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Special Theme: Cultural Competence: SPECIAL THEME ARTICLES

A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes

Kagawa-Singer, Marjorie PhD; Kassim-Lakha, Shaheen MPH

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Abstract

In this article, we provide an anthropological perspective of the fundamental relationship between culture and health, and outline systemic changes needed within the social and legal structures of our health care system to reduce the risk of cross-cultural miscommunication and increase the likelihood of improving health outcomes for all populations within our multicultural U.S. society.

INTRODUCTION

The literature documents that all ethnic minority populations in the United States lag behind European Americans (whites) on almost every health indicator, including health care coverage, access to care, and life expectancy, while surpassing whites in almost all acute and chronic disease rates.1,2,3 For example,

  • ▪ infant mortality rates among African Americans, Native Americans, and some Asian American and Pacific Islander groups are twice as high compared with those rates among whites;
  • ▪ maternal mortality for African Americans is four times higher than that for whites;
  • ▪ Vietnamese women and Hispanic women are at a four- to eightfold greater risk for cervical cancer;
  • ▪ the rates of diabetes and its sequelae for African Americans, Hispanics, Asian Americans, Native Americans, and Native Hawaiians are two to four times that of white Americans4; and
  • ▪ end-stage renal disease (ESRD) is much more prevalent in ethnic minority populations and is seven times more likely for Mexican Americans, 6.6 times for African Americans, and 6.3 times for Native Americans than for whites.5

While not completely understood or well explained, these disparities are variously attributed to barriers to routine access to preventive care, low levels of cultural competence among health care professionals in providing health care, and lack of proportional representation of minorities in the health professions.6,7 Demographic trends show that ethnic minorities now constitute about 25% of the population, and will be the majority of the U.S. population by 2050.8 Thus, little hope exists that these statistics will improve without a concerted transformation of the health care structure to facilitate access and the training of all health care practitioners, including physicians, to reduce the dissonance that occurs across cultural differences. Moreover, as the organization and delivery of health services are increasingly based on the distinct values and expectations of managed care, these health disparities may be further exacerbated by clashes with the belief systems and expectations of cultural subpopulations.9

Theoretical models outside the traditional biomedical paradigm offer very promising constructs to reduce the disparities in health care.10,11,12 For example, “culture” is the fundamental construct of anthropology and informs the perspective presented in this paper.13,14 Culture shapes the milieu in which the patient/family/physician encounter occurs. If the clinician recognizes the cultural context of the encounter and can assess and negotiate among all participants' potentially conflicting interpretations, expectations, beliefs, and values, he or she may be better able to provide optimal care to the patient and family. Effective cross-cultural interactions require that the clinician integrate multiple cultures in the clinical encounter: his or her own culture, that of the patient/family, and the health care institution's culture. Successful integration of these arenas constitutes cultural competency, or ethnorelative practice: that is, the ability to evaluate behavior relative to its cultural context so that the physician and patient/family are able to reach mutually desired goals of medical care. The strategy that we describe in this article, named the “culturally-based systems approach,” fosters respect for diversity by recognizing the integrity of each culture.15

WHY ATTEND TO CULTURAL DIFFERENCES?

The function of any culture is to ensure the survival and well-being of its members within a particular ecologic niche. An extensive body of literature in the social sciences clearly indicates that health and the means to maintain, regain, or attain well-being are culturally defined.16,17 Every culture defines what health is for its members, determines the etiology of diseases, establishes the parameters within which distress is defined and signaled, and prescribes the appropriate means to treat the disorder, both medically and socially.18 Thus, an understanding of the role of a patient's culture is fundamental to medical care.

By necessity, then, cultures are dynamic, responsive, coherent systems of beliefs, values, and lifestyles that have developed within particular geographic locations, using available technology and economic resources; they evolve as needed to adapt to changing environmental conditions. Hammond sees culture as comprising seven nested elements: environment, economy, technology, religion/world view, language, social structure, and belief and values.19 This multidimensional entity is passed from one generation to the next to help ensure its members' survival. The resulting lifestyle (i.e., cultural) patterns characteristic of each group—such as diet, marriage rules, and means of livelihood—influence gene expression, health status, and disease prevalence.20

These cultural tools are then used by its members to manipulate the environment for food and shelter, make cognitive and emotional sense of the chaos around them, and provide them meaning and purpose in life. Culture also makes predictable and controllable, through beliefs, values, and rituals, the unpredictable and inevitably uncontrollable events such as sickness, and prescribes appropriate means to communicate caring, ensure safety, and provide social support for its members.15

The multiple elements of culture are woven into an integrated whole fabric. The metaphor of weaving is useful to understand cultural variations. The technique of weaving is universal, but the patterns that emerge from each group are culturally identifiable.15 The symbols and metaphors used in the weavings express the ethos of each culture and the place of the individual within that cosmos. The two functions of culture are analogous to the warp and woof or the perpendicularly woven threads of a tapestry: the integrative and the prescriptive. The integrative function provides individuals with the beliefs and values that provide meaning in life and a sense of identity, and the prescriptive are the rules for behavior that support an individual's sense of self-worth, and maintain group function and welfare.21 Specific, discrete beliefs and behaviors are like the threads in the tapestry. A single thread of one cultural tapestry can be taken out and compared across cultural groups for its inherent characteristics (such as postpartum rituals), but the usefulness and integrity of the thread as representative of the entire tapestry cannot be judged unless seen within the pattern of the entire cultural fabric within which such behaviors were meant to function.22,23 Taken out of context, a single thread, like a belief or behavior, may be misinterpreted or even disregarded as unnecessary or maladaptive, especially if evaluated against a standard appropriate for another culture. In one study that compared the emotional responses of Japanese Americans and European Americans to cancer, the responses were found to be equally strong, but quite culturally identifiable.24 The idiom of strength for the Japanese Americans was of endurance—to bear the distress stoically, and the metaphor was bamboo. In comparison, the European Americans used the idiom of fighting an external enemy, and the metaphor was of oak. Moreover, gender differences modified the responses considerably. The Japanese American women and the European American men were more similar, and experienced more distress, than the Japanese American men and the European American women, who were both able to draw on their social support networks more readily and accept the dependent role more easily. The use of each mode of coping was adaptive for the appropriate cultural group, and likely maladaptive if used by the other.

The use of the human form in Western art often highlights the underlying belief that human beings are made in God's image, and that they are central to the meaning of the universe. This belief in humankind's primary place in the cosmic order is also fundamental in the Western health care system. Individuality and the values of autonomy form the basis of Western bioethics.25 The belief in the primacy of individuality also frames how professionals are educated to provide care and how recipients of care are expected to respond within the system. This Western European and U.S. belief system, however, is not universal. Without understanding the fundamental nature of culture and the integrity of differing belief systems, the risk of conflict and its negative impact on health outcomes is inevitable.26

MISUSE OF THE CONCEPT OF CULTURE

Culture is not race. The Office of Management and Budget (OMB) designated six racial/ethnic categories and stated that they be used to monitor political allocation of resources, not as scientific evidence of genetic differences, as is implicitly assumed in the use of these categories in most medical and health studies when reporting ethnic/racial differences in health outcomes for non-Hispanic whites, Hispanics, African Americans, Asian Americans, Native Americans, and Native Hawaiians and other Pacific Islanders.27 Genetic studies indicate greater within-group variation among the members of these six categories than between groups, thus rendering these categories as social/political constructs and not biologically-based differences.28,29,30 Two primary problems arise from this practice. First is the stereotypical assumption that genetic differences are primary causes of differences in disease incidence, prevalence, and mortality, and second is the subsequent diversion of attention from the more proximal and malleable social and political causes of disease and intragroup variability, vulnerability, and strength.

Each of the six OMB-defined racial/ethnic categories contains many distinct national groups and multiple ethnic groups within each national group, each with its own culture or subculture. As noted, each member may hold varying levels of acculturation and assimilation to his or her group that will indicate differential expressions of cultural beliefs and practices and underscores the need for assessment of individual variation both within and between cultural groups and families.31 For example, a case presentation routinely includes a racial designation, such as “a 65-year-old Chinese male presents with chest pain.” What information does “Chinese” convey? This man could have been born in Hong Kong, be a college professor who speaks five languages including English, and lives six months of the year in the United States and six months in Hong Kong. This man could also be a monolingual Chinese gentleman, born in the United States, unmarried, and living alone in Chinatown in New York, with little education and very poor. Lack of accountability for these differences perpetuates stereotypical evaluations and diverts the clinician from accurately assessing the strengths of and potential conflicts with individual patients and their families.32

Cultures are also not homogeneous or monolithic. Varying levels of acculturation, assimilation, age, education, income, family structure, gender, wealth, foreign versus U.S.-born status, and refugee or immigrant status all modify the degree to which one's cultural group membership may influence health practices and health status. Moreover, each cultural group, such as Cambodian American or African American, is not a monolithic, static group. In a multicultural society such as the United States, each cultural group is contemporaneously undergoing modifications and mixtures that render it different from the cultural group of origin, and uniquely American.

Interestingly, protective and health-promoting beliefs and practices of cultural groups other than the dominant European American population are rarely studied. Most research instead focuses on documenting the vulnerabilities of non–Western/European-American cultures. This bias in research clouds our ability to see equal validity among different cultural strategies to meet life's adversities. The Western biomedical model and European-American lifestyle are not the only ways to ensure health. Migrant studies indicate that when immigrants come from countries where disease incidence rates are lower than in the United States, such as diabetes in Latin American countries or breast cancer in Chinese and Japanese women, the incidence rates of these diseases begin to mirror those of the host culture after a relatively short time in the United States.33,34

From this discussion of the multidimensional and dynamic nature of culture, it becomes clear that culture is a term that is vaguely conceptualized and inaccurately used in medical training and practice. Most often it is glossed over erroneously as synonymous with race or as a catch-all, monolithic term to describe people who are phenotypically similar and assumed to have the same beliefs, values, and behaviors. Such use results in stereotypical thinking, not scientific thinking. We know that less than 5% of diseases are genetically caused, and that the other 95% are due to lifestyle/environmental factors. Studies on adherence to medical treatments show that only 20–50% of medical regimens are followed.35,36 Patients resist lifestyle changes, and culture forms lifestyle. Therefore, if physicians attended to the influence of culture on health behavior, outcomes of medical care might well be improved.

TOWARD A NEW PARADIGM

The fundamental unit of medical care is the doctor/patient–family dyad. As noted, however, doctor–patient communication pedagogy in biomedicine and Western bioethics is based upon monocultural Western European-American concepts, values, and beliefs.37 In the dominant, middle-class, European-American ethos, the individual is viewed as autonomous, egalitarian, rational, self-assertive, and self-aware.38 Cultivation of the rational mind is of the essence, and healthy interpersonal relationships are characterized by open, verbal communication.39,40 This European-American perspective has evolved from the movement of the Western Age of Enlightenment in the 18th century.41 During that period, the Cartesian duality of body and mind raised rationality and science above the human's emotional and basic animal nature and created a belief in the self as unique, singular, and exclusive, with the right to live (and die) with dignity. Even dignity, however, is largely a New Testament and Christian contribution based on “the supreme value of the God-given soul.”42 Assuring one's dignity is a justifying moral argument in Western concepts (e.g., death with dignity) of health care decision making,43 yet the transcultural applicability of these values and assumptions, although unsubstantiated, is frequently unquestioned.44,45 These Eurocentric beliefs and values are rarely seen as culturally bound, and their universal applicability is assumed. Therefore, beyond language differences, the impact of culture differences on the nature and quality of the health care provided is usually ignored because it is inadequately understood and therefore seen as unnecessary.

A new paradigm for practice would support cross-culturally expert practitioners with the ability to differentiate culturally dependent from culturally independent normal and abnormal beliefs and behaviors. Outcomes for culturally competent practice would indicate that patients and families are able to promote, maintain, and/or regain mutually desired and obtainable levels of health within the realities of their life circumstances.

This new paradigm is fundamental to the concept of cultural competency. Professional groups and government agencies are now using “cultural competency” as a means to address the miscommunication that occurs in culturally discordant clinical encounters and to eliminate racial disparities in health outcomes.46 Definitions abound, but empirical evidence is lacking. More problematic than the lack of clarity in the definition, however, is the lack of discussion of the goal or the “why” of these skills. Cultural competency is a means to a mutually desirable end, but most discussions of cultural competency have the implicit message that the effort is unidirectional to educate the patient into the biomedical model. This negates the integrity of culture and is problematic in a multicultural society.

Culturally competent medical practice describes a skill set that enables a physician, in a culturally discordant encounter, to respectfully elicit from the patient and family the information needed to make an accurate diagnosis and negotiate mutually satisfactory goals for treatment. Our discussion above of culture answers the “what” and “why” of cultural competency. The remainder of the paper describes how to develop the skills required.

The culturally-based systems approach, developed previously by the first author47 and described here, is offered as a template for culturally competent practice. The desired level of practice for a cross-culturally competent expert is a bicultural or multicultural status. That is, the individual is sufficiently knowledgeable about his or her own culture as well as about one or more other cultures of patients that he or she treats to recognize the differences, understand what they mean, and translate or bridge those differences to accomplish clear and effective communication of information and caring.

The culturally-based systems approach is based upon the following propositions:

  • ▪ Proposition 1: The goal of human behavior is to fulfill the three universal human needs of safety and security, integrity and meaning, and a sense of belonging. Every culture provides its members a unique pattern of ways to achieve these needs and gain a sense of well-being. Both the means and the ends are culturally identifiable.48
  • ▪ Proposition 2: Distress and disease, biologically and/or socially induced, are experienced in a sociocultural context that can both potentiate and/or ameliorate the condition. Distress will primarily be communicated through the symbols provided within a particular cultural environment, and may thus be culturally variant in construct and label, as well as meaning.
  • ▪ Proposition 3: The objective of health practitioners is to improve health outcomes and increase the quality of life for each individual patient.
  • ▪ Proposition 4: Culturally-based, or culturally informed, communication is key to effective doctor–patient relationships. When we understand that the purpose of every culture is to ensure the individual's survival and emotional well-being, the stage is set to negotiate with patients and their families among a wider set of options.49,50,51

Following the lines of logic of these four propositions, behavior becomes more comprehensible when understood within its contextual meaning. Additionally, in a cross-cultural encounter, the physician and patient have four alternatives for communication (Figure 1):

Figure 1
Figure 1:
Sources of individual physicians' beliefs and values.
  • ▪ The physician could work exclusively within the biomedical paradigm,
  • ▪ the patient and physician could function exclusively within each of their native cultures, or
  • ▪ the physician could work within the patient's cultural framework.

Each of these has strengths, but none is optimal to ensure a mutually satisfactory outcome. The fourth strategy is the most preferable:

  • ▪ The physician and the patient negotiate between their concepts of the etiology of the disease and the most appropriate means of treatment to reach mutually desirable goals.48,52

After providing adequate information to patients and families to make informed choices, clinicians are often challenged to honor individual choice and patient autonomy when the decisions of the patient's family counter the clinician's best judgment (e.g., “futile” treatment or withholding information about a terminal diagnosis, or refusing treatment). The result of this tension is often painful and turbulent interactions. The culturally-based systems approach's model and risk assessment indicate the steps necessary to determine whether the patient and the patient's family have adequate information to make informed choices and to elicit the values and circumstances within which all parties are making their decisions. The task for the clinician and staff is to personally respect the other's belief system, and not denigrate the individuals in the negotiation process. Such interactions require skilled clinicians who are sophisticated, aware, and skilled in culturally-based communication strategies, and agencies that are prepared to support their staffs in resolving such issues personally, professionally, and legally.

The following three sections of this article delineate the origins of the differing views of the clinician, patient/family, and organization/institution to indicate areas of clarification to implement the culturally-based systems approach.

Culture of the Provider

Each clinician develops his or her own lens to view reality. This lens is refracted primarily through the clinician's natal culture, but then is modified by professional socialization, the culture of men or of women, and that of Western biomedicine as well. These sets of beliefs and values intersect to varying degrees to form the clinician's blended worldview (Figure 2). However, they may conflict with each other and with those of the patient and family. Which template of patterns and behaviors is considered the “right” way is dependent upon one's world view. Miscommunication is likely when the physician uses his or her Western biomedical template of treating disease and illness as the right way, rather than one of several options. The essences and rationalities of other cultural patterns are lost. If interventions are instituted with such a one-sided ethnocentric perspective, the patient or family will likely feel misunderstood, and the prescribed intervention would probably fail. For example, the cultural edict against telling a Muslim patient that he or she has a terminal diagnosis, which from the U.S. concept of patient autonomy would be done to foster anticipatory grief counseling, is antithetical to that U.S. concept. Yet within the context of the cultural belief of some Muslim traditions, to do so would be unethical. Thus, even though grief, bereavement, and mourning are universal responses to dying and to the loss of loved ones, the manner and meaning in which these occur and the proper moral protocol for their observance are culturally distinct.53

Figure 2
Figure 2:
Cross-cultural communication alternatives in the clinical encounter. The line over “1” indicates the provider–patient dyad. The line over “2” connecting the patient’s and provider's concepts of health indicates that the provider expects the patient to work within the biomedical cultural system (which may not always be appropriate or understood by the patient). The two circles near “3” show a third alternative, in which the provider works within the patient's cultural system without integration of biomedical explanations that may be more appropriate to the U.S. cultural and technologic context. In the fourth alternative, “4,” both parties clarify their positions with each other and negotiate their objectives to minimize misunderstanding and come to mutually agreeable strategies to optimize health outcomes within the parameters of the patient/family wishes and desires and biomedical feasibility. (Adapted from Kagawa-Singer M, Chung X. Model for culturally-based care. J Med Educ. 1987;55:200–3.)

The culturally-based systems approach requires that the practitioner first be aware of his or her own cultural beliefs and values in order to recognize when they may differ from those of the patient, and evaluate the patient's responses objectively.54 Both parties bring their cultural views to the interaction. When the physician and the patient are from different cultural backgrounds, the physician needs to ask questions that respectfully acknowledge these differences and build the trust necessary for the patient to confide in the physician. Physicians can use knowledge about particular cultural beliefs, values, and practices as hypotheses about an individual's beliefs and practices, but then must assess the degree to which an individual patient or family might adhere to their cultural background, if at all. One way to begin this dialogue is by conducting a RISK reduction assessment to elicit information about the patient's Resources, Identity, Skills, and Knowledge (Table 1). Identifying the patient's perspective may help avoid the pitfalls of stereotyping or ignoring the potential influence of culture, and may reduce the risk of miscommunication.

Table 1
Table 1:
“RISK” Reduction Assessment to Ascertain Level of Cultural Influence

While understanding the patient as an individual in the context of culture does not prevent conflicts over differing values, beliefs, or practices, information gained from such an assessment serves to identify areas for negotiation of conflicts should they occur. When the doctor and the patient/family have some understanding of each other's perspective, such negotiations can take place in an atmosphere of mutual respect rather than frustration and misunderstanding.

Culture of the Patient/Family—Whose “Gold Standard” Should Be Used?

Anthropologists make an important distinction between disease and illness that provides physicians an avenue to tease out the influences of culture on the disease experience.52,55,56Disease is the objective, measurable pathophysiology that creates the illness, which is the meaning of the disease to the individual and his or her social group. The meaning of the illness includes the assumed etiology—be it natural (such as a fall that breaks a bone), supernatural (God's will, witches, or malevolent spirits), or metaphysical (such as bad airs or seasonal changes for which one is unprepared).57 Importantly, the assumed etiology establishes the groundwork for negotiating mutually acceptable objectives of care.

Biomedicine views most diseases as natural mechanistic errors, correctable with interchangeable or repairable parts (e.g., hip or heart) or by manipulating chemical pathways that are the cause of distress (e.g., psychotropic medications or hormonal manipulation). In Western biomedicine, disease is separate from moral status. The spiritual or metaphysical causes of disease have little credibility. Thus the biomedical model negates the belief structures of many cultural groups, including some European-Americans.25 The efficacy of treatments for many pathophysiologic processes that are attributed to metaphysical or supernatural causes, however, has yet to be widely tested.58 Although discussion of complementary and alternative therapies is beyond the scope of this paper, training in cultural competency provides the clinician with a different template to use to elicit information about and evaluate the rationale for traditional, non-biomedical concepts of the symptoms. Such assessments provide information to determine the meaning of the disease, the impact of the illness on the patient and his or her family network, and their coping strategies.

The effect of ethnic minority status on American groups of color is essential to understand the phenomenon of differential treatment and the necessity for culturally competent practice.3 Differential treatment in medical care occurs when external identifiers of group membership, such as skin color, language, or religion, are used to judge the relative value of individuals and resources are allocated based upon those criteria in a prejudicial manner.9,29,31 The effects of discrimination and racism, uncovered in recent studies, cannot be overcome as barriers to optimal care by merely appreciating cultural differences, because most often, these reactions occur unconsciously.30,59,60,61,62,63 The unconscious use of skin color to stereotype patients is one of the most common ways in which cultural differences—and ignorance of them—pose a risk to effective cross-cultural communication.

We next discuss the changes needed in physicians' care within the context of change needed in health care organizations.

Culture of the Organization and Institution

The culturally-based systems approach cannot function in a vacuum. It requires a transformation of the Western-culture–based health care system. Culturally competent care requires competence in the individual physician, and the institutional will and skill to promote such care.64,65,66

Most mainstream health care agencies are structured within the European-American cultural model. These agencies will need to make major structural and process changes to transform themselves into multicultural agencies that will be capable of providing optimal care in a more equitable manner to all segments of the U.S. society. An added value to this perspective is also the self-reflective realization that many of the “vulnerabilities” attributed to cultures other than European-American cultures are due to misinterpretations of these cultural values, beliefs, and practices. These practices may actually be effective in promoting health, and thus these cultural beliefs and practices may actually be resources.

The clinical encounter occurs within an agency milieu that must value and promote culturally-based care to facilitate the clinician's efforts. Hospitals, as medical organizations, continue to be associated with problems in terms of the intensity and quality of care.67,68 In one study utilizing Medical Expenditure Panel Survey data, minority patients were found to be more likely to receive primary care in a hospital setting than from a private physician or clinic, had more trouble getting appointments, and had to wait longer to see the physician even with insurance. In addition, Hispanics were significantly less likely than whites to believe that their primary physicians listened to them, and Asians were least satisfied with their interactions with health care staff.69

Culturally competent practice requires institutional commitment and the creation of infrastructure to promote and support patient and employee diversity, and responsiveness to cross-cultural issues. Specific interventions include finding ways to achieve diversity in residents' training, such as recruiting ethnically diverse faculty and attending medical staff; developing policies and procedures that integrate the principles of cultural competency into the ongoing work of the organization; and, finally, establishing formal means of consultation with the community to be served for the verification of need for the program and appropriateness of the intervention, including patient educational materials.70 The last should be particularly emphasized in the program planning and implementation phases to ensure availability, accessibility, acceptability, and accountability of appropriate, culturally responsive services.71

An internal quality improvement project team comprising multidisciplinary staff from all levels of the organization, and reflecting the diversity of the populations served, could guide and lead the initiative. In the case of hospitals or long-term care institutions, existing accreditation standards for patient care, or human resources policy guidelines, such as those of the Joint Commission on Accreditation of Healthcare Organizations72 or the American Academy of Pediatrics Strategies for Achieving Diversity,73 may be used to promote, maintain, and measure physician interest and leadership.

The cross-cultural education curricula would be based on the values and principles outlined in numerous theoretical models for health care practitioners.63,74,75,76 Successful educational interventions require that all agency personnel, e.g., nurses, social workers, allied health personnel, management, and administrative staff, be included and trained together. Educational activities may include a variety of communication mechanisms, ranging from audiovisual to grand rounds, workshops, and resident rotations. In addition to such traditional instruction methods, self-directed and computer-assisted learning activities are being developed to facilitate self-learning with minimal interruption to patient care responsibilities.77 Health care team experiential modules have been effective in facilitating communication and coordination of care across diverse care settings, disciplinary perspectives, and ethnic backgrounds to develop the knowledge, attitudes, and skills necessary to provide culturally competent care.

Evaluation

Donabedian's model of structure, process, and outcome provides a useful framework for assessing the nonclinical aspects of the proposed institutional changes to promote and support culturally competent practice.78 This model examines outcomes in terms of how well the care provided meets or exceeds clinical/administrative standards, given the characteristics of the health care environment and its resource use, i.e., that environment's strategies to achieve improved health care and patients' satisfaction. The evaluation question has two parts:

  • ▪ Does the adoption of a multifaceted, strategic cultural competence initiative by senior/executive management and the board improve the level of culturally competent care provided by the institution?
  • ▪ Does the implementation of a cultural competency training program for health care professionals result in (1) improved patient satisfaction and (2) equal health outcomes across all ethnic groups being served by the health care organization?

Other proposed but untested measures of structure and process include:

  • ▪ level of representation of cultural diversity among physicians, management and nursing staff;
  • ▪ management support and accountability for cultural competence training of staff;
  • ▪ staff motivation to participate in training; multidisciplinary participation in training;
  • ▪ employee awareness of cultural competency strategic initiative;
  • ▪ achievement of related management goals;
  • ▪ integration of cultural competency principles into ongoing service delivery; and, finally,
  • ▪ degree of institutionalization of cultural competence values, e.g., in menus, patient entertainment, patient education, hospital rules and regulations such as religious observances, and attention to assigning or consulting gender-appropriate caregivers.

Such changes should be reflected in measures of patient satisfaction, although current patient satisfaction questionnaires themselves need to be validated for cross-cultural assessment purposes. Indicators such as better adherence to medical care, follow-up appointments, health care utilization patterns, modification of high-risk health behaviors, promotion of culturally-based health protective behaviors, and reductions in disparities of health outcomes across culturally diverse groups are also important outcome measures.

IMPLICATIONS FOR MEDICAL EDUCATION

Culture is fundamental to the development and management of disease in every population, for its purpose is to teach its members what to do to survive, how to do it, and why they should persevere in the face of adversity. As such, physicians would benefit themselves as well as their patients by learning how to be cross-culturally effective in the delivery of medical care.

The tapestry metaphor concretizes how cultures express their identities using the universal technique of “weaving” their multiple elements into unique wholes. The characteristic patterns and meanings that emanate from different groups result in culturally identifiable societies that continue to evolve in response to ever-changing environmental forces and resources. Continuing this tapestry image, variations on a cultural theme occur within subgroups as well as individuals. Individuals are unique, and each develops his or her own interpretations of cultural “guidelines.” For example, the French Impressionist school of painting in the 1800s had particular characteristics and “rules,” but all of the major painters had individual interpretations that make their work clearly identifiable. So it is with each patient and family.

The first step in implementing the culturally-based systems approach is to be aware of our own beliefs, values, and biases. The second step is to increase the accuracy of the clinical assessment by conducting a “RISK” reduction assessment, in a culturally informed, patient-centered medical interview rather than using culture or race as stereotypical explanatory factors. Finally, using models of quality of care and patient satisfaction familiar to most health practitioners, health care agencies can institutionalize structural and systemic changes to provide optimal care for all patients.

The logic of the cultural construction of reality makes it impossible to view the effects of cross-cultural differences as epiphenomenal. Culture is fundamental to health-related behavior.79,80 If physicians attend to cultural differences and build the skills necessary for cross-cultural expertise, they will improve health outcomes and increase quality of life for patients from an array of cultural backgrounds. If we ignore culture, we will perpetuate and exacerbate the differential outcomes and unequal distribution of disease burden present today.

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