Providing Culturally Sensitive Health Care

Today, 11 percent of people living in America were born in another country.16 By 2050, according to some estimates, ethnic minorities will account for 47 percent of the nation's population.¹⁷

No wonder then, that in some areas of the country, hospital signs are written in five or more languages and interpreters are as valuable as a nurse willing to work an extra shift.

Such diversity adds another layer of complexity to interactions between health care professionals and patients. For instance, consider the real-life example of a Native American receiving radiation for cancer. He asks his doctor if he can use the tribal sweat lodge to purify himself. But his Anglo physician recommends against it. The man foregoes the sweat lodge, but feels depressed and spiritually deprived, possibly affecting his overall health and recovery.

"Cultural disparity issues are huge in the health care system," says Nancy Kressin, PhD, an associate professor in the health services department of Boston University who has a grant from the National Institutes of Health to test interventions designed to increase health care providers' cultural competency. "I don't think we really know the dimensions of it."

Even defining cultural competency is challenging. Basically, says Dr. Kressin, it means having the health care practitioner develop an awareness and recognition of the ways in which the sociocultural backgrounds of the patient and provider influence the patient's health. "It's the development of clinical practice skills to provide culturally sensitive care."

For instance, in her work, she finds that different ethnic or cultural groups have different explanations for high blood pressure. African Americans, for instance, are more likely to believe it's related to stress, and that the only way to lower blood pressure is to minimize stress. With that understanding, says Dr. Kressin, culturally appropriate ways could be developed to encourage black patients to take their hypertension medication-even if they have less stress in their lives.

Carmen R. Phaneuf, RN, NP, a nurse practitioner who manages a diabetes program at a family health center in New Jersey, runs up against cultural issues all the time in her practice, where one-third to one-half of her patients are Hispanic. One of her diabetes patients visited a "voodoo doctor" who, he said, "squeezed his pancreas back into place," curing his diabetes. The man stopped taking his insulin, Ms. Phaneuf says, and by the time she saw him, spiked a blood sugar level of 410.

Misunderstanding a patient's cultural context can be dangerous in other ways. Laurie Scudder, RN-C, PNP, a pediatric nurse practitioner, recalls a student nurse who examined a Vietnamese child with what looked like long, narrow bruises over her body. The student was ready to call the authorities and report child abuse when a doctor intervened and explained about the Vietnamese custom of "coining," in which families rub a coin across a child's skin to increase blood flow, sometimes causing bruising. "The family didn't have enough language to explain this practice to the student," she recalls.

Obviously, few health care professionals have the time to become steeped in the cultural uniqueness of all their patients. And they don't have to, says Dr. Kressin.

She recommends a model developed by Cornell University researchers called ESFT: Explanatory, Social risk, Fears and Concerns, and Therapeutic contracting. Through this process, health care professionals ask patients to explain their illness in their own words, try to understand the social or financial issues that may make it difficult for patients to follow prescribed treatment, ask about patient fears and concerns regarding the treatment, and have the patient use the "teach back" technique described in the cover story to ensure they understood the information.

"By using this approach, providers better understand where each individual patient is coming from," she says.