Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself

Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, The Doctors Company

The need for culturally safe, patient-centered care to improve health outcomes is growing as healthcare professionals provide care to our increasingly multicultural society. A practitioner’s cultural competence—the ability to understand and interact effectively with people from other cultures—is critically important in helping to eliminate health disparities and social disadvantages for all patients, regardless of their ethnicity or race.

Clinicians must be able to understand how each patient’s sociocultural background affects health beliefs and behavior. By understanding the patient’s social determinants of health, practitioners are better able to care for multicultural populations. A number of tools are available to help practitioners screen for social determinants of health. In its Family Practice Management, the American Academy of Family Physicians, provides “A Practical Approach to Screening for Social Determinants of Health.”

Health Literacy

Health literacy is also a social determinant of care that can affect practices. People from all age, race, income, and education levels are challenged by an inability to obtain, process, and understand the basic health information and services needed to make appropriate health decisions and to follow instructions for treatment. The AHRQ Health Literacy Universal Precautions Toolkit provides guidance to help practitioners promote better understanding by all patients.

Consider the following scenario involving health literacy: A married 32-year-old Middle Eastern female with uterine fibroids presented at the office of a gynecologist. After years of infertility and pain, a hysterectomy was recommended. The patient spoke English moderately well but with a heavy accent. She declined offers of an interpreter and for a translation of the surgical consent form. Eight weeks posthysterectomy, the patient asked the physician how soon she could expect to become pregnant.

Addressing the Problem

The Doctors Company’s closed claims studies have shown that inadequate provider-patient communication frequently contributes to patient noncompliance, poor patient outcomes, and litigation. In multicultural and minority populations, communication factors may play an even larger role because of the behavioral, cognitive, linguistic, contextual, and cultural barriers that must be overcome. Research has shown that services for minorities can be improved by removing language and cultural barriers.

When cultures and languages create barriers, clinicians are unable to deliver the care they have been trained to provide. Culturally competent care depends on resolving systemic and individual cultural differences that can create conflicts and misunderstandings. If the provider is unable to elicit patient information and negotiate appropriate care, negative health consequences may occur.

Traditionally, training in cross-cultural medicine has focused on providing a list of common health beliefs, behaviors, and key “dos and don’ts.” This approach, which does not consider acculturation and socioeconomic status, can lead to stereotyping.

An alternative approach, first proposed by Drs. Carrillo, Green, and Betancourt in 1999, helps clinicians elicit a patient’s beliefs and preferences in order to identify and address the patient’s concepts, concerns, and expectations. This communication model is called ESFT: Explanatory model of health and illness, Social and environmental factors, Fears and concerns, and Therapeutic contracting.¹

Case Example

Consider this scenario with an example of the ESFT approach: A 62-year-old Dominican patient presented with hypertension. In the past two years, she had been seen by several physicians, had multiple tests to rule out any underlying etiology, and tried a variety of medications to control her blood pressure. Despite these efforts, her blood pressure remained poorly controlled. The patient, whose primary language was Spanish, had limited English skills but refused an interpreter at all clinic appointments. It appeared that the patient was nonadherent with taking the antihypertension medicine—taking it only periodically when she felt tense or stressed. Further inquiry by the physician revealed that the patient was illiterate and did not understand the complex medication regimen she had been given.

The physician was able to explore the patient’s explanatory model for hypertension using the ESFT approach. The patient strongly believed that her hypertension was episodic and related to stress. She didn’t take her daily antihypertension medication because it didn’t fit her explanatory model. The physician was able to reach a compromise by explaining that, although her blood pressure goes up during stressful times, her arteries are under stress all the time, even though she didn’t feel it. Taking medications daily would relieve the arterial stress but would not help with her emotionally stressful episodes. The physician was able to negotiate with the patient to add relaxation techniques to her daily routine.

Bias and Ethnocentricity

Biases affect how we view and care for individuals. They are the attitudes or internalized stereotypes that can affect healthcare professionals’ perceptions, actions, and decisions in an unconscious manner that often contribute to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics.² All of us come from different backgrounds and tend to see the world from our own perspective.

Failing to recognize or respect the views of others can manifest itself in a form of bias known as ethnocentricity. Ethnocentricity may take the form of explicit bias such as xenophobia, overt racism, or religious bias. Explicit bias occurs at a conscious level, but when the individual is not aware of the bias, it is implicit bias. Bias can result in a lack of cultural competence evidenced by failure to consider the terminology, comfort care, and remedies implemented by persons from a culture other than that of the healthcare provider.

What You Can Do

Consider the following strategies to address cultural diversity challenges in your practice:

• Follow AHRQ’s Cultural Competence and Patient Safety recommendations on the use of language assistance, cultural brokers, training, and their guide Improving Patient Safety Systems for Patients with Limited English Proficiency.
• Conduct a self-assessment: Cultural and Linguistic Competence Health Practitioner Assessment, available from the Georgetown University National Center for Cultural Competence. 
• Use a communication model such as ESFT or LEARN:

Listen to the patient’s perception of the problem.

Explain your perception of the problem.

Acknowledge and discuss differences and similarities.

Recommend treatment.

Negotiate treatment.

• Ask the patient or interpreter to repeat back what you said during the informed consent process, during the discussion of the treatment plan, or after any patient educational session with you or your staff. The repeat-back process is effective for determining the extent of the patient’s understanding.
• Plan ahead when caring for patients with limited or no English proficiency by identifying the main languages spoken in your area, adding primary language to intake forms, and translating important patient information material and consents. See the CDC Gateway to Health Communication, “Health Equity Guiding Principles for Inclusive Communication.”
• Use “Ask Me 3,” a tool that identifies three simple questions all clinicians should be ready to answer—regardless of whether the patient asks. More information is available in our article “Rx for Patient Safety: Use Ask Me 3 to Improve Patient Engagement and Communication” and “Ask Me 3: Good Questions for Your Good Health” on the Institute for Healthcare Improvement’s website.
• Learn more about AHRQ’s teach-back and show-me methods, effective ways to evaluate patient understanding by asking the patient to repeat back instructions or demonstrate a skill.
• Use appropriate language services for your LEP patients.
  • Partner with your health plans and hospitals to identify written and oral language services.
  • Allow staff who are fluent in the language and comfortable translating during visits to act as interpreters.
  • Learn your state requirements. In some states, Medicaid plans may call for providing language access.
• Explain to patients/family members who refuse healthcare interpreter services how important it is to their care and safety that you and the patient/family member understand each other. If the patient continues to refuse interpreter services, suggest a referral to a clinician who speaks the patient’s primary language. Document the patient record with the patient’s refusal and your explanation of the risks and benefits of an interpreter.
• Plan to care for patients who have sensory impairment by asking their preferred way to communicate. Provide options for video interpretation or messaging technology and large-font material. Allow patients who are blind to record instructions, and provide them with a description of their surroundings.
• Be aware of your implicit biases in clinical encounters by evaluating behavior, communication, and clinical decisions. Read The Joint Commission’s “Quick Safety 23: Implicit Bias in Health Care” and take a test that can measure your attitudes and beliefs at Implicit Association Test (IAT).
• Evaluate your telemedicine practice for disparities in accessing care. See CRICO Recently Asked Questions on Telehealth/Virtual Care.
• Obtain more information from these useful websites:
  • U.S. Department of Health and Human Services, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services (CLAS).
  • U.S. Department of Health and Human Services, Think Cultural Health, A Physician’s Practical Guide to Culturally Competent Care.
  • Agency for Healthcare Research and Quality, What Is Cultural and Linguistic Competence?
  • Health Resources and Services Administration, Culture, Language, and Health Literacy Resources.

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