Providing culturally competent care is no longer an option for Texas health systems. Hispanics comprise nearly all of the state’s growth during the past decade. By 2050, racial and ethnic minorities will make up nearly half of the U.S. population.
Dallas-Fort Worth has a rich tapestry of cultures and hundreds of dialects. Local healthcare systems are working to meet the needs of those populations.
The federal government recently released enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Healthcare–a blueprint to help organizations improve healthcare quality in serving our nation’s diverse communities. They offer a framework for the delivery of culturally respectful and linguistically responsive care and services.
Texas Health Resources has a diversity and inclusion department that uses the CLAS framework for patient care.
Baylor Health System collects data on race, ethnicity, and language, said Guwan Jones, director of diversity workforce planning. Her department attempts to recruit system leadership that is representative of Dallas-Fort Worth’s diversity and looks for ways to improve health disparities.
For the past two years, the Methodist Health System employee intranet has given top billing to a section on diversity awareness and cultural competence. The site underscores the importance of delivering culturally competent care, provides tactics and practical advice on how to provide it, information about translation services, and highlights available system resources. Ongoing classes through Methodist’s organizational effectiveness department reinforce key concepts and best practices. Classes are available to all staff, nurses, and physician residents.
Language and Literacy Barriers
Language and literacy are among the greatest barriers to effective care. Of the more than 37 million U.S. adults who speak a language other than English, nearly half say they speak English less than “very well.” Health service use may also be affected by the availability of interpreters. Among non-English speakers who needed an interpreter during a health care visit, less than half report that they always or usually had one.
Mina Kini, THR director of diversity and inclusion, estimates there are about 230 languages spoken in North Texas, with 60 to 80 spoken by patients at its facilities. The system has employed Spanish interpreters at Texas Health Harris Methodist Hospital Fort Worth and four employees at the system level who travel to the other THR sites. Two of those are Spanish interpreters, one is Burmese, and one specializes in sign language. It also uses translation services for written documents, which affect patients less frequently.
Jones said Baylor has access to some form of translation at all of its facilities. It’s especially important that discharge instructions be in native languages—and usable. “We discovered our Spanish discharge instructions were written at college-level. Most folks do not speak university-level Spanish,” she said.
Systems have targeted the needs of specific populations. UT Southwestern teamed up with the Trans Pride Initiative to offer a Chest and Breast Wellness Day to provide transgender men and women, and masculine women an opportunity to have a comfortable environment for breast cancer screenings.
UTSW also participated in a study to determine if barbers could influence African-American men to consult a physician about hypertension. The study found that patrons of black-owned barbershops who had their blood pressure regularly measured there and who were encouraged to follow up with their physicians were nearly nine times more likely to see a physician than patrons who were simply given hypertension literature.
Challenges Navigating the Healthcare System
Compounding the problem is widespread lack of health literacy. One-third to one-half of U.S. adults do not have the literacy skills to navigate the healthcare system. Studies have shown that poor health literacy is associated with higher rates of hospital readmissions, treatment complications, and death.
Health literacy is the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions. Reading comprehension and understanding numbers are the key components.
Many Americans have a difficult time with simple math. Almost half of the U.S. population has difficulty calculating the difference between a regular and sale price or estimating the cost per ounce of a grocery item. One out of four patients cannot understand information about when an appointment is scheduled.
Educational attainment certainly is important for health literacy. Yet 17 percent of high-school graduates and 10 percent of those with higher education have inadequate health literacy. For example, 16 percent of highly educated people could not correctly answer questions about risk magnitudes (i.e., “Which is the greater risk: 1, 5 or 10 percent?”). Methodist Generations addresses health literacy for adults age 55 and over. The program includes computer classes, health screenings, and information sessions regarding changes in Medicare and Medicaid.
Unfortunately, patients often either hide their lack of knowledge or do not acknowledge it. Of those scoring at the lowest level on a 1992 National Adult Literacy Survey, only 29 percent said they did not read well and only 34 percent admitted they did not write well. In a study at a women’s clinic, physicians could identify only 20 percent of those with low literacy.
A classic example: Former New York City Mayor Rudolph Giuliani believed he was cancer-free when his doctor told him that his prostate biopsy was “positive.” A positive biopsy indicates cancer is present.
The Steep Cost of Inequities in Health and Healthcare
Long-existing inequities in health and healthcare have come at a steep cost. A recent federal report found that the burden of insufficient and inequitable care related to racial and ethnic health disparities has been estimated to top $1 trillion.
The annual National Healthcare Disparities Report, published by the federal Agency for Healthcare Research and Quality, has consistently shown that blacks and Latinos suffer from poorer quality of care and worse access to care than whites on a number of indicators. As many as 83,000 deaths each year are attributed to racial and ethnic health disparities
Cultural competency is considered a key weapon in closing the disparities gap in healthcare. It is the ability to deliver care that meets patients’ social, cultural and linguistic needs. Health systems are beginning to adopt comprehensive strategies to respond to the needs of racial and ethnic minorities.
State and federal guidelines are promoting greater responsiveness toward growing population diversity. One of the top goals of the federal government’s Healthy People 2020 initiative is to eliminate racial and ethnic health disparities. Many health systems are finding that cultural competence strategies are a good business practice.
Key efforts include providing interpreter services, recruiting minority staff, using community health workers, locating clinics in neighborhoods that serve target populations, and training staff to be culturally sensitive.
Steve Jacob is editor of D Healthcare Daily and author of Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]