Introduction
The United States is arguably the most culturally diverse nation on the planet; this situation is, additionally, becoming more pronounced as more people are seeking to immigrate to countries with bigger economies, such as the American one. The healthcare system, which was designed in areas where the population was more homogeneous, has had to face the challenge of handling a population that has a very diverse cultural background; thus making many of the former approaches obsolete in regards to culture.
The healthcare system, therefore, needs to adapt quickly to the ever-changing demographics; to respond to the patients’ needs, values and perceptions, and lifestyle; and how these factors affect their health. If the system cannot adapt quickly enough, then the health of the minority groups may be in serious jeopardy; indeed, cultural incompetence has been shown to contribute to the disparity demonstrated among people from minority cultural and ethnic minorities.
However, despite the need for having a versatile healthcare system vis-à-vis cultural diversity, the system still faces barriers that prevent the healthcare providers from showing more sensitivity. Some of the barriers include cultural homogeneity in the staff manning these facilities; lack of organizational infrastructure to handle patients from diverse cultural backgrounds; and lack of initiative and motivation to make the healthcare system culture-friendly (Woloshin, 1995).
Culture and Cultural Sensitivity
Cultural competency describes a situation whereby the policy and approaches in an organization are formatted in a manner that takes into account the cultural differences of the target clientele, and offers services that are either specially formatted for each of the different cultural groups, or has systems that are versatile enough to respond to challenges offered by this diversity. In the healthcare industry, this would mean that minority status would not relegate a patient to poor or incomplete services. A sustained effort to achieve competency would not only ensure the health of minority individuals visiting the healthcare agency, but it would improve the overall health of the population and would empower such communities to take more charge of their welfare.
Proper competency programs would have to find a way of factoring in the cultural practices of individuals or communities into the traditional medical and nursing practices; this would enable the medical practitioners to navigate the water of multicultural practices; avoiding traps that commonly result in alienation of minority individual and whole communities from the healthcare system.
Culture can be described as a set of learned beliefs that are shared by a group of people who identify themselves as a distinct entity within the larger society. Such a group shares factors that identify them; such include language, art, customs, religion, attire, taboos, social structure, and values (Robins et al, 1998; Donini-Lenhoff and Hedrick, 2000). Additionally, the way the culture of an individual is portrayed or perceived is affected by gender, sexual orientation, age, and socioeconomic status.
An emerging field
As mentioned before, cultural incompetence results in disparities in health affecting the minority section of the population; such would result from various factors such as poor communication, disregard for cultural beliefs/taboos/practices of the patient or language barriers; sentiments of racial discrimination or segregation; and mistrust (Denboba et al, 1998; Gornick 2000).
In response to the problem posed by existing and increasing disparity, a new field, cultural competence, has merged. The main aim of this field is to reduce/prevent disparities in access and quality of healthcare services in minority populations. The effects of achieving this goal would be twofold; on one side, the proportion of the population disadvantaged by the system would get relieved from the disparity plaguing them; on the other, the healthcare industry will be set to expand to the growth of the clientele base to populations that were underserved by it.
Health disparity and chronic disease management
The disparity in health as determined by racial and ethnic origin has been shown to affect in particular the management and outcome of chronic diseases. There is a disproportionate distribution of prevalence of diabetes, heart disease, and obesity among minority populations in the United States. This disparity has been blamed on (among other things) the lifestyle, socioeconomic status, and ineffective or non-existent primary preventive measures.
Additionally, while the whole healthcare system has serious flaws in regards to the effective management of chronic diseases (due to its fragmented nature); the minority population has borne the brunt of this situation; generally, minorities show poor outcomes and higher mortality rates from chronic diseases and their co-morbidities than the general populations. This disparity is bound to increase with the ever-changing demographics of the country in favor of cultural and ethnic diversity.
Literature Review
The lack of preparedness to handle existing and increasing diversity in the American population has been widely recognized; in addition, the effect of this on the general health of the minority population has also been noted as causing disparities in quality and access to healthcare services.
In an attempt to decipher how the problem occurred in the first place, barriers to competence have been discovered. These include lack of diversity among the staff in the healthcare industry (Woloshin, 1995); poor organizational infrastructure (that is not designed to handle a culturally diverse population); and inefficient communication between diverse patient and healthcare service providers. The elimination of these barriers would also remove their significant contribution to the health disparity seen among populations from a minority cultural, racial, or ethnic background.
Culture
The emergence of the cultural sensitivity concept has prompted investigators into the subject of defining culture especially in the context of the health of the individual and the population encompassed by the parameters of the culture. The culture of an individual/population is made up of the values, practices, taboos, customs, beliefs (Donini-Lenhoff and Hedrick, 2000; Robins et al, 1998); these are shaped by various factors working in isolation or combination; including the socioeconomic status, race, sexual orientation, gender, nationality, physical state, age, citizenship status et cetera. All these factors act to determine how people carry themselves; how they view the culture of others; and how people from other cultures perceive them. The result is that a group can be identified as distinct and unique from the general population.
Diversity
The American population is experiencing reduced cultural homogeneity. There has been a misconception that the United States is a ‘melting pot of cultures; whereby various cultures are merged resulting in a homogenous ‘American culture’. The reality, however, is that the American population is a patchwork of cultures; whereby every distinct group goes to some length to preserve their unique identity in the face of encroaching hegemony.
As a result, the United States population is arguably the most culturally diverse in the world. This trend is predicted to increase; according to the 2000 United States census, the next century is going to witness an unprecedented increase in ethnic diversity (USBC, 1999) (see figure 1).
Unfortunately, the healthcare industry has not demonstrated the capacity to handle the prevailing and future increases in diversity. This has resulted in the disparities being currently experienced in access and quality of healthcare services provided by the healthcare industry to minority groups including African-Americans, Hispanics, Asian/Pacific Islanders, native-Americans, and Alaska-Natives.
Disparities in healthcare
As mentioned before, there has been an acknowledgment of the disparity that exists in quality and access to healthcare services among minority groups. This disparity is caused by several factors working in isolation or combination; such include the socioeconomic status and its influence; such as the ability to pay for medical insurance. Healthcare experts have isolated the shortcomings of the healthcare sector as contributing significantly to this disparity.
Some of the factors may include the ability of the patient to recognize symptoms and syndromes of the disease; the threshold for seeking medical care (and the issues that would prevent a suffering person from seeking care such as mistrust and discrimination); the willingness to undergo some of the diagnostic and/or treatment procedures (as some may go against the belief system of the patient’s culture); and the ability to understand the treatment and lifestyle changes required to complete the recovery process (Denboba et al, 1998; Gornick 2000).
Cultural competency
Key in achieving cultural competency is the healthcare workforce; any improvement to the way minority group patients are treated in the system must involve the acquisition of skill and changes in attitudes among the medical professionals who form the first line of the system. The ultimate goal, therefore, of any cultural competency program is to develop a workforce that can deliver a standard quality of care to all people regardless of race, ethnicity, or English proficiency. In the long run, such achievements would result in a system that can handle a diverse society. Additionally, this would reduce the disparities (Denboba et al, 1998).
Barriers to Culturally Competent Care
The key to solving any problem is understanding why it occurs in the first place. For the prevailing cultural incompetence, several of these factors have been identified as contributing to the problem.
Lack of Diversity in healthcare management and staff
Many authors have incriminated the hegemony in the healthcare management and workforce as a barrier to the provision of culturally sensitive services. In the United States, where minorities represent approximately 28% of the total population, they only account for 3% of the teaching staff in medical school, and 17% of the health officers in county and city healthcare institutions (Collins et al, 1999). Many other statistics have shown similar trends in the composition of healthcare workers (see figure 2).
Additionally, minority groups are generally underrepresented among healthcare professionals (see figure 3). Studies have linked the racial composition of the healthcare workforce with the quality of care provided to minority patients. Additionally, there has been a recognition of the racial concordance between physician and the patient- such that patients perceive better services when delivered by a person with whom they share a racial and/or ethnic background (Saha et al, 2000; Morales et al, 1999; Copper-Patrick et al, 1999).
Patient satisfaction has been linked with the clinical outcomes of some of the conditions; such as control of blood pressure (Orth et al, 1987; Putman et al, 1985; Moy and Bartman, 1995). In addition to this, doctors from a minority ethnic/racial background have been shown to serve a large proportion of minority patients (Saha et al, 2000; Moy and Bartman 1995; Komaromy et al, 1996).
Poor organizational infrastructure
The healthcare system was designed in an era where diversity was not as pronounced and increasing as it is today. As such, some systems are incapable of serving the current society (Flores & Vega, 1998). Several sectors have been deemed wanting. One of the major concerns is the language barriers (Woloshin, 1995); in systems that do not have provisions for interpretation and those that do not format the health education in languages that can be understood by minority patients have lower patient satisfaction; experience higher rates of poor adherence to medical regimes; and have poorer health outcomes for minority patients (Carrasquillo, 1999; Baker et al, 1998).
Inefficient communication
Apart from obvious language barriers, there also are other factors that stand in the way of fluent communication between a patient and a health worker; and that contribute to the delivery of unsatisfactory services (Ayanian & Epstein, 1991). This arises when such a worker fails to see or disregard the cultural differences between themselves and their clients, such results in patient dissatisfaction and the expected poor clinical outcomes (Bentacourt et al, 1999). Additionally, when such a provider fails to put any effort in appreciating the clients’ culture, (they) often depend on anecdotal information and stereotyping; which may affect their management of the patient and the making of crucial clinical decisions.
Achieving Cultural Competence
To achieve cultural competency, deliberate steps have to be taken to remedy the various shortcomings affecting the system; and contributing to the poor quality of services for minorities.
Organizational cultural competence
Systems should be put in place to develop a cadre of minority healthcare managers (leaders) and professionals in the healthcare system to address the existing under-representation. Such would serve both to improve patient satisfaction at the service delivery points and to increase cultural sensitivity at the policy formulation level.
Additionally, during the formulation of policies on the delivery of healthcare, representatives of minority populations should be invited as stakeholders in both the process and the outcome.
Systemic cultural competence
The structure of the healthcare system has to be reformed to enable it to handle the current diversity and to be flexible enough to handle the expected demographic change. To achieve this, a lot of information has to be collected from the target communities to recognize the needs that have not been fulfilled.
Some of the interventions that can be instituted to achieve systemic competency include having full-time interpreters on-site for facilities located within communities with a large number of the concerned community; and having a mechanism of getting such services within short notice for less common languages. Additionally, health promotion information should be written in the relevant language or English but taking into consideration the English proficiency of the target population.
The effort to detect medical errors due to systemic cultural incompetence should be stepped up to improve the targeting of interventions to reduce this. The drive to improve cultural competence should be incorporated into the standards using Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and by the National Committee for Quality Assurance (NCQA) to measure the quality of services offered by healthcare providers.
Finally, the situation has to be constantly monitored through a rigorous collection of information to determine whether the interventions are benefiting the population they were targeted at.
Clinical cultural competence
Healthcare professionals have to be acutely aware of how culture can affect the health beliefs of a person. Additionally, they have to be prepared to handle diversity through appropriate training. They also must learn to appreciate the role of the patient as a stakeholder in the process and outcome of treatment and empower them to take more charge of their medical regime.
To achieve this, training programs should be developed and instituted both as professional development courses and incorporated into the curricula of medical training institutions. On the other hand, the patients themselves should be educated on how to transcend smoothly from one level of the healthcare system to the other; and to take more charge of their management in the system.
Expected Benefits of Cultural Competency Programs
Many of the expected outcomes of instituting cultural competency programs across the healthcare system are based on postulations rather than direct linkage; the explicit connection has however been made between reduction of the language barrier and improvement in the quality of service provided to minority patients. However, the overall expectation for these programs is the reduction of the disparity in health currently afflicting minority populations in the United States.
In order, however, to attain the goals of improving cultural competence is ensure that the changes will be worthwhile to both public and private healthcare purchasers. As such, any effort to change the system should be approached as a partnership whereby the various stakeholders are allowed to influence the process for the best of their interest to avoid resistance which would cripple the whole process. This is especially in the view that some of the players in the system have vested interests that would be adversely affected by the expansion of services to include underserved groups; or affected by standards that would be formulated to ensure industry-wide cultural competency and enforced, for example by the Joint Commission on Accreditation of Healthcare Organizations.
The desirable outcome, that is reducing the disparity in health among minorities caused by cultural incompetence in the healthcare system cannot be achieved through bulldozing and arm twisting; the only way forward is education, wide consultation, and consensus by the various stakeholders in the industry. If however achieved, this will constitute a major step in improving the general health not only by the minority population but that of the American society at large.
Conclusion
The American population is rapidly losing the homogeneity of the past; and is quickly becoming increasingly fragmented vis-à-vis cultures. The healthcare industry has not effectively responded to these demographic changes. This has resulted in the development of a disparity in the access and quality of healthcare services offered to minority patients.
Given the increasing proportion of minority communities in the United States and the increasing number of distinct ethnic groups, the industry faces the daunting task of offering standard quality service to all people regardless of their cultural orientation. To achieve this, there has to be a total abandonment of the one-size-fits-all approach to healthcare provision.
It is however advisable that instead of pursuing a policy of creating services targeted or formatted for specific groups, the industry should concentrate on increasing its capacity to respond quickly and effectively to the increasingly frequent new challenges offered by cultural diversity.
References
Ayanian J. Z and A. M. Epstein (1991): Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Heart Disease. New England Journal of Medicine 325: 226–30.
Baker D. W., R. Hayes, and J. P. Fortier (1998): Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish-Speaking Patients. Medical Care 36: 1461–70.
Betancourt J. R, J. E. Carrillo, and A. R. Green (1999): Hypertension in Multicultural and Minority Populations: Linking Communication to Compliance. Current Hypertension Reports 1: 482–88.
Carrasquillo O. (1999): Impact of Language Barriers on Patient Satisfaction in an Emergency Department. Journal of General Internal Medicine 14: 82–87.
Collins K. S, A. Hall, and C. Neuhaus (1999): U.S. Minority Health: A Chartbook (New York: The Commonwealth Fund).
Cooper-Patrick L., Gallo, J. J. Gonzales, J. J. Vu, H. T. Powe, N. R. Nelson, C. Ford, D. E. (1999): Race, Gender, and Partnership in the Patient–Physician Relationship. Journal of the American Medical Association 282: 583–89.
Denboba D. L, Bragdon, J. L. Epstein, L. G. Garthright, K. Goldman, T. M. (1998): Reducing Health Disparities through Cultural Competence: Journal of Health Education 29: S47–S53.
Donini-Lenhoff F. G and H. L. Hedrick (2000): Increasing Awareness and Implementation of Cultural Competence Principles in Health Professions Education: Journal of Allied Health 29: 241–45.
Flores G. and L. R. Vega (1998): Barriers to Health Care Access for Latino Children: A Review. Family Medicine 30: 196–205.
Gornick M. E. (2000): Disparities in Medicare Services: Potential Causes, Plausible Explanations and Recommendations: Health Care Financing Review 21: 23–43.
Komaromy M., Grumbach, K. Drake, M. Vranizan, K. Lurie, N. Keane, D. Bindman, A. B. (1996): The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations. New England Journal of Medicine 334: 1305–10.
Morales L S., William E. Cunningham, Julie A. Brown, Honghu Liu and Ron D. Hays (1999): Are Latinos Less Satisfied with Communication by Health Care Providers? Journal of General Internal Medicine 14: 409–17.
Moy E. and B. A. Bartman (1995): Physician Race and Care of Minority and Medically Indigent Patients. Journal of the American Medical Association 173: 1515–20.
Orth J. E, Stiles WB, Scherwitz L, Hennrikus D, Vallbona C (1987): Patient Exposition and Provider Explanation in Routine Interviews and Hypertensive Patients’ Blood Pressure Control. Health Psychology 6: 29–42.
Putnam M. Samuel, William B. Stiles, Mary Casey Jacob and Sherman A. James (1985): Patient Exposition and Physician Explanation in Initial Medical Interviews and Outcomes of Clinical Visits. Medical Care 23: 74–83.
Robins L S, Fantone, J. C. Hermann, J. Alexander, G. L. Zweifler, A. J. (1998): Improving Cultural Awareness and Sensitivity Training in Medical School: Academic Medicine 73 (Supplement 10,: S31–S34.
Saha S., Taggart, S. H. Komaromy, M. Bindman, A. B. (2000): Do Patients Choose Physicians of Their Own Race? Health Affairs 19: 76–83.
Stanton A. L (1987): Determinants of Adherence to Medical Regimens by Hypertensive Patients. Journal of Behavioral Medicine 10: 377–94.
U. S. Bureau of the Census, Population Division National Estimates (1999): Annual PopulationEstimates by Sex, Race, and Hispanic Origin, Selected Years from 1990 to 1998.
Woloshin S. (1995): Language Barriers in Medicine in the United States: Journal of the American Medical Association 273: 724–28.
Appendix A
