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Executive Summary

Noteworthy problems with access to health care and poor health outcomes among racial and ethnic minorities have been documented. Provision of "culturally competent" medical care is one of the strategies advocated for reducing or eliminating racial and ethnic health disparities. Cultural competence has been defined by the Office of Minority Health as "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations." This report examines culturally competent care from the patient's perspective, explores methods for assessing culturally competent care, and identifies areas for further research. In particular, the authors sought to:

• develop a conceptual framework that identifies domains of culturally competent care from the patient's perspective;
• review the literature focusing on these domains;
• summarize the salient issues and current knowledge; and
• discuss the policy and research implications.

Aspects of Culturally Competent Care from the Patient's Perspective
Patient–provider communication. Patient–provider communication can be affected by such factors as differences in verbal and non-verbal communication styles and explanatory models of illness. Minority patients and individuals from lower socioeconomic backgrounds tend to receive less health-related information from their providers compared with non-minorities and individuals from higher socioeconomic backgrounds. Lack of patient–provider communication about the use of complementary and alternative medical practices is also a noteworthy problem.

• Provider/health system recommendations: The authors recommend that health care providers and health systems continually monitor their patient populations through quantitative and qualitative data collection methods. Specifically, data collection should include patients' race or ethnicity, socioeconomic status, English language skills, and preferred language or language spoken at home. Intake forms should be modified to include questions that measure health literacy, English proficiency, language spoken at home, and use of complementary and alternative medical practices.
• Applied research recommendations: Research is needed to examine factors that influence patient–provider interactions among diverse racial/ethnic groups. Further research is needed to investigate the roles that patient navigators/coaches, community health workers, parish nurses, interpreters, and case managers can play in influencing patient–provider communication.

Shared decision-making and respect for patient preferences. Patient-centered care requires effective patient–provider partnerships, including shared decision-making among providers, patients, and families. Providers should work with patients to select treatments that take into account patients' health-related values, weighing available treatment options and patient preferences. Current research shows that minority and low-income populations are more likely than white or higher-income patients to feel disenfranchised in the decision-making process and perceive a lack of respect for their preferences. In addition, studies have found that patients who make frequent use of complementary or alternative medicine often feel that providers do not respect their decision to use such therapies instead of (or in addition to) conventional medicine.

• Provider/health system recommendations: The authors recommend that providers investigate patients' explanatory models of common diseases and their health-related values and preferences (e.g., why a patient thinks he has lung cancer and how he wants to involve his family in end-of-life decisions). At the systems level, policies should aim to democratize decision-making processes among patients, their families, and providers. Additionally, policies are needed to recognize patients' rights to use alternative therapy or community-based programs in addition to conventional medical facilities.
• Applied research recommendations: Research is needed to investigate the association between patients and providers' race/ethnicity and their treatment preferences. It is also important to examine what happens when patients and providers disagree on treatment options. More research is needed to determine how patients' disclosure of their use of complementary or alternative medicine affects patient–provider interactions. Finally, research is needed to examine the use of lay health workers or other "cultural communicators" as facilitators. Cultural communicators observe the doctor–client interaction and help the health care provider and client understand each other.

Experiences leading to trust or distrust. Only a few studies have looked at the underlying causes of patient dissatisfaction and distrust of providers among racial and ethnic minorities. The existing studies consist mainly of small, qualitative investigations of special populations. Current research indicates that minority patients who have race-concordant providers report higher levels of satisfaction with their care and lower levels of distrust.

• Provider/health system recommendations: It is important to evaluate the factors that affect patients' trust in their providers. Such factors may differ by racial/ethnic populations as well as socioeconomic and insurance status. Providers should seek to develop open channels of communication and empower patients

  to speak up about issues affecting their trust.

• Applied research recommendations: Further research is needed to understand why some patients prefer to be race concordant with their providers, and to gauge the effects of racial concordance on access to care, quality of care, and health outcomes. Research is also needed to explore and understand the root causes of distrust in providers, particularly among Latino and African American patients, for which studies conducted in different health care settings have yielded contradictory results. Finally, there is a need to explore whether differences in levels of trust of providers among racial and ethnic minorities, compared with whites, result from past experiences with the medical system or varying expectations.

Experiences of discrimination. Compared with white patients, racial and ethnic minorities perceive more instances of racism in the medical care system, tend to be less satisfied with their health care, and have higher levels of distrust in their health care providers. The reasons for these perceptions have not been definitively determined. Research on the role of racial bias or discrimination in the practice and delivery of health care is needed, as are valid measures for use in large-scale, population-based studies of the causes and health effects of perceived discrimination.

• Provider/health system recommendations: Providers need to be aware that racial and ethnic minority patients might perceive discrimination or bias in the health care system. Specific complaints of discrimination should be investigated and structural, system-wide changes and improvements should be sought. Patients should be given opportunities to voice their concerns about discrimination.
• Applied research recommendations: More research is needed to determine the placement of responsibility (e.g., on providers, staff, or others) for discrimination in health care settings and the characteristics (of patients or of the providers/staff members) that are most associated with incidents of bias. In addition, understanding the consequences of perceived discrimination or bias on health is an important next step for future research.

Linguistic competence. Compared with English-speaking patients and those with higher levels of health literacy, limited English proficiency (LEP) patients and those with low health literacy are less likely to use health care services and adhere to medical regiments and more likely to have worse health outcomes. Linguistic competence includes communication strategies for LEP individuals and those with low health literacy. Language concordance between patients and providers is the most effective strategy to improve communication and health outcomes for LEP patients, though the use of professional interpreters can also be effective. Still, the majority of LEP patients lack access to trained interpreters. There are also effective techniques for communicating with patients with low health literacy.

• Provider/health system recommendations: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee for Quality Assurance (NCQA) should require hospitals and health plans to collect data on their patients' health literacy and English proficiency as part of the accreditation process. Insurers and policymakers should provide incentives for health care providers to improve services that specifically target patients who have low health literacy or limited English proficiency. Providers and health care systems should avoid the use of ad-hoc interpreters to communicate with LEP patients, and instead rely on trained bilingual staff and professional interpreters. Health plans and providers must monitor and assess the quality of interpreter services. Finally, medical schools and other health professional schools should incorporate issues pertaining to communication with patients who have low health literacy and/or LEP into their curricula. Medical schools should seek to increase recruitment and retention of bilingual students.
• Applied research recommendations: Further research is needed to assess the impact of various communication strategies for low health literacy patients, considering effects on health-related knowledge, compliance with care regimens, and health outcomes. More research on the mechanisms through which low health literacy and LEP may affect health outcomes is also needed. Finally, it is important to consider the implications for the health care system of patients who have both low health literacy and LEP.

Patient–provider communication, shared decision-making, and trust affect the quality of care of all patients, not just racial/ethnic minorities or those with low socioeconomic status. However, problems in these areas of patient-centered care disproportionately affect vulnerable populations. Incorporating patients' perspectives on culturally and linguistically appropriate services into current measures of quality will provide important data and create opportunities for providers and health plans to make improvements.