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Topic last updated Jan. 2006
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Addressing Issues
Improving
Cultural Competency:
HRSA Practices and Perspectives
Please
note: Some
links on this page take you outside the Better Diabetes Care website. The NDEP
does not endorse or otherwise guarantee the accuracy of links that take you out
of this website. Health
Resources and Services Administration (HRSA) Materials
www.hrsa.gov/financeMC/ftp/cultural-
competence.pdf
HRSA has a long-standing and particular interest in cultural competence
because so many of its grantees provide care to traditionally underserved
populations that include culturally and linguistically diverse communities.
HRSA has developed Cultural Competence Works: Using Cultural
Competence To Improve the Quality of Health Care for Diverse Populations
and Add Value to Managed Care Arrangements. Health Resources
and Services Administration, U.S. Department of Health and Human
Services, 2001.
This
resource explains HRSA's experience in developing culturally
appropriate programs and shows that practicing cultural competence
-- the set of behaviors, attitudes, skills and policies that help
organizations and staff work effectively with people of different
cultures -- can help expand and improve access to quality health
care.
Many
health care providers, and especially HRSA grantees, have developed
creative and successful programs to address the needs of underserved,
culturally diverse communities, including interpreter services,
cultural competence training for staff, targeted outreach programs,
and other culturally appropriate interventions. Here are some excerpts
from the resource that discusses successful practices for delivering
culturally appropriate care.
Cultural Competence and Managed Care
There is great potential for collaboration between managed care
organizations and HRSA grantees, especially around issues of cultural
competence. Many managed care organizations are now serving culturally
diverse, underserved populations since Medicaid beneficiaries are
being enrolled in managed care. Many HRSA service delivery grantees
have a range of creative and successful practices for serving those
populations. These services frequently include interpretation, translated
written materials, transportation, and child care assistance for
clients.
It
is a natural fit, therefore, for HRSA grantees to develop relationships
with managed care organizations to continue to serve these populations.
Further, grantee organizations with long-standing links to the community
and culturally competent programs are able to use those strengths
as a bridge to managed care providers or systems. Some HRSA grantees
have collected data to show that culturally competent care is worth
the investment.
Successful
Practices in Delivering Culturally Competent Care |
HRSA
programs that most successfully provide culturally
competent services tend to:
Define
Culture Broadly: Understanding how
factors in addition to race, language, and ethnicity
contribute to a person's sense of self in
relation to others, is an integral part of providing
culturally competent care. Other factors include
shared attributes (such as gender or sexual orientation),
or shared life experiences (such as survival of
violence and/or trauma, education, occupation,
or homelessness). They affect how a person seeks
and uses medical care, and are influenced by their
culture group's historical relationship
to the medical establishment. [back]
Value
Clients' Cultural Beliefs:
Cultural competence is demonstrated by the extent
to which a program is able to learn about and
value its target community's knowledge,
attitudes, and beliefs about health care. In order
to communicate effectively with clients, providers
need to understand how to talk about sensitive
issues such as sexuality, drug use, and personal
violence, among others. [back] For example, complications
of diabetes including impotence and disability
from neuropathy or vascular disease, and the need
for behavioral change for self-management, all
need to be approached from a culturally sensitive
perspective. [back]
Recognize
Complexity in Language Interpretation:
Being able to speak a client's language
is essential, but it does not always guarantee
effective communication between the client and
the provider. Communication is more than simply
shared language; it must also include a shared
understanding and a shared context as well.
There
are three overarching concepts to consider when
providing culturally and linguistically appropriate
health care:
-
recognize the linguistic variation within a
cultural group;
-
recognize the cultural variation within a language
group; and
-
recognize the variation in literacy levels in
all language groups.
Because
not all programs can afford to hire full-time
staff, most need to use multiple strategies to
meet their language needs. Contracting with commercial
telephone interpreter services, though somewhat
costly, has been very useful to smaller programs,
especially those who have seen a rapid increase
in the number of languages spoken by new clients.
Other programs have found some individuals may
not be literate in their native language.
[back]
Facilitate
Learning Between Providers and Communities:
Creating environments where learning can occur
is crucial to improving the health of both individuals
and communities. Health care providers need to
learn more about the cultural context, knowledge,
beliefs and attitudes of the communities they
serve. Communities need to learn more about how
the health care delivery system works. Both need
to learn how collaboration between providers and
communities will improve access and quality of
care through improved cultural competence. [back]
Involve the
Community in Defining and Addressing Service Needs:
Programs that are truly culturally competent involve
clients and community members in identifying community
needs, assets, and barriers, and in creating appropriate
program responses. In this approach, clients and
community members play an active role in needs
assessment, program development, implementation,
and evaluation.
Some
organizations institutionalize this relationship
by making individuals from the community voting
members of their governing boards. Others ensure
input and recommendations by using community advisory
boards, client panels, task forces, or town meetings.
Still others sponsor locally based community research
(interviews, focus groups, etc), and integrate
the results into program design.
Some
programs integrate clients and community members
into programs by using volunteers from the target
community in a variety of program areas, serving
as peer advocates who help new clients negotiate
the system. Most programs also try to hire individuals
from the community, or from cultural, economic,
and linguistic backgrounds that complement those
of community members. [back]
Collaborate
with Other Agencies: A number of
programs have been proactive in their communities
to expand culturally competent services by combining
forces with other local agencies and organizations.
Some programs, for example, have built strong
collaborative relationships with medical school
residency programs, and find benefit in these
staffing arrangements for the provision of culturally
competent care. [back]
Professionalize
Staff Hiring and Training: Ways
to professionalize hiring and training practices
are to:
-
establish specific hiring qualifications and
mandated training requirements for all staff
in language, medical interpretation, and cultural
competence as their positions necessitate
-
produce a comprehensive and replicable training
curriculum and qualifying factors
- allocate
the budget and time for staff training including
training for new staff, annual updates and review,
as well as testing and job application criteria.
[back]
Institutionalize
Cultural Competence: Ways to institutionalize
cultural competence in a health delivery system
include:
-
make it an integral part of strategic planning
at all levels
-
make staffing and activities for cultural competence
an integral piece of a sustainable funding stream;
and
- design
cultural competence activities that can be replicated
(both for other cultural groups and for other
health care programs). [back]
Critical
to the long-term survival of culturally competent
service delivery is sustainable funding for staff,
training and other essential activities. Of all
of the goals, this may be the most difficult to
achieve. |
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HRSA Perspectives on Cultural Competence
The Bureau of Primary Health Care at the Health Resources and Services
Administration has developed an excellent resource, The Provider's
Guide to Quality and Culture erc.msh.org/mainpage.cfm?
file=1.0.htm&module=provider&language=English
The guide is of particular interest to health care providers seeking
resources on cultural issues within the context of quality of care,
and it responds to four of six national aims (safety, effectiveness,
patient-centeredness and equity) articulated by the National Institute
of Medicine's Crossing the Quality Chasm: A New Health System for
the 21st Century report.
The guide helps health care providers examine their own cultural
beliefs, attitudes and biases as well as learn more about how cultural
differences may affect clinical outcomes. It provides basic information
on the culture, health strengths, and health challenges of people
from some of the regions and groups of the world.
The
following excerpts are presented to help users locate some of the
website's areas of interest.
| Note |
| Avoid
Stereotypes
While recognizing that there are many similarities
among people from the same culture, it is important
for health care providers to remember that each
individual has a unique personal history, belief
system, communication style and health status.
What may be true about some or most individuals
from a particular region or country may not be
true of all individuals from that region or country.
Stereotyping a patient can lead to misconceptions
about the individual seeking your care. We caution
you to keep this important caveat in mind. |
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Hispanic/Latino
Perspective
Health care providers and health care systems in a variety of clinical,
prevention, and social service settings are being called upon to
understand, and effectively respond to the growing needs of over
35 million Hispanics in the United States. They are being asked to facilitate greater
access to, and utilization of, health care services for this patient
population, as well as to learn useful ways to enhance one-to-one
provider-patient interactions.
Combining respect for the benefits of mainstream medicine, tradition,
and traditional healing, along with a strong religious component
from their daily lives (over 77 percent of Hispanics in the United
States are Catholic), Hispanic patients may bring quite a broad
definition of health to the clinical or diagnostic setting. Respecting
and understanding this view can be benefit all health care providers
in treating and communicating with the patient.
Please
note: Some
links on this page take you outside the Better Diabetes Care website. The NDEP
does not endorse or otherwise guarantee the accuracy of links that take you out
of this website.
For
information from the Bureau of Primary Health Care on the common cultural characteristics la familia (family), respeto
(respect), personalismo (personalized relationships), and
confianza (trust) for Hispanics in
the United States, visit
erc.msh.org/mainpage.cfm?
file=5.2.0f.htm&module=provider&language=english.
African
American Perspective
This section provides information on African-American culture as
it relates to the health of individuals, families, and communities.
We hope that the material contained here will be useful to providers
as they formulate effective strategies to eliminate health disparities
for the diverse African-American population.
erc.msh.org/mainpage.cfm?
file=5.4.1.htm&module=provider&language=English&ggroup=culture
American
Indian and Alaska Native Perspective
This section explores issues of concern to providers working with
the diverse populations that embody the term American Indian and
Alaska Native (AI/AN). It is designed to broaden provider understanding
of culture and health within Native American populations. We hope
that the material contained here will stimulate further thought
and action to reduce the disparities in health care that affect
AI/AN peoples.
erc.msh.org/mainpage.cfm?
file=5.4.7.htm&module=provider&language=English
| Note |
| There
is federal legislation concerning language access
responsibilities:
Federal law: Title VI of the Civil Rights Act
"No person in the United States shall, on the
ground of race, color or national origin, be excluded
from participation in, be denied the benefits
of, or be subjected to discrimination under any
program or activity receiving Federal financial
assistance." 6 |
|
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Asian
American Perspective
This section is designed to help health care professionals achieve
positive health outcomes across the diverse populations of Asian
Americans in the United States. We hope that this information will
help health services planners, administrators, educators, and providers
to facilitate greater access to and utilization of culturally competent
health services by Asian-American clients. It is also our hope that
the material contained here will improve provider understanding
of important cultural factors in Asian-American perception of risk
and patterns of health-seeking behaviors and stimulate further thought
and action to reduce disparities in health care among Asian-American
groups. erc.msh.org/mainpage.cfm?
file=5.1.0f.htm&module=provider&language=english
Pacific
Islander Perspective
Pacific Islanders are a highly diverse population indigenous to
the thousands of islands in the Pacific Ocean. They comprise more
than 19 different ethnic groups with different histories, languages,
and cultural traditions. The three largest Pacific Islander groups
in the U.S. are Hawaiians, Samoans, and Chomorros (from the Marianas,
primarily Guam). Three-fourths of the Pacific Islanders living in
the U.S. reside in California and Hawaii. Other states having a
significant Pacific Islander population include Washington, Oregon,
Texas, and Utah.
erc.msh.org/mainpage.cfm?
file=5.4.8.htm&module=provider&language=English&ggroup=culture
Linguistic Competency
Professional interpretation requires a minimum level of proficiency
in two languages and the demonstrated ability to convey a complex
message using words and grammar that are appropriate to both the
provider and the patient. Professional interpreters are trained
to convey messages without the distortion that can result from interjecting
their own opinions, beliefs, or prejudices.
-
Use of family and friends as interpreters is often problematic
and best avoided.
- Clinic
staff used as interpreters must be trained.
erc.msh.org/mainpage.cfm?
file=4.5.0.htm&module=provider&language=English
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Cultural Competency in Medical Education and
Professional Medical Organizations
- The Liaison Committee on Medical Education Accreditation Standards states that "Faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments."
www.lcme.org
- The Association of American Indian Physicians is developing a course on cultural competency for medical providers.
- The Education Center for Texas Health Steps Cultural Competency Web Based Long Distance Learning Program
www.thsteps.org/welcome_index.htm
This course has been approved for 1/2 hour of AMA PRA Category
1 credit and is designated as ethics and/or professional responsibility
training. CME credit is awarded to the physicians, PA's, and APN's.
The course is approximately 45 minutes long, with an additional
10-20 minutes of optional activities. It has been planned and
implemented in accordance with the Essential Areas and Policies
of the Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of the Texas Medical Association
and the Texas Nurses Association. The Texas Medical Association
is accredited by the ACCME to provide continuing medical education
for physicians.
- The
following professional medical specialty groups have published
guidelines and/or policies relating to the care of culturally
diverse populations:
- Quality Care for Diverse Populations Video
www.aafp.org/x13887.xml
Quality Care for Diverse Populations is a training program developed by the American Academy of Family Physicians to assist physicians and other health care professionals in becoming more culturally proficient in the provision of care to their patients. The program includes five video vignettes depicting simulated physician-patient visits in an office setting as a means to explore ethnic and sociocultural issues found in today’s diverse health care environment. Written collateral materials, including learning objectives, discussion questions and cultural determinants for each vignette, complement the video elements. The written material provides background information on the key issues and sets the stage for each video simulation. Tools and tips to enhance patient encounters and a list of resources to guide additional inquiry are also provided. A list of questions for pre- and post-testing is included as well.
The program is available in two formats, video and CD-ROM, to suit group training and self-learning needs. Both formats, entitled Cultural Competency, may be ordered online (www.aafp.org/catalog) or via telephone (1-800-944-0000). The item numbers are 723 (videotape and manual), and 724 (CD-ROM).
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Issues: Cultural Competency References |
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