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Cultural competence in health care

Cultural competence in health care refers to the ability for health care systems to demonstrate cultural competence toward patients with diverse values, beliefs, and behaviors.[1] This process includes consideration of the individual social, cultural, and linguistic needs of patients for effective cross-cultural communication with their health care providers.[2] The goal of cultural competence in health care is to reduce health disparities and to provide optimal care to patients regardless of their race, ethnic background, native languages spoken, and religious or cultural beliefs. Cultural competency training is important in health care fields where human interaction is common, including medicine, nursing, allied health, mental health, social work, pharmacy, oral health, and public health fields.

The term cultural competence was first used by Terry L. Cross and colleagues in 1989,[1] but it was not until almost a decade later that health care professionals began to be formally educated and trained in cultural competence. In 2002, cultural competence in health care emerged as a field[3] and has been increasingly embedded into medical education curriculum since then.

Although cultural competence in health care is a global concept,[4] this article focuses on cultural competence as practiced in the United States.

Definitions

Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and that enables them to work effectively in cross-cultural situations.[1] Essential elements that enable organizations to become culturally competent include valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized cultural knowledge, and having developed adaptations to service delivery reflecting an understanding of cultural diversity.[1] By definition, diversity includes differences in race, ethnicity, age, gender, size, religion, sexual orientation, and physical and mental ability.[5] Accordingly, organizations should include these considerations in all aspects of policy making, administration, practice, and service delivery.[6]

Cultural competence involves more than having sensitivity or awareness of cultures. It necessitates an active process of learning and developing skills to engage effectively in cross-cultural situations and re-evaluating these skills over time.[7] Cultural competence is often used interchangeably with the term cultural competency.

Cultural competence in various settings

Health care system

A health care system, sometimes referred to as health system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations. A culturally competent health system not only recognizes and accepts the importance of cultural diversity at every level but also assesses the cross-cultural relations, stays vigilant towards any changes and developments resulting from cultural diversity, broadens cultural knowledge, and adapts services to meet the needs that are culturally-unique.[1]

As more and more immigrants are coming to America, the challenges for American health care systems to meet the health needs of the increasing number of diverse patients are becoming very obvious. The challenges include but are not limited to the following:[1]

  • Sociocultural barriers
  • Poor cross-cultural communication
  • Language barriers
  • Attitudes toward health care
  • Beliefs in diagnosis and treatment
  • Lack of cultural competence in the design of the system

Leadership and workforce

In response to a rapid growth of minorities population in the United States, health care organizations have responded by providing new services and undergoing health reforms in terms of diversity in leadership and workforce. Despite improvements and progress seen in some areas, minorities are still underrepresented within both health care leadership and workforce.[2] To improve the weak minorities representation in leadership and workforce, an organization must acknowledge the importance of cultures, be sensitive to cultural differences, and establish strategic plans to incorporate cultural diversity.

According to the national survey of the U.S. health care leaders conducted by the search firm Witt/Kieffer, respondents viewed diverse leadership as a valuable business builder. They associated it with improved patient satisfaction, successful decision-making, improved clinical outcomes, and stronger bottom line.[8]

To successfully recruit, mentor, and coach minority leaders in health care, it is important to keep these social science principles and cultural values in mind:[9]

  • Branding - how health care leaders brand diversity in their organizations? Without inclusion, branding would not be complete
  • The concepts of self-categorization and "othering"
  • Lack of leadership commitment - diversity and inclusion should be an imperative of their organization
  • The compelling national demographics of health care leadership and workforce.

Clinical practice

To provide culturally sensitive patient-centered care, physicians should treat each patient as an individual, recognizing and respecting his or her beliefs, values and care seeking behaviors.[10] However, many physicians lack the awareness of or training in cultural competence. With the constantly changing demographics, their patients are increasingly getting diverse as well. It is utterly important to educate physicians to be culturally competent so that they can effectively treat patients of different cultural and ethnic backgrounds.

In response to the increasingly diverse population, several states (WA, CA, CT, NJ, NM) have passed legislation requiring or strongly recommending cultural competency training for physicians.[11] In 2005, New Jersey legislature enacted a law requiring all physicians to complete at least 6 hours of training in cultural competency as a condition for renewal of their New Jersey medical license, whether or not they actively practice in New Jersey.[12] Physicians' responses to this CME requirement varied, both positively and negatively. But the overall feedback was positive towards the outcomes of participation in and satisfaction with the programs.[13]

In order to provide culturally competent care for their diverse patients, physicians should at the first step understand that patients' cultures can influence profoundly how they define health and illness, how they seek health care, and what constitutes appropriate treatment. They should also realize that their clinical care process could also be influenced by their own personal and professional experiences as well as biomedical culture.[10] Dr. Like pointed out in one of his articles that "in transforming systems, transcultural nurses, physicians, and other health care professionals need to remember that cultural humility and cultural competence must go hand in hand."[14]

Research

Cultural competence in research is the ability of researchers and research staff to provide high quality research that takes into account the culture and diversity of a population when developing research ideas, design, and methodology. Cultural competence can be crucial for ensuring that the sampling is representative of the population and therefore application to a diverse number of people.[15] It is important that a study's subject enrollment reflect as closely as possible the target population of those affected by the health problem being studied.

In 1994, the National Institutes of Health established policy (Public Law 103-43) for the inclusion of women, children, and members of minority groups and their subpopulations in biomedical and behavioral clinical studies.[16] Overcoming challenges to cultural competence in research also means that institutional review board membership should include representatives of large communities and cultural groups as representatives.

Medical education

The critical importance of training medical students to be future culturally competent physicians has been recognized by accrediting bodies such as the Accreditation Council on Graduate Medical Education[17] (ACGME) and the Liaison Committee on Medical Education (LCME) and other medical organizations such as American Medical Association (AMA) and the Institute of Medicine (IOM).

According to the LCME standard for cultural competence, "the faculty and students must demonstrate an understanding of the manner in which people of diverse culture and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments."[18] In response to the mandates, medical schools in the U.S. have incorporated teaching cultural competency in their curricula. A search on cultural competency in the curriculum of a medical school revealed that it was covered in 33 events in 13 courses in Spring 2014. A similar search was performed on health disparities yielding 16 events in 10 courses covering the topic.

The cultural competence curriculum is intended to improve the interaction between patients and physicians and to assure that students will possess the knowledge, skills, and attitudes that enable them to provide high quality and culturally competent care to patients and their families as well as the general medical community.[19]

Patient education

Patient-Physician communication involves two sides. While physicians and other health care providers are being encouraged or required to be culturally competent in delivery of quality health care, it would be reasonable to encourage patients as well to be culturally sensitive and be aware that not all health care providers are equally competent in cultures. When it comes to illness, cultural beliefs and values affect greatly a patient's behavior in seeking health care. They should try their best to communicate their concerns relating to their beliefs, values and other cultural factors that might affect care and treatment to their physicians and other health care providers. If effective communication is unlikely achieved, then they should be provided with language assistance and interpretation services. Recognizing that patients receive the best care when they work in partnership with doctors, the General Medical Council issued guidance for patients "What to expect from your doctor: a guide for patients" in April 2013.[20][21]

Challenges to cultural competence

Language barriers

Linguistic competence involves communicating effectively with diverse populations, including individuals with limited English proficiency (LEP), low literacy skills or are not literate, disabilities, and individuals with any degree of hearing loss.[22] According to the U.S. Census in 2011, 25.3 million people are considered limited English proficient, accounting for 9% of the U.S. population. Hospitals frequently admit LEP patients for treatment. With cultural and linguistic barriers, it is not surprising that it is hard to achieve effective communication between the health care providers and the LEP patients.

In order to improve communication and mutual understanding, health care systems have used the professionally trained interpreters to help health care providers to communicate with patients whose English proficiency is limited. Studies have shown that trained professional interpreters or bilingual health care professionals have a positive effect on LEP patients' satisfaction, their quality of care, and outcomes.[23]

The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care developed by the Office of Minority Health (OMH) are intended to advance health equity, improve quality and help eliminate health care disparities.[24] The three themes of the fifteen CLAS standards are: 1) Governance, Leadership, and workforce; 2) Communication and Language Assistance; 3) Engagement, Continuous Improvement, and Accountability. The standards clearly emphasized that the top levels of an organizational leadership hold the responsibility for CLAS implementation, and that language assistance should be provided when needed, and that quality improvement, community engagement, and evaluation are importance.[25] This is a very good resource for health care systems and organizations to follow to become culturally and linguistically competent in the delivery of health care.

Cultural barriers

See also

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Cross, TL; Bazron, BJ; Dennis, KW; Isaacs, MR (March 1989). "Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed" (PDF). Georgetown University Child Development Center, CASSP Technical Assistance Center. 
  2. 2.0 2.1 Betancourt, Joseph R.; Green, Alexander R.; Carillo, J. Emilio (October 2002). Cultural competence in health care: emerging frameworks and practical approaches (PDF). New York, NY: The Commonwealth Fund. 
  3. Thackrah, RD; Thompson, SC (8 July 2013). "Refining the concept of cultural competence: building on decades of progress". The Medical journal of Australia 199 (1): 35-38. Retrieved 14 July 2014. 
  4. Goodman, Neal R. "Cultural Competence in the Global Healthcare Industry". Association for Talent Development. Retrieved 15 August 2014. 
  5. The American Heritage® New Dictionary of Cultural Literacy. (2005). Third Edition. Boston: Houghton Mifflin Company.
  6. "Conceptual Frameworks / Models, Guiding Values and Principles". National Center for Cultural Competence. Retrieved 6 August 2014. 
  7. Office of Minority Health. (2002). Teaching cultural competence in health care: A review of current concepts, policies and practices. Washington D.C.: U. S. Department of Health and Human Services. Contract Number: 282 - 98 - 0029.
  8. Witt/Kieffer (2011). "Building the Business Case - Healthcare Diversity Leadership: a National Survey Report" (PDF). Retrieved 17 July 2014. 
  9. Rich VL. Advancing diversity leadership in health care. Nursing administration quarterly. Jul-Sep 2013;37(3):269-271.
  10. 10.0 10.1 Like, RCL; Barrett, TJ; Moon, J (Summer 2008). "Educating Physicians to Provide Culturally Competent, Patient-Centered Care" (PDF). Perspectives: A View of Family Medicine in New Jersey 7 (2): 10–20. 
  11. "CLAS Legislation Map". Think Cultural Health. Office of Minority Health. Retrieved 6 August 2014. 
  12. "NJ Cultural Competency". Office of Attorney General. New Jersey Division of Consumer Affairs. Retrieved 6 August 2014. 
  13. Like, Robert C. (23 Sep 2011). "Educating clinicians about cultural competence and disparities in health and health care". Journal of Continuing Education in the Health Professions 31 (3): 196–206. doi:10.1002/chp.20127. 
  14. Like, Robert C. (October 1999). "Culturally Competent Managed Health Care: A Family Physician’s Perspective". Journal of Transcultural Nursing 10 (4): 288–289. doi:10.1177/104365969901000403. 
  15. U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity-A supplement to Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Service.
  16. U.S. Department of Health and Human Services. (2010). Human Subjects Protection and Inclusion of Women, Minorities, and Children Guidelines for Review of NIH Grant Applications. p. 1. Retrieved 11 May 2010.
  17. Adrian Jacques H. Ambrose, Susan Y. Lin, and Maria B. J. Chun (2013) Cultural Competency Training Requirements in Graduate Medical Education. Journal of Graduate Medical Education: June 2013, Vol. 5, No. 2, pp. 227-231.
  18. Liaison Committee on Medical Education. Functions and structure of a medical school : standards for accreditation of medical education programs leading to the M.D. degree. Washington, D.C.: Association of American Medical Colleges; 2013.
  19. American Association of Medical Colleges (AAMC). Cultural competence education for medical students. Washington, DC: AAMC; 2005.
  20. "What to expect from your doctor: a guide for patients". General Medical Council. Retrieved 9 August 2014. 
  21. "Press release: GMC publishes first guide for patients on what to expect from their doctor". General Medical Council. 22 April 2013. Retrieved 9 August 2014. 
  22. Goode, Tawara D.; Jones, Wendy. "Definition of Linguistic Competence" (PDF). National Center for Cultural Competence. Retrieved 6 August 2014. 
  23. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Medical care research and review : MCRR. Jun 2005;62(3):255-299.
  24. The Office of Minority Health (OMH). National Standards on Culturally and Linguistically Appropriate Services (CLAS) - 2013; http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Accessed July 15, 2014.
  25. Koh HK, Gracia JN, Alvarez ME. Culturally and Linguistically Appropriate Services--advancing health with CLAS. "The New England journal of medicine". Jul 17 2014;371(3):198-201.

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