Culture Competency
Nowhere are the divisions of race, ethnicity, and culture more sharply drawn than in the health of the people in the United States. Despite recent progress in overall national health, disparities continue in the incidence of illness and death among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, Alaska Natives, and Pacific Islanders, as compared with the US population as a whole.
Health and human service organizations are recognizing the need to enhance services for culturally and linguistically diverse populations. Providing culturally and linguistically appropriate healthcare services requires an understanding of cultural competence.
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or
among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).1
Cultural competence requires that organizations:
- have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally.
- have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.
- incorporate the above in all aspects of policy making, administration, practice, service delivery, and involve systematically consumers, key stakeholders, and communities.
Cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum.2
Cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.3
Principles of cultural competence include:
- Define culture broadly.
- Value clients’ cultural beliefs.
- Recognize complexity in language interpretation.
- Facilitate learning between providers and communities.
- Involve the community in defining and addressing service needs.
- Collaborate with other agencies.
- Professionalize staff hiring and training.
- Institutionalize cultural competence.
Improved quality of care is the outcome measure that indicates whether implementing training programs, policies, and culturally or linguistically appropriate standards makes a difference. A new trend in the literature suggests that using cultural competency in a focused or strategic way can be a helpful adjunct to the quality improvement process. For example, if a program wants to analyze patterns of broken appointments, it might examine variables such as age, gender, or race/ethnicity. If the analysis reveals that adolescents have the highest rate of broken appointments, the program can target specific strategies to this group. Does the clinic need to have weekend hours, when teens can more easily slip away from home? Would providing free transportation or reminder calls from caseworkers help? Does the provider reflect a youth-sensitive approach to the clinic’s client base?5
What's the Difference? Cultural Competence, Awareness, and Sensitivity
Cultural competence emphasizes the idea of effectively operating in different cultural contexts, and altering practices to reach different cultural groups. Cultural knowledge, sensitivity, and awareness do not include this concept. Although they imply understanding of cultural similarities and differences, they do not include action or structural change.6
What is Cultural Competence?
How Does Cultural Competence Apply to HIV/AIDS, Viral Hepatitis, STD, and TB Prevention?
From Health Resources and Services Administration (HRSA) Care ACTION: Improving HIV/AIDS Care in a Changing Environment, August 2002, Mitigating Health Disparities Through Cultural Competence:
The recent Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care states that "racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as patients' insurance status and income, are taken into account.”7
These findings and others like them are not news to people concerned with the care of individuals living with HIV disease. Study after study has demonstrated unequal access to care and poorer health outcomes among certain segments of the HIV-positive population. For example, analysis of data from the HIV Cost and Services Utilization Study revealed that compared with nonminorities, women and African Americans with HIV disease who are receiving care are less likely to receive antiretroviral therapy, protease inhibitors, and prophylaxis for pneumocystis pneumonia. These disparities remained even after adjusting for gender, age, education, and insurance coverage.8 Follow up in 1997 revealed improvements, but African Americans and Hispanics were still only about half as likely as whites to participate in HIV clinical trials or to get experimental medicines. Other minorities were also less likely than whites to get experimental treatment.9
Disparities in access to quality care extend beyond race and gender to other segments of the population that are often marginalized. For example, HIV-infected injection drug users are less likely to receive antiretroviral therapy than non-drug users are.10 It follows that disparities in access to quality HIV care are related to disparities in survival, which have been reflected in AIDS mortality data for some time.11
Being competent in cross-cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings12. For HIV/AIDS prevention and treatment to succeed, the special needs and life contexts of those who are marginalized because of race, ethnicity, socioeconomic status (SES), sexual orientation, age, or gender must be sensitively addressed. Cultural competence must be demonstrated not only by intervention programs and staff, but also by surveillance staff, researchers (and their investigations), as well as by those delivering prevention services, care, and treatment programs to those who are HIV-infected.
Learn More About Cultural Competence
HIV/AIDS, TB and Cultural Competence
Case Studies in Cultural Competency
From the AIDS Education Training Center—National Multicultural Center
Compendium of Culturally Competent Promising Practices
From the AIDS Education Training Center—National Multicultural Center
From the AIDS Education Training Center—National Multicultural Center
AIDS Education and Training Center National Multicultural Center
Web resources on cultural competency including marginalized populations, provider stigma, and HIV health literacy
TB and Cultural Competency (PDF)
From the New Jersey Medical School Global Tuberculosis Institute
Mitigating Health Disparities Through Cultural Competence (PDF)
From Health Resources and Services Administration (HRSA) Care ACTION
A Clinical Guide on Supportive and Palliative Care for People with HIV/AIDS
From HRSA, the guide offers chapters on Culture and Care and Special Populations
Survey of Americans on HIV/AIDS -- Part Three: Experiences and Opinions by Race/Ethnicity and Age
From the Henry J. Kaiser Family Foundation
Cultural Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment
From the New Jersey Medical School Global Tuberculosis Institute
Migrant and Seasonal Farmworkers: Health Care Access and HIV/AIDS in this Population (PDF)
From the New York State Department of Health
Cultural Competence: Caring for Veterans living with HIV/AIDS (PDF)
From the AIDS Education and Training Center National Multicultural Center
General Cultural Competence Information
From the American Academy of Family Physicians
Online resources to improve the accessibility and quality of health care for minority, immigrant, and indigenous communities
From HRSA
National Standards for Culturally and Linguistically Appropriate Services in Health Care (PDF)
2001 FINAL REPORT from the Health and Human Services Department Office of Minority Health
National Standards on Culturally and Linguistically Appropriate Services (CLAS)
From the Office of Minority Health
From the Office of Minority Health
A Physician’s Practical Guide to Culturally Competent Care
From the Office of Minority Health, the Website offers CME and CEU credit and equips health care professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve
A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
From the Office of Minority Health
From the Office of Minority Health
From the Office of Minority Health
Culture, Language and Health Literacy
HRSA list of online cultural competency resources. Includes culture/language specific and disease/condition specific resources, guidelines for clinicians, research, online training resources, health professional education resources, and more
Compendium of Cultural Competence Initiatives in Health Care
From the Henry J. Kaiser Family Foundation, a report on public and private sector activities to reduce cultural and communication barriers to health care
Assessing Organizational and Practitioner Cultural Competence
HIV Provider Cultural Competency Self-Assessment
From the AIDS Education and Training Center National Multicultural Center
From the Health Resources and Services Administration Center for Health Services Financing and Managed Care
Cultural Competence Health Practitioner Assessment (CCHPA)
From the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development
From the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development
From the National Center for Cultural Competence at Georgetown University’s Center for Child and Human Development
Understanding and Targeting Specific Populations
From National Minority AETC:
- BESAFE: A Cultural Competency Model for African Americans
- BESAFE: A Cultural Competency Model for American Indians, Alaska Natives, and Native Hawaiians
- BESAFE: A Cultural Competency Model for Asians and Pacific Islanders
- BESAFE: A Cultural Competency Model for Latinos
- BESAFE: Un Modelo de Competencia Cultural para Latino
Web resources from The Provider’s Guide to Quality and Culture
Web Resources from The Provider’s Guide to Quality and Culture
1 What is Cultural Competency? Office of Minority Health
2 Conceptual Frameworks / Models, Guiding Values and Principles, National Center for Cultural Competence, Center for Child and Human Development, Georgetown University,
3 Davis, 1997, cited in How is Cultural Competence Integrated in Education, by Mark A. King, Anthony Sims, & David Osher, Center for Effective Collaboration and Practice
4 HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
5 HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
6 How Does Cultural Competency Differ from Cultural Sensitivity/Awareness? Center for Effective Collaboration and Practice
7 National Academies Press, Washington, DC, 2003
8 Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. N Engl J Med. 1998;339:1897-904, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
9 Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281:2305-15, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
10 Celentano DD, Galai N, Sethi AK, et al. Time to initiating highly active antiretroviral therapy among HIV-infected injection drug users. AIDS.2001;15:1727-8, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
11 Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2001;13(1):34-5.Tables 29, 30, cited in HRSA Care Action: Mitigating Health Disparities Through Cultural Competence
12 How is Cultural Competence Integrated in Education, by Mark A. King, Anthony Sims, & David Osher, Center for Effective Collaboration and Practice
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