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, disparities continue in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaska Natives, and Pacific Islanders, as compared with the US population as a whole.
Health and human service organizations are recognizing the need to enhance services for culturally and linguistically diverse populations. Providing culturally and linguistically appropriate healthcare services requires an understanding of cultural competence.
What is Cultural Competence?
What's the Difference? Cultural Competence, Awareness, and Sensitivity
How Does Cultural Competence Apply to HIV/AIDS, STD, and TB Prevention?
Learn More About Cultural Competence
What is Cultural Competence?
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).1
Cultural competence requires that organizations:
- have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally.
- have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.
- incorporate the above in all aspects of policy making, administration, practice, service delivery, and involve systematically consumers, key stakeholders, and communities.
Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum.2
Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.3
Principles of cultural competence include:4
- Define culture broadly.
- Value clients’ cultural beliefs.
- Recognize complexity in language interpretation.
- Facilitate learning between providers and communities.
- Involve the community in defining and addressing service needs.
- Collaborate with other agencies.
- Professionalize staff hiring and training.
- Institutionalize cultural competence.
Improved quality of care is the outcome measure that indicates whether implementing training programs, policies, and culturally or linguistically appropriate standards makes a difference. A new trend in the literature suggests that using cultural competency in a focused or strategic way can be a helpful adjunct to the quality improvement process. For example, if a program wants to analyze patterns of broken appointments, it might examine variables such as age, gender, or race/ethnicity. If the analysis reveals that adolescents have the highest rate of broken appointments, the program can target specific strategies to this group. Does the clinic need to have weekend hours, when teens can more easily slip away from home? Would providing free transportation or reminder calls from caseworkers help? Does the provider reflect a youth-sensitive approach to the clinic’s client base?5
What's the Difference? Cultural Competence, Awareness, and Sensitivity
Cultural competence emphasizes the idea of effectively operating in different cultural contexts, and altering practices to reach different cultural groups. Cultural knowledge, sensitivity, and awareness do not include this concept. Although they imply understanding of cultural similarities and differences, they do not include action or structural change.6
How Does Cultural Competence Apply to HIV/AIDS, STD, and TB Prevention?
From Health Resources and Services Administration (HRSA) Care ACTION: Improving HIV/AIDS Care in a Changing Environment, August 2002, Mitigating Health Disparities Through Cultural Competence:
The recent Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care states that "racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as patients' insurance status and income, are taken into account.”7
These findings and others like them are not news to people concerned with the care of individuals living with HIV disease. Study after study has demonstrated unequal access to care and poorer health outcomes among certain segments of the HIV-positive population. For example, analysis of data from the HIV Cost and Services Utilization Study revealed that compared with nonminorities, women and African Americans with HIV disease who are receiving care are less likely to receive antiretroviral therapy, protease inhibitors, and prophylaxis for pneumocystis pneumonia. These disparities remained even after adjusting for gender, age, education, and insurance coverage.8
Follow up in 1997 revealed improvements, but African Americans and Hispanics were still only about half as likely as whites to participate in HIV clinical trials or to get experimental medicines. Other minorities were also less likely than whites to get experimental treatment.9
Disparities in access to quality care extend beyond race and gender to other segments of the population that are often marginalized. For example, HIV-infected injection drug users are less likely to receive antiretroviral therapy than non-drug users are.10
It follows that disparities in access to quality HIV care are related to disparities in survival, which have been reflected in AIDS mortality data for some time.11
Being competent in cross-cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings12. For HIV/AIDS prevention and treatment to succeed, the special needs and life contexts of those who are marginalized because of race, ethnicity, socioeconomic status (SES), sexual orientation, age, or gender must be sensitively addressed. Cultural competence must be demonstrated not only by intervention programs and staff, but also by surveillance staff, researchers (and their investigations), as well as by those delivering prevention services, care, and treatment programs to those who are HIV-infected.
Learn More About Cultural Competence
HIV/AIDS, TB and Cultural Competence
Mitigating Health Disparities Through Cultural Competence
From Health Resources and Services Administration (HRSA) Care ACTION
ftp://ftp.hrsa.gov/hab/august2002.pdf
National Minority AIDS Education and Training Center (NMAETC)
Web resources on African American, Latino/Hispanic, Asian/Pacific Islanders, American Indian and Alaska Natives, Hawaiian Natives cultural histories and beliefs, State of HIV/AIDS, Patient Barriers to Care, Provider Challenges to Delivering Care, and Recommendations for Clinical Delivery
http://www.nmaetc.org/
Cultural Aspects of AIDS and Cultural Aspects of Tuberculosis in Refugees and Immigrants
Bibliographies from State University of New York Institute of Technology (SUNYIT)
http://culturedmed.sunyit.edu/bib/aids/index.html
http://culturedmed.sunyit.edu/bib/Tuberculosis/index.html
A Clinical Guide on Supportive and Palliative Care for People with HIV/AIDS
From HRSA, the guide offers chapters on Culture and Care and Special Populations
http://hab.hrsa.gov/tools/palliative/chap14.html
http://hab.hrsa.gov/tools/palliative/chap15.html
Special Initiatives: What is Culturally Competent HIV Care?
From HRSA, includes information on deaf/hard of hearing people, gay/bisexual people, the homeless, and mental illness
http://hab.hrsa.gov/special/culture.htm
Cultural Competence
Resources from the AIDS Education & Training Centers National Resource Center
http://www.aids-ed.org/aidsetc?page=et-30-34&catid=cultcomp&pid=1
Survey of Americans on HIV/AIDS -- Part Three: Experiences and Opinions by Race/Ethnicity and Age
From the Henry J. Kaiser Family Foundation
http://www.kff.org/hivaids/pomr080404pkg.cfm
General Cultural Competence Information
Cultural Competence Works: Using Cultural Competence To Improve the Quality of Health Care for Diverse Populations and Add Value to Managed Care Arrangements
From HRSA
ftp://ftp.hrsa.gov/financeMC/cultural-competence.pdf
National Standards for Culturally and Linguistically Appropriate Services in Health Care
2001 FINAL REPORT from the Health and Human Services Department’s Office of Minority Health
http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf
National Standards on Culturally and Linguistically Appropriate Services (CLAS)
From the Office of Minority Health
http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15
CLAS A-Z: A Practical Guide for Implementing the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
From the Office of Minority Health
http://www.omhrc.gov/assets/pdf/checked/CLAS_a2z.pdf
A Physician’s Practical Guide to Culturally Competent Care
From the Office of Minority Health, the Website offers CME and CEU credit and equips health care professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve
https://cccm.thinkculturalhealth.org/
A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
From the Office of Minority Health
http://www.omhrc.gov/templates/content.aspx?ID=4375&lvl=2&lvlID=107
Developing a Self-Assessment Tool for Culturally and Linguistically Appropriate Services in Local Public Health Agencies
From the Office of Minority Health
http://www.omhrc.gov/assets/pdf/checked/LPHAs_FinalReport.pdf
Cultural Competency Resources
From the Office of Minority Health
http://www.omhrc.gov/templates/browse.aspx?lvl=1&lvlID=3
Cultural Competence Resources for Health Care Providers
HRSA list of online cultural competency resources. Includes culture/language specific and disease/condition specific resources, guidelines for clinicians, research, online training resources, health professional education resources, and more
http://www.hrsa.gov/culturalcompetence/
Compendium of Cultural Competence Initiatives in Health Care
From the Henry J. Kaiser Family Foundation, a report on public and private sector activities to reduce cultural and communication barriers to health care
http://www.kff.org/uninsured/6067-index.cfm
Why is Cultural Competence Important for Health Professionals?
Article from Diversity RX
http://www.diversityrx.org/HTML/MOCPT1.htm
Cultural Competence Primer
From the National Medical Association (NMA)
http://www.askme3.org/pdfs/NMAPrimer.pdf
Resources on Cultural Competency in Medicine
From American Medical Student Association (AMSA)
http://www.amsa.org/programs/gpit/cultural.cfm
Assessing Organizational and Practitioner Cultural Competence
Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile
From the Health Resources and Services Administration Center for Health Services Financing and Managed Care
http://www.hrsa.gov/culturalcompetence/indicators/default.htm
A Guide to Planning and Implementing Cultural Competence Organizational Self-Assessment [PDF]
From the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development
http://gucchd.georgetown.edu/nccc/documents/ncccorgselfassess.pdf
Cultural Competence Health Practitioner Assessment (CCHPA)
From the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development
http://www11.georgetown.edu/research/gucchd/nccc/features/CCHPA.html
Promoting Cultural and Linguistic Competency: Self Assessment Checklist for Personnel Providing Primary Health Care Services
From the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development
http://www11.georgetown.edu/research/gucchd/nccc/documents/Checklist%20PHC.pdf
Planning, Implementing and Evaluating Culturally Competent Service Delivery Systems in Primary Health Care Settings: Implications for Policy Makers and Administrators
From the National Center for Cultural Competence at Georgetown University’s Center for Child and Human Development
http://www11.georgetown.edu/research/gucchd/nccc/documents/Getting_Started.html
Understanding and Targeting Specific Populations
Cultural Groups
Web resources from The Provider’s Guide to Quality and Culture
http://erc.msh.org/mainpage.cfm?file=5.0.htm&module=provider&language=English&ggroup=&mgroup=
Patient Provider Interaction
Web Resources from The Provider’s Guide to Quality and Culture
http://erc.msh.org/mainpage.cfm?file=4.0.htm&module=provider&language=English&ggroup=&mgroup=
Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients
From the Gay and Lesbian Medical Association (GLMA)
http://ce54.citysoft.com/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf
1 What is Cultural Competency? Office of Minority Health
2
Conceptual Frameworks / Models, Guiding Values and Principles, National Center for Cultural Competence, Center for Child and Human Development, Georgetown University,
3 Davis, 1997, cited in How is Cultural Competence Integrated in Education, by Mark A. King, Anthony Sims, & David Osher, Center for Effective Collaboration and Practice
4 HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
5 HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
6 How Does Cultural Competency Differ from Cultural Sensitivity/Awareness? Center for Effective Collaboration and Practice
7 National Academies Press, Washington, DC, 2003
8
Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. N Engl J Med. 1998;339:1897-904, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
9 Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281:2305-15, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
10
Celentano DD, Galai N, Sethi AK, et al. Time to initiating highly active antiretroviral therapy among HIV-infected injection drug users. AIDS. 2001;15:1727-8, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
11 Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2001;13(1):34-5.Tables 29, 30, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
12
How is Cultural Competence Integrated in Education, by Mark A. King, Anthony Sims, & David Osher, Center for Effective Collaboration and Practice
