Cultural competence is a neglected concept in all aspects of American society. This may be surprising to many, but cultural competence has been grossly neglected in the health care field. As a result, there has been racial inequalities in regards to treatment, prognosis and availability of care. The health care field as a whole needs to continually improve its policy and attitude towards this growing culturally diverse population. Although there has been improvement in racial disparities in health care, it is a lifelong journey to attempt to achieve absolute equality.
In order to be culturally competent, one must first be open to understanding the different behaviors and concepts of cultures different from ones own culture.
Knowing and using these concepts and behaviors is vital to understanding that cultural competence is a component that allows for effective evaluations, treatments or interventions when dealing with their patients. To achieve the goal of cultural competence one must have a firm grasp of what cultural is and how it relates to cultural competency.
Culture is simply the way of life of different groups of people.
Customs, religion, verbal and nonverbal language, family dynamics, cuisine, beliefs, values etc., all these and more make up the many facets of culture. For example: in the Philippines, it is customary for the family to take care of the needs of their elders. Once a person becomes too feeble to be on their own, the family comes in to help meet the needs of their relative. By comparison, in the United States of America, once a person becomes too old, they usually get moved to a nursing or retirement home.
Another comparison between the Philippines and United States of America is the use of our time which is an example of individualistic vs. collectivist cultures (Lattanzi, J.B., Purnell L.D., 2006, pp. 86-87)(1). In the American culture, we are a time based people. When we are required to be at a place at a certain time, we make sure to be there on time or at least a few minutes early. By contrast, in the Philippines, when an event has a certain start time, what they really mean is that the event will start an hour after the posted time. These are some ways culture is defined in society. No concept is better than the other, just different. Once one begins to understand culture, they are then able to help in dealing with people of different cultures, thus becoming more culturally competent.
There are many definitions regarding cultural competence, all touching on the need to improve the access and quality of care. One definition describes cultural competence as “the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients social, cultural and linguistic needs” (Betancourt, Green, & Carrillo, 2002)(2). Another definition set forth by Cross, Bazron, Dennis, & Isaacs (1989), “a set of behaviors, attitudes, and policies that come together in a continuum to enable a health care system, agency, or individual rehabilitation practitioner to function effectively in trans-cultural interactions. In practice, cultural competence acknowledges and incorporates, at all levels, the importance of culture, the assessment of cross-cultural relations, the need to be aware of the dynamics resulting form cultural differences, the expansion of cultural knowledge, and the adaption of services to meet culturally unique needs” (Leavitt, 2010, p. 4)(3). Of all the definitions out there about cultural competency, the fact remains, that they all encapsulate the responsibility that health care practitioners must be aware, and adaptable to the multitude of different needs for their diverse patients.
As one strives to become culturally competent, he/she can use many different models or concepts to improve there competence. Systems such as Lattanzi’s Steps to Culturally Competent Practice for the Physical Therapist, or the Purnell’s Model for Cultural Competence(4) (Lattanzi & Purnell, 2006, pp. 22-31) allows a health care practitioners to acquire and use the knowledge and awareness needed to work with ethnically/ racially diverse populations. Lattanzi’s Steps focus on the personal development of a physical therapist in cultural competence. Purnell’s model on the other hand, gives the health care practitioner a broader understanding of culture. Using these methods or models will make health care practitioners better suited to completely meet the needs of any patient. No matter what one thinks, to become culturally competent, you must start with improving yourself.
Since the turn of the millennium, there has been a steady rise in the demand for cultural competence in the health care workforce. This is the result of the many disparities throughout the health care field. For many minorities, these disparities often result in unequal access to housing, education, and health care, etc. This unequal access makes minorities more susceptible to illness, injuries or even death.
The rapidly changing demographics in the United States is one of the major reasons for an increased understanding of cultural competence. From the very beginning, the United States of America has been a vast melting pot of cultures and customs. We have seen almost 14 million immigrants come into the United States between the years 2000 and 2010, increasing the immigrant population by 28 percent, and thus making it the highest decade of immigration for the United States of America (Camarota, 2011)(5). With this increase, we are sure to see a rise in the need for health care and the challenges that the minorities face to get access to that care. As more and more immigrants come into the United States, they bring along their customs and cultures. These customs impact the way immigrants live their lives to seeking health care, and how they undertake the treatment needed to help in their ailments. Examples range from what type of community the family moves to, who lives in the home with the family, what schools the children go to, religious factors play a role as well. How they seek their care greatly depends on their customs and cultures as well. Health care providers must understand these different aspects of culture when dealing with a minority. Without proper understanding, effective communication and proper treatments are unattainable.
The disparities between whites and non-whites are numerous. A few examples of disparities are: African Americans morbidity and mortality rates are significantly higher than that of whites. Hispanic women contract cervical cancer at twice the rate of white women. In Americans Indians, they are twice as likely to be diagnosed with diabetes (Russel, 2010)(6). One can go on with the amount of disparities there are out there, but the fact remains that without proper access to health care, more people will go without proper diagnosis and treatments.
Another example of disparities in the health care field, is the quality of access provided to children; African American, Latino, and Asian/Pacific Islander children were met with lower rates of access to primary care providers, having no source of care, higher odds of being uninsured, going more than 1 year since last physician visit, as well as higher odds of appendix issues (Flores, 2010)(7). The quality of the care for minority children is also much more disproportionate than compared to white children. Disparities ranging from lower/higher adjusted odds of being assigned healthcare providers, health care communication between physician and patient, shorter child wellness visits, to health care providers not knowing how the parents raise their children. These disparities help only to worsen the trust minorities have not only in the healthcare system but with there physicians as well.
Lower access and quality of access could also be attributed to a lower socioeconomic position. This means that even if someone has healthcare, they may have a lower quality of health. Care plan performance is also compromised by the socioeconomic position a person holds. Examples of this are: fewer tests taken for proper treatments, fewer immunization rates for children, lower quality of hospitalization, lower prenatal care, etc. Although, these disparities have been discussed many times, progress to fix the problems has been slow. In any case, disparities found throughout the health care field mark the time for improvement.
Third, racial bias is still perpetuated in the health care system. For the most part, it is an unconscious bias that stems from the preconceived stereotypes we have of minorities. These stereotypes allow us to make judgments of the patients, which in turn hinders the relationship between the patient and healthcare provider. According to Penner, Blair, Albrecht, & Dovido (2014), racial bias creates disparities in health in “three paths: the discrimination path, the physician decision path, and the physician-patient relationship path”(8). The first path deals with the racial discrimination someone deals with everyday. This gives way to “negative, stress-related psychological responses” (Penner et al, 2014)(9), with consequences to the health of a person. The other two paths deal with the physician bias on judgments and treatment decisions, as well as the indirect effect on the patient from physicians bias. The second path means that a physician will use the negative racial stereotypes of a patient and form their decisions on these stereotypes. The third path involves the doctor-patient relationship. Examples of this path are, faster speech, use of jargon, not allowing the patient to speak, short visit times, etc. (Penner et al. 2014)(10). Each one of these paths can lead a physician to form an ethnocentric, racial, or economical bias towards how they deal with patients. Whether this bias is unconscious or conscious, it is in the health care system and can lead to a lower quality of health care for the patients; and without the proper assessment and action, improvements in these disparities will never happen.
As stated earlier, the United States of America recorded the highest immigration rate for any decade between the years 2000 and 2010 (Flores, 2010)(11). A whooping 28 percent increase in the immigrant population. The number only continues to rise in western cultures. Health care providers and the systems they are a part of need to meet the demands of this ever growing and diverse population. Meeting these demands allow for better communication between physicians and patients, supervisors and subordinates, etc. Ethical conflicts can be resolved much quicker between health care practitioners. It also brings forth personal and professional growth in the physician and his/her abilities.
People with disabilities exist in all societies, yet, how these people are viewed by their cultures and the cultures of other groups is vast. “The cultural interpretation on how society attaches value and meaning to a particular type of disability” (Leavitt, 2006, p. 295)(12). Examples range from the person being held in high esteem by the community, full acceptance as a normal individual, being discriminated against, to being shunned or neglected (Leavitt, 2006, pp. 291-310)(13). There is also a persistent range of variation with regards to how people with disabilities are treated in society. These views affect how a person will live their life and how they go about seeking the treatment they need. Although, as we continue into this new millennium, the models of how people with disabilities, in many western cultures, have become more focused on the human rights of the individuals.
According to Wilson-Stronks, A., Lee, K.K., Cordero C.L., Kopp, A.L. & Galvez, E. (2008), “Culturally competent initiatives targeted to specific populations can help reduce the disparities seen in the service provision and care”(p. 15)(14). As a more diverse population becomes active in our society, programs for understanding these cultures are becoming commonplace in hospitals and other health institutions. Programs range from courses that focus on language, understanding of cultural traditions and rituals, workforce communication skills, to creating a more accommodating physical space (Wilson-Stronks et al, 2008)(15).
Effective communication is defined by Froehlich, J., Roy, M.C., Augustoni, B., Arsenault, A.K., & Eldredge, J. (2014), “the artful interplay between listening and speaking with attention to both verbal and nonverbal communication coupled with an awareness and sensitivity to human diversity”(p. 85)(16). This and language factors play a major factor when dealing with patients of another racial or ethnic background. For example, the first two generations in a Latino family may not understand or have limited access to the English language. This often leads the family to rely on someone in the family who can translate or them, usually a young child or teenager. Effective communication with patients sets the tone for the patients safety and allows for better diagnosis and treatment. Many hospitals and health care institutions have provided their staff with materials and tools to accommodate a more diverse population. Language courses have been provided, technological aids are available, interpreters can be provided, all of which allows the physician to communicate clearly with the patient.
Creating an environment that can accommodate a more diverse population allows for health care systems to be more adaptable when dealing with their patients. The placement of directional signs and information booths that are acceptable and accessible to patients has become more commonplace. Although the use of bilingual signs do help, patients may not be able to interpret the meaning behind the sign. Health care institutions might regard using information booth representatives, or the use of universal “health care symbols” (Wilson-Stronks et al, 2008)(17) to meet the literacy and language needs of the patients (pp. 30-39)(18).
Each of these ways to improve the needs of a culturally diverse population begin with the institution making the necessary guidelines and principles as well as providing programs for their workers. As “health care institutions move towards the elimination of health care disparities, they do so by demonstrating a commitment to the provision of culturally competent care and to building healthy relationships with the communities they serve” (Lefebvre, K., & Lattanzi, 2010, p. 112)(19). A culturally competent health care practitioner is not only able to meet the health care needs of a patient but the cultural needs and demands of the patient as well. Thus building trust between the patient, physician and health care institution.
Another reason for cultural competence in the health care field is the need for proper navigation of the health care system. Culturally diverse patients already have barriers or delays in dealing with healthcare issues. Treatments, diagnosis, appointment schedules, medical test, etc. are all pieces of the same puzzle when dealing with the health care system. To meet the needs and provide proper care to an increasingly diverse population, programs and services are going to be a continuous need and learning process.
“Continuing competence and competency are requirements for one’s current professional responsibilities and is designed to build ones capacity to perform one’s responsibility in the future for a given role”(Rowe, J. 2014, p. 682)(20). Since the implementation of the National Culturally and Linguistically Appropriate Services (NCLAS) in 2001 and the enhanced version in 2013, health care providers and institutions have been able to actively help in the reduction of racial, ethnic, and economical disparities in the health care system. Also, with the enhanced version, health care providers can now address inequalities the patient has every step of the way (Murillo, S., 2013)(21). This means that health care providers can ensure respectful and effective care that is sympathetic to culturally diverse needs.
State-sponsored activities and NCLAS standards have been put in place by 21 states so far, with another 9 states enacting state-sponsored activities to help reduce racial and cultural disparities in the health care system (“Tracking CLAS,” n.d.)(22). In Washington, Oregon, California and New York for example, have set up laws and policies requiring health care practitioners to undergo and complete continuing education courses in order to improve upon cultural and linguistic issues of the diverse patient population. Also, these states, in accordance with the NCLAS standards have provided programs and tool kits for health practitioners to help leaders and mangers address key problems in the healthcare field. One program such as the Developing Equity Leadership through Training and Action (DELTA) in Oregon, that, upon completion of the program, “individuals and their healthcare organizations act as a driving force of equity and inclusion in Oregon’s health promoting systems”(“Oregon DELTA,” n.d.)(23). This DELTA program is a result of Oregon House Bill 2611 being enacted in 2013. Another example of states enacting laws for better cultural competence is Washington State’s law RCW 43.70.615 which “establishes and ongoing multicultural awareness and education program as an integral part of its health profession regulation” (2006)(24). These programs and policies help educate health care practitioners and to bring awareness regarding the the skills and knowledge needed in order to better understand the connection between culture competence and health.
Nine states including Delaware, Kansas and Louisiana for example have set state-sponsored implementation activities in regarding cultural competency. This means that although there is no state law requiring continuing education or cultural competence programs, institutions are still promoting the use of the NCLAS standards. They also provide information online such as Delaware’s Bureau of Health Equity (“Bureau of Health Equity,” n.d.)(25) and Kansas’s What is Cultural Competence (“What is Cultural Competence,” 2012)(26) websites. Be it through reports, training programs, workshops or health plans, health care institutions are seeing that the NCLAS Standards do improve the quality of access and care provided to culturally diverse populations.
As we can see, racial and ethnic disparities still do exist in healthcare. Language barriers, socioeconomic status, racial discrimination, etc. not only hinders a patients access to care and the treatment they get, it also hinders how health care practitioners can help the patients in these situations. Understanding and improving our own racial or ethnic bias, providing a more open environment and the use of effective communication, not only between both physician and patient but also in the hierarchy of an institution can and will eliminate many disparities in health care.
Lastly, there a rise in the need for cultural competence as more states began to enact laws for the implementation of the NCLAS Standards. As well with the enactment of the NCLAS Standards already in law, institutions have begun to right the disparities seen between racial groups. This can only lead to a better and brighter future not only for the culturally and ethnically diverse populations, but for everyone that is part of the health care system in the United States. Everyone of us in the health care system must take part in the implementation and advancement of cultural competence not only for the betterment of our patients but for the improvement of ourselves and society as a whole.
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