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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
Center for American Indian Research and Education, School of Public Health, University of California at Berkeley, Berkeley, California.
Training Research & Development, Inc., Hickory,
North Carolina.
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
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
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
7. the establishment of policies and procedures to
encourage participation in the design, implementation, and evaluation of programs by both staff
and the community
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-
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.
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.,
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.
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