Serving Diverse Populations

January-February 1999


"Cultural Competence" Not Optional for Healthcare Organizations

Healthcare organizations that are unfamiliar with the concept of "cultural competence" will soon (if they haven't already) find themselves at a disadvantage. Without cultural competence — the ability to effectively serve culturally diverse populations — they will neither provide the highest-quality care nor attract and retain patients and personnel. They will be hampered in today's managed care environment, which is driving healthcare organizations to improve the overall health of the communities they serve while providing fewer acute care services and cutting costs. To meet these goals, organizations will increasingly be required to recognize the United States' changing demographics and to adopt innovative care delivery, staffing, and marketing systems.

Experts at a recent national New York Academy of Medicine conference explained how healthcare organizations and professionals can prepare for serving diverse groups.

A New Way of Thinking
Recognizing attitudes and habits that limit the ability of traditional American healthcare to meet the needs of diverse groups is the first step. For example, Risa J. Lavizzo-Mourey, MD, noted that U.S. healthcare professionals tend to regard disease, outcomes, and patients' beliefs as distinct from each other. When caring for a person, physicians and other caregivers should assess the patient's cultural and ethnic background, considering the prevalence of diseases in the patient's particular group, as well as the person's health beliefs and behaviors.

Knowing how disease prevalence varies in different subpopulations affects individual diagnoses, treatment (e.g., the efficacy of some drugs varies by population), health education initiatives, and health promotion and disease prevention efforts, said Lavizzo-Mourey, who is director, Institute on Aging, University of Pennsylvania School of Medicine, Philadelphia. To be effective, health education and prevention programs must be culturally appropriate — tailored to address a culture's life-style behaviors.

"Health beliefs have a tremendous effect on treatment outcomes," she said. People from cultures that believe a patient can be hurt if a healer speaks negatively about their condition will be reluctant to seek Western medicine. As a physician, she said, "I need to gather all information about a patient — gender, sexual orientation, beliefs. If we don't ask about health beliefs, we run the risk of offending, or at least of not managing a person's problems in the best way."

Lavizzo-Mourey stressed that this is a new way of thinking. "Providers have to focus on a population — not just an individual." The only way they can improve the health of a population within current budget constraints, she said, is "to know the individual patient but also the population."

But she cautioned against stereotyping. Race is not the only factor in understanding variations in outcomes, she said. "Culture is the appropriate focus" (although culture includes race), she said. Black infants with low birth weight born in the United States tend to have poorer outcomes than such infants born in Africa, she pointed out; and although recent smoking reduction is about the same for African Americans and whites and for men and women, more black men than white smoke and more white women than black smoke. "So we have to take into account many cultural factors other than race," she said. Research in this area is lacking; Lavizzo-Mourey noted that most of her examples are for whites or African Americans because little investigation of other populations has been done.

Another physician, Henry Chung, advised healthcare professionals to use cultural and ethnic guidelines judiciously. Such lists, he said, are "not a substitute for getting information from patients and families." Chung, medical director of Chinatown Health Clinic, New York City, and the Asian Health Center of Flushing, Queens, NY, also recommended rejecting the notion that patients and providers must be ethnically matched. "We shouldn't aim for that as a goal. It won't happen, and it will alienate a provider if you funnel only his race to him."

Consequences of Cultural Incompetence
A tragic example of what can happen when patients and healthcare professionals do not understand each other's beliefs and cultures was provided by Anne Fadiman. In her award-winning book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, she traces the story of Lia Lee, the epileptic daughter of Hmong refugees who settled in Merced, CA, after fleeing Laos at the end of the Vietnam War. Lia's parents believed that her epilepsy occurred because a spirit had stolen her inner spirit (thus the book's title). Unable to understand most directions they received from Lia's pediatricians because of their limited knowledge of English, and opposed to many treatments common in Western medicine (e.g., spinal taps, blood tests), the parents found it difficult to adhere to the treatment regimens prescribed for their daughter. Their lack of "compliance" (a term that implies moral superiority, several speakers said) frustrated and angered American physicians and nurses, who made inadequate attempts to understand the parents' beliefs and to ensure that directions were clearly translated. Nor did they try to incorporate Hmong healing rituals and practices into Lia's care. Eventually a neurological catastrophe left Lia in a persistent vegetative state. More culturally sensitive care might have prevented the event and it certainly would have made the long course of Lia's illness much more tolerable for Lia, her family, and her caregivers.

In the eight years she spent on the book, Fadiman developed recommendations for changing traditional U.S. healthcare practices to avoid situations like Lia's. They include the following:

  • Encourage bilingual children of immigrants and refugees to enter the healthcare professions.
  • Secure more and better interpreters.
  • Encourage patients' traditional practices that are not harmful.
  • Listen to patients without criticizing or telling them they are wrong.
  • Include cross-cultural education in medical school curricula.
  • See the illness from the patient's point of view. Fadiman and other speakers cited a questionnaire by Arthur Kleinman that clinicians can use to learn about patients' cultural beliefs ("Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research," Annals of Internal Medicine, vol. 88, 1978). It includes queries asking what the patient thinks caused his or her problem; whether the patient has tried any home remedies or other treatments; and what type of treatment the patient thinks the physician should provide.

Henry Chung said he asks additional questions after his first or second encounter with patients. He believes it is important to address the question of racism. If patients are not Asian, he asks them how they feel about working with a physician not of their race. He also asks patients how they think they are getting along with him and whether patient and doctor are understanding each other.

Diversity and Health Policy
In addition to changing medical practice, America needs public policy initiatives that respond to its growing ethnic diversity and changing demographics. "My biggest concern is that in Social Security and Medicare reforms we not try to balance the costs on the backs of immigrants," said Clayton Fong, executive director, National Asian Pacific Center on Aging, Seattle. He fears that such reforms will lead to a two-tiered healthcare system. "We no longer have a safety net for immigrants coming here since 1986. A time bomb is ticking."

Implications for Healthcare Providers
The conference's messages point to a role for all U.S. healthcare organizations — Catholic and non-Catholic alike. They must proactively advocate at all political levels policies that increase access to adequate care for all cultural and ethnic groups, as well as research that provides guidance for caring for all subpopulations.

Organizations and their staffs should also advocate cultural competence initiatives in hospitals, nursing homes, clinics, and all other sites where health and social services are delivered to various ethnic groups. They should support changes in the training of physicians, nurses, and others so that the entire healthcare team provides culturally competent care.

Cultural competence cannot be optional for Catholic organizations, which have an explicit mission to recognize the inalienable human dignity of each individual; to care for the poor and vulnerable; to provide holistic care; and to promote the common good. Their raison d'ˆtre is to carry on the healing mission of Jesus Christ, who treated all people equally. By embracing cultural competence, Catholic organizations can strengthen their mission while enhancing the lives of individuals of all cultures, ages, and genders.
—Judy Cassidy


Harold J. Hodgkinson, PhD, director, Center for Demographic Policy, Institute for Educational Leadership, Alexandria, VA, examined demographic trends that have profound implications for relationships, health, and social conditions in the United States and the world. According to Hodgkinson:

  • Fertility rates among whites are below the replacement level in the United States. To maintain current population levels, the United States needs immigrants.
  • Ninety percent of the world's population growth is in the southern part of the world, where poverty and lack of education create pressure for people to move to the United States and to Europe.
  • A growing number of elderly are living alone.
  • By 2010 whites will be the smallest ethnic minority in the world.
  • The U.S. population is aging rapidly; one in four baby boomers will live past the age of 85. Their benefits will be paid for by a smaller, more diverse group than now pays for them.
  • The census for 2000 includes 66 categories of races.
  • Hispanics are the fastest-growing minority in the United States.
  • The U.S. population is transient; 43 million Americans moved between March 1993 and March 1994. Transiency lessens people's willingness to affiliate with others, diminishing social cohesion and increasing crime.


Copyright © 1999 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Serving Diverse Populations

Copyright © 1999 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.