CULTURALLY COMPETENT CARE FOR PATIENTS OF ALL RACES, ETHNICITIES, AND RELIGIONS

Health Disparities and Health Risk Factors

Racial minority groups in the United States have higher rates of morbidity and mortality and a greater range of health conditions such as diabetes, hypertension, obesity, asthma, and heart disease compared to White people. In fact, the life expectancy of a White American is 4 years longer than that of a non-Hispanic Black American (CDC, 2023a). Black, Hispanic, and Asian Americans experience a greater number of chronic comorbidities than their White counterparts and have more limited access to healthcare (Lopez et al., 2021).

Examples of these specific health disparities include:

• Black individuals between the ages of 51 and 55 are 28% more likely to have a chronic health condition than White people in the same demographic.
• Black males have a four times greater risk of being diagnosed with schizophrenia than White males.
• Results from a study showed that providers are more likely to diagnose a White person with alcohol use disorder than an Asian American even though both have the same symptoms.
• A study conducted in 2020 concluded that Black people were 1.26 times more likely than White people to die in the emergency room or hospital.
• A Black woman is far more likely to die in childbirth than a White woman, and in 2021, non-Hispanic Black women died 2.6 times more often from pregnancy-related complications than non-Hispanic White women in the United States.
• Black infants were more than twice as likely to die compared to White infants in 2021.
• In 2021, Black, Hispanic, and Asian adults were less likely to use mental health services than White adults.
• American Indian, Alaskan Native, and Hispanic people were more than twice as likely to be uninsured in 2021 as White people.
• In the 2021–2022 flu season, approximately 60% of Hispanic, Black, American Indian, and Alaskan Native adults did not receive a flu vaccination, while less than half of White adults did not receive a flu vaccination.
• Between 2019 and 2021, American Indian, Alaskan Native, Hispanic, and Black people encountered greater declines in life expectancy compared to White people.
  (CDC, 2023b; Rees, 2020; Hill et al., 2023)

Best Practices for Culturally Competent Care for Patients of All Races, Ethnicities, and Religions

Best practices for culturally competent care include screening and providing resources to address needs related to health disparities, learning about racial and ethnic differences among diverse populations, being more inclusive of alternative methods of healing, and being aware of how personal religious beliefs can impact care of the patient.

SCREEN FOR SOCIAL NEEDS

Black and Hispanic households have had a lower median household income than White households since the U.S. Census Bureau began collecting data in 1967. In 2022, the median household incomes were:

• $52,860 for a Black household
• $62,800 for a Hispanic household
• $81,060 for a non-Hispanic White household
  (Guzman & Kollar, 2023)

Individuals in lower income households may have a harder time obtaining health insurance or paying for costly procedures and medications. They may also have reduced access to resources necessary to promoting a healthy quality of life, such as stable housing and fresh, unprocessed foods (ODPHP, n.d.).

Clinicians should screen all patients for needs related to healthcare, housing, food, and legal assistance, and then provide information and resources that can address these needs. Health disparities can be addressed through improved access to care and access to basic needs that can improve patients’ health (Lopez et al., 2021).

LEARN ABOUT HEALTHCARE NEEDS FOR PATIENTS OF VARIOUS RACES AND ETHNICITIES

A patient’s race, ethnicity, or religion may contribute to various healthcare-related considerations:

• Physiologic variations make some groups more prone to certain diseases and conditions, such as sickle cell anemia among non-Hispanic Black Americans or Tay-Sachs disease among Eastern European Jews.
• A patient’s reaction to pain may be culturally prescribed; for example, Middle Eastern and Hispanic cultures encourage the open expression of emotions related to pain while Asian cultures value stoicism.
• Different ethnic groups have different norms of psychological well-being and acceptance of mental illness.
• Perceptions of appropriate personal space and physical contact, including between the sexes, vary among cultures.
• Different food preferences among cultural groups can be a factor in whether a patient is receiving adequate nutrition while in a hospital or other healthcare setting.
• Cultural views on sex roles, families, and relationships may impact areas such as decision-making, privacy, and information sharing among patients, loved ones, and healthcare providers.
• Most cultures use traditional herbal remedies, so it is important to ask a patient if they are taking anything in addition to prescriptions.
  (Taylor et al., 2019; Galanti, 2019)

Common Healthcare Considerations for Native American Patients

Native Americans, Native Hawaiians, and Pacific Islanders comprise a small part of the U.S. population, but it is important to recognize that they identify differently than the more common “White,” “Black or African American,” and “Hispanic or Latino” racial and ethnic categories. Clinicians need to educate themselves about diverse populations and learn how to respectfully inquire about a patient’s cultural background (Dillard et al., 2021).

Healthcare considerations for Native American patients can include:

• A patient who avoids eye contact may be doing so as a sign of respect and not because they are not paying attention.
• Individual illness is often seen as a family matter, and family usually likes to be involved.
• During labor and delivery, the laboring person may be encouraged to be stoic.
• Long hair is often considered to be an indicator of a healthy child, and they may believe cutting it could lead to illness or death.
• Negative thoughts are believed to expedite death, so a patient may not want to talk about a terminal prognosis or do-not-attempt-resuscitation order (DNAR).
• Tobacco may be viewed as sacred, which can pose challenges when trying to counsel a patient to quit smoking.
  (Galanti, 2019)

Common Healthcare Considerations for Black Patients

Healthcare considerations for non-Hispanic Black patients can include:

• Certain types of cancer, such as prostate and cervical, have high mortality rates among African Americans. This may be due to general mistrust of hospitals and healthcare in general, which leads to delayed screening.
• Organ and blood donation may be considered taboo out of fear that it will expedite the donor’s death.
• “High” blood could be confused with high blood pressure in some southern U.S. states. Red meat may be thought to cause “high” blood, and “low” blood may be thought to occur from too much vinegar, lemon juice, and garlic.
• A possible reluctancy to trust doctors and hospitals due to a long history of racial health disparities and being discriminated against.
  (Galanti, 2019)

Common Healthcare Considerations for White Patients

Healthcare considerations for White American patients can include:

• Husbands and wives typically share equal authority when making healthcare decisions for their child.
• There are usually no postpartum rituals.
• Some believe that childhood vaccines cause autism and may refuse to allow their children to be vaccinated.
• Stoicism is often expected after someone dies.
• Aggressive approaches to illness are usually preferred.
• Antibiotics are often asked for by patients because germs are considered to be the cause of disease.
• Patients frequently research health information online and may request treatments based on their own Internet search.
  (Galanti, 2019)

Common Healthcare Considerations for Hispanic Patients

Healthcare considerations for Hispanic patients can include:

• Large, extended families may visit the patient and show their love by spending as much time with the patient as they can.
• There may be a hesitancy to discuss emotional and psychological issues, especially by Hispanic males.
• Wives may prefer that their husbands make decisions for both their own health and the health of their children.
• The laboring person may be stoic during labor.
• Prenatal care may not be considered necessary since some believe that pregnancy is a normal condition.
• Room temperature or hot water to drink may be preferred when a person is ill due to beliefs about the hot/cold balance of the body.
• Hospice may be refused by family members who believe it will cause their loved one to give up hope and their will to live.
  (Galanti, 2019)

Common Healthcare Considerations for Southeast Asian Patients

Healthcare considerations for Southeast Asian (from Cambodia, Laos, and Vietnam) patients can include:

• Many are Buddhist and believe in reincarnation.
• Modesty is typically very important, and extra time may be needed to accommodate modesty concerns during procedures.
• Giggling at what would be considered an “inappropriate” time may indicate a patient is nervous or uncomfortable.
• It may be preferred that the eldest male relative is addressed first when a patient arrives with relatives.
• A baby may not be considered “human” until a few days after birth; this may have evolved as a defense mechanism from high infant mortality rates to keep mothers from bonding too early.
• Intravenous lines should not be put in an infant’s scalp when possible because the head is often considered to be personal, vulnerable, and untouchable.
• Family members may request to wash the body after death and place a coin in the deceased family member’s mouth.
• Surgery may be feared due to the belief that the soul is connected to different parts of the body and that surgery could sever the connection.
  (Galanti, 2019)

Common Healthcare Considerations for East Asian Patients

Healthcare considerations for Asian patients from China, Japan, Korea, and the Philippines can include:

• Respecting and providing for one’s parents is highly valued.
• Hand gestures like gesturing to come with the index finger may be considered an insult to Filipinos and Koreans.
• It is considered polite to refuse at first, so interventions such as pain medication may need to be offered more than once before the patient agrees.
• Pronouns are nonexistent in most Asian languages, and the words he or she in English could be mixed up by the patient or misunderstood.
• Stoicism while in pain is valued; it is important to offer pain medication regularly based on the situation and using body language as an indicator that it may be needed.
• New birthing parents often do not bathe or exercise for the first month after giving birth.
• Some skin lesions (e.g., “Mongolian spots”) are birthmarks that are more common for Asian infants; they can be mistaken for bruises.
• Cancer is often greatly feared and stigmatized, so it can be helpful to refer to cancer as a “growth” and chemotherapy as “medication.”
• The words for the number “4” and “death” are pronounced the same way in many Asian languages, so Asian patients may want to avoid being admitted to rooms like 4 or 14.
  (Galanti, 2019)

BE MORE INCLUSIVE OF NON-WESTERN MEDICINE METHODS OF HEALING

Clinicians can broaden their perspectives and educate themselves about non-Western medicine and holistic methods of healing that patients may use in order to better care for such patients. Results from a cross-sectional survey of 144 healthcare professionals indicated that 80% of respondents knew how socioeconomic factors affect health, but only 9% of the same respondents indicated knowledge of various alternative healing traditions (Dillard et al., 2021).

LEARN ABOUT HOW A PATIENT’S RELIGION IMPACTS THEIR HEALTHCARE

A patient’s religion/spirituality is often an important consideration in regard to medical decisions and culturally competent care. Therefore, healthcare providers must be aware of and respectful of a patient’s religious beliefs as they relate to issues such as diet, medicines that may include animal products, modesty, the preferred gender of their health providers, prayer times that may interfere with treatment regimens, and more.

Examples of beliefs in specific religions that may need to be accommodated during the care of the patient include:

• Adherents of Buddhism may refuse mind-altering medication during the dying process.
• In the Church of Jesus Christ of Latter-day Saints (Mormon) religion, individuals are not supposed to drink alcohol, coffee, or tea.
• In Hinduism, the right hand is used to eat, and the left hand is used for hygiene and going to the bathroom.
• Muslims who practice Islam do not eat pork, and contact between genders is not allowed.
• Jehovah’s Witnesses do not accept blood transfusions and do not eat food that has blood in it.
• Kosher laws that prescribe certain dietary restrictions are followed by some Jews. Likewise, in some Jewish religious movements, cremation is not allowed, and amputated limbs are buried in consecrated ground.
• Roman Catholics do not eat meat on Fridays, particularly during the season of Lent.
• Seventh-day Adventist members may refuse narcotics or stimulants.
• Adherents of Sikhism are not permitted to cut hair on any part of their body.
  (Swihart et al., 2023)

Similarly, many patients may turn to their religious faith in order to reduce their anxieties, respond to healthcare challenges, and make difficult healthcare decisions, including end-of-life care and preparations. Health professionals should therefore provide an opportunity for patients to discuss their religious and spiritual beliefs and tailor their evaluation and treatment to meet patients’ specific needs.

In addition to an awareness of Protestant, Catholic, Jewish, and Muslim religions, providers should learn about the different religions and be aware of how their own personal religious beliefs could vary from those of the patient. Even though the primary religion in the United States is Christianity, education about other religions with which a portion of patients identify can improve the understanding of the clinician and help them to provide better care.