Throughout the mid-19th century, clinicians noted the impact of socio-environmental factors on healthcare. From unusually high incidences of breast cancer in Italian nuns to cancers that only seemed to affect chimney sweeps in Great Britain, medical literature of the period carefully traced the connections between cultural background and wellness. This led some physicians to theorize that disease was strongly related to societal dysfunction and inequality, and that improving schools and working conditions could help to alleviate disparities in mortality across social classes.
By the 20th century, the link between cultural factors and health outcomes was well established, as was the recognition of racial disparities in health care. In the United States, the study of how socio-economic status impacts public health quickly broadened to include other categories of inequality. The U.S. Department of Health and Human Services’ landmark report “Health, United States, 1983” revealed that minority populations in the United States bore an unequal share of the total death and illness experienced by Americans.1
THE IMPORTANCE OF CULTURAL COMPETENCE EMERGES
The facts seem clear. But why and how does a patient’s cultural background impact their health outcomes? By the end of the 20th century, researchers turned their attention to this pressing question. They discovered a host of cultural issues impacting every phase of medical intervention: Help-seeking behavior, responses to pharmaceutical interventions, access to healthcare, affordability of care and incidences of specific conditions all vary widely in correlation with cultural background. For clinicians and policymakers, this means that cultural competence is important for understanding and responding to their patients’ needs.
Healthcare providers and organizations exhibit cultural competence when they deliver services that are carefully attuned to the social, cultural and linguistic needs of their patients.2 For the purposes of understanding cultural competence in the framework of public health, we can think of a person’s culture as all of the dimensions that contribute to their worldview, beliefs and behaviors, including their race and ethnicity, language, religious beliefs, socio-economic status and geographic region.3 Each of these dimensions can have a profound impact on health outcomes.
RACE AND ETHNICITY
Race and ethnicity are tightly linked. Ethnicity refers to a person’s nation or nations of origin, while their race is social construct based on physical features like skin color and face shape. Both influence health outcomes on several levels.
In the U.S., cardiovascular disease is the number one killer of women of all races.4 However, white women are more likely than non-white women to consider themselves well-informed of risk factors for cardiovascular disease. Mortality among black Americans is far greater, by as much as 47%, than for white Americans.5 In addition, non-white Americans are more likely to report feelings of unease at the doctor’s office.6
It has been suggested that help-seeking behavior and responsiveness to medical advice is in part responsible for this disparity.7 Non-white patients, especially African Americans and Latinos, are less likely to seek medical intervention at the first sign of symptoms. Additionally, they are slightly more likely to reject physician advice.
However, the relatively small increase in rejection of medical advice (only 3 or 4%) cannot account for the vast disparities between white and non-white patient outcomes. Instead, it has been suggested that a general sense of anxiety and fear of discrimination may be related to both delayed help-seeking and variances in following medical advice.
About 9% of the U.S. population is estimated to have limited proficiency in the English language. Language barriers can present huge challenges in administering healthcare to a diverse population.
In many cases, patient stress can be compounded when receiving medical advice in a language that is not their own or when they’re relying on the accuracy of a translator. This is especially crucial in communicating risk factors associated with medical intervention, where improper understanding could lead a patient to decline lifesaving treatment or fail to comply with instructions.8
Fortunately, language barriers are not insurmountable. In many clinical settings, minor children or relatives with greater English proficiency than the patient are used as interpreters, but this should be avoided, as nuances can be lost in translation. Rather, quality printed materials in a variety of languages can be offered along with professional medical interpreters. The federal government even offers funding and support for the recruitment and training of qualified interpreters.
In 2012, the Journal of the American Medical Association released a study outlining the ways in which the care of American Muslims varied from the rest of the population.9 The study found that certain tenets of the Islamic faith had an effect on the way patients responded to treatment. For instance, the Islamic prohibition against consuming hallucinogenic drugs could cause some patients to decline sedative or narcotic painkillers.
It is difficult to form policy around religious disparities in healthcare. For one, collecting religious data is far from standard for medical practitioners. Additionally, researchers suggest that self-reported religion is less of a factor than an individual’s personal “religiosity,” meaning how deeply they believe in their religious practice and how rigorously they apply its guidelines.
Still, religion is an important consideration in creating treatment plans and health policy.
As it was in the 19th century, so it is today. A person’s social class can have a huge impact on their health outcomes.10 In the United States, this is most pronounced in the areas of a healthcare access and affordability.
Since 1960, healthcare costs have tripled in proportion to our GDP. As healthcare costs have gone up, wages have stagnated, leading to a population who may have limited access to healthcare providers compounded by an inability to access health insurance or other means of paying for their treatment.
The U.S. government has famously battled this cultural factor and its effect on healthcare. The Affordable Care Act was meant to address the access issue, bringing millions of Americans onto the rolls of health insurance providers.
Still, this does not address the fact that low-income patients are less likely to seek healthcare in the first place and more likely to be exposed to high-risk environments due to the terms of their employment or lifestyle. The bonds between economic inequality and healthcare inequality are tightly woven.
As policymakers and providers work to solve this issue, it is incumbent upon healthcare providers to be aware of their patient’s socio-economic status and work with them to find treatment plans that are affordable and effective.
A seminal 2006 study entitled “Eight Americas” looked at the ways an individual’s cultural factors interacted with their geographical location and found startling differences among populations in different locations.11
Between the highest and lowest life expectancies, they found a thirty-five year differential and startling decreases in life expectancy for low-income whites in the Appalachian region. Since these discrepancies couldn’t be explained by other cultural factors, the researchers surmised that something about the regional character of Appalachia was contributing to these numbers.
For policymakers, this means that in addition to federal efforts to eliminate healthcare disparities, it is important to consider local policy changes that can reach individuals in specific locations that could contribute to their willingness to seek and responsiveness to medical treatment.
RECOGNIZING THE NEED FOR CHANGE IN CULTURAL COMPETENCE
Human beings are complex, social animals. It can be difficult to meet people where they’re at, especially when we come from such different backgrounds. Still, it is the goal of all good policymakers to develop systems wherein different populations can experience more or less the same treatment.
As it stands, healthcare in the United States has a long way to go to address its structural inequalities. To do so will require committed involvement on all levels of the process, from the patient to the physician to the policymaker.
Are you ready to improve your own cultural competence and begin to positively impact the health of the world around you? Learn about some of the career options within public health and consider whether an online Master of Public Health (MPH) is your opportunity to take part.
- Retrieved on December 28, 2017, from ncbi.nlm.nih.gov/pmc/articles/PMC1550690/
- Retrieved on December 28, 2017, from hpi.georgetown.edu/agingsociety/pubhtml/cultural/cultural.html#1)
- Retrieved on December 28, 2017, nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect
- Retrieved on December 28, 2017, from strokeassociation.org/idc/groups/heart-public/@wcm/@global/documents/downloadable/ucm_300377.pdf
- Retrieved on December 28, 2017, from ncbi.nlm.nih.gov/books/NBK25528/table/a2000af96ttt00003/?report=objectonly
- Retrieved on December 28, 2017, from webmd.com/anxiety-panic/features/beyond-white-coat-syndrome#1
- Retrieved on December 28, 2017, from hpi.georgetown.edu/agingsociety/pubhtml/cultural/cultural.html
- Retrieved on December 28, 2017, from ncbi.nlm.nih.gov/pmc/articles/PMC4566365/
- Retrieved on December 28, 2017, from sciencelife.uchospitals.edu/2012/06/07/a-religious-approach-to-health-disparities/
- Retrieved on December 28, 2017, from cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/HistoricalNHEPaper.pdf
- Retrieved on December 28, 2017, from journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0030260#s4