Cultural Clues



The recent flurry to train health care providers for underserved areas has policymakers asking whether we need a more culturally competent workforce.

By Melissa Hansen

For many state policymakers, having an adequate health care workforce is not just about numbers. It’s about having doctors, nurses, technicians and assistants who can connect with patients in a way that improves their health and avoids costlier conditions.

The recent flurry of both state and federal activity to train health care providers for under-served areas has opened the door to policymakers who want a more culturally competent workforce—providers who recognize when cultural differences matter and can adapt their ways of communicating with patients accordingly. It sounds simple, but it’s not.

Take, for example, an overworked doctor who diligently explains to a young immigrant patient exactly when and how she needs to take her medication, not realizing that his efforts are ineffectual because he really should be talking to the grandmother who controls and distributes all medicines in the household.

Or it could be an elderly gentleman who nods enthusiastically as a nurse quickly reviews instructions on which pills to take for each of his ailments, but who never mentions that his failing eyesight prevents him from distinguishing one bottle from another.

It’s clear that the provider-patient relationship—and the communication between them—is very important.

In fact, a lack of understanding between providers and patients is thought to contribute to the estimated one-third of patients who do not adhere to prescribed medication regimens. This can lead to serious complications and more hospitalizations, that in turn, ends up costing the U.S. health system an estimated $100 billion to $290 billion every year.

The idea is that, until providers truly understand their patients’ distinct cultures, languages, home lives and values—being “culturally competent” in wonk-speak—they will not be able to adequately and clearly communicate with them about their health or needed health care.

Cultural competence basically derives from the knowledge, skills and attitudes needed to help individual health care providers or teams understand—for an individual patient—what cultural factors might affect that patient’s care and to use that knowledge to tailor medical instructions and guidance. It involves avoiding stereotyping and over-generalizing, and includes recognizing how personal beliefs, values and assumptions may guide communications and interactions with patients.

What Have States Done?

Having a more culturally competent workforce is a goal described in the 2002 Institute of Medicine’s report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” In it, the health care community called for all health care providers to participate in “cross-cultural education.”

Efforts to improve the cultural competency of the health care workforce have been part of the larger effort to reform the health care system in general in some states.

The Oregon Legislative Assembly first addressed cultural competency education in 2011 through the Health Systems Transformation legislation, which identified this type of education as “essential to eliminating health disparities.” After consulting with stakeholders—including health licensing boards, health professional associations, community-based organizations, and advocacy organizations, in 2013, Oregon lawmakers passed legislation to require this continuing education as a condition of licensure by 2017. The legislation also directed the state’s Health Care Authority to report to the legislature on its effectiveness.

Five other states have laws requiring certain providers to take cultural competency education. Although the specifics of these laws differ, proponents of increased cultural competency hope that, over time, these efforts will improve the doctor-patient relationship, increase patients’ adherence to treatments, reduce health disparities and, ultimately, improve patients’ health.

Can You Teach That?

The definition of cultural competency has evolved since the 2002 Institute of Medicine report was published. So, too, have methods of training health care professionals to provide culturally competent care.

In the early 2000s, many programs used an approach that taught about the attitudes, values, beliefs and behaviors of specific cultural groups. Imagine a doctor carrying a “cheat sheet” that details how to address different ethnic or religious groups. Many providers felt this approach relied too heavily on stereotypes and placed too much emphasis on “political correctness,” not actual, effective connections and communication with patients.

Today, most experts in the field agree that cultural competency education should encompass teaching providers to be aware of their own cultural beliefs and that their patients and colleagues might hold different beliefs. It also should give providers skills that help them use their new understanding to be responsive to the health needs of their patients.

What About Community Health Workers?

Some states are looking to improve culturally competent care by including a relatively new type of professional—the community health worker—as an integral part of the team of professionals who provide services under Medicaid.

Community health workers go by a number of names—promotoras, village health workers, health aides, community health promoters and lay health advisers. Regardless of their titles, they often are recruited from the communities they serve and trained on the culture of medicine and health systems—they learn the language of providers and how to navigate the health system.

On any given day, community health workers might direct clients to appropriate services, help arrange transportation and provide emotional, social support and, with training, monitor blood glucose levels, measure blood pressure, and offer translation services. In short, they help bridge cultural divides that separate patients from health systems.

Community health workers serve as cultural—and sometimes linguistic—interpreters. Legislators are able to pave the way for community health workers to be part of provider teams by taking advantage of a new federal regulation that allows state Medicaid programs to directly reimburse community health workers if they so choose. Several states also are developing educational and training standards for these providers.

Minnesota legislation allows trained community health workers serving under an authorized Medicaid provider—such as a doctor or advanced practice registered nurse—to receive Medicaid reimbursement for educating patients and coordinating their care.

The law passed after a coalition of educational institutions, health care providers, government agencies, businesses, foundations and nonprofit groups created a statewide standardized training program and reported the potential Medicaid cost benefits to the Legislature. As of 2009, more than 80 community health workers in Minnesota had enrolled as Medicaid providers.

Do These Efforts Really Matter?

It’s a big question, with no easy answer. In short, there is not enough information to say for sure. But a look at the data acquired so far shows reason to believe that efforts to train providers in cultural differences improves their care. If nothing else, patients perceive their quality of care improves when providers are more skilled at reading their cultural clues. A few studies suggest, however, that actual cultural competency skills—and not just a perception of skills—improve care and can reduce costs.

New Mexico, for example, found that, between 2007 and 2009, managed care Medicaid patients supported by community health workers used emergency rooms, prescription drugs and nonessential doctor services less often.

In a systematic review of several cultural competence training programs by the Agency for Healthcare Research and Quality, researchers found strong evidence that cultural competence training increases the knowledge of health care providers and good evidence that it also can improve their attitudes and skills.

Each program was designed differently, however, perhaps reflecting the complexity of creating these training programs. From the program evaluations, it is difficult to conclude which kind of training is the most effective in achieving a particular desired result and even tougher to draw conclusions on which specific types of knowledge, attitudes or skills are affected by cultural competence training.

For many, it makes sense that, when health care professionals communicate effectively and provide high-quality care to patients from diverse backgrounds—race, ethnicity, gender, age, sexual orientation, disability, religion, home country and socio-economic status—patients’  health improves and disparities decrease.

“Cultural competency training is an important component in addressing disparities in health and health care,” says Dr. Robert C. Like, director of the Center for Healthy Families and Cultural Diversity at Rutgers’ Robert Wood Johnson Medical School.

“We are slowly beginning to develop a body of evidence that shows this training does help reduce disparities.” But, he says, “it is still an area of research. As better guidelines and assessment tools for these educational programs are developed, it will become easier to evaluate their impact and effectiveness. It will also be important to couple these educational efforts with transforming our health care organizations and service delivery systems to provide culturally responsive and effective care to our increasingly diverse population.”

Melissa Hansen is an NCSL program principal who covers minority health and Medicaid topics.

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