Cultural Competence in

Healthcare

Fern R. Hauck, MD, MS

Department of Family Medicine
University of Virginia Health System
“I don’t think one can ever really know any
but one’s own countrymen. For men and
women are not only themselves; they are
also the region in which they were born,
the city apartment or farm in which they
learned to walk, the games they played as
children, the old wives’ tales they
overheard, the food they ate, the schools
they attended, the sports they followed, the
poets they read, the god they believed in. It
is all of these things that have made them
what they are and these are the things that
you cannot come to know by hearsay; you
can only know them if you have lived
them.
It is all of these things that have made them
what they are and these are the things that
you cannot come to know by hearsay; you
can only know them if you have lived
them.”

Somerset Maughan, The Razor’s Edge

(Introduction), 1944.
 Definition of Cultural Competence

“The knowledge and interpersonal skills that

allow providers to understand, appreciate,
and work with individuals from cultures
other than their own. It involves an
awareness and acceptance of cultural
differences; self-awareness; knowledge of
the patient’s culture; and adaptation of
skills.”
AMA, Culturally Competent Health Care for Adolescents, 1994.
 Culturally Competent Healthcare Systems

• Interpreters or bilingual providers

• Cultural diversity training for staff
• Linguistically and culturally
appropriate health education and
information materials
• Tailored healthcare settings
Task Force on Community Preventive Services, 2002.
Comparisons of Cultural Norms and Values
Aspects of Culture Mainstream Other Cultures
American Culture
Communication and Explicit, direct Implicit, indirect
language communication. communication.
Emphasis on content - Emphasis on context
-meaning found in – meaning found
words. around words.
Time and time Linear and exact time Elastic and relative
consciousness consciousness. Value time consciousness.
on promptness – Time spent on
time=money. enjoyment of
relationships.
 Comparisons of Cultural Norms and Values
( continued)

Aspects of Culture Mainstream American Other Cultures

Culture
Relationships, Focus on nuclear family. Focus on extended family.
family, friends Responsibility for self. Loyalty and responsibility
Value on youth, age seen to family. Age given status
as handicap. and respect.
Values and norms Individual orientation. Group orientation.
Independence. Preference Conformity. Preference
for direct confrontation of for harmony.
conflict.
Beliefs and Egalitarian. Challenging Hierarchical. Respect for
attitudes of authority. Individuals authority and social
control their destiny. order. Individuals accept
Gender equity. their destiny. Different
roles for men and women.

Gardenswartz L, Rowe A. Managing Diversity: A Complete Desk Reference and Planning Guide, 1993.
Commonwealth Fund 2001 Healthcare Quality
Survey
• 6,772 adults surveyed
• Communication problems reported more
commonly for African Americans (Af A),
Hispanics (H) and Asian Americans (As A)
• H and Af A adults highest uninsured rates
• H and As A patients had greatest difficulty
understanding information from doctor
• Less than one half of limited English proficient
patients always or usually had interpreters
• Af A, H, and As A more often felt that they had
been treated disrespectfully or with little
understanding of their culture
Commonwealth Fund 2001 Healthcare Quality
Survey (www.cmwf.org)
• Three main factors in ensuring that minority
populations receive optimal medical care:
 Effective patient-physician communication
 Overcoming linguistic and cultural barriers
 Access to affordable health insurance
• Policy implications
 Financing interpreters (few states only)
 Training of clinicians and medical students in
communicating and interacting effectively with
patients from different cultures
 Expanding health coverage and access to all
Promoting Cultural Diversity and Cultural
Competency
Self-Assessment Checklist
 “Ethnic Mnemonic”
E: Explanation
T: Treatment
H: Healers
N: Negotiation
I: Intervention
C: Collaboration and Communication
Developed by: Steven J. Levin, MD; Robert C. Like, MD; Jan E. Gottlieb, MD.
Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical
School.
 “Ethnic Mnemonic” – “E”
E: Explanation
What do you think may be the reason you have
these symptoms?
What do friends, family, others say about these
symptoms?
Do you know anyone else who has had or who
has this kind of problem?
Have you heard about/read/seen it on
TV/radio/newspaper? (If patient cannot offer
explanation, ask what most concerns them
about their problem).
 “Ethnic Mnemonic” – “T”
T: Treatment
What kinds of medicines, home remedies or
other treatments have you tried for this illness?
Is there anything you eat, drink, or do (or
avoid) on a regular basis to stay healthy? Tell
me about it.
What kind of treatment are you seeking from
me?
 “Ethnic Mnemonic” – “H”
H: Healers
Have you sought any advice from
alternative/folk healers, friends or other people
(non-doctors) for help with your problems?
Tell me about it.
 “Ethnic Mnemonic” – “N”
N: Negotiation
Negotiate options that will be mutually
acceptable to you and your patient and that do
not contradict, but rather incorporate your
patient’s beliefs.
Ask what are the most important results your
patient hopes to achieve from this intervention.
 “Ethnic Mnemonic” – “I”

I: Intervention
Determine an intervention with your patient.
May include incorporation of alternative
treatments, spirituality, and healers as well as
other cultural practices (e.g. foods eaten or
avoided in general, and when sick).
 “Ethnic Mnemonic” – “C”
C: Collaboration and Communication
Collaborate with the patient, family members,
other health care team members, healers and
community resources.
Effectively use interpreters in encounters with
patients with limited English proficiency.
International Family Medicine Clinic
 International Family Medicine Clinic
Goals
 Provide comprehensive, high quality, culturally
competent care to the growing population of
limited English proficiency (LEP) patients
 Develop systems to more efficiently care for
patients, including better communication with
community partners and standardized
screening and evaluation
 Become a resource for the medical center and
others who serve LEP patients
 Document, evaluate and advocate
 Current Clinic Structure
 5 half-day sessions
 3 clinicians
 Interpreters
 New refugee patients
scheduled after Health
Department Screening
 Special forms, cultural profiles, and database
 Mental health: referral to Family Stress Clinic
(bilingual, volunteer counselors)
 International Health Intern
 Common Health Issues
 Full range of acute and chronic illnesses
 Infectious diseases

 Skin rashes

 Dental disease

 Need for eye exams and glasses

 Children: developmental issues

 Anemia/nutritional deficiencies

 Preventive care, e.g., Pap smears,

mammograms for women
 Common Health Issues (2)
 Depression, anxiety, PTSD
 Medically unexplained symptoms (e.g.,
backaches, headaches, abdominal pain)
 Culturally-based syndromes
 Community Partners & Patients Served
Refugees Immigrants Limited Visas
Partners ESL ESL
International Rescue Blue Ridge Medical UVa International
Committee (IRC) Center/Rural Health Studies Office
Health Department Outreach Project/
English as a Second Lay Health Promoter
Language (ESL) Program/Wellness
Passport Program
Countries Mexico China
Middle East Central and South Korea
(Afghanistan) America Central & South
Eastern Europe Other America
(Bosnia-Herzegovina, Other
Croatia)
Africa (Togo, Liberia,
Sudan, Congo)
Somali Bantu (soon)
 Community Outreach & Collaboration
 ESL program/health literacy presentations and
role plays
 Health fairs
UVa Refugee and Immigrant Health
Advisory Board
Patient Demonstration – Part 2

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