1714 6th Biennial Symposium on Minorities, the Medically Underserved & Cancer Supplement to Cancer Achieving Cultural Competency and Responsive Health Care Delivery Felicia Schanche Hodge, Forrest D. Toms, Ph.D.2 Tessie Guillermo3 1 Dr.P.H. 1 Center for American Indian Research and Education, School of Public Health, University of California at Berkeley, Berkeley, California. 2 Training Research & Development, Inc., Hickory, North Carolina. 3 Asian and Pacific Islander American Health Forum, Inc., San Francisco, California. Presented at the 6th Biennial Symposium on Minorities, the Medically Underserved & Cancer, Washington, DC, April 23–27, 1997. Address for reprints: Dr. Felicia Schanche Hodge, Center for American Indian Research and Education, School of Public Health, University of California at Berkeley, 1918 University Avenue, Suite 2-A, Berkeley, CA 94704. Received June 22, 1998; accepted June 30, 1998. © 1998 American Cancer Society A s we approach the end of the decade and prepare to face the challenges of the new century, it is becoming increasingly clear that the health care industry has largely failed selected segments of the American public, particularly those who are members of ethnic and racial minority groups and other underserved populations. This failure of the health care delivery system to adequately provide culturally appropriate medical services to these groups has led to increased efforts to incorporate culturally appropriate criteria into health care programs and services. This movement was initiated in an effort to provide ways to serve a rapidly growing, diverse patient population. As the demography of the country continues to grow, health care organizations and other institutions must now focus their efforts on how best to offer services to diverse populations. Concerns have also been raised over understanding the make up of ethnic diversity as well as establishing culture sensitivity standards for health programs that adequately address the access needs of all groups. The 1990 Census reports the nation’s population at 248.7 million, a 10% increase since 1980.1 Present demographic changes and projections indicate that populations among racial/ethnic groups continue to grow in the United States. Recent predictions2,3 report that, over the next half century, the United States will undergo dramatic demographic shifts. Between 1996 and the year 2050, Hispanic groups are predicted to increase to 24.5% of the total population; African Americans will account for 14.1%; Asian/Pacific Islanders will account for 8.2%; American Indians, Eskimos, and Aleuts will account for 1.0%; and white Americans will account for 52.8%. Thus, by the year 2050, non-European racial/ethnic groups will represent approximately 47% of the U.S. population. Several states, such as California, have predicted population shifts that will result in the “minority becoming the majority” population.3,4 With the makeup of American society changing, the demands on health service organizations have never been greater. There is a growing need to assist health care providers and organizations in responding to the culturally diverse needs of their clients—a population that has been underrepresented and underserved largely due to personal, societal, and organizational barriers. Establishing Cultural Competency Standards America’s strong value orientation and belief in equal treatment and/or sameness appears to be one of the major barriers to incorporating cultural competency principles into existing health service delivery practices for minorities and underserved groups. Cultural Cultural Competency/Hodge et al. competence includes an awareness, understanding and acceptance of behaviors, attitudes, and beliefs of other groups. It also includes implementing policies in the health care system or agency that enable staff to work effectively in cross-cultural situations. This value of diversity and its acceptance will make the health care system accessible for all groups. The delivery of health care services to diverse populations must take into account cultural and language differences and variance of health beliefs, values, and practices not only among a diverse patient population but also among health service providers, because providers also come to the medical encounter with their own sets of beliefs and ways of interacting. Providers who are not members of the ethnic/minority group that they are serving need to be aware of the cultural and ethnic differences that may affect the quality of care; for such lack of awareness leads to miscommunications and misunderstandings in the medical setting. These misunderstandings can result in noncompliance and inadequate care for patients outside the mainstream. The significance of the patient/provider interaction is paramount to the provision of quality of care. For special populations, such as many American Indians/Alaska Natives, a provider needs to be aware that such factors as direct eye contact and directed questions without attention to the details of their communication style may lead to a medical encounter that is ineffective and prohibitive to their receiving quality health care. Health care professionals’ readiness and preparedness to deliver services to diverse populations also requires leadership skills in the management of organizational diversity. To achieve cultural competency, we recommend: 1. training of health care workers to acknowledge and be aware of the language, health care beliefs, values, and practices of the patient population 2. staff that is representative of clients being served at all points of contact 3. appropriate communication tools (interpreters for verbal communication and translation for written material) 4. recognition of varying language and communication styles that are related to culture/ethnicity 5. sensitivity and respect for cultural practices 6. recognition of the diversity within ethnic and racial communities 7. the establishment of policies and procedures to encourage participation in the design, implementation, and evaluation of programs by both staff and the community 1715 8. provision of health care services that are available, acceptable, accessible, adaptable, and appropriate. (Adapted from “Towards a Culturally Competent System of Care”.5) Establishing cultural competence standards depends heavily on recognizing the needs of the target population. To achieve this goal, health care organizations need to form partnerships or linkages with community groups. These linkages should prove to be instrumental in identifying service needs, to understanding and increasing awareness of the service population, and to establishing acceptable policies and procedures that are needed and valued by the community. The ultimate success of cultural competence may depend largely upon the willingness of the health care delivery system to collaborate with diverse ethnic groups. We have come so far, and there is still work to be done. The further establishment of standards and curricula are still needed to meet the needs of a culturally competent health care delivery system. Moreover, as health care professionals ponder the question of how to better serve diverse clients, even larger questions remain: How will cultural competency be defined and put into operation? What parameters and guidelines must be established in order to develop the necessary policies, procedures, and practices for organizations and providers? Who decides what the standards for policies, procedures, and practices should be? Will the necessary resources be provided to conduct the research and evaluation and to develop the necessary educational tools and resources to increase the awareness, knowledge, and skills of providers? These questions will have to be addressed both nationally and locally. To assist health care systems and providers to move toward achieving culturally competent service delivery, the following considerations are offered: 1. Organize a national initiative to define and set standards for achieving culturally competent systems of care. This initiative would set forth criteria for developing policies, procedures, practices, and methods for monitoring and evaluating programs, services, and personnel. 2. Identify the resources, private and public, to conduct formative and summative research on (a) what programs and services currently exist at the national, state, and local levels; (b) the barriers and roadblocks that ethnic, racial, and underserved groups experience that prevent them from receiving culturally competent care; and (c) the readiness and preparedness of health care providers to deliver culturally competent services. 3. Conduct community needs assessments of under- 1716 CANCER Supplement October 15, 1998 / Volume 83 / Number 8 served and ethnic/racial groups and their communities to determine their needs, existing resources, and effective community-based models. 4. Develop training curricula, program models, and educational tools that can be used to increase the knowledge and skills of providers and clients regarding culturally competent health care delivery. Achieving cultural competency in health care delivery systems requires that providers understand the cultural milieu and viewpoints of their clients in order to determine how their needs can best be served. It requires that providers and their agencies become more culturally self aware of how their values, beliefs, and world views impact on the services they deliver to diverse consumers. It requires that health care organizations take a closer look at the polices, procedures, and practices to make sure they are representative of the client population served. Now that state and local agencies are taking more responsibility for the management of health care services, we encourage them to take a proactive role in cultural competence implementation and evaluation. With the advent of managed care and the changing health care delivery system, states and local areas need to be aware that cultural competence is a significant part of community health and the provision of optimal health care. REFERENCES 1. 2. 3. 4. 5. United States Bureau of the Census. 1990 Census of the population: characteristics of the population. Washington, DC: Department of Commerce, 1990. Toms F, Hobbs A. Who are we: building a knowledge base about different ethnic, racial, and cultural groups in America. Hickory, NC: Training and Research Development, Inc., 1997. Hayes-Bautista D. The health status of Latinos in California. Woodland Hills, CA: The California Endowment and California Health Care Foundation, 1977. Hodge F. The health status of American Indians in California. Woodland Hills, CA: The California Endowment and California Health Care Foundation, 1977. State of California. Towards a culturally competent system of care. vol. 1. Sacramento, CA: Department of Health, 1989.