How Cultural Competence Reduces Racial Disparities in Health

A model of evidence-based culturally competent healthcare for COVID-19 and more.

Posted Apr 14, 2020

Recent articles have purported that COVID-19 is negatively impacting Black and Latina/o American communities to a greater extent than White communities. One reason cited for this disparity is the result of limited access to healthcare, which is associated with lower socioeconomic status and higher rates of preexisting health conditions.

However, research supports that racial/ethnic health disparities are significantly more complex and can also be attributed to the direct effects of racial discrimination and healthcare service delivery disparities. By addressing tangible predictors of racial mental and physical health disparities, practical action steps can be implemented. This will also limit the negative stereotypes and implicit blame that can be placed on Latina/o and Black individuals for racial health disparities.

I propose that racial mental and physical health disparities must be addressed with a multilevel approach. Ideally, that approach would include interventions at multiple levels of the environment (e.g., community, social, structural). However, this is beyond the scope of this article. Here I'll focus on addressing racial health disparities at three levels of healthcare organizations, including the organizational, leadership, and provider/staff level, with a culturally competent healthcare approach.

Culturally competent healthcare interventions have previously addressed racial health disparities (Handtke, Schilgen, & Mösko, 2019), and thus could reduce health disparities related to COVID-19 and other illnesses. My evidence-based, systemic, and culturally competent model—or ESC model—includes: 1) reconceptualization of health to include physical and mental health outcomes, 2) culturally competent services at all organizational levels, and 3) continuous prioritization and measurement of culturally competent services.

In future posts, I will also address the notion of intersectionality and racial health disparities, or how interactive social identities impact an individual’s health status.

Predictors of Racial Disparities in Health 

Racial discrimination experienced by Latina/o and Black individuals is a direct and significant predictor of negative mental and physical health outcomes, even after controlling for the effects of socioeconomic status in some studies (Lee & Ahn, 2012; Pascoe & Richman, 2009; Williams & Mohammed, 2009). Notably, even greater racial discrimination among higher socioeconomic status Latina/o and Black individuals has been found, which has subsequently explained a portion of racial health disparities experienced by Black individuals (Colen, Ramey, & Williams, 2018).

Two forms of racial discrimination are recognized in the literature, including subtle or chronic (also referred to as racial microaggressions) and overt or acute (Sue, 2010). In my doctoral dissertation, I found that both racial microaggressions and overt/acute racial discrimination were significantly linked to negative mental health outcomes among Latina/o adults (Campos, 2015), whereas other research has linked both forms to poor physical health outcomes among Black and Latina/o individuals (Williams & Mohammed, 2009). 

Perceived racial discrimination is conceptualized as an identity-specific and chronic stressor that results in biological changes, such as cellular aging, that can lead to impairments of multiple biological systems (Seeman et al. 2004). These impairments in biological systems are hypothesized to subsequently contribute to physical and mental illnesses, such as hypertension, adverse cardiovascular outcomes, and psychological disorders (Dolezsar et al.  2014; Lewis, Cogburn, & Williams, 2015).

In addition to the stress pathway, another proposed pathway presents poor health-related behaviors as a mediator between racial discrimination and poor mental and physical health outcomes (Pascoe & Richman, 2009). Because negative mental health symptoms directly and indirectly affect physical health (Ohrnberger, Fichera, & Sutton, 2017), mental health must be viewed as integral to physical health. As noted, racial discrimination is independently linked to negative mental and physical health outcomes, underscoring the importance of addressing both as unique health outcomes. 

Actual disparities in healthcare service delivery are also found to be significant predictors of racial health disparities. Indeed, the general public has come to understand the notion of racial microaggressions occurring repeatedly across settings inclusive of healthcare settings (Sue, 2010). Racial/ethnic minority individuals often receive lower quality healthcare services, such as fewer diagnostic procedures (Williams, Lawrence, & Davis, 2019) and negative verbal and nonverbal communication styles from providers (Penner et al. 2018). Healthcare providers/staff often receive limited—if any—evidence-based culturally competent service training that could address existing limitations.

Organizational, Leadership, and Provider/Staff Interventions to Address Racial Disparities in Health

Intervention 1. Healthcare organizations at all levels must reconceptualize health to include physical and mental health outcomes 

This intervention would require healthcare organizations, leaders, and providers/staff to view health as a multidimensional construct inclusive of both mental and physical outcomes.  

Level 1: Healthcare organizations should aim to provide a broader range of services, inclusive of mental health services when appropriate and consistent with their business models and strategies. For example, counseling services that address an individual’s overall wellness may be provided, particularly in light of understanding how racial discrimination impacts both physical and mental health among Latina/o and Black individuals. Subsequently, processes must be established to hold providers accountable for successfully delivering mental and physical health services to racial/ethnic minority individuals. This will be reviewed further in the second intervention. 

Level 2: Next, healthcare leaders must promote and model values consistent with the reconceptualization of health as a multidimensional construct, particularly in light of providing comprehensive services that target racial health disparities. Leadership should set clear expectations of providers/staff to use measures that assess patients’ mental health symptoms (e.g, psychological symptom screening measures, clinical interviews) in addition to physical health symptoms. 

Level 3: Providers/staff, as noted, should assess mental health symptoms through screenings, clinical interviews, or other methods to determine the presence and possible social causes of existing mental and physical health symptoms. In working with racial/ethnic minority individuals, providers/staff should asses the specific role racial discrimination may have in existing symptoms. As clinically indicated, providers should refer patients to an appropriate mental health provider (e.g., psychologist) while considering the patient’s cultural identity, background, and provider preference in terms of linguistic and cultural matching. 

Intervention 2. Culturally competent services must be applied at all levels

This intervention would require culturally competent services to be applied at the organizational, leadership, and provider/staff level. Specific actions must be taken at each level that are practical rather than theoretical and result in effective change.

Level 1: At the organizational level, hiring and retaining Latina/o and Black employees must be prioritized. Leadership pipelines of racial/ethnic minority individuals should also be established in order to increase equal racial/ethnic representation at leadership levels. Extensive research denotes that equal representation of racial/ethnic minority individuals at all organizational levels (including provider and staff levels) predicts positive organizational, employee, and patient outcomes.

Level 2: Leadership must also receive leadership development training intended to effectively facilitate cultural competence among providers/staff. In order for providers and staff members to excel in implementing culturally competent services, they must be supported by leadership that values employee diversity and inclusion. Inclusive leadership development trainings are recommended. It should be noted that not all leadership development trainings are created equally, with research supporting limited positive outcomes from some leadership development programs. However, when leadership development trainings are supported by evidence-based models, positive organizational and employee improvements have been found.

Level 3: Providers and all staff members should attend culturally competent service trainings as required by the organization. Providers and staff members should also seek additional opportunities to expand their repertoire of culturally competent skills and abilities. As previously noted, not all trainings are created equally, and thus, evidence-based trainings and consultants must be sought by the organization. In one study, providers receiving evidence-based cultural competence training demonstrated significant improvements in diversity attitudes and decreased unconscious bias when compared to a hospital that did not receive the training (Weech-Maldonado et al. 2016). Evidence-based cultural competence models should at a minimum facilitate understanding a patient’s worldview, including his or her linguistic and cultural matching preferences; cultural values that can positively and negatively impact health; and sociocultural factors (e.g., racial discrimination) that can positively or negatively impact health. Cultural competence also includes ongoing introspection of one’s intersecting social identities, implicit and explicit biases, and personal values and beliefs. 

Intervention 3.  Healthcare organizations, leadership, and providers/staff must continuously prioritize and measure culturally competent service delivery

This intervention would require providers and all staff members to accept accountability for measuring and monitoring their culturally competent service delivery. Organizations and leaders must also hold providers and all staff members accountable.

Level 1: Healthcare organizations must consider culturally competent service delivery as an imperative to target racial health disparities. Existing gaps in culturally competent services must be identified through focus groups and quantitative surveys with both providers/staff and patients. Subsequently, these gaps can be used to guide strategic goals and identification of metrics to measure goal attainment (e.g., increased racial/ethnic minority patient appointment follow-up, increased patient adherence to treatment).

Level 2: Next, healthcare leaders must hold their providers and staff accountable for meeting measurable targets and goals associated with culturally competent service delivery (e.g., racial/ethnic minority patient retention, increased patient adherence to treatment). For example, related performance expectations should be reviewed and discussed at least quarterly.

Level 3: Providers and all staff members should assess their own cultural competence through introspection, peer support groups, and feedback from patients. Although leadership is expected to hold providers accountable, providers and staff members must also feel as though they are part of a workplace culture that expects individual accountability.  

In sum, this ESC model and the associated interventions have the power to address racial physical and mental health disparities among Black and Latina/o communities in the United States. Healthcare organizations, leaders, and providers/staff are encouraged to view themselves as part of the solution to a long-standing socio-cultural issue.

References

Campos, I.D. (2015). Acculturation, enculturation, and familismo as moderators in the links of general racial discrimination and racial micro aggressions with posttraumatic stress symptoms. (Doctoral dissertation). Available from ProQuest Dissertations & Theses Global database. (UMI No.10679093). 

Colen, C. G., Ramey, D. M., & Williams, D.R. (2018). Racial disparities in health among non poor African Americans and Hispanics: The role of acute and chronic discrimination. Social Science & Medicine, 199, 167-180. https://doi.org/10.1016/j.socscimed.2017.04.051

Dolezsar, C. M., McGrath, J. J., Herzig, A. J. M., & Miller, S. B. (2014). Perceived racial discrimination and hypertension: A comprehensive systematic review. Health Psychology, 33(1), 20–34. https://doi.org/10.1037/a0033718

Handtke, O., Schilgen, B., & Mösko, M. (2019). Culturally competent healthcare - A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PloS one,14(7), e0219971.  https://doi.org/10.1371/journal.pone.0219971

Lee, D. L., & Ahn, S. (2012). Discrimination against Latina/os: A meta-analysis of individual-level resources and outcomes. The Counseling Psychologist, 40, 28-65. doi:10.1177/0011000011403326

Lewis, T. T.,  Cogburn, C. D., Williams, D. R. (2015). Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. Annual Review of Clinical Psychology, 11, 407–40. https://doi.org/10.1146/annurev-clinpsy-032814-112728

Ohrnberger, J. Fichera, E., & Sutton, M. (2017). The relationship between physical and mental health: A mediation analysis. Social Science Medicine, 195, 42-49. https://doi.org/10.1016/j.socscimed.2017.11.008

Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta- analytic review. Psychological Bulletin, 135, 531-554.  doi:http://dx.doi.org.lp.hscl.ufl.edu/10.1037/a0016059

Penner, L. A., Phelan, S. M., Earnshaw, V., Albrecht, T. L., & Dovidio, J. F. (2018). Patient stigma, medical interactions, and health care disparities: A selective review. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), Oxford library of psychology. The Oxford handbook of stigma, discrimination, and health (p. 183–201). Oxford University Press.

Seeman, T. E., Crimmins, E., Huang, M. H., Singer, B., Bucur, A., Gruenewald, T., et al. (2004). Cumulative biological risk and socio-economic differences in mortality: MacArthur studies of successful aging. Social Science & Medicine, 58, 1985–1997. 

Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. New York, NY: Wiley & Sons. doi:10.1016/S0277-9536(03)00402-7.

Weech-Maldonado, R., Dreachslin, J.L., Epane, J.P., Gupta, S., & Wainio, J.A.  (2016). Hospital cultural competency as a systematic organizational intervention. Healthcare Management Review, 43 (1), 30-41. doi: 10.1097/HMR.0000000000000128

Williams, D.R.,  Lawrence, J.A.,  Davis. B.A. (2015). Racism and Health: Evidence and Needed Research. Annual Review of Public Health, 40, 105-125. https://doi.org/10.1146/annurev-publhealth-040218-043750

Williams, D.R., & Mohammed, S.A. (2009). Discrimination and racial disparities in health: evidence and needed research.  Journal of Behavioral Medicine, 32, 40-47. doi: 10.1007/s10865-008-9185-0