Addressing Cultural Competence as an Element of Health Literacy and Patient-Centered Care

Laura M. Cascella, MA, CPHRM

Inadequate health literacy is a well-known communication issue facing patients and their healthcare providers. Patients’ inability to properly receive, process, understand, and act on health information can result in a host of problems, including uninformed decision-making, nonadherence, poor outcomes, and lack of trust in the healthcare community. Inadequate health literacy also can lead to misunderstandings and mismanagement of patient expectations, which can increase liability risk for healthcare providers.

Strategies for addressing health literacy often target patient comprehension and involve speaking clearly, avoiding jargon, using words that patients understand, reducing redundancy and ambiguity, and so forth. Although these strategies are crucial, another critical element of effective communication — cultural competence — is overlooked at times.

Cultural competence and health literacy sometimes are viewed as separate issues, but a patient’s beliefs, values, and experiences can significantly shape how the patient perceives and understands health information — which, in turn, influences health literacy. The Institute of Medicine (IOM) report Health Literacy: A Prescription to End Confusion astutely notes: “A definition of health literacy that does not recognize the potential effect of cultural differences on the communication and understanding of health information would miss much of the deeper meaning and purpose of literacy for people.”¹

Further, just as poor health literacy can result in suboptimal outcomes, cultural differences between patients and providers can lead to misconceptions, interpersonal conflicts, contrasting views about health conditions and treatments, and poor outcomes.²

Because of the critical and consequential nature of cultural competence, healthcare providers should recognize it as a distinguishing feature of patient-centered care and a vital component of developing an effective communication process with patients. Yet, the expectation that healthcare providers can develop an extensive understanding of, and proficiency with, numerous and multifaceted cultures is impractical — particularly for providers who serve diverse patient populations. Beyond that, culture is dynamic and people are continually shaped by their personal experiences and the convergence of various cultures.⁴ Thus, two people from the same ethnic or religious background can have vastly different understandings and perceptions of health information based on their geographical locations, family influences, personal experiences, value systems, societal norms, and many other factors.

Healthcare providers cannot realistically account for all of these variances, but they can work toward a better understanding of culture and its role in patient care and outcomes. Incorporating strategies into practice that promote cultural literacy and health literacy will help establish the framework for a culturally competent and patient-centered model of care. Some examples of strategies and best practices to consider include the following:⁵

• Use a self-assessment to better understand your own attitudes, beliefs, values, and practices. A self-assessment can help gauge knowledge and skills associated with cultural competence and identify areas for improvement. Georgetown University’s National Center for Cultural Competence offers information and tools related to self-assessment.
• Participate in education and training about the meaning of culture and how it affects quality of care and healthcare delivery. Encourage other clinical and nonclinical staff members to participate in cultural competence training as well, and consider including it as part of new employee orientation and periodic in-service training.
• Be aware of health disparities and discrimination affecting various populations, as well as common types of implicit and explicit bias that can affect clinical judgment and reasoning.
• Respect patients’ personal values, experiences, preferences, and expressed needs. Discuss with patients their understanding of and experience with illness, and acknowledge patients’ feelings and concerns.
• Identify ways to build trust, establish rapport, and find common ground with patients even if you have differing perspectives. Be aware of how some patients’ cultural backgrounds or personal experiences might have cultivated distrust in the healthcare system or healthcare profession.
• With permission, include patients’ families members and significant others in discussions about health conditions and treatment. These individuals can help support patients’ understanding of health information and adherence to care plans.
• Consider coordinating with traditional healers to support patient care for patients whose primary source of care is not Western medicine. These collaborations can help bridge cultural gaps and build patient trust.
• Ask patients about what they perceive as barriers to their care and possible ways that the care team can help address these barriers and develop realistic goals and treatment plans.
• Use techniques and methods that can aid in cross-cultural communication and help determine whether patients fully understand health information. Examples of such techniques and methods include motivational interviewing, the LEARN model, the explanatory model, the RESPECT model, and the teach-back technique.
• Make patients aware of interpreter services and auxiliary aids, and use these resources to help communicate effectively with patients who have limited English proficiency or disabilities. (Note: Although including families and significant others in patient care is a strategy for improving cultural competence, these individuals should not be used as interpreters. Learn more about acceptable language assistance services.)
• Be aware that words can have no meaning or different meanings in other languages. A straight translation of words might not make information culturally relevant, meaningful, or accurate (e.g., the word “once” in English means one time, but “once” in Spanish means eleven). Thus, finding qualified interpreters who understand cultural variations is essential.
• Provide patients with culturally appropriate and easy-to-understand printed materials (e.g., educational brochures and follow-up care instructions) and multimedia. Offer resources in languages that reflect your patient population.
• Make efforts to view every patient as a unique individual. Although cultural values are important considerations when communicating with patients and planning their care, a narrow focus on these aspects can result in stereotyping and depersonalization.
• Identify qualified people and resources within your organization and externally that can help improve communication with culturally diverse patients and serve as an informational resource for staff members.
• Consider ways to address health disparities and foster cross-cultural knowledge sharing, such as implementing an advisory committee with patients, family members, and community members from diverse backgrounds.

American culture, at its heart, is diverse. People of varying nationalities, ethnicities, religions, and social backgrounds — and who have a range of preferences, beliefs, values, and experiences — live in the United States and participate in its institutions and systems, including healthcare.

This diversity calls for (a) recognition that patients have varying needs in relation to communicating and understanding health information and navigating the complex health system, (b) a commitment to developing a better understanding of culturally competent care, and (c) an approach that implements strategies and best practices that support a patient-centered approach to communication and comprehension.

For more resources on this topic, see MedPro’s Risk Resources: Health Literacy and Cultural Competence.

Endnotes

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¹ Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: The National Academies Press. https://doi.org/10.17226/10883

² Lie, D., Carter-Pokras, O., Braun, B., & Coleman, C. (2012). What do health literacy and cultural competence have in common? Calling for a collaborative health professional pedagogy. Journal of Health Communication, 17 Suppl 3(0 3), 13–22. doi:10.1080/10810730.2012.712625

³ Ibid.

⁴ Institute of Medicine. (2002). Speaking of health: Assessing health communication strategies for diverse populations. Washington, DC: The National Academies Press.

⁵ Institute of Medicine, Health literacy: A prescription to end confusion; Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of the National Medical Association, 100(11), 1275–1285. https://doi.org/10.1016/s0027-9684(15)31505-4; U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). National standards for culturally and linguistically appropriate services (CLAS) in health and health care. Think Cultural Health. Retrieved from https://thinkculturalhealth.hhs.gov/clas/standards; Health Research & Educational Trust, Institute for Diversity in Health Management. (2011, July). Building a culturally competent organization: The quest for equity in health care. Retrieved from www.hret.org/quality/projects/resources/cultural-competency.pdf; Lotts, L. (n.d.). What is culturally competent care? Nurse Practitioner Schools. Retrieved from www.nursepractitionerschools.com/faq/what-is-culturally-competent-care/; Sutton, M. (2000, October). Cultural competence. Family Practice Management, 7(9), 58-60.

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