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Transforming
the Face of Health Professions Through Cultural
& Linguistic Competence Education:
The Role of the HRSA Centers of Excellence
Preface
In 2002, the Institute of Medicine issued an important
report, Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health Care, which showed
that racial and ethnic minorities in the United
States are less likely to receive equal routine
medical procedures and that they experience a
lower quality of health services. A large body
of research demonstrates significant variation
in the rates of medical procedures by race, even
when insurance status, income, age, and severity
of conditions are comparable, the report said.
Furthermore, minorities of all kinds, including
Black or African American, American Indian or
Alaska Native, Native Hawaiian or other Pacific
Islander, Hispanic or Latino, and many Asian
Americans, are less likely to get certain medications
or procedures, such as kidney dialysis or transplants.
By contrast, the report added, they are more
likely to receive certain less-desirable procedures,
such as lower limb amputations for diabetes
and other conditions. The committee recommended
a number of ways to reduce racial and ethnic
disparities in health care, including increasing
awareness about disparities among the general
public, health care providers, insurance companies,
and policy-makers.
Recognizing the significant role that the Centers
of Excellence can play in ensuring that cultural
and linguistic competency is not an adjunct
to health care, but is a core component of quality
health care. The Health Resources and Services
Administration (HRSA) of the United States Department
of Health and Human Services is working with
the Centers of Excellence (COE) program to reduce
disparity in the health care system by increasing
the number of underrepresented minorities working
in the health field. HRSA and the COEs also
are working together to foster the teaching
of cultural and linguistic competency content
in the educational curricula among HRSA grant
recipients.
This curriculum guide, “Transforming
the Face of Health Professions Through Cultural
& Linguistic Competence Education: The Role
of the HRSA Centers of Excellence,” is
one result of the efforts of HRSA and the COEs.
The publication of this guide is a significant
achievement brought about by the efforts of
a large number of dedicated individuals who
have worked over many months to develop a cohesive
and valuable curriculum guide.
The staff of HRSA wish to commend the efforts
of the Expert Team and Magna Systems Inc., which
have worked for more than 18 months to pull
together all of the many and disparate elements
contained in this curriculum guide. We also
wish to acknowledge the significant contribution
of the COEs themselves and the steps they are
taking in teaching cultural and linguistic competence
and fostering an environment in which the health
professions educational institutions learn from
each other about the best ways to enhance culture
and linguistic competency education.
As the demography of the United States changes,
the issue of disparity in health care becomes
more important each day. Our Nation’s
health profession schools—and particularly
the COEs—have been working for many years
to develop methods of serving our Nation’s
underserved and vulnerable populations. The
COEs in particular have done so successfully
and creatively.
But it is clear that we need to do more to
raise awareness of the problem among all health
care providers, to improve approaches to health
care in all settings that demonstrate cultural
and linguistic competence, and to improve diversity
in the U.S. health care workforce.
HRSA has a long-standing commitment to cultural
and linguistic competence, and has addressed
the problem of disparity in health care by working
in partnership with the COEs, as well as providing
funding to grantees that serve the disadvantaged,
underserved, and diverse populations of the
United States. HRSA believes strongly that a
key component to solving the problem of disparity
in health care is to have a diverse workforce
that is culturally and linguistically competent.
We envision that this curriculum guide is but
one step along the road to developing such a
workforce.
Captain Henry Lopez, M.S.W.
Division Director
Lieutenant Commander Jacqueline Rodrigue, M.S.W.
Senior Program Management Officer
Bureau of Health Professions
Health Resources and Services Administration
U.S. Department of Health and Human Services
Rockville, Maryland
March 2005
Opening Commentaries
As a way of providing a general context for
the materials in the Curriculum Guide, two Nationally
recognized experts in the field of cultural
and linguistic competence in health care were
asked to comment on its format, content, and
potential value to those who educate health
care professionals. In the following commentaries,
they not only accomplish this task, but also
provide important food for thought and cautionary
insights from both clinical and educational
perspectives.
Commentary I: Transforming the Face
of Health Professions through Cultural and Linguistic
Competence Education
By Joseph Betancourt, M.D., M.P.H.
Joseph Betancourt, MD, MPH, is the Senior Scientist
in the Institute for Health Policy, the Program
Director for Multicultural Education in the
Multicultural Affairs Office of the Massachusetts
General Hospital-Harvard Medical School in Boston,
and an Assistant Professor of Medicine in the
Harvard Medical School.
Consider these situations:
A 54-year-old Hispanic woman with hypertension
whose blood pressure has been difficult to control
because, although she says she takes her medication
every day, she believes she knows when her pressure
is high and thus takes it at different times
of the day, and occasionally not at all.
A 64-year-old African-American man who
has angina but is reluctant to go for a cardiac
catheterization because of mistrust due to a
poor experience a family member had in the health
care system, and memories of the invasive procedures
done as part of the Tuskegee Syphilis Study.
A 42-year-old limited-English proficient
Chinese man whose 8-year-old asthmatic daughter
is being given herbal remedies (in addition
to her prescribed inhalers) for her condition
because this tradition has been passed down
for generations.
A 72-year-old Italian woman who has just
had a CT scan consistent with metastatic colon
cancer whose son asks the surgeon not tell her
the diagnosis because it will “kill her”.
In almost every clinical setting across the
Nation, health care professionals face scenarios
like these each day. In fact, these are all
real patients and real clinical cases. For each
of these individuals, culture plays a large
role in shaping their health values, beliefs,
behaviors, and choices. Interestingly, though,
the situations presented here are common across
cultures for many patients. Currently, an educational
movement referred to as “cultural and
linguistic competence” has emerged, with
the goal of providing health care professionals
with the knowledge and skills to manage these
“cross-cultural” challenges effectively
in the clinical encounter. This field is in
fact not new, yet has been re-energized over
the last ten years with pronouncements by the
Institute of Medicine, American Medical Association,
and the American Nursing Association, among
others, that cultural and linguistic competence
is necessary for the effective delivery of health
care in the United States.
Many have considered cultural and linguistic
competence to simply be the skills or strategies
necessary for addressing language barriers in
a clinical encounter, or learning as much as
one can about specific patients from specific
cultures. Whereas the former is extremely important
and remains a key component of such competence,
the latter is more problematic. Previous efforts
in cultural and linguistic competence have aimed
to teach about the attitudes, values, beliefs,
and behaviors of certain cultural groups—such
as the key practice “do’s and don’ts”
for caring for the “Hispanic” patient,
for example. While in certain situations learning
about a particular local community or cultural
group can be helpful (following the principals
of community-oriented primary care), a closer
examination of the definition of culture highlights
that these efforts—when broadly applied—are
reductionist and can lead to stereotyping and
oversimplification of culture.
The curriculum development project, “Transforming
the Face of Health Professions through Cultural
and Linguistic Competence Education,”
aims to address this tension by providing a
guide consisting of strategies, tools, and resources
for implementing and integrating cultural and
linguistic competency content and methods into
existing academic programs under the leadership
of the HRSA Centers of Excellence. Through the
use of an expert consensus process, this curriculum
guide provides a template and starting point
for cultural and linguistic competence education
ranging from guiding principles on the issue
and implementation strategies to evaluation,
dissemination, and a compendium of resources
for teaching.
Pedagogically, this project highlights that
cultural and linguistic competence has evolved
from gathering information and making assumptions
about various cultural groups and their beliefs
and behaviors to developing of a set of skills
that are in essence an expansion of the concept
of patient-centered care. It expands the repertoire
of knowledge and skills classically defined
as being “patient-centered” to include
those that are especially useful in cross-cultural
interactions, but remain vital to all clinical
encounters. This guide includes frameworks for
teaching health care professionals to be aware
of certain cross-cutting social and cultural
issues that affect all patients, while providing
methods to deal with information clinically
through negotiation once it is obtained. It
also provides methods for eliciting patients’
understanding of illness, strategies for identifying
and bridging different styles of communication,
skills for assessing decision-making preferences
and the role of family, techniques to determine
the patient’s perception of biomedicine
and use of complementary and alternative medicine,
tools for recognizing sexual and gender issues,
mechanisms for negotiation, and the importance
of being aware of issues of mistrust, prejudice,
and the effect of race and ethnicity on clinical
decision-making. The project stresses that,
while it is important to understand all patients’
health beliefs, it may be particularly crucial
to understand the health beliefs of those who
come from a different culture or have a different
health care experience. In sum, all of these
skills would assist health care providers with
the patients presented here.
The HRSA Centers of Excellence now have the
opportunity to expand their role in cultural
and linguistic competence education. This project
forms the foundation for a broad portfolio of
educational methods that can be considered in
this process. It has a particularly high value
as a guide and as a grounding set of principles
in the field, which should be expanded upon
by the COEs as local need dictates.
Cultural and linguistic competence can be taught
and learned. Just as in many other areas of
clinical education, case-based, interactive
sessions that highlight the clinical applications
of such competence are the gold standard. When
utilized in an inductive manner, selectively
when the clinical scenario dictates (just as
one would use the review of systems), these
skills provide a window into the individual
patient’s values, beliefs, and behaviors
that are relevant to the process of health care
delivery. In conclusion, these are skills that
can be used by any health care professional,
in any clinical setting, no matter where the
practice, in an effective and time-efficient
manner.
Boston, Mass.
March 2005
Commentary II: Gaining Insight into
the Framework, Elements, Topics, Content, and
Resources Relevant to Cross-Cultural Education
By Jerry Johnson, M.D.
Jerry Johnson, M.D., is a professor of medicine
and project director and principal investigator
for the Center of Excellence for Diversity in
Health Education and Research at the University
of Pennsylvania, School of Medicine, in Philadelphia.
Culture, the shared values, beliefs, and behaviors
of members of a group, influences the presentation
of symptoms by patients, the decisions of physicians,
and the patient’s receptivity to recommendations.
Thus, culture profoundly influences diagnosis,
treatment, and responsiveness. On the one hand,
cultural differences lead to miscommunications
and misunderstandings that lead to misdiagnoses.
More commonly, practitioners miss opportunities
for optimal illness management. Thus, practitioner
understanding and recognition of the cultural
context of the patients’ illness is essential
to a successful therapeutic relationship. Some
have argued that physicians should not attempt
to learn ethnic-specific cultural characteristics
but should instead learn a generic approach
to cross-cultural interactions. In support of
this thinking there is ample evidence that belonging
to a racial or ethnic group is not tantamount
to adherence to the traditional cultural beliefs
of that group. Other factors intermingled with
ethnicity influence health beliefs: gender,
social and economic class, age, the length of
time in the United States, whether the patient
lives in a rural or urban area, level of education,
and language. Nevertheless, since many traditional
health beliefs and practices originate in distinct
ethnic groups, ethnicity is an important clue
to common cultural beliefs. While a generic
approach is helpful, the physician informed
of cultural tendencies is better prepared to
ask the right questions, understand the patient’s
response, avoid confusion and misunderstandings,
and negotiate differences in thinking. The skillful
practitioner uses knowledge of cultural beliefs
and practices to enhance, rather than detract,
from the ability to understand each individual
as a unique person.
This curriculum guide presents insights into
the conceptual framework, elements, topics,
content within topics, and resources relevant
to cross-cultural education and training in
the health professions. Most important, the
resources represent a wealth of information
and experience that educators experienced in
teaching in this field or newcomers can use.
While directed to Centers of Excellence funded
by the HRSA, the guide is applicable to any
health care program or institution. The targeted
trainees range from students to faculty, though
at times the targeted population is unclear.
Experienced educators will value the resources,
the numerous examples of teaching methods used
by their colleagues, and the insights to evaluation.
Less experienced educators will find helpful
hints in all aspects of cross cultural education
from planning to delivery. They will still have
to match the content and methods to the larger
curricula in which it must fit.
In addition to focusing on current and future
practitioners, the guide contains multiple references
to organizational competence and assessment.
Moreover, the organizations may be teaching
institutions (health schools) or may be sources
of care (such as hospitals and health systems).
While practitioner performance (competence)
can be modified by teaching, and schools may
be susceptible to change by faculty (who are
ostensibly teachable), I’m unconvinced
that organizations that deliver care (meaning
hospitals and health systems) can be influenced
by teaching. Educators and investigators may
still wish to assess the cultural competence
of these delivery systems, but changing the
competence of delivery systems should not be
an expected outcome of this or any educational
guide.
The curriculum is not a substitute for leadership
or commitment to cross-cultural education. Nor
is it a substitute for intimate knowledge of
the unique, but limited, opportunities for curricula
change of each institution, and the need to
adapt teaching methods to the overall curricula
of the school. Undoubtedly, the content will
overlap with materials taught in some institutions
under the auspices of professionalism, humanism,
ethics, introduction to history taking, or another
title suggesting nothing about culture. This
overlap is not a criticism, since the guide
should enhance or complement those courses rather
than compete with them. Its length may present
some problems; it has some redundancies, and
some sections may seem overly philosophical
(interesting but difficult to know how to translate
into teaching). Nevertheless, the information
to be gleaned is worth the effort.
Chapters 3 through 10 offer the full range of
perspectives of cross-cultural education. Some
of the more interesting perspectives follow:
In Chapter 3 (Strategies for Success), the rationale
for education programs on cross cultural care
is discussed. Among these reasons, the reader
should be cautious about expecting educational
programs to solve the multifaceted tasks of
eliminating health disparities. Indeed, one
would not expect competence in taking an appropriate
medical history of a person with heart failure
to result in improved outcomes of persons with
heart failure. Several models or standards of
competence are discussed. The reader will want
to distinguish those that focus on the practitioner
(Bell and Evans, and Bennett) from those that
focus on the organization (CLAS, Cross, and
Lewin).
Chapter 4 (Establishing a Framework) is related
to the previous chapter’s focus on the
organization, but offers a more formal conceptual
and philosophical underpinning (Banks and Campinha-Bacote),
a process of instructional systems development.
Chapter 5 (Content) focuses on content, as reflected
in attitudes, knowledge, and skills. The reader
will find the full range of the content areas
of cross-cultural education, and models of some
elements of curricula. Note that these examples
represent only a fraction of what should be
taught.
Chapter 6 (Delivery) overlaps with and elaborates
on the framework and conceptual issues of Chapter
3 and, to a lesser extent, the content of chapter
5. The highlight of the chapter may be the multiple
tools that are introduced (Chapter 10, Resources,
contains still more such tools). Since the number
of hours in a curriculum is fixed and limited,
each institution will have to establish priorities,
sequence the courses, modify the content and
delivery method to match different levels of
trainees, and match the courses to the larger
curriculum.
Chapter 7 (Assessment and Evaluation) begins
with a framework and concludes with several
useful examples, including questionnaires and
standardized patient protocols. One of the proposed
methods of evaluation was applied as part of
a research project, a funding barrier that may
prohibit others from using this approach.
Chapter 10 (Resources) is one of the most comprehensive
resource guides the reader will find.
This guide is a wonderful resource for all persons
interested in cross-cultural education and training
in the health professions.
This curriculum development project was
managed by Magna Systems, Inc., pursuant to Contract
number 230-03-0009 with Department of Health and
Human Services, Health Resources and Services
Administration, Bureau of Health Professions,
Division of Health Careers Diversity and Development
Government Project Officer:
Jacqueline Rodrigue, M.S.W., LCDR, USPHS
Project Expert Team
Authors
Josepha Campinha-Bacote, Ph.D.,
A.P.R.N., B.C., C.N.S., C.T.N., F.A.A.N.
Debra Claymore-Cuny, M.Ed.Adm
Denice Cora-Bramble, M.D., M.B.A.
Jean Gilbert, Ph.D.
Roger M. Husbands
Robert C. Like, M.D., M.S.
Roxana Llerena-Quinn, Ph.D.
Francis G. Lu, M.D.
Maria L. Soto-Greene, M.D.
Beau Stubblefield-Tave, M.B.A.
Gayle Tang, M.S.N., R.N.
Contributors
Ronald Braithwaite, Ph.D.
Leonard G. Epstein, M.S.W.
Elizabeth Lee-Rey, M.D.
Henry Lewis III, Pharm.D.
Guadalupe Pacheco, M.S.W.
Sheila Norris, R.Ph., CAPT, USPHS
Jeanean Willis, DPM, CDR, USPHS
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Reviewers Joseph Betancourt,
M.D., M.P.H.
Denice Cora-Bramble, M.D., M.B.A.
Jerry C. Johnson, M.D.
Denise V. Rodgers, M.D. |
Project Editorial Team
Editors
Jean Gilbert, Ph.D.
Maria L. Soto-Greene, M.D. (COE Perspective)
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Editorial
Consultant
Joseph Burns |
Magna Systems Incorporated
Project Management Team
Susmita S. Murthy, Ph.D.
Paul Purnell, M.S.
Jacqueline Butler, M.S.W., L.I.S.W.
Sarah Cha
Ernest Yoshikawa
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