Betancourt, Joseph R. MD, MPH; Green, Alexander R. MD, MPH
The Institute of Medicine (IOM) report, Unequal Treatment,1 recommended that all health care professionals should receive training in cross-cultural communication—or cultural competence—as one of multiple strategies for addressing racial/ethnic disparities in health care. This recommendation emerged from robust evidence highlighting the fact that the failure of health care providers to acknowledge, understand, and manage sociocultural variations in the health beliefs and behaviors of their patients may impede effective communication, affect trust, and lead to patient dissatisfaction, nonadherence, and poorer health outcomes, particularly among minority populations. Similarly, another IOM report, Crossing the Quality Chasm,2 noted that patient-centered care—particularly its attributes of being respectful of patients' values, beliefs, and behaviors—is an essential pillar of quality.
As the field of cultural competence has evolved, there has been a call to better elucidate its key teaching principles, as well as strategies to engage clinicians in this area of education, and to develop frameworks for evaluation of its impact on health care outcomes. In this perspective, we aim to share our key perspectives in all of these areas, with a particular focus on how to measure the impact of cultural competence training on health care outcomes.
The Evolution and Key Principles of Cultural Competence
Cultural competence is the ability of health care professionals to communicate with and effectively provide high-quality care to patients from diverse sociocultural backgrounds; aspects of diversity include—but go beyond—race, ethnicity, gender, sexual orientation, religion, and country of origin. Previous efforts in cultural competence education used the “categorical approach,” which meant teaching about the attitudes, values, beliefs, and behaviors of specific cultural groups, such as Latino patients. Whereas learning about a particular local community or cultural group can be helpful to a clinician, being presented with, and learning, a set of specific cultural beliefs and behaviors that are attributed to a particular group can lead to stereotyping and oversimplification of a culture, rather than to respect for its complexity. Cultural competence has thus evolved from the categorical approach to an approach focusing on the development of a set of skills and a framework that allow the clinician to assess—for an individual patient—what sociocultural factors might affect that patient's care.3 Training under this approach provides clinicians with numerous skills they can use to provide better patient care: (1) methods, such as using the explanatory model—that is, asking questions to elicit a patient's understanding of his or her illness, (2) strategies for identifying and bridging different styles of communication, (3) skills for assessing decision-making preferences and the role of family, (4) techniques for ascertaining the patient's perception of biomedicine and his or her use of complementary and alternative medicine, (5) tools for recognizing sexuality and gender issues, (6) mechanisms for negotiating, and (7) methods for bringing to bear an awareness of issues of mistrust and prejudice and of the impact of race and ethnicity on clinical decision making. These skills can, in fact, be helpful in the care of all patients, but they may be especially helpful in the care of patients who come from cultures different from the culture of the clinician, who have had a different health care experience, or who have perspectives that might differ from that of the Western medical model. Years of teaching have provided us with the following lessons about how to ensure that clinicians are fully engaged and committed to cultural competence training.
The “buy-in” is critical
It is critically important to secure “buy-in” from clinicians: A clinician has bought in to this approach or plan when he or she truly understands the impact of cultural competence and the significance of its link to quality health care. The buy-in is accomplished by making the case—with the use of real clinical scenarios as well as the peer-reviewed literature—that cultural competence is a skill that will truly help clinicians provide high-quality care to any patient they see, regardless of the patient's background.
Focus on cases and clinical applications
Didactics can be especially ineffective in the teaching of cultural competence. The focus should be on using clinical cases and on teaching skills that have real and relevant clinical applications.
Address the demand for the categorical approach
Given the time constraints of the medical encounter, clinicians may demand “quick facts” about different cultures (i.e., they may use the previously discussed categorical approach) rather than developing a framework within which they can explore these issues with each individual patient. An effective way to address this demand is to draw parallels to the ways in which we obtain other clinical information about patients. For instance, we never assume, just because a patient has a cough and a fever, that he or she has pneumonia; instead, we ask a set of questions, from the framework, that help us generate a differential diagnosis. The same approach could be described for cross-cultural care—the clinician needs a framework from which to assess the sociocultural factors that are most important to the individual patient under his or her care.
It is important to teach cultural competence in a developmental fashion. During undergraduate medical education, educators can expect to secure buy-in, raise awareness, provide general knowledge, and teach basic skills. During graduate medical education, cases and clinical scenarios are likely to be more advanced, and education can focus on building skills. Continuing medical education should provide information on updates and on new techniques in the field, as well as explore cases that are more discipline-specific.
Integrate when possible
It may be important to have specific courses on cross-cultural care and communication. However, integrating concepts of cultural competence into other clinical teaching may be effective in highlighting that this field is not an “add-on” but is essential to effective patient care.
Evaluating Cultural Competence and Linking It to Health Care Outcomes
Research has shown that cultural competence training improves the attitudes, knowledge, and skills of clinicians that are related to caring for diverse populations, including facilitating a richer dialogue with the patient and both seeking and sharing more information during the medical visit.4,5 Cultural competence training also improves patient satisfaction, but there are few published studies that have shown any impact on patient adherence or health care outcomes.
Thus, there is a need to create a framework within which the impact of cultural competence on health care outcomes can be evaluated. One of us (J.R.B.) previously proposed a stepwise model to measure the impact of cultural competence training on health care outcomes.6 Here, we expand on that proposal by describing some necessary characteristics of a cultural competence intervention that might be expected to improve health care outcomes and by also describing the strategies for evaluation that would be most effective in identifying an impact.
Key framework for evaluation
Research has shown that the interventions that are successful in changing performance and health care outcomes are those using practice-enabling strategies (e.g., office facilitators or methods of patient education) or reinforcing methods (e.g., feedback or reminders) in addition to predisposing or disseminating strategies. Given this research, we suggest that an educational intervention has the best chance of having an impact on health care outcomes if it is multifaceted and if it includes at least several of the components discussed below—in essence, if it creates a culturally competent biosphere.
Focus on a particular condition.
To have the best opportunity to detect the impact of an educational intervention on health outcomes, it would be necessary to select a specific clinical condition (e.g., diabetes, asthma, hypertension). Such a selection would allow the use of a specific set of quality metrics for measurement, and that is the process that has been used to evaluate educational interventions in general.
Target a specific population.
Targeted interventions focusing on specific patient populations are the approach that is most likely to have an impact. For example, in an effort to target diabetic Latinos, the educational intervention for clinicians might emphasize issues related to dealing with language barriers, understanding common conceptualizations of diabetes in the Latino community, and so on.
Teach specific skills.
Standard cultural competence training that uses an agreed-on set of principles and an effective teaching methodology should serve as the foundation for change, but, for the purposes of evaluation, a set of targeted, specific skills should be taught and measured. For instance, one may want to teach general cultural competence, but part of that process is teaching a specific screening tool for nonadherence that can be applied to a selected chronic condition, such as hypertension, asthma, or diabetes.
Develop practice-enabling strategies.
The part of the intervention that has to do with the development of practice-enabling strategies might include decision-support tools (e.g., prompts in the electronic medical record for the clinician to ask specific questions), other reminders, and algorithms for handling common cross-cultural challenges. Other parts of the intervention could be instructional tool kits that highlight the key principles of cultural competence, pocket cards, and such support items that would facilitate the use of skills in the medical setting by the clinician.
Create a patient component.
Research has shown that developing a patient-based intervention, when possible, can improve the chances of affecting health outcomes. For instance, a clinician might provide the patient with a list of the key questions that the provider has been taught to ask, so that the patient can begin to give those questions consideration and feel more comfortable responding to them.
Given the application of these principles and an environment with the aforementioned characteristics, there are several measures that would support an evaluation of educational activities on health outcomes.
Measurement of patient and physician satisfaction.
Because physician–patient communication and patient satisfaction have been directly linked to clinical outcomes such as adherence and blood pressure control,1 it is worthwhile as a process measure to assess the satisfaction of both the patient and the physician with the clinical encounter vis-á-vis specific cross-cultural components. It is essential that survey questions be clearly linked to the key skills being assessed and that they not be general questions that are not sensitive or specific enough to detect the impact of the educational intervention.
Processes of care measures and health care outcomes.
If it can be determined (perhaps through chart review) that physicians are using cross-cultural skills in the clinical encounter, the impact of health care outcomes and the quality of care can be determined. For example, if, because physicians are now following a cultural competence curriculum, patients are now more frequently asked about their understanding of their condition (the explanatory model) and, as a result, become more adherent to their medication regimens, then a positive effect may be detected.
Test ordering or utilization.
As in the case example presented above, a clinician can determine, through medical chart review, whether the use of particular cultural competence skills, such as the more frequent identification of a patient's explanatory model, provides greater benefits to the patient. Two of the potential benefits would be that the patient undergoes additional appropriate testing (e.g., mammogram, pap smear, hemoccult tests, cholesterol screening) and/or avoids unnecessary tests (e.g., diagnostic imaging for back pain or headache) when they are not indicated.
Control for confounders
Any study that attempts to randomly assign clinicians to receive or not receive cross-cultural training and that then compares patient outcomes must also take into account patient panel characteristics such as level of education and socioeconomic status. It would be unfair to compare two groups of clinicians who care for very different patient panels. For example, a randomized controlled trial that focuses on training an intervention group to communicate more effectively with persons with asthma by measuring asthma-related emergency room visits and hospitalizations must take into account the environments in which these patients live. Even when asthmatic persons are taking the right medications, they can be adversely affected by their physical environment.
Cultural competence education is a requirement for medical school and residency accreditation, as well as for continuing medical education credits and medical licensure in some states. The American Medical Association and the American College of Physicians, among others, have produced policy position papers stating that cultural competence is necessary for the effective practice of medicine. Cultural competence training should be held to the same standards as other educational interventions and activities and should be evaluated in a stepwise fashion by using the tools of health services research and the principles of quality improvement.
Cultural competence represents an important building block of clinical care and a skill set that is central to professionalism and quality. It is not a panacea that, on its own, will improve health outcomes and eliminate disparities; rather, it is a necessary capability if clinicians are to deliver the highest-quality care to all patients. Just as we strive to meet other challenges in American health care, so should we focus on developing the skills needed to care for diverse populations.
The authors thank Ignatius Bau, program officer, The California Endowment, for reviewing a draft of the manuscript and sharing insightful thoughts and comments. They also acknowledge the important contributions of Dr. J. Emilio Carrillo, who is responsible for some of the theoretical underpinnings of this work, which have been developed collaboratively over the past 10 years. Finally, they thank Marina Cervantes, research assistant, Disparities Solutions Center, for her assistance in the preparation of this manuscript.
This work was supported by grant no. 20051880, entitled “Manuscripts on Cultural Competency,” from The California Endowment.