Addressing Issues  

Improving Cultural Competency:
Rationale and Tips

The Rationale for Cultural Competence in Health Care

Census Data
Consistent with long-standing predictions, Census 2000 data revealed significant increases in minority and foreign-born populations across the United States. California's "minority" populations became the majority in 1999, and many other states not historically perceived as racially or ethnically diverse are yearly receiving thousands of newcomers from around the globe. The increasing diversity of the nation brings with it a host of opportunities and challenges that are experienced with increasing frequency and immediacy in health care facilities, from small rural clinics to large urban medical centers.

What do these demographics mean for the health care provider?
Ethnic groups sometimes referred to as "minorities" are in fact the "emerging majority" in overall US population statistics, and even more so in terms of those with diabetes. Thus, becoming a well-informed health care provider, open to other cultures and learning how others view and treat illness within their culture will be very important for effective patient care in the ever-changing landscape of the U.S. population.  Below is a list of facts about a few of the ethnic minority groups in the U.S.

Hispanic/Latino
The Hispanic/Latino population in the US is growing five times as fast as the general population.

Asian American
- Asian Americans are the fastest-growing ethnic group in the US increasing at rates eight times as fast as the general population primarily due to immigration.
- The adoption of western diet and sedentary life style has lead to a dramatic increase in the prevalence of diabetes even in Asian Americans that show no or little weight gain.

Pacific Islander
- The Pacific islanders are the smallest group of minorities in the United States. In addition to the indigenous populations in American Samoa, Hawaii and Micronesia, there are significant populations in Hawaii, and Washington, California, and Nevada (Las Vegas).
- Pacific Islanders include primarily Hawaiians, Samoans and people from Micronesia and like the Native Americans, have some of the highest prevalence of diabetes in the world.

African American
African Americans may have fewer language barriers in communicating with health care providers than other ethnic groups, but represent a large, culturally diverse population with different approaches to effective communication.

American Indian
American Indian tribes are among those groups with the highest prevalence of type 2 diabetes in the world. Although most American Indians speak English, it may be as a second language, and cultural differences in lifestyle, communication and perceptions obligate the provider to take steps to ensure culturally competent health care for a positive outcome.

Statistics on health care disparities
The burden of diabetes is much greater for minority populations than the white population. For example, 10.8 percent of non-Hispanic blacks, 10.6 percent of Mexican Americans, and 9.0 percent of American Indians have diabetes, compared with 6.2 percent of whites.3

Certain minorities also have much higher rates of diabetes-related complications and death, in some instances by as much as 50 percent more than the total population.4 5 Statistics on health care disparities include the following:

• African Americans, Hispanic/Latino Americans, American Indians/Alaska Natives, and native Hawaiians all experience higher death rates from diabetes than the general population.
• Asian American/Pacific Islanders experience higher mortality from cerebrovascular accidents.
• African Americans, Hispanic/Latino Americans and American Indians/Alaska Natives all experience higher rates of potentially avoidable lower extremity amputations.
• The rate of end-stage renal disease is 2.6 times higher among African Americans than among whites.
• Hypertension is common in Hispanic, African American, and Pacific Islander populations.
• Overweight and obesity are common in some Hispanic groups, African American, Pacific Islander, and American Indian populations.

Practical Tips for Health Care Providers

Thus, knowing the data, what are some practical tips for health care providers?  Below is an excerpt from a newsletter for clinicians "Cultural Competency in Practice" by Jennie McLaurin, MD, FAAP that provides practical tips to help clinicians draw out culture-bound perspectives on illness by using The Explanatory Model.

"It can be daunting to attempt to ascertain all these cultural components in the context of a fifteen-minute office visit. A practical approach to understanding is the Explanatory Model. It can be as brief or complex as the clinician determines, and it treats each encounter uniquely, helping to avoid stereotyping and the impossibility of ever fully knowing a patient's culture. The Explanatory Model simply involves asking good questions. The clinician asks the patient such questions as:

• What do you think caused this problem?
• What have you done to treat this?
• Have you asked anyone else to help you?
• What are some of the ways your parents might have treated this? Traditional ways of treating this?
• What do you want the medicine to do? What medicine do you believe works best for you? Why?
• How does your faith/religion help you to be well?
• Are there any foods or drinks that you know of that will help you with____?

There are obviously many such questions that can be asked. It is patient-centered and allows communication to go beyond the traditional interrogational style of clinical medicine. Importantly, this approach recognizes individuality and allows cultural humility on the part of the clinician. Collaboration and negotiation are possible as a result."

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