Foundations

Foundations

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:

FoundationsTo respond to current and projected demographic changes in the United States.

By 2060, over the next three decades, the U.S. Census Bureau projects significant changes in the demographic makeup of this nation’s population that characterized by age, race and ethnicity, and foreign-born status. The U.S. Census Bureau reports that between 2014 -2044, the U.S. population will become even more diverse and it is projected that the U.S. will become a plurality nation in 2044. While the non-Hispanic White (alone) population will still be the largest, no race or ethnic group is projected to have greater than a 50 percent share of the nation’s total.  More than half of all Americans are projected to belong to a minority group, and the nation will become “majority-minority.” The child population within the U.S. is even more diverse and is projected to experience this “majority-minority” crossover in 2020.

Data from the most recent U.S. Census Bureau reveals that 21.5% of the nation’s population five years of age and over speak a language other than English at home. Within the U.S. population, it is estimated that 4.5% reside in limited English speaking households, which are defined as households where no one above 14 years of age speaks only English or speaks a non-English language and English “very well.”

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 U.S. population as a whole.

Each year since 2003, the Agency for Healthcare Research and Quality has produced the National Healthcare Quality Report and the National Healthcare Disparities Report.These reports to Congress are mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). The most recent report (2015) indicated that disparities related to race and socioeconomic status persist among measures of access and all National Quality priorities.

The Office of Minority Health, Department of Health and Human Services (HHS) is leading the charge to implement the HHS Action Plan to Reduce Racial and Ethnic Health Disparities, and includes five national goals. The five goals of the HHS Disparities Action Plan are to: 1)Transform health care; 2) Strengthen the nation’s health and human services infrastructure and workforce; 3) Advance the health, safety and well-being of the American people; 4) Advance scientific knowledge and innovation; and 5) Increase the efficiency, transparency and accountability of HHS programs.

AHRQ source:
Retrieved from https://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html
Office of Minority Health Source:
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=10

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.

Policy and Regulation. 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 and linguistically 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.

This law and a series of related federal executive orders and regulations address rights to language access services (including but not limited to interpretation and translation) for any individual with limited English proficiency. In 2013, the U.S. Department of Health and Human Services, Office of Minority Health promulgated  the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care  as a way to improve the quality of services provided to all individuals, which will ultimately help reduce health disparities and achieve health equity. Additionally, a number of state laws and policies address requirements for both language access services and cultural competence training for licensed health care professionals.

State and federal agencies increasingly rely on private accreditation entities to set standards and monitor compliance with these standards.  For example, both the Joint Commission, which accredits and certifies hospitals and other health care programs,  and the National Committee for Quality Assurance, dedicated to improving health care quality through measurement, transparency, and accountability, include cultural and linguistic competence. The National Quality Forum, develops standards to measure and report the quality and efficiency of healthcare in the Unites States which endorse cultural and linguistic competence.

Finally professional organizations have created standards for their disciplines/specialties that require cultural competence training as a component of their  accreditation processes. Professions that have adopted such standards include physicians, nurses, physician assistants, dentists, pharmacists, psychologists, social workers, occupation and physical therapists, speech and language pathologists and audiologists.

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.

“Recognizing that culture plays an important role in communication helps us better understand health literacy. For people from different cultural backgrounds, health literacy is affected by belief systems, communication styles, and understanding and response to health information.
Source: National Libraries of Medicine. Health Literacy. Retrieved on 3/19/17 from http://nnlm.gov/outreach/consumer/hlthlit.html

An array of definitions of health literacy are prevalent in the health care literature. Nutbeam defined “health literacy as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.” In 2000, the U.S, Department of Health and Human Services defined health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. In 2004, with the issuance of the Institute of Medicine (IOM) study, this focus began to shift from viewing health literacy solely in the domain of the individual to include the skill of health care professionals and the capacity of health care systems as well as other entities that provide health information. The IOM concluded that “Health literacy is a shared function of social and individual factors. Individuals’ health literacy skills and capacities are mediated by their education, culture, and language. Equally important are the communication and assessment skills of the people with whom individuals interact regarding health, as well as the ability of the media, the marketplace, and government agencies to provide health information in a manner appropriate to the audience” (page 32).

Lastly, the work of Rima Rudd and colleagues brings us full circle. Rudd pushes us to re-envision and redefine health literacy from a completely different lens. There are two primary assertions from her work. First, she asserts that major responsibility for health literacy should rest in the design and implementation of health care that removes systemic barriers to the communication of health information and which facilitates access to, and the meaningful engagement of people in, such processes. Second, she posits that it is essential to recognize the broader socio-cultural contexts in which health literacy is experienced. She postulates that in order to optimize health and well-being, health information must be adapted to the everyday lives of people and the everyday occurrences in the communities in which they live. According to Rudd, and commensurate with these insights, health literacy is the capacity of professionals and health institutions to provide access to information and support the active engagement of people.

References

Colby, Sandra L. and Jennifer M. Ortman, Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Current Population Reports, P25-1143, U.S. Census Bureau, Washington, DC, 2014.  Retrieved on 7/4/16 from http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf

U.S. Census Bureau, American Fact Finder, 2015 American Community Survey-1 Year Estimates, Table S1601.

Data Source: U.S. Census Bureau, American FactFinder, 2015 American Community Survey- 1 Year Estimates, Table S1602.

Rudd R, McCray A, Nutbeam D. Health Literacy and Definition of Terms. In: Begoray D, Gillis D, Rowlands G, eds. Health Literacy in Context: International Perspective. New York. NY: Nova Science Publishers, Inc; 2012.

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Committee on Health Literacy, Board on Neuroscience and Behavioral Health, Institute of Medicine. Introduction. In: Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, D.C.: National Academies Press; 2000.

"Health Care Rx: Access For All." (chart book). Washington, D.C., U.S. Department of Health and Human Services, 1998.

"The Initiative To Eliminate Racial and Ethnic Disparities in Health." (policy statement). Washington, D.C., U.S. Department of Health and Human Services, 1998.

The HIV/AIDS Epidemic in the United States, 1997-1998. (fact sheet). Atlanta, GA., Centers for Disease Control and Prevention, 1998.

Cross, T., Bazron, B., Dennis, K., and Isaacs, M. "Towards A Culturally Competent System of Care," vol. 1, Washington, D.C., National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center, 1989.

Goode, T. "The Cultural Competence Continuum." Training and Technical Assistance Resource Manual, (paper presented at conference on Culturally Competent Services and Systems: Implications for Children and Youth with Special Health Needs). Rio Grande, Puerto Rico, 1998.

Like, R. "Treating and Managing the Care of Diverse Patient Populations: Challenges for Training and Practice." (paper presented at national conference on Quality Health Care for Culturally Diverse Populations: Provider and Community Collaboration in a Competitive Marketplace.) New Brunswick, N.J., Center for Healthy Families and Cultural Diversity, Robert Wood Johnson Medical School, 1998.

Mason, J. "Rationale for Cultural Competence in Health and Human Services," Training and Technical Assistance Resource Manual, (paper presented at national conference on Culturally Competent Services and Systems: Implications for Children With Special Health Needs.) Rio Grande, Puerto Rico, 1998.

World Health Organization. Healthy Literacy Definition Health Promotion Glossary. Geneva, Switzerland; 1998.

"Poor Communication With Patients Can Get You Sued." Physicians Risk Management Update, vol. 4(1), Physicians Insurance Exchange, 1995.

"A Vision for America's Future: An Agenda for the 1990s." (policy statement). Washington, D.C., Children's Defense Fund (1990).