This course provides learners with a review of the different cultural groups healthcare providers encounter in their work including non-traditional groups outside the confines of race and ethnicity such as the LGBTQ community. It also provides a summary of the events that led to the establishment and implementation of the National CLAS standards with a brief overview of each standard. Lastly, it provides actionable insight on patient care encounters that providers can start implementing in their interactions with patients right away such as patients in the LGBTQ community.
After completing this continuing education course, the participant will be able to complete the following objectives.
There are 7 billion people in the world today who speak a staggering 6000+ languages. The world’s population is becoming increasingly mobile with resultant blurring of traditional language, racial and ethnic lines. Up to one-third of the United States population identified as being a racial or ethnic minority in the 2000 census. This 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.1
Culture is focused on the ways 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. People who share a cultural belief are organized into groups such as a family, or they could be grouped by other identifiers such as gender, age or common interests. 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.1
There are several nontraditional groups which have now been recognized as cultural groups in healthcare such as adolescents, deaf youth, street youth, 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. Sometimes healthcare providers may inadvertently use offensive language which can completely erode the patient’s trust in the clinician’s credibility ultimately leading to poor health outcomes and noncompliance.1
The American Association of Colleges of Nursing established the Essentials of Baccalaureate Nursing Education in 2008 which led to a vast increase in cultural competency standards in nursing curricula nationwide.2 By 2008, more than 90% of US medical schools added cultural competency training to their curriculum. Pharmacy, nursing and dental schools also added cultural competency training to their curriculum.3
The National Quality Forum defines cultural competency as “the ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient and family-centered, evidence-based, and equitable.4”
There are multiple cultures. The only way to identify patient’s cultural concerns is to ask. The following are a few examples.
There are certain cultural practices that healthcare providers should be aware of. For example, for Muslims, it is important to understand fasting during the holy month of Ramadan and being aware that children of certain ages may be allowed to participate in fasting. In addition, in some Muslim subcultures, it may be inappropriate to touch any female patients even a handshake.
Native Americans believe in “passive forbearance” which proposes the idea that individuals should be able to choose their path free of intervention from other family members.1
Different cultures ascribe varying importance to values; for example, Latino culture values “personalismo” which is defined as politeness in the face of adversity or stress. Machismo refers to strong masculine pride and dictates interactions with certain male Latino subgroups. Note that adherence to cultural beliefs relies heavily on the degree of acculturation and does not happen homogeneously within all cultural groups. For example, within the Latino cultural group, there are different national subgroups such as Cuban, Venezuelan, Mexican, etc.
Note that within the health-conscious community, immunizations can be viewed with distrust among certain subcultural groups in the United States. Sometimes patients make decisions based on sensationalized media reports often wrapped in droves of miseducation and misinformation.
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 goal of the study was to examine the natural history of syphilis in patients with hopes of justifying the treatment of syphilis among black patients.5
The study involved a total of 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 6 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.5
The advisory panel eventually found out that the study was ethically unjustified and found that the knowledge gained was pale in comparison to the risks that the participants incurred. This 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, their widows and their children. The Center for Disease Control and Prevention 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 and the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created. This eventually led to the creation of the National Bioethics Advisory Commission in 1995.5
The Tuskegee experiment was evil and inexcusable. It left a bad taste for older African American patients who often choose to avoid preventative health care 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 are rapidly changing although a lot of work remains to be done.
The perceived role of healthcare providers differs significantly between various cultures with some cultures viewing 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.
As the culture of medicine shifts from a more paternalistic view to one where patients are viewed as active participants in their own care, providers are encouraged to provide services tailored to the patient’s individual values. At one time, stereotyping by healthcare providers was viewed as taboo in healthcare but as the culture in healthcare continues to evolve, identifying patients by a cultural group they identify with has been associated with improved health outcomes.
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 healthcare provider nonverbal communication remains the best predictor of patient satisfaction. Research showed that if clinical providers were attentive to the patient’s needs, appeared interested and made eye contact during a clinical encounter; a physician race did not matter on the participant's evaluations.6
Cultural competency has been identified as one of the main strategies deployed to dispel disparities in healthcare. Cultural competency is the ability of the healthcare provider to effectively comprehend the language, actions and values of a specific religious, racial, ethnic and other social groups. Cultural competency has become a key aspect of health care policy and practice where it is now seen to enhance healthcare practices rather than detract from it.
The office of Minority Health of the US Department of Health and Human Services along with 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 which are 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 leading to improved health status.
Standard 1: Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.7
Standard 2: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources.
Standard 3: Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area.
Standard 4: Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.7
Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
Standard 7: Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.7
Standard 9: Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organizations’ planning and operations.
Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
Standard 11: 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.
Standard 12: 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.
Standard 13: Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness.
Standard 14: Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints.
Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public.7
Health organizations which receive federal funding are required to keep standards 4 through 7. Several states have followed suit to the federal government by enacting cultural competency legislation as well.
This course includes an in-depth study of the LGBTQ community patients because of studies and growing concern of healthcare disparity for this community.
Transgender has become a general term which refers to people who are transgender, transsexual or gender non-conforming.8 Gender dysphoria defines distress attributed to gender incongruence as it relates to the patient’s mind and body. The LGBTQ nomenclature is in flux constantly, and clinicians must make it a point to keep up with the newer terms even as the field continues to evolve.8
There are several studies which have documented the disparities in health care endeavors involving the lesbian, gay, bisexual, transgender and queer communities. It has been established that lesbian and bisexual women are less likely to receive standard preventive screenings for cervical, breast and colon cancer screenings.8
Lesbian, gay, bisexual, transsexual and questioning communities have a growing stack of inequalities in healthcare delivery including sexual health, mental health and substance use. Clinical providers educated and competent in cultural awareness for the LGBTQ communities have now become a necessity to bridge the health inequalities affecting these communities.8
The World Health Organization defines sexual health as a state of physical, mental and social well-being in relation to sexuality. Sexual wellness necessitates a respective and positive approach to sexuality and sexual relationships as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.9
There has been an increased prevalence of transgender diagnoses with most studies observing a higher male to female than the female to male ratio.10
Sexual health is very intricate in the cultural, legal and socioeconomic and political fabric of communities which provide a context to the lives of the LGBTQ community. Until 1992, homosexuality was considered a mental illness at which time it was declassified by the World Health Organization.11
People in the LGBTQ community may experience fear in disclosing their sexual orientation which can lead to higher rates of sexually transmitted diseases including human immunodeficiency virus (HIV) in patients who are gay, bisexual or men having sex with men especially in countries where their sexual choices are criminalized.11 Unfortunately, some people in the LGBTQ community still get attacked if they display affection publicly, even in countries where there is anti-discrimination legislation in place. Overall, there are increased reports of bullying and poor access to healthcare among the LGBTQ communities, especially in poorer countries.11
LGBTQ individuals report higher rates of suicide, anxiety, depression and drug or alcohol dependence.11 Men who only have sex with women are six times less likely to commit suicide compared to men who have sex with men.11 The cause for the increased health disparities among the LGBTQ community is multifactorial and complex.
Gender dysphoria is a relatively new medical term which attempts to name and explain the dysphoric symptoms that people in this community may experience. As patients in the transgender community transition both socially and medically, they experience a unique set of challenges that clinical providers must remain aware of, so they can provide appropriate support during their transition. There is a stark sparsity of research in transgender health and transgender communities.10
Most of the research among the transgender population has been on patients transitioning from male to female transgender. There is a great need for gender affirmation in these trans-men and trans-women due to the stigma and discrimination they often face. There are specific challenges faced by the transgender population which may make them more vulnerable to certain ails. For example, transgender men who receive testosterone therapy may experience increased vaginal atrophy which can make them more susceptible to sexually transmitted diseases including HIV.8
Lesbian and bisexual women typically have a lower incidence of sexually transmitted diseases compared to heterosexual women. However, there is a diverse group of women who identify as lesbian, and a thorough and appropriate sexual history must always be performed. Note that bisexual women are more likely to report having an increased number of sexual partners as well as an increased rate of chronic pain and cervical cancer.12
Bacterial vaginosis has been shown in multiple studies to be more common among bisexual and lesbian women. Although human papillomavirus (HPV) related cancers have been shown to occur in women participating in female to female transmission of genital HPV with occurrences of cervical neoplasia.12 In spite of these facts, cervical cancer screening remains low among the lesbian and bisexual community. Homosexual men have an increased rate of HPV associated anal cancers compared to heterosexual men.
It is imperative that clinicians create a safe environment for patients to feel comfortable providing their medical history and receiving necessary medical care. Electronic Medical Records which allow patients the ability to identify themselves as LGBTQ can cue clinical providers to the patient’s potential needs and challenges. Clinician cultural competency can ameliorate the quality of patient interactions.
There have been continued reports of negative experiences by the LGBTQ community specifically as it relates to unequal healthcare treatment and homophobia. According to a 2010 study, a national survey of LGBT physicians, 65% of them reported hearing derogatory comments about LGBT patients from healthcare professionals. 34% of them reported witnessing discrimination in care against patients in the LGBT community.13
A 2011 survey of transgender people noted that 19% of survey responders reported being refused medical care because of their gender identity.14
The joint commission and the Institute of Medicine have both voiced that sexual orientation and gender identity should be included as part of the electronic medical record.15,16 Having this information in the electronic medical record is imperative for tracking and analyzing health disparities in the LGBTQ community at the population level.
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 the LGBTQ community. There has been a push to include competencies in the medical and nursing curriculum which address issues surrounding sex, gender, sexuality, and other related topics.
Continuing medical education to nurses, physicians and other clinical providers on LGBTQ issues has become the best recourse given the sparsity of LGBTQ issues in the curriculum.
The Health Equality Index (HEI) is a benchmarking tool which was established in 2007 and is used to designate healthcare facilities in the United States which are leaders in LGBTQ healthcare equality.17
Despite the increased awareness of the need for a diverse and culturally competent workforce, there remains a glaring lack in the resources needed 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. Nurses, as the largest group in the healthcare workforce, should continue to champion as patient advocates.18
In conclusion, our Nation is a vessel for many ethnic nationalities each with its own subculture and ideas on health care. The healthcare professional are caregiver that hasve a responsibility to care for a variety of 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 and an awareness of how one’s own ideas can impact care. Healthcare professionals should seek out resources to be better able to understand how to care for a diverse patient population.