Cultural proficiency and linguistic competence are widely recognized as fundamental aspects of quality in health care—especially for diverse patient populations—and as essential strategies for reducing disparities by improving access, utilization, and quality of care.1 The National Standards on Culturally and Linguistically Appropriate Services (CLAS) under the direction of the Department of Health and Human Services’ Office of Minority Health mandate attention to cultural proficiency and language access to recipients of federal funds. Additionally, the Office for Civil Rights’ Title VI of the Civil Rights Act of 1964; Limited English Proficiency Policy Guidance for Recipients of Federal Financial Assistance prohibits discrimination against national origin as it affects limited English proficient (LEP) persons.
The Joint Principles of the Patient-Centered Medical Home state that “care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”
According to the Association of American Medical Colleges (AAMC), it is imperative that health care professionals are educated on issues of culture because of the growing diversity in the U.S. population and the strong evidence of racial and ethnic disparities in health care.2 In 2000, the Liaison Committee on Medical Education (LCME) introduced two standards about cultural competence that inspired medical schools to introduce cultural competence education into the undergraduate curriculum. The Tool for Assessing Cultural Competence Training (TACCT) is a self-administered assessment tool that can be used by medical schools to examine all components of the entire medical school curriculum.
Additionally, the federal CLAS standards ask that “health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.”
Landmark reports, such as Missing Persons: Minorities in the Health Professions,3 Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,4 and In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce5 provide clear evidence of the growing need for diversity in the physician workforce to serve an increasingly multicultural U.S. population. Additionally, the Future of Family Medicine recommendations include “a comprehensive family medicine career development program and other strategies will be implemented to recruit and train a culturally diverse family physician workforce that meets the needs of the evolving US population for integrated health care for whole people, families, and communities.”
More than 23 million Americans speak English less than "very well" and thus have LEP.6 Clear documentation exists regarding how the lack of language services creates a barrier to and decreases the quality of health care for limited English persons.7-10
Standardized data collection would allow researchers to disentangle factors associated with health care disparities. The current national commitment to reduce health disparities may be compromised without more research on measurement quality. For example, self-report measures are required for research on disparities in the United States, although such measures are developed primarily in mainstream samples, and must be appropriate when applied in culturally and ethnically diverse groups.11
There is strong evidence of examples of disparate access to care and utilization of services in the literature on disparities in health care access.12, 13
1Goode TD, Dunne MC, Bronheim SM. The Evidence Base for Cultural and Linguistic Competency in Health Care. The Commonwealth Fund, October 2006.
2Medical Education and Cultural Competence: A Strategy to Eliminate Racial and Ethnic Disparities in Health Care, supported by The Commonwealth Fund; Pipeline Projects, Division of Diversity Policy and Programs, Association of American Medical Colleges, 2005.
3Sullivan Commission on Diversity in the Healthcare Workforce. Missing Persons: Minorities in the Health Professions. The Sullivan Commission, 2004.
4Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academic Press, 2003.
5Institute of Medicine Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Healthcare Workforce. Smedley BD, Butler AS, Bristow LR, eds. In the Nation’s Compelling Interest: Ensuring Diversity in the Healthcare Workforce. Washington, DC: National Academies Press, 2004.
6U.S. Census Bureau. Selected Characteristics of the Native and Foreign-Born Populations (Table no. S0602). 2005 American Community Survey (ACS).
7Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111(1):6-14.
8Ghandi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15(3):149-154.
9Derose KP, Baker DW. Limited English proficiency and Latinos’ use of physician services. Med Care Res Rev. 2000;57(1):76-91.
10Jacobs, EA, Agger-Gupta, N, Chen, AH, Piotrowski, A, & Hardt, E. Language barriers in health care settings: An annotated bibliography of the research literature. Woodland Hills, California: The California Endowment, 2003.
11Stewart AL, Nápoles-Springer AM. Advancing health disparities research: can we afford to ignore measurement issues? Med Care. 2003;41(11):1207-1220.
12Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(Suppl 1):108–145.
13Lillie-Blanton M, Martinez RM, Salganicoff A. Site of medical care: do racial and ethnic differences persist? Yale J Health Policy Law Ethics. 2001;1:15-32.
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Principles for Improving Cultural Proficiency and Care to Minority and Medically-Underserved Communities (Position Paper)