Multiculturalism, Diversity, and Care Delivery

Key Concepts

Changing demography and an evolving culture in the United States are changing emergency medicine practice as disparities in health and health care delivery continue, despite efforts to improve care.
Emergency department interventions should focus on social determinants of health, health literacy, and empowerment of patients to participate in their care.
Treatment plans created with patients and based on what matters to them have the greatest opportunity for success.
Emergency clinicians will improve the quality of care provided if they can meet federal standards for culturally and linguistically appropriate care, recognizing that patients with limited English proficiency have a right to medical interpretation.
Culturally sensitive, patient-centered, and trauma-informed care will improve patient clinician communication and satisfaction, decrease medical errors, and promote patient follow-through with recommendations.

Foundations

Background and Importance

In recent years, many high-profile incidents have put the role of multiculturalism, diversity, inclusion, and health equity in the forefront of public discourse. To obtain high-quality care, patients must first enter a health care system where many have experienced barriers to access based on race, religion, ethnicity, socioeconomic status, age, sex, disability status, language, sexual orientation, gender identity, and residential location. These issues highlight both the progress and challenges in understanding equity in society. As a microcosm of larger society within health care, the practice of emergency medicine (EM) should embrace a greater understanding and awareness of the roles of multiculturalism and diversity in the delivery of health care.

The population of the United States (US) continues to become more diverse. Women now comprise over half of the US population. By 2030, one in five Americans is projected to be aged 65 years and over. Minority groups (any group other than non-Hispanic White alone) are projected to become the collective majority as early as 2044, and almost one in five of the nation’s total population is expected to be foreign-born by 2060. As a specialty, EM is in a unique position to serve this diverse population. In many emergency departments (EDs), the majority of visits are with patients from minority backgrounds. Emergency physicians routinely encounter patients from diverse cultural backgrounds representing various customs, practices or beliefs. All major national EM membership organizations now have policies and statements on diversity, inclusion, and equity. Policies on cultural awareness and emergency care focus on how emergency clinicians should consider the patient’s culture, as it relates to history and presenting symptoms, in developing a treatment plan that is mutually agreed upon by the patient and physician. Statements also focus on beliefs and commitments to the goals of attaining equity, diversity, and inclusion in emergency medicine that reflects our multifaceted society. There is consensus around the development and promotion of education, research, and services that assist EDs in improving health for all, with a focus on eliminating health inequities. ^, To attain these goals, emergency clinicians must become culturally competent to meet the needs of diverse patient populations.

Rationale For Cultural Competence

Changing Demographics

Both the US population and the types of health problems seen by emergency clinicians are constantly changing. ⁵ According to US Census data from the 2018 American Community Survey, 14% of the US population identified as foreign-born. Additionally, 28% of the population identified as other than “White alone” and 18% described themselves as Hispanic or Latino. These changing demographics do not speak to the diversity within the various groups. The category Hispanic, for example, is an ethnic grouping counted in the race category of the census, but it fails to capture the significant range of diversity represented by Spanish speakers. Hispanics may share some cultural practices and speak similar versions of the Spanish language, but they have major differences in vocabulary and dialect, history, socioeconomic status, cultural identity, self-reference (Hispanic or Latino), levels of acculturation, health beliefs, habits, access to care, and health outcomes. The changing cultural landscape will challenge EM providers to recognize, account for, and address these differences when providing care for their patients.

Racial and Ethnic Disparities in Health Care Access and Outcomes

An overarching goal of the Healthy People 2030 Project is to “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.” Numerous studies find that we are not meeting that goal. ⁵ When compared to Whites, racial and ethnic minorities have a lower likelihood of having a usual source of care, fewer physician visits, and fewer health expenditures. Hispanics and Blacks are less likely to initiate or receive mental health services when compared to Whites. Hispanics have lower health care use, including ED visits and outpatient mental health services, when compared to Whites and Blacks. Hispanic, Asian, and Black patients are less likely to have a consistent primary care provider. With respect to unmet needs from ED visits, Black women fared the worst compared to men and women from White, Hispanic, and Asian backgrounds. Black patients are among the most disadvantaged of the racial/ethnic groups with a greater proportion impoverished, unemployed but looking for work, or in poor to fair health.

Factors resulting in racial/ethnic disparities in health care contribute to differences in access to care. While these differences in access to care may correlate with access to financial resources or health insurance, other factors such as culture, language, and discriminatory practices may also contribute to these variations. Studies indicate that “implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned individuals is present among many health care providers of varying specialties, levels of training, and levels of experience.” Reproductive biology and conditions specific to gender may also result in differences in health service use as it relates to gender.

Tests and Treatments

Disparities in ED pain treatment persist a decade after identification of racial and ethnic differences in analgesic administration. ^, Studies indicate that provider bias may contribute to a skewed assessment of pain and therefore inadequate treatment. Lee et al. reviewed studies from 1990 to 2018 comparing racial and ethnic differences in the administration of analgesia for acute pain and found that Black and Hispanic patients were less likely than White patients to receive analgesia for acute pain. Goyal et al. found that Black children with appendicitis are less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.

Racial and ethnic differences in provision of medically appropriate procedures and therapies have been documented. Wilder et al. found that Blacks and Hispanics were significantly less likely to receive any antidote when presenting to the ED for acute drug overdose. Miller et al. found that a protocol-driven care pathway eliminates the racial disparity among Black and White participants with chest pain in the acquisition of index-visit cardiovascular testing. Despite decades-old identification of these differences and regardless of the setting, health care disparities remain a real and pervasive threat to patient care, but studies indicate that protocol-driven pathways may help to decrease racial disparities.

Health Outcomes

Even perceived discrimination has a significant effect on health. ^, Thames et al. performed a cross-sectional bioinformatic analysis relating perceived discrimination (measured by the Perceived Ethnic Discrimination Questionnaire [PED-Q]) to the activity of proinflammatory, neuroendocrine, and antiviral transcription control pathways relevant to the conserved transcriptional response to adversity (CTRA) in peripheral blood leukocytes. They found that differential exposure to racial discrimination may contribute to racial disparities in health outcomes in part by activating threat-related molecular programs that stimulate inflammation and contribute to increased risk of chronic illnesses.

Lee et al. evaluated the association between discrimination and leukocyte telomere length (LTL), a biologic marker of systemic aging. High discrimination was associated with shorter LTL after controlling for sociodemographic factors, health factors, depressive symptoms, and stress. Results suggest that discrimination experiences accelerate biologic aging in older African American males and females alike. This finding helps advance our understanding of how discrimination generates greater disease vulnerability and premature death in African Americans.

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