Do clinicians need cultural competence? More than 6000 languages are spoken in the world's 191 countries,¹ and approximately 32 million Americans speak a total of 329 languages other than English in their homes.² Also, more than 1 million health care workers are immigrants.³ The absence of cultural competence, which is qualitative and dynamic, is easier to identify than its presence.

Culture encompasses language, thoughts, communications, customs, beliefs, values, and racial, ethnic, religious, or social institutions. Competence is the capacity to operate within the culture effectively.² Cultural competence includes linguistic competence in the culture's native language, as well as understanding culturally specific nuances.

Ideal cultural competence occurs in individual staff, programs, and systems. At a minimum, cultural competence erases stereotypes and biases that undermine therapeutic relationships. At best, it promotes therapeutic relationships, treatment adherence, and best outcomes.

Core Components

Culture colors experiences and coping behaviors. It influences when, how, and where a person seeks treatment, and patients wear their culture into examination rooms. Normative cultural values, language, patient beliefs, and provider practices are critical elements of culture.¹

Normative cultural values (interpersonal interaction expectations) include nonverbal cues, body language, level of formality, expressions of respect, families' role, and approaches to sensitive subjects.

Language, even when spoken fluently, creates barriers.

• The Navajo language, for example, has no word for "germ"⁴
• One culture's acceptable terms (eg, "minority") may offend in another
• Even within a unique culture, terminology and syntax can be unintentionally offensive. Those suffering from mental illness may bristle when described as schizophrenic, preferring to be described as persons suffering from schizophrenia.
• People express symptoms differently; eg, some cultures use "fatigue" interchangeably with "depression"
• Prescription instructions translate poorly into some languages

Patient belief systems impact access, help-seeking behaviors, and treatment adherence. Some Latin cultures maintain that it is better not to know if you have cancer, because little can be done.¹ In many instances, culture may dictate visiting a physician only when feeling ill?eschewing primary prevention and routine monitoring. Cultures defined by ethnic exclusivity, family authority, and skepticism about medicine often delay treatment.²

Folklore can color the meaning of illness. Some cultures associate breast cancer with sinful behavior. Others consider speaking about or planning for one's death a bad omen. Ethnicity is the second most common predictor of patients'willingness to create advance directives.⁴

Provider beliefs and practices shape treatment decisions, albeit unconsciously.¹ Clinician culture potentially affects questions asked and treatment and diagnostic decisions. Culture influences trust and communication.

Studies have found that Hispanics were 7 times less likely to receive an analgesic for pain than whites, and that pediatricians were 17 times less likely to prescribe nebulizers for home use to Hispanic children.¹ Among numerous factors, language and cultural incompetence are often suspect. For example, women with limited English receive fewer mammograms and Pap smears.¹ Perceived language problems cause up to 20% of Spanish-speaking individuals to refuse or delay treatment.²

Competence Matters

Patient and staff satisfaction increases in settings emphasizing cultural competence.^5,6 It is more than just psychological? one study found increased adherence among racial and ethnic minorities in settings emphasizing respect and dignity.⁶

Poor competence undermines trust and increases the likelihood of diagnostic errors, inappropriate treatment, and poor adherence.² Studies indicate that African Americans, Asians, and Hispanics, perceiving bias and disrespect from clinicians, believe that care would improve if they were of a different group identity.⁷

Five Basic Interventions

Cultural competence is built on staff recruitment, use of interpreter services (Table 1^8,9), cultural competency training, culturally appropriate client education materials, and culturally specific health care settings. An excellent tool for assessing cultural competence on an organization level can be found at www.hrsa.gov/culturalcompetence/indicators/. Former Surgeon General David Satcher recommends that staff members think of the acronym CRASH:

C: Consider culture when you are interacting with patients.

R: Respect other peoples'cultures, and learn how respect is communicated within those cultures.

A: Assess and affirm culture, including positive feedback about the person's culture.

S: Sensitivity to the other person's culture and the impact of one's own culture are key and must be expressed.

H: Humility is needed, based on the fact that few people become experts in other cultures.¹⁰

Counseling Tips

Cultural competence is patient-centered. One should avoid the common error of myopically defining a person within one cultural identity based on language or ethnic origin. People have multiple cultural identities that define them in relation to others, and recognizing these issues vastly improves counseling (Table 2¹¹).

Final Thought

Clinicians were once encouraged to detach themselves from patients, believing that clinical accuracy was enhanced by objective, nonpersonal interactions. Yesterday's skill has become today's liability. Effective heath care delivery depends on cultural competence.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria,Va.

References

1. Flores G. Culture and the patient-physician relationship: achieving cultural competency in health care. J Pediatr. 2000;136:14-23.

2. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent healthcare systems: a systematic review. Am J Prev Med. 2003;24(3 suppl):68-79.

3. Millman J. Developing nations lure retirees, raising the idea of "outsourcing boomers" golden years. The Wall Street Journal. November 14, 2005:A2.

4. Berger JT. Culture and ethnicity in clinical care. Arch Intern Med. 1998;158:2085-2095.

5. Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43:356-373.

6. Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Ann Fam Med. 2005;3:331-338.

7. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19:101-110.

8. Cross Cultural Health Care Program. Guidelines for providing health care services through an interpreter. Available at: www.xculture.org/training/index.html.

9. Wick J, Zanni G. Cultural competence: a pragmatic plan for fulfilling a professional imperative. Consult Pharm. 2001;16:197-211.

10. Satcher D, Ninan P, Masand P. A Surgeon General's Perspective on Cultural Competency: What Is It and How Does It Affect Diagnosis and Treatment of Major Depressive Disorder? Available at: www.medscape.com/viewprogram/4489. Accessed February 20, 2007.

11. Hoar S. Cultural competence. Available at: www.gwu.edu/~iscopes/LearningMods_Culture.htm. Accessed February 23, 2007.