Cultural Competency: Current Practice

Cultural competency is essential to working in healthcare in such a diverse world. There are approximately 8 billion people in the world today (Morse, 2023) who speak over 7,000 languages (Ethnologue, n.d.). The world's population is becoming increasingly mobile, resulting in the blurring of traditional language, racial, and ethnic lines. Over two-fifths of the United States population identified as a racial or ethnic minority in the 2020 census (Jensen et al., 2021). This population is not unique to the United States; more than 50 countries have reported that greater than 15% of their population is accounted for by immigrants (Kaljee & Stanton, 2011). Healthcare facilities have a responsibility to provide staff that reflects their service area. They also have a responsibility to ensure staff are educated on cultural issues relevant to their service area.

Cultural competency goes beyond language to encompass important concepts such as values, social factors, beliefs, and much more. It is important that healthcare providers practice cultural competency in care, as it can increase patient satisfaction as well as foster trust and collaboration. This course will explore fundamental topics related to culture and cultural competency, providing information on communication strategies, models of care, and practical approaches to delivering care that is culturally competent.

Before defining culture and cultural competency, it is important to provide definitions for common words used when discussing culture.

Race: This is a social construct and term that has been used to group or classify individuals. These classifications have been used to identify and often marginalize people across the globe. Our physical appearance, cultural backgrounds, and social factors help classify our race (National Human Genome Research Institute, 2025). According to the United States Census Bureau (2024), there are five major races, and they include:

• White: Those with origins in Europe, North Africa, or the Middle East.
• Black or African American: Those with origins in Africa.
• American Indian or Alaskan Native: Those with origins in North, Central, and South America with community attachment and/or tribal affiliation.
• Asian: Those with origins in the Far East, Southeast Asia, and the Indian Continent, including China, Japan, India, Cambodia, Korea, Vietnam, Pakistan, Thailand, and the Philippines.
• Native Hawaiian or Other Pacific Islander: Those with origins in the Pacific Islands, such as Hawaii, Guam, and Samoa.

Ethnicity: This term refers to the social group that an individual identifies with or belongs to and is often made of factors that include a proper name that expresses the community, common ancestry, shared memories that are often historical, elements of a common culture, including language and religion, a sense of solidarity, and a link to a homeland. Ethnic groups are connected through cultural unity and a sense of identity. It is important to note that components of ethnicity can evolve or change over time (EBSCO Information Services, 2024).

Diversity: This term encompasses the inclusion of individuals from various racial, ethnic, and social backgrounds, as well as sexual orientations, genders, ages, experiences, and opinions (Oxford University Press, 2021; Servaes et al., 2022). It is often used to describe or encompass individual and unique differences (The George Washington University, n.d.).

Equity: This refers to justice and fairness. Equity, different from equality, means acknowledging and adjusting to imbalances (National Association of Colleges and Employers, n.d.). Equity, resources, and opportunities are made available to promote equality and fairness. Differences and divergences are included and should be celebrated (Jurado de Los Santos et al., 2020).

Inclusion: This refers to an active intention to engage with diversity (The George Washington University, n.d.). This requires an intention to address barriers, such as challenges or biases, to make others feel represented and accepted. Inclusion can enhance collaboration between patients, providers, and coworkers.

Culture: This is focused on how groups of people understand their history, share their values, and engage in similar behaviors while sharing a similar worldview. Culture is not necessarily equivalent to racial and ethnic groups. It may reflect a similar socioeconomic background, religious background, sexual orientation, or even occupation, such as the military culture or nursing culture (Raeff et al., 2020). People who share a cultural belief are organized into groups, such as a family, or can be grouped by other identifiers, such as gender, age, or common interests.

Cultural competency: Numerous definitions of cultural competency exist, and it has evolved over time. Generally, it refers to a set of values, behaviors, attitudes, and beliefs that enable effective cross-cultural communication. It represents the ability to do the following (National Center for Cultural Competence, n.d.):

• Value similarities and differences
• Have an awareness of differences and respond appropriately to them
• Conduct a cultural self-assessment
• Institutionalize cultural knowledge
• Adapt to cultural diversity
• Respect the practices and beliefs of others (whether you share in these or not)
• Investigate, assess, and mitigate personal biases
• Communicate, even in the place of language or communication barriers
• Practice cultural competency while providing care
• Advocate for diversity, equity, and inclusion

Cultural competency is the ability of the healthcare provider to comprehend the beliefs and values of specific religious, racial, ethnic, and other social groups. Healthcare in the 21st century should and must be practiced in a culturally competent manner. Health-related cultural beliefs can be seamlessly integrated into the care of patients (Kaljee & Stanton, 2011). The National Quality Forum (2008) defines cultural competency as "the ongoing capacity of healthcare systems, organizations, and professionals to provide diverse patient populations with high-quality care that is safe, patient and family-centered, evidence-based, and equitable."

Cultural humility: This is a tool that can be used to embrace self-reflection to learn about one's internal beliefs and thoughts that may influence cultural identity. It is an ongoing process that requires critical evaluation. Cultural humility also involves self-awareness and self-critique (Yeager & Bauer-Wu, 2013). It also requires healthcare providers to mitigate power imbalances by valuing others' voices, perspectives, and ways of life.

A cultural assessment needs to be done for each individual. Skills in assessment and interventions are also important in the care of culturally diverse patients. Do not depend on standard knowledge of the cultural norms of the group the patient seems to fit. Inadequate cultural assessment can erode the patient's trust in the healthcare provider's credibility, leading to poor health outcomes and noncompliance (Kaljee & Stanton, 2011).

Evaluate cultural information that is relevant to the care of the patient. This assessment includes asking open-ended questions and allowing for the expression of the situation. Asking the patient what they think about the illness or injury and how it will impact their lives can reveal cultural perceptions. The healthcare provider can alleviate fears and form a partnership with the patient, which will enhance the outcome.

Components of a cultural assessment include the following, though this list is not all-inclusive (Narayan & Mallinson, 2022):

• Basic demographics
• Cultural identity and background
• Preferred language
• Communication style
• Family dynamics, including role and structure
• Beliefs and practices, including beliefs around health concepts and religion
• Dietary preferences
• Social determinants of health
• Social and community involvement

Besides a cultural assessment, healthcare providers should participate in implicit bias testing. Given the unconscious nature of implicit bias, directly asking providers about their own biases through a self-report survey is not recommended. Two common methods used to assess implicit bias are Implicit Association Testing (IAT) and the Assumption Method (AM).

IAT is a computer-generated online testing method that "measures implicit associations between participants' concepts and attitudes across a wide range of domains: race and ethnicity, disability, sexuality, age, gender, religion, and weight" (Project Implicit, 2021). AM is a clinical vignette-based testing method that measures differences across participants' responses (FitzGerald & Hurst, 2017). Priming is another way to measure reactions related to inherent and subconscious attitudes. The Semantic Priming Test uses words, and the Visual Priming Test uses images. With these tests, a prime (word or image) is produced on a screen for a specific period before the target is shown. The participant is told to focus on separating the targets (Ocejo & López, 2024). Affect Misattribution Procedure (AMP) is another test used to measure and evaluate implicit bias (Payne et al., 2005).

These are just some examples of common tests used to measure and evaluate implicit bias. There are others; however, they may not be commonly used, and their validity has not been verified.

Scenario/situation/patient description

Amina is a 68-year-old female who immigrated from Ethiopia in the past year. She presented to her appointment with complaints of headaches, dizziness, and increasing fatigue. She had limited proficiency in the English language. Amina's daughter, Sarah, accompanied her to the appointment and acted as her interpreter, as she spoke English proficiently. Amina did not make a lot of eye contact when talking with the staff, especially if the staff were male. Her responses were very brief, or she would nod slightly to answer a question.

While talking with Amina and Sarah, it was found out that Amina does not consistently use her medication that was prescribed for high blood pressure. Her previous medical records were obtained, and there was mention of missed follow-up appointments and missed diagnostic scans. In the notes and summaries after the visits, the provider mentioned noncompliance. It also appears that Sarah has acted as the interpreter during each visit, and no formal interpreter has been used.

The nurse practitioner, Ama, who has been working on strengthening her cultural competency skills, decided to approach this situation in a different manner. Rather than relying on Sarah to be the interpreter, Ama requested that a certified interpreter be present for the exam and conversations. While waiting for the interpreter, Ama decided to search for medical practices in cultures in Ethiopia.

Once the interpreter became available, it was found that Amina speaks Amharic fluently. She let the interpreter know that she struggles to understand her diagnosis of hypertension. After discussing her diagnosis with a relative back in Ethiopia, she began using various herbal remedies instead of taking her prescribed medication for hypertension. It is also extremely uncomfortable for Amina to discuss personal medical conditions with males. Now that Ama has more of a holistic view of Amina's situation, it is clear that what is labeled as noncompliance is actually a linguistic barrier.

Intervention/strategies

There are many different interventions and strategies that Ama can employ here. First, she will be using a professional interpreter to ensure there is accurate and effective communication through this visit. Also, any materials or documents that are printed will be in the English version, as Sarah has requested a copy, and in the language in which Amina is fluent. Using a teach-back method here is appropriate; this would ensure that Amina and Sarah understand what Ama is trying to convey.

A cultural assessment should also be performed. A culturally sensitive assessment tool should explore the preferred language, roles of the family and community, decision-making practices, previous interactions with other providers in Ethiopia and America, and beliefs related to her diagnosis, illness in general, and healing. These are only some of the topics that will be covered during the cultural assessment. After the cultural assessment was performed, it was revealed that Amina would prefer to involve only Sarah in her medical discussions, she prefers female clinicians, and values both traditional and holistic practices.

Other methods to incorporate include collaborative care planning. Ama should integrate traditional and holistic measures where appropriate. This can be done by exploring herbal remedies that would not interfere with the prescribed antihypertensive. Also, Ama should work to foster a trusting relationship that provides psychological safety. This could involve sitting at the patient's eye level, not asking questions too quickly, acknowledging the challenges and obstacles of immigrating to America, providing ample time to answer questions, and, where possible, ensuring a female provider or nurse is caring for Amina. For system-level support, an alert is put in Amina's chart to ensure others can see her preferred language, preferences, cultural considerations, and the need for an interpreter.

Discussion of outcomes

At her follow-up, Amina's hypertension improved significantly over the last three months. Her blood pressure decreased after Amina consistently took her antihypertensive and followed Ama's advice about which herbal remedies to avoid. She saw a significant reduction in her headaches, fatigue, and dizziness. Her attendance at appointments and scans improved, as did her satisfaction and ability to ask questions related to her diagnosis; the interpreter played a significant role in this. Amina now kept a blood pressure log and felt more confident in her ability to manage her high blood pressure. At her follow-up appointment, Amina mentioned feeling respected and heard, and she valued that the provider took time to learn about her preferences and cultural beliefs.

Strengths and weaknesses

There were many strengths and weaknesses associated with this case study. Strengths included the following:

• Effective communication with the interpreter. This fostered patient safety and decreased reliance on Sarah for information.
• A cultural assessment was performed. This explored cultural beliefs and preferences to gain a more holistic understanding of Amina. This also decreased the assumptions of noncompliance.
• Patient-centered collaboration. This case study showed an improvement in patient satisfaction and the patient's diagnosis through patient-centered collaboration.
• System-level awareness. Highlighting the patient's needs and preferences will ensure that other healthcare providers are aware of important concepts, such as the patient requiring an interpreter.

There are also weaknesses associated with this case study, and they include the following:

• Late recognition of the linguistic barriers Amina was facing. If an interpreter had been used at previous visits, the patient may have had an improved understanding of her diagnosis earlier.
• Systemic gaps related to cultural and linguistic barriers. 
• Previous providers used family members as interpreters.

Leininger's Cultural Care Diversity and Universality Theory and the Sunrise Model

Most facilities have a standard tool to use as a model of care. Many tools are based on Madeleine Leininger's theory. Leininger's theory is founded on the idea that cultural heritage and customs are important to each group. Leininger's Cultural Care Diversity and Universality Theory and the Sunrise Model, which emerged from the theory, initiated the revolution in defining cultural care and utilizing cultural care concepts in the nursing assessment process. The Sunrise Model utilizes Leininger's Culture Care Diversity and Universality Theory components, which focus on patient care in a global environment and are multifaceted, incorporating the culture's characteristics in an interdependent relationship (Leininger, 2002).

It is imperative that healthcare providers understand these customs and can care for each patient individually to preserve the cultural atmosphere. This level of care translates into transcultural patient care.  Several models of care were developed, including the Giger and Davidhizar Transcultural Assessment Model and the Purnell Model for Cultural Competence.

Giger and Davidhizar's Transcultural Assessment Model

Giger and Davidhizar's Transcultural Assessment Model is based on six data collection areas (Giger & Haddad, 2021). The model centers on the idea that, although cultures differ in their characteristics, they share fundamental factors.

• Communication: What language is spoken? How is silence used? Notice the pronunciation of words. What non-verbal forms of communication are used?
• Space: What is personal space? Notice body movements during conversations.
• Social Organization: Note gender and sexual orientation, geography, socioeconomic status, ethnicity, family role, religion, age, and life cycle status.
• Time: How is time used? How important is time? Is there a greater emphasis on the past, present, or future?
• Environmental controls: What are current health practices? What is the definition of health and illness?
• Biological variations: Physical dimensions, genetic susceptibility to disease, nutritional preferences, social support, and coping structure.
• Cultural uniqueness: Place of birth, race, and length of time in the country.

The Purnell Model for Cultural Competence

The Purnell Model for Cultural Competence is an assessment tool used in primary, secondary, and tertiary care. The model has its roots in biology, anthropology, sociology, economics, geography, political science, pharmacology, nutrition, communication, family development, and social support (Purnell, 2002). Concepts from each discipline are reflected in the domains used in the model. It is conceptualized as a circle, with society being the outer ring, community the second ring, family the third ring, and the inner ring is the person. The Purnell Model comprises 12 domains that serve as guides for assessment. These are (Purnell, 2002):

1. Heritage: Origin, residence, economics, topography, politics, education, occupation.
2. Communication: Language, dialects, time, names, touch, facial expression, body language, spatial distancing, volume, tone, eye contact.
3. Family role and organization: Structure, gender, roles, child-rearing, social status, roles of children, and older adults.
4. Workforce: Language barriers, autonomy, dominant culture, secondary culture.
5. Biocultural ecology: Biological and physical characteristics.
6. High-risk behaviors: Safety, alcohol, and drug use.
7. Nutrition: Common foods, rituals, limitations, and health promotion.
8. Pregnancy and child-rearing: Fertility practices, views on pregnancy and child-rearing, birthing, and postpartum.
9. Death: Rituals, bereavement.
10. Spirituality: Religion, the meaning of life, prayer, spirituality.
11. Healthcare practices: Traditions, responsibility for health, self-medication, rehabilitation, beliefs, barriers.
12. Healthcare practitioner: Perceptions, folk practices, gender, and healthcare status.

The model is based on the assumption that all healthcare providers need the same information. The assessment is based on four factors of how the person functions in each of the following areas: global society, family, personal practice, and health practices. Furthermore, it is assumed that all cultures share similar core components, but each culture has specific variations that can evolve over time. The model also assumes that providers understand the importance of culture in the assessment and care of each patient.

Campinha-Bacote Model of Cultural Competence in Healthcare Delivery

Another model that deserves attention is the Model of Cultural Competence in Healthcare Delivery by Campinha-Bacote. There are five assumptions associated with this model (Campinha-Bacote, 2002).

1. Cultural competence is not one single event, but an ongoing process.
2. There are five constructs associated with cultural competence: Cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire.
3. There is often more variation within ethnic groups than across ethnic groups.
4. Healthcare providers' levels of cultural competence are directly related to their ability to deliver culturally responsive care and services.
5. Cultural competence is vital and essential in providing effective and culturally responsive care to ethnically and culturally diverse patients.

The five constructs associated with this model are important to define and incorporate into practice (Campinha-Bacote, 2002).

• Cultural awareness: This involves self-examination and self-reflection of one's own professional and cultural background.
• Cultural knowledge: This is the active process of obtaining information and education about diverse ethnic and cultural groups.
• Cultural skill: This is the ability to gather important cultural information related to a patient's presenting symptom or problem, as well as the ability to perform a physical assessment that is culturally based.
• Cultural encounters: This is the process where the provider is encouraged to actively and directly engage in interactions that are cross-cultural with patients who are from diverse cultural backgrounds.
• Cultural desire: This is the healthcare provider's motivation to want to engage in the process of developing cultural awareness, knowledge, skills, and encounters.

Other models

There are many other models that providers can use for guidance or incorporate into care. Some of these models are specific to disadvantaged populations, such as those experiencing poverty or mental or physical impairment. Other models are motivated by race and ethnicity. They are used to train providers, as a practice tool for clinical encounters, or as a framework for healthcare systems.

Now that culture has been defined, it is time to review specific cultural and personal variables that may be important to patients.

Religion

Religion is an organization that shares beliefs and practices. Spirituality is a person's sense of connection to something bigger than themselves. Individuals within the same religion may have different beliefs and practices (Jensen, 2021).

It is important to recognize the many different religions that are practiced today. The following list is not all-encompassing, as many other religions and practices exist.

Buddhism

This originated in South Asia; it is one of the world's largest religions. In Buddhism, individuals believe that life cycles through a period of suffering and rebirth. The goal is to achieve a state of nirvana, or total enlightenment. Buddhists do not believe in a god or type of deity but believe in supernatural beings that can aid or hinder them on their paths to nirvana (National Geographic Society, 2023). Buddhists also believe in four noble truths, which include the following (Aich, 2013):

1. Life is full of suffering (Duhkha): Examples of suffering include disease, death, old age, sorrow, and despair.
2. The cause of suffering (Duhkha-samudaya): Attachment is the cause of suffering. Attachment, derived from the word trishna, is associated with or translated from craving, thirst, clinging, desire, and lust. Attachment is also associated with dvesha, or hate and avoidance, as well as avidya, or ignorance.
3. Stopping suffering (Duhkha-nirodha): This is where nirvana comes in; working through life without attachment can help Buddhists achieve nirvana.
4. Extinguishing suffering (Duhkha-nirodha-marga): This represents another path, often referred to as marga, that Buddha called the Eightfold Path to liberation. This path can enable a Buddhist to be free from misery.

Christianity

With over 2 billion practitioners, it is the most widely practiced religion. At the center of this religion is Jesus Christ and His birth, death, and resurrection. Christians, followers of Christianity, are considered monotheistic, believing in only one God. Christians who believe God sent Jesus to save the world also believe Jesus will return for the Second Coming. This religion is outlined in the Holy Bible (History, 2025a).

The three elements of God include the following:

1. The Father
2. The Son
3. The Holy Spirit

These three exist as one God and are referred to as the Holy or Blessed Trinity (Stanford Encyclopedia of Philosophy, 2025).

Hinduism

This has been identified as the oldest religion and is sometimes referred to as Sanatana Dharma. Hinduism, considered a natural religion, is practiced by Hindus. It is a natural and indigenous religion with diverse traditions and philosophies. All beings, including organisms, are Divine manifestations and have equal worth. The Divine can do the following:

1. Manifest in different ways.
2. Be worshipped in many ways.
3. Speak and relate to individuals in different ways.

Hindus also believe in pluralism, which allows for diversity. Both alike and unlike can connect through unique and varying characteristics with the Divine and on their own. Pluralism allows for increased religious and social freedom (Hindu American Foundation, 2022).

Islam

The second largest religion is Islam. Like Christianity, this is considered a monotheistic faith, only believing in one God named Allah. Followers of Islam, also known as Muslims, try to live in complete submission to Allah. Muslims follow the Koran, believing there will be a judgment day and that life exists after death (History, 2025b).

There are five pillars to the Islamic faith, and they include the following:

1. Shahada: This means the profession of faith.
2. Salat: This means prayer, which occurs five times throughout the day and is performed while facing Mecca. Prayer is often performed in a certain way, such as on a rug or mat.
3. Zakat: This involves the donation of income to those who are in need.
4. Sawm: This centers around fasting. During Ramadan, which occurs in the ninth month of the Islamic calendar, Muslims observe fasting during daylight hours.
5. Hajj: This means pilgrimage. If Muslims are able, which is dependent on their financial and health status, they should at least once travel to Saudi Arabia to the holy city (Canby, 2019).

Jehovah's Witnesses

This religion is newer, starting in the 19th century. Jehovah's Witnesses do not believe in the Trinity; they believe Jesus is a separate entity and that the Holy Spirit refers to the power of God. Kingdom Halls serve as a gathering center for Jehovah's Witnesses (Schmalz, 2023). While some of their beliefs are similar to those of Christians, such as living morally by the Bible and aiming to live honestly, they hold unique beliefs and perspectives. For example, Jehovah's Witnesses do not observe Christmas or non-religious holidays, such as birthdays. Jehovah's Witnesses' beliefs also prevent them from receiving blood transfusions (Pavlikova & van Dijk, 2021).

Judaism

This is another older religion that follows monotheism, believing there is only one God. Abraham is the founder of Judaism. Followers of Judaism are referred to as Jews. Jews, along with rabbis (their spiritual leaders), worship in places called synagogues. Followers of Judaism also follow the sacred text called the Tanakh. The Torah, the first five books of the Tanakh, is more well-known and provides a guideline for Jews to follow (History, 2025c).

There are many other religions that patients may practice, including Sikhism, Jainism, Cao Daiism, and many others.

Age

There are clusters of people within a cultural group who hold personal beliefs that differ from those of their group. These individuals possess all the cultural beliefs of the group, along with their own unique individual differences. Age is one of those situations. Significant physical and developmental differences exist between infants, children, adolescents, adults, and aging adults.

Children face additional challenges due to the group's beliefs about the role of children, who are often perceived as having limited cognition, communication, and judgment. Also, the caregiver's race, ethnicity, and religion may impact the child. The family unit may differ significantly, and culture plays a significant role in determining the design, roles, and functions of the family dynamic (Committee on Family Caregiving for Older Adults et al., 2016).

The aging adult has the added complications of the group's culture and beliefs about the aged, with possible cognitive, physical disability, and judgment limitations. The aging adult who is considered a minority will often have poorer health, such as an increase in chronic disease and higher rates of premature death (National Academies of Sciences, Engineering, and Medicine et al., 2017). This subset of the population faces barriers such as ageism, which is prejudice, bias, stereotyping, and discrimination based solely on someone's age (World Health Organization [WHO], 2021). Stereotypes include older adults being frail, dependent on others, or unable to contribute to society (Stubbe, 2021).

Disability

Individuals with disabilities have additional experiences and beliefs surrounding their disability, with added complications from the disability, such as communication, cognition, and functional limitations. (Van Herwaarden et al., 2020). Those with mental illness have different experiences and beliefs about mental illness. Stigma and acceptance of mental treatment can be a significant obstacle to care planning.

With the shift towards diversity and equity, barriers to inclusion emerge. Such barriers that patients with disabilities experience include attitudinal barriers, physical barriers, a lack of education, inappropriate education, or organizational and policy barriers.

Attitudinal: Attitudinal barriers are a common and basic type of barrier that can contribute to and lead to the formation of other barriers. Common attitudinal barriers include stereotyping, stigma, discrimination, and prejudice. For example, many individuals tend to assume that those with disabilities have a poor quality of life. A disability should not be considered a deficit (Centers for Disease Control and Prevention [CDC], 2025). Attitudinal barriers further stigma and discrimination and deny others dignity and equal opportunity. Negative attitudes foster a disabling environment and intensify discrimination and other barriers to inclusion.

Physical: Physical barriers also pose a challenge to inclusion, including environmental and structural barriers that prevent access and mobility. Examples of physical barriers include the absence of wheelchair ramps or accessible walkways (CDC, 2025).

Communication: Communication barriers exist for many, including those with disabilities. Individuals with disabilities involving reading, writing, hearing, and speaking are more likely to experience communication barriers. Examples of barriers include the following (CDC, 2025):

• No Braille or large print material available for those with vision impairments.
• Individuals with audio impairments may face communication barriers if there is no closed captioning on videos.
• No interpreter or someone fluent in American Sign Language is available.
• If someone has a cognitive impairment, using technical and over-medicalized language will result in a communication barrier.

Financial: Financial barriers exist for disabled and non-disabled individuals. Financial barriers include a lack of insurance coverage, gaps in coverage that may not include rehabilitation services, lower income for individuals with disabilities, confusion, or a lack of information regarding costs, payments, and insurance coverage. Not only is a lack of transportation a barrier, but so is the cost of transportation (Soltani et al., 2019).

Education can serve as a barrier to inclusion. If education is not inclusive, does not provide information on resources, or introduces bias, it is a barrier to inclusion.

Organizational barriers to inclusion encompass a variety of barriers at administrative, programmatic, and architectural levels. Examples include microaggressions, emotional barriers, jargon, and insensitive behaviors (Abbott & McConkey, 2006).

Policy can implement change. Unfortunately, it can also act as a barrier to inclusivity due to a lack of awareness of laws and regulations, a lack of the ability to enforce laws and regulations, or a lack of ability to make change. Policy barriers can also include a lack of funding (CDC, 2025).

Social barriers, often related to social determinants of health, are more likely in those who are disabled. The following are statistics related to social barriers for those who are disabled (CDC, 2025):

• Those with disabilities are less likely to be employed.
• Those with disabilities are less likely to have completed high school.
• Children with disabilities are more likely to experience violence.

Barriers in healthcare exist that can make it more difficult for those with disabilities to get the care they deserve. Healthcare barriers include a lack of communication, inconvenient scheduling, insufficient time to care for patients or explain necessary information, and poor attitudes among providers and staff (CDC, 2025).

Military

Military members have different cultures and beliefs related to their training and warrior status. These may include hyper-masculine qualities such as toughness, stoicism, and aggressiveness, as well as values like self-sacrifice. (Shields et al., 2017).

Unfortunately, healthcare is often underutilized by veterans because they believe that non-military healthcare members are unable to meet their needs due to a lack of understanding of the military experience.

There are many health conditions that military members and veterans are at greater risk of experiencing, such as suicide, infectious diseases, exposure to harmful chemicals, hearing loss, and traumatic brain injuries. They are also at an increased risk of experiencing mental illness, such as anxiety, depression, and post-traumatic stress disorder.

It is pertinent that healthcare providers aim to understand the various branches of the military and what they are likely to experience, moving beyond just physical injuries to also consider the emotional and psychological toll (National Academies of Sciences, Engineering, and Medicine et al., 2017).

Mental illness

Culture also influences aspects of mental health and illness. When there is a cultural difference and a healthcare provider lacks knowledge or awareness of the differing culture, these differences become obstacles, and the healthcare provider is less likely to meet the patient's needs (Nair & Adetayo, 2019). Members of racial and ethnic minorities who have a mental illness are:

• More likely to receive inadequate care.
• Less likely to have access to and receive needed mental health services.

Cultural barriers for patients with mental illness include the following (Fountain House, 2022; Stubbe, 2021):

• Mistrust of healthcare providers/care they receive.
• Lack of diverse healthcare members.
• Alternative idea of health and illness.

Cultural Groups

Within each culture, there are often sub-cultural groups. For example, within cultures worldwide, there are pockets of health-conscious communities that are vigilant against vaccinations. Immunizations are often viewed with distrust. It is essential to recognize that individuals within cultures may hold differing beliefs due to their unique experiences.

Previous non-traditional cultural groups are now gaining popularity. For example, several nontraditional groups have now been recognized as cultural groups in healthcare, such as adolescents, deaf youth, street youth, and gay and lesbian youth. These groups have shared values and make similar but non-homogeneous healthcare decisions. Failure of the healthcare provider to recognize the individual patient's identification with a group can negatively impact health outcomes (Kaljee & Stanton, 2011).

Other Important Factors

There are many other essential cultural and personal variables that are important to patients that deserve attention (Care Quality Commission, 2024). There are numerous other variables that contribute to a patient's preferences and culture, which deserve attention but have not been discussed here.

• Food and drinks: Never make assumptions about the kind of dietary preferences patients may have. Patients should be involved in dietary education and decision-making. Providers should consider how food and drinks are presented and always allow for a change in preferences, such as in cases involving patients with dementia.
• Healthcare preferences: Patients have varying healthcare preferences and experiences. Their belief about the cause of their illness can influence health decisions. These same beliefs may guide their decisions surrounding end-of-life care.
• Celebrations and social interactions: It is important to understand the habits and community/social interactions the patient can be a part of. There may be certain celebrations or social gatherings that patients would be interested in, depending on their cultural and personal preferences.

The culture of medicine shifted from a more paternalistic view to one where patients are viewed as active participants in their care. Providers are encouraged to provide services tailored to the patient's values. At one time, stereotyping by healthcare providers was viewed as taboo in healthcare; however, as the culture in healthcare continues to evolve, identifying patients by the cultural group they identify with has been associated with improved health outcomes.

Cultural competency has been identified as one of the primary strategies employed to address disparities in healthcare. Cultural competency has become a key aspect of healthcare policy and practice, where it is now seen as enhancing healthcare practices rather than detracting from them.

Self-awareness is the first step toward culturally competent care. This awareness starts with knowing one's values and beliefs, as well as nursing values and beliefs. Self-awareness is helpful when assessing and understanding the cultural beliefs of patients. Being aware of your own biases and attitudes allows you to become more appreciative and sensitive to the needs of patients. The healthcare provider must engage in introspection and reflection of their own attitudes toward different ethnic backgrounds and how those beliefs may impede care when working with different cultures. Healthcare providers must be able to develop skills in delivering culturally competent care.

The perceived role of healthcare providers differs significantly between various cultures. Some cultures view the healthcare provider as a trusted confidant who is expected to provide valuable advice as needed. Other cultures may view any advice provided as an intrusion. Thus, healthcare providers should adjust their practices based on the patient's background and expectations.

Empathy is an integral part of providing culturally competent healthcare, enabling providers to appreciate, perceive, and respond to a patient's verbal and nonverbal cues. Several studies have shown that nonverbal communication remains the best predictor of patient satisfaction.

The office of Minority Health of the U.S. Department of Health and Human Services (HHS) and the Agency for Healthcare Research and Quality established the National Standards on Culturally Linguistically Appropriate Services (CLAS). The CLAS standards are a collection of guidelines, recommendations, and mandates designed to eradicate ethnic and racial health disparities. The idea undergirding the CLAS standards is that better communication tailored to specific social, racial, and ethnic groups eventually leads to improved health status.

Principal Standard

• Provide effective, equitable, understandable, and respectful quality care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, Leadership, and Workforce

• Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
• Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce responsive to the service area population.
• Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance 

• Offer language assistance to individuals who have limited English proficiency and other communication needs, at no cost to them, to facilitate timely access to all healthcare and services.
• Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
• Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and minors as interpreters should be avoided.
• Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement, and Accountability

• Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization's planning and operations.
• Conduct ongoing assessments of the organization's CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
• Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
• Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
• Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
• Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
• Communicate the organization's progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Health organizations that receive federal funding are required to keep standards 4 through 7. Several states have followed suit with the Federal government by enacting cultural competency legislation as well.

Cultural differences can affect how patients view healthcare interventions purported by a perceived dominant cultural group. The Tuskegee experiment began in 1932 under the direction of the Public Health Service in conjunction with the Tuskegee Institute. The study's goal was to examine the natural history of syphilis in patients with the hopes of justifying the treatment of syphilis among black patients (CDC, 2024a).

The study involved 600 black men who were enrolled in the study without obtaining informed consent. The patients were told they were being treated for a "bad blood" condition. The study was initially supposed to last for six months, but ended up running for 40 years. In the end, the patients enrolled did not receive adequate treatment for syphilis, even when penicillin was established as the treatment of choice for syphilis. In 1972, the Assistant Secretary for Health and Scientific Affairs appointed a panel to review the study practices (CDC, 2024a).

The advisory panel eventually found out that the study was ethically unjustified and found that the knowledge gained was pale compared to the risks that the participants incurred. This knowledge resulted in a class-action lawsuit and an out-of-court settlement. The federal government eventually established a program to provide healthcare benefits to the study participants, widows, and children. The CDC eventually became responsible for the federal program. The Tuskegee experiment led to the creation of the National Research Act, which was signed into law in 1974. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created. This commission eventually led to the creation of the National Bioethics Advisory Commission in 1995 (CDC, 2024a).

This experiment left a bad taste for older African American patients who often choose to avoid preventative healthcare measures, especially when supported or purported by the federal government. However, with the advent of a more diverse healthcare workforce, the attitude among minority groups is rapidly changing, although much work remains to be done. The Tuskegee experiment led to groundbreaking laws on ethics in research and established an acute awareness of cultural competency.

There are many legal standpoints of equality and discrimination that have migrated into healthcare. The following are only some examples:

Title VI of the Civil Rights Act of 1964 does not allow federally funded programs to discriminate based on race, color, or nationality (Pakianathan et al., 2016). Therefore, federally funded healthcare programs must provide equal care to all patients. Furthermore, Title VI mandates equal care for patients with limited English-speaking skills. The Title also requires language assistance for any one part of a federally funded program, including a healthcare program (Pakianathan et al., 2016). This mandate includes Medicare, Medicaid, and state children's health programs.

Section 1557 of the Affordable Care Act (ACA) prohibits any discrimination based on color, sex, race, age, national origin, and disability. It also states that females and males must be treated equally in their care (U.S. Department of HHS, 2020).

The Individuals with Disabilities Education Act (IDEA) ensures that public education is available to children with disabilities, including early access to special education services to younger children, such as infants and toddlers (U.S. Department of Education, 2025).

The National Health Law Program works on all levels to advance access to quality health care. The program removes components of cultural identity, such as race, age, sexual orientation, and identity, as they feel they should not predict health outcomes. The equity vision promotes quality health care for all, without conditions and regardless of circumstances. Health is viewed as a fundamental right (DiAntonio, 2020).

Specific laws are set to protect certain populations, such as older adults. For example, the Older Americans Act was passed in 1965 to increase community and social services for older adults. These are just some examples. There are many state legislation bodies and professional regulatory bodies that require or recommend education in order for relicensure and to demonstrate acts of cultural competence within a professional workspace.

Healthcare providers must create a safe environment for patients to feel comfortable providing their medical history and receiving necessary medical care. Electronic medical records that allow patients to identify themselves as lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) can cue clinical providers to the patient's potential needs and challenges. Healthcare providers' cultural competency can ameliorate the quality of patient interactions.

There have been continued reports of negative experiences by the LGBTQ+ community, specifically related to unequal healthcare treatment and homophobia.

The Joint Commission and the Institute of Medicine have voiced that sexual orientation and gender identity should be included in the electronic medical record (Office of Disease Prevention and Health Promotion, 2022). Having this information in the electronic medical record is imperative for tracking and analyzing health disparities in the LGBTQ+ community.

Education of the medical community to become competent in the care of the LGBTQ+ community has been identified as the way forward in helping bridge the gap in the healthcare disparities affecting this community. There has been a push to include competencies in the medical and nursing curriculum that address issues surrounding sex, gender, sexuality, and other related topics. Continuing education should be pursued by healthcare providers, physicians, and other clinical providers.

The Healthcare Equality Index (HEI) is a benchmarking tool established in 2007. It is used to designate healthcare facilities in the United States that are leaders in LGBTQ+ healthcare equality (Human Rights Campaign Foundation, n.d.). However, despite the increased awareness of the need for a diverse and culturally competent workforce, there remains a glaring lack of resources to train culturally competent providers. It has become obvious that cultural competency is an issue no longer relegated to the federal government, state governments, or even healthcare organizations, but rather a central, fundamental issue necessary to provide appropriate healthcare in the 21st century. As the largest group in the healthcare workforce, providers should continue to champion as patient advocates (Human Rights Campaign Foundation, n.d.).

Scenario/situation/patient description

A 66-year-old Hispanic male resides in a rural community. He contacted his primary care provider's office with the following complaints: temperature of 100.2 degrees for three days, headache, body ache, fatigue, and nasal congestion with a runny nose. They underwent a COVID-19 polymerase chain reaction (PCR) test at their local pharmacy yesterday, received their positive test result today, and are anxious to speak to their healthcare provider about treatment.

Intervention/strategies

A telehealth appointment is conducted with their healthcare provider. The patient's condition warrants community-based treatment, and strategies are discussed. The patient specifically asks about medication to cure COVID-19. They had heard about it from a friend and believed many people get it through their local livestock supply store. Their healthcare provider responds that they understand from speaking with other local healthcare professionals that some are recommending Ivermectin therapy, which, coincidentally, is available for livestock. The healthcare provider proceeds to write that prescription to be filled at the pharmacy.

Discussion of outcomes

The CDC reports that the U.S. Food and Drug Administration has not authorized the use of Ivermectin to prevent or treat COVID-19 (CDC, 2024b). Likewise, Ivermectin has not been recommended by the National Institutes of Health's COVID-19 Treatment Guidelines Panel for treating COVID-19. The healthcare provider's decision to prescribe this medication appears to be influenced by their implicit bias to conform to their patient's request and some colleagues' anecdotal treatment recommendations. It is not an evidence-based treatment decision.

Strengths and weaknesses of the approach used in the case

Typically, healthcare professionals intend to provide optimal care to all patients, but implicit bias may negatively impact their aim. Conformity bias is an implicit bias associated with the tendency to be influenced by other people's views (Brecher et al., 2019).

In conclusion, our Nation is a vessel for many ethnic nationalities, each with its own subculture and ideas on healthcare. Healthcare professionals are caregivers who have a responsibility to care for various individuals with different ethnic backgrounds and cultural beliefs. Cultural competence is important in healthcare and is an ongoing process of learning, advocating, and understanding. Conflicts need to be identified, as well as an awareness of how one's own ideas can impact care. Healthcare professionals should seek out resources to better understand how to care for a diverse patient population.

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