12Culture and competence: Ethnicity and race
Abstract: Increased racial/ethnic diversity and mobility worldwide is leading inevitably to more frequent communication across racial/ethnic cultures where cultural communication competence is vital. Instead of treating cultures as static, demographic categories, we explicate these competencies by adopting the definition in speech code theory that views culture as the codes and practices that accomplish goals. Consequently, cultural communication competence would constitute the codes and practices that help achieve communication goals in specific contexts with specific groups of people. The codes describe the rule systems that define communication competence in various cultures such as the expectations of appropriate and effective communication in a given context. Practices are the enactments of competent communication often considered skills. Finally, functions describe desirable communication outcomes and provide an understanding of what it takes to achieve those outcomes. Lack of communication competence across racial/ ethnic cultures is implicated in adverse physical, psychological, educational, and relational outcomes. The chapter uses the health context as an exemplar to examine how codes and practices affect health outcomes and how interventions can improve cultural health communication competencies.
Keywords: ethnicity, race, culture, ethnic glossing, codes, practices, functions, health disparities
1Introduction
The racial and ethnic diversity around the “global village” requires the attention of anyone studying communication processes. Based on a sample of 160 countries around the globe, Fearon (2003) found 822 ethnic groups that were larger than 1 % of the total population for their respective countries, and half of the countries worldwide have between three to six ethnic groups that constitute a significant proportion of their national populations. Such racial/ethnic diversity continues to increase with rising immigration in different parts of the world, such as England and Wales (Office for National Statistics 2013), Canada (National Household Survey 2011), New Zealand (Statistics New Zealand 2013), China (National Bureau of Statistics of the People’s Republic of China 2011), and South Korea (National Statistics 2012). The United States, in particular, shows an increasing level of diversity, and projections suggest that the country soon will become a “minority majority nation” (i.e., whites will make up less than 50 % of all ethnic/racial groups) (U.S. Census 2012). With such increasing racial/ethnic diversity and mobility across national borders, communication across ethnic and racial cultures inevitably raises questions about communication competencies that must be addressed and reflected in theory, research, and practice.
This chapter discusses communication competence in an ethnic/racial cultural context in which language and other differences pose obstacles and challenges as well as opportunities. The focus is on racial/ethnic minority groups and describing the challenges they may face, such as discrimination, poor education outcomes, poor parent–child relationships, and disparities of health care and health outcomes, which are influenced by a lack of cultural communication competence. Much of the literature is drawn from the U.S. culture but is intended as exemplars to illustrate cultural competence issues that exist in other national and cultural contexts. The health care context is discussed in greater detail given its significant influence on people’s lives with particular consideration to how ethnic/racial cultural competence plays a role in improving health care access and quality; thereby reducing health disparities (see also, Chapter 19 in this volume). The chapter concludes with suggestions on cultural competence interventions.
2Communication competence
Spitzberg (1988) defined communication competence as “the ability to interact well with others” where “the term ‘well’ refers to accuracy, clarity, comprehensibility, coherence, expertise, effectiveness and appropriateness” (p. 68). The judgment of competence is based on social evaluations of what is appropriate and effective (Spitzberg 2000), and it involves values, rules, norms, and expectancies. The dimensions of communication competence are identified as motivation (an individual’s approach/avoidance orientation in various social situations), knowledge (plans of action, knowledge of how to act, procedural knowledge), and skill (behaviors actually performed) (Spitzberg and Cupach 1984). These three interdependent dimensions correspond with cognitive (knowledge and understanding), affective (attitudes and feelings), and behavioral (behavioral skills) components. This chapter is premised on the belief that ethnic/racial culture is intricately implicated in all of these aspects of competence.
3Culture
To provide an in-depth analysis of how ethnic/racial culture and competence are intertwined, it is important to first define culture. Here, we avoid treating ethnic/racial culture and competence as a demographic category so as not to over-simplify its complexity and richness (Schoenberg et al. 2005). The categorical approach leads to what Trimble (1990) called “ethnic glossing” in which cultures are treated as homogenous groupings. This homogenous view is inconsistent with findings that have demonstrated at least as many variations within as across groups (Mann et al. 1998). Categorizing also suggests that individuals have a single cultural affiliation; this assumption is at odds with a mobile, multicultural world in which multi-racial/ethnic children are becoming more common and multiple identities are typically salient in any interaction (e.g., gender, ethnic, role identities). This view has important implications for understanding competent communication adaptation for various subgroups within a larger group, especially when overlapping memberships and multiple identities exist.
In this chapter, we adopt the definition of culture suggested in speech code theory (Philipsen, Coutu, and Covarrubias 2005). We argue that defining culture as a speech code that is enacted through communication in a community context is appropriate in recognizing variations within racial/ethnic groups and multiple identities because it focuses on processes, functions, and structures that are common across a variety of cultural definitions (Baldwin et al. 2006). Hence, this definition provides a better framework to discuss communication competence.
Speech code theory is based on the ethnography of communication (Philipsen, Coutu, and Covarrubias 2005) that takes a bottom up approach to observe communicative conduct of people in a community, grounding definitions of culture in the interpretations and explanations of situated conduct that produces codes of meaning and value. In other words, human beings draw on contextual factors and previous experiences with similar incidences or interactions and similar populations to interpret and explain speech conduct. These explanations form codes of meaning and value that are enacted, formulated, and reformulated through speech conduct.
A key concept in this theory, speech code, is defined as “a system of socially-constructed symbols and meanings, premises, and rules, pertaining to communicative conduct” (Philipsen 1997: 126). Thus, speech code is a construct that observer-analysts formulate to interpret and explain communicative conduct in a particular speech community. Specifically, the observer notices and uses resources to interpret and judge participants’ lives within a community. Based on these observations, researchers construct hypotheses about the lives of the people in the community, which is then used for future interpretations and evaluations. These formulated hypotheses are considered the speech codes (structures) that are enacted in practices (processes) to achieve outcomes (functions).
One virtue of this theory is it suggests that culture is seen as an evolving complex of structures, functions, and processes that humans observe, describe, and socially construct over the course of their social lives. This theory centers on the person who can construct, deconstruct, ignore, alter, or adapt it to new purposes. At the same time, the theory abstracts the codes, practices, and functions to describe situated cultures. This approach highlights the flexibility and fluidity of culture, and conceptualizes it not as a static entity, but rather as a constantly constructed and evolving process that is co-created through human interactions and conduct.
This view of culture is important in analyzing communication competence among racial and ethnic groups as it situates communication competence in what is appropriate and normative for specific groups or other subgroup identities (e.g., based on socioeconomic status, profession, etc.) and requires adaptation to the various cultural codes, practices, and functions within a social context. The emphasis of this theory is on observing, formulating hypothesis, and then interpreting and evaluating, which is particularly helpful in approaching racial/ethnic groups without preconceptions of the culture and the people being studied. The use of this theory represents an emerging trend in culturally grounded research (Hecht and Krieger 2006). While developed using an ethnographic method, we believe the theory is appropriate to methodological pluralism. Keeping this definition of culture in mind, we turn to cultural communication competence.
4Defining culturally competent communication
Communication competence is clearly implicated by the definition of culture as constituting codes and practices that accomplish goals. These codes are the rule systems that define competence; practices are the enactments of competent communication, and functions are the goals they achieve. However, the task is problematic because, as yet, there is no single, universally accepted definition of cultural competence. The United States Department of Health and Human Services (DHHS 2001) defines cultural competence as “the ability … to understand and respond effectively to the cultural and linguistic needs” (p. 25) of interactants. Cross et al. (1989) defined cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” (p. 13). Orlandi (1992) defined it as “a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups” (p. vi). Further, Moritsugu (1999) focused on culture-specific knowledge and defined cultural competence as “the knowledge and understanding of a specific culture that enables an individual to effectively communicate and function within that culture. This competence usually entails details regarding language and metalanguage, values, and customs, symbols and worldviews” (p. 62). Dunn (2002) defined cultural competence as “the ability to communicate between and among cultures and to demonstrate skill outside one’s culture of origin” (p. 107).
Despite their variety, these definitions describe cultural competence as practices (e.g., behaviors, attitudes, knowledge enacting competent communication) andfunctions (e.g., effective communication). Codes are implicated in some of these definitions (e.g., policies, language, values, customs, symbols, and worldviews), although others focus exclusively on practices and functions. Our conclusion is that cultural communication competence is best seen as focusing on three main areas: codes and how competence is manifested within and across cultures, practices that have been described to enact cultural communication competence in various cultures, and functions of cultural communication competence in various communication contexts.
Further, we argue that ethnicity and race are best seen as cultural constructions. As argued above, reifying each into categorical constructs distorts the within group variance and has limited applicability. Instead, cultures construct “ethnicity” and “race” and establish codes, practices, and functions in the process. We turn next to discussions of the codes, practices, and functions of ethnic/racial communication competence. For stylistic purposes, we drop the “ethnic/racial” modifier in this discussion.
5Codes of cultural communication competence
Codes are the rules that determine what is considered culturally competent communication and that describe the expectations of appropriate and effective communication given the context. Additionally, codes are based on shared common verbal and nonverbal behavioral patterns, common rules, and common goals (Collier, Ribeau, and Hecht 1986). These cultural codes are not assumed, rather are co-constructed by the individuals within the cultural systems and affected by their immediate environments such as neighborhoods (Dressler, Dos Santos, and Balieiro 1996). For example, Philipsen (1975) described the speech codes required to construct “manhood” in a south-side Chicago neighborhood he labeled “teamsterville”. Carbaugh (1988) also explicated American speech codes that were represented by discussions on the Phil Donahue Television Show.
During interactions across racial/ethnic groups, a lack of shared codes can be problematic. For example, African Americans and European Americans may differ in what constitutes competent communication (Hecht, Larkey, and Johnson 1992). Various researchers have explored such code differences, including rules or norms for assertiveness expressions (Ryoko 1999), facework (Leersnyder, Boiger, and Mesquita 2013; Ting-Toomey 2005) and politeness (Bailey 1997).
Cultures also differ on rules for the preferred amount and perceptions of eye contact. Many European Americans view avoidance of eye contact as a sign of dishonesty, whereas African Americans are more likely view it as a show of respect for a superior (Gilliam and Van Den Berg 1980). Among many Native Americans in the United States, direct eye contact when addressing a superior is interpreted as rude or disrespectful (Kalbfleisch 2009). Likewise, Middle Eastern cultures, largely Muslim, have strict rules regarding eye contact between the sexes that permit only a brief moment of eye contact between a man and a woman, if at all (Simpson and Carter 2008). In Asian, Latin American, and African cultures, extended eye contact can be taken as an affront or a challenge of authority (Zhang 2006) and these differences may manifest themselves among recent immigrants. Similar cross-cultural differences are found in other communication aspects, such as how people show respect to others (Bailey 1997), express their emotions (Mesquita and Frijda 1992), and persuade others (Glenn and Stevenson 1977).
The communication rule mismatch probably manifests itself the most among immigrant families. Many immigrant children adopt the rule systems of their host cultures while their parents are typically slower to adopt, which results in obstacles in parent–child communications. For example, the U.S. culture encourages greater verbal expressiveness in showing affection than do many other cultures. In the United States, Korean and Vietnamese immigrant parents, who come from traditionally more reserved cultures, may not respond verbally to their children, which can result in hurt feelings among the children (Pyke 2000). Korean American college students also tend to adhere less strongly to the Asian cultural codes than do their parents, which sometimes results in parent–child conflicts, especially about dating and marriage (Ahn, Kim, and Park 2008).
Such code mismatches can also be observed in educational contexts among international students. Many sojourning Chinese students share rules for competent classroom communication – face negotiation, maintaining roles, harmony and relationships – that are not compatible with New Zealand classrooms (Holmes 2006). Many international students in the United States also experience a shift from the lecture method that uses a teacher-centered class management style in their home cultures to a freer, more interactive student-centered learning environment. This means that students must adapt to solving problems instead of memorizing facts, and they must learn to locate information themselves instead of depending on their teachers (Ladd and Ruby 1999). Furthermore, many international students in Australia must learn to overcome their intercultural communication apprehension and push themselves to participate in class discussions (Robertson 2000), which sometimes is considered inappropriate in their familiar teacher-centered learning environments.
As discussed, code differences pose challenges in interactions for individuals from different racial/ethnic groups. Groups and their members must attempt to take the perspective of the other culture to understand the codes, or they must share or develop codes to establish successful relationships in intercultural encounters (Collier, Ribeau, and Hecht 1986). These issues are even more problematic when the multi-layered nature of identity is considered (Hecht and Choi 2012). Rarely does an interactant enact a single identity; rather, multiple identities sometimes compete with each other. For example, a teacher may enact gender, national, ethnic, and role (teacher) identities. With the matrix of rules and expectations evoked by individual identities and the complex interaction between two or more identities, it is a wonder that accommodation through communication convergence occurs as frequently as it does (Gallois, Ogay, and Giles 2005). Therefore, it is relevant to turn the discussion to practices that enable competent communication.
6Practices of cultural communication competence
Researchers have identified multiple domains of culturally competent communication practices (Burchum 2002; Campinha-Bacote 2003; Papadopoulos and Lees 2002; Suh 2004). For instance, Burchum (2002) suggested six domains of cultural competence: cultural awareness, cultural knowledge, cultural understanding, cultural sensitivity, cultural interaction, and cultural skill. Campinha-Bacote (2003) identified five domains: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Despite the differences, researchers stress similar domains of cultural competence in different cultural competence models, typically including cultural awareness, cultural knowledge, cultural sensitivity, cultural skill, cultural encounter/interaction, and cultural desire.
The first domain, cultural awareness, is the practice of developing consciousness of a culture (including one’s own culture) and the ways in which culture shapes values and beliefs (Burchum 2002). The second domain is cultural knowledge, which refers to the acquisition and processing of information about different cultures (Burchum 2002). The third domain is cultural sensitivity or the ability to appreciate, respect, and value cultural diversity and realize how one’s personal and professional cultural identity influences practice (Burchum 2002). The fourth domain is cultural skill, which refers to the ability to communicate effectively with those of other cultures, including using various procedures and techniques to accommodate cultural beliefs based on the occasion (Burchum 2002). A fifth domain is cultural interaction or encounter, which includes the personal contact, communication, and exchanges that occur between individuals of different cultures (Bur-chum 2002). The sixth domain, cultural desire, is the motivation to seek cultural encounters, obtain cultural knowledge, conduct culturally sensitive assessments, develop cultural awareness, and become culturally competent (Campinha-Bacote 2003). These domains can be categorized into the cognitive, affective, and behavioral components as described by communication competence theory (Spitzberg and Changnon 2009; Suh 2004).
7Functions of cultural communication competence
As noted, culture is functional because it defines desirable outcomes and provides an understanding of what it takes to achieve those outcomes. Unfortunately, in the realm of communication across racial/ethnic groups, less desirable outcomes are more frequent. In a U.S. national survey, 39 % of Latinos, 27 % of Asian Americans, 23 % of African Americans, and 16 % of whites reported communication problems related to culture (Collins et al. 2002). Thus, cultural communication competence has important implications for the outcomes that people experience including physical, psychological, and material well-being of racial/ethnic minority groups. These outcomes, in particular, have implications for key experiences in various contexts, including interpersonal relationships, education, and family processes in which cultural communication occurs.
In interpersonal interactions among people of different racial/ethnic backgrounds, miscommunications and relational problems that result from a lack of cultural communication competence can be caused by both language barriers and a lack of cultural understanding. For example, according to the 2010 American Community Survey (U.S. Census 2012), the U.S. foreign-born population was estimated to be 40 million, which accounted for 13 % of the total U.S. population. Among this population, 100 commonly spoken languages exist in the United States (Shin and Bruno 2003). The U.S. Census (2010) estimated that 55.4 million people (20 % of the U.S. population) speak a language other than English at home, half of whom are considered to have limited English proficiency. As a result, English as a second language (L2) skills are one of the most immediate determinants of intercultural interaction quality (MacIntyre et al. 2003).
Message transmission during communication is severely impaired when people do not share a common language or when they lack of adequate L2 proficiency. In addition, language learners are sometimes watchful and defensive when using L2, especially when attention is paid to their language competence (Matsuoka and Evans 2005). Non-native language speakers also are likely to perceive themselves as less competent communicators (Burroughs, Marie, and McCroskey 2003), which may result in them being less motivated to communicate interculturally compared to native speakers (Lu and Hsu 2008).
In addition to language barriers, a lack of shared cultural background can lead to communication problems in interpersonal interactions. As discussed above, individuals from different cultures often differ in their cultural communication styles, such as assertiveness expressions (Ryoko 1999), facework (Leersnyder, Boiger, and Mesquita 2013; Ting-Toomey 2005), and politeness (Bailey 1997), all of which may cause misunderstanding in interpersonal interactions. Many significant outcomes exist for these problematic interactions and lack of skills. We examine these implications through a functional analysis of education and family contexts, given their importance in so many other areas of life.
Cultural communication competence has a significant influence on educational attainment. For example, in the United States, ethnic minority students, including those of African, Latino, and Native American heritages constitute a proportionally smaller share in science, technology, engineering, and mathematics (STEM) fields (Cooper and Burciaga 2011). Moreover, one in five school-age children in the United States come from immigrant families (Suarez-Orozco and SuarezOrozco 2001) and are more likely to fail in school compared to native students because of lower levels of communication competence in the host culture (Huguet, Navarro, and Janes 2007). Further, only 50 % of immigrant students finish obligatory education levels compared to two-thirds of native students who finish them (Mo-reno-Manso et al. 2013). Over 60 % of immigrant school children go no further than primary education (Moreno-Manso et al. 2013).
These poor educational outcomes are attributable to some combination of at least three primary causes. First, immigrant students in primary school (9–10 years old) have poorer linguistic knowledge (Moreno-Manso et al. 2013) and, in general, experience problems with the language used in school (Stanat et al. 2012). Limited English proficiency, especially in reading and writing, negatively affects students’ school achievement, which results in achievement gaps between native speaking and English learner students (Grant and Wong 2003). Second, poor educational outcomes result from cultural differences in communication and learning styles. International and immigrant students may have different cultural communication and learning styles, which pose challenges in adjusting to new educational environments and may result in worse educational outcomes (Holmes 2006; Ladd and Ruby 1999). Third, students who lack the confidence in language and cultural competence may be apprehensive of communications and that could deter them from participating in class discussions (Robertson et al. 2000). This apprehension places them at higher academic risk of failing in school or dropping out before graduation (Chesebro et al. 1992).
Cultural communication competence affects the well-being of family members and parent–child relationships, which is complicated by both language and culture. Language barriers of immigrant families are known to lead to a range of adjustment problems, such as in interpersonal relationships and education attainments as mentioned earlier. For children of recent immigrants, language barriers can present additional challenges. While many children are themselves bilingual, their parents and grandparents may not be. As a result, these children find themselves serving as “language and culture brokers” to their elders (Kam, Cleveland, and Hecht 2010). In other words, these children have to serve as intermediaries, putting them in positions of power and giving them access to information that may be inappropriate to their age and/or family roles. Fortunately, the outcomes of language and cultural brokering are not universally negative for these youth. Brokering frequency leaves children little free time to engage in risky behavior, and positive feelings about their brokering may help reduce their risky behaviors (Kam 2011).
Another challenge facing immigrant families concerns the parent–child relationship. Immigrant children who are born and/or grew up in the United States tend to learn English and the American culture faster than their parents, and they have higher acculturation levels. The discrepancy in acculturation levels between parent and child, or the acculturation gap, tends to negatively influence parent– child communications and relationships (Unger et al. 2009), and may result in experiences of alienation (Qin 2006).
Qin (2006) suggested that the acculturation gap among immigrant parents and children leads to the development of different frames of reference. Immigrant parents tend to compare their children to those in their home cultures, whereas immigrant children compare their parents to the parents of non-immigrant friends or other parents depicted in mainstream media. A mismatch of expectations and behaviors between parents and children can occur and lead to dissatisfaction in parent–child relationships. These parent–child communication and relationship issues further contribute to a range of interpersonal, school, and health outcomes.
Adjustment in parent–child relationships is positively associated with the child’s quality of relationships with his or her peers (Schneider, Atkinson, and Tardif 2001), school outcomes (Pianta, Nimetz, and Bennett 1997), and school adjustment (Magnus et al. 1999). Similarly, it is negatively associated with youth substance use and delinquent behaviors (Griffin et al. 2000). Culturally sensitive parental training might alleviate these problems (Forehand and Kotchick 1996) although immigrant families are difficult to enroll in such interventions.
8Cultural communication competence in health care: An exemplar
We turn next to a more in-depth analysis of cultural communication competence using the health care context as an exemplar (see also Chapter 19 in this volume). We choose the health care context because of the importance of health outcomes and the ongoing discussion of health disparities that racial and ethnic minority groups tend to suffer (Ndiaye et al. 2008). For instance, in the United States, racial/ ethnic minority groups are often less likely to have health insurance (Flores et al. 1998), thus, they have worse quality of health care (Weech-Maldonado et al. 2003). They also are more likely to be exposed to environmental hazards at work (Frumkin, Walker, and Friedman-Jimenez 1999) and at home (Adeola 1994), and health disparities occur as a result.
African Americans have the highest rates of mortality from heart disease, cancer, cerebrovascular disease, and HIV/AIDS of any U.S. racial/ethnic group, while American Indians have highest rates of diabetes and liver disease, and Asian Americans experience higher rates of stomach, liver, and cervical cancers compared to national averages (Smedley, Stith, and Nelson 2003). Further, Hispanics are more likely than are whites to die from diabetes (Smedley, Stith, and Nelson 2003). Racial/ethnic-based health disparities also are reported in other health areas and other parts of the world. Such disparities include the risk of HIV infection among men who have sex with men in Canada and the U.K. (Millett et al. 2012), diabetic outcomes between black and white patients in the U.K. (Alshamsan et al. 2012), and cancer survival rate between Maori and non-Maori patients in New Zealand (Hill et al. 2010). Thus, health disparities based on ethnicity and race appear to be prevalent worldwide.
These health disparities are, at least in part, attributable to a lack of cultural competence in the health care system. In general, minorities may receive fewer or lower quality services as a result of communication problems, including inadequate communication, poor message choices, language barriers, and a general lack of intercultural competence (Hecht and Lu 2014), all of which pose issues with access to healthcare. Thus, a lack of cultural competence and, specifically, a lack of shared codes and incompetent practices, contribute to health disparities. Furthermore, an improvement in cultural competence among patients and providers can potentially reduce health disparities (Brach and Fraserirector 2000). Researchers address cultural competence in health communication by examining two main content areas: the health care system and patient-specific issues.
8.1Cultural competence in the health care system
Healthcare access is a crucial contributor to health disparities and is, in part, attributed to communication competence. For example, health promotion messages frequently do not reach underserved groups, usually racial/ethnic minorities, because they are often poorly designed in content and form (O’Malley, Kerner, and Johnson 1999). As a result, such populations may not be aware of the available health care services or may lack knowledge needed in accessing and using these services.
Even when access issues are overcome, other barriers exist. Cultural (in)competence is found in barriers presented in three areas of the health care system: organizational, structural, and clinical (interpersonal) (Betancourt et al. 2003). Organizational barriers refer to leadership and workforce factors, such as unrepresentativeness of racial/ethnic minorities in policy making. Structural barriers refer to factors related to health providers within the health care system, such as the availability of interpreter services for racial/ethnic minorities and health education materials for providers. Finally, clinical barriers describe culturally diverse health beliefs and medical practices across racial/ethnic groups that affect health care.
Organizational barriers, such as racial/ethnic incongruence between patient and doctor, may contribute to problems (Johnson et al. 2004). Healthcare providers often communicate with racial/ethnic minority patients who are not from the provider’s own cultural background. As a result, the cultural orientation of the medical care system, or its providers, may not be congruent with the cultural perspectives of some patient groups (Johnson et al. 2004). When this incongruence occurs, potential challenges in communicating with patients tend to arise. Such challenges include accurately describing health care, effectively using an unskilled interpreter to interview or counsel a patient, eliciting a patient’s perspective on his or her illness during a consultation, and eliciting a patient’s perspective of healing and medication therapy during a consultation (White-Means et al. 2009). Consequently, patient–provider communications may not serve all groups equally (Johnson et al. 2004).
Unfortunately health professionals, particularly whites in the U.S. medical system, often lack cultural communication competence. Non-Hispanic blacks and Hispanics in medicine and pharmacy as well as multi-racial nursing students report significantly higher cultural competency scores than do their non-Hispanic white counterparts (White-Means et al. 2009).
In addition, health professionals tend to have limited knowledge of the influence of culture on patient–doctor relationships and communication. As a result, providers tend to lack the motivation to address cultural issues during medical encounters (Rosenberg et al. 2006). For example, U.S. nurses are generally found to be unprepared educationally to achieve an adequate level of cultural competence required to communicate competently in the context of culturally diverse workplaces (Kavanagh et al. 1999).
Cultural incompetence of health professionals is manifested in many ways, and perhaps none is more consequential than biases and stereotyping among health care providers (Johnson et al. 2004). For example, White-Means et al. (2009) found a general preference for whites versus blacks and for light skin versus dark skin among professionals in medical, pharmacy, and nursing schools. Such biases manifest a lack of cultural competence, especially in terms of partial knowledge or inadequate understanding of minority populations. A lack of cultural knowledge can lead to stereotypical assumptions that, for example, all members of a group think and behave in the same way, thus ignoring differences that reflect gender, class, age, and experience. Even worse, the failure to recognize cultural differences, a feeling that these differences are not significant, or a belief that attention to individualized care will transcend such differences, can result in discrimination in health care delivery, whether intended or unintended (Johnson et al. 2004).
Cultural biases that result in poor provider–patient communication affect minority health care profoundly. Providers may communicate lower expectations to patients in disadvantaged social positions because of race/ethnicity, income, education, etc. compared to their more advantaged counterparts. Such lowered expectations may, in turn, affect the amount and quality of health information patients receive and their subsequent health behaviors (Van Ryn and Fu 2003). By itself, racism/discrimination experienced by individuals often leads to worse physical and mental health outcomes (Hecht and Lu 2014).
Conversely, improvement in cultural competence can play a positive role in reducing or even eliminating health disparities (Campinha-Bacote 2003). Physician communication competence is important to ensure that patients understand medical advice and health behaviors (Parchman et al. 2009). For example, considering patient compliance with health care instructions, medical training has traditionally focused on diagnosis and treatment of disease. The assumption has generally been that if these two factors are satisfactorily managed, the desired outcomes of care will inevitably follow. When it does not, failure is often blamed on patient noncompliance. However, the cultural competence of health care providers in providing sufficient health information, treatment suggestions, and ensuring patient understanding has largely been ignored. Thus, improved cultural competence of health care providers enhances patient outcomes such as patient satisfaction (Betancourt and Green 2010) and compliance with treatment regimens (Langer 1999).
8.2Cultural competence among patients
Because competence is a relational issue (Spitzberg and Cupach 1984), one cannot ignore all of the players involved in communication interactions. The competence of patients also may be an issue, and patient competency is implicated in many ways. For example, U.S. patients with poor English language proficiency are less likely to receive regular medical care (Johnson et al. 2004) and are more likely to face higher risks of nonadherence to medication (Flores 2006).
One reason patient competence is important is because some of the structural problems described above can be overcome if patients have adequate cultural communication competence and health literacy. As a relational phenomenon, it is not completely incumbent on the system or provider to overcome barriers. For example, racial/ethnic incongruence between patient and provider may pose less of a challenge if minority patients have adequate knowledge of health care. Unfortunately, minority patients often lack knowledge of culture and its effect on health care quality. Additionally, their own minority cultural ways of expressing stress and anxiety are not necessarily appropriate in the majority culture context (Rosenberg et al. 2006). As a result, ethnic minorities usually rate the quality of health care more negatively than do whites (Johnson et al. 2004). For instance, racial/ ethnic minority patients are more likely than are majority patients to report that their doctor does not listen to everything they say, they do not fully understand their doctor, or they have questions during the visit but do not ask them (Collins et al. 2002). Johnson et al. (2004) reported that, in the United States, African Americans, Hispanics, and Asians were more likely than whites to perceive bias and a lack of cultural competence in the health system. Specifically, minorities perceive that: 1. they would have received better medical care if they belonged to a different race/ethnic group and 2. the medical staff judged them unfairly or treated them with disrespect based on race/ethnicity and how well they spoke English.
Other patient factors also influence the communication processes. Immigrant acculturation level, for example, influences health care access and use, experience, and compliance. Immigrant patients, who are usually racial/ethnic minorities, are often less verbally and affectively expressive during medical encounters (Cooper et al. 2003), which negatively affects the amount of information and treatment they receive from physicians (Street 1991). Here, acculturation level, as reflected in language proficiency and cultural knowledge, is the main factor. A lack of adequate language proficiency in health care settings, including knowledge of terminology and procedures, poses a barrier to health care access, affects the quality of care (e.g., amount of information) that patients receive, and results in inappropriate care because of poorly communicated or interpreted symptoms and treatment (Flores 2006).
Considering these factors, culturally competent language interpretation is needed. However, one study in the United States reported that no interpreter was used in 46 % of emergency department cases that involved patients with limited English proficiency (Baker et al. 1996). Moreover, few clinicians receive training in working with interpreters (Flores et al. 2003) and the quality of interpreting does not always meet the needs of the patients or their families, especially when using untrained persons, such as family members or bilingual staff members (Karliner et al. 2007).
8.3Cultural communication competence interventions in health care
Consequently, interventions to improve cultural competence are necessary and essential for public health. Improvement in cultural competence can lead to more appropriate services, such as prevention and screening activities undertaken with full knowledge of risk factors, better informed diagnoses, treatment options formulated and presented in cultural contexts, and patient education on treatment regimens culturally tailored to improve the likelihood of adherence (Brach and Fraseri-rector 2000). The question, then, is how to improve cultural competence.
Brach and Fraserirector (2000) suggested that improvement of cultural competence can be achieved by providing access and changing clinician and patient behaviors, including improved communication, increased trust, greater knowledge of epidemiology and treatment efficacy, and expanded understanding of patients’ cultural behaviors and environments. Given that interventions involve a web of issues that require involvement of all parties because of the relational nature of competence (Spitzberg and Cupach 1984), cultural competence intervention is a complex challenge that requires broad improvements that target not only the health care system and health care providers but also patients’ competence levels (Brach and Fraserirector 2000). In this section, we provide suggestions based on our review of the relevant literature.
Given the cultural competence issues in the health care system discussed above, programs designed to address systemic issues in the cultural competence of health care delivery seem to be a natural choice. Techniques frequently discussed in the literature to develop a culturally competent health system align broadly with the following categories: 1. interpreter services, 2. recruitment and retention policies for minority staff, 3. training, 4. coordinating with traditional healers, 5. use of community health workers, 6. culturally competent health promotion, 7. including family and/or community members in care-giving, 8. immersion into another culture, and 9. administrative or organizational accommodations (Brach and Fraserirector 2000). These techniques correspond with and can be categorized into structural, clinical, and organizational components of a culturally competent health system (Betancourt et al. 2003).
Betancourt et al. suggested that interventions should include innovations in the health care system and structural design to ensure that minorities obtain quality health care (structural), educational initiatives that aim to teach providers the tools and skills to deliver quality care to diverse populations (clinical), and efforts to increase the numbers of under-represented minorities in the health profession, including health care leadership (organizational). Among these, the technique mostly commonly discussed and incorporated in practice is training culturally competent health professionals.
Because structural changes are usually more difficult to achieve, many health care interventions involve cultural training for health providers, such as nurses and physicians. Interventions that target the cultural competence of health care professionals facilitate communication between providers and patients and can mitigate misunderstandings, improve relationships, and promote health care quality (Kumagai and Lypson 2009). Moreover, cultural competence of providers facilitates the intercultural connections between providers and patients from the targeted racial/ethnic groups (Kavanagh et al. 1999). A shift in cultural orientation and change of cultural competence enables providers to attend to associations between the dynamic relationships within unfamiliar social, political, and economic circumstances. Developing such relationships allows providers to develop co-responsibility with consumer groups to advocate improved health and health care. In addition, cultural competence allows providers to understand the health and illness perspectives and behaviors of patients, family health care decisions, treatment expectations, and compliance with health care treatment plans (St Clair and McKenry 1999).
Recognizing the importance of health providers’ cultural competence, scholars have conceptualized ways to improve their cultural competence training (De Leon Siantz 2008; Lu and Hecht 2014; Padela and Punekar 2009). Rosenberg et al. (2006) discussed two commonly used training methods; one focuses on the physician themselves, the other on the patients. First is the Balint group method, which emphasizes physicians’ self-awareness of being a parent, child, man/woman, professional, and so forth, rather than teaching culture-specific competencies. This self-awareness of identity increases physicians’ cultural sensitivity overall and helps them become more competent in communicating with varied patient populations.
The second approach seeks to shift physicians from their present disease-focused paradigms toward the practice of a more patient-centered care paradigm. Patient-centered care is designed to “see the illness through the patients’ eyes” to provide services based on patients’ needs, and includes outcomes that patients care about (e.g., patient satisfaction) in the outcome evaluation system (Saha, Beach, and Cooper 2008). Instruction in a patient-centered approach seeks to motivate learning about aspects of patients’ cultures that affect their illness experience and learning skills to elicit patients’ perspectives.
Lavizzo-Mourey and Mackenzie (1996) suggested that cultural competence training of health providers must involve demonstrated awareness and integration of three population-specific issues: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. First, failure to address the variations in health beliefs in the clinical setting threatens patient satisfaction and, potentially, threatens clinical outcomes. Thus, cultural sensitivity or cultural appropriateness in delivering health care to a culturally diverse patient population by recognizing the variations in beliefs and values is especially important. Second, disease incidence varies among racial and ethnic subpopulations. Accurate data can guide decisions to allocate resources effectively for health education, screening, and treatment programs to address more prevalent diseases of the targeted population. Third, treatment efficacy can vary among different populations; therefore, flexibility in diagnostic and treatment protocols or formularies is needed to deliver the most cost-effective (not necessarily the cheapest) treatment for the population served.
Overall, cultural competence of health providers requires knowledge of the cultural group they are serving and culturally appropriate services to fit patients’ needs based on cultural awareness and training skills (Lu and Hecht 2014). Eight content areas taught within a commonly accepted rubric of cross-cultural education curriculum include general cultural concepts, racism and stereotyping, physician–patient relationships, language, specific cultural content, access issues, socioeconomic status, and gender roles and sexuality (Dolhun, Munoz, and Grum-bach 2003). Lu and Hecht (2014) suggested including acculturation in provider training to enhance awareness that individual immigrants might take different routes in adjusting to the new majority culture. For example, some immigrants may adhere to their original culture after an extended stay in the host culture, while others may assimilate to the host culture and become familiar with its health care practices. In practice, instead of assuming an original cultural identity of patients based on their ethnicities, health providers may need to assess the patients’ acculturation levels and adjust the care accordingly.
In addition to those targeting health care providers, researchers have developed a number of interventions for targeting minority communities and patients to enhance the organizational aspects of the healthcare system. Some of these interventions begin by including communities in the healthcare system by recruiting and retaining minority staff in health care, using community health workers, coordinating with traditional healers, and including family and community members in health decision-making.
Including minority staff in health care, with their shared cultural beliefs and common language, can improve communication, create a more welcoming environment, and structure the health system to better reflect the needs of minority communities (Cooper-Patrick et al. 1999). In addition, minority staff can create a multi-cultural work environment, which promotes learning of culturally appropriate provider behaviors of non-white health professionals (Paez et al. 2008). Using community health workers helps bring in individuals who had not previously sought care, provides cultural linkages, overcomes distrust, and contributes to patient–provider communications. Such improvements increase the likelihood of patient follow-up and provide more cost-effective health services to isolated communities that have traditionally lacked access (Goicoechea-Balbona 1997; Riddick 1998).
Systems of healing represent the worldviews, social organization, and traditional forms of spirituality of the cultures that practice them (Kirmayer 2012). Not surprisingly then, community members report high comfort levels in seeking traditional healing (Hartmann and Gone 2012), which places great value in coordinating with traditional healers within the healthcare system. Moreover, including traditional healing in the health care system helps clinicians better understand the alignment between the values and worldviews in which their own health system is embedded and those held by their patients (Hartmann and Gone 2012), which consists of an important component of cultural awareness. Last, the potential for including family and community members in health decision-making may ensure cultural appropriateness of care because many cultures place family at the center of health-related decision-making (Quinn et al. 2012).
Outside the health care system, culturally competent health promotion for community members also is needed to encourage healthy behaviors, prevention, risk reduction, early detection and treatment, and proper care of chronic or acute diseases (Kok, van den Borne, and Mullen 1997). Netto et al. (2010) reviewed interventions that targeted minority groups to prevent coronary heart diseases and summarized five principals for adapting behavioral interventions for ethnic minority groups: 1. use community resources to publicize the intervention and increase accessibility; 2. identify and address barriers to access and participation; 3. develop communication strategies that are sensitive to language use and information requirements; 4. work with cultural and religious values that either promote or hinder behavioral change; and 5. accommodate varying degrees of cultural identification. Specifically, culturally competent health promotion programs may include brief interventions, such as screening services in the community and public information campaigns. Thus, messages and materials need to be carefully designed to incorporate culture-specific attitudes and values.
In addition to specific suggestions of developing culturally competent health interventions, targeting and tailoring are two commonly discussed intervention approaches to ensure delivery of culturally appropriate care to minority groups. The targeting approach identifies a specific group and develops interventions based on shared group characteristics, while tailoring focuses on individuals and interventions that are intended to reach specific persons (Kreuter et al. 2003). Both approaches start with a well-developed understanding of the audience and base the intervention development on this understanding. At the minority group level, DiazCuellar and Evans (2013) suggested that to provide optimal care with a diverse world population, it is necessary to understand the health care and health promotion needs for various groups, which include health-seeking behaviors, cultural beliefs and values, attitudes, cultural nuances, and perceptions about health. Among minority groups, individuals may share a range of cultural characteristics (e.g., individualistic); however, salience of these characteristics may vary by person and may require individual-level measurement and adjustment (Kreuter et al. 2003).
We argue that a cultural grounding approach (Hecht and Krieger 2006) is appropriate and key to culturally competent health promotion intervention development. Culturally grounded interventions are informed by knowledge of the targeted culture with the active participation of cultural insiders in message design, production, and distribution. Following a cultural grounding approach, culturally competent health interventions should inductively identify shared and salient identities of minority group members and develop messages that consider local perspectives.
As discussed, cultural competence interventions should target the health care system, health providers, and minority individuals and communities. Delivering the interventions is the next issue. A large number of organizations and institutions have been involved and devoted to developing cultural competence programs, including public (federal, state, and local) and private sector initiatives (health care institutions or professional organizations, foundations, academic institutions/policy research organizations, and others) (The Henry J. Kaiser Family Foundation 2003). Those in the healthcare field use different channels of interventions, including online resources (e.g., websites providing information for health providers); workbooks or brochures that introduce culture, cultural biases, and cultural competence; and in-person training programs based in schools or hospitals.
Lie et al. (2011) reviewed existing cultural competence intervention programs and concluded that, in general, these programs are effective in improving health providers’ cultural competence. However, they pointed out that most existing evaluation studies have focused on provider competencies, such as improved knowledge, attitudes, and skills, but rarely on patient outcomes, such as health improvement. Other cultural competence efforts, such as health care system updates, community bridging activities, and training of individual community members are rarely evaluated.
One challenge is how best to measure racial/ethnic minority group membership or identification. Scales to measure (multi-group) ethnic identity (Brown et al. 2014; Yoon 2011) and, consequently, cultural congruence are needed to ensure that evaluation reflects the true complexity of ethnic/racial cultures. Overall, a better evaluation system is needed to enhance intervention development.
9Conclusion
The theoretical understanding of communication competence must reflect the pervasiveness of racial/ethnic variations and the importance of communicating across these differences. Research clearly demonstrates that, at the very least, language and other cultural factors add complexity to the challenges of competent communication. Competency in intra-ethnic communication does not guarantee success in inter-ethnic communication. In everyday experiences, the lack of communication competence during an encounter is often attributed to a lack of cultural competence or adaptation.
We suggest that race and ethnicity should not be treated as categorical variables because of the existing variations within racial/ethnic groups and the multiple identities of racial/ethnic minority individuals. Instead, we use a speech code theory, which conceptualizes cultural communication competence as the codes and practices that help achieve communication goals in specific contexts with specific groups of people.
Health, one particularly consequential context, serves as an extended exemplar to discuss, in depth, the role of cultural competence; specifically, how codes and practices affect health outcomes and how interventions can improve cultural communication competencies. We suggest that culturally competent interventions target all parties involved in communication, including the health care system, health providers, the racial/ethnic minority communities, and minority individuals to ensure health care access and quality and to reduce health disparities. An efficient program evaluation system also is necessary to provide feedback for current interventions and to contribute to the theory of effective intervention development. This exemplar is intended to show the important role that cultural competence plays in affecting outcomes as well as the complexity of the challenges involved. Lessons could be learned from the exemplar, not only for cultural competence programs, but also for other areas such as education, interpersonal relationships, etc.
Overall, lack of cultural competence contributes to disparities in various physical, psychological, educational, and rational outcomes across racial/ethnic groups. Despite the existing body of literature that addresses solutions or interventions, more research is needed to provide powerful theories and practices. Clearly, the challenges to cultural competence theory and practice are great, but so are the potential rewards in quality of life that addressing these challenges can bring.
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