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Cultural Competence In Health And Human Services

Nowhere are the divisions of race, ethnicity, and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, disparities continue in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaska Natives, and Pacific Islanders, as compared with the US population as a whole.

Health and human service organizations are recognizing the need to enhance services for culturally and linguistically diverse populations. Providing culturally and linguistically appropriate healthcare services requires an understanding of cultural competence.


What is Cultural Competence?

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. (Adapted from Cross, 1989).(1)

Cultural competence requires that organizations:

  • have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally.
  • have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.
  • incorporate the above in all aspects of policy making, administration, practice, service delivery, and involve systematically consumers, key stakeholders, and communities.

Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum.(2)

Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.(3)

Principles of cultural competence include:(4)

  1. Define culture broadly.
  2. Value clients' cultural beliefs.
  3. Recognize complexity in language interpretation.
  4. Facilitate learning between providers and communities.
  5. Involve the community in defining and addressing service needs.
  6. Collaborate with other agencies.
  7. Professionalize staff hiring and training.
  8. Institutionalize cultural competence.

Improved quality of care is the outcome measure that indicates whether implementing training programs, policies, and culturally or linguistically appropriate standards makes a difference. A new trend in the literature suggests that using cultural competency in a focused or strategic way can be a helpful adjunct to the quality improvement process. For example, if a program wants to analyze patterns of broken appointments, it might examine variables such as age, gender, or race/ethnicity. If the analysis reveals that adolescents have the highest rate of broken appointments, the program can target specific strategies to this group. Does the clinic need to have weekend hours, when teens can more easily slip away from home? Would providing free transportation or reminder calls from caseworkers help? Does the provider reflect a youth-sensitive approach to the clinic's client base?(5)


What's the Difference? Cultural Competence, Awareness, and Sensitivity

Cultural competence emphasizes the idea of effectively operating in different cultural contexts, and altering practices to reach different cultural groups. Cultural knowledge, sensitivity, and awareness do not include this concept. Although they imply understanding of cultural similarities and differences, they do not include action or structural change.(6)


How Does Cultural Competence Apply to HIV/AIDS, Viral Hepatitis, STD, and TB Prevention?

From Health Resources and Services Administration (HRSA) Care ACTION: Improving HIV/AIDS Care in a Changing Environment, August 2002, Mitigating Health Disparities Through Cultural Competence:

The recent National Academy of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care states that "racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as patients' insurance status and income, are taken into account."(7)

These findings and others like them are not news to people concerned with the care of individuals living with HIV disease. Study after study has demonstrated unequal access to care and poorer health outcomes among certain segments of the HIV-positive population. For example, analysis of data from the HIV Cost and Services Utilization Study revealed that compared with nonminorities, women and African Americans with HIV disease who are receiving care are less likely to receive antiretroviral therapy, protease inhibitors, and prophylaxis for pneumocystis pneumonia. These disparities remained even after adjusting for gender, age, education, and insurance coverage.(8) Follow up in 1997 revealed improvements, but African Americans and Hispanics were still only about half as likely as whites to participate in HIV clinical trials or to get experimental medicines. Other minorities were also less likely than whites to get experimental treatment.(9)

Disparities in access to quality care extend beyond race and gender to other segments of the population that are often marginalized. For example, HIV-infected injection drug users are less likely to receive antiretroviral therapy than non-drug users are.(10) It follows that disparities in access to quality HIV care are related to disparities in survival, which have been reflected in AIDS mortality data for some time.(11)

Being competent in cross-cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings.(12) For HIV/AIDS prevention and treatment to succeed, the special needs and life contexts of those who are marginalized because of race, ethnicity, socioeconomic status (SES), sexual orientation, age, or gender must be sensitively addressed. Cultural competence must be demonstrated not only by intervention programs and staff, but also by surveillance staff, researchers (and their investigations), as well as by those delivering prevention services, care, and treatment programs to those who are HIV-infected.


Learn More About Cultural Competence

HIV/AIDS, TB and Cultural Competence

Case Studies in Cultural Competency
From the AIDS Education Training Center--National Multicultural Center

Electronic Library
From the AIDS Education Training Center--National Multicultural Center

AIDS Education and Training Center National Multicultural Center
Web resources on cultural competency including marginalized populations, provider stigma, and HIV health literacy

TB and Cultural Competency
From the New Jersey Medical School Global Tuberculosis Institute

Resources from the AIDS Education Training Centers National Resource Center

Cultural Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment


General Cultural Competence Information

Case Studies: Videos
From the American Academy of Family Physicians

National Standards for Culturally and Linguistically Appropriate Services in Health Care
From the Health and Human Services Department's Office of Minority Health

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS)
From the Office of Minority Health

A Physician's Practical Guide to Culturally Competent Care
From the Office of Minority Health, the Website offers CME and CEU credit and equips health care professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve

A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
From the Office of Minority Health

Cultural and Linguistic Competency
From the Office of Minority Health

Culture, Language, and Health Literacy
HRSA list of online cultural competency resources. Includes culture/language specific and disease/condition specific resources, guidelines for clinicians, research, online training resources, health professional education resources, and more


Assessing Organizational and Practitioner Cultural Competence

HIV Provider Cultural Competency Self-Assessment
From the AIDS Education and Training Center National Multicultural Center


Understanding and Targeting Specific Populations

From National Minority AETC:

Patient Provider Interaction 
Web Resources from The Provider's Guide to Quality and Culture