Cultural Competence in Healthcare

    What is Cultural Competence?

    The U.S. Center for Disease Control (CDC) defines cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.” In this context, culture refers to the integrated, shared patterns of behavior of racial, ethnic, religious, and social groups. These shared patterns include language and other forms of communication, actions, customs, thought, beliefs, values, and institutions. Competence refers to the capacity of an individual or organization to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities.1

    One example of cultural competence is understanding the difference between “translation” and “interpretation.” While a translator converts one written language into another (e.g., reading a document in English and writing it verbatim in Mandarin Chinese), an interpreter orally communicates both the words and their overall meaning to someone in another language and/or dialect. This can require not only fluency in both languages but also a mastery of the local customs, preferences, and idioms that are essential for a full and proper understanding and conveyance of the meaning of the communication (sometimes referred to as “localization”).

    In a healthcare setting, it is vital that patients and providers communicate fully and completely. This helps the providers understand the patient’s complaints, facilitates effective treatment, and helps ensure that the patient understands what medications or follow-up treatments are necessary for the best possible outcome. It also helps foster trust between the medical providers, the patients, and the community at large.

    How Does Cultural Competency Relate to Healthcare?

    According to the American Hospital Association, cultural competence in health care describes “the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring health care delivery to meet patients’ social, cultural, and linguistic needs.”2 Achieving cultural competency in the delivery of health care services can involve overcoming language barriers, bridging the health literacy gap, and navigating social and cultural differences in communication styles. In order to succeed, a healthcare organization must engage in a top-down campaign to encourage cultural competency, from the executive suite to the boots-on-the-ground workers. Executives must foster a culture of inclusion and emphasize the importance of cultural competency, both from ethical and business-savvy perspectives.

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    Barriers to Community Health Goals

    Surprisingly, analyzing persistent big-picture issues through a lens of cultural competency can provide insight into how to solve seemingly insurmountable obstacles. For example, if a certain demographic has been resistant to vaccination, it may be valuable to examine the reasons individuals and communities are falling short of the targeted goals. A culturally competent examination could reveal that a particular neighborhood is failing to access vaccine clinics in accordance with targeted medical goals because its citizens lack reliable internet access to obtain appointments; another neighborhood may lag behind because of a mistrust of social institutions, while a third may have a widely-held inaccurate belief in a deleterious side effect as a result of communications from a community leader. The actions a culturally competent healthcare organization should take to effectively address the issue of low vaccination rates will depend on the specific motivations behind each community group’s hesitancy. Cultural competency can help healthcare providers focus on these issues and develop solutions targeted to address each demographic’s concerns.

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    Disparate Health Outcomes

    Cultural competency can also reveal flaws or weaknesses that disproportionately affect LEP individuals in the healthcare system. For example, patients who speak limited to no English may experience a much greater incidence of medication errors as a result of miscommunication with pharmacists. Providing easy access to interpretation/translation/localization services at the point of service (when patients fill prescriptions) could reduce negative outcomes significantly across this demographic and significantly reduce the rate of re-admission (and subsequently necessary intensive medical interventions).

    How Can LEP Affect Patient Care?

    People with limited English proficiency (LEP), which the US Census Bureau defines as those who report speaking English less than “very well,” constitute about 8 percent of the US population five years and older—a total of nearly 25 million people.3 This population, on average, is less educated than their English-proficient peers and more likely to live in poverty.4

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    Lower Quality Care

    In the context of medical treatment, LEP individuals frequently experience lower quality provider experiences in addition to suboptimal health outcomes. According to the National Academy of Medicine, "racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as patients' insurance status and income, are taken into account."5 Studies have also indicated that LEP patients have longer hospital stays, worse outcomes, and less success with follow-up care or medication.

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    Cultural Competence Promotes Equity

    Striving for cultural competence in healthcare systems can help combat the entire scope of the issues facing LEP individuals and improve their health outcomes. Cultural competency can increase patient engagement and help reduce racial and ethnic disparities. It can improve communication by normalizing the use of interpretive services. It can help bridge the gap and increase trust between patients, families, and communities and their healthcare providers.

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    Health Literacy Challenges

    Compounding the problem, there is a wide disparity in the health literacy rates between LEP and English-speaking patients. Health literacy is the degree to which a patient is able to obtain, process, and understand basic health information in order to make the best health decisions. It is influenced not only by a patient’s personal knowledge, communication skills, and culture, but also by the communication skills of their treating providers. Medical professionals are increasingly noting the correlation between patient health and health literacy, observing that more effective patient comprehension and understanding tends to result in more effective treatment (and patient adherence to recommended treatment, follow-up, and aftercare).

    LEP patients diagnosed with diabetes, for example, are less likely to adhere to their physician’s recommended medication regimen for type 2 diabetes than English-fluent patients; they are also more likely to fall victim to adverse effects caused by pharmacy translation errors.

     

    Studies have consistently shown that LEP individuals receive inferior care compared to English-proficient patients and that they demonstrate reduced understanding of treatment plans and disease processes, less patient satisfaction, and more medical errors resulting in physical harm.6 Some of these disparities are caused by communication barriers, but they also can reflect cultural differences, clinician biases, and ineffective systems.

    How Does Cultural Competence Improve Healthcare?

    • Fostering Community Trust
    • Reducing Inefficiency and Waste
    • Developing More Complete Data

    Fostering Community Trust

    Increasing trust by improving communication allows medical providers to more effectively address issues in their local communities. It is vital to establish a system in which all community members—including LEP patients—feel heard and understood. This enables healthcare providers to not only respond to immediate patient needs but also engage in effective preventive care, inform the public of new health risks, and respond to emergent public health issues.

    Reducing Inefficiency and Waste

    From a business perspective, decreasing language barriers and other obstacles to effective communication can improve efficiency, reduce redundancy, and decrease wasted time and resources. For example, educating a team about the resources available, standard operating procedures, and recommended best practices for LEP patients can reduce the amount of time a patient waits for care while their team locates and contacts appropriate translation, interpretation, and/or localization services.

    Developing More Complete Data

    Another benefit to improving cultural competency is developing a more complete collection of patient data. This has health benefits that are both immediate and long term. Rather than struggling through each interaction as a discrete event, a health care team that understands a patient’s overall health needs and risks can both better treat current conditions and more effectively develop care plans to prevent future issues and treat chronic conditions.

    Cultural competence in a hospital or care system can lead to numerous benefits for the organization, patients, and community, including improved health outcomes, increased respect and mutual understanding from patients, and increased participation from the local community. From a business perspective, culturally competent organizations may enjoy lower costs and fewer care disparities.7

    How Can an Organization Become More Culturally Competent?

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    Cultural Competence vs. Cultural Awareness

    Cultural competence is more than learning about and being sensitive to the needs of a population (generally referred to as “cultural awareness” or “cultural sensitivity”). Cultural competency emphasizes the idea of effectively operating in different cultural contexts and altering practices to specifically address and connect with different cultural groups.8 Beyond just learning about cultural similarities and differences, cultural competency requires organizations to take action and implement structural change.

    In order to become culturally competent, a health care organization must begin by establishing a practice of developing skills for communication and interaction across cultures. This involves learning about different cultural practices and world views, particularly those that affect the organization directly; developing positive attitudes towards cultural differences; and cultivating an awareness of one’s own world view. It also involves identifying the specific regional, cultural, ethnic, and sociological challenges and differences in its surrounding community.

    For an organization to reach cultural competency, however, merely obtaining this knowledge is not enough. Becoming a culturally competent health care organization requires implementing systems to recognize cultural differences, increase knowledge, locate resources, educate care providers on how to access and utilize resources, and promote an attitude of positivity and inclusion that fosters connection and communication.

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    CDC Guidance

    This, according to the CDC, is what differentiates cultural competence from awareness. Competence is “the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.” The CDC advises that the core principles of cultural competence include:

    • Defining culture broadly (to include race, religion, age, and other characteristics that set apart a particular demographic)
    • Valuing patients’ cultural beliefs
    • Recognizing complexity in language interpretation (e.g., differences in regionalism, localization, dialect, and more)
    • Facilitating learning between providers and communities
    • Involving the community in defining and addressing service needs
    • Collaborating with other agencies
    • Professionalizing staff hiring and training (e.g., establishing protocols and best practices)
    • Institutionalizing cultural competence as an expectation.10

    Implementing training programs, policies, and standards that are culturally and linguistically appropriate should, ultimately, make a positive difference in the community. Trained staff working with certified medical interpreters can effectively bridge the communication gap between LEP patients and medical providers. Ideally, this results in improvement both at the patient level (better patient outcomes) and at the community level (improved public health metrics).

    Practical Steps

    Cultural competence is a goal, not a benchmark. As demographics shift, public health needs evolve, and communities change, organizations must remain cognizant and adaptable. This never-ending journey involves reflecting, learning, and participating, both on an individual and a systemic level. A culturally competent healthcare provider nurtures its workers’ skills, desire, and empathy while providing them with a framework to easily access the resources they need to connect and communicate effectively with their patients.

    The CDC recommends that a health care organization seeking to become culturally competent first take steps to understand the local community and the role it plays in the larger community. The organization should collect data using surveys of the local community regarding how it can best serve the its members. Then, it should analyze that data and communicate its findings in order to determine priorities. Once it establishes its goals, it should educate its staff and align its programming and resources to meet its specific community needs.

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    Translation and Interpretation Resources

    In certain markets, developing a bilingual or multi-lingual translation and interpretation program in house and employing expert interpretation staff members will be an efficient way to address local demographic needs. However, not all healthcare communities have the resources on staff to employ full-time or on-call expert interpreters. Some communities may wish to contract with individuals to perform professional interpretation tasks on an on-call basis to connect to diverse local populations. Other health care providers, especially those that serve very diverse communities from a variety of backgrounds who may speak a wide range of languages, may wish to contract with a professional communication and interpretation company for LEP patients. This option is an excellent way to ensure access for a wide variety of patient demographics.

    Specific programs can help providers address the link between social determinants of health, such as literacy, and their disproportionate impact on LEP individuals. Utilizing the resources offered by professional translation and interpretation providers can help populations with LEP receive better healthcare communication in their language. These can include

    • Language-specific appointment setting and follow-up support
    • Health literacy materials for inpatient and outpatient care
    • Patient experience mapping and needs analysis
    • Dedicated customer service lines based on language.

    Services like video remote interpreting can provide on-demand, full-service, virtual interpretation at the touch of a button. These advances in technology could significantly improve the patient experience as well as streamline patient care.

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    Educating Staff for Cultural Competence

    Numerous factors are motivating hospitals and care systems to become culturally competent. These include the desire to more effectively help patients achieve the best possible outcomes and a commitment to improving overall public health as well as the practical motivations of increasing efficiency, reducing wasted resources, and improving cost/benefit ratios.

     

    Training hospital staff to recognize and understand the cultural and clinical dynamics in interactions with patients is a top-down objective. Achieving cultural competency involves developing and acquiring the skills needed to identify and assist patients from diverse cultures, so that every member of an organization’s staff can quickly identify the services required by a patient and increase positive health outcomes.

    The CDC advises that an effective educational or training program for cultural competence is inextricably linked with a lasting awareness and understanding by hospital staff. It recommends a four-step training process:

    1. Cultural assessment
    2. Multiple training methods
    3. Ongoing education
    4. Measurement and tracking.

    From start to finish, these steps involve taking a frank look at the needs of the community and how well they are (or aren’t) being met; conducting in-person and simulated training, including interactions between community and staff; repeating and reviewing training exercises; and measuring and tracking data to monitor efficacy and improvement.

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    National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Healthcare

    The US Department of Health and Human Services (office of Minority Health) released the National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care in 2000. HHS notes that providing culturally and linguistically appropriate services (CLAS) is “a way to improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and achieve health equity. CLAS is about respect and responsiveness: Respect the whole individual and [r]espond to the individual’s health needs and preferences.”11

    In 2013, the department updated the standards and released a blueprint with guidance and implementation strategies.12 This update expanded upon the concepts of culture, reflecting new developments and trends in healthcare and emphasizing the role of leadership and governance as drivers of culturally competent and equitable health care. Its principal standard remained unchanged: “to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.” The agency noted that

    The pursuit of health equity must remain at the forefront of our efforts; we must always remember that dignity and quality of care are rights of all and not the privileges of a few.

    The CLAS standards note that “[t]hough health inequities are directly related to the existence of historical and current discrimination and social injustice, one of the most modifiable factors is the lack of culturally and linguistically appropriate services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of all individuals.” Health organizations that wish to achieve cultural competence may be best served by addressing the practical, immediately addressable cultural and linguistic needs of their patient populations by partnering with a professional interpretation and translation service.

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    NCQA Accreditation

    In order to achieve distinction in multicultural healthcare, an organization needs a comprehensive strategy to improve its response to the health care needs of minority members and those with limited English proficiency (LEP). The National Committee for Quality Assurance (NCQA) Multicultural Healthcare (MHC) accreditation is widely recognized as the seal of approval in healthcare. Pursuing accreditation from the NCQA can help an organization

    • Identify gaps in care (data, policy and practice)
    • Establish standardization criteria
    • Equitably serve all customers and communities
    • Build a plan to address disparities
    • Identify opportunities for improved and enhanced patient experiences.

    Taking these steps to correct inequities often leads to improved outcomes, decreased costs, and improved satisfaction ratings from members, providers, and community members.

     

    The bottom line is that improving communication between healthcare providers and patients improves the healthcare experience for everyone involved. Patients experience a better quality of care and improved outcomes; healthcare providers improve efficiency, save money, and deliver better patient care. If your healthcare organization is interested in improving its cultural competence, contact us today.

    References

     

    1Cultural Competence In Health And Human Services. CDC.gov. https://npin.cdc.gov/pages/cultural-competence. Published October 21, 2020. Accessed March 20, 2021.

    2Becoming a Culturally Competent Health Care Organization. AHA.org. https://www.aha.org/system/files/hpoe/Reports-HPOE/becoming-culturally-competent-health-care-organization.PDF. Published June 2013. Accessed March 20, 2021.

    3Detailed Languages Spoken at Home and Ability to Speak English for the Population 5 Years and Over: 2009-2013. Census.gov. https://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html. Published October 2015. Accessed March 20, 2021.

    4Zong, Jie and Batalova, Jeanne. The Limited English Proficient Population in the United States in 2013. MigrationPolicy.org. https://www.migrationpolicy.org/article/limited-english-proficient-population-united-states-2013. Accessed March 20, 2021.

    5Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, 2003. doi:10.17226/10260. Accessed March 23, 2021.

    6Alexander R. Green, MD, MPH and Chijioke Nze. Language-Based Inequity in Health Care: Who Is the ‘Poor Historian’? AMA J. Ethics. 2017;19(3):263-271. doi:10.1001/journalofethics.2017.19.3.medu1-1703. Accessed 20 Mar 2021.

    7Becoming a Culturally Competent Health Care Organization. AHA.org. https://www.aha.org/system/files/hpoe/Reports-HPOE/becoming-culturally-competent-health-care-organization.PDF. Published June 2013. Accessed March 20, 2021.

    8Cultural Competence in Health and Human Services. CDC.gov. https://npin.cdc.gov/pages/cultural-competence. Published October 21, 2020. Accessed March 20, 2021.

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    11What is CLAS? HHS.gov. https://thinkculturalhealth.hhs.gov/clas/what-is-clas. Accessed March 21, 2021.

    12National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. HHS.gov. https://thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf. Published 2013. Accessed March 21, 2021.

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