Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Preface

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.

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.

Project Editorial Team

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