Too often, cultural competence is thought of as something that's "nice to achieve." But it's essential to optimal care. Your ability to deliver culturally competent care can affect everything from your patient's access to health care to whether he or she shows up for appointments.

"You need to have a broad understanding of how to interact with many different cultures," says Erin Shilling, PT, a physical therapist at UCLA Medical Center in Los Angeles. She notes that connecting with patients promotes a working relationship and makes them more likely to return for follow-up visits.

Culture is important

The diversity of the U.S. population continues to grow. Unfortunately, disparity in health care among ethnic groups is growing too. According to the most recent census data, people of color are less likely to be insured than whites, which can be partly explained by differences in income and types of employment. Latinos, African-Americans, Asians, and American Indian/Alaska Natives are less likely to have a regular source of medical care and less likely to have visited a health care provider in the past year than whites.

One reason for this lack of access may be health care providers' insensitivity to patients' cultural needs, which may result from a lack of knowledge of culturally based health beliefs and practices (see How cultural beliefs can affect health care) or perceived lack of time. Yet, not taking time to learn about a patient's culture deprives you of a growth experience and a deeper connection with the patient. Shilling's parents are from different cultures, and she cares for patients with a wide range of cultures at UCLA. She finds comfort in knowing that "it's possible for people of many cultures to interact positively."

So, how can you deliver culturally competent care that benefits you, your patients, and your patients' families? Let's find out what steps you can take.

Seek to understand

Experts agree that the single most important tactic for working with people of different cultures is understanding their values in the following areas:

* Health care beliefs. "Try to understand your patient's culture and how it affects his or her approach to health care in general, and physical or occupational therapy specifically," advises Awilda Haskins, PT, EdD. As an associate professor of physical therapy at Florida International University, Haskins has a diverse student body and is accustomed to working with patients and families of different cultural heritages.

Be alert for a mismatch between your own and your patient's beliefs. For example, Americans pride themselves on independence and may not value older adults as much as many other cultures. "In some cultures, elders are pampered and not allowed to exert themselves when they are sick," says Haskins, who cites African, Asian, and Hispanic cultures as examples. This outlook can be frustrating for the therapist eager to achieve optimal independence in a limited time frame.

Culture can even affect preferences for complementary therapy. For example, some experts have noticed that Americans use yoga and massage, while Hispanics may prefer herbal remedies.

Keep in mind that you may need to take more time to explain the role of physical, occupational, or speech therapy. In his essay on culture and occupational therapy, Michael Iwama, PhD, OT, noted that many nonwesterners find occupational therapy difficult to understand and integrate with their cultural views.

* Family involvement. The family's role in care varies considerably by culture. "We are a very individualistic society, so we tend to deal with a patient one-on-one," says Haskins. "We sometimes don't remember to include family." Shilling says, "Even in Europe, we see high cohesiveness of family, with people living with their families until they are in their 30s and getting married."

Ask patients how much help they expect-and want-from their family, and involve the family based on those preferences. Asking first is especially important given Health Insurance Portability and Accountability Act regulations that restrict discussion of a patient's condition with family members unless he or she has given permission, points out Jo Ann Gardner, PT, MBA, corporate rehabilitation director for Greystone HCM in Tampa, Florida. It may take time to work out family involvement, but it's well worth the effort and can help avoid misunderstandings down the road.

* Gender roles. In cultures with strong machismo values, women are more likely to be primary caregivers, which may affect goals for patients in the home setting. "Our goals need to be eye-to-eye with the patient," says Shilling. If a male patient never prepared meals or did the laundry at home, these would be unlikely therapy goals. And, if a culture values the mother as "caregiver," watch for increased stress when the mother is the patient.

Gender can even affect basic communication. Haskins notes that in the Haitian Creole culture, the husband may speak for the wife, so you'd want to ask the wife if her spouse needed to be present when discussing the treatment plan.

* Time. Culture often plays a role in how time is perceived, which can create problems for therapists faced with a limited number of visits. The patient may not understand the therapist's timeline.

Nidhi Mahendra, PhD, CCC-SLP, assistant professor at California State University, East Bay, uses the example of "clock" versus "event" time. "If you think a visit is scheduled for 20 minutes, you're on clock time," she says. "Event time means you believe the visit ends when the patient's needs are taken care of." Those from a culture with the perspective of event time may become upset when the number of allotted visits end before their needs are met. "It helps to explain the situation in the beginning," says Mahendra, who is a member of the California Speech-Language-Hearing Association's Diversity Committee.

Caution: Assume nothing

There's a fine line between understanding and generalizing, or worse, stereotyping. Learn about cultures, but pay attention to individual differences instead of taking a cookbook approach. "Hispanics in the United States come from all over the world, including Cuba, Colombia, Venezuela, and Mexico," says Haskins. "There are geographic variations and variations among individuals." The patient's level of acculturation depends on how recently he or she immigrated and his or her social structure. Patients based in a community of a single culture, for instance, are likely to have had less exposure to American culture. In addition, remember that patients may also come from a blended cultural heritage, expanding their cultural influences.

A therapist may mistakenly think, "I don't need to worry about the patient's culture. I can just treat the person the way I would want to be treated. I'll be fair." However, Haskins explains that what is "fair" varies by culture. For example, white people expect to arrive at their appointment time and be seen. However, in some cultures (Hispanic, for example), first come, first served is the norm, which could create conflict if you don't explain the scheduling process ahead of time.

Also, don't assume that patients aren't adhering to a treatment regimen through disinterest; always consider the possible impact of culture. For example, an American Indian patient may not return for treatment because the therapist didn't acknowledge the value of traditional healing interventions. Cambodians may use coining (rubbing the skin with the side of a coin), which can cause bruises. The therapist may incorrectly believe that the patient is a victim of abuse or isn't taking care of the injured area.

Tools and resources

Your attitude can play a large role in promoting cultural competency, says Sabrina Salvant, EdD, OTR/L, assistant professor of clinical occupational therapy at Columbia University, New York. She emphasizes a thorough assessment for patients of all cultures. "Look at the chart for general information, such as contraindications to therapy, then put it aside. Go in with a clear mind and without any preconceived notions," Salvant advises. Learn what the patient values and what he or she hopes to achieve through therapy. Taking this time up front will help you create a client-centered treatment plan and avoid wasted time from lack of adherence to the treatment plan.

To help with this process, the therapy evaluation form should include an area for cultural assessment. Another tool is a list of eight questions developed by Arthur Kleinman, MD, a professor of medical anthropology at Harvard Medical School, Cambridge, Massachusetts (see Eight questions for assessment). Although the term "sickness" may need to be modified for patients undergoing therapy, the questions still provide a good reference for defining the patient's beliefs.

To evaluate pain in pediatric patients, you can turn to the appropriate Oucher scale, which is available in Hispanic, African-American, and Caucasian versions. This picture scale consists of a series of faces that reflect increasing levels of "hurt." Each face is assigned a numeric value that's used to track the level of pain over time. Another option is the Wong-Baker FACES Pain Rating Scale, which uses cartoon faces instead of photographs. Each face is assigned a number and a brief description of the "hurt." Instructions for the scale have been translated into many languages, including Spanish, French, Japanese, and Vietnamese.

Don't forget to ask about education, religion, type of work, complementary medicine, and support systems, as you would for all patients. Your assessment may reveal key information. For example, members of some cultures may practice voodoo and be skeptical of western medicine (see Resources for cultural competency for more information).

Cultural preparation

Identify the most common cultures you encounter and learn more about them by viewing movies, seeking out favorite foods and, if you have the opportunity, visiting the country. Also, try to place yourself in situations in which you encounter different cultures. Salvant says, "The more information you have is key, and the more you place yourself in different cultural situations, the more you'll learn. Otherwise you're a spectator in life."

Don't forget to consider your experiences, positive and negative, with other cultures to see how they've affected your attitudes. "Look within yourself," adds Shilling. "Say, 'I'm going to treat everyone with empathy and compassion.'" You may want to take a self-assessment quiz such as the one available on The Provider's Guide to Quality & Culture Web site (see Resources for cultural competency).

Once you've looked internally, take a look around the waiting and treatment areas where you work. Is the environment inviting to people of different cultures? Haskins recommends providing consumer magazines in different languages and hanging artwork that reflects the cultures of the patients you treat. A painting by Diego Rivera or Frida Kahlo, for example, might be preferable to one by Norman Rockwell if your patients are primarily of Mexican heritage.

When learning about different cultures, include nonverbal as well as verbal behavior. For example, Muslim women may avoid eye contact because modesty is important, and you shouldn't interpret it as evasiveness.

Most of all, don't let fear of making a mistake stop you from reaching out to patients of different cultures. If you offend someone, acknowledge the mistake and learn from it.

Language barriers

Perhaps the most challenging part of being culturally competent is overcoming language barriers. Your facility should have a list of translators for patients who can't speak English. When using an interpreter, be sure to look at the patient, not the interpreter. Speak in a normal tone of voice, pausing every few sentences to allow the interpreter to translate.

While it may be tempting to use family members to translate, don't do it; this violates the 2000 guideline from the Office of Civil Rights. If a patient speaks a less common language such as Hungarian, though, you may need to ask a family member to temporarily translate until a translator can be located. Shilling, who recently worked with a patient from Hong Kong, adds that translators may not be able to be present for every therapy session in its entirety, so she emphasizes the need to "show not tell." "I turn up the volume by gestures and body language. Demonstration is always important, but particularly in these cases," she says.

Patient education

Mahendra says it's important to have patient education handouts translated into different languages. They can be part of other internal resources, such as a binder or flip chart with common phrases in different languages. "This helps build rapport quickly," she says.

Reading level isn't a cultural issue, but it's worth remembering that many consumers read at or below a fifth grade level, so it's important to assess the patient's literacy to make sure you can provide appropriate material. "You might want to rely more on videos, drawings, and illustrations that transcend literacy barriers," Haskins says.

Lifelong learning

Although you can never totally learn about a culture, it's worth making the effort to ensure that patients receive the care they need. Reading a single book or taking one tutorial isn't enough. As Salvant says, "Becoming culturally competent is a lifelong endeavor."

How cultural beliefs can affect health care

* Hispanics may believe in a bilongo, or hex, which requires consulting with a healer.

* Many African cultures believe in the "evil eye," so patients of African descent may be upset by direct comments of praise.

* During Ramadan, Muslims fast from sunrise to sunset; this includes abstaining from pharmaceuticals.

* Traditional Navajo medicine includes chanting, prayer, sand painting, dancing, and herbs.

* Pacific Islanders believe health has four components: spiritual, psychological, physical, and the relationship with family.

Source: The Provider's Guide to Quality & Culture Web site. http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English. Accessed May 3, 2007.

Eight questions for assessment

These questions, developed by Arthur Kleinman, MD, a professor of medical anthropology at Harvard Medical School, Cambridge, Massachusetts, will help you evaluate a culturally diverse population.

1. What do you call the problem?

2. What do you think has caused the problem?

3. Why do you think it started when it did?

4. What do you think the sickness does?

5. How severe is the sickness? Will it have a short or long course?

6. What kind of treatment do you think you (or the patient, if asking a family member) should receive? What are the most important results you hope to receive from this treatment?

7. What are the chief problems the sickness has caused?

8. What do you fear most about the sickness?

Resources for cultural competency

Web sites

American Physical Therapy Association, http://www.apta.org

American Occupational Therapy Association, http://www.aota.org

American Speech-Language-Hearing Association - Office of Multicultural Affairs,

http://www.asha.org/about/leadership-projects/multicultural

California Speech Language Hearing Association - Diversity Issues Committee, http://www.csha.org/diversity.htm

The Henry J. Kaiser Family Foundation, http://www.kff.org/minorityhealth/index.cfm

The Office of Minority Health, http://www.omhrc.gov

National Center for Cultural Competence, http://gucchd.georgetown.edu/nccc

Oucher!! http://www.oucher.org

The Provider's Guide to Quality & Culture, http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English

Think Cultural Health, http://www.thinkculturalhealth.org

Articles and books

Iwama MK. Revisiting culture in occupational therapy: A meaningful endeavor. OTJR. 24(1):2, 2004.

Lattanzi JB, Purnell LD. Developing Cultural Competence in Physical Therapy Practice. Philadelphia, Pa., FA Davis, 2005.

Royeen M, Crabtree JL. Culture in Rehabilitation: From Competency to Proficiency. Upper Saddle River, N.J., Prentice Hall, 2005.