Cultural Competency in Caring
for Diverse Populations
Fern R. Hauck, MD, MS
Department of Family Medicine
University of Virginia Health System
POM-1, September 21, 2009
Cultural Beliefs and Health Care
Cultural beliefs influence how people:
• Understand normal bodily functions
• React to signs and symptoms
• Identify abnormal functions
• Classify diseases
• Speculate about and determine etiologies
• Determine their prognoses
• Consult others
• Choose healers and treatments
• Expect healers to behave
• Evaluate results
• Make medical decisions
Different understandings about these
concepts can contribute to disagreement
between healthcare professionals and
their patients!
The Case of MH*
• MH was a healthy 70-year-old Hmong, widowed woman
with an asymptomatic goiter who suddenly had trouble
• Step-sons brought her to the ER, physicians diagnosed
thyroid cyst had ruptured and compressed her trachea.
• They intubated her with an endotracheal (ET) tube after
quickly getting permission from family without presence
of a trained interpreter.
• Days 2-3: Surgical team recommended operation to
remove the blood, remove the thyroid and place a
temporary tracheostomy until the swelling decreased.
• Family: refused surgery, preferring to wait and reevaluate
*Culhane-Pera KA, Vawter DE. J Clin Ethics 1998;9(2):179-90.
The Case of MH (Cont’d)
• Day 4: Surgeons asked for assistance from
family physician who understands the culture
and speaks Hmong, a Hmong patient advocate,
and a trained interpreter.
• Family continued to refuse surgery.
• Patient pleaded to have ET tube removed
because of discomfort and being restrained, felt
she could breathe without it.
• Day 5: Patient and family requested extubation;
family felt swelling had decreased and asked for
trial period of extubation. Family said it would be
ok to re-intubate if needed, patient did not.
Would you extubate MH?
1. Yes
2. No
3. Unsure, need more information
What would you like to know about
the Hmong to help you make a
What would you like to know about
the Hmong?
• Who are the Hmong? Social structure?
Religious beliefs?
• Beliefs about illness/thyroid disease?
Preferred treatments?
• Reactions to surgery? Fears? Concerns?
• How do people make medical
decisions/role of family?
Hmong Culture
• Who are the Hmong? Social structure? Religious
– Began coming to U.S. 30 years ago from Laos after
Vietnam War—they fought on side of U.S. About
187,000 reside in U.S., mostly in CA, WI, MN.
– Previously had been subsistence farmers; exposure
to modern U.S. culture has caused in some Hmong
debilitating chronic illnesses.
– Patriarchal society that values family-based decision
– Animist religion: spirit world and everyday world live
side by side.
Hmong Culture
• Beliefs about illness? Thyroid disease? Preferred
– Illness results from:
• Natural causes (imbalance between yin and yang, buildup of air or
wind in body, change in weather, germs)
• Social causes (fights between people, curses)
• Spiritual causes (loss of soul due to fright, fate)
• Supernatural causes (spirits)
– Healing and healers:
• Coining, herbs, massage
• Soul callers and chanting
• Shamans who communicate directly with wild and tame spirits
– Goiter: caused by build-up of wind in the neck, which if
symptomatic could be relieved by coining and poking with a
needle to release the wind and decrease the pressure (MH’s
family denied that they had done this)
Hmong Culture
• Reactions to surgery? Fears? Concerns?
– Fear of loss of soul, as well as morbidity and
– Unable to fulfill social roles
– Suspicious of doctor’s motivations
– Adverse effects in next life: mutilation, metal
in body
– Usually not accepted unless tests show that
surgery is required for a cure
Hmong Culture
• How do people make medical
decisions/role of family?
– Family is responsible for sick people and
consequences of treatment
– Sons need to be good sons
– Frequently, clan leader, male family leader, or
other patriarchal figure makes decisions
Perspectives of All Parties
• Surgeons:
– Life-saving treatment, would die without ET
tube or tracheostomy
– Confused by different approaches of patient
and sons
– Couldn’t guarantee re-insertion of ET tube
– They have the superior biomedical view
Perspectives of All Parties
– ET tube miserable, causing suffering
– Swelling had decreased, could breathe on
– Up to her to decide, not doctors
– Multiple explanations and alternatives
available to explain the problem
– Considered her needs in this life, next life,
and afterlife
Perspectives of All Parties
• Family:
– Condition had improved (they were examining her
neck often)
– Remove ET tube, but re-insert if needed
– Avoid surgery and tracheostomy
– They and patient have right to decide
– Family responsible for consequences
– Underlying spiritual etiology had been taken care of
(divination ritual determined that dead father was
angry with sons for being disrespectful of their stepmother. Sons made verbal amends.)
– Distrust of surgeons
– Need to be good sons
Now, what would you do regarding
the patient’s and family’s request to
1. Would not extubate.
2. Would extubate.
3. Would transfer to a different physician
who would extubate her.
4. Extubate, but would reintubate if she has
trouble breathing without the ET tube.
How the Story Ends
• Ethics Committee (Day 6) and Hospital lawyer (Day 7)
– Patient and family have right to refuse therapy as they are
competent and understand consequences
– Surgeons are not required to act against their moral values
– Family is responsible for decisions and subsequent outcomes
• Care transferred to another surgeon who removed the
ET tube
• Patient breathed w/ minimal difficulty and was
discharged to home
• Patient found to be doing well at follow-up visit
No matter which cultures are involved, these
areas cause the most difficulty when patient and
provider are from different cultures:
• Meaning & importance of
• Etiologic understandings
• Perceptions of
appropriate treatments
• Psychosocial contexts for
• Autonomy, self-efficacy
• Prevention orientation
and activities
• Family involvement &
• Pain expression &
• End of life decisionmaking
• Informed consent
• Expectations of health
• Willingness to participate
in groups & classes
• Diet and food
Source: Kaiser Permanente, 2003. Cultural Issues in the Clinical Setting.
The LEARN Model for Effective CrossCultural Communication and Negotiation*
• Listen with sympathy and understanding of the
patient’s perception of the problem
– Listen to the patient’s and family’s concepts of illness,
reactions to biomedical approaches, and desires for
• Explain your perceptions of the problem
– Explain your biomedical assessment, using drawings
and other methods that can facilitate understanding
*Berlin EA, Fowkes WC. Western J Med 1983; 139:934-8.
The LEARN Model for Effective CrossCultural Communication and Negotiation*
• Acknowledge and discuss the differences and
– Acknowledge differences and similarities between
Hmong and biomedical perspectives; emphasize
common ground
• Recommend treatment and listen to their
• Negotiate treatment and all areas of care,
accommodating the patient’s and family’s beliefs
and practices
Linguistic Competency
• Minority populations currently comprise ~30% of
the U.S. population
• By 2030, estimated to reach at least 40%
• 45 million people in the U.S. speak a language
other than English at home
• Spanish is the most common language spoken
by limited English proficient (LEP) individuals
• Therefore, medical interpreting has become a
priority for health care in the U.S.
Linguistic Competency Legislation
• August 2000: Department of Health and Human
Services Office of Civil Rights issued “policy
guidance on the prohibition against national
origin discrimination as it affects persons with
limited English proficiency.”
– Recommended that entities develop procedures for
identifying language needs of patients, provide
interpreters, and establish and distribute policies
regarding interpreter services
Linguistic Competency Legislation
December 2000: Office of Minority Health published Standards on
Culturally and Linguistically Appropriate Services (CLAS):
14 standards directed primarily at health care organizations, but
individual providers encouraged to use.
4 are currently mandated for recipients of federal funds:
Offer and provide language assistance services at no cost to LEP patients
during all hours of operation
Provide patients in their own language notices of their right to receive
language assistance services
Assure competence of language assistance; family/friends should not be
used (unless requested by patient); children should never be used
Provide patient-related materials and post signs in commonly encountered
languages of that service area
Small practices are not required to provide the same level of language
services as bigger offices or hospitals
Certain amount of flexibility permitted
Working with Interpreters
• UVA has Language Office
• When appointments made, system automatically
sends request to Language Office
• Language Office schedules internal interpreters
(Spanish) and requests outside interpreters for
other needed languages (included ASL)
• Telephone interpreters available 24/7 as backup
via CyraCom service (“blue phones”) and you
can access also via any phone
Working with CyraCom Interpreters
Other Resources
• Health Sciences Library Website, click on
Culture and Communication in Health
• Numerous books and articles about
specific cultures and practices
• Numerous internet resources
• NY Times Sept. 20, 2009: A Doctor For
Disease, A Shaman For the Soul.

Cultural Competency in Caring for Diverse Populations