Cultural Competence in
Respiratory Care
• Identify how the beliefs, attitudes and
behaviors of major American cultural
groups impact public health.
• Create heightened appreciation for the
influence of cultural competency in health
• Identify strategies for enhancing cultural
competency in respiratory care.
Basic Diversity Terminology
Culture: An integrated pattern of human
behavior that includes thoughts,
communications, languages, practices,
beliefs, values, customs, courtesies, rituals,
manners of interacting, roles, relationships
and expected behaviors of a racial, ethnic,
religious or social group.
Culture Defined Broadly
• Term culture inclusive of:
Sexual Orientation
Shared Experiences (i.e. poverty, mental illness,
addiction, homelessness, etc.)
What Culture is Not:
• Culture is not:
– Race
– Stereotypic generalizations about the behaviors, emotions and
values of a group of people.
– A laundry list of values behaviors and facts related to a group
of people.
– Rigid or static categorizations of people without a deep and
fundamental awareness of their differences.
– Superficial adoption of customs, language, dress or behavior
in a patronizing manner.
“What is Cultural Competence?”, Family Resource Coalition Report, Fall/Winter 1995-96
Basic Terminology
• Cultural awareness: Being cognizant,
observant and conscious of similarities and
differences among cultural groups
• Cultural sensitivity: Understanding the needs
and emotions of your own culture and the
culture of others.
• Cultural Competence: Has many definitions!
Definitions of Cultural Competence
Cross et al, 1989
• Cultural competence is a set of congruent
behaviors, attitudes, and policies that come
together in a system, agency or among
professionals and enable that system, agency or
those professions to work effectively in crosscultural situations.
Definitions of Cultural Competence
Denboba, MCHB, 1993
a set of values, behaviors, attitudes, and
practices within a system, organization, program
or among individuals and which enables them to
work effectively cross culturally.
… the ability to honor and respect the beliefs,
language, interpersonal styles and behaviors of
individuals and families receiving services, as
well as staff who are providing such services.
Definitions of Cultural Competence
Health Resources and Services Administration,
Bureau of Primary Health Care
• Cultural and linguistic competence is a set of congruent
behaviors, attitudes and policies that come together in a
system, agency or among professionals that enables
effective work in cross-cultural situations. "Culture"
refers to integrated patterns of human behavior that
include the language, thoughts, communications,
actions, customs, beliefs, values, and institutions of
racial, ethnic, religious or social groups. "Competence"
implies having the capacity to function effectively as an
individual and an organization within the context of the
cultural beliefs, behaviors and needs presented by
consumers and their communities
Cultural Competence Within the
Health Care System Requires:
• Culturally Competent Care: Administered with
sensitivity for a patients culture and health-related
• Culturally Competent Staff: That reflect the ethnic
communities they serve with understanding and respect
for the beliefs, attitudes, interpersonal styles and healthrelated beliefs of their patients.
• Organizational Management: Who develop policy,
procedures and processes the assure uniform patient
Changing National Demographics
Changing demographics result in an increased need to
medical delivery responsive to multicultural populations:
Population Size and Composition: 2003
Approximately 33.5 million foreign-born people live in
the United States.
The foreign born represent 11.7 percent of the U.S.
Source: US Census Bureau, Current Population Survey, Annual Social and Economic
Supplement, 2003
Changing National Demographics
• Percent Distribution of Foreign
Born by World Region of Birth:
Latin America (LA)
Asia (A)
Europe (E)
Other Regions (O)
Source: US Census Bureau, Current
Population Survey, Annual Social and
Economic Supplement, 2003
Different Customs, Beliefs and
• Health is absence of Disease
•Seeks traditional health care providers
(i.e. physicians, nurses, surgeons,
•Seeks medical system to prevent and
treat illness
• Health is a state of harmony within
body, mind, spirit
•Seeks alternative medical practitioners
(i.e. herbalists, shamans, midwives etc.)
• Seeks medical system when in acute
stage of illness
•Values independence and freedom
•Values interdependence with family and
•Future oriented
• Present oriented: here and now
• Gestures have universal meaning
• Gestures have taboo meanings,
depending on culture
•Individual interests are valued and
•Individual interests are subordinate to
family needs
Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners,
March, 2004
Why be Culturally Competent?
• Because many cultures populate
our country:
– Culture inclusive of many factors
– Changing national demographics.
– Vast array of customs, beliefs, practices
• Because it’s the law.
Why be Culturally Competent?
• Because It’s the Law:
– The Civil Right’s Act of 1964: Title VI
“No person in the United States shall, on the grounds
of race, color or national-origin, be excluded from
participation in, denied the benefit of, or be
subjected to discrimination under any program or
activity receiving federal financial assistance.”
It’s the Law
• Emergency Medical Treatment and Active
Labor Act :
Also known as the Patient Anti-dumping Act,
requires hospitals that participate in the
Medicare program that have emergency
departments to treat all patients (including
women in labor) in an emergency without regard
to their ability to pay.
It’s the Law
• Medicaid :
Medicaid regulations require Medicaid providers
and participating agencies, including long-term
care facilities, to render culturally and
linguistically appropriate services.
It’s the Law
• Medicare
Medicare addresses linguistic access in its
reimbursement and outreach education policies.
“Medicare providers are encouraged to make
bilingual services available to patients wherever
the services are necessary to adequately serve a
multilingual populations.”
Importance of Cultural Competence
• Cultural Competence is necessary to
improve the health care outcomes of a
culturally diverse population of
patients who utilize the health care
Health Care Disparities
• Research indicates that clinical encounters
between culturally insensitive health care
practitioners and patients from different
cultural backgrounds can contribute to
disparities and barriers to appropriate
health care.
Health Care Disparities
• Disparities in health care delivery has been
documented among:
African Americans
Native Americans
Pacific Islanders
Health Care Disparities
• In the U.S., ethnic minority populations lag
behind the European population on a number
of key health indicators including:
Health care coverage
Access to health care
Life expectancy
Acute and chronic disease states
Health Care Disparities
• Common barriers to providing culturally
sensitive health care include:
– Underestimation of need for service
– Lack of appreciation for cultural belief differences
related to illness, suffering, and dying
– Language and other communication barriers
Health Care Disparities
• Culturally competent health care
guidelines will help eliminate
these disparities.
Key Components of Culturally
Appropriate Care Include:
Hiring and Training
Culturally Diverse Health System
Culturally Biased Health Care
• Patients from other races and socio-economic status
tend to be viewed more negatively by physicians
(VanRyn and Burke, 2000)
• Hispanics and Blacks are less likely to receive major
therapeutic and diagnostic procedures for their
conditions ( VanRyn and Burke, 2000)
• Vietnamese, Hispanics and Blacks have higher mortality
rates for cancer and studies indicate that physicians
manage cancer different based on race ( Bach et al,
1999: King and Brunetta, 1999)
Culturally Biased Health Care:
• A patient’s race and gender have been shown to
influence a physicians decision to refer for
cardiac catherization. (Schulman et al, 1999)
• Physicians fail to recognize the presence of pain
in patients who are culturally different resulting
in under medication. (Todd et al, 1993)
Cultural competence requires willingness to adapt
to the needs of patients and their family
members, and to meet those needs in an
objective, non-judgmental way including
Ability to demonstrate empathy
Ability to value diversity
The capacity for cultural self assessment
Awareness of the dynamics that exist when cultures
– A clinical demeanor based on an understanding of
cultural diversity
Hiring and Training
for Cultural Competence
• Hire a culturally diverse work force.
• Develop a comprehensive training curriculum in
the elements of cultural competence.
• Mandate training in language, medical
interpretation and cultural competence for all
employees as required by their position.
• Allocate the budget and time for employee
orientation, training and up-dates in the area of
cultural competence
• Cultural competence requires behaviors
that exemplify appropriate interactions
between health care professionals and their
patients in the areas of:
– Patient cultural assessment
– Treatment planning and adherence
– Patient education and communication
– Clinical decision making
• Patient Cultural Assessment: the need to assess cultural,
environmental and socioeconomic factors as part of
diagnostic procedures.
– Cultural: Race, family structure, gender roles, religion and
spirituality, dietary habits and time/space orientation.
– Social: Support networks, socioeconomic status, community
resources, literacy level and lifestyle behaviors.
– Environment: Aculturalization, knowledge of U.S health care
system, political history, racism and discrimination and
geographic access.
• Models for patient cultural assessment:
– LEARN model (Berlin and Fowke’s):
• (L) – Listening to the patients perspective
• (E) – Explaining and sharing one’s own perspective
• (A) – Acknowledging differences and similarities between
the two perspectives.
• (R) – Recommend a treatment plan
• (N) – Negotiating a mutually agreed-on treatment plan
• Models for patient cultural assessment:
– Patient Explanatory Model (Klienman et al) Elicitation
techniques for gaining information from patient and/or
family members about onset, treatment and prognosis:
What do you call your problem? What name does it have?
What do you think caused your problem?
What is your sickness doing to you?
What problems has it caused you?
Will it last a short or long time?
What type of treatment do you think you should get?
What do you hope to get from the treatment?
• Factors affecting treatment planning:
– Cultural health beliefs
• Traditional/folk medicine practiced
• Religious practices
• Patients views about health, medications and health care
– Role of family
• Family member designated as key decision maker
• Family members responsible for giving and monitoring care
• Extended family members to be included in care planning
• Factors affecting treatment planning:
– Socioeconomic factors
• Ability to pay for treatment over time
• Limited resources may lead to skipping or sharing medications with
other family members
– Environmental factors
• Patients work schedule can result in missed appointments
• Lack of transportation presents barriers to keeping appointments
• Exposure to environmental toxins ( i.e. pollution, allergens, roaches,
etc.) can decease the effectiveness of therapy
Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for
Medicaid Practitioners, March, 2004
• Negotiation of treatment plans:
– The patient and the healthcare provider must acknowledge
their differences about the treatment plan/methods and
come to a mutually-agreeable but beneficial alternative.
– Process of negotiation involves:
Relationship building
Problem clarification
Agenda setting
Follow-up care management
Patient Communication/Education
• Barriers to effective communication:
Lack of awareness of patient expectations
Devaluing the patient or the patients’ family health care views
Language barriers
Cultural norms/customs for interpersonal communication
Patient feeling rushed
Physician biases
Collins et all, 2002; IOM, 2003:Rivadeneyra et al., 2000
Promote Effective Communication
• Translation: When written words in one language are translated
into another. Patient materials must be developed and written in
the clients language.
• Interpretation: Conversation between two speaker is translated
from one language to another including sign language. This is
usually performed by a third party.
• Medical Interpretation: Goes beyond routine interpretation with
emphasis placed on the ability to interpret for the provider and
the patient within a medical context
Patient Communication/Education
• Suggested strategies for effective cross-cultural
– Use open ended questions
– Collect information via conversation rather than intensive
– Do not interrupt the patient
– Communicate in an unhurried manner
– Allow the patient time to ask questions
– Speak in a normal tone
– Explain medical terms in simple language
– Use validating techniques to assure the patient you are
Patient Communication/Education
Suggestions for non-verbal cross-cultural communication:
• Speak directly to the patient.
• Understand that lack of eye contact may not imply lack
if interest.
• Limit the use of gestures.
• Be aware of the patients’ cultural norms for
appropriate distance.
• Social touching of the patient may be unacceptable.
• Slouching or exposing the sole of the foot can be
viewed as unacceptable.
• Use interpreters when needed.
Patient Communication/Education
Patient education to help in understanding the
nature and conditions of their illness and
changing risky behaviors:
– Consider literacy and education level of the patient
– Overcome language barriers through the use of
– Incorporate concepts familiar to patient views
related to health values, beliefs and practices.
Betancourt et al. 1999; Buchwald et al.,1993, Flores, 2000
Clinical Decision Making
• Culturally sensitive clinical decision making must
– The clinicians preconceived assumptions about the patient
and the cause of their illness.
– Professional norms, behaviors and training that distance the
clinician from the patient and their individual needs.
– The complex health care system and institutional operations
that promote cost control, clinical productivity and workforce
competence over patient preferences and individual needs.
Goals of a Culturally Diverse Health
• To value the diverse cultural beliefs of all clients.
• To promote effective communication between
providers and the diverse community of interest
they serve.
• To hire and train for cultural competence with
the same seriousness as applied to other
essential clinical skills.
• To institutionalize cultural competence
Institutionalize Cultural Competence
• Integrate cultural competence into the strategic
planning at all levels
• Include funding for culturally diverse staffing as
well as training and other essential activities.
• Make cultural competence a criterion for
employee evaluation.
• Involve your community of interest in the
process of defining and addressing health
service needs.
Culturally Competent Health Care is
• More complete and specific information gathering is
provided for the provider resulting in more accurate
• Treatment plans supported by the family are developed
which increase patient compliance.
• There is a greater use of health services by ethnic
populations and reduced delays in seeking care.
• Communication between healthcare provides and
patients is enhanced.
• The compatibility between Western and traditional
health practices is enhanced.
Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally
Competent System of Care, Volume I. Washington, DC: Georgetown
University Child Development Center, CASSP Technical Assistance Center.
Denboba, D., U.S. Department of Health and Human Services, Health
Services and Resources Administration (1993). MCHB/DSCSHCN
Guidance for Competitive Applications, Maternal and Child Health
Improvement Projects for Children with Special Health Care Needs.
Census Bureau’s Web site: http://www.census.gov, Foreign-Born Population Data
Paulson and Dekker,, Healthcare Disparities in Pain Management, J Am Osteopath Assoc
James et al., Association of Race/Ethnicity with Emergency Department Wait Times,
Pediatrics 2005;115:e310-e315
Kagawa-Singer and Blackhall, Negotiating Cross-Cultural Issues at the End of Life: "You Got
to Go Where He Lives, JAMA 2001;286:2993-3001
• Achieving Cultural Competence: A Guidebook
for Providers of Services to Older Americans
and Their Families: www.aoa.gov/prof/adddiv/
“Health Care RX: Access for ALL”,The Presidents
Initiative on Race, U.S. Department on Health
and Human Services, Health Resources and
Service Administration, 1999, P.17-18.

Diversity & Cultural Competence in Respiratory Care