The United States has been called the great “melting pot” in reference to the arrival of various nationalities on its shores. This metaphor assumes that immigrants from diverse backgrounds transform their identities and assimilate to the norms, values, and beliefs of the dominant racial and ethnic group.(1)
The immigration landscape changed over the past several decades, however, and so has the way we view the country’s interracial and multicultural composition. Whereas most immigrants in the early 20th century were Caucasians of European descent, the waves of immigrants since the 1970s have come predominately from Latin America and Asia and are more widely multicultural and multiracial.(2)
This diversity has led to seismic shifts in the racial composition of the United States, with significant growth in major minority groups such as African Americans (13.4%), Hispanics and Latinos (18.5%), and Asians (5.9%).(3)
As such, the notion that the culturally diverse immigrants “melt” and assimilate into the traditional American culture is not entirely accurate. Many modern immigrant groups nurture their specific racial, ethnic, and cultural identities and encourage their children to carry on these traditions in addition to integrating with their adopted country.
Thus, the “salad bowl” metaphor is considered a more precise conceptualization of American immigration since the 1970s: “…not only does the salad bowl metaphor allow for the individuality of ethnic identities it represents, but it also paves the way for selective integration between ethnic groups based on their need to integrate in host societies.”(1,p114) This perspective suggests that the integration process is relational. The culturally diverse immigrants select which values and norms to adopt or adapt and, in turn, stimulate changes to the host nation’s own culture.
Hence, healthcare must be adapted to be mindful and capable of treating culturally diverse patients — something the medical industry has not accomplished, as evidenced by the ethnic and racial disparities in healthcare during the COVID-19 pandemic.
While serving diverse patients’ health and wellness needs can present challenges, it is critical to society. To be culturally competent, physicians must increase their ability to communicate with and care for diverse patient populations.
The Importance of Cultural Competency
Cultural competency is relevant in the United States, with its workplaces’ and its schools’ increasingly broad array of cultural, racial, and ethnic groups. Cultural diversity is linked to several learning benefits, such as enhanced information, knowledge, and creativity.(4) However, before we can learn from one another, we must have a level of understanding about each other.
Cultural competency helps us recognize and respect “ways of being” that are not necessarily our own so that we interact with others in a manner that builds trust, respect, and understanding across cultures. Cultural diversity also makes our country a more interesting place to live as people from diverse cultures contribute new languages, ways of thinking, knowledge, and broadening experiences.
Nonetheless, because we live in an increasingly interconnected and multicultural world, this can generate problems or misunderstandings based on a lack of cultural sensitivity and inadequate communication. Thus, gaining insights about other cultures can help us understand different perspectives of the world we live in and dispel negative stereotypes and personal biases.
Through improved cultural intelligence and efforts to learn more about others from diverse backgrounds, healthcare providers can understand the culturally driven ways that people think, feel, and act. Demonstrating an understanding and sensitivity to other cultures will help us overcome and prevent racial and ethnic divisions and provide better care for all patients. Given the racial and ethnic composition of the United States, it is unlikely that a physician will have a homogenous patient population; consequently, it behooves us to become more culturally sensitive and knowledgeable about the differences among our patients.
Cultural Influences in Healthcare
Caring for diverse populations is a challenge for most providers and healthcare organizations. It is often necessary to bridge chasms related to language, religion, and traditions in caring for patients from culturally diverse backgrounds. While it is not possible for us to review every culture in this article, we include several selected examples in healthcare from geographically and culturally diverse areas.
Note that the examples discussed below are intended to introduce the various aspects of these cultures but that they may not be representative of specific individuals with that cultural heritage. Healthcare providers should listen and learn from each patient and not assume or act on a broad national stereotype. Therefore, we also provide resources for practitioners interested in learning how to better manage patient care for those who are culturally diverse from the providers and their staff.
Providing care for patients with Hispanic or Latino heritage. Patients with Hispanic or Latino heritage may place a premium on personal relationships. With this in mind, asking about the patient’s family and interests before focusing on health issues generally promotes rapport and trust. These patients may be reluctant to discuss emotional problems with their doctor; careful and sensitive probing over multiple visits might be necessary before the patient shares their feelings and emotions.
Large extended families are common in these communities, so several generations of the family may accompany the patient for a medical appointment. The patient may even request that multiple family members be present during the examination.
Modesty is important to Hispanics and Latinos, especially among older women. Healthcare providers should try to keep older women covered whenever possible. Given that these cultures tend to have a higher acceptance of hierarchical order and established gender roles,(5) more traditional women may defer to their husbands in decision-making. Hence, it is important to find out whom they may want to consult before making healthcare decisions.
Since it is common for family members to request that a fatal diagnosis not be shared with the patient, early in the patient-provider relationship, ask the patient and immediate family members how much information and with whom they want it shared.
Family members may resist hospice for fear it will emphasize the fact that their loved one is dying and thus encourage the individual to give up hope or will to live. The family of a terminal patient may also be reluctant to remove life support lest it is seen as encouraging death. Alternatively, if the patient or family believes the illness is “punishment by God,” life support may be considered interfering with the opportunity for patients to redeem their sins through suffering.
Hispanic and Latino patients tend to exhibit a present-time orientation or “live for the moment” mentality, which could impede medical compliance and follow-up care. For example, it may be necessary to explain the need for preventive medication (e.g., related to hypertension or high cholesterol levels) or the importance of finishing antibiotics even after symptoms have subsided.
Among Hispanic patients who follow traditional practices, “fat” is considered a sign of being healthy. Many Mexican foods are high in fat and very high in salt; thus, nutritional counseling may be necessary for people who have diabetes and those who have high blood pressure. It is often helpful to connect compliance with medical treatments to something they care about personally, such as dancing at a daughter’s wedding or seeing a grandchild.
Traditionally, it is common for matriarchs in the community to advise new mothers to avoid cold temperatures, bathing, and exercise for six weeks postpartum. Similarly, they advise that a baby with a fever be bundled up, countering the medical advice and cooling measures the healthcare practitioner suggests to the mother.
Including the grandmother in patient teaching is helpful, because she may have the most influence on day-to-day healthcare issues, especially if she lives with the family.
A chubby baby boy is considered healthy in Hispanic and Latino cultures; consequently, additional instruction regarding diet and diabetes education is often warranted. “Belly button binders,” which some may use to prevent an “outie,” should be part of a discussion. Rather than advising caregivers not to use them, instruct them about making sure the area is clean and that the binder is not too tight.
In these cultures, many diseases are thought to negatively affect children, including mal de ojo (“evil eye”), caída de la mollera (fallen fontanelle, often caused by dehydration), and empacho (stomach pain). The “evil eye” is generally believed to be caused by envious compliments. Healthcare providers should touch the child when giving a compliment, especially if the child is wearing a red string with a large brown seed (“deer’s eye”), denoting belief in the evil eye.
Ask Hispanic patients about their use of herbal remedies. For example, manzanilla (chamomile tea) is used to treat colic, and it is generally safe and sometimes helpful. However, greta (a yellow to grayish-yellow powder) and azarcón (a bright reddish-orange powder) are used to treat empacho (stomach pain), and contain lead, so they can be dangerous.(6)
If providers discover patients are using either or both, it is important not to embarrass patients or make them feel that they made a mistake. Instead, ask what remedies, if any, the patient has tried in a way that implies that all of your patients attempt self-treatment before seeing the doctor. Explain that you need to know what those treatments were to avoid prescribing something that could result in a harmful interaction.
Implying that patients are being criticized for trying home remedies or seeing other healers may lessen their trust and rapport with their doctor; proper cultural sensitivity and communication can circumvent adverse reactions
Providing care for patients with Southeast Asian heritage. Patients of Southeast Asian heritage value hierarchical authority and have great respect for elders in their culture.(5) When relatives accompany a patient for a medical appointment, it is considered respectful to address the eldest person present first — especially if the elder is a male. Adult children are expected to care for their aging parents and will often accompany them to the appointment.
Often, a first- or second-generation family member will be fluent in English and serve as the translator for the patient; however, it is important to note that the translator may not be the decision-maker of the family. Among older generations, men are traditionally the decision-makers, and either the husband or eldest son (e.g., if his father is deceased) may take on the role.
It may be difficult to obtain an accurate health history from older individuals, as many Southeast Asian patients were rarely told the names of illnesses, medicines, or procedures performed in their native countries. Both male and female patients tend to be modest to the extent of avoiding some medical screening procedures such as pap smears, PSA testing, and colonoscopies. Thus, clinicians may need to take extra time to explain the purpose of these screening tests and make every effort to protect the patient’s modesty.
If a patient is diagnosed as terminal, family members may wish to shield them from that fact. Upon admission or when the need arises, healthcare providers should ask patients to identify how much information they want to be given regarding their condition and to whom the information should be provided. In most of Southeast Asia, diagnoses are typically given to the family first; they decide whether to tell the patient.
Southeast Asians practice many different religions or belief systems. For example, many who are Buddhists believe in reincarnation; others practice Christianity; some are traditional animists who believe that spirits inhabit objects and places and that ancestors must be worshipped so their spirits do not harm their descendants. Each of these belief systems comes with its own unique practices that can influence a patient’s medical treatment plan and compliance.
Traditional patients may wish to consult a shaman or a non-medical healer about their diagnosis or treatment plan. It is not unusual for a patient to ask the doctor to share their findings with the shaman and receive the shaman’s opinion. Alternative therapies like cupping and coining (“coin rubbing”) are traditional remedies. Physicians should be careful not to confuse marks left on the body by these practices with forms of abuse. Children may wear “spirit-strings” around their wrists or necks, which should not be cut or removed because some consider these to carry the children’s life-souls.
Finally, some patients might have concerns about blood being drawn. They may fear it will sap their strength, cause illness, force their souls to leave their bodies, or will not be replenished.(6) It requires tact and understanding to encourage these patients to accept this kind of medical testing.
Providing care for patients with Russian heritage. Patients with Russian heritage tend to value power distance (e.g., behaviors represent status roles) and avoid uncertainty (e.g., needing detailed background and contextual information).(5) Formality is of great importance and is a sign of respect. Providers can demonstrate their respect by referring to their Russian patients as “Mr.” or “Ms.” and never assuming that using the first name is appropriate with these patients.
Further, individuals with Russian heritage prefer direct eye contact and communication with their healthcare providers; in contrast, those from Middle Eastern or Southeast Asian cultures avoid direct eye contact as a sign of deference and respect.
Most Russians have a “prepare for the future” mentality and put a high value on punctuality. These patients may arrive early to appointments to be seen first. As such, providers might consider giving Russian patients the first appointment of the day to avoid making them wait. Unlike other cultures, the sex of the provider is usually not an issue with Russian patients. Still, they may prefer to have a family member of the same gender present when receiving personal care (e.g., with male doctors and female patients).
In the past, it was common for physicians to withhold an ominous diagnosis from their patients, but that is no longer considered ethical. Russian patients, however, prefer this approach and often want to withhold fatal diagnoses from the patient. Suppose the physician believes that withholding a medical diagnosis or information may be an issue in caring for a Russian patient. In that case, they might consider asking patients how much information they want to be given regarding their condition or with whom they would like to share the information.
Russian patients, especially elderly individuals, may not like taking large numbers of pills. Providers may improve compliance by spacing medication dosage so that as few pills as possible are given at one time. Notably, patients who participated in the Russian healthcare system typically are uncomfortable choosing among various treatment options because these patients may have been treated under a system that offered no choices — the patient did whatever the doctor recommended.(7) For this reason, the physician will be viewed as an authority figure, and patients are likely to seek their direct recommendations or advice.
Providing care for patients with Middle Eastern heritage. Patients with Middle Eastern heritage are relationship-oriented and value long-term and trusted associations. Effective relationships with Middle Eastern patients often involve two-way communication. The provider may need to share personal information for Middle Eastern patients to feel comfortable sharing information about themselves. Consequently, healthcare providers may be expected to take a personal interest in their patients and their lives.
As with all high-context cultures that rely on implicit and non-verbal communication, it is particularly important to be familiar with their hand gestures, volume or tone of voice, and facial expressions. For example, for many Iranians, the “thumbs up” signal is a rude gesture. Understanding these nuances in culture is crucial to fostering effective and meaningful interactions.
Middle Easterners have a past and present time orientation, meaning that they honor the past and live in the moment. Human interaction is given a higher priority than “clock time,” so physicians must emphasize this expectation if being punctual for appointments is important to the medical practice’s schedule.
These patients are family-oriented; the collective family is seen as being more important than the individual. Providers should expect many family members to participate in the care of the patient.
This concern about the care of a family member should guide physicians to include family members in patient education. The entire immediate family may participate in decision-making, but traditionally the eldest male is the final decision-maker on behalf of the patient. Women typically defer to husbands for decision-making regarding their own and their children’s health. In fact, the husband may answer questions that are addressed to his wife.
Direct eye contact with members of the opposite sex may be interpreted as a sign of sexual interest, particularly from females to males, so female patients may avoid direct eye contact with male providers. Middle Eastern patients will often not be comfortable with healthcare providers of the opposite gender, considering that sexual segregation is extremely important. The medical practice should assign same-sex caregivers whenever possible. Female patients should be ensured modesty with adequate coverings during exams and procedures.
Islam is a dominant force in the lives of many Middle Easterners, so patients of the Islamic faith must have the opportunity to pray facing east toward Mecca several times a day. Furthermore, Muslims may not take medications, eat, or drink from sunrise to sunset during Ramadan. This period of fasting, self-sacrifice, and introspection is based on the Islamic calendar and occurs at a different time each year. Some Muslims may be exempt from daytime fasting if they are ill or pregnant.
Providers should be aware that observant Muslims do not eat pork, which is considered haram (impermissible or unlawful). Medications delivered in pill or capsule form often contain gelatin, which is typically derived from pork. They are also expected to abstain from alcohol, which may be found in cough medicine. For these reasons, Middle Eastern patients may prefer injections that are halal (permissible or acceptable) and which they believe are often more effective.
Many followers of this faith have a fatalistic attitude regarding health and believe that everything is in Allah’s hands (e.g., Inshallah, meaning “God willing”), making their health-related behavior of little consequence or importance. When a Middle Eastern patient is diagnosed as terminal, family members may wish to shield them from that fact. As previously mentioned, it is important to ask patients to identify how much information they want to be given regarding their own condition or to whom the information should be provided.
These patients may not want to plan for death, since doing so can be seen as challenging the will of Allah. Physicians might approach them by demonstrating their understanding and respectfully asking, “Some [Muslim] families feel that making such decisions is interfering with the will of Allah. Is this a belief you share, or do you want to begin discussing the decisions that need to be made?”
Notably, Muslims may not allow for organ donation since, according to Islam, the body should be returned to Allah in the condition in which it was given (whole). For the same reason, they may be reluctant to allow an autopsy, but they will accept a post-mortem examination if required by law. In other cases, those who are in favor of organ donation say that because it can save a life, it falls under the Islamic doctrine that “necessity allows the prohibited.” Physicians should approach these topics carefully to discover the wishes of the patient and family.
Damp, cold drafts, and strong emotions may be thought to lead to illness. For example, the “evil eye” (envy) is believed to cause illness or misfortune. Amulets worn to prevent misfortune include the hamsa (a hand with a blue stone in the palm) or a round blue stone with a blue and white “eye” in the center.(6) Given the importance of cultural nuances to health and wellness outcomes, providers and their staff need greater understanding of the impact of cultural diversity in healthcare.
Improving Physician and Staff Cultural Competency
Physicians and staff must understand the impact of cultural diversity in healthcare. Cultural differences can be a source of frustration for both patients and healthcare professionals and may result in poor health outcomes. By practicing cultural competency when caring for patients from diverse backgrounds, healthcare providers can improve health outcomes, increase patient satisfaction, and reduce frustration.
Developing the cultural intelligence of healthcare providers. Working with people from different backgrounds can be difficult due to cultural barriers that cause misunderstandings and detract from efficient and effective interactions.(8)
Earley and Ang(9) proposed a multifactor concept of cultural intelligence (CQ), defined as an individual’s capability to deal effectively in situations characterized by cultural diversity. CQ has four dimensions: meta-cognition, cognition, motivation, and behavior.
Meta-cognition refers to the control of cognition and is comprised of the processes that individuals use to obtain knowledge. Cognition refers to the actual knowledge of cultural differences that an individual acquires or learns through international experience or education. Motivation is the desire to initiate and direct energy toward learning how to function effectively in an unfamiliar context. Behavior is an individual’s capability to exhibit appropriate verbal and nonverbal actions when interacting with people from diverse cultural backgrounds.(9) Past research on CQ has developed a cultural intelligence scale to measure the level of cultural competency for individuals and employees.(10)
In hiring new employees, a medical practice might measure applicants’ existing levels of CQ in order to determine which individuals would be the best fit for an increasingly diverse patient population. Beyond recruitment and selection of ideal personnel, the medical practice can develop higher levels of CQ in their existing staff. CQ can be learned, developed, and enhanced through exposure to other cultures via educational opportunities (e.g., cultural sensitivity training and workshops) and international travel (e.g., employee retreats and conferences abroad).(11) These training experiences result in better care for culturally diverse patients and growth opportunities for the practice.
Bridging language barriers in healthcare. The most fundamental and essential tool to improving the healthcare of culturally diverse patients is communication skills. Often patients from different backgrounds and cultures do not speak English or have limited English abilities. The patient may not be able to rely on a family member or friend to serve as a translator and interpret or convey medical jargon accurately.
The translator may not understand the need to interpret everything the patient and/or doctor says and may summarize the information instead. Medical interpreter services that the practice can call on at short notice are readily available in most medical communities. We recommend choosing a practical and economical method for the medical practice.
When possible, the translator should conduct face-to-face translations instead of telephone or virtual visits with an interpreter. This enables the interpreter to convey nuances observed in non-verbal communication and help build a relationship between the patient and the care providers. If a practice has large numbers of patients with limited English proficiency, healthcare providers might consider scheduling all patients with a common language in blocks of time. An interpreter could come in for that period and help with multiple patients. The cost for professional interpreters varies from approximately $20 to $26 per hour, but that can fluctuate based on the location and experience of the interpreter.(12)
Another interpreter option is to employ bilingual staff members. If professional interpreters are not feasible for the practice, hire trained and competent dual-role bilingual staff members for roles such as receptionist or medical assistant, or train the existing employees in needed language skills. These staff members can provide interpreter services and perform their regular duties in the clinic, saving the cost of paying an outside interpreter and making the service more accessible.
If neither of these options is viable, the practice could use a remote interpreter service. Telephone interpreter services can be a quick and convenient way to accommodate patients with limited English proficiency when in-person services are unavailable. This is also a great option for infrequently encountered languages or for practices that have only an occasional need for such services.
Many telephone services offer instant access 24 hours a day, seven days a week, and charge by the minute. After the encounter, the standard procedure should be for the interpreter to follow up immediately with written information and instructions in the patient’s native language.
The following are suggestions for using an interpreter:
Ask the patient for permission to use an interpreter.
Provide additional time for the visit.
Speak briefly with the interpreter outside the exam room to explain the purpose and goals of the visit.
Sit facing the patient and speak directly to him or her, not to the interpreter. If using an interpreter over the telephone, conduct the visit in a private room with a speakerphone or a second handset to preserve confidentiality.
Use short sentences and speak slowly and clearly, avoiding the use of medical jargon.
After speaking, pause to allow the interpreter to translate for the patient.
Ask the patient to repeat key information back to you to ensure understanding.
Record the name of the interpreter in the chart.
Understanding and Respecting Cultures
To provide culturally appropriate care, caregivers must learn about the patient’s ethnic and religious background. Some might believe that it is “politically incorrect” to ask about cultural or religious beliefs in a medical examination; however, understanding these cultural aspects is vital to the success of the interaction. The key to success is in the way it is done. If healthcare providers ask patients about their culture with respectful curiosity and genuine interest, most patients are delighted to be the “chief explainer” about their culture.
Take advantage of this excellent opportunity to market medical services to ethnic populations. For example, one of the authors (NHB) has several referring physicians from Vietnam who have many Vietnamese patients. To build a relationship with his Vietnamese colleagues, he contributed articles for their Vietnamese dental and medical journals.
To demonstrate cultural inclusivity, NHB and his staff learned a few words of Vietnamese to use with their patients. Being able to say “hello,” “thank you,” and “good-bye” in another language is not a difficult task, and it goes a long way in helping the doctor and staff to connect on a human level with the local ethnic community. If some words and terms are difficult to pronounce, asking the Vietnamese doctors and patients for some verbal coaching is also a great way to build rapport.
By understanding and respecting the unique healthcare needs of those with cultural differences, the doctor and the practice will find that they can bridge the cultural divide.
The Bottom Line
Focusing on cultural diversity in patient populations may present the potential for stereotyping, which must be avoided. It is important to understand the ecological fallacy, which argues that inferences cannot be made about an individual based on the group’s aggregated, national-level cultural behaviors. Gaining cultural competency allows healthcare providers to treat individuals of diverse backgrounds in an inclusive rather than exclusive manner.
It is never appropriate to make sweeping statements and refer to everyone in a certain culture as “being aggressive” or “always avoiding eye contact.” For instance, although he or she knows that certain cultures generally prefer to keep social distance, the culturally competent practitioner does not assume that everyone from that cultural background wants to socially distance. Culturally competent practitioners use the cultural knowledge they already have, then modify their perspective and behaviors based on their interactions with the specific patient being treated.
Using these guidelines gives healthcare providers a “best first introduction,” but if they are not entirely correct, the provider will have the cultural intelligence to change their approach. We hope these insights will allow you to know your culturally diverse patients in light of the broad generalizations that we have provided. Vive la difference!
References
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Ku L and Flores G. Pay Now or Pay Later: Providing Interpreter Services in Health Care. Health Aff (Project Hope). 2005;24(2):435–444. https://doi.org/10.1377/hlthaff.24.2.435 .