The Compelling Need for Cultural and Linguistic Competence
The rationale to incorporate cultural competence into organizational policy are numerous. The National Center for Cultural Competence has identified six salient reasons for review:
To respond to current and projected demographic changes in the United States.
The make-up of the American population is changing as a result of immigration patterns and significant increases among racially, ethnically, culturally and linguistically diverse populations already residing in the United States. Health care organizations and programs, and federal, state and local governments must implement systemic change in order to meet the health needs of this diverse population.
Data from the 1990 census reveal that the number of persons who speak a language other than English at home rose by 43 percent to 28.3 million. Of these, nearly 45 percent indicate they have trouble speaking English.
The results of a March 1997 survey conducted by the Census Bureau reveal that one in every ten persons in the United States is foreign-born. Currently, the US foreign-born population comprises a larger segment than at any time in the past five decades. This trend is expected to continue.
The Children's Defense Fund predicts that early in the first decade following the year 2000, there will be 5.5 million more Latino children, 2.6 million more African-American children, 1.5 million more children of other races and 6.2 million fewer white, non-Latino children in the United States.
To eliminate long-standing disparities in the health status of people of diverse racial, ethnic and cultural backgrounds.
Nowhere are the divisions of race, ethnicity and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, there are continuing disparities in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaskan Natives and Pacific Islanders as compared with the US population as a whole. In recognition of these continuing disparities, the President of the United States has targeted six areas of health status and committed resources to address cancer, cardiovascular disease, infant mortality, diabetes, HIV/AIDS and child and adult immunizations aggressively. (See Health Disparities Among Ethnic and Racial Groups.)
To improve the quality of services and health outcomes.
Despite similarities, fundamental differences among people arise from nationality, ethnicity and culture, as well as from family background and individual experience. These differences affect the health beliefs and behaviors of both patients and providers have of each other.
The delivery of high-quality primary health care that is accessible, effective and cost efficient requires health care practitioners to have a deeper understanding of the socio-cultural background of patients, their families and the environments in which they live. Culturally competent primary health services facilitate clinical encounters with more favorable outcomes, enhance the potential for a more rewarding interpersonal experience and increase the satisfaction the individual receiving health care services.
Critical factors in the provision of culturally competent health care services include understanding of the:
- beliefs, values, traditions and practices of a culture;
- culturally-defined, health-related needs of individuals, families and communities;
- culturally-based belief systems of the etiology of illness and disease and those related to health and healing; and
- attitudes toward seeking help from health care providers.
In making a diagnosis, health care providers must understand the beliefs that shape a person's approach to health and illness. Knowledge of customs and healing traditions are indispensable to the design of treatment and interventions. Health care services must be received and accepted to be successful.
Increasingly, cultural knowledge and understanding are important to personnel responsible for quality assurance programs. In addition, those who design evaluation methodologies for continual program improvement must address hard questions about the relevance of health care interventions. Cultural competence will have to be inextricably linked to the definition of specific health outcomes and to an ongoing system of accountability that is committed to reducing the current health disparities among racial, ethnic and cultural populations.
To meet legislative, regulatory and accreditation mandates.
As both an enforcer of civil rights law and a major purchaser of health care services, the Federal government has a pivotal role in ensuring culturally competent health care services. Title VI of the Civil Rights Act of 1964 mandates that no person in the United States shall, on ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.
Organizations and programs have multiple, competing responsibilities to comply with Federal, state and local regulations for the delivery of health services. The Bureau of Primary Health Care, in its Policy Information Notice 98-23 (8/17/98), acknowledges that: "Health centers serve culturally and linguistically diverse communities and many serve multiple cultures within one center. Although race and ethnicity are often thought to be dominant elements of culture, health centers should embrace a broader definition to include language, gender, socioeconomic status, housing status and regional differences. Organizational behavior, practices, attitudes and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served. Health centers should develop systems that ensure participation of the diverse cultures in their community, including participation of persons with limited English-speaking ability, in programs offered by the health center. Health centers should also hire culturally and linguistically appropriate staff."
The Maternal and Child Health Bureau, through its program efforts related to state accountability and Healthy People Year 2000/2010 Objectives includes an emphasis on cultural competency as an integral component of health service delivery. The National Health Promotion and Disease Prevention Objectives emphasize cultural competence as an integral component of the delivery of health and nutrition services.
State and Federal agencies increasingly rely on private accreditation entities to set standards and monitor compliance with these standards. Both the Joint Commission on the Accreditation of Healthcare Organizations, which accredits hospitals and other health care institutions, and the National Committee for Quality Assurance, which accredits managed care organizations and behavioral health managed care organizations, support standards that require cultural and linguistic competence in health care.
To gain a competitive edge in the market place.
The provision of publicly financed health care services is rapidly being delegated to the private sector. Issues of concern in the current health care environment include the marketing of health services and the cost-effectiveness of health care delivery. The potential for improved services lies in state managed-care contracts that can increase retention and access to care, expand recruitment and increase the satisfaction of individuals seeking health care services.
To reach these outcomes, managed care plans must incorporate culturally competent policies, structures and practices to provide services for people from diverse ethnic, racial, cultural and linguistic backgrounds.
To decrease the likelihood of liability/malpractice claims.
Lack of awareness about cultural differences may result in liability under tort principles in several ways. For example, providers may discover that they are liable for damages as a result of treatment in the absence of informed consent. Also, health care organizations and programs face potential claims that their failure to understand health beliefs, practices and behavior on the part of providers or patients breaches professional standards of care. In some states, failure to follow instructions because they conflict with values and beliefs may raise a presumption of negligence on the part of the provider.
The ability to communicate well with patients has been shown to be effective in reducing the likelihood of malpractice claims. A 1994 study appearing in the journal of the American Medical Association indicates that the patients of physicians who are frequently sued had the most complaints about communication. Physicians who had never been sued were likely to be described as concerned, accessible and willing to communicate. When physicians treat patients with respect, listen to them, give them information and keep communication lines open, therapeutic relationships are enhanced and medical personnel reduce their risk of being sued for malpractice.
Effective communication between providers and patients may be even more challenging when there are cultural and linguistic barriers. Health care organizations and programs must address linguistic competence--insuring for accurate communication of information in languages other than English.
Permission is granted to copy and distribute this Web page (part of the NCCC Policy Brief "Rationale for Cultural Competence in Primary Care") or reproduce excerpts as long as credit is given to the National Center for Cultural Competence.
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- CDC's Office of Minority Health, Eliminating Racial & Ethnic Health Disparities
- CDC's Racial and Ethnic Approaches to Community Health
- U.S. Department of Health and Human Services