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Introduction

Early in my career as a prosthetist, I worked with an elderly patient after she had a transtibial amputation. She returned repeatedly for follow-up visits with vague and inconsistent reports of discomfort and pain after the initial fitting of her prosthesis. The home health physical therapist reported that she could not determine the specific nature of the complaints or a possible cause. During my evaluations, I did not detect inappropriate redness or other signs of improper fit or function. I told the patient that it was difficult to know how to proceed based on her descriptions of the discomfort, and I asked if there was some other reason for her return visits. She responded that since God had allowed her leg to be amputated, she did not believe it was right to replace it. Many years later, I recognized that a cultural difference was a key element in that encounter. This article describes the importance of understanding culture, cultural sensitivity, and culturally sensitive communication as part of effective patient care.

Changing Demographics

The U.S. population has become increasingly diverse in recent decades. According to U.S. Census Bureau information (cited by the American Congress of Obstetricians and Gynecologists), "from 2000 to 2009, there was a 32 percent increase in the Asian population, a 37 percent increase in individuals of Hispanic origin, an 18 percent increase in American Indians and Alaskan Natives, and a 13 percent increase in the African American population. The white non-Hispanic population increased by only 2 percent."¹ In 2015, the percentage of the U.S. population identified as white was 77 percent, which constitutes a clear racial majority.² The Pew Research Center predicts that by 2055 (within the career span of students currently graduating from O&P programs) "the U.S. will not have a single racial or ethnic majority."3 Additionally, "about 14 percent of the USA population do not speak English at home," and 47 percent of them report that they "have difficulty speaking English."⁴

Over 90 percent of the respondents to the 2000 American Board for Certification in Orthotics, Prosthetics and Pedorthics Practice Analysis of the Disciplines of Orthotics and Prosthetics identified themselves as "non-Hispanic, Caucasian/White," dropping to just over 80 percent by the 2015 analysis, due to small increases in other ethnic groups.^5,6 Even after this drop of more than ten points, the percentage of white practitioners remained higher than the percentage of white people in the general population, and this racial disparity may remain a fixture of the O&P profession for some time to come.

Challenges in Providing Care

Cultural differences between the patient and provider can affect access to care and the quality of care provided. The U.S. Department of Health and Human Services reports that "social, cultural, and language barriers to healthcare access are numerous and problematic. Cultural and linguistic differences and levels of acculturation may affect communication, level of trust, and the ability to navigate the American health system."¹¹ Tucker et al. state, "empirical evidence of the prevalence of race/ethnicity and income-related health disparities among minority populations in the United States is startling…. Alarmingly, these health disparities persist after controlling for unhealthy behaviors and inadequate access to healthcare."¹²

Lack of cultural awareness and insensitivity can negatively impact quality of care. Diagnosis and prognosis are based in part on cultural norms for the appropriate manner in which to respond to various types of questions. Thus, if a practitioner and a patient are from different cultures, they may misunderstand each other when discussing important aspects of care.⁴ For example, if a practitioner from a culture where reporting pain is encouraged is working with a patient from a culture where expressions of pain are minimized, the practitioner may underestimate the seriousness of a medical problem.

Additionally, practitioners and patients may not have the same treatment goals or priorities. "When an individual's culture is at odds with that of the prevailing medical establishment, the patient's culture generally will prevail, often straining physician-patient relationships."¹ This can result in limited compliance with a treatment plan a practitioner advises if it is culturally inappropriate for the patient. For example, a patient from a culture with a strict code of modesty may not return for necessary follow-up appointments if the practitioner has a different cultural assumption of what is appropriate. These types of misunderstandings can be reduced if practitioners increase awareness of their patients' cultures.

Cultural Sensitivity Versus Stereotyping

Awareness of common features of an identifiable group of individuals is a generalization; it is not the same as forming or perpetuating a stereotype. "A stereotype is an ending point, and no effort is then made to ascertain whether it is appropriate to apply it to the person in question. A generalization, on the other hand, serves as a starting point…. A generalization is a statement about common trends within a group, but with the recognition that further information is needed to ascertain whether the generalization applies to a particular person."¹³ The assumption that "the characteristics of the group uniformly apply to all members of that group" without "a consideration of individual differences" is stereotyping, and does not allow for individual variation or exceptions.⁷ Generalization about members of a group, however, can guide practitioners in delivering care that is most appropriate for each individual by acknowledging different cultural norms and focusing attention on important characteristics or preferences of each individual patient.

Cultural Awareness, Sensitivity, and Competence

An individual may be able to identify differences between him or herself and people who are not part of the same culture, and an observant practitioner may likewise identify differences between his or her own culture and that of a patient's. Cultural awareness goes beyond simply recognizing differences and includes "recognizing and understanding the cultural implications of behavior."⁷ A culturally aware practitioner respectfully considers the impact of his or her behavior and approaches on a patient from a different culture. Cultural sensitivity goes even further than awareness, and involves "the integration of cultural knowledge and awareness into individual and institutional behavior."⁷ This sensitivity affects how a clinician interacts with each patient, and impacts communication choices, specific behaviors during treatment, and recommendations and options offered to patients. A practitioner who identifies cultural differences, understands how those differences can affect health habits and healthcare practices, and then integrates that understanding into his or her own day-to-day interactions with patients can be described as culturally sensitive.

Providing healthcare in a culturally sensitive manner involves responsiveness to "the attitudes, feelings, and circumstances of people that share common identifying characteristics (e.g., race, religion, language, and socioeconomic status)."¹² Cultural competence requires deeper integration of this sensitivity into practices and protocols to ensure that the care provided will "accommodate cultural differences in health-related values and beliefs."¹² It is "the routine application of culturally appropriate healthcare interventions and practices."⁷ To provide this type of care, practitioners must be aware of their own cultures, accept different cultural norms, and adapt their skills accordingly.

Cultural Sensitivity Experts

While practitioners should pay close attention to whether they are sensitive to their patients' cultures, what matters most are "the perceptions and feelings of patients regarding whether or not the healthcare experienced is responsive to their health-related cultural values and beliefs."¹² Patients know what they require to feel safe, respected, and comfortable. Practitioners should actively solicit preferences, opinions, and feelings from their patients.

Siebert et al. point out, "the patient and associated family members need to be encouraged to help educate their caregivers and vice versa."⁴ An ongoing dialogue regarding cultural issues should be maintained over the course of treatment.

Giving patients an opportunity to describe religious, spiritual, or other beliefs about amputation or disfigurement without disagreeing or challenging them, and asking whether the design of a prosthesis or the way care is provided is consistent with those values, can provide the practitioner with insight regarding how each patient prefers to be treated. For example, bodily disfigurement is considered shameful in many cultures, and can contribute to social isolation. Some patients may prefer that practitioners pay particular attention to the aesthetic features of the device. Providing a range of acceptable and aesthetically pleasing choices and working to meet patients' expectations, rather than attempting to change their perceptions, will indicate the practitioner is sensitive to those patients' needs.

Specific Strategies

In response to increasing diversity and inadequate training on cultural sensitivity in community-based primary care clinics, Tucker et al. propose a literature-based theoretical model called the Patient-Centered, Culturally Sensitive Health Care (PC-CSHC) Model. The model is intended to describe "the process by which patients' experience of PC-CSHC leads to patient health behaviors and outcomes." Tucker et al. cite the following attributes as elements of patient-centered healthcare: respect for patients, collaborative communication strategies, and knowledge sharing between patients and their healthcare providers.¹² Cultural diversity requires that healthcare providers effectively apply these principles of patient-centeredness during patient encounters. Cultural sensitivity can be demonstrated in a variety of ways, "including wait time, who the patient sees, and how the patient is treated by medical and other staff in the healthcare delivery process."¹² Office staff can play a key role in conveying sensitivity to patients by communicating policies clearly even if they are considered norms within the provider's culture, assisting patients in completing required paperwork if there is a language or literacy barrier, and offering greater scheduling flexibility for patients with transportation limitations or those from cultures that attend to time constraints differently than the provider.

The Importance of Language and Communication

It has been said that "effective communication launches effective care."⁴ Communication challenges may represent the most significant barriers to the delivery of quality healthcare. In 2002, Siebert et al. published a checklist "designed to facilitate cultural awareness and sensitivity in medical settings." Effective communication was a primary theme in their research. "Communication is the essential foundation for any type of educational advancement. This is particularly critical in healthcare settings where stress frequently intensifies the need for clear communication. Patients and family members must understand treatment options and recommendations along with what is required of them to comply with the treatment plan. Otherwise, the best possible outcomes cannot be realised…. Assuring information is conveyed and received as intended must consistently be a top priority."⁴

Thus, in a typical U.S. healthcare setting, if patients are not comfortable communicating in English, they should be provided with interpretation services and written instructional materials in an appropriate language and at an appropriate literacy level. According to Tucker et al., "there is still a mismatch between existing reading materials at most healthcare sites in the United States and patients' actual literacy level[s]."¹² Practitioners should be aware that patients "nodding and indicating some type of affirmative response does not necessarily guarantee understanding has been achieved."⁴ Siebert recommends continual confirmation of the other person's interpretation and comprehension. Allowing more time for asking questions, re-explaining, and requesting that the patient and/ or caretakers repeat instructions may facilitate comprehension.

Building Trust

Cultural sensitivity contributes significantly to building trust between clinicians and patients. "Displays of cultural sensitivity by healthcare providers result in their patients having feelings of comfort with and trust of their providers, both of which enhance patients' satisfaction with care…and sense of interpersonal control in the healthcare process."¹² It enables patients "to feel comfortable with, trusting of, and respected during the healthcare process and can result in greater adherence to treatment and improved health outcomes."¹² However, as Siebert et al. point out, a lack of trust can have the opposite consequences, leading to a lack of faith in the possibility of recovery and noncompliance with treatment instructions.

Conclusion

The primary issue in the encounter described at the beginning of this article was cultural rather than prosthetic, and centered on a religious belief about whether prosthetic replacement of an amputated limb was appropriate. I affirmed the patient's right to make the decision regarding the use of the prosthesis, and asked her to return if she encountered problems while using it. At the time, I was not aware of how deeply cultural differences can impact the trust level between practitioners and patients, and consequently was not as sensitive to and respectful of my patient's concerns as I should have been.

A first step in developing cultural sensitivity is to examine our own values, beliefs, and behaviors, and be willing to "explore possible biases or prejudices toward other cultures," which may be based in fear.^4,7 It is common to attempt to "change the patient's perspective instead of focusing on the goal at hand-expediting recovery by altering care to accommodate the patient's needs."⁴ Going through the challenging process of developing awareness of and sensitivity toward other cultures is likely to increase our patients' satisfaction with our services, and may even contribute to increased job satisfaction.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.

References

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2. United States Census Bureau. Quick facts, United States. (accessed March 24, 2017).
3. Pew Research Center. 2016. 10 demographic trends that are shaping the U.S. and the world. www.pewresearch.org/fact-tank/2016/03/31/10-demographic-trends-that-are-shaping-the-u-s-and-the-world (accessed March 24, 2017).
4. Seibert, P. S., P. Stridh-Igo, and C. G. Zimmerman. 2002. A checklist to facilitate cultural awareness and sensitivity. Journal of Medical Ethics 28 (3):143-6.
5. National Commission on Orthotic and Prosthetic Education. 2000. Practice Analysis of the Disciplines of Orthotics and Prosthetics. www.ncope.org/summit/pdf/PracticeAnalysis.pdf (accessed February 24, 2017).
6. American Board for Certification in Orthotics, Prosthetics and Pedorthics. 2015. Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics, www.abcop.org/individual-certification/Documents/ABC%20Practice%20Analysis%20of%20the%20Discipline%20of%20Orthotics%20and%20Prosthetics.pdf (accessed March 24, 2017).
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8. National Institutes of Health. Cultural respect. www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect (accessed March 24, 2017).
9. Betancourt, J. R., A. R. Green, and J. E. Carrillo. 2002. Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund, New York.
10. Definitions related to cultural & linguistic competence. www.dbhds.virginia.gov/library/cultural%20and%20linguistic%20competence/clc-relateddefinitions.pdf (accessed March 26, 2017).
11. American Institutes for Research. Teaching cultural competence in health care: A review of current concepts, policies, and practices. minorityhealth.hhs.gov/assets/pdf/checked/1/em01garcia1.pdf (accessed March 24, 2017).
12. Tucker, C. M, T. M. Arthur, J. Roncoroni, W. Wall, and J. Sanchez. 2015. Patient-centered, culturally sensitive health care. American Journal of Lifestyle Medicine 9 (1):63-77.
13. Galanti, G. A. 2000. An introduction to cultural differences. Western Journal of Medicine 172 (5):335-6.