Ms. Weiss is a Santa Monica, CA-based healthcare consultant.
For 32 million Americans, English is a second language. And for these people and countless other ethnic and racial groups, the traditional American hospital or clinic can be a strange and even frightening place. Cultural barriers between patients and providers can lead to misunderstanding, misdiagnosis, and failed treatment.
Many providers may not be aware of cultural differences among ethnic racial groups. For example:
- Voodoo is an integral part of the cultures of Ghana and Nigeria, where disease is often treated with liquid homemade remedies and potions. Physicians should, accordingly, prescribe liquid rather than tablet medication for patients from those countries. It could mean the difference between compliance and noncompliance.
- In Japan most patients do not have a primary care physician but, rather, get all their care through a one-stop clinic. Both new and temporary Japanese residents of the United States should be educated on how to gain access to a multisite healthcare delivery system.
- In one Alaskan Native American culture, tradition calls for serving moose nose to elders, even if they are hospitalized — which requires hospitals to have a flexible menu service.
- Some Asian patients are particularly reluctant to seek psychiatric treatment, but an Asian-speaking therapist can help ease their fears.
- In some African cultures, people beat their bodies, engage in feverish prayer, and wail when they are depressed. An uninformed healthcare provider might misinterpret such behavior and mistakenly prescribe antipsychotic medications, rather than helping people through their emotional difficulties.
- Undocumented persons often worry about gaining access to healthcare services, especially in California. Proposition 187 — which is currently being reviewed in the courts — would restrict state benefits and services for the undocumented. Teaching staff how to react to unusual questions and act as if they were there to help, rather than impede access to healthcare, can make a difference.
These challenges are not limited to a handful of cities. The 1990 census showed that in 51 of the nation's largest cities (with a population of at least 100,000), African Americans, Hispanics, Asians, and Native Americans made up more than half the population. By the year 2009 Hispanic Americans will number 38 million — 12.9 percent of the population.
Difficulty in understanding English is also a common barrier to care. More than 1 in 10 patients at large urban hospitals need an interpreter, according to a study by the National Public Health and Hospital Institute, based in Washington, DC.
Transcending Barriers
How are hospitals and other healthcare providers meeting the challenge of a changing population? Many are developing internal and external communications programs.
- Elmhurst Hospital, Queens, NY, established a bicultural program that provides mental healthcare services for Chinese and Korean patients. All of the program's staff members speak Chinese or Korean as their native language.
- Good Samaritan Hospital and Health System, Dayton, OH, began a Japanese Relations Program in response to the presence of more than 120 Japanese-owned businesses in the area. A Japanese-speaking coordinator oversees strategies that include publishing bilingual healthcare brochures, holding seminars that describe the American healthcare system to Japanese on temporary U.S. assignment, and establishing on-site screenings and wellness programs at Japanese firms.
- CareAmerica Health Plans, Woodland Hills, CA, allows policyholders to conduct all dealings with the health plan in Spanish. The program, Servicios en Espa¤ol, includes Spanish-language enrollment forms, physicians who speak Spanish, and a Spanish-language advertising campaign. Servicios en Espa¤ol, which has been operating for more than two years, has helped CareAmerica achieve a 32 percent Hispanic managed care market share in the greater Los Angeles area.
- Fairbanks Hospital, the sole hospital in a 500,000-square mile area in Alaska, serves a number of different Native American groups. The hospital holds workshops to educate its staff about the differing local cultures, belief systems, and communication styles. The seminar, called "Caring across Cultures: Communications and Care Issues," includes an overview of native cultures, a discussion of common healthcare problems, and an exploration of issues in cross-cultural communications. Faculty includes anthropologists and linguists from the University of Alaska, a family physician, health aides, and native Alaskans.
- Beth Israel Hospital, New York City, has a long tradition of outreach programs to meet the healthcare needs of immigrants. Recently the hospital has provided care for Cambodian refugees and Soviet emigres, facilitated by interpreters, bilingual staff members, and, in some instances, bilingual medical records. Five years ago, Beth Israel opened a separate clinic for Japanese patients.
- Elmhurst Hospital in suburban Chicago targets Hispanics with a Spanish-language newsletter, a Spanish-speaking physician referral service, and community education programs taught by Spanish-speaking physicians.
- Before beginning their training program, residents at Columbia-Presbyterian Medical Center, New York City, participate in an intensive one-week session in Spanish to learn the words necessary for taking a patient's history and conducting a physical examination.
- San Francisco General Hospital produced multilanguage brochures, flash cards, and easy-to-understand educational materials distributed through community agencies that serve the targeted population. It also held staff sensitivity training sessions to increase awareness and understanding of cultural diversity.
The Queen of Angels Program
California most clearly demonstrates the cultural diversity increasing throughout the United States. With the state population more than 43 percent minority (25.8 percent Hispanic, 9.6 percent Asian, 7.4 percent African American, and 0.8 percent Native American), healthcare providers are searching for better ways to communicate.
Queen of Angels-Hollywood Presbyterian Medical Center is a prime example of how a changing ethnic neighborhood can turn challenge into opportunity. Queen of Angels' fee-for-service clientele has been replaced by health maintenance organization members and MediCal (Medicaid) recipients. And a once preponderantly Anglo population now has four significant ethnic constituencies — Hispanic (59 percent), Armenian (17 percent), Korean (11 percent), and Anglo and all others (13 percent) — each having different expectations, languages, and cultural norms.
The medical center met the challenge by creatively blending public relations, advertising, and community outreach strategies into a highly effective multicultural marketing program.
Stronger community relations programs now augment promotional activities at Queen of Angels community clinics. One such program is the Greater Hollywood Health Partnership, a consortium of area churches, community organizations, and the medical center (which is itself the result of the merger, several years ago, of Catholic and Presbyterian hospitals). The partnership provides a forum in which medical center personnel work with their constituents on key community issues, such as Proposition 187.
Because churches are trusted institutions in the multicultural community, they serve as a perfect entry point for preventive care and other healthcare services, says Bob Steward, Queen of Angels foundation president, who along with Queen of Angels Community Relations Director Gwyn Dilday led efforts to create the partnership.
"The key to making our strategy work was to understand the various constituencies in our community," explains the medical center's director of marketing, Scott Larson. "The most important quality the Queen of Angels team possesses is our willingness to change, because our marketplace is changing everyday."
An umbrella campaign, created by Hill & Knowlton, a public relations agency, focused on three main areas: the hospital's Angel Delivery obstetric program, men's health, and physician referral.
One good example of how the strategy works was a special promotion launched in May. "May was targeted as 'Mother's Month,' which coincided with Mother's Day both in the U.S. and in Mexico," says Alan Elias of Hill & Knowlton. "We had a monthlong promotion featuring a contest with a complete set of nursery furniture for new and expectant mothers as the grand prize."
The marketing effort included flyers, posters, and advertisements in Spanish, Armenian, Korean, and English. Materials were delivered door-to-door in neighborhoods near Queen of Angels Community Care clinic. Print ads were taken out in newspapers that went to each ethnic group, and Spanish-language radio time was purchased, backed by public relations efforts to get the news media to run stories about the event.
The contest drew more than 1,000 inquiries about Angel Delivery maternity services during the month of May. More than 5,000 women in the local service area participated in the contest. The medical center's obstetric department clinic was running at full capacity by the end of the promotion.
June was dubbed "Father's Month," honoring the role of the father in the family. The Hispanic, Armenian, and Korean cultures all place a premium on close-knit family ties. By following up Mother's Month with a special Father's Month (timed to coincide with Father's Day), the medical center demonstrated its concern for the community. The Father's Month promotion also featured a set of nursery furniture as a grand prize.
The hospital also tries to speak to the community through a billboard program that features tender images of mothers and fathers with their babies. And it maintains a constant public relations effort to try to keep the hospital in the news. A number of special celebrations and events are held in and around the hospital. Publicity is aimed at both English and foreign-language publications, including Vida Nueva, the Los Angeles Archdiocese's Spanish-language newspaper.
"We find the most effective way to reach the target communities is to attempt to be everywhere at once," says Elias. "We reach people in their homes, as they are walking or driving, at community centers, and through the airwaves."
Multiethnic marketing campaigns differ from single-culture campaigns because so many more variables must be covered. "Before you begin marketing to the community, you must market within your own institution," advises Hill & Knowlton's Greg Waskul. "This means hiring multilingual staff or training existing staff to become multilingual, adapting signage so it's customer-friendly, and creating a menu that will be appetizing for each patient."
Another key to success at Queen of Angels is its continual evaluation of program results and its experimentation with various marketing tactics. For example, direct mail is being considered for later this year to support mammography and prostate cancer initiatives. A speakers' bureau sends multilingual physicians, other health professionals, administrators, and board members to appear throughout the community.
America is changing. Forty percent of the U.S. population will be nonwhite in 2025, compared with 25 percent today. To successfully communicate with diverse cultures, one must continually learn about and respect diversity and build the bridges necessary for greater understanding and sensitivity to the needs of all whom we serve.
Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.