Barriers to Culturally Competent Health Care

Abstract

Barriers to culturally competent health care are defined as obstacles or hindrances that make it difficult to obtain or access good health or health care. Despite efforts and goals in the United States and many other countries around the world to reduce or eliminate obstacles, significant disparities continue, especially with what the professional literature refers to as vulnerable populations. Vulnerable populations include the following:

Barriers to culturally competent health care are defined as obstacles or hindrances that make it difficult to obtain or access good health or health care. Despite efforts and goals in the United States and many other countries around the world to reduce or eliminate obstacles, significant disparities continue, especially with what the professional literature refers to as vulnerable populations. Vulnerable populations include the following:

• the economically disadvantaged

• racial and ethnic minorities (including those of mixed race or ethnicities)

• the uninsured and underinsured

• older adults

• children

• the homeless

• people with human immunodeficiency virus (HIV)

• people who are stigmatized for whatever reason, which includes substance misuse

• people with chronic health conditions and severe mental illness

• rural populations

• people with low acculturation and low levels of education

• gender disparities

• refugees and undocumented immigrants.

Overall these disparities are due to environmental, psychological, and social factors; maldistribution or shortage of human and fiscal resources; and lack of access to health-care systems. From this list, it seems clear that under the right set of circumstances, any group or individual can be vulnerable.

Barriers can be categorized in several domains that will be discussed in this chapter: language and health literacy, availability, accessibility, affordability, appropriateness, accountability, adaptability, acceptability, awareness, attitudes, approachability, alternative practices, and additional services. It should be noted that these domains are not categorically imperative or perfectly distinct categories; they can overlap.

3.1 Language and Health Literacy

Language and health literacy barriers include the medical jargon used by health-care providers, inadequate reading level of the patient, or lack of fluency in English or in the patient’s mother tongue. Several studies in the United States have identified that a lack of fluency in language is the primary barrier to receiving adequate health care, and not just for people for whom English is a second language.

Language barriers may involve both oral and written language. Interpretation refers to oral communication while translation refers to written communication. Interpretation requires more than word-for-word substitution. Professional interpreters must not only demonstrate bilingual proficiency, but they must also be knowledgeable of idioms, slang, and colloquialisms as well as medical terminology. Sign language may be a concern for some because there is no standard worldwide sign language. Besides American Sign Language, there are multiple Arabic sign languages. Language and literacy barriers may result in the following:

• Language barriers can negatively affect perceptions of patient and provider care, resulting in patients not returning for follow-up care.

• Language barriers may result in a patient leaving against medical advice. A patient who perceives that he or she is not understood by the health-care provider or who does not understand a provider who is using medical technology may simply leave.

• Limited English proficiency (LEP) can result in unsafe situations caused by poor patient comprehension of their medical condition, treatment plan, or discharge instructions; an inaccurate and incomplete medical history being obtained by the health-care provider; ineffective or improper use of medications or serious medication errors; improper preparation for tests and procedures; and poor or inadequate informed consent.

• Be alert to comments and behaviors from patients and family members that might mean they do not understand the provider. Such cues include “Can I take these forms home to complete?” or “I forgot my glasses. I’ll wait until (friend or family member) comes to help me.”

• LEP patients who do not receive professional interpretation services at admission and discharge have longer lengths of stay and higher readmission rates compared with patients who receive professional interpretation services.

• Just because someone speaks the language does not necessarily mean he or she has the skills to be successful at interpretation.

• Improper interpretation is prone to additions, substitutions, omissions, volunteer opinions, and sematic errors.

• Compared with professional medical interpreters, ad hoc interpreters such as patients’ family members or house staff frequently make medical interpretation errors. These errors are significantly more likely to have clinical consequences.

• Use only certified interpreters when at all possible.

• Use dialect specific interpreters whenever possible.

• Create a system for interpretation and translation.

• Compile a list of commonly used words in the dominant languages of the patients using the facility. This list does not replace the need for an interpreter but may be helpful if a professional interpreter is not available.

• Allow time for interpretation.

• Be aware that social class differences can affect interpretation.

• Maintain eye contact with both the patient and the interpreter.

• Non-professional interpretation and using children or other family members can lead to a breach of confidentiality. Also, patients might not speak freely, especially regarding issues such as sexuality, drug and alcohol misuse, and domestic violence.

• Do not place the patient in a precarious situation by asking the patient in front of the family if it is acceptable for a family member or friend to interpret.

• Do not use family members except in nonconfidential situations such as obtaining demographic and admitting data and teaching about medication administration and dietary requirements.

• Do not use individuals known to the family as interpreters due to confidentiality issues.

• Language barriers may involve written as well as oral communication. It is therefore important to provide written materials in the patient’s native language.

• Translate satisfaction surveys into the languages of the population served.

• Translate treatment plans and medication requirements into the languages of the patients who come to the facility.

• Translate pamphlets on common illnesses and diseases into the languages of the patients who come to the facility.

• Ensure that translated material is at a grade 6 reading level.

• Create pamphlets on high-risk behaviors and occupations that are high-risk.

3.2 Availability

Availability is defined as a health-related system offering a needed service and doing so at a time that is reasonable. Patients are routinely referred to Emergency Departments for care when health-care providers’ offices and clinics are closed, adding to patient dissatisfaction and increased cost to the patient and health-care system. Pharmacy hours can be severely restricted in the evening and at night, especially in high crime unsafe neighborhoods, making their services unavailable.

• Create fast-track systems with expanded hours of services in Emergency Departments that can be staffed by advanced practice nurses.

• Open satellite urgent care centers making services more readily available and taking some of the workload off the Emergency Department.

• Provide patients with a temporary supply of medications until the local pharmacy is open.

3.3 Accessibility

Accessibility is defined as the ability of the patient to actually get to a service when needed. Transportation services may not be available, or challenging road conditions and rivers and mountains may make it difficult for people to obtain needed health-care services when no health-care provider is available in their immediate region. Although federal law requires public facilities to be accessible to people with disabilities, there are still private clinics where accessibility may be a problem. Extremely rural hospitals have critical access facilities receive cost-based reimbursement but access can still be a concern when the closest facility is 50+ miles away.

• Make vans available at convenient locations and at specified times to transport patients to clinics.

• Provide guidance for accessing services and navigating the health-care delivery system by advertising in local newspapers, in newsletters, and on public transportation systems. Local convenience stores and restaurants are additional sites to advertising services.

• Provide telephone triage systems where patients and families can talk with a nurse to determine the acuity of a health concern.

3.4 Affordability

Affordability is defined as having the financial resources to access and use health-care services. The service might be available, but if patients do not have financial resources, they may wait until their health condition is more severe, resulting in longer recovery times and an increase in cost.

• Partner with local philanthropic agencies to provide financial services.

• Involve social workers to get patients funds on a temporary basis.

3.5 Appropriateness

Appropriateness is defined as having a service that is needed and congruent with the patient’s and family’s cultural belief system. Maternal and child services might be available, but there might be a greater need for geriatric and psychiatric services. Perhaps the critical access hospital does not have an infectious disease specialist.

• Partner with larger organizations that have full-service capabilities to offer hours in rural areas on a regular basis.

• Offer full-service health promotion and wellness services, testing, and education a few days each week on a regular basis.

3.6 Organizational Accountability

Organizational accountability is defined as health-care providers’ seeking resources for their own education and learning about the cultures of the people they serve.

• Provide cultural competence in orientation programs.

• Obtain local, regional, or national organizations and personnel to provide cultural competence workshops.

• Update staff annually on the practices, values, and health beliefs of the populations the organization serves.

• Provide staff with assessment forms and guides for culturally competent assessment and interventions.

• Incorporate cultural data on intake assessment forms.

• Provide print and online resources for staff.

3.7 Adaptability

Adaptability is defined as the health-care environment being able to change and to offer additional services when needed. For example, a mother brings her child to the clinic for an immunization. Can she get a mammogram at the same time or must she make another appointment?

• Provide several times during the week when full-service health promotion and wellness, services, testing, and education are available. Advertise these hours in local stores, houses of worship, banks, and post offices.

3.8 Acceptability

Acceptability is defined as being able to meet the requirements and provide satisfaction to a patient or family needing a health-care service. Are services and patient education offered in a language preferred by the patient?

• Match sex of the patient and health-care provider whenever requested and if available.

• Provide ethnic concordant providers if requested whenever possible.

3.9 Awareness

Awareness is defined as the patient and family being cognizant of needed health-care services. Is the patient aware that needed services exist in the community? The service may be available, but if patients are not aware of it, the service will not be used.

• Advertise in local newspapers, in newsletters, and on public transportation systems services that are available in the community. Include convenient stores, grocery stores, houses of worship, and restaurants. Include advertisements in foreign languages where appropriate.

• Partner with local and regional radio and television stations (including foreign-language stations) that advertise the services that are available to patients in the community.

3.10 Attitudes

Attitude is defined as a state of mind or feeling about a patient’s or family’s health beliefs and values. Adverse subjective beliefs and attitudes from caregivers increase the chance that the patient will not return for needed services until the condition is more severe. Do health-care providers have negative attitudes about patients’ home-based traditional practices?

• Do not tell patients that they are wrong for using home-based treatments.

• Do not let judgmental attitudes interfere with acceptance of patients and families.

3.11 Approachability

Approachability is defined as the patient or family feeling it is easy to talk or deal with health-care providers. Do patients feel welcomed? Do health-care providers and receptionists greet patients in the manner in which they prefer?

• Greet patients formally until told to do otherwise.

• Introduce yourself by name and position.

• Maintain eye contact without staring when greeting patients and families. Note that in some cultures, people do not maintain eye contact with people in higher social positions.

3.12 Alternative Practices

Alternative practices are defined as complementary and alternative health-care practices and traditional and folk practices. While some practices are not harmful and may be helpful, some patients may overuse folk practices and folk practitioners before seeking allopathic care.

• Incorporate nonharmful alternative practices into treatment plans.

• Partner with local folk healers and educate them on when referral to allopathic care is advisable.

• Refer patients to alternative folk practitioners when the condition (for example: evil eye) warrants it.

3.13 Additional Services

Additional services are defined as value-added benefits that improve health-care access and adaptability. For example, are child- and adult-care services available if a parent must bring children or an aging parent with them for an appointment?

• Network with local organizations and churches that can volunteer sitter services with professional oversight.

• Assist patients with navigating the intricacies of the health-care system.

• Assist patients and families with completing bureaucratic forms.

• Conduct focus groups to determine community needs.

3.14 Reflective Exercises

• 1. What barriers do you see to culturally competent care in your organization? School, work, etc.

• 2. What language barriers to you see in your community such as English as a second language, educational levels, health literacy, etc.?

• 3. What affordability concerns for health care do you see in your community?

• 4. What complementary/alternative health-care practices do you use?

• 5. What complementary/alternative health-care practices are available in your community?

• 6. How do you want to be addressed? First name, last name with a title?

• 7. How do you address older people in your community? First name, last name with a title?

• 8. Is public transportation readily available to health-care services in your community? What might be done to improve them?

• 9. What does your organization do when a patient needs an interpreter?

• 10. In addition to English, what other languages are health care instructions provided in your organization?