The Appeal and Problems of a Cultural Competence Approach to Reducing Racial Disparities

E liminating racial disparities in health care is a high priority goal for health care organizations. Disparities have been observed across a wide range of treatments and health conditions, from treatment of pain due to bone fracture to the treatment of HIV/AIDS. Inequalities between whites and blacks have been documented most frequently, but other non-white groups are disadvantaged as well. Research suggests that access to treatment and provider recommendations tend to account for the inequality. Seeking to eliminate racial disparities, many researchers and administrators have turned to cultural competence programs. Cultural competence in health care began with efforts to improve immigrant patients’ utilization and adherence by educating providers about immigrants’ cultures and how to effectively use interpreters. Subsequently, cultural competence programs were deployed to improve care for native-born minority patients as well. The approach is now widespread: the Affordable Care Act mentions cultural competence; several states require cultural competence training for medical students; and it is common in continuing medical education. The ubiquity of cultural competence programs suggests a widespread commitment to reducing racial inequality. In this issue of JGIM, Saha and colleagues contribute to this effort by presenting an empirical assessment of the effect of self-reported cultural competence on patient outcomes. In cultural competence terms, Saha et al. present important findings based on high quality clinical and survey data and methods. In this editorial, I will describe both their contribution, as well as my view that the foundation for cultural competence’s popularity is also the source of its fundamental problems. Saha and his colleagues seek to remedy a significant problem in the cultural competence field. As they note, there have been few empirical studies demonstrating that cultural competence improves the quality of interpersonal or technical care provided to minority race patients. Saha et al. tackle this problem by evaluating whether health care providers who rate their cultural competence higher have patients with better HIV management and whether there is a stronger positive effect among minority race patients. In order to assess providers’ cultural competence, Saha and colleagues had to first define the construct. Starting from the notion that cultural misunderstanding is a primary source of racial disparities, cultural competence programs began with efforts to reduce racial disparities by teaching about the “cultures” of non-white racial and ethnic groups. Quickly, criticism arose that this approach reinforces stereotypes about racial and ethnic minorities, suggests that racial groups have homogenous cultures, and fails to recognize how white racism and other systems of inequality affect care. Subsequently, most academic publications advised that to be cultural competent, providers should inquire about—and respect—patients’ individual health beliefs and attitudes rather focus on “cultural traits” of racial groups. Saha et al. review the literature and develop a survey instrument based on the current conception of cultural competence. Their instrument primarily assesses providers’ openness to patients’ experiences and perspectives, with some attention to knowledge of inequality. With this measure, they find that for minority race patients, there is a positive effect of provider cultural competence. These findings suggest that better cultural competence among providers will reduce disparities. Yet, we must proceed cautiously before making that conclusion. While Saha and colleagues’ findings contribute to the cultural competence literature, it is unclear that their research will be used to reduce racial disparities in health care. To understand the potential obstacles to reaching that goal, we must examine the cultural competence field in terms of contemporary racial ideology. Doing so reveals what may be an intractable conflict between the appeal of cultural competence and its real potential to reduce racial disparities. Before describing my perception of the conflict, we must define racial ideology. Generally, ideology is the broad set of beliefs that people in a society use to organize their thinking about the social world. Racial ideology helps people make sense of racial categories and inequality by Published online February 13, 2013