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Jointly presented by
1998 Conference Proceedings"The National Conference on Quality Health Care for Culturally Diverse Populations: Provider and Community Collaboration in a Competitive Marketplace" was held at the New York Academy of Medicine, New York, New York, October 1 - 4, 1998. Presented by the U.S. Department of Health and Human Services’ Office of Minority Health, the New York Academy of Medicine, and Resources for Cross Cultural Health Care, the intent of the conference was to provide an opportunity for health care providers, community representatives, and policymakers to learn about practical, cost-effective initiatives for delivering high-quality health care to culturally diverse populations.
More than 400 participants from 26 states and four countries shared their experiences in presentations and discussions over the course of the two-and-a-half-day conference. This convergence of ideas and experiences reflected current efforts aimed at meeting the needs of diverse populations, elicited questions that might guide future deliberations, and revealed opinions about the value of such conferences in supporting participants’ cross-cultural efforts.
This report integrates comments, presentations, and documents from the conference to summarize overall conference themes and recommendations for future efforts. 1. The Growing Diversity of American Society: Implications for the Nation’s Health Care System 2. Cultural Competence in Health Care and the Role of Government 3. Recognizing and Integrating Diversity's Dimensions into the Patient-Provider Relationship 4. Cultural Diversity and Health Professions Training in the Shadow of Anti-Affirmative Action 5. Cultural Competence in the Health Care Setting: Emerging Importance, Uncertain Direction 6. Managed Care Plans and the Challenge of Cultural Competence IV. Conference Plenary Presentation (separate web page)
Featuring 116 speakers and panelists, the conference included plenary sessions and in-depth workshops on each of four major themes:
The conference targeted the information needs of several audiences concerned with delivering quality health care: health care managers and executives; health care professionals in practice and education; consumers and representatives from diverse communities; and individuals engaged in quality improvement policy, accreditation, and research. The 28 workshops were organized according to five concurrent tracks:
The themes and tracks worked together to create the structure of the conference, with the themes representing the overarching conference goals and the tracks providing a consistent framework for the sessions. This intersection of themes and tracks meant attendees interested in management, for example, could attend a session on health care management and organizational improvement for each theme covered during the conference. The conference agenda provides a full listing of workshop topics and titles.
The rationale for the conference developed from the need to value cultural competence in health care as good business practice in an ethnically diverse society. The content stressed practical experience rather than theory. The rationale was based on integrating the clinical and social justice need for cultural competence into a framework that recognizes a highly competitive health care environment focused on market share and health plan enrollment. By respecting the ethical base for culturally competent actions in the health care setting, while addressing how and why such actions could be "good for business," the conference offered a unique learning opportunity for attendees.
Taking the conference from concept to reality required more than a strategy to support the meeting financially; it also was critical that the sources of support reflect the conference vision and theme. To achieve this objective, the conference presenters extended the request for assistance to a health care community defined as broadly as possible. Thus, a plan was established to solicit support from multiple sectors: foundations, the pharmaceutical industry, associations, universities, providers, and the federal government.
In the end, the conference fully achieved the sponsorship objectives. Five regional and national foundations joined three offices within the U.S. Department of Health and Human Services, three health care associations, a pharmaceutical company, and three provider organizations. These supporting organizations also formed the core of the conference advisory group, commenting on the proposed program content and format, assisting in disseminating information about the conference, and providing overall guidance. Most important, the concerted, collaborative effort of the sponsoring organizations came to symbolize the breadth of vested and committed interests embodied in the conference agenda and its overall purpose.
The National Conference presenters and participants reaffirmed the importance of and expanded the growing discourse on cultural competence in health care. Presenters especially focused on articulating the rationale for high-quality health care for culturally diverse populations and on strengthening their efforts to improve the care provided within diverse communities and to individual patients.
The following conclusions drawn from the discussions among the participants and expert presenters reflect the importance of addressing cultural competence in health care, the status of current efforts, and the challenges that remain.
1. The Growing Diversity of American Society: Implications for the Nation’s Health Care System Although cultural diversity has always been a core part of the American story, its evolution at this time is occurring in ways that distinguish it from earlier trends. These differences are evidenced in the sheer numbers, the shifts in primary countries of origin, and the fact that culturally diverse populations and communities extend far beyond the nation’s cities to virtually all parts of America. Each of the world’s 210 nations is represented in the U.S. population, and cultures are blending and merging continually. In fact, the draft U.S. Census for 2000 allows for 66 different categories of ethnic and racial combinations. Furthermore, the racial and ethnic terms we have adopted are becoming less and less meaningful. For example, the term "Hispanic" is becoming less and less relevant, given the great number of Spanish-speaking subcultures represented throughout the country and the inadequacy of using one label to describe them all. The manifestation of these changes has significant implications for government, politics, policy, and health care throughout the United States.
Immigration and diversity are a growing part of the economic engine that drives the United States, especially as the white population ages and as more individuals from diverse backgrounds join the middle and upper classes. Moreover, individual mobility, an ingrained feature of our society, has created diverse communities throughout the nation. As Dr. Harold Hodgkinson, director of the Center for Demographic Policy at the Institute for Educational Leadership, reminded attendees, 43 million Americans change their addresses each year, with seven million moving to a different state. As such, the contention that diversity is found only in inner and coastal cities has not been true for a long time. Today, cultural diversity is increasing throughout the Midwest, suburbs, and small towns of America. These dynamics reinforce the importance of cultural knowledge and training not only for the major teaching hospitals and city providers of care but also for caregivers and communities across the country. This growing diversity affects all aspects of the health care system and warrants action to address the health care needs of all members of American society. 2. Cultural Competence in Health Care and the Role of Government The federal government and state governments in California, Massachusetts, Minnesota, and elsewhere are taking a more active role in assuring high-quality health care for diverse communities. Some states, such as New Jersey, have reviewed their current systems’ relationship to Medicaid populations, including by addressing factors such as patient health beliefs and mistrust of providers among some ethnic groups. California has formalized cultural and linguistic requirements for health plans through an elaborate process developed with input from many sectors–advocates, community members, providers, and others. Federal efforts include introducing Medicare and Medicaid managed care plan regulations in 1998, clarifying civil rights rules with respect to interpreter programs, and detailing specific guidelines and requirements such as the need to use epidemiological data in targeting health education programs. A recent effort to develop national standards on cultural competence may provide clarity for policy makers and providers in establishing appropriate services for diverse populations.
Such efforts merit special consideration because they represent an elevation and specificity related to cultural competence that previously had been absent from state and federal policy. Nonetheless, they also raise many questions about how to ensure that policy translates into high-quality health care services. Definitions of terms (for example, the meaning of "24-hour access" for language services) and a fair balance between community need and provider or plan capacity also need clarification and careful consideration. In addition, there is a continuing need to build capacity to address cultural competence issues at the state level in particular, and to assess and disseminate experiences as they unfold. Perhaps of greatest value would be the expansion of efforts from the few states that are leaders in this area to the vast majority that have done comparatively little in assuring quality health care for culturally diverse populations.
3. Recognizing and Integrating Diversity's Dimensions into the Patient-Provider Relationship
The U.S. population’s increasing diversity can profoundly affect the patient-provider relationship and the clinical encounter. Understanding generalized cultural characteristics at the group level may provide clinicians with a degree of insight into the cultural background of a patient, but providers must be careful not to make assumptions about individual patients. While cultural background obviously shapes an individual patient, so do many other factors, such as gender, sexual orientation, class, education, immigrant status, and familial status. As Dr. Harold Hodgkinson warned, "If I were you and if I had a Hispanic patient, I would never treat them on that basis. I’d want to know what country they came from and I’d want to know how long they’ve been in the United States. If it’s been 30 days that they’ve been here, you’ve got one set of issues. If they’re second generation of an immigrant family, that’s something very different and you have to know those things."
Individual providers and their organizations must be knowledgeable about the patient populations they serve. The predictors of disease and effectiveness of treatments often vary by subpopulation, so effective medical care rests on understanding these differences. However, this task is becoming increasingly complex. In addition to the growing number of cultures present across the United States, rising levels of intermarriage and multi-ethnic children have produced new cultural mixes.
To address their patients’ individual needs effectively, health care practitioners must acknowledge the need for a substantially broader base of information and understanding. Clearly, knowledge of specific genetic predispositions and familiarity with the ways in which individuals from different cultures manifest certain conditions and respond to treatments are paramount to effective care. For example, according to Dr. Risa Lavizzo-Mourey, director of the Institute on Aging at the University of Pennsylvania School of Medicine, the efficacy of medications used to treat diabetes and hypertension, and to support smoking cessation varies by population group.
Practitioners’ understanding of cultural issues must extend to the interpersonal relationship and individual patients’ belief systems, as well. Again, Dr. Hodgkinson provided an example of some of the non-language factors that could impact communication. "High context cultures are people where the words are only a little part of it. The gestures, nuances, the eyebrows, the way people change their pitch and loudness, and how they speak" all affect the patient-provider encounter. In addition, health beliefs related to fatalism and the role of family in medical decisions, and attitudes toward authority all influence the acceptance and course of medical care.
Finally, it is important for providers to recognize the field of health care as a unique culture with its own language, attitudes, behavior, and perspective of others. Understanding this fact and attempting to view the medical system from the patient’s point of view will go a long way toward improving the patient-provider relationship. Moreover, it is important for providers to realize that they bring their personal beliefs, attitudes, experiences and biases to the health care setting.
4. Cultural Diversity and Health Professions Training in the Shadow of Anti-Affirmative Action As the cultural diversity of the United States increases, so too do efforts to expand the pool of health care practitioners from diverse cultural backgrounds. An increase in the number of bilingual/bicultural people in the health professions will result in improved outcomes for patients as well as valuable education for fellow staff.
Individual academic health centers and national organizations such as the Association of American Medical Colleges, seek to increase diversity within the health care professions, viewing this diversity as essential for patient care. Because the vast majority of health care professionals are likely to be treating patients from diverse cultures, knowledge of varied cultural medical beliefs, attitudes, and behaviors is crucial and must be taught at the earliest opportunity in training programs.
Implementing cultural competence in medical and health professions education involves not only adding courses on cultural competence but also showing students how cultural competence impinges on every other course. As Anne Fadiman, author of The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, asserts, medical students must view cultural competence as important to patient care as learning how to use a scalpel correctly.
Professional schools also have recognized the critical role that diversity plays in the educational setting. The presence of people from diverse cultures in the academic setting provides an additional opportunity for students and faculty alike to learn more about individuals from various cultural communities.
In all, there is growing acceptance of the place for a broad and diverse cultural perspective within the health professions workforce. Anti-affirmative action policies, however, have injected great uncertainty into academic medicine’s efforts to achieve greater diversity through medical school enrollment. These decisions, in large part, are resulting in substantial decreases in the number of minorities who are entering the medical field and increasing the disparity in the number of physicians who bring a native cultural perspective to medicine and health care. Without corrective measures or breakthrough innovations in recruitment, this trend likely will continue.
5. Cultural Competence in the Health Care Setting: Emerging Importance, Uncertain Direction
As cultural diversity has gained visibility in the U.S., some providers have developed targeted initiatives such as interpreter programs, recruitment strategies, and workforce training to improve their ability to serve these communities. To date, however, few rules and fewer organizational or system models have been put in place to guide health care providers in addressing cultural diversity. Instead, hospitals, clinics, and others rely on their own ingenuity to develop effective ways to transform organizations into more beneficial providers for diverse populations and communities. Many providers simply are unsure about the value of investing in cultural competence beyond cosmetic actions, perceiving little financial or market benefit in focusing on care for diverse communities and patients.
One of the first steps for many providers is to determine why cultural competence is important for the organization. Social justice or improved health outcomes are the major motivations for many providers. For others, however, business motivations for cultural competence are at least as important. John O’Brien, chief executive officer of the Cambridge Health Alliance, noted that some providers have come to realize, with the growing diversity of their communities, they must adapt to caring for these populations if they are to survive. This becomes more apparent as providers sense inadequacy in what they have done to date. For example, surveys of patients may indicate an underlying mistrust of the system that leads some to choose other providers. Health care organizations also are recognizing the proliferation of state regulations and accreditation requirements that incorporate some aspect of cultural sensitivity into their treatment plans. Still others are considering the costs and benefits of cultural competence, seeing potentially greater adherence to treatment regimens and better outcomes.
The organizational process for addressing diversity frequently requires an introspective examination to identify barriers such as institutional racism, lack of information available in different languages, and lack of staff diversity. Part of this self-examination involves the ability to see cultural competence as a "competitive niche" that gives an organization an advantage. Board and executive management involvement is key to this internal assessment and the external review.
A second step involves developing a strategy to improve knowledge and skills among all staff. Some providers believe that this effort requires a systems approach that extends throughout the organization and into the community. Reaching out to the community is especially critical for gaining trust and for addressing cultural concerns. Bringing the community into the organization through membership on advisory boards, education programs, or cultural representations (e.g., paintings in waiting areas) benefits the providers and patients. Vital to these efforts are both staff and patient education: staff members need to learn about the cultures of those they care for and patients about the system of care and how to negotiate it.
It is important for health care organizations to consider how they can assist clinicians in providing culturally competent care. Specific actions on the part of health care organizations may include:
The third step involves assessing the effectiveness of cultural competency initiatives and staff actions. Such assessments can be conducted at the organizational, division, or department level. Employment of reliable assessment tools, as part of this process, is essential. Although these tools are becoming available, many are not well known and most have not been widely disseminated. Cultural competence assessment tools may gain credibility as the number of organizations using them increases and the value of the results for patients and health care settings is affirmed.
6. Managed Care Plans and the Challenge of Cultural Competence
In today’s competitive managed care marketplace, with its focus on the financial margin, cultural competence can be a "difficult sell." Moreover, there are characteristics common to the design and requirements of managed care participation that may be inimical to effective care for culturally diverse patient populations. For example, shorter office visits allow less time for providers to take detailed histories and negotiate cultural issues in treatment planning. Also, provider choice may be restricted in plans with few professionals who speak specific languages or are knowledgeable about patients’ cultural characteristics.
Like other health care providers, managed care organizations must embrace a business and outcomes rationale to justify cultural competence as a priority. They also may be able to use expertise in serving diverse communities as a way to differentiate themselves from other plans. In states requiring increasing accountability for serving diverse populations, managed care organizations’ attention to how they address these populations’ needs may facilitate adherence to related requirements. One issue gaining increasing attention is risk management, since the liability potential of cultural incompetence can be a strong incentive for change.
If managed care organizations are serious about improving their marketing, services, and effectiveness in caring for culturally diverse enrollees, they likely will have to revisit with the board, administration, and staff, the fundamental goals of their organization to assure that linguistic and cultural competence becomes a central component of their strategy. Without this acceptance, cultural competence is likely to "get lost" among other priorities.
The clinical, service delivery, education, government, and community priorities outlined at the conference demonstrate a broad-based concern about the future of health care for culturally diverse communities. The conference offered the opportunity to consider the actions that each perspective can use to progress in this area. However, underlying the discussion is a recognition that society is of two minds: professing a desire to recognize diversity, yet sometimes displaying a reluctance to invest in services that will properly address it.
Guaranteeing high-quality care for culturally diverse populations must remain a primary goal for health care in the United States. Too often the provider community’s actions, dictated by the market and the bottom line, treat cultural competence ambivalently or as a trivial part of its "business." One difficulty is that organizations have little guidance in implementing initiatives. Similarly, many physicians are equally challenged, especially in the context of limited time and resources. Finally, society remains undecided about the importance of cultural competence as well, as evidenced by the growing success of anti-affirmative action initiatives and restrictions on services for immigrants and refugees.
Proving the value of culturally competent care, by demonstrating its effectiveness, is critical to the process of gaining wider acceptance. The challenge that lies ahead is to craft strategies for integrating linguistic and cultural competence as essential elements of the American health care agenda. |
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| As with the rest of DiversityRx, this section
is a work in progress and we welcome information on other efforts, programs,
and reports that will expand upon the information offered here. Please let us know if you have other examples
to include here. | ||||||
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DiversityRx is sponsored by: |
 The National Conference of State Legislatures |
 Resources for Cross Cultural Health Care |
 Henry J. Kaiser Family Foundation | |||
