Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowledge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective patient-centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ from his or her own. This adaptability, coupled with a genuine curiosity about a patient’s beliefs and values, lay the foundation for a trusting patient-provider relationship.
A Definition of Culture
Culture , in its broadest sense, reflects the whole of human behavior, including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination. Language is a part of culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups. Each group is identified by a particular body of shared traits (e.g., a particular art, ethos, or belief; or a particular behavioral pattern) and is rather dynamic in its evolving accommodations with internal and external influences. Any individual may belong to more than one group or subgroup, such as ethnic origin, religion, gender, sexual orientation, occupation, and profession.
Distinguishing Physical Characteristics
The use of physical characteristics (e.g., gender or skin color) to distinguish a cultural group or subgroup is inappropriate. There is a significant difference between distinguishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group leads to misunderstandings about the individual. The stereotype, a fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. People can and do respond differently to the same stimuli. Stereotyping occurs through two cognitive phases. In the first phase, a stereotype becomes activated when an individual is categorized into a social group. When this occurs, the beliefs and feelings (prejudices) come to mind about what members of that particular group are like. Over time, this first phase occurs without effort or awareness. In the second phase, people use these activated beliefs and feelings when they interact with the individual, even when they explicitly deny these stereotypes. Multiple studies have shown that healthcare providers activate these implicit stereotypes, or unconscious biases, when communicating with and providing care to minority patients ( Stone and Moskowitz, 2011 ). With this in mind, you can begin learning cultural competence by acknowledging your implicit, or unconscious, biases toward patients based on physical characteristics.
At the same time, this does not minimize the value of understanding the cultural characteristics of groups, nor does this deny the interdependence of the physical with the cultural. Genotype, for example, precedes the development of the intellect, sensitivity, and imagination that leads to unique cultural achievements, such as the creation of classical or jazz music. Similarly, a person’s phenotype, like skin color, precedes most of the experience of life and the subsequent interweaving of that phenotype with cultural experience. Although commonly used in clinical practice, the use of phenotypic traits to classify an individual’s race is problematic. The term race has been used to categorize individuals based on their continent or subcontinent of origin (e.g., Asian, Southeast Asian). However, there is ongoing debate about the usefulness of race, considering the degree of phenotypic and genetic variation of individuals from the same geographic region ( Relethford, 2009 ). In addition, the origins of race date back to the 17th century, long before scientists identified genetic similarities. Over time, beliefs about particular racial groups were shaped by economic and political factors, and many believe race has become a social construct ( Harawa and Ford, 2009 ).
Genomics and Personalized Medicine
A growing body of research examines genetic markers associated with racial and ethnic groups and potential interactions with environmental determinants in predicting disease susceptibility and response to medical treatment. An explosion of genome-wide association studies (GWAS) are attempting to link genomic loci, or single-nucleotide polymorphisms (SNPs) with common diseases such as rheumatoid arthritis, type 1 and type 2 diabetes mellitus, and Crohn disease ( Visscher et al, 2012 ). Personalized medicine, as defined by the National Cancer Institute, is “a form of healthcare that considers information about a person’s genes, proteins and environment to prevent, diagnose and treat disease” ( Su, 2013 ). Direct-to-consumer genetic testing is rapidly evolving and will likely become more affordable and accessible to our patients. Healthcare providers in all disciplines will need to become fluent in the language of genomics and learn how to discuss risks and benefits of gene testing with their patients and families ( Calzone et al, 2013 ; Demmer and Waggoner, 2014 ). With this new emphasis, it will be perhaps even more important to acknowledge unconscious biases and seek to understand the patient’s unique cultural and personal health beliefs and expectations.
Cultural Competence
Culturally competent care requires that healthcare providers be sensitive to patient’s heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background ( Cuellar et al, 2008 ). Many models have been proposed to teach cultural competence. Most include the domains of acquiring knowledge (e.g., understanding the meaning of culture), shaping attitudes (e.g., respecting differences of individuals from other cultures), and developing skills (e.g., eliciting patient’s cultural beliefs about health and illness) ( Saha et al, 2008 ). Some of these domains overlap with core aspects of the patient-centered care model ( Fig. 2.1 ). Seeleman et al (2009) have proposed a framework for teaching cultural competence that emphasizes an awareness of the social context in which specific ethnic groups live. For ethnic minority individuals, assessing the social context includes inquiring about stressors and support networks, sense of life control, and literacy. In doing so, healthcare providers will need to be flexible and creative in working with patients. Campinha-Bacote’s (2011) Process of Cultural Competence Model is another approach and includes five cultural constructs: encounters, desire, awareness, knowledge, and skill. Box 2.1 defines these five constructs.
CULTURAL ENCOUNTERS—The continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge.
CULTURAL DESIRE—The motivation of the healthcare professional to “want to” engage in the process of becoming culturally competent, not “have to.”
CULTURAL AWARENESS—The deliberate self-examination and in-depth exploration of one’s biases, stereotypes, prejudices, assumptions, and “isms” that one holds about individuals and groups who are different from them.
CULTURAL KNOWLEDGE—The process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups.
CULTURAL SKILL—The ability to collect culturally relevant data regarding the patient’s presenting problem, as well as accurately performing a culturally based physical assessment in a culturally sensitive manner.
Cultural Humility
Cultural humility involves the ability to recognize one’s limitations in knowledge and cultural perspective and be open to new perspectives. Rather than assuming all patients of a particular culture fit a certain stereotype, healthcare providers should view patients as individuals. In doing so, cultural humility helps equalize the imbalance in the patient-provider relationship. ( Borkan et al, 2008 ). A provider may know many specific details about a patient’s particular culture, yet not show cultural humility. Cultural humility involves self-reflection and self-critique with the goal of having a more balanced, mutually beneficial relationship. It involves meeting patients “where they are” without judgment to avoid the development of stereotypes. Attaining cultural humility is an ongoing process shaped by every patient encounter that involves openness, partnership, and genuine interest in understanding our patients’ belief systems and lives ( Fahlberg et al, 2016 ).
The Impact of Culture
The information in Box 2.2 suggests that racial and ethnic differences, as well as social and economic conditions, may affect the provision of specific healthcare services to certain groups and subgroups in the United States. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups. Although death rates have declined overall in the United States over the past 50 years, the poorly educated and those in poverty still die at higher rates from the same conditions than those who are better educated and economically advantaged. Morbidity, too, is greater among the poor. Data from the 2013 Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report reveal a variety of healthcare disparities. A significantly higher rate of Hispanic and non-Hispanic blacks were uninsured compared with Asian/Pacific Islanders and non-Hispanic whites. The infant mortality rate among infants born to non-Hispanic black women is more than double the rate for infants born to non-Hispanic white women. Compared with white women, a much higher percentage of black women die from coronary heart disease before age 75 (37.9% versus 19.4%). This same difference was observed between black and white men (61.5% versus 41.5%) (CDC, 2013). These rather stark facts are sufficient to underscore the need for cultural awareness in health and medical care professionals. Cultural and practice differences exist among healthcare professionals as well. Allopathic providers often demonstrate skepticism regarding the use of complementary and alternative medicine (CAM) without considering the possibility of potential benefit to patients.
Age, gender, race, ethnic group, and, with these variables, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care. Consider, for example, the ethnic and racial differences in the treatment of depression in the United States. The prevalence of major depressive disorders is similar across groups; however, compared with white Americans, black and Latino patients are less likely to receive treatment. Although some of the disparity is related to differing patient attitudes and perceptions of counseling and medication, there is growing evidence suggesting clinician communication style and treatment recommendations differ on the basis of patient race and ethnicity ( Shao et al, 2016 ). Similarly, in the pediatric population, black and Latino children in the United States also experience health disparities, including lower overall health status and lower receipt of routine medical care and dental care compared with white children. Flores and colleagues (2010) , in a systematic literature review, demonstrated that, compared with white children, black children have lower rates of preventive and population health care (e.g., breast-feeding and immunization coverage), higher adolescent health risk behaviors (e.g., sexually transmitted infections), higher rates of asthma emergency visits, and lower mental health service use. There is a clear need to better understand why these differences exist more globally, but removing cultural blindness at the individual patient level is an important first step.
Furthermore, the possible beneficial and harmful effects of many culturally important herbal medicines, which are used but not always acknowledged, must be understood and, in trusting relationships, reported to us if we are to guide their appropriate use. Crossing the cultural divide helps, but skepticism is a barrier. For example, many allopathic medical providers question the notion that complementary and alternative medicine might be a helpful adjuvant therapy for the prevention and treatment of acute otitis media. However, in several randomized controlled studies, xylitol, probiotics, herbal ear drops, and homeopathic treatments have been shown, compared with placebo, to have a greater effect in reducing pain duration and decreasing the use of antibiotics. Although skepticism can be put aside, evidence-driven guidance is still essential. Cultural competence is entirely consistent with that.
The Blurring of Cultural Distinctions
Some cultural differences may be malleable in a way that physical characteristics are not. For example, one group of people can be distinguished from another by language (see Clinical Pearl, “Language Is Not All ”). However, globalization, the growing diversity of the U.S. population, and evidence of healthcare disparities mandate more and more that we learn one another’s languages. Although modern technology and economics may eventually lead to universality in language, we can begin by acknowledging and overcoming our individual biases and cultural stereotypes. Because it is impossible to learn the native languages of all of our patients, when language barriers arise, we must become aware of our resources and know how to effectively use interpreters ( Seeleman et al, 2009 ). Use of medical interpreters has a positive impact on healthcare quality, but we continue to use suboptimal methods of communication (e.g., family members). Although greater adoption of medical interpreter use involves policy and system-level changes, healthcare provider training and encouragement remain critically important ( DeCamp et al, 2013 ).
A patient who knows the English language, however well, cannot be assumed to know the culture. Consider the diversity of the populations in Britain, India, American Samoa, and South Africa who are English speaking. The absence of a language barrier does not preclude a cultural barrier. You will likely still need to achieve a “cultural translation.”
The Primacy of the Individual in Health Care
The individual patient may be visualized at the center of an indefinite number of concentric circles. The outermost circles represent constraining universal experiences (e.g., death). The circles closest to the center represent the various cultural groups or subgroups to which anyone must, of necessity, belong. The constancy of change forces adaptation and acculturation. The circles are constantly interweaving and overlapping. For example, a common experience in the United States has been the economic gain at the root of the assimilation of many ethnic groups. Although this results in greater homogeneity among the population, an individual’s gender, ethnic behaviors, or sexual orientation and identity will likely be unique. Predicting the individual’s character merely on the basis of the common cultural behavior, or stereotype, is not appropriate. Based on the Joint Commission 2010 report, “Checklist to Improve Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Across the Care Continuum,” White and Stubblefield-Tave (2016) remind us that unconscious bias, stereotyping, racism, gender bias, and limited English proficiency underlie healthcare inequalities. They offer their own checklist of recommendations for healthcare providers to address these issues with the goal of reducing disparities in care ( Box 2.3 ).
This modified “culturally competent checklist” is provided as a guide to help providers partner with patients and families to provide high-quality care. Although some items are simple, others are quite complicated and difficult to achieve. On our path to achieving cultural humility, we should strive to incorporate as many of these recommendations as possible into our routine clinical practice.
- 1.
Humanize your patient.
- 2.
Identify and monitor conscious and unconscious biases.
- 3.
Do a teach-back.
- 4.
Help the patient to learn about his or her disease or condition.
- 5.
Welcome a patient’s friend, partner, and/or family members.
- 6.
Learn a few key words and phrases in the most common languages in your area.
- 7.
Use a qualified medical interpreter as appropriate.
- 8.
Be aware of the potential for “false fluency” (clinician language skill should be tested and certified).
- 9.
Seek training in working with an interpreter.
- 10.
Consider the health literacy of one’s patients.
- 11.
Respond thoughtfully to patient complaints.
- 12.
Hold one’s institutions accountable for providing culturally and linguistically competent care.
- 13.
Advocate that the affiliated institution’s analyses of patient satisfaction and outcome include cultural group data and that the results lead to concrete action.
- 14.
Encourage patients to complete patient satisfaction and demographics forms.
Ethical issues often arise when the care of an individual comes into conflict with the utilitarian needs of the larger community, particularly with the recognition of limited resources and, in the United States, rising healthcare costs. Cultural attitudes of our patients, at times vague and poorly understood, may constrain our professional behavior and confuse the context in which we serve the individual. Box 2.4 offers a guide to help understand the patient’s beliefs and practices that can lead to individualized, culturally competent care. Particular attention should be paid to caring for patients who self-identify as being lesbian, gay, bisexual, and transgender (LGBT). Unfortunately, these individuals face discrimination and disrespect in the healthcare setting. Thus, it is imperative that healthcare providers invest time in becoming culturally competent and develop cultural humility to work effectively with LGBT patients. Specific responsibilities include providing a welcoming and safe environment, gathering a history with sensitivity and compassion, and performing a physical examination using a “gender-affirming” approach (i.e., using the correct name and pronouns). Box 2.5 provides useful terminology ( Center for Excellence for Transgender Health, 2016 ).
