Culturally Effective Health Care
Welcome to the training on Culturally Effective Health Care provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
The goal of this module is to equip Texas Health Steps providers and others to employ best practices and professional ethics to serve the health-care needs of culturally diverse children and adolescents and their families, as well as to meet legal requirements for confidentiality, informed consent, and language assistance to families who are not proficient in English.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Assess how culturally effective practices can affect health-care services and health outcomes in diverse populations.
- Employ professional ethics to determine how to make your clinical practice more culturally effective.
- Apply legal requirements related to confidentiality, informed consent, and language assistance services for patients and families who are not proficient in English.
Please note this module expires on 3/24/2023.
This module was released on 3/24/2020.
Patients and Families
Be a Prepared Patient. The Center for Advancing Health website offers resources to help patients communicate with health-care providers, understand medical checkups, prescriptions, medical tests, and other subjects.
Speak Up. The Joint Commission offers bilingual Speak Up materials to help patients and families understand the health-care process. Videos for children are also included.
Deaf or Hard-of-Hearing: Tips for Working with Your Doctor, from the American Academy of Family Physicians.
How to Talk with the Doctor, a bilingual tip sheet from the Centers for Disease Control and Prevention.
- Agency for Healthcare Research and Quality (HHS). (2015). Health Literacy Universal Precautions Toolkit, 2nd Edition.
- American Academy of Pediatrics. (2015). Policy Statement: Enhancing pediatric workforce diversity and providing culturally effective pediatric care: implications for practice, education, and policy making. Pediatrics, 132(4):1105-1116.
- American Academy of Pediatrics. (2013). Policy Statement: Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 132(1):198-203.
- American Academy of Pediatrics, Committee on Bioethics. (2011). Policy Statement: Informed consent, parental permission, and assent in pediatric practice. Pediatrics, 95(2):314-317.
- American Academy of Pediatrics. (2008). Policy Statement: The Medical Home. Pediatrics, 110:184–186.
- American Academy of Pediatrics. (2007). Policy Statement: Contraception and Adolescence. Pediatrics, 120(5):e1135-e1148.
- American Academy of Pediatric Dentistry. (2018). Oral Health Policies & Recommendations (The Reference Manual of Pediatric Dentistry), 40(6):18-19, p. 12.
- American College of Physicians. (2012). Ethics Manual, Sixth Edition.
- American Dental Association. (n.d.) Principals of Ethics and Code of Conduct.
- American Medical Association. (n.d.) Physician Exercise of Conscience. Code of Medical Ethics.
- American Psychological Association. (2018). APA Dictionary of Psychology.
- Berlin, E. A., & Fowkes, W. C., Jr. (1983). A teaching framework for cross-cultural health care. Western Journal of Medicine, 139:934-938.
- Betancourt, J. R. (2006). Cultural competence and medical education: many names, many perspectives, one goal. Academic Medicine, 81(6):499-501.
- Brakman, A., Ellsworth, T. R., & Gold, M. (2015). Gay, lesbian, and bisexual youth grouped, show increased risk for unintended pregnancy. AHC Media.
- Campinha-Bacote, J. (2011). Delivering Patient-Centered Care in the Midst of a Cultural Conflict: The Role of Cultural Competence. OJIN: The Online Journal of Issues in Nursing, 16(2) Manuscript 5, May 31.
- Carrese, J., Malek, J., Watson, K., Lehmann, L. S., Green, M. J., McCullough, L. B, . . . Doukas, D. J. (2015). The Essential Role of Medical Ethics Education in Achieving Professionalism: The Romanell Report. Academic Medicine, 90(6).
- Centers for Disease Control and Prevention. (2019). Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students—19 States and Large Urban School Districts, 2017. MMWR Morbidity and Mortality Weekly Report, 68:67-71.
- Centers for Disease Control and Prevention. (2014). Practical Strategies for Culturally Competent Evaluation.
- Derrington, S. F., Paquette, E., & Johnson, K. A. (2018). Cross-cultural Interactions and Shared Decision-making. Pediatrics, 142(Supplement 3):S187-S192.
- Eddey, G. E. & Robey, K. L. (2005). Considering the culture of disability in cultural competence education. Academic Medicine, 80(7):706-712.
- Equality Texas. (2019). Texas State of Equality Report.
- Frieden, J. (2019). Want Your Practice to Be Seen as LGBTQ-Inclusive? Drop Some Clues. MedPage Today, October 14.
- Gattamorta, K. A., Salerno, J. P., & Castro, A. J. (2019). Intersectionality and Health Behaviors Among US High School Students: Examining Race/Ethnicity, Sexual Identity, and Sex. Journal of School Health. 89(10):800-808.
- Georgetown University, Health Policy Institute. (n.d.). Cultural Competence in Health Care: Is it important for people with chronic conditions?
- Hancock, T. U. (2005). Culturally effective health care in the assessment of poor Mexican families in the rural southeastern United States. Child Welfare, 84(5):689-711.
- Hersh, L., Salzman, B., & Snyderman, D. (2015). Health Literacy in Primary Care Practice. American Family Physician, 92(2):118-24.
- Jackson, R. (2006). Parental Health Literacy and Children’s Dental Health: Implications for the Future. Pediatric Dentistry, 28(1).
- Jecker, N. S., Carrese, J. A., & Pearlman, R. A. (1995). Caring for patients in cross-cultural settings. Hastings Center Report, 25(1):6-14.
- Johns Hopkins Medicine. (2017). Physicians Vastly Underestimate Patients’ Willingness to Share Sexual Orientation, Study Finds. (news release)
- The Joint Commission and the California Endowment. (2011). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide.
- Juckett, G. (2005). Cross-cultural medicine. American Family Physician, 72(11): 2267-2274.
- Kesselheim, J. C., Johnson, J., & Joffe, S. (2008). Pediatricians’ Reports of Their Education in Ethics. Archives of Pediatric & Adolescent Medicine, 162(4):368-373.
- Kleiman, S. (2006). Discovering cultural aspects of nurse-patient relationships. Journal of Cultural Diversity, 13(2):83-86.
- Kodjo, C. (2009). Cultural Competence in Clinician Communication. Pediatrics in Review, 30(2):57-e64.
- Kuo, D. Z, & Turchi, R. M. (2010). Best practices: Kids with special healthcare needs. Contemporary Pediatrics, Aug. 1.
- Levin, S., Like, R., & Gottlieb, J. (2000). ETHNIC: A framework for culturally competent clinical practice. In Appendix: Useful Clinical Interviewing Mnemonics. Patient Care, 34(9):188-189.
- Lipson, J., & Dibble, S. (2005). Culture & Clinical Care. School of Nursing Press, University of California, San Francisco. (textbook for purchase online.)
- National LGBT Health Education Center, A Program of the Fenway Institute. (2016). Understanding the Health Needs of LGBT People.
- Nielson-Bohlman, L., Panzer, A. M., Hamlin, B., & Kindig, D. A. (2004). Health Literacy: A Prescription to End Confusion. Institute of Medicine of the National Academies.
- Perkins, H. S. (2006). Ethics Expertise and Cultural Competence. AMA Journal of Ethics, Virtual Mentor, 8(2):79-83.
- Scandurra, C., Mezza, F., Maldonato, N. M., Bottone, M., Bochicchio, V., Valerio, P., & Vitelli, R. (2019). Health of Non-binary and Genderqueer People: A Systematic Review. Frontiers in Psychology, 01453.
- Schiavo, J. H. (2011). “Oral Health Literacy in the Dental Office: The Unrecognized Patient Risk Factor.” Journal of Dental Hygiene, 85(4):248-255.
- Spring Institute for Intercultural Learning. (2019). “The Role of Cultural Competence on Delivering Patient-Centered Care.”
- Texas Demographic Center. (2018). TDC Estimates Download Tool (for state population).
- Texas Department of State Health Services, Health Professions Resource Center. (2018). Texas Projections of Supply and Demand for Primary Care Physicians and Psychiatrists, 2017 – 2030.
- Texas Health and Human Services Commission. (n.d.). Children with Special Health Care Needs (CSHCN) Services Program.
- Texas Health and Human Services Commission. (n.d.). Disability Etiquette.
- Texas Health and Human Services Commission. (n.d.). Office for the Elimination of Health Disparities.
- The Texas Tribune. (2015). Interactive: Demographics of State Doctors, Health Care Professionals.
- Thornton, R. G. (2000). Informed Consent. Baylor University Medical Center, Proceedings.
- U.S. Census Bureau. (2015). Selected Social Characteristics in the United States.
- Migration Policy Institute. (2019). State Immigration Data Profiles: Texas.
- U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). Think Cultural Health.
- U.S. National Library of Medicine. (2014). What is Informed Consent.
- Health Literacy Coalition of Central Texas. (2014).
- Voices of Transgender Adolescents in Healthcare (video). (2015). University of Michigan Health System Adolescent Health Initiative.
The medical definitions in this module were obtained or adapted from American Academy of Pediatrics, American Academy of Pediatric Dentistry, American Psychological Association, Centers for Medicare and Medicaid Services, Human Rights Campaign, Independent Living Institute, Johns Hopkins Medicine, Mayo Clinic, and Syracuse University.
Continuing Medical Education (Ethics Accredited)
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This course has been designated by The Texas Department of State Health Services, Continuing Education Service for credit(s) of education in medical ethics and/or professional responsibility.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded contact hour(s) of Continuing Nursing Education.
Social Workers (Ethics Accredited)
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded contact hour(s) of Continuing Social Work Education.
This course has been designated by The Texas Department of State Health Services for contact hours of education in professional ethics and social work values.
Certified Health Education Specialists
Sponsored by The Texas Department of State Health Services, Continuing Education Service, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to total entry-level Category I contact education contact hours.
Licensed Marriage and Family Therapists (Ethics Accredited)
The Texas Department of State Health Services, Continuing Education Service is an approved provider (#466) by the Texas State Board of Examiners of Marriage and Family Therapists to offer continuing education contact hours to Licensed Marriage and Family Therapists. The Texas Department of State Health Services, Continuing Education Service has awarded contact hour(s) for Licensed Marriage and Family Therapists and contact hour(s) in professional ethics for Licensed Marriage and Family Therapists.
Licensed Professional Counselors (Ethics Accredited)
The Texas Department of State Health Services, Continuing Education Service is an approved provider (#690) by the Texas State Board of Examiners of Professional Counselors to offer continuing education contact hours to Licensed Professional Counselors. The Texas Department of State Health Services, Continuing Education Service has awarded contact hour(s) for Licensed Professional Counselors and contact hour(s) in professional ethics for Licensed Professional Counselors.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated hour(s) for attendance.
Certified Community Health Worker
The Texas Department of State Health Services, Promotor(a)/Community Health Worker Training and Certification Program has certified this course for contact hour(s) of continuing education for Certified Community Health Workers and Community Health Worker Instructors.
Disclosure - CEHC
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee has the following relevant financial relationships to disclose:
- May Lau - Physician - American Academy of Pediatrics CATCH grant, Texas Pediatric Foundation grant.
- May Lau - Physician - Gilead stockholder.
- May Lau - Physician - Speaker for Texas Pediatric Society.
- May Lau - Physician - Merck Speaker's Bureau for Nexplanon.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
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1. Culturally Effective Health Care Checklists
Download the Georgetown University National Center for Cultural Competence self-assessment checklists, designed for health-care providers and office and patient support staff.
2. General Resources
Culturally Effective Health Care
- American Academy of Pediatrics (AAP) Policy Statement on providing culturally effective pediatric care.
- Cultural Competence in Clinician Communication from Pediatrics in Review.
- Ethics for the Pediatrician in providing culturally effective health care, from Pediatrics in Review.
- Human Rights Campaign. (2019). Healthcare Equality Index.
- Vanderbilt University Medical Center. (2019). Trans Buddy Program.
- Think Cultural Health, an initiative of the U.S. Department of Health and Human Services’ Office of Minority Health.
- Family-Centered Medical Home from the AAP.
3. Professional Guidelines for Improving Culturally Effective Health Care
Many professions have standards or guidelines for how to deliver health care. Choose any of the links below to become more familiar with the most up-to-date guidelines for serving diverse children, adolescents, and their families.
- Addressing Disparities through Dental-Medical Collaborations, Part 1. The Role of Cultural Competency in Health Disparities: Training of Primary Care Medical Practitioners in Children’s Oral Health.
- A Physician’s Practical Guide to Culturally Competent Care from the U.S. Department of Health and Human Services (HHS).
- Cultural Competency: Dentistry and Medicine Learning from One Another.
- Culturally Competent Nursing Care: A Cornerstone of Caring.
- Cultural Competency in Nursing Education from the American Association of Colleges of Nursing.
- Standards and Indicators for Cultural Competence in Social Work Practice from the National Association of Social Workers.
4. Specific Health-Care Contexts
- Food Insecurity. The 2-question Hunger Vital Sign Screen.
- Housing Instability. The 3-question Housing Instability Measures Regarding Housing Circumstances.
- Sandel, M., Sheward, R., Ettinger de Cuba, S., Coleman, S. M., Frank, D. A., Chilton, M., & Cutts, D. (2018). Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics, 141(2): e20172199.
- Texas Health Steps, age-specific medical checkup forms, guidelines, screenings, growth charts, and other materials.
- U.S. HHS, Office of Minority Resource Center.
- U.S. HHS, Health Resources and Services Administration: Culture, Language and Health Literacy.
- Culturally and Linguistically Appropriate Standards from HHS.
- Effective Communication in Hospitals from HHS.
- Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile from HHS.
- Management Sciences for Health, The Provider’s Guide to Quality and Culture, from HHS.
- U.S. HHS, Office of Minority Health, Cultural Competency. Executive Summary: A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations
- Developing Culturally effective Health Care in Disaster Mental Health Programs: Guiding Principles and Recommendations from the National Mental Health Information Center.
- American Academy of Pediatrics. (2019). Engaging Patients and Families: Interpreter Services, from the Culturally Effective Care Toolkit, Chapter 5.
- Health Care Interpreter Network.
- Interpreters in Mental Health.
- Working with an Interpreter: A Guide for Health Care Professionals, from Massachusetts General Hospital.
5. Specific Populations
The following links provide additional information about the health, health-care delivery needs, and preferences of specific populations. Some of the listed resources include links to an online translator. Note that for translating medical, oral health, and other information to the patient, this resource should never be used as a substitute for a professional interpreter.
- Adolescents: Adolescent Health: A Guide for Providers.
- African Americans: NursingWorld.org, Race Consciousness and the Health of African Americans.
- American Indians: U.S. National Library of Medicine, American Indian Health.
- Asian Americans: Temple University Center for Asian Health.
- Child and Adolescent Mental Health: University of Texas at Austin, Texas Institute for Excellence in Mental Health.
Deaf and Hard of Hearing:
- Deaf Culture: University of Texas at Dallas Callier Center Topic Card 9: On Being Deaf — A Cultural View in the “Texas Connect” Guide.
- National Association of the Deaf position statement on Health Care Access for Deaf Patients.
Hispanics: Pew Hispanic Center and Robert Wood Johnson Foundation.
Immigrants: AAP Immigrant Child Health Toolkit.
Health Care for Lesbians and Bisexual Women. (2018). From the Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (ACOG).
- Guidelines for the Care of Lesbian, Gay, Bisexual, and Transgender Patients, from the Gay and Lesbian Medical Association.
- LGBT Behavioral Health Equity.
- Office-based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth: AAP policy statement and AAP technical report.
Persons with Disabilities: University of Kansas Beach Center on Disability.
Rural Populations: U.S. HHS Agency for Healthcare Research and Quality, Improving Health Care for Rural Populations.
Seasonal and Migrant Farmworkers: National Center for Farmworker Health, Inc.
6. Health Literacy Resources
- AAP Culturally Effective Care Toolkit.
- Centers for Disease Control and Prevention. Understanding Health Literacy.
- Fact Sheet on Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons from HHS.
- Health Literacy: A Prescription to End Confusion from the Institute of Medicine of the National Academies.
- Speaking of Health–Assessing Health Communication Strategies for Diverse Populations from the Institute of Medicine of the National Academies.
7. Cultural Competency Requirements Under Federal and State Law
- AMA Code of Medical Ethics.
- The Ethics of Cultural Competence from Academic Medicine.
8. Informed Consent
- A Practical Guide to Informed Consent from TempleHealth.org.
- Risk Management from the Texas Medical Liability Trust.
9. Motivational Interviewing
- Motivational Interviewing from the AAP.