Cultural Competence: Healthcare Disparities and Political Issues

CHAPTER 9 Cultural Competence


Healthcare Disparities and Political Issues



Joseph R. Betancourt, Alexander R. Green



Background


Cultural competence has recently gained increasing attention from healthcare policy makers, providers, insurers, and educators as a strategy to improve quality of care and eliminate racial/ethnic disparities in healthcare. Cultural competence is grounded in two basic principles:1 first, it is important to explore and understand the sociocultural factors that influence a patient’s values, beliefs, and behaviors related to health and healthcare; and second, it is critical to develop multilevel strategies in the design and delivery of healthcare in an effort to bridge the gaps in quality that result from sociocultural and linguistic barriers. Ultimately, the goal of cultural competence is to create a healthcare system and workforce that are capable of delivering the highest quality of care to every patient, regardless of race, ethnicity, culture, or language proficiency. Such a system would be equitable, of high quality, and free of disparities based on individual patient characteristics. Bringing this to fruition requires action by various sectors of healthcare, yet each may have different motivations, approaches, and leverage points for advancing cultural competence.


The purpose of this chapter is to present the perspectives on cultural competence as expressed by experts in the field within government, academia, managed care, and community healthcare. Through key informant interviews we were able to identify how individuals in these different sectors view cultural competence – including their motivation, vision, and experience in making it ‘actionable’ – as well as how efforts in this area link to quality improvement and the elimination of racial and ethnic disparities in healthcare.



Cultural Competence Emerges


Cultural competence has emerged as an important healthcare issue for three very practical reasons. First, as the US becomes more diverse, clinicians will increasingly see patients with a broad range of thoughts regarding health and well-being, oftentimes influenced by their social or cultural background. Culture can be seen as an integrated pattern of learned beliefs and behaviors that can be shared among groups and includes thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices and customs. Culture is shaped by multiple influences, including race, ethnicity, nationality, language, and gender, but also extending to socioeconomic status, physical and mental ability, sexual orientation, and occupation, among others. For instance, patients may present their symptoms quite differently from the way healthcare providers have read about them in their medical textbooks; they may have limited English proficiency, thus limiting their ability to communicate; they may have different thresholds for seeking care, or expectations about the care they receive; and they may hold beliefs that in-fluence whether or not they adhere to our recommendations.2


Second, research has shown that effective provider–patient communication is directly linked to improved patient satisfaction, adherence and, subsequently, health outcomes.3 Thus, patient dissatisfaction, nonadherence, and poorer health outcomes may result when sociocultural differences between the patient and the provider are not effectively addressed in the clinical encounter.4 This is further complicated by situations in which the patient has limited English proficiency or low health literacy. Ultimately, these barriers do not just apply to minority groups (African-Americans, Hispanics, Asian, Pacific Islanders, and Native Americans/Alaska Natives: taken from US Office of Management and Budget definition [OMB-15 Directive]), but may just be more pronounced in these cases.


Finally, two recent Institute of Medicine Reports – Crossing the Quality Chasm5 and Unequal Treatment6 – both highlighted the importance of patient-centered care, evidence-based guidelines, and cultural competence as a means of improving quality, achieving equity, and eliminating the significant racial/ethnic disparities in healthcare that persist today. These recommendations are based on the premise that improving health systems and provider–patient communication are important components of addressing racial and ethnic disparities in healthcare that occur even when variations in such factors as insurance status, income, age, comorbid conditions, stage of presentation, and symptom expression are taken into account.


In our previous research1,7 we have described three main levels of cultural competence in healthcare:


• Organizational cultural competence focuses on increasing the diversity of the healthcare workforce and leadership as a means of improving quality of care.

• Systemic cultural competence focuses on strategies that address structural processes of care, including implementing racial/ethnic and language preference data collection (as a way of monitoring quality of care); developing specific culturally competent quality improvement projects to address disparities; ensuring interpreter services and culturally and linguistically appropriate health education materials and signage; and creating mechanisms for community assessment and input.

• Clinical cultural competence focuses on educational and training strategies that highlight the importance of sociocultural factors on patients’ health values, beliefs, and behaviors, and equip providers with the tools and skills to effectively address these in the clinical encounter.

It is felt that this practical framework for cultural competence has the potential to broaden access, improve quality, and eliminate racial/ethnic disparities in healthcare.



Perspectives from the Field


The authors conducted interviews with national experts in cultural competence from academia (residency programs, medical schools, and professional organizations) community health centers, managed care, and the government (including representatives from agencies of the Department of Health and Human Services and state and county Departments of Health). Key informants were asked to define cultural competence in their domain of healthcare, identify key actionable components of cultural competence, describe leverage points for action and implementation, and identify links to quality and the elimination of racial/ethnic disparities in healthcare. Key informants were selected from lists of:


1. Nationally recognized experts in cultural competence who had presented at one of a series of national meetings on the topic. (National Conference Quality Health Care to Culturally Diverse Populations. The New York Academy of Medicine, October 1998; Providing care to diverse Populations: State Strategies for Promoting Cultural Competency in Health System. AHRQ ULP Program, June 1999; Difference Matters: Multiculturalism in Medical Education. Harvard Medical School, June 1999; Kaiser Family Foundation’s Conference ‘Race, Ethnicity, and Medical Care: Improving Access in a Diverse Society,’ October 1999.)

2. Members of national expert cultural competence advisory panels. (HCFA QISMC Cultural Competence Quality Measure Review Panel; Association of American Medical Colleges Diversity Project Team; Office of Minority Health CLAS Project Advisory Group; New York Academy of Medicine Working Group on Racial/Ethnics Disparities.)

3. Snowball sampling using sequential recommendations from initial key informants.

A total of 37 interviews were completed in the Spring and Summer of 2002 (individuals and affiliations listed in Appendix). Interviews were taped, transcribed, and qualitatively coded by three independent coders according to a coding structure that disseminated major themes according to frequency and relevance. The coding scheme was designed and overseen by a qualitative methods expert, and the final themes were reviewed for content appropriateness by an expert in cultural competence. Below, we describe the major issues that arose among the different stakeholder groups.



Government



Increasing access to quality healthcare for the most vulnerable


Given the roles and responsibilities of federal, state, and local government in developing and managing healthcare delivery and financing systems for some of America’s most vulnerable populations (including children, the elderly, and socioeconomically disadvantaged groups), the overarching motivation for cultural competence was couched in terms of ‘increasing access to quality care for all patient populations’.




‘… to increase accessibility to our services through working to have our staff and providers really understand the cultural attitudes and beliefs patients have towards health.’


The implied assertion was that many groups, including minorities who experience sociocultural barriers, have difficulty getting appropriate, timely, high-quality care due to several issues such as having a different cultural perspective about health and healthcare, having different expectations about diagnosis and treatment, or experiencing language barriers in the clinical encounter. As such, ‘cultural competence’ aims to move what many consider on the whole to be a ‘one size fits all’ healthcare system to be more responsive to the needs of an increasingly diverse nation and patient population.




‘… it’s being able to communicate with people with different social mores, different languages, different views, different religions, any kind of differences. It’s a means of overcoming the barriers that have been created in the systems and messages we’re presenting.’



Key capacities of cultural competence


Key informants in government highlighted three essential components underlying the delivery of culturally competent care:


1. Organizational capacities, including diversity among staff and providers, and strategies for diversity in hiring practices and recruitment. Across the board, it was seen as critical to have the diversity of the communities being served also represented among the providers and staff who are providing healthcare.



‘We’re not keeping up with our demographic changes, and we’re going to continue to have disparities if we don’t start increasing diversity in the health professions.’


2. Systemic capacities, including data collection methods to both assess the needs of the patient populations that are served (not only quantitatively, but qualitatively through the development of community linkages and mechanisms for community advising) and track progress in improving health outcomes (with ties to accountability); improving the capacity to care for limited English proficient patients through the development of effective interpreter services; and exploring the use of emerging technologies (evidence-based computer aides, voice recognition) to help us meet the challenges of caring for diverse populations.



‘… the issue of language is probably the one that has been studied the most and that we have the best data for making the case for cultural competence and what happens when you don’t have the appropriate translation.’


3. Training capacities, including cultural competence education for senior management, healthcare providers, and staff. This training should focus on knowledge and skills, and should equip providers with tools and skills to deliver quality care to all patients (with an acknowledgement that systems need to be in place to facilitate this goal).



‘… if we can develop cross-cultural education curricula for the various health professions I think we can at least start making an impact on the attitudes, knowledge and skills of practitioners when they start serving more diverse populations.’



Purchasing power as leverage to advance cultural competence


Various strategies and approaches were delineated to facilitate the evolution and development of cultural competence in healthcare. Among them, the influence of government as the largest healthcare purchaser, and the use of contractual requirements (federal and state), emerged as the strongest leverage points. Experts agreed that healthcare purchasers – both government based, as through Medicare, and private, through large purchasing coalitions seen in industry – could help stimulate change if they understood the impact of healthcare delivery that was not culturally competent.




‘The trick of course is getting the purchaser to be interested and educated enough about [cultural competence] to be able to develop the right policy … and so that makes the purchaser–advocate partnership really critical.’


The role of the Centers for Medicare and Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, and state healthcare provider licensure and medical school accreditation organizations were also named specifically, as well as the need to make the ‘business model’ for these interventions.




‘… we’re not going to convince purchasers or business people unless we make the business model.’



Cultural competence as one step toward eliminating disparities


Informants developed a clear link between cultural competence and eliminating racial/ethnic disparities in healthcare. However, there was agreement that disparities are multifactorial (due to socioeconomic disparities, educational disparities, etc.) and that cultural competence alone could not address this problem. There was a sense, however, that cultural competence was crucial to systems and quality improvement, especially given disparities in our longstanding populations, and the emergence of new populations. It was also stated that, in fact, these cultural competence ‘adjustments’ in healthcare delivery are synergistic with the larger movement of quality improvement, and should occur at the level of systems, and at the level of the clinical encounter.




‘That’s what we’re talking about in terms of cultural competency … providing quality care to individuals who in the past have not received it … and when I think of quality care, that’s what we’re looking for all Americans, not only for diverse populations.’


The Culturally and Linguistically Appropriate Services (CLAS) Standards project was often referred to as an effective blueprint for improving the cultural competence of our healthcare system. (This project was developed by the Office of Minority Health and can be found at http://www.omhrc.gov/clas)



Academia



Training the future healthcare workforce to care for diverse populations


Key informants in academic medicine were motivated to advance cultural competence as an educational strategy to prepare the future healthcare workforce to care for diverse patient populations. This group tended to view cultural competence primarily from the standpoint of the provider–patient interaction, with a focus on communication. They stressed the importance of providers having an awareness and understanding of culture (one’s own and that of others), knowledge of the relationship between cultural beliefs and behaviors, and the ability for introspection. Many described cultural competence as a level of self-awareness or selfreflection and knowledge, but equally referred to the development of skills needed to improve quality of care.




‘… the ability of medical practitioners to identify cultural indicators in the history taking, diagnosis, and treatment of any patients.’


Despite this, some expressed concern that there is still too much focus on stereotyping strategies or ‘cookbook practices’ (i.e. treat ‘Hispanics’ this way and ‘African-Americans’ another way), and little focus on the factors that impact the individual patient. They mentioned additional components that needed to be integrated into training such as the importance of empathy, the impact of socioeconomic class on patients’ ability to obtain quality care, the development of communication skills, and the importance of addressing racism and bias in the clinical encounter.




‘I think too often we want to leap to the knowledge and skill base rather than going to the mental assumptions and biases that are brought to the medical interaction … and understanding issues of context and culture and language.’



Cultural competence education gaining momentum


When discussing the practical aspects of operationalizing cultural competence, key informants referred to the implementation of programs on cross-cultural education in the health professions. Many cited regulatory/accreditation pressures (including those from the Accreditation Council of Graduate Medical Education for residency training and the Liaison Council on Medical Education for medical schools), societal pressures, and the growing diversity of patients, students, and faculty as leverage for moving agendas forward. Funding opportunities that have developed, especially through professional societies, foundations, and government, also provide an important incentive.




‘I think the funding issue is particularly relevant for medical education … Very often just getting things started is enough to allow for things to happen. But you have to make that initial commitment. And with the best of intentions sometimes it actually takes the resources and the resources are usually dollars.’

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Aug 11, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Cultural Competence: Healthcare Disparities and Political Issues

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