Cultural Competency

A Definition of Culture

Culture , in its broadest sense, reflects the whole of human behavior, including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination. Language is a part of culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups. Each group is identified by a particular body of shared traits (e.g., a particular art, ethos, or belief; or a particular behavioral pattern) and is rather dynamic in its evolving accommodations with internal and external influences. Any individual may belong to more than one group or subgroup, such as ethnic origin, religion, gender, sexual orientation, occupation, and profession.

Distinguishing Physical Characteristics

The use of physical characteristics (e.g., anatomy or skin color) to distinguish a cultural group or subgroup is inappropriate. There is a significant difference between distinguishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group leads to misunderstandings about the individual. The stereotype, a fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. People can and do respond differently to the same environment or situation. Stereotyping occurs through two cognitive phases. In the first phase, a stereotype becomes activated when an individual is categorized into a social group. When this occurs, the beliefs and feelings (prejudices) come to mind about what members of that particular group are like. Over time, this first phase occurs without effort or awareness. In the second phase, people use these activated beliefs and feelings when they interact with the individual, even when they explicitly deny these stereotypes. Multiple studies have shown that healthcare providers activate these implicit stereotypes, or unconscious biases, when communicating with and providing care to minority patients ( FitzGerald and Hurst, 2017 ). With this in mind, you can begin learning cultural competence by acknowledging your implicit, or unconscious, biases toward patients based on physical characteristics.

At the same time, this does not minimize the value of understanding the cultural characteristics of groups, nor does this deny the interdependence of the physical with the cultural. Genotype, for example, precedes the development of the intellect, sensitivity, and imagination that leads to unique cultural achievements, such as the creation of classical or jazz music. Similarly, a person’s phenotype, such as skin color, precedes most of the experience of life and the subsequent interweaving of that phenotype with cultural experience. Although commonly used in clinical practice, the use of phenotypic traits to classify an individual’s race is problematic. The term race has been used to categorize individuals based on their continent or subcontinent of origin (e.g., Asian, Southeast Asian). However, there is ongoing debate about the usefulness of race, considering the degree of phenotypic and genetic variation of individuals from the same geographic region ( Relethford, 2009 ). In addition, the origins of race date back to the 17th century, long before scientists identified genetic similarities. Over time, beliefs about particular racial groups were shaped by economic and political factors, and many believe race is a social construct ( Richeson and Sommers, 2016 ). Racism, defined as discrimination directed against a person or people of a particular racial or ethnic group, has been shown to negatively impact health over the life course. This occurs through inequitable access to resources and opportunities, such as education and healthcare, and stressful experiences that result in altered physiologic responses and changes in health behavior (Williams et al., 2019). Historically, the American healthcare system has discriminated against racial and ethnic minorities in edu cation, research, and direct patient care. Structural racism remains an ongoing problem within the healthcare system and is reflected in well-documented health disparities and inequities. As healthcare providers, you will encounter patients impacted by racism on a daily basis. After examining your own biases, you can strive to create a safe space for dialogue with patients, provide support, and refer to resources when appropriate (Trent et al., 2019).

Cultural Competence

Culturally competent care requires that healthcare providers be aware of and responsive to patients’ background and cultural experiences, including their preferences, values, language, and traditions, among other things ( Stubbe, 2020 ). Many models have been proposed to teach cultural competence. Most include the domains of acquiring knowledge (e.g., understanding the meaning of culture), shaping attitudes (e.g., respecting differences of individuals from other cultures), and developing skills (e.g., eliciting patient’s cultural beliefs about health and illness) (Saha et al., 2008). Some of these domains overlap with core aspects of the patient-centered care model ( Fig. 1.1 ). Seeleman et al. (2009) have proposed a framework for teaching cultural competence that emphasizes an awareness of the social context in which specific ethnic groups live. Assessing the social context includes inquiring about stressors and support networks, sense of life control, and literacy. Healthcare providers need to be flexible and creative in working with patients. Campinha-Bacote’s (2011) Process of Cultural Competence Model is another approach and includes five cultural constructs: encounters, desire, awareness, knowledge, and skill. Box 1.1 defines these five constructs.

Cultural Humility

Cultural humility involves the ability to recognize one’s limitations in knowledge and cultural perspective and be open to new perspectives. Rather than assuming all patients of a particular culture fit a certain stereotype, healthcare providers should view patients as individuals. In doing so, cultural humility helps to equalize the imbalance in the patient-provider relationship (Borkan et al., 2008). A provider may know many specific details about a patient’s particular cultures, yet not show cultural humility. Cultural humility involves self-reflection and self-critique with the goal of having a more balanced, mutually beneficial relationship. It involves meeting patients “where they are” without judgment to avoid the development of stereotypes. Attaining cultural humility is an ongoing process shaped by every patient encounter that involves openness, partnership, and genuine interest in understanding our patients’ belief systems and lives (Fahlberg et al., 2016).

The Impact of Culture

The information in Box 1.2 suggests that racial and ethnic differences, as well as social and economic conditions, may affect the provision of specific healthcare services to certain groups and subgroups in the United States. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups. Although death rates have declined overall in the United States over the past 50 years, the poorly educated and those in poverty still die at higher rates from the same conditions than those who are better educated and economically advantaged. Morbidity, too, is greater among the poor. Data from the 2013 Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report reveal a variety of healthcare disparities. Hispanic and non-Hispanic Blacks were uninsured at a significantly higher rate compared with Asian/Pacific Islanders and non-Hispanic Whites. The infant mortality rate among infants born to non-Hispanic Black women is more than double the rate for infants born to non-Hispanic White women. Compared with White women, a much higher percentage of Black women die from coronary heart disease before age 75 (37.9% vs. 19.4%). This same difference was observed between Black and White men (61.5% vs. 41.5%) (CDC, 2013). Due to societal stigmatization and discrimination, when compared with cisgender populations, transgender and gender diverse individuals are at greater risk for suicidality, being victims of violence, mental health comorbidities, human immunodeficiency virus (HIV)/sexually transmitted infection (STI) exposure, homelessness, and lower rates of insurance coverage (Office of Disease Prevention and Health Promotion [ODPHP], 2010, James et al., 2016). It is critical to understand that, although these disparities have been shown to occur in racial and ethnic minority groups and other marginalized populations, their root causes lie in inequitable access to resources, opportunities, and healthcare and greater physiologic stress (allostatic load) in affected individuals (Williams et al., 2019). These rather stark facts are sufficient to underscore the need for cultural awareness in health and medical care professionals. Cultural and practice differences exist among healthcare professionals as well. Allopathic providers often demonstrate skepticism regarding the use of complementary and alternative medicine (CAM) without considering the possibility of potential benefit to patients.

The Blurring of Cultural Distinctions

Some cultural differences may be malleable in a way that physical characteristics are not. For example, one group of people can be distinguished from another by language (see Clinical Pearl, “Language Is Not All”). However, globalization, the growing diversity of the US population, and evidence of healthcare disparities mandate more and more that we learn one another’s languages. Although modern technology and economics may eventually lead to universality in language, we can begin by acknowledging and overcoming our individual biases and cultural stereotypes. Because it is impossible to learn the native languages of all of our patients, when language barriers arise, we must become aware of our resources and know how to effectively use interpreters (Seeleman et al., 2009). Use of medical interpreters has a positive impact on healthcare quality, but we continue to use suboptimal methods of communication (e.g., family members). Although greater adoption of medical interpreter use involves policy and system-level changes, healthcare provider training and encouragement remain critically important (DeCamp et al., 2013).

The Primacy of the Individual in Healthcare

The individual patient may be visualized at the center of an indefinite number of concentric circles. The outermost circles represent constraining universal experiences (e.g., death). The circles closest to the center represent the various cultural groups or subgroups to which anyone must, of necessity, belong. The constancy of change forces adaptation and acculturation. The circles are constantly interweaving and overlapping. For example, a common experience in the United States has been the economic gain at the root of the assimilation of many ethnic groups. Although this results in greater homogeneity among the population, an individual’s ethnic behaviors or sexual orientation and gender identity will likely be unique. Predicting the individual’s character merely on the basis of the common cultural behavior, or stereotype, is not appropriate. Based on the Joint Commission 2010 report, “Checklist to Improve Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Across the Care Continuum,” White and Stubblefield-Tave (2016) remind us that unconscious bias, stereotyping, racism, gender bias, and limited English proficiency underlie healthcare inequalities. They offer their own checklist of recommendations for healthcare providers to address these issues with the goal of reducing disparities in care ( Box 1.3 ).

Ethical issues often arise when the care of an individual comes into conflict with the utilitarian needs of the larger community, particularly with the recognition of limited resources and, in the United States, rising healthcare costs. Cultural attitudes of our patients, at times vague and poorly understood, may constrain our professional behavior and confuse the context in which we serve the individual. Box 1.4 offers a guide to help understand the patient’s beliefs and practices that can lead to individualized, culturally competent care. Particular attention should be paid to caring for patients who self-identify as lesbian, gay, bisexual, transgender, queer, or questioning and are considered sexual or gender minorities (SGMs). Unfortunately, these individuals face discrimination and disrespect in the healthcare setting. Thus it is imperative that healthcare providers invest time in becoming culturally competent and develop cultural humility to work effectively with SGM patients. Specific responsibilities include providing a welcoming and safe environment, gathering a history with sensitivity and compassion, and performing a physi cal examination using a “gender-affirming” approach (e.g., using the patient’s correct name and preferred pronouns). Box 1.5 provides useful terminology ( Center for Excellence for Transgender Health, 2016 ) and Box 1.6 reviews the social, legal, and medical dimensions of transition for transgender and gender-diverse people.