Improving care and interactions with racially and ethnically diverse populations in healthcare organizations.
Subject: Health care industry (Management)
Author: Reynolds, Duane
Pub Date: 07/01/2004
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2004 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: July-August, 2004 Source Volume: 49 Source Issue: 4
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management; Health care industry
Product: Product Code: 9139340 Institute of Medicine NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences SIC Code: 8000 HEALTH SERVICES
Organization: Organization: Institute of Medicine
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 120190134
Full Text: EXECUTIVE SUMMARY

The need for healthcare managers to develop strategies that address culturally appropriate care for racial and ethnic populations continues to grow in importance. Healthcare organizations within the United States serve a range of diverse people, but they are not adequately meeting the needs of specific populations. Cultural and linguistic barriers are posing problems for an industry that is already financially strained. If strategies to provide more culturally appropriate care are not implemented, financial pressures will continue to rise and quality of care will suffer. Healthcare organizations can and should promote cultural competence among their physicians and employees.

This article attempts to define the scope of the problem through literature and case studies. It also offers healthcare managers strategies for improving cultural understanding and competency within their organization.

DESCRIPTION OF THE PROBLEM

Demographic Shift

The demographic landscape of the United States has changed dramatically in the last 20 years, transforming into an increasingly diverse and multicultural country. The U.S. Census Bureau reported that the minority population grew from 20 percent in 1980 to 31 percent in 2000 (Hobbs and Stoops 2000). Of this population, 31.8 million spoke a language other than English in their homes. From 1980 through 2000, the three fastest-growing racial categories were Asian and Pacific Islander (204 percent), Hispanic (141.7 percent), and "Other" (127.3 percent). As a result of the shifting demographics, healthcare providers are facing increased challenges in addressing the need to care for patients with varying cultural and ethnic backgrounds.

One component of this challenge is linguistic barriers. Patients with limited English proficiency (LEP) experience obstacles when accessing healthcare (Riddick 1997). Individuals with LEP may experience delays in making appointments; are more likely to have misunderstandings regarding time, date, and location of appointments; and may have difficulty communicating with employees of healthcare institutions (Riddick 1997). These issues are likely to exacerbate medical problems that require timely treatment and may reduce the quality of care provided. Language and cultural barriers have become such a challenge that in 1999 the U.S. Department of Health and Human Services' (HHS) Office of Minority Health developed standards of care within these areas. In addition, the Office for Civil Rights (2003) and HHS enforce federal laws that prohibit discrimination by healthcare providers who receive funding from the HHS. Antidiscrimination laws are established by Section 504 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act of 1964, Title II of the Americans with Disabilities Act of 1990, Community Service Assurance provisions of the Hill-Burton Act, and the Age Discrimination Act of 1975. These laws mandate that providers who accept federal money must "ensure meaningful access to and benefits from health services for individuals who have limited English proficiency" (Beckley 2002). Healthcare providers may face legal recourse for noncompliance or violating language requirements (Beckley 2002).

Cultural barriers introduce another level of depth to the challenges that healthcare providers and organizations face. Cultural care conflicts arise when two ethnocentric views confront one another, resulting in tension (Riddick 1997). Press (2002) contends that all patients have their own medical system when they access care. The idea of a self-identified medical system is directly influenced by a patient's cultural beliefs and experiences. Broadly defined, culture is made up of learned and transmitted beliefs as well as information and values that shape attitudes and generate meaning among members of a social group (Riddick 1997). The values and expectations that a patient brings to the care experience may be in conflict with the values of the clinician who is providing care. What results is a less-than-adequate healthcare experience that leaves both patient and clinician dissatisfied with the interaction.

Researchers within Diversity Rx discuss culture on a macro level (national, ethnic, or racial groups) and a micro level (age, gender, and religious beliefs) (Riddick 1997). The combination of these two cultural tiers shapes individual views and dictates people's interaction with others and, more importantly, healthcare decisions. Healthcare providers who were brought up in the U.S. culture are increasingly finding their medical views in conflict with patients from other cultural backgrounds. Care provided in the past was monocultural and suited for Euro-American culture; however, this traditional model is not as appropriate for different cultures (Rashidi and Rajaram 2001). The consequences of cultural disconnect are disparities in the quality of care received by racial and ethnic minority populations.

Institute of Medicine's Findings

In March 2002 the Institute of Medicine (IOM) issued a report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare," that addresses the disparate treatment of minorities within the healthcare system. The report reveals that healthcare providers exhibit prejudice, bias, and stereotyping that may contribute to the disparity of care found between white Americans and minority populations. According to the IOM (2002), even when holding access-related factors, such as degree of insurance coverage and ability to pay, the care experienced by minorities is of lower quality.

Researchers at the IOM reviewed 100 studies that analyze the healthcare quality for various racial and ethnic minority populations. The findings indicate that "minorities are less likely than whites to receive needed services, including clinically necessary procedures" (IOM 2002). Disparities existed in the treatment of illnesses such as diabetes, HW/AIDS, mental illness, cardiovascular disease, and cancer and in routine care for common health problems.

Several factors were identified as possible sources for healthcare disparities. The first set of variables was the operation of healthcare systems and the regulatory and legal environments in which these systems operate. Factors represented in the initial category include (1) language and cultural barriers, including the lack of interpretive services offered within health organizations; (2) fragmentation of the healthcare system and the possibility of more minorities being enrolled in lower-priced managed health plans with increased utilization controls; (3) physician incentive programs used to contain costs; and (4) the location in which minorities receive care.

The next set of factors focused on clinical interactions. The IOM identified three possible provider-related mechanisms that may contribute to disparities: (1) prejudice against minorities, (2) higher levels of clinical uncertainty in communicating to ethnic populations, and (3) stereotypes held by providers about the behavior or health of minorities. Also noted was that patients may react to provider behavior and prejudice, which potentially results in lower quality of care (IOM 2002; Fadiman 1997; Rashidi and Rajaram 2001).

The IOM has issued possible solutions that may help providers eliminate the differences in healthcare quality experience by minority populations. Recommendations were focused on cross-cultural educational approaches that encompass knowledge, attitudes, and skills of providers. Each of these suggestions is explored in greater detail in the following section.

Cultural Disparity in Healthcare

Cultural disparities have severe implications for the healthcare industry. Whether real or perceived, communication barriers and prejudice within the healthcare system have the potential to escalate into more significant problems. The issue of most concern, as identified by the IOM, is quality of care. Many factors may contribute to the poor quality of care experienced by racial and ethnic minorities. Confusion and miscommunication of medical history can lead to inaccurate diagnosis and treatment, which may potentially result in exacerbated illnesses (Riddick 1997). Patients who do not have a clear understanding of treatment guidelines are likely to be noncompliant, which ultimately leads to the need for further health system encounters that require more expensive and invasive treatments (Riddick 1997).

However, many providers are realizing that being culturally and linguistically diverse may have a positive impact on patient satisfaction, outcomes, and the bottom line (Beckley 2002). Brach and Fraser (2002) note the increased emphasis that is being placed on cultural competence and quality by Medicare/Medicaid and other public insurers. Monitoring and enforcement efforts are not current priorities for these agencies, as minority populations and costs associated with poor quality care continue to grow. However, Medicare and Medicaid oversight will be inevitable. A study cited by the National Managed Health Care Congress (2003) estimates that if healthcare disparities were eliminated in the state of Pennsylvania, dollar savings to the U.S. healthcare system would total $30 million per year for diagnoses that are common to minorities. Alternatively, viewing cultural competence as a business strategy may serve to generate greater market share and increased revenues (Brach and Fraser 2002). At some point in the future, healthcare professionals and providers will be forced to make cultural diversity and understanding a priority within their organizations, or they will suffer penalties from Medicare and Medicaid. Consequently, a strong, proactive approach to increasing cultural competence will prove beneficial.

Case Studies

The Tuskegee Syphilis Study. During a medical research study, 399 poor African-American sharecroppers, who were identified as having syphilis, were told that they were being treated for the disease. However, they were actually being deceived by officials of the U.S. Public Health Service for the sake of medical research. The Tuskegee study lasted from 1932 to 1972, only formally ending when a public apology to its victims was delivered by President Bill Clinton on behalf of the U.S. government ("Doing Bad ..." 1994).

As evidenced by this case, covert racism and ethical misconduct are still very much a reality. In fact, the IOM (2002) asserts that there is "empirical evidence that even well-intentioned whites, who are not overtly biased and who do not believe that they are prejudiced, typically demonstrate unconscious implicit negative racial attitudes and stereotypes." It may be reasonable to assume that providers find prejudice and discrimination morally wrong and inconsistent with their professional values, but the reality is that healthcare providers, just as other members of society, may not recognize coven manifestations of prejudice in their own behavior (IOM 2002). The legacy of the Tuskegee study has dramatically affected the reputation and credibility of the medical industry and has strained its relations with the African-American community.

The Hmong Refugee Population. In the literary masterpiece The Spirit Catches You and You Fall Down, by Anne Fadiman (1997), the clash between culture and traditional western medicine is explored through the experiences of a young child who belongs to the Hmong ethnic population. The book chronicles the story of Lia Lee, who was diagnosed at a very young age with the disease referred to in western medicine as epilepsy. With beliefs deeply rooted in spiritual medicine, Lia's family struggles to understand and accept the medical care their daughter receives within the U.S. healthcare system. Fadiman exquisitely maneuvers through a detailed history of the Hmong culture while recounting Lia's progression and experiences within the Merced Community Medical Center in Merced, California. The care that Lia receives leads to misdiagnoses and eventual decline in health status as a result of communication barriers and lack of understanding from both the Lee family and her providers. Fadiman's account allows the reader to begin to understand dimensions of the Hmong cultural identity and the challenges that the U.S. healthcare system faces in adequately addressing the health needs of a defined population.

Several underlying themes are identified and posed as challenges for the Merced Community Medical Center, including (1) a lack of basic cultural knowledge, (2) a lack of appreciation and respect for culture, (3) a lack of translation and interpretive services, and (4) an elitist and paternalistic approach to healthcare. These problems, despite efforts to improve them, are still present and impede the quality of care and respect that patients receive (Fahrenwald et al. 2001; Riddick 1997; Maltby 1999; IOM 2002; Bonder, Martin, and Miracle 2001; Cole 2002). The story of Lia is a visible example of the inadequacies that exist within the U.S. healthcare system.

DEVELOPING CULTURAL COMPETENCE

Improving Cultural Understanding

To provide more appropriate care, managers and practitioners in healthcare organizations must become culturally competent when addressing the needs of diverse patient populations. Campinha-Bacote (1994) defines cultural competence as a continuous process of effectively developing the ability to work within the cultural context of a community, a family, and individuals from a diverse cultural and ethnic background. Essentially healthcare managers must develop strategies that promote respect for individuals and cultural dissimilarities, incorporating a trust-promoting method of inquiry (Riddick 1997). In addition, management needs to support the development of cultural competence among providers and other employees within healthcare institutions.

Culture is an extremely important component of one's life. For practitioners to respond to the specific needs of individual clients, they must be culturally competent (Bonder, Martin, and Miracle 2001). An understanding of culture and respect for differences will allow healthcare managers to make more culturally appropriate planning and intervention decisions. Researchers have also noted that knowledge of specific cultures permits providers to understand how their patients' culturally based beliefs can affect the course and outcome of disease (Riddick 1997). The basic premise of cultural competence is conceptually understood and presented by many researchers, but specific standards of competence vary widely and are difficult to rely on in developing a true level of competence.

On the individual level, developing cultural competence is a challenge that many clinicians are not well trained and suited to accomplish. According to Bonder, Martin, and Miracle (2001), "it is not a simple matter to gather the information about a client's 'cultural mores' [or about] culturally and socio-politically relevant factors." Despite the apparent challenges and difficulties in developing cultural competence, efforts to do so are still essential.

Cultural Competence Standards

Many models for culturally competent standards exist. The difficulty is in deciding which standards are best suited for a uniform level of culturally competent guidelines within the healthcare industry. The HHS's (1999) Office of Minority Health (OMH) developed a list of 14 standards for Culturally and Linguistically Appropriate Healthcare Services (CLAS), which healthcare organizations and practitioners should use to ensure cultural competence. Other models for cultural competency standards exist (AOA 2000; APA 1998; Riddick 1997), but a uniform guideline of national standards for cultural and linguistic competencies did not become available until 1999. A central challenge is in trying to determine what information should be utilized to establish cultural competence (Riddick 1997). CLAS standards were developed to replace the patchwork of various definitions, recommendations, and terms with a universal set of guidelines (HHS 1999).

The CLAS standards outlined by the OMH provide standards applicable to laws that address the responsibilities of healthcare providers in rendering appropriate care to ethnic populations. Furthermore, OMH researchers found that most cultural competency models focused mainly on linguistic and interpretive, as opposed to cultural, competence (HHS 1999). The literature review conducted by researchers at the OMH indicates that "a lack of attention to cultural issues leads to less than optimal healthcare, and that addressing these concerns or using certain CLAS interventions leads to improved outcomes" (HHS 1999). Improving communication, understanding cultural customs, and respecting diversity will create better relationships between racial and ethnically diverse populations and healthcare organizations. This will ultimately lead to better health outcomes. By developing policy and educational initiatives based on the standards set forth by CLAS, healthcare managers may avoid potential legal ramifications but, more importantly, will ensure that their organizations are addressing the needs of their defined populations based on a uniform set of expectations. Healthcare organizations should adhere to standards of culturally competent care (see Appendix A for the GLAS standards).

Translation and Interpretive Service Limitations

Efforts to improve patient care in hospitals and health systems have mainly focused on translation and interpretive services. Maltby (1999) identifies several problems associated with practitioners who exclusively rely on interpreters. First, clinicians may not summon the services of an interpreter as a matter of policy when a non-English-speaking patient accesses the health system; rather, they do so as the need for such a service arises. Second, interpreters may not accurately translate what either party is trying to communicate. Interpreters are also susceptible to cultural filtration and bias when translating messages. Cultural filtration occurs when cultural beliefs or ideas are applied and/or removed as a result of the interpreter's bias. Translation of materials, such as health pamphlets, also presents potential issues of cultural filtration. Although translation and interpretation may be good reference points, healthcare managers must be aware of their limitations and must seek to develop a deeper understanding of the cultural influences that affect decisions. The true manifestation of poor communication and quality rests with the inability of healthcare professionals to understand the cultural underpinnings of ethnic groups (Cole 2002). If generally held cultural beliefs of the populations whom a healthcare institution serves were better understood, providers would be better able to win trust and influence health behavior (Cole 2002; Beckley 2002; Bonder, Martin, and Miracle 2001).

Cultural Competence Models

A move toward improving cultural understanding among healthcare providers and within healthcare organizations is critical. Several approaches have been developed to aid health professionals in developing culturally competent skills.

The LEARN model for cross-cultural healthcare was developed by Berlin and Fowkes (1983) and is commonly taught to medical students and residents (see Appendix B). This model assumes that cultural understanding is a constant work in progress and allows for ease of recognition when dealing with culturally diverse patients. The limitation of this model is the relative lack of breadth that can be obtained, but it does provide a starting point and conceptual framework for improving cultural sensitivity.

Bonder, Martin, and Miracle (2001) discuss three approaches for developing cultural competence: (1) fact-centered approach, (2) attitude-centered approach, and (3) ethnographic questioning. The fact-centered method relies on the premise that factual information can be effective in designing population-specific methods, which may be applied during cross-cultural interactions. Information regarding the health behavior and beliefs of a particular group are obtained through this approach. A similar method, which focuses on multicultural knowledge, is suggested by the IOM (2002). The advantage of the fact-centered approach is that it provides a beginning reference for clinicians.

The attitude-centered approach, also described by the IOM, focuses on developing an open-minded awareness and respect for valuing different cultures. Rather than concentrating on specific skills, this approach relies on a provider's ability to challenge personal biases.

The final alternative presented encompasses ethnographic methods of questioning, often used in the field of anthropology. Ethnographic research incorporates both quantitative and qualitative methods derived from interviewing techniques, participant observation, and prolonged fieldwork (Savage 2000). Many researchers (DeSantis 1994; Savage 2000; Lambert and McKevitt 2002; Fahrenwald et al. 2001; Bonder, Martin, and Miracle 2001) have noted the benefits of anthropology and its applications to healthcare. Ethnographic interviewing techniques give practitioners a strategy for questioning that supports learning how to ask (Briggs 1986). Savage (2000) affirms that "ethnography can help healthcare professionals solve problems beyond the reach of many research approaches, particularly in the understanding of patients' and clinicians' worlds."

It is important for healthcare management to realize that culture is not stagnant but continually developing. Bonder, Martin, and Miracle (2001) support the idea that culture has continuity and is generally stable, but cultural knowledge changes over the course of an individual's life. Different encounters and interactions affect a culture. As people are exposed to new situations and ideas, they grow and develop in their beliefs and behaviors (Riddick 1997). Understanding this reality can provide a sense of encouragement for healthcare organizations that are struggling to meet the challenges of cultural and ethnic populations.

When ethnic groups seek out medical care, the process of mutual accommodation has been initiated. Mutual accommodation is defined as "the process by which individuals from differing cultures reach a compromise or understanding about how they will resolve conflict" (Bonder, Martin, and Miracle 2001). Campinha-Bacote (1999) describes the concept of cultural desire as the motivation of healthcare providers to engage in active learning to increase cultural competence. To improve communication and understanding of ethnically diverse patients groups, cultural desire among healthcare managers and providers must increase. Once the willingness to learn had increased, the process of mutual accommodation between patients and healthcare organizations is likely to occur.

STRATEGIES FOR MANAGEMENT ACTION

Recommendations

In an attempt to improve quality of care and relationships with racially and ethnically diverse patients, the following strategies are recommended for healthcare managers to employ:

1. Acknowledge the need to become more culturally competent, and incorporate this realization into the strategic plan and vision of the organization. The diversity imperative must be as equally weighted as other strategic initiatives to invoke cultural change within the organization.

2. Develop a committee that represents the diversity of the organization in regard to position, profession, race, ethnicity, gender, religion, age, and other components. The committee should be composed of, but not limited to, senior leaders of the organization, and it must include the chief executive officer. The committee will be charged with developing a strategic agenda to improve the overall diversity of the organization and with creating a diversity awareness program.

3. Develop a policy in the workplace that goes beyond prohibiting discrimination and promotes respect for differences.

4. Outline the moral imperative and business case for diversity, and begin to communicate this throughout the organization.

5. Require that all recruiting efforts include persons of various racial and ethnic groups, along with other dimensions of diversity represented within the community served.

6. Have all publications and patient information translated to the appropriate language based on the community served.

7. Host diversity forums in which people of various racial and ethnic groups share mores and customs of their culture.

8. Host educational seminars for physicians and associates that feature a cultural anthropologist who is familiar with the community the organization serves.

9. Develop a diversity calendar in celebration of religious and cultural holidays. Allow employees to observe religious functions without fear of termination.

10. Provide ongoing training on diversity and racism within the organization.

11. Employ or contract interpreters. The benefit of this service will far outweigh the costs, as legal ramifications are avoided and communication with patients is improved.

12. Develop a strategy to promote open communication between the organization and minority populations within the community.

13. Develop targeted outreach initiatives that are culturally appropriate for the community served by the organization.

14. Measure and reward small successes in the diversity movement of the organization.

15. Do not be afraid to make mistakes; learn from those mistakes.

The aforementioned strategies can begin to improve customer and patient satisfaction, quality of care, and access to care for diverse populations. In the broader culture of the organization, improving an understanding of and respect for diversity can promote recruitment, retention, and productivity in the work environment (Dreachslin 1996; Esty, Griffin, and Schorr-Hirsch 1995).

CONCLUSION

Improving cultural understanding should he a priority for healthcare management and organizations. An ever-increasing cultural and ethnic population requires a more culturally sensitive approach to care. Quality of care is reliant on an organization's ability to communicate and understand the cultural factors that affect health behavior. Physicians and other healthcare professionals within a hospital or health system must be encouraged and supported by healthcare management to enable achievement of greater levels of cultural competence. The HHS's Office of Minority Affairs has outlined 14 national standards for developing culturally and linguistically competent care within healthcare organizations and among providers. These standards allow for uniform and acceptable guidelines for culturally competent care. In addition, various strategies for management of organizations have been presented and can begin to bridge the gap between racial and ethnic populations and the organizations that provide care to these populations. It is important that healthcare managers are cognizant of these standards for the benefit of patients, for adherence to federal law and quality standards, and for the financial survival of the organization in the future. More importantly, a moral imperative should drive healthcare managers to work toward improving the lives of the communities their organizations serve.

Appendix A:

CLAS STANDARDS

1. Promote and support the attitudes, behaviors, knowledge, and skills necessary for staff to work respectfully and effectively with patients and each other in a culturally diverse work environment.

2. Have a comprehensive management strategy to address culturally and linguistically appropriate services, including strategic goals, plans, policies, procedures, and designated staff responsible for implementation.

3. Utilize formal mechanisms for community and consumer involvement in the design and execution of service delivery, including planning, policy making, operations, evaluation, training, and, as appropriate, treatment planning.

4. Develop and implement a strategy to recruit, retain, and promote qualified, diverse and culturally competent administrative, clinical, and support staff to address the needs of the racial and ethnic communities being served.

5. Require and arrange for ongoing education and training for administrative, clinical, and support staff in culturally and linguistically competent service delivery.

6. Provide all clients with limited English proficiency access to bilingual staff or interpretation services.

7. Provide oral and written notices, including translated signage at key points of contact, to clients in their primary language informing them of their right to receive interpreter services free of charge.

8. Translate and make available signage and commonly used written patient educational material and other materials for members of the predominant language groups in service areas.

9. Ensure that interpreters and bilingual staff can demonstrate bilingual proficiency and receive training that includes the skills and ethics of interpreting and knowledge in both languages of the terms and concepts relevant to clinical or nonclinical encounters. Family or friends are not considered adequate substitutes because they usually lack these abilities.

10. Ensure that the clients' primary spoken language and self-identified race/ ethnicity are included in the healthcare organization's management information system as well as any patient records used by provider staff.

11. Use a variety of methods to collect and utilize accurate demographic, cultural, epidemiological, and clinical outcome data for racial and ethnic groups in the service area, and become informed about the ethnic/cultural needs, resources, and assets of the surrounding community.

12. Undertake ongoing organizational self-assessments of cultural and linguistic competence, and integrate measures of access, satisfaction, quality, and outcomes for CLAS into other organizational internal audits and performance improvement programs.

13. Develop structures and procedures to address cross-cultural ethical and legal conflicts in healthcare delivery and complaints or grievances by patients and staff about unfair, culturally insensitive or discriminatory treatment, or difficulty in accessing services, or denial of services.

14. Prepare an annual progress report that documents the organization's progress with implementing CLAS standards, including information on programs, staffing, and resources.

Source: HHS Office of Minority Affairs. 1999. "Assuring Cultural Competence in Healthcare: Recommendations for National Standards and Outcomes-Focused Research Agenda." [Online information; retrieved 2/23/03.] http://www.omhrc.gov/clas/.

Appendix B

The LEARN Model for Cross-Cultural Healthcare

Listen to your patient from his or her cultural perspective

Explain your reasons for asking for personal information

Acknowledge your patient's concerns

Recommend a course of action

Negotiate a plan that take into consideration your patient's cultural norms and personal lifestyle

Source: Berlin, E. A., and W. C. Fowkes, Jr. 1983. "A Teaching Framework for Cross-Cultural Healthcare: Application in Family Practice." Western Journal of Medicine 139 (6): 934-38.

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For more information on this article, please contact Mr. Reynolds at dereynol@aol.com.

Duane Reynolds, The Ohio State University, Columbus, Ohio
Gale Copyright: Copyright 2004 Gale, Cengage Learning. All rights reserved.