual healing, folk medicine, and meditation. Of these practices, the use of herbal medicines likely holds the most relevance in terms of its influence on conventional pharmacotherapy.

Worldwide, an estimated 80% of the population uses herbs; in the developing world, rates can be as high as 95%.⁵⁰ To further complicate this situation, recent trends include the use of combinations of herbal products or extracts, vitamins, and various other natural and synthetic ingredients that are packaged and marketed with a pharmaceutical appearance (nutraceuticals) or included in energy drinks. Also of concern is the recent trend of adding pharmaceutical compounds to products sold as “natural remedies.”⁵¹ Given the prevalence of herbal medicine use worldwide, the World Health Organization (WHO) has provided guidelines for the growth and collection⁵² and manufacturing of these products.⁵³

The use of traditional healers and CAM is a cross-cultural phenomenon. A holistic approach for the prevention and treatment of diseases has long been used by American Indians and practices from other cultures have also been important since Spaniards first came to the North American continent more than 500 years ago.^54,55 The long-standing integration of traditional healing practices has taken a new dimension with globalization and increased internet access by all populations. For example, Chinese practices of traditional medicine are expected to be easily found in United States cities with large populations of Asian heritage but they may also be common in cities where Asians-Americans are a relatively small part of the population.^56,57 Similarly, products like prickly pear cactus (“nopal”), a plant native to Mexico and the Southwest United States and used to treat diabetes, has been exported to and used in China.

In the United States, the most recent national survey documented CAM use in more than 35% of the population.⁵¹ However, certain regions of the country with large populations of diverse racial and ethnic groups may actually use CAM more frequently. For example, in areas near the border with Mexico, herbal product usage rates have been documented at 65%.^56,57 In a 2012 systematic review of the prevalence of herb usage among racial and ethnic minorities, the overall (ranges) rates were reported as followed: African Americans 17% (1%-46%), Hispanics 30% (4%-100%), and Asians 30% (2%-73%).⁵⁸

With increasing use of CAM, healthcare providers should consider potential problems with conventional pharmacotherapy. CAM practices generally are not considered standard medical approaches. Unlike standard treatments, they may not go through appropriate research methods or quality assurance to prove they are safe and effective; as a result, less is known about most types of CAM. In the United States, distributors of herbal products are not required to follow current Good Manufacturing Practices.

Surveys have demonstrated low disclosure rates of CAM use by patients to their healthcare providers. Minorities—including Asian Americans, Hispanics, and African Americans—may have lower disclosure rates than non-Hispanic whites for two reasons: conventional providers do not ask about CAM use, and/or patients may be concerned about disapproval from their providers.⁵⁹ One strategy for inquiring about CAM use is to ask open-ended questions and to avoid being judgmental when patients do report their use of CAM. For example, providers could ask, “What vitamins, herbal products, home remedies, or supplements do you use to treat (insert condition)?” instead of asking, “Do you take supplements?” A recent study has documented that Latinos disclose at higher rates when asked specifically about use of herbal medicine teas.⁶⁰ It is beneficial to have an understanding of patterns of CAM use by different racial, ethnic, or cultural groups, but it is equally important to evaluate each individual with an approach that encourages disclosure and inspires trust. When inquiring about the use of CAM, the approach of the healthcare provider must be open, neutral, nonjudgmental, and respectful of the individuals’ cultural practices and their choice to use traditional medicine. In cases where the provider identifies any concerns or potential harm, when they approach the issue in the manner described above, they are in a better position to provide the patient with the necessary guidance. As health science training integrates more understanding of CAM practices, especially herbal medicines and dietary supplements, healthcare professionals will be better equipped to address CAM related issues and concerns.

Numerous factors can influence cultural values and beliefs toward healthcare as suggested by social determinants of health. Age, gender, race, ethnicity, sexual orientation, religion, geography, neighborhood, acculturation, and linguistic identities all shape how people behave and what they value. One of the dangers of learning to work with patients and families from different cultures is confusing stereotypes with generalizations. Stereotypes may be damaging to patients as they are an end point or assumption about the way people will behave.¹⁵ Generalizations, however, can provide a framework or beginning to understanding how patients may respond in healthcare situations.¹⁵ When developing a framework to work with patients, understanding the degree to which individuals identify themselves within different cultures is worthy of consideration.

Social Identity

One aspect of culture is linked to how social identity is defined. Social identity can be described as a person’s sense of self, based on memberships to various social groups.^61,62 Social group membership can be based on gender, age, ethnicity, race, family, sexual orientation, religion, or other cultural factors. Individuals’ social identities consist of membership to multiple groups. For example, a person may identify as a young (age), Catholic (religion), female (gender), Hispanic (ethnicity), of African descent (race). Identification with a particular group (eg, Hispanic) is the individual’s ingroup. Conversely, group in which the individual does not identify (eg, non-Hispanic Caucasian) is the individual’s outgroup.⁶³

An individual’s identification with a social group is influenced by contextual factors,⁶⁴ such as individuals within the immediate environment. For example, an African American woman may identify more strongly with her gender ingroup in the presence of several African American males but identify more strongly with her racial ingroup in the presence of several white women. In other words, there are instances in which one social group membership may become more salient and thus be more influential on behaviors than other group memberships. Understanding how strongly a patient identifies with a particular social group will assist healthcare providers in identifying the influence of that social group’s cultural norms and expectations on the patient’s healthcare decision-making. For example, a patient who has recently immigrated must redefine how they identify with cultural ingroups or outgroups in the new context. This, in turn, defines how individuals experience the process of acculturation within dominant cultural groups in a new host country.

Acculturation

Culturally competent providers are familiar with the concept of acculturation and its role in the area of health. Acculturation can be defined as the process by which individuals from one cultural group experience changes in behaviors, attitudes, and beliefs as a result of continuous contact with a different culture.⁶⁵ Acculturation has been studied in relation to a number of health behaviors and its influence cannot be underestimated.⁶⁶

Levels of acculturation have been associated with differences in help-seeking behavior, healthcare utilization rates, adherence, presentation and perception of illness, attitudes toward healthcare providers and treatment, and beliefs about healing.⁶⁷ Acculturation measurement tools have been used in research in an attempt to capture the relationship between acculturation and health disparities or health outcomes.¹³ Research has been conducted in Mexican American populations with increasing studies in other racial, ethnic, and immigrant populations. Some weaknesses in theories of acculturation (in studies conducted in the United States) exist because assumptions are made that immigrant populations are able to choose to participate fully in American society and that the ultimate goal is to assimilate into American culture.¹³

Regardless of how acculturation is measured or researched, understanding concepts related to acculturation can be helpful to providers. One model of acculturation that provides a framework for understanding acculturation describes assimilation, integration, marginalization, and separation as four possible outcomes of the acculturation process. In this framework, there are two cultures of reference, the home culture (the culture from which the individual comes) and the host culture (the culture to which the individual is introduced or is immersed).⁶⁸ This relationship can have varying levels of effect on each other and can be bidirectional in nature.

Individuals may have the least difficulty adapting to the new host culture when they are able to assimilate or integrate.⁶⁸ In assimilation, individuals lose (willingly or unwillingly) much of their identity from their home culture and adopt the new host culture. In integration, the individual is able to adopt identities from both the host and home culture. These individuals may be considered bicultural or even bilingual.

Through the process of marginalization and separation, individuals have a more difficult time adapting to a new host culture.⁶⁸ When individuals are marginalized, they have strong identities to their home culture and may not be able to adapt well to the host culture. Marginalized individuals may include more recent immigrants or refugees. Persons who are in separation may never really understand their home culture or their host culture. They may live “in between” cultures, never fully learning the home culture or host culture. This phenomenon may occur in children who have never completed their basic education in either culture (thereby never mastering one language) or who do not have enough exposure to cultural events and traditions from their home or host culture to entirely understand or appreciate either heritage. When interacting with bicultural or bilingual patients, it is important for healthcare providers to consider the cultural group most salient to the patient’s social identity as the influence of home or host culture can vary due to contextual influences.^69–71

Individual versus Collective Influences

There are other factors that influence how persons interact in cultures. For example, different cultures place varying emphasis on the importance of individual and the collective influences on decision-making.⁷² Those persons who come from more individualistic cultures (eg, the United States) are more likely to place greater emphasis on an individual’s self-reliance and emotional distance from others within the individual’s group.⁷³ Patients from individualistic cultures expect greater individual responsibility for healthcare decisions.⁷⁴

Alternatively, persons who come from collective cultures experience greater emphasis on interdependence and family integrity.⁷³ Patients from collectivist cultures experience increased community participation with their healthcare decision-making.⁷⁵ It is important to note that some cultural groups (eg, Latino, African American, and American Indian) may identify as being particularly familistic—the family unit has a core influence on their cultural and community identity.⁷⁶ A greater emphasis on the family unit leads to different attitudes and behaviors such as different expectations for seeking healthcare (eg, an aunt or godmother caring for the ill) and the development of different beliefs, norms, and traditions.⁷⁷

Health Beliefs and Practices Found in Various Cultures

Although it is not feasible to understand the intricacies of every culture, it is possible to explore common characteristics of various cultures in order to learn more about them. It is important to recognize that the traits identified in this text are generalizations about a particular cultural group. Not every member of these groups will demonstrate these characteristics. Ultimately, care should be individualized, but the following generalizations can serve as a guide to working with patients from a particular race, ethnicity, religion, or other cultural group. In some cases, clinicians can apply the mantra, “Treat others as they would want to be treated,” also called the Platinum Rule.⁶⁷

Individuals from different cultures may have different beliefs about the origins of health and illness and may not subscribe to the WBM.^35,47 Some cultures may view health as the result of harmony with nature or the balance of natural forces. Still others may believe that health is a result of good luck or reward for good behavior. Views about the origins of illness may also differ depending on culture. Some believe that illness is the result of an imbalance in natural forces while members of other cultures may point to supernatural powers as the cause of disease or illness. Various cultures describe illnesses that are only recognized within that culture. These “culture-bound syndromes,” also often referred to as folk-illnesses, are often manifested through changes in behavior, cognition or affect without the presence of signs or symptoms that can be objectively confirmed.^15,78 There are a variety of culture-bound syndromes that have been documented. For example, conditions such as empacho (stomach pain caused by ball of food blocking the digestive tract), susto (illness arising from extreme fright), mal de ojo (illness caused by the “evil eye” resulting from excessive admiration or envy), or caída de la mollera (depression of anterior fontanelle in infant) can be found in Latin American cultures.^36,46 Dhat is a culture-bound syndrome reported in Indian cultures that manifests as fatigue, weakness, or sexual dysfunction thought to be caused by loss of semen during urination, masturbation, or nocturnal emission.⁷⁹ Culture-bound syndromes are also found in Western cultures. Anorexia nervosa, an eating disorder characterized by extreme weight-loss caused by self-starvation, is well-recognized in Western cultures but may not be acknowledged in other cultures.⁸⁰

Certain healthcare practices may stem from historical events or experiences not explained by the WBM. Some African Americans, for example, may practice geophagy (eating of earth or clay).⁴⁶ This practice has historical significance and was noted among some slaves from Africa who may have focused on eating red clays, which are iron rich.⁴⁶ Additionally, African Americans may not trust the healthcare system or research projects because of previous injustices, including slavery and the Tuskegee syphilis study.⁸¹ The latter example refers to research conducted by the United States Public Health Service from 1932 to 1972, in which African American men with syphilis were recruited to participate in a study to investigate the natural course of untreated disease.⁸¹ This project continued until the early 1970s despite the availability of penicillin and confirmation in the 1940s that penicillin was an effective treatment for syphilis.

As discussed previously, it is important to recognize that members of various cultures may employ the use of traditional healers, CAM such as herbs, or other practices such as massage. Traditional healers who may be involved in the care of a patient include curanderos(as) in some Latin American cultures, “medicine men or women” in various American Indian communities, voodoo doctors by African Americans practicing voodoo, or santeros (mediums) among individuals practicing Santería (religious practice originating in Nigeria in which the gods [orishas] of the Yoruban people are matched to Catholic saints and connected to various health problems).^36,46

Furthermore, religious rituals or ceremonies are often an important part of treatment in many cultures. Some American Indian cultures, for example, may practice divination (diagnosis) or singing in the treatment of illness. Three types of divination include motion in the hand (pollen or sand is sprinkled around the patient while song is sung and diagnostician moves hand to determine the cause), stargazing (prayer to star spirit is made by stargazer and rays of light thrown by star are used to determine cause of illness), and listening (diagnostician listens for certain sounds to help in diagnosis). For some members of American Indian cultures, these practices may have a profound psychologic effect and allow the patient to feel cared for in a personal way.⁴⁶ Patients from various religious backgrounds will include prayer as a way of coping with life stresses.⁸²

Other culturally based healthcare practices may lead to physical signs on the body that might be taken as signs of injury or abuse. Patients of Asian descent may practice coining (coins are dipped in oil and heated and then rubbed on skin), cupping (heated glass cups are placed on skin to create vacuum), moxibustion (heated incenses or wood applied over the skin), or pinching of skin in order to draw out illnesses.³⁶ These practices may produce bruises, burns, or welts on the skin that might be confused with signs of physical abuse.⁴⁶ Clinicians should be aware that cultural beliefs may have led to the practice of alternative forms of healing and this should be taken into consideration when evaluating a patient.

Family roles and communication styles may also differ based on culture. Certain cultures have strong family values or close-knit family structures. As a result, the healthcare encounter with patients from these cultures may involve the participation of other members of the family. Communication styles will also vary; thus, clinicians should be aware of communication characteristics when working with patients of various cultures. Table e3-4 includes various characteristics related to healthcare beliefs, practices, and values that have been found in select racial and ethnic groups represented among the population of the United States.

The cultural influence of religion on healthcare can be critical. For example, a patient who comes from the Jewish or Muslim faith may be unwilling to accept omega-3 fatty acids as a therapy option for hypertriglyceridemia because the gelatin formulation may not adhere to the dietary restrictions of the religions.⁴⁶ A female patient whose religion embraces greater physical distance between women and men in social situations may not be comfortable working with a male healthcare provider. A devout Christian family may be concerned about discussions of contraception or emergency contraception. To elicit information about a patient’s religious or spiritual concerns, providers may ask, “I feel that I can help you better if you can tell me what religious or spiritual needs I should consider in your healthcare.” Table e3-5 lists some health beliefs and practices found in common worldwide religions.

A diverse society will yield diverse health beliefs and practices. Potential differences among individuals in their acculturation levels can affect observance of cultural practices. Developing a general understanding of common cultural health behaviors can help clinicians to approach patients in a culturally competent manner.

Developing communication skills to interact with diverse populations includes recognizing personal styles of communication. However, providers should have communication skills to recognize if a barrier may exist, and they should work to care for patients regardless of the language they speak. Understanding personal communication styles provides insight to clinicians so they may be able to prevent or acknowledge any bias or expectations during clinical encounters. By recognizing personal cultural biases, clinicians can better serve the patients.

Barriers related to cross-cultural communication can affect the provider-patient relationship. From the perspective of the Joint Commission, the threat to effective communication is threefold: language differences, cultural differences, and low literacy levels.^43,87 Patients can also have communication barriers because of differences in age or gender with the provider.⁸ A person with a lower level of education may not be comfortable working with a provider who has obtained a college education and/or attended graduate school. An older patient may not believe that a younger provider has enough work or life experience to be qualified. A man from a more conservative religious upbringing may not feel it is appropriate to be counseled by a female provider. Other barriers to care may exist because of fear and distrust in the provider due to race or ethnic background, prejudices, or lack of familiarity or knowledge of the culture.^8,48 For example, a patient who is of Chinese descent may not feel comfortable with a provider who is Mexican American because of a perception of unfamiliarity and a lack of opportunity to interact with persons of the other background.

Communication Skills

Communication skills needed to work with patients from diverse cultures include looking for nonverbal cues.^8,46,48 Providers can often gain clues for how to interact with patients by observing their behaviors and following patients’ mannerisms. Patients will have varying preferences of eye contact, personal space, and physical contact.^8,46 Some patients prefer indirect eye contact and may view direct eye contact as rude or intrusive. A comfortable distance for personal space also varies across cultures.^8,48,88 In some cultures, patients prefer only a handshake or a nod of acknowledgment for greetings, whereas in other cultures, patients will welcome a light tap on the shoulder or even a hug.

Verbal cues include recognizing whether patients prefer to be called using their first name or last name.^8,15,46 Some patients embrace the opportunity to talk and get to know their provider before jumping into medical information. Using a vocabulary that is consistent with the culture and education of patients is another strategy that can help providers gain trust.

To develop skill sets to work with patients from diverse communities, providers can identify cultural “brokers” or community liaisons.¹⁷ These liaisons are often respected community members and leaders who recognize the importance of connecting the healthcare community with the community being served. Liaisons may be religious leaders or mothers and grandmothers in the community. The key is to align providers with these community liaisons to help interpret what cues (nonverbal and verbal) and ways of communicating are most appropriate.

Limited English Proficiency and Hearing Impairment

According to Census 2010 data, 20% of people living in the United States 5 years of age and older speak a language other than English in the home.¹⁹ LEP occurs when a person is not able to communicate effectively (reading, speaking, writing, or understanding) in the English language because of English not being the primary language.^21,40

Linguistic competency encompasses understanding issues related to working with patients with LEP and/or hearing impairments such as learning basic terms and greetings, working with an interpreter or language-assistance lines, and using non-English patient education/materials.

For healthcare providers to more effectively communicate information to patients with LEP, it is important to identify the most common languages spoken among their patients. As outlined in the CLAS standards, organizations receiving federal funds (indirect or direct) must provide meaningful access to persons with LEP.^21,39,40 Using professionally trained interpreters has been shown to improve clinical care, improve patient safety, and increase satisfaction for patients with LEP.^89–92 In addition to having qualified interpreters, it is important to train healthcare providers to use and interface with professional phone interpreter services.⁹³ A variety of online resources are available to begin learning about working with interpreters and translators (Table e3-6).

While interpreter services may exist, challenges persist to identify patients with language assistance needs as well as to maintain a consistent and qualified language assistance workforce in the healthcare system.⁹⁴ In the event that a trained interpreter is not available, the clinician may need to work with an ad hoc interpreter (eg, bilingual coworker, family member, and friend), which poses a greater risk for error.⁴⁸ Children (minors) should not be used as interpreters. Clinicians should be actively aware of the interpretation situation. If the interpretation appears to be muddled or the process seems confusing, then it is appropriate to insist upon finding a more reliable source of interpretation.

Organizations and clinicians can also create a positive environment for patients with LEP by having written materials translated into the common languages found in the served population. Materials should be translated by certified translators and not by staff members, family, or friends who state that they are bilingual.

Tools for Working Across Cultures

Clinicians should recognize that assessing culture in the patient encounter is not necessarily a new concept.⁴⁸ The “social history” of patients provides room to explore the patient’s individual and family situation, work and home environment, unique dietary needs, and education background, among other sociocultural influences. However, tools have been developed to help providers further address unique cultural situations that can arise in the patient encounter.

One model frequently cited for working with patients from diverse cultures is LEARN (listen, explain/empathize, acknowledge, recommend/respect, and negotiate).⁸⁸ In the LEARN model, providers are called to listen to their patients’ perceptions of their health with an open mind. Providers should then take time to explain their perceptions and empathize with the patient. Acknowledgment of commonalities and differences in the approach to understanding health and treatment options for the patient can help to build trust.⁸⁸ When providers recommend a treatment plan in a way that is respectful of the patient’s culture and beliefs, the provider and patient can find a common ground. With this baseline respect, a plan can be negotiated to navigate through the healthcare system.

While barriers do exist for cross-cultural communication, clinicians can overcome these challenges by understanding verbal and nonverbal cues to communication. They also should recognize that quality interpretation is essential in the patient encounter. Tools for navigating across cultures include learning how to listen, empathize, and negotiate a treatment plan with patients.

Both individuals and organizations demonstrate the capacity for providing a culturally competent environment. Before understanding other cultures, individual practitioners should understand their own personal values and beliefs. Additionally, assessment of attitudes, practices, policies and structures within an organization can assist in planning for and incorporating cultural competence into the provision of healthcare within organizations.¹⁸

The process of self-evaluation may begin with the simple act of a practitioner reflecting on the values and beliefs that shape their world view, their perceptions of health and illness, and the existence of stereotypes or myths about other cultures.¹⁶ To assist in this process, self-assessment instruments have been developed to guide individual healthcare providers in their reflection of cultures, values, and beliefs.

A variety of assessment tools designed for use by individual practitioners are available in both written and online formats (Table e3-7).^95–104 Domains that are typically assessed by these instruments include values and belief systems, communication styles, experience in cultural diversity, materials and resource evaluations, and others.^96,97 Many of these tools pose specific examples or questions within each domain that allow practitioners to assign ratings that reflect their level of cultural competence. Although there are no correct answers, these instruments provide individuals the opportunity to identify personal attitudes, values, and beliefs that do not foster cultural competence. By becoming aware of these issues, the practitioner may then make plans to improve upon or change these characteristics and move toward a more culturally competent approach to providing healthcare.

The assessment of the cultural competence of organizations and systems is just as important as individual assessments and should not be overlooked. Assessing the cultural competency of an organization promotes the principles of equal access and the provision of services in a nondiscriminatory manner.⁹ To plan for and incorporate cultural competence into an organization, attitudes, policies, practices, and structure within the organization should be considered. An essential part of this assessment involves determining the needs, preferences, and satisfaction of patients and consumers who are served by the organization. Tools that may be used by organizations to assess cultural competence are also summarized in the accompanying table (see Table e3-7). Additionally, steps for planning and implementing an organizational self-assessment are summarized in Table e3-8.

Instruments that assist organizations to assess their level of cultural competence have also been developed (see Table e3-7). Some of these assessments focus on an evaluation of the practice setting or workplace, while others also consider the members of the healthcare staff working in the organization. The National Center for Cultural Competence created a guide to planning and implementing cultural competence in an organization (see Table e3-8). According to this guide, the proposed steps are useful for planning and implementing organizational self-assessment.

Regardless of which tool is used, an assessment of cultural competency should be conducted periodically on an ongoing, long-term basis.¹⁸ Individuals and organizations are on a cultural-competency continuum at all times, with varying levels of awareness, knowledge, and skills. Periodic use of these tools can help individuals and organizations identify in which direction they are moving on the continuum in order to make necessary adjustments.¹⁰⁶

Engaging in assessments of cultural competency can result in several benefits to the individual practitioner or organization.¹⁸ One benefit includes the ability to determine whether providers or healthcare organizations are meeting the needs of the patients being served. Additionally, the process can improve patient and customer satisfaction, and allow for the identification of strengths that the individual practitioner or organization has to offer. Ultimately, conducting assessments allows for the recognition of opportunities for growth and improvement in order to create a healthcare environment that can achieve better patient outcomes.

The influence of culture on healthcare encompasses understanding social determinants of health and how environments and community networks help shape the health of individuals and families. The United States—with its culturally diverse society and health disparities, patient-safety concerns, and workforce shortages—has unique opportunities and challenges in patient care. To work in this environment, clinicians should understand legal and regulatory issues related to cultural and linguistic competency. To excel in diverse patient care, providers need the knowledge and skills to elicit patients’ explanation of their health status, recognize potential cultural influences on healthcare beliefs and practices, and communicate effectively with patients from different languages and cultures. Individual and organizational self-assessments can reveal helpful information about attitudes, values, and capacity to provide culturally and linguistically responsive services to patients and communities. The ability for providers and organizations to navigate well in a diverse population can help to create a safer and positive healthcare environment for patients to receive care.