Cultural Competence: More Than Just Language

Do clinicians need cultural competence?More than 6000 languagesare spoken in theworld's 191 countries,¹ and approximately32 million Americans speak a total of329 languages other than English in theirhomes.² Also, more than 1 million healthcare workers are immigrants.³ Theabsence of cultural competence, whichis qualitative and dynamic, is easier toidentify than its presence.

Culture encompasses language,thoughts, communications, customs,beliefs, values, and racial, ethnic, religious,or social institutions. Competenceis the capacity to operate within the cultureeffectively.² Cultural competenceincludes linguistic competence in the culture'snative language, as well as understandingculturally specific nuances.

Ideal cultural competence occurs inindividual staff, programs, and systems.At a minimum, cultural competenceerases stereotypes and biases thatundermine therapeutic relationships. Atbest, it promotes therapeutic relationships,treatment adherence, and bestoutcomes.

Core Components

Culture colors experiences and copingbehaviors. It influences when, how, andwhere a person seeks treatment, andpatients wear their culture into examinationrooms. Normative cultural values,language, patient beliefs, and providerpractices are critical elements of culture.¹

Normative cultural values (interpersonalinteraction expectations) includenonverbal cues, body language, level offormality, expressions of respect, families'role, and approaches to sensitivesubjects.

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, terminologyand syntax can be unintentionallyoffensive. Those sufferingfrom mental illness may bristle whendescribed as schizophrenic, preferringto be described as persons sufferingfrom schizophrenia.
• People express symptoms differently;eg, some cultures use "fatigue"interchangeably with "depression"
• Prescription instructions translatepoorly into some languages

Patient belief systems impact access,help-seeking behaviors, and treatmentadherence. Some Latin cultures maintainthat it is betternot to know ifyou have cancer,because little canbe done.¹ In manyinstances, culturemay dictate visitinga physicianonly when feelingill?eschewingprimary preventionand routinemonitoring.Cultures definedby ethnic exclusivity,family authority,and skepticismabout medicine often delay treatment.²

Folklore can color the meaning of illness.Some cultures associate breastcancer with sinful behavior. Others considerspeaking about or planning forone's death a bad omen. Ethnicity is thesecond most common predictor ofpatients'willingness to create advancedirectives.⁴

Provider beliefs and practices shapetreatment decisions, albeit unconsciously.¹ Clinician culture potentially affectsquestions asked and treatment anddiagnostic decisions. Culture influencestrust and communication.

Studies have found that Hispanicswere 7 times less likely to receive ananalgesic for pain than whites, and thatpediatricians were 17 times less likelyto prescribe nebulizers for home use toHispanic children.¹ Among numerousfactors, language and cultural incompetenceare often suspect. For example,women with limited Englishreceive fewer mammograms and Papsmears.¹ Perceived language problemscause up to 20% of Spanish-speakingindividuals to refuse or delay treatment.²

Competence Matters

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

Poor competence undermines trustand increases the likelihood of diagnosticerrors, inappropriate treatment, and pooradherence.² Studies indicate that AfricanAmericans, Asians, and Hispanics, perceivingbias and disrespect from clinicians,believe that care would improve ifthey were of a different group identity.⁷

Five Basic Interventions

Cultural competence is built on staffrecruitment, use of interpreter services(Table 1^8,9), cultural competency training,culturally appropriate client educationmaterials, and culturally specific healthcare settings. An excellent tool forassessing cultural competence on anorganization level can be foundat www.hrsa.gov/culturalcompetence/indicators/. Former Surgeon GeneralDavid Satcher recommends that staffmembers think of the acronym CRASH:

C: Consider culture when you areinteracting with patients.

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

A: Assess and affirm culture, includingpositive feedback about the person'sculture.

S: Sensitivity to the other person's cultureand the impact of one's ownculture are key and must beexpressed.

H: Humility is needed, based on thefact that few people becomeexperts in other cultures.¹⁰

Counseling Tips

Cultural competence is patient-centered.One should avoid the commonerror of myopically defining a personwithin one cultural identity based on languageor ethnic origin. People have multiplecultural identities that define themin relation to others, and recognizingthese issues vastly improves counseling(Table 2¹¹).

Final Thought

Clinicians were once encouraged todetach themselves from patients, believingthat clinical accuracy was enhancedby objective, nonpersonal interactions.Yesterday's skill has become today's liability.Effective heath care deliverydepends on cultural competence.

Dr. Zanni is a psychologist andhealth-systems consultant basedin Alexandria,Va.

References

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

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

3. Millman J. Developing nations lure retirees, raising the idea of "outsourcingboomers" 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 ofhealth care provider educational interventions. Med Care. 2005;43:356-373.

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

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

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

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

10. Satcher D, Ninan P, Masand P. A Surgeon General's Perspective on CulturalCompetency: What Is It and How Does It Affect Diagnosis and Treatment ofMajor 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.