Cultural Competence: Introduction
Family practitioners have recognized the importance of cultural competence in health care for many years. “The American Academy of Family Physicians is committed to ensuring high quality of care and patient safety by promoting access for limited English proficient (LEP) patients, cultural proficiency, expanded health workforce diversity, and reduced health disparities in the provision of medical care to our nation’s LEP and racial/ethnic medically-underserved populations. Cultural proficiency is a necessary component for patient safety and adherence. All persons, regardless of race, ethnicity, or primary language deserve access to high quality health services.” (AAFP Position Paper 2008)
The AAFP is not alone, however. Knowledge and skills of cultural competence are recognized as an essential element of quality medical care for America’s diverse population by medical professions (AAFP and American Medical Association), accrediting bodies (Centers for Medicare and Medicaid Services and Joint Commission), organizations that set requirements for medical education (Association of American Medical Colleges and Liaison Committee on Medical Education), and at least five state medical licensure boards.
The US Government embraces and requires culturally competent medical care. In December 2000, the Department of Health and Human Services endorsed the National Standards for Culturally and Linguistically Appropriate Services (CLAS) as a way to achieve the national Healthy People 2010 goal to eliminate health disparities. Indeed, Title VI of the 1964 Civil Rights Act guarantees equal access to federally funded services, regardless of people’s gender, age, race, ethnicity, religion, or national origin, including people of limited English proficiency.
Multiple reports illustrate how quality care for a diverse American population requires a primary care system that is culturally competent and patient-centered. The Institute of Medicine’s (IOM) 2001 report “Crossing the Quality Chasm” documented the failures of the American medical system and asserted that the system must become equitable and patient-centered, as well as safe, timely, efficient, and effective. The following year, the IOM released Unequal Treatment, a powerful critique of how health care providers’ prejudices, biases, and stereotyping contribute to unequal treatment of racial and ethnic minorities.
Given these requirements and mandates for culturally competent quality care, this chapter addresses three topics. Why is cultural competence important? What about culture is important in medicine? And how can physicians provide culturally competent care in clinical settings?
Why Is Cultural Competence Important?
Health, illness, and treatment are strongly influenced by cultural contexts. It may seem strange to practitioners of scientifically based biomedicine that the cultures of providers and patients are major factors in clinical encounters. It is the case, however, that all humans have been socialized from childhood to define and experience the world in ways that are shared with other members of their group. Culture provides concepts, rules, behaviors, and meanings that are basic to and are expressed in the ways people relate to other people, to the supernatural, and to the environment. A person’s culture is like a pair of glasses with just the “right prescription” that is created by socialization and life experiences. Through these cultural lenses, people interpret and categorize the events of the world, rendering the world understandable, orderly, and predictable. Culture is learned, and no single individual is a repository for his or her entire culture. Not all members of a cultural group believe, think, or act in the same manner. This point is very important for health care providers, who must avoid presuppositions about patients based on their participation in particular cultures.
The changing demographics of the United States provide compelling reasons for health care providers to consider the impact of cultural factors on health, disease, and health care. The population is diverse. While the 2010 census results are not yet available, the data from the 2000 census is informative. By 2000, non-Hispanic whites comprised 69.1% of the population, non-Hispanic blacks 12.1%, Hispanics 12.5%, Asians 3.6%, and American Indians 0.7%. The population as a whole will grow more slowly than it has in the past but subgroups within it will have different trajectories, such that the aggregated current ethnic minority populations will eventually outnumber the historic majority of European Americans by 2060. Differential birth and immigration rates influence the changing composition of American society. In the 2000 census, foreign-born individuals comprised 13.3% of the total population, up from 8% in 1990, and in some American cities, more than half of the residents were foreign born. (The 2010 census will soon analyze changes in the last ten years.) While the projected rate of growth in immigrants, refugees, and undocumented foreign-born residents is a highly politicized issue, for providers, it means one thing for sure—cultural differences are in the foreground of the health care arena.
Family physicians must be aware that terms such as race and ethnicity do not have universally accepted definitions. Within medicine, the term “race” usually refers to biological differences between populations that have ancient origins in geographically distinct areas in the world, while the term “ethnicity” is most commonly used to refer to cultural differences, such as beliefs about health, illness, and treatment. Within anthropology, however, race and ethnicity are understood as social categories that humans create for a variety of purposes, such as to describe, understand, influence, or control human behavior.
True, family histories and genetics have biological meaning and thus sometimes racial/ethnic categories are used as surrogate markers for genetics. However, they are rudimentary markers based on population genetics, and are not reliable for individual variations. As mapping of the human genome illustrates, there are more differences within racial/ethnic categories than differences between them. Until the era of “individual genomic medicine” arrives, physicians will have to guard against using stereotypes and assumptions that can occur when ethnic/racial categories are used as biological markers.
In addition, people in racial/ethnic categories do not necessarily share the same cultural values, beliefs, and behaviors. The variations of culture within racial and ethnic categories are staggering, so the categories must not be reified or objectified. For example, not all African Americans are Christians; not all Christians refused to use contraception; not all Middle Easterners are Muslims; not all Muslim women wear headscarves. While these examples may seem obvious, it is too easy for human beings to generalize (and physicians in particular, given biomedicine’s strong training of generalizing from pattern recognition) and to stereotype from generalities.
People from ethnic/racial minority groups have worse health status and health care statistics than people from majority populations. Since 2003, the Agency for Healthcare Research and Quality has published annual National Healthcare Disparities Reports that clearly describe the disparities of quality health care between majority and minority populations in the United States. For instance, African Americans, Native Americans, and Hispanics have worse healthcare outcomes for diabetes, cancer, and cardiovascular disease; have more delay in receiving antibiotics for pneumonia and thrombolytic therapy for heart attacks; have higher rates of postoperative pulmonary embolism and septicemia; have more hospitalizations for uncontrolled diabetes; and report receiving less health care information from health care providers.
These ethnic/racial disparities in health are due to a complex interaction of many factors, from those that increase exposure to disease to those that decrease access to health care. One socioeconomic factor is that people without health insurance and economic resources have worse health care than people with insurance and economic resources. Another factor is that people with limited English proficiency and poor literacy skills have poor quality health care services. However, even after controlling for socio-economic class, ethnic minority groups still have worse health status than majority peoples. Institutional discrimination and individual discriminatory practices in health care settings have been cited as contributing causes, which must be addressed.
Eliminating discriminatory practices based on assumptions of racial/ethnicity categories and based on assumptions of cultural beliefs and values—many of which are unconscious—is an aim of culturally competent care.
An anthropological perspective makes the distinction between disease and illness, with physicians focusing on the biological processes of disease and patients focusing on the experience of the illness. A movement toward patient-centered medical care with emphases on improved communication, patient satisfaction, relevant health information appropriate for patients’ health literacy levels, and primary care medical homes (and hence, improved healthcare outcomes) has been built upon Engel’s bio-psycho-social model to keep patients’ human dimension in the center of medical interactions. Addressing patients’ cultural beliefs, values, and expectations, and incorporating their family and community in the therapeutic process improve health care outcomes.
The patient-centered care approach requires that physicians elicit and respectfully respond to patients’ beliefs, concerns, and experiences with their illnesses—all culturally influenced dimensions. Patient-centered care is culturally competent care.
What About Culture Is Important?
MT was a 72-year-old Hmong woman with a severe headache, blurred vision, and gait instability. A CT scan revealed intracerebellar hemorrhage, and evidence for early pontine herniation. Neurologists and neurosurgeons recommended a craniotomy to evacuate the clot, reduce the pressure, and save her life. The family refused an operation, and left the hospital against medical advice to perform traditional Hmong treatments.
In this situation, and similar situations when patients and physicians have different perspectives about appropriate responses to illness, exploring the cultural issues can be enlightening. This chapter describes seven concepts about the influence of culture on patients and physicians that are pertinent to providing medical care in cross-cultural settings. After the description of each concept, the information is applied to MT’s case.
A word of caution. Readers need to consider the following descriptions of general cultural beliefs and practices as information that illustrates the significance of culture in diagnosing and treating disease and illness. The information should not be interpreted as stereotypical statements about all people from any specific cultural group. Cultural beliefs and practices can vary considerably among members of any one group.
All cultures have an internally consistent system of beliefs about how the body functions normally, how and why it can be influenced by factors that cause it to function abnormally, and how it can be restored to health. Human beings have created many systems of thought about bodily functions and malfunctions: the Chinese system of balance between yin and yang; the Aryuvedic concept of balance in nature; Western systems of biomedicine, homeopathy, and naturopathy; as well as systems indigenous to many ethnic groups. Each culture group’s beliefs about the functioning of the natural, social, and supernatural worlds are germane to its ideas about health, illness, and healing. The natural realm includes ideas about the connections between people and the earth’s elements of soil, water, air, plants, animals, etc. The social realm connotes ideas about individuals and the appropriate interaction between people of different ages, genders, lineages, and ethnic groups. And the supernatural realm includes the religious beliefs about birth, death, afterlife, reincarnation, souls, spirits, and interaction between the spiritual world and the human world.
Application to the case.
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