Chapter 64: Cultural & Linguistic Competence

Family physicians deliver care across the lifespan from infancy to the end of life, all within increasingly diverse communities. Many of these communities face existing and persistent health and healthcare disparities. Growing diversity and persistent disparities are among several arguments for the provision of care and services, which are patient-centered as well as culturally and linguistically appropriate. This may include decisions and actions that are congruent with the patient’s value systems and orientation to health and illness.

Every patient interaction is a unique cultural experience; each encounter is an opportunity to overcome the potential impediments in the exchange of information between physicians, patients, and their families. The American Academy of Family Physicians (AAFP) recognized the importance of culturally proficient and linguistically competent care in a 2008 position paper: Principles for Improving Cultural Competency and Care to Minority and Medically-Underserved Communities. The AAFP is not alone in its recognition of the crucial role of cross-cultural health in the effective delivery of healthcare. The list includes other influential groups such as the American Association of Medical Colleges (AAMC), Liaison Committee on Medical Education (LCME), the Center for Medicare and Medicaid Services (CMS), and national, international bodies, such as The Joint Commission, The Commonwealth Fund, and the World Health Organization (WHO).

The Institute of Medicine (IOM) produced a landmark report entitled Crossing the Quality Chasm, which crystallized the failures of the American medical system and asserted that the system must be changed to one that is equitable, patient-centered, safe, and effective. The following year the IOM released Unequal Treatment, Confronting Racial and Ethnic Disparities in Health Care, which identified cross-cultural education as a possible intervention in the reduction of healthcare disparities. The documentary Unnatural Causes continued this narrative by examining how social determinants of health, including racism and class distinctions, created health inequalities within communities of color across the nation.

Emergent Diversity in American Communities

The changing demographics of the United States provide one of many compelling reasons for healthcare providers to consider the impact of cultural factors on health, disease, and healthcare. The population is increasingly diverse–aging, coming out, immigrating, and acculturating (Box 64-1). Currently, minorities represent one-third of the US population. Projections indicate that the United States will be a “majority-minority” nation by 2042, with the nation projected to be 54% minority in 2050 (Box 64-2).

Health and Healthcare Disparities

The performance of the US healthcare system reveals significant inequities across populations with missed opportunities in terms of preventing disease, disability, and morbidity and mortality indices. Disparities in health and healthcare are due to a complex interaction between many factors, from those that increase exposure to disease to those that decrease access to healthcare. The trends reveal that individuals from communities of color are in poorer health, face greater challenges in accessing care, experience significant navigation problems within the system, and receive a quality of care that is inferior to that of their nonminority peers. Individuals with limited English proficiency and low health literacy skills have also experienced lower-quality healthcare.

Examples of disparities include the following:

• African Americans are 3 times more likely to die from asthma than non-Hispanic whites. Asian American adults are less likely than white adults to have heart disease; they are also less likely to die from heart disease.

• Lesbians are less likely to obtain preventive services for cancer.

Health Determinants

Family physicians should factor in population health, socioeconomic status, and structural barriers, such as number and location of public health centers, pharmacies, and hospitals that may not be easily accessible. Other factors to consider include access to fresh foods, transportation, adequate housing, and recreation, which also contribute to overall health and well-being. These ecological determinants influence health and disease prevalence, but are rarely included in patient histories. Expanding the biopsychosocial model to include ecological factors provides a larger contextual model to evaluate patient’s health risks, susceptibilities, and health outcomes. Asking salient questions that reflect the patient’s broader living situation is a more effective approach in guiding healthcare decisions and health interventions.

Theorizing Health and Illness Causation and Establishing the Therapeutic Relationship

Health and disease are interrelated dynamic processes. Definitions of both include biomedical, social, ecological, spiritual, and psychological constructs. Illness is a socially influenced condition and must be viewed within the socially recognized reality defined by the patient. Illness causation and etiologies influence the physician-patient interaction, and a culture-centered approach to care encourages physicians to offer solace and relief from the patient’s viewpoint and experiences. There is a power differential with every clinical encounter, which impacts the physician-patient alliance. Medical and psychological problems are managed within this context and require the physician to mediate this imbalance through various techniques. These include affirmations and strengths that the patient may exhibit through healthy behaviors, lifestyle choices, beneficial existential cultural beliefs, and practices that advance health.

Family medicine offers helpful strategies through supportive and intentional counseling, such as motivational interviewing, which encourages affirmations and self-reflections that are patient-directed. Other skills that empower patients include expressing empathy during the encounter and exhibiting a practice style that encompasses and appreciates diversity. Physician attributes such as eliciting the patient’s goals and projecting a willingness to negotiate care options and patient preferences has been shown to increase visit satisfaction and adherence to treatment. Although time constraints create limitations on patient interactions, these activities do not add significantly to the length of the visit and do improve overall quality of care. Finally, cultural humility, a process of continual self-reflection, awareness, and growth in learning about diverse populations, change, and the relational dynamics between patients and physicians, is crucial to providing a mutually effective partnership in practice.

Explanatory Models of Health, Illness, and Care

Patient-centered care focuses on engaging patients and their families in the care management plan and healthcare decision making. Health advocacy is linked to this model of care and encourages patients to be actively involved in the design and planning of their own healthcare delivery, in addition to the larger medical system. Attributes associated with patient-centered care mirror some of the tenets of culturally competent care. They include care that is “whole-person”-focused; encourages patient empowerment and engagement; and emphasizes communication and coordination that is sensitive to the patient’s linguistic level, personal preferences, cultural strengths, and values. The foundation for these principles is derived from Engel and Roman’s biopsychosocial model, which maintains the patient’s human dimension as the central focus to the medical encounter. Physicians are required to go beyond the traditional reductionist biomedical approach and incorporate cultural variables regarding family and community, health beliefs, and expectations in the therapeutic process.

Engel’s biopsychosocial approach recognizes the complex interactions between healthcare delivery and the patient’s beliefs and behaviors concerning wellness, illness, and disease. It is supported and enhanced by the clinical lessons offered by Kleinman’s explanatory model, a tool for ­physicians to aid in providing culturally competent care. The model is elicited through open-ended questions, originally eight questions, focused on how patients perceive their illness state, their beliefs regarding causality, and perceived forms of treatment. This information provides contextual data, which strengthens the therapeutic alliance and informs the physician regarding diagnosis and management. The advantages in using this approach have been validated through qualitative and quantitative research that enriches medical practice as well as population health. Practical applications give physicians a living illness experience associated with their patients. It also provides information about sick roles and behaviors that are linked to care in various scenarios covering social health issues, including HIV-AIDS, domestic violence, and other community ills.

Mental and Behavioral Health

Mental health can be seen as the result of the complex interactions between biological, psychological, social, and cultural factors. The influence of any of these factors can be stronger or weaker depending on the illness or disorder. Cultural and social factors can affect a patient’s belief as to symptom causation and inform their reaction and reception to a diagnosis of mental illness.

Despite its prevalence in all cultures, mental health can carry with it a significant amount of shame and stigma around a diagnosis. In other cultures, acknowledging the illness can have consequences on the perception of the entire family. Cultural and religious communities have the power to demystify mental illness, while assisting and supporting individuals and their families.

Because of the complexities that exist around mental illness, numerous disparities exist and persist in culturally diverse communities. The US Surgeon General’s report on mental health found the following:

• Minorities have less access to, availability of, and receive mental health services.

• Minorities in treatment often receive a poorer quality of mental healthcare.

• Minorities are underrepresented in mental health research.

• Racial and ethnic minorities collectively experience a greater disability burden from mental illness than do whites; this higher level of burden stems from minorities receiving less care and poorer quality of care, rather than from the fact that their illnesses are inherently more severe or prevalent in the community.

Application of Cultural Information and Skills in Clinical Interactions

Several tools that are available to family physicians can provide guidance in interacting with patients and ­incorporate cultural elements as part of the clinical assessment. Beginning with the Berlin and Fowkes’ LEARN model (Box 64-3), others have been developed, including the BATHE, ESFT, ETHNIC, and CRASH frameworks. They provide the patient an opportunity to engage and elaborate on signs and symptoms from their cultural perspective.

Going Beyond the Clinical Interview

Fundamental to every clinical encounter is establishing a therapeutic relationship with a patient that is affirming, inclusive, and collaborative. This chapter provides information for family physicians to assist in establishing that relationship. The information presented should be viewed as a starting point along the continuum of cultural and linguistic competency. This lifelong process begins with recognizing the inherent strengths and value of human diversity. The continuum also includes the confrontation of personal and societal bias, fosters the growth of cultural awareness and sensitivity, and develops the cross-cultural knowledge and skills that will improve clinical practice.

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Healthcare

The National CLAS standards provide a blueprint with which to operationalize and institutionalize the concepts of cultural and linguistic competency and are intended to advance health equity, improve quality, and help eliminate healthcare disparities. The standards can assist physicians, small practices, and large hospitals plan and implement culturally and linguistically appropriate services geared toward improving care and services. Physicians need to be active members in clinics, hospitals, and medical societies in order to create culturally and linguistically competent institutions. Physicians can be powerful advocates for hiring bilingual-bicultural workers, employing trained interpreters, creating health education approaches for patients with limited English proficiency, ensuring quality translation, and engaging institutions in caring for diverse patients (Box 64-4). The National CLAS standards are referenced throughout the following case study to illustrate their application; however, to achieve the intended outcomes, the standards should be implemented in their entirety. The National CLAS standards and their accompanying guidance document, A Blueprint for Advancing and Sustaining CLAS Policy and Practice, are available through the HHS Office of Minority Health, Think Cultural Health website.

GT was a 42-year-old Spanish-speaking Latin American woman who presented at the family medicine center with headaches, malaise, nausea, one episode of vomiting, and weakness of one day’s duration. The patient presented with several teenage children who appeared challenging to manage in the clinic. The constant interruptions made it difficult for the provider to obtain the history and conduct a physical exam. On initial presentation the patient noted that the headaches were increasingly severe and unusual because of the intensity. Previous headaches had been relieved with over-the-counter (OTC) medications. After a series of pointed questions through the use of a nurse interpreter who spoke Spanish, the patient was informed that the diagnosis was most likely the “flu,” or exacerbation of stress-related tension headaches. The vital signs and examination were nonfocal, except for bradycardia of 55, and a temperature of 99.8°F. The patient presented later to the local emergency department, and did not return to the clinic because of worsening symptoms and was urgently evaluated, and stabilized for toxic exposure to the dried oleander leaves prepared for medicinal purposes. The leaves were obtained from a curandero local to the area where the patient lived.

In the current example there are several points to ­consider.

The Importance of Effective Communication

• National CLAS standards 4, 5, 6, 7, 8, and 13 are just a few of the standards that can assist in providing effective communication regardless of cultural or linguistic background.

The use of a lay or ad hoc interpreter is problematic and should not be acceptable in the clinical setting (Box 64-5). A certified interpreter should be the standard for healthcare communications and if unavailable, other modalities, such as phone banks and/or virtual interpreter programs should be utilized. Physicians should be familiar with the different roles and types of interpreters. This includes video remote interpreting, telephonic, and in-person interpreting. It is also important for physicians to appreciate the importance of using certified interpreters who have been assessed for their language proficiency and knowledge of medical terminology. The use of interpreters includes recognizing the importance of verbal, nonverbal cues, posture, and positioning with interpreters. In addition, the value of touch as therapeutic can be helpful in solidifying the physician-patient relationship, while the interpreter remains in the background.

Effective communication is fundamental to providing healthcare to diverse patients. Care that acknowledges and supports the patient’s cultural beliefs and practices (eg, folk medicine, alternative treatments) allows patients to participate in negotiating a management plan. It may also reveal questionable or even harmful responses to the illness condition, and provide a teachable moment for change. Care that includes cultural accommodations when appropriate builds trust in the professional’s and patient’s faith in the clinical process. Care that includes cultural negotiations and accommodations encourages patients and their families to participate in the clinical process, and builds trust in the professional relationship.

Conversational styles vary across cultures and are challenging. For optimal communication, physicians must adapt their standard interviewing techniques to match patient’s communication styles. Do not assume that one methodology will be effective for interviewing and relaying clinical information. In addition, appreciation for verbal-nonverbal cues is important. Although physicians may feel comfortable with a straightforward approach with direct eye contact, patients from various backgrounds and cultures may feel intimidated and threatened by this position. They may not answer questions, chose to change the subject, or simply remain silent. Misinterpretation of delivery of information can result in problems with adherence, follow-up, and outcomes.

Physicians can learn general approaches from community experts, such as bilingual-bicultural colleagues, and make adaptations as they are attuned to people’s verbal and nonverbal cues.

Recognizing the Important Roles of Traditional Medicine and Traditionalist Practitioners

• National CLAS standards 4, 9, 11, 12, and 13 are a few of the standards that could assist in recognizing the important roles that traditional medicine and practitioners serve as forms of community support.

Recognizing folk illness beliefs and, interpretation of signs and symptoms is also linked with how patients respond to illness and disease. Culture influences help-seeking behaviors, which will be expressed in multiple ways, such as when and who is consulted first, treatment preferences, and expectations for healing. Indigenous practices and practitioners, such as herbalists, shamanists, and curanderos, may not be discussed during the family practice visit unless rapport is established and cultural sensitivity is demonstrated. Medicinal therapies may be taken alongside prescription medications, and may be substituted because of side effects, the appearance of the pills, or confusion about the regimen. Family physicians should be familiar with some commonly used botanicals and herbs, since drug toxicities can present as chief complaints. Examples include ginseng and licorice, causing hypertension; chamomile tea, leading to anaphylaxis; ephedra (ma huang), causing a wide range of cardiovascular effects; and liver enzyme induction with eucalyptus oil, sassafras, and comfrey. In this case, early signs of oleander toxicity could have been identified during the history-gathering process, instead of the premature diagnosis of “flu,” viremia, or tension headache. Family physicians should sensitively ask their patients what they are taking and encourage them to bring their remedies into the office to discuss together.

A visit to the family medicine clinic or hospital may be the last resort when patients become ill. Patients may ­experience shame and humiliation by other family or community members if they seek care outside of normative practices or standards. Family physicians must therefore exhibit an open and nonjudgmental attitude, avoiding bias in evaluation and treatment. Family physicians should consider mobilizing additional resources and recognized community health experts in working with culturally diverse patients, especially where there may be knowledge gaps or other challenges.

Utilize an Inclusive and Participatory Care Model

• National CLAS Standards #1, 10, 11, and 13 are a few of the standards that could assist in identifying, utilizing and maintaining an inclusive and participatory care model.

Encourage a participatory care model. Patient’s and physician’s information is interpreted through a cultural lens and influences the direction of the clinical questions leading to the diagnosis. Physicians who use a participatory framework allow patients to actively participate in the physician-patient exchange. Patients can offer explanatory models about their beliefs, perceptions of illness, and disease states, as well as offer information about their treatments. Patients allowed to engage and interject their health concepts and ideas will share more crucial information during the visit. The result will be a more accurate diagnosis, more appropriate management plan, and better adherence to treatment. Patient satisfaction leads to better patient follow-up, even if the diagnosis is inconclusive, or in this case, inaccurate. In this particular case, the patient most likely felt dissatisfied with the diagnostic explanation offered and sought care in the emergency department (ED) as a last resort. This was also a missed learning opportunity for the physician, since the patient did not return for follow-up care.

The quality of interpersonal care and interpersonal communications impacts all aspects of the health encounter. Research confirms that when physicians are more inclusive in their interactions, and when patients are more involved as partners, consensus around treatment is more successful with increased satisfaction with care. A participatory model of caregiving that includes a biopsychosocioecological framework has a greater impact on positive behavior change and sustaining the physician-patient relationship. This has a direct effect on outcome rating scores, and liability protection independent of diagnostic accuracy.

Providing cross-cultural care requires physicians to participate in lifelong learning both intellectually and experientially. Continuous self-reflection, evaluation, and reevaluation is required if family physicians are to remain current in their understanding of changing demographics and emerging dominant populations regionally and nationally. Self-study, participation in discussion networks, and virtual community exchanges may be an efficient strategy to engage in the learning process. This is a required educational journey if one is to partake in the universal goal to offer care that is personally meaningful and continues the ongoing search to address human sickness and healing in society.

The following sources are recommended for further information:

• American Academy of Family Physicians (AAFP). Cultural competency video: Quality Care for Diverse Populations.

• American Board of Family Medicine: Cultural Competency Methods in Medicine Module. Five modules that qualify for Part IV recertification credit were released in fall 2010.

• American Muslim Health Professionals: http://amhp.us/

• Asian and Pacific Islander American Health Forum: http://www.apiahf.org

• Colorado Health Foundation: http://www.coloradohealth.org/

• Cross Cultural Health Care Program: www.xculture.org

• Cultural Competence Online for Medical Practice: http://www.c-comp.org

• Ethnomed: www.ethnomed.org

• Gay and Lesbian Medical Association (GLMA): www.glma.org

• HHS Health Resources and Services Agency (HRSA) toolkits, videos

• Health Resources and Services Administration (HRSA): Effective Communication Tools for Healthcare Professionals

  • HHS Office of Minority Health, Think Cultural Health: https://www.thinkculturalhealth.hhs.gov

  • Resources include

    • National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.

    • A Physician’s Practical Guide to Culturally Competent Care (9 CME)

• National Center for Cultural Competence (NCCC): http://nccc.georgetown.edu/.

• National Coalition for LGBT Health: http://lgbthealth.webolutionary.com/.

• National Council on Interpretation in Health Care: http://www.ncihc.org/.

• National Health Law Program: http://www.healthlaw.org.

• National Hispanic Medical Association: http://www.nhmamd.org/.

• National Institutes for Health: http://www.nih.gov/clearcommunication/culturalcompetency.htm.

• National Medical Association: http://www.nmanet.org/.

• Provider’s Guide to Quality and Culture: http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=english.

• Resources for Cross-Cultural Health: www.diversityrx.org.

• Society of Healthcare Professionals with Disabilities: http://www.disabilitysociety.org/.

• W. K. Kellogg Foundation: http://www.wkkf.org./

• World Education; Culture, Health and Literacy: http://www.worlded.org/us/health/docs/culture/about.html.