Strategies to Reduce Health Disparities

Cultural Competence

Presenters: Marsha Lillie-Blanton, Dr.P.H., Vice President, Health Policy, The Henry J. Kaiser Family Foundation, Washington, DC Tawara D. Goode, M.A., Director, National Center for Cultural Competence, Child Development Center, Georgetown University Medical Center, Washington, DC

The public perception of race and health care is a gauge to determine when change is required. The Henry J. Kaiser Family Foundation conducted a survey of 5,500 people to determine public perceptions of race and health care. Compared with other sectors (workplace, education, housing), racism in medical care was viewed by black and Hispanic persons as less of a major problem. However, the survey also indicated that various populations view their ability to receive quality care very differently.

When asked how they perceive quality of care for black people and white people, about 70 percent of black persons perceive that they receive lower quality care than white people. About 67 percent of white people surveyed believe that black people receive the same care as white people do. Similar differences are identified between Hispanic and white people.

White and Hispanic participants were also asked, "How often do you think our health care system treats people unfairly based on whether or not they have health insurance; on how well they speak English and on what their race and ethnic background is?" About 69 percent of both white and Hispanic people believe not having coverage creates unfair treatment. As far as language and racial background, about the same number of Hispanic and white people (52-54 percent) perceive unfairness, while 43 percent of both groups do not think it occurs as often or ever.

When asked to compare the severity of the following three problems–the cost of insurance and medical care, having enough doctors and health providers near, or getting care because of their race or ethnic background–black and Hispanic people were most concerned with cost. Even though quality of care is perceived as low, more black and Hispanic persons saw cost as the biggest barrier to quality health care.

Key findings of this study include:

• Racial differences in health care are reduced but not eliminated after adjusting for socioeconomic condition, health status, and health coverage.
• Minority Americans are more likely to perceive themselves to be at a disadvantage because of their race.
• Minority Americans are more likely to perceive cost of coverage and care as a major problem.

Cultural competence in the provision of care can minimize the perception of disadvantage in accessing quality health care. Cultural competence is a congruent set of behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables organizations or professionals to work effectively in cross-cultural situations. There are five elements to cultural competence:

1. Valuing diversity.
2. Having the capacity for cultural self-assessment.
3. Managing for dynamics of differences.
4. Having the ability to institutionalize cultural knowledge.
5. Adapting to diversity in policies, values, structures, and services.

Cultural competence can be viewed as a developmental process that occurs over a continuum of possibilities. These possibilities are:

• Cultural destructiveness.
• Cultural incapacity.
• Cultural blindness.
• Cultural pre-competence.
• Cultural competency.
• Cultural proficiency.

Cultural competence can be achieved by engaging in such ongoing activities as:

• Developing a process for self-assessment.
• Developing and implementing policies and guidelines.
• Conducting and participating in training and professional activities.
• Providing a forum for safe and honest dialogue with and among agency personnel and the diverse communities they serve.

A study of cultural competency among seven Maternal and Child Health (Title V) sites revealed the following lessons:

• Organizational self-assessment is time, labor, and resource intensive.
• Organizational self-assessment is affected by the sociopolitical and economic climate of the State.
• Organizational self-assessment is affected by locus of investment (for example, whether the effort is program- or State-driven, whether there is buy-in from the top, and/or the existence of community partnerships and collaborators).
• Consumer and family member participation in the organizational self-assessment process is crucial.
• Organizational self-assessment proved to be an impetus for systems change within Title V programs by incorporating cultural competence in block grant applications, organizational policy, structures, procedures, and practices.

Additional Resources

Cohen E, Goode TD. Policy Brief 1: Rationale for cultural competence in primary health care. Washington (DC): National Center for Cultural Competence, Georgetown University Child Development Center, Center for Child Health and Mental Health Policy-University Affiliated Program; 1999 Winter.

Frederick Sneiders Research and The Henry J. Kaiser Family Foundation. Perceptions of how race and ethnic background affect medical care: Highlights from focus groups. Menlo Park (CA): The Foundation; 1999 Oct.

Georgetown University Child Development Center, National Center for Cultural Competence. A Planners Guide: Infusing principles, content and themes related to cultural linguistic competence. Washington (DC): The Center; 2000 Winter.

Goode TD. Definitions of cultural competence. Washington (DC): National Center for Cultural Competence, Georgetown University Child Development Center, Center for Child Health and Mental Health Policy-University Affiliated Program; 2000 Apr.

Goode TD, editor. National Center for Cultural Competence. Towards a culturally competent system of care, Volume 1. Cross T, Bazron B, Dennis K, et al. CASSP Technical Center, Center of Child Health and Mental Health Policy, Georgetown University Child Development Center. Washington (DC): The Center; 1999 Jun.

Goode TD, Sockalingam S, Brown M, et al. Policy Brief 2: Linguistic competence in primary health care delivery systems: implications for policy makers. Washington (DC): National Center for Cultural Competence, Georgetown University Child Development Center, Center for Child Health and Mental Health Policy-University Affiliated Program; 2001 Jan.

Goode TD, Harrison S. Policy Brief 3: Cultural competence in primary health care: partnerships for a research agenda. Washington (DC): National Center for Cultural Competence, Georgetown University Child Development Center, Center for Child Health and Mental Health Policy-University Affiliated Program; 2000 Summer.

Henry J. Kaiser Family Foundation. Chart pack: Race, ethnicity, and medical care: A survey of public perceptions and experiences. Menlo Park (CA): The Foundation; 1999 Oct.

Henry J. Kaiser Family Foundation. Race, ethnicity and medical care: A survey of public perceptions and experiences. Menlo Park (CA): The Foundation; 1999 Oct.

Henry J. Kaiser Family Foundation. Toplines: Key facts: Race, ethnicity, and medical care. Menlo Park (CA): The Foundation; 1999 Oct.

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