The Importance of Cultural Competency in Healthcare

I write a lot about healthcare inequity and social determinants of health. Today I’d like to talk about something that can improve—or worsen, if undertaken lightly—the effects of those things: Cultural competency.

The idea of cultural competency was first presented by Dr. Derald Wing Sue in the early 80s. It’s defined by the American Psychological Association as “the ability to understand, appreciate and interact with people from cultures or belief systems different from one’s own.” Dr. Sue argues that one can never fully understand another person’s culture, and it’s good practice to keep that in mind. This is a journey.

Let’s have a look at the what, the why, and the how of cultural competency.

Within healthcare, cultural competence is the ability of health providers and organizations to deliver health care services that meet the cultural, social, and religious needs of patients and their families. Culturally competent care can improve patient quality and care outcomes.

A big part of being culturally competent is the ability to communicate effectively and empathetically with people from other cultures. This is not an easy endeavor. Some communication barriers are concrete and clear. If you and I don’t speak a common language, we’re going to have a hard time discussing anything of substance. This is particularly true in a medical situation where interactions can be nuanced (“describe how you feel”) or technical (“how’s your glucose, what was your last A1C score?”)

Difficulties experienced by two people who speak the same language but come from widely disparate cultural backgrounds are less obvious but can have an equally devastating effect on those involved. In a medical situation this can result in inferior treatment, poorer outcomes, and higher costs.

Beyond communication, cultural competence includes understanding the religious and social tenets that may impact a person’s healthcare status. These beliefs may include dietary restrictions, medication usage, prayer timing, modesty, and provider gender preference. Healthcare organizations can identify more effective approaches to their patients if they understand these factors.

Cultural competency has three core components:

• Awareness: Acknowledge that your own culture and upbringing shapes your ingrained perceptions, behaviors, and language. Understand that you may be unaware of these entrenched biases.
• Knowledge: Learn about different cultural practices and worldviews, so that you can understand, accommodate, and speak about them.
• Skills: Develop skills to interact thoughtfully and effectively across cultural boundaries.

This article is focused on the ramifications for healthcare, but cultural competence can also improve interactions in schools, workplaces, social situations, and community services. In all settings, it plays a crucial role in creating inclusive and welcoming environments, reduces disparities, and improves outcomes for people from all backgrounds.

This could mean ensuring equitable access to quality education, creating work environments that don’t cause stress, or promoting social unity. It could also mean a more productive and effective society.

At the personal level, cultural competency gives you a broader worldview, and an appreciation for perspectives and opinions that may differ from yours. Most would agree that this can improve your personal and work relationships, and expand your emotional and social intelligence.

In a business environment, customer relationships and engagement are strengthened when there is mutual understanding and respect between an organization and their customers. Cultural competence allows you to avoid missteps and create services, products, and marketing that best resonate with your intended audience. Leaders who are open to the culture of their diverse team members are better able to understand how to motivate them, and resolve potential conflicts, leading to better employee retention and productivity.

In a healthcare setting, cultural competence can reduce misdiagnoses, improve patient safety, increase instructional and medication adherence, and reduce costs related to avoidable treatments and care such as unnecessary testing, For example, according to a study by KFF, adults with limited English proficiency are more likely to be in poor health and use the emergency room for healthcare services. They are also less likely to have received healthcare services in the past three years.

The chart below illustrates some of the challenges patients may have related to communication. (Source: KFF.org)

Cultural competence can help mitigate some of the health inequities that patients experience. Beyond the practical resolution of communication challenges and religious and social preferences, cultural competence allows everyone—both staff and patients—to feel welcome, comfortable, respected, and valued. This sense of inclusivity naturally boosts morale and productivity and can decrease employee and patient turnover.

Cultural competency has immense value for you, your organization, your patients/customers, and your community. If you think that you’ve got this covered because once a year you have a mandatory online diversity training, think again, sorry.

Understanding different perspectives requires first understanding your own inherent biases (we all have them!), and then learning about other cultures and religions, fostering empathy, and developing active listening and communication strategies.

Here are some skills that you can strive to improve, through both structured training, immersive experiences, and self-study.

• Education: Programs that highlight the value of diversity and teach cultural sensitivity are important, but they need to go deeper than a 60-minute webinar or a one-off training session. Exposure to multiple media is necessary. Seek out a range of resources like books, art, films, and workshops to get a more well-rounded perspective.
• Active listening and communication: Do you listen, or wait to talk? Prioritize listening over talking; culturally competent interactions require your communication to be thoughtful, inclusive, and accessible to people from different cultural backgrounds.
• Diverse network building: Consciously thinking about including a variety of cultural perspectives when building your professional and personal networks is a great way to build an understanding and appreciation of diverse viewpoints.
• Reflective practice and ongoing check-ins: To maintain and evolve your competency requires regular self-assessment. Without persistent expansion of your knowledge and skills, it’s easy to fall back into a narrower focus. Similarly, poorly designed interventions, or too little training and exposure, can lead to poorer competency.

In the healthcare industry, cultural competency is gaining traction, but we have a way to go. For example, in a questionnaire-based study at a historically diverse medical school, second-year students were found to have more education and training than first year students—as one would hope! But, more surprisingly, the second-year students were less skilled in managing sociocultural issues. And both groups scored below the 60th percentile on the Hispanic health knowledge questionnaire.

For healthcare organizations, some strategies for improving cultural competence include:

• Assess the cultural and religious makeup of your constituents (patients, members, caregivers, community) and plan for the proper language and other supports.
• Provide cultural and religious awareness training on matters that impact healthcare decisions such as dietary restrictions, provider preferences, and use of alternative medicine.
• Ensure verbal and written communications meet the language needs of your constituents; have interpretation and translation services available.
• Reflect cultural diversity in healthcare materials and promotions.

As you embark on improving your cultural competency, there are some barriers to keep in mind:

• Invisibility of the issue: We’ve been living in a world steeped in systemic racial, economic, and cultural bias. When the status quo is so prevalent, it can be difficult to see that an issue exists. It’s sometimes too easy to assume that the dominant monoculture’s norms apply universally.
  
  Here’s an example: Psychological models developed in Western cultures often prioritize individualism and personal autonomy, which may be unpalatable to cultures which emphasize working together as a group, and community interdependence.
  
• Inherent, ingrained stereotyping and bias: Preconceived notions about other cultures, often formed without malice over years, can lead to misunderstandings and conflict. When these biases are unconscious, as they often are, they are difficult to address without ongoing concerted effort, deliberate reflection, and continuing education, interaction, and exposure. Which leads us to …
  
• Lack of exposure: It’s hard to impossible for those who’ve had limited interactions with diverse cultures to develop the necessary skills for effective cross-cultural collaboration. Again, first recognition, then ongoing and broad-spectrum exposure are key.
  
• Resistance to change: When talking about this topic, it’s not uncommon for some to feel criticized for their current behavior, and many people have an aversion to change. Recognition of your own resistance, (are you sensing a theme here?), is key to overcoming it, and enjoying the fruits of both personal and organizational growth.

There’s no question that the U.S.—and the world—is becoming more global and diverse  with each passing year. According to the 2020 U.S. Census, the Diversity Index in the U.S. is 61.1%, which means if you chose two people at random, there is a more than 61% chance that those people will be of different races or ethnicities. And according to KFF.org, there are 26 million people in the U.S. with limited English language proficiency.

As a healthcare industry, we must take cultural competency seriously if we are to truly serve our communities.

Cultural competency enriches interactions in personal and professional spheres. It reduces healthcare costs and improves clinical outcomes for many who have historically suffered from health inequity and inferior treatment.

By embarking on this ongoing journey of learning and adaptation, individuals and organizations can achieve greater success and contribute to a more inclusive world. That sounds pretty great to me, how about you?