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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.
References
used to prepare this document
"
A Vision for America's Future: An Agenda for the 1990s." (policy
statement). Washington, D.C., Children's Defense Fund (1990).
"
Health Care Rx: Access For All." (chart book). Washington,
D.C., U.S. Department of Health and Human Services, 1998.
"
Poor Communication With Patients Can Get You Sued." Physicians
Risk Management Update, vol. 4(1), Physicians Insurance Exchange,
1995.
"
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.
Links
CDC's Office of Minority Health, Eliminating Racial & Ethnic Health Disparities
and the CDC's Racial and Ethnic Approaches to Community Health
U.S. Department of Health and Human Services
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