Racial, ethnic and cultural disparities exist in all aspects of society, but nowhere are they more clearly documented than in health care. People of diverse racial, ethnic and cultural heritage suffer disproportionately from cardiovascular disease, diabetes, HIV/AIDS and every form of cancer. In addition, their infant mortality rates are generally higher, and their childhood immunization rates are lower.1
Although disproportionate poverty and lack of health insurance contribute greatly to the disparities, health care organizations and individual medical practices are also responsible in that they often fail to provide culturally competent health care.
Cultural competence: A set of congruent behaviors, attitudes and policies that come together as a system, that system, agency or those professionals to work effectively in cross-cultural situations. The word “culture” is used because it implies the integrated pattern of human thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group. The word competence is used because it implies having a capacity to function effectively.2
How is your practice doing?
Understanding patients' diverse cultures — their values, traditions, history and institutions — is not simply political correctness. It is integral to eliminating health care disparities and providing high-quality patient care. Culture shapes individuals' experiences, perceptions, decisions and how they relate to others. It influences the way patients respond to medical services and preventive interventions and impacts the way physicians deliver those services. In a society as culturally diverse as the United States, physicians and others in health care delivery need sensitivity toward diverse patient populations and work to understand culturally influenced health behaviors.
At the individual practice level, there are several things groups can do to cultivate cultural competence:2
Value diversity. In other words, do not merely tolerate people of differing backgrounds and viewpoints, but consider differences as strengths.
Conduct a cultural self-assessment. One example of a fairly comprehensive cultural competence self-assessment tool is shown below. It was developed by Tawara D. Goode of the Georgetown University Child Development Center.
Be conscious of the dynamics when people from different cultures interact. Diversity can cause conflict and force individuals out of their comfort zones, but it need not cause division.
Institutionalize cultural knowledge. Its importance must be emphasized by those at the top of the organization, and it should be evident in the group's policies and practices.
Adapt service delivery to reflect an understanding of cultural diversity. In other words, move beyond theory and into practice by carrying out changes to meet the needs of your diverse patients.
There is a vast difference between a group that merely preaches diversity and a group that lives it. Physicians can lead the way in creating more culturally competent delivery systems and eliminating the striking disparities that exist among their patients.
Cultural competence self-test
The following self-assessment can assist physicians in identifying areas in which they might improve the quality of their services to culturally diverse populations.
Promoting Cultural and Linguistic Competency
Self-Assessment Checklist for Personnel Providing Primary Health Care Services
Directions: Please enter A, B or C for each item listed below.
A = Things I do frequently
B = Things I do occasionally
C = Things I do rarely or never
Physical Environment, Materials & Resources
____ I display pictures, posters, artwork and other decor that reflect the cultures and ethnic backgrounds of clients served by my program or agency.
____ I ensure that magazines, brochures and other printed materials in reception areas are of interest to and reflect the different cultures of individuals and families served by my program or agency.
____ When using videos, films or other media resources for health education, treatment or other interventions, I ensure that they reflect the cultures and ethnic background of individuals and families served by my program or agency.
____ I ensure that printed information disseminated by my agency or program takes into account the average literacy levels of individuals and families receiving services.
When interacting with individuals and families who have limited English proficiency, I always keep in mind that:
____ Limitations in English proficiency are in no way a reflection of their level of intellectual functioning.
____ Their limited ability to speak the language of the dominant culture has no bearing on their ability to communicate effectively in their language of origin.
____ They may or may not be literate in their language of origin or English.
____ I use bilingual-bicultural staff and/or personnel and volunteers skilled or certified in the provision of medical interpretation during treatment, interventions, meetings or other events for individuals and families who need or prefer this level of assistance.
____ For individuals and families who speak languages or dialects other than English, I attempt to learn and use key words in their language so that I am better able to communicate with them during assessment, treatment or other interventions.
____ I attempt to determine any familial colloquialisms used by individuals or families that may impact on assessment, treatment or other interventions.
____ When possible, I ensure that all notices and communiqués to individuals and families are written in their language of origin.
____ I understand that it may be necessary to use alternatives to written communications for some individuals and families, as word of mouth may be a preferred method of receiving information.
Values & Attitudes
____ I avoid imposing values that may conflict or be inconsistent with those of cultures or ethnic groups other than my own.
____ I screen books, movies and other media resources for negative cultural, ethnic or racial stereotypes before sharing them with individuals and families served by my program or agency.
____ I intervene in an appropriate manner when I observe other staff or clients within my program or agency engaging in behaviors that show cultural insensitivity, racial biases and prejudice.
____ I recognize and accept that individuals from culturally diverse backgrounds may desire varying degrees of acculturation into the dominant culture.
____ I understand and accept that family is defined differently by different cultures (e.g., extended family members, fictive kin, godparents).
____ I accept and respect that male-female roles may vary significantly among different cultures and ethnic groups (e.g., who makes major decisions for the family).
____ I understand that age and life-cycle factors must be considered in interactions with individuals and families (e.g., high value placed on the decision of elders, the role of eldest male or female in families, or roles and expectation of children within the family).
____ Even though my professional or moral viewpoints may differ, I accept individuals and families as the ultimate decision makers for services and supports impacting their lives.
____ I recognize that the meaning or value of medical treatment and health education may vary greatly among cultures.
____ I accept that religion and other beliefs may influence how individuals and families respond to illnesses, disease and death.
____ I understand that the perception of health, wellness and preventive health services have different meanings to different cultural or ethnic groups.
____ I recognize and accept that folk and religious beliefs may influence an individual's or family's reaction and approach to a child born with a disability, or later diagnosed with a disability, genetic disorder or special health care needs.
____ I understand that grief and bereavement are influenced by culture.
____ I seek information from individuals, families or other key community informants that will assist in service adaptation to respond to the needs and preferences of culturally and ethnically diverse groups served by my program or agency.
____ Before visiting or providing services in the home setting, I seek information on acceptable behaviors, courtesies, customs and expectations that are unique to the culturally and ethnically diverse groups served by my program or agency.
____ I keep abreast of the major health concerns and issues for ethnically and racially diverse client populations residing in the geographic locale served by my program or agency.
____ I am aware of the socioeconomic and environmental risk factors that contribute to the major health problems of culturally, ethnically and racially diverse populations served by my program or agency.
____ I am well versed in the most current and proven practices, treatments and interventions for major health problems among ethnically and racially diverse groups within the geographic locale served by my agency or program.
____ I avail myself to professional development and training to enhance my knowledge and skills in the provision of services and supports to culturally, ethnically, racially and linguistically diverse groups.
____ I advocate for the review of my program or agency's mission statement, goals, policies and procedures to ensure that they incorporate principles and practices that promote cultural and linguistic competence.
How to use this checklist
This checklist is intended to heighten the awareness and sensitivity of personnel to the importance of cultural and linguistic competence in health and human service settings. It provides concrete examples of the kinds of beliefs, attitudes, values and practices that foster cultural and linguistic competence at the individual or practitioner level. There is no answer key with correct responses. However, if you frequently responded “C,” you may not necessarily demonstrate beliefs, attitudes, values and practices that promote cultural and linguistic competence within health care delivery programs.
Self-assessment developed by Tawara D. Goode, Georgetown University Child Development Center-UAP. Adapted with permission from Promoting Cultural Competence and Cultural Diversity in Early Intervention and Early Childhood Settings and Promoting Cultural Competence and Cultural Diversity for Personnel Providing Services and Supports to Children With Special Health Care Needs and Their Families (June 1989; latest revision July 2000).