Cultural Proficiency: The Importance of Cultural Proficiency in Providing Effective Care for Diverse Populations (Position Paper)

A position paper of the American Academy of Family Physicians (AAFP)

The vision of the AAFP is “to transform healthcare to achieve optimal health for everyone.” All persons, regardless of linguistic or other cultural characteristics, deserve access to high quality health services. However, in our nation and elsewhere, health inequities persist, and health outcome disparities remain an ethical and practical dilemma (1). Culturally and linguistically appropriate services, broadly defined as care and services that are respectful of and responsive to the cultural and linguistic needs of all individuals (2), hold the promise to reduce these health outcome disparities. Such services are the hallmark of culturally proficient health care delivery for our nation’s increasingly diverse population.

Cultural proficiency is broadly recognized as the knowledge, skills, attitudes and beliefs that enable people to work well with, respond effectively to, and be supportive of people in cross-cultural settings. Cultural proficiency is not solely the acceptance of cultural differences, but rather a transformational process that allows individuals to acknowledge interdependence and align with a group other than their own. Culturally proficient health care, in particular, makes use of a patient’s language and culture as tools to improve outcomes for that individual.

“Culture” is a term whose meaning has evolved and broadened. In 2013, the enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (3) define culture as:

“The integrated pattern of thoughts, communications, actions, customs, beliefs, values and institutions associated, wholly or partially, with racial, ethnic or linguistic groups, as well as with religious, spiritual, biological, geographical or sociological characteristics. Culture is dynamic in nature, and individuals may identify with multiple cultures over the course of their lifetime.”

The enhanced CLAS standards list the following elements of culture, acknowledging that culture is not limited to the following:

  • Age
  • Cognitive ability or limitations
  • Country of origin
  • Degree of acculturation
  • Educational level attained
  • Environment and surroundings
  • Family and household compositions
  • Gender identity
  • Generation
  • Health practice, including use of traditional healer techniques such as Reiki and acupuncture
  • Linguistic characteristics, including language(s) spoken, written or signed; dialects or regional variants; literacy levels; and other related communication needs
  • Military affiliation
  • Occupational groups
  • Perceptions of family and community
  • Perceptions of health and well-being and related practices
  • Perceptions/beliefs regarding diet and nutrition
  • Physical ability or limitations
  • Political beliefs
  • Racial and ethnic groups - including but not limited to - those defined by the US Census Bureau
  • Religious and spiritual characteristics, including beliefs, practices and support systems related to how an individual finds and defines meaning in his/her life.
  • Residence (i.e. urban, rural or suburban)
  • Sex
  • Sexual orientation
  • Socioeconomic status

Cultural proficiency is an essential element for patient safety and adherence. The National Center for Culture Competence provides six reasons for the implementation of cultural proficiency (4):

  1. To respond to current and projected demographic changes in the United States.
  2. To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds.
  3. To improve the quality of services and primary care outcomes.
  4. To meet legislative, regulatory and accreditation mandates.
  5. To gain a competitive edge in the market place.
  6. To decrease the likelihood of liability/malpractice claims.

These six reasons touch upon two overarching and intertwined themes: social justice and good business practice. Cultural proficiency, with its expected outcome, health equity, is not simply the “right thing to do.” In today’s era of accountable care and emphasis on improving care and controlling cost, cultural proficiency is a “must do.” Cultural proficiency potentially can save both lives and money (5).

The AAFP endorses the document, National Standards for Culturally and Linguistically Appropriate Services in Health and Heath Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, from the Office of Minority Health, US Department of Health and Human Services, April 2013. The Blueprint (3) describes 15 distinct standards that are organized around 3 themes:

Theme 1: Governance, Leadership and Workforce
Theme 2: Communication and Language Assistance
Theme 3: Engagement, Continuous Improvement and Accountability

The Principal Standard of the Blueprint is, “To provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.” This standard frames the essential goal of the remaining 14 standards and aligns with AAFP’s vision “to transform healthcare to achieve optimal health for everyone.”

AAFP adopts the Principal Standard and the remaining 14 CLAS standards (3) with the following family medicine-specific perspectives on the three themes listed above.

Governance, Leadership and Workforce
Creating an environment in which culturally diverse individuals feel welcome and valued is of great importance to AAFP in order to infuse multicultural perspectives into the plan, design and execution of AAFP-driven health initiatives, not just for AAFP members but the population as a whole. Recruiting and retaining culturally diverse individuals into the field of family medicine is an important strategy to reduce disparities in health outcomes. Preparing and supporting a workforce that demonstrates the attitudes, knowledge and skills necessary to work effectively with diverse populations is another.

Leadership in AAFP aspires to reflect the diversity of the community it serves. Leadership commitment to integrating cultural and linguistic competency is essential in order to move cultural proficiency from theory to action.

Structural and governance examples of AAFP’s leadership commitment to the principles of cultural proficiency include its Subcommittee on Health Equity, its cross-commission Cultural Proficiency Section and its National Conference of Constituency Leaders.

Communication and Language Assistance
The AAFP endorses the 2013 enhanced CLAS standards that improve patient safety and reduce medical error due to miscommunication. Patients need to understand their care and participate in decisions regarding their health. In order to ensure that individuals with limited English proficiency have equitable access to health services, AAFP supports the use of qualified interpreters who demonstrate special language aptitude in both the language of medical terminology and in health systems.

All AAFP members or their staff should be knowledgeable about the types of communication and language services available and be prepared to share this information with patients.

The AAFP supports private and public payer initiatives that facilitate access to, and reward the promotion and provision of, appropriate and professional language services in diverse care settings, particularly at the practice level. Without support from such initiatives to provide resources, these vital services will be beyond the practical reach of what many individual practices will be able to deliver.

Organizations must comply with requirements such as Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, and other relevant federal, state and local requirements. Written materials (informed consent, instructions, notices of non-coverage of services, etc.) and signage should be easy to understand and translatable.

Engagement, Continuous Improvement and Accountability
With its vision “to transform health care to achieve optimal health for everyone”, AAFP integrates cultural proficiency in advocacy, policy-making and governance.

AAFP promotes cultural proficiency training of its members and their staff by providing enduring, updated materials and resources in multiple venues.

AAFP supports the ongoing collection of social and demographic data of all patients in all settings so that outcomes can be stratified, disparities will be identified and solutions to promote health equity may be planned and implemented. The patient-centered medical home standards, endorsed and promoted by AAFP, exemplify this commitment. An additional example of this commitment is AAFP’s participation in efforts to integrate public health and primary care. The sharing of community-based data and resources between the two entities holds the potential to promote health equity for local populations in all states.

AAFP supports its members’ direct engagement of community and rewards this behavior by conferring the status of fellow to individual members who, among other activities, promote the health of their communities through education and service beyond the usual standards of medical practice.

AAFP is accountable to its members and to the communities its members serve. AAFP recruits diverse leadership and encourages its members to advocate for diverse populations. The AAFP’s governance structure promotes grass roots input: ideas and resolutions are presented and debated democratically by a diverse representation of membership.

Summary
AAFP supports the broad adoption of cultural proficiency standards by government, payers, health care organizations, practices and individuals. When cultural proficiency is an expected standard in health care delivery, “optimal health for everyone” means every one.

References:

1) American College of Physicians. Racial and Ethnic Disparities in Health Care, Updated 2010. Philadelphia: American College of Physicians; 2010: Policy Paper.
2) American College of Physicians, 2010; Griffith, Yonas, Mason and Havens, 2010.
3) National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Office of Minority Health, US Department of Health and Human Services, 2013.
4) Policy Brief 1: Rationale for Culture Competence in Primary Care. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and Human Development. Goode TD and Dunne C.
5) Commonwealth Fund Publication No. 962, The Evidence Base for Cultural and Linguistic Competency in Health Care. Goode TD, Dunne C, Bronheim SM, 2006.

(2008) (2014 COD)