CE/CME

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).

Credit Hours: 1.00 CE

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Goal

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.

Target Audience

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:

  1. Assess how culturally effective practices can affect health-care services and health outcomes in diverse populations.
  2. Employ professional ethics to determine how to make your clinical practice more culturally effective.
  3. Apply legal requirements related to confidentiality, informed consent and language assistance services for patients and families who are not proficient in English.
  4. Notes on Nomenclature

    This module uses the terms “health-care provider” and “provider” to denote clinicians who are educated, trained and licensed to deliver health care.

    This module uses the term “culturally effective health care,” as adopted by the American Academy of Pediatrics. The term “culturally competent health care” has a similar meaning, and you will see references and resources in this module using that term as well. 

    The term “professional interpreter” used in this module refers to trained and certified health-care interpreters. In addition, the term “caregiver” refers to parents, legal guardians, family members and others who may be responsible for a child’s health care.

Please note this module expires on 8/29/2026.

This module was released on 8/29/2023.

Patients and Families

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.

Featured

American Academy of Pediatrics. (2013, reaffirmed 2021). Policy Statement: Office-based care for lesbian, gay, bisexual, transgender, and questioning youthPediatrics. 132(1):198-203.

American Academy of Pediatrics. (2018). Policy Statement: Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4): e20182162.

American Academy of Pediatrics. (2016). Policy Statement: Enhancing pediatric workforce diversity and providing culturally effective pediatric care: implications for practice, education, and policy makingPediatrics, 132(4):1105-1116.

American Academy of Pediatrics, Committee on Bioethics. (2011). Policy Statement: Informed consent, parental permission, and assent in pediatric practicePediatrics, 95(2):314-317.

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. (2022). APA Dictionary of Psychology.

American Psychological Association. (2022). A Guide to Sexual Orientation and Gender Diversity Terms

Berlin, E. A., & Fowkes, W. C., Jr. (1983). A teaching framework for cross-cultural health careWestern Journal of Medicine, 139:934-938.

Betancourt, J. R. (2006). Cultural competence and medical education: many names, many perspectives, one goalAcademic Medicine, 81(6):499-501.

Boston Medical Center Health System. (2021). Cultural Humility vs. Cultural Competence — and Why Providers Need Both.

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. MMWR Morbidity and Mortality Weekly Report, 68:67-71.

Derrington, S. F., Paquette, E., & Johnson, K. A. (2018). Cross-cultural Interactions and Shared Decision-making. Pediatrics, 142(Supplement 3):S187-S192.

Equality Texas. (2020). Texas State of Equality Report

Frieden, J. (2019). Want Your Practice to Be Seen as LGBTQ-Inclusive? Drop Some Clues.MedPage Today, October 14, 2019. 

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?

Johns Hopkins Medicine. (2017). Physicians Vastly Underestimate Patients’ Willingness to Share Sexual Orientation, Study Finds

Kodjo, C. (2009). Cultural Competence in Clinician CommunicationPediatrics in Review, 30(2):57-e64.

LGBT Demographic Data Interactive. (2019). Los Angeles, CA: The Williams Institute, UCLA School of Law.

Lipson, J. G., & Dibble, S. L. (2005). Culture & Clinical Care . San Francisco, CA: UCSF Nursing Press.

Levin, S., Like, R., & Gottlieb, J. (2000). ETHNIC: A framework for culturally competent clinical practice. Downloadable summary from the Global Library of Women’s Medicine, International Federation of Gynecology and Obstetrics.

Migration Policy Institute. (2019). State Immigration Data Profiles: Texas.

Mor-Anavy, S., Lev-Ari, S., & Levin-Zamir, D. (2021). Health Literacy, Primary Care Health Care Providers, and Communication. Health Literacy Research and Practice, 5(3):e194-e200.

National LGBT Health Education Center, A Program of the Fenway Institute. (2016). Understanding the Health Needs of LGBT People

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.

Shah, P., Thornton, I., Turrin, D., & Hipskind, J. E. (2022). Informed Consent. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Stubbe, D. E. (2020). Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus, 18(1):49-51.

Texas Department of State Health Services, Health Professions Resource Center. (2021). Trends, Distribution, and Demographics: Primary Care Physicians.

Texas Department of State Health Services, Health Professions Resource Center. (2022). 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.

U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. 

U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). Think Cultural Health.

Medical Definitions

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 Disease Control and Prevention, 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 1.00 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 1.00 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 1.00 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 1.00 contact hour(s) of Continuing Social Work Education.

This course has been designated by The Texas Department of State Health Services for 1.00 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 1.00 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 1.00 contact hour(s) for Licensed Marriage and Family Therapists and 1.00 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 1.00 contact hour(s) for Licensed Professional Counselors and 1.00 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 1.00 hour(s) for attendance.

Disclosure - CEHC

One of the requirements of continuing education is disclosure of the following information to the learner:

  1. 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.
  2. Commercial Support.
    The THSTEPS Web-based Continuing Education Series has received no commercial support.
  3. 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.
  4. 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.
  5. 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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Additional

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 about 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. (2022). Healthcare Equality Index.

Implicit Association Test (IAT). (2023). The Harvard Office for Equity, Diversity, Inclusion, and Belonging. 

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.

Medical Home

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.

Dentists

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.

Family Physicians

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.

Nurses

Culturally Competent Nursing Care: A Cornerstone of Caring.

Cultural Competency in Nursing Education from the American Association of Colleges of Nursing.

Social workers

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, from the AAP’s Pediatrics.

Medicaid Providers

Texas Health Steps, age-specific medical checkup forms, guidelines, screenings, growth charts, and other materials.

U.S. HHS, Office of Minority Health Resource Center.

U.S. HHS, Health Resources and Services Administration: Culture, Language and Health Literacy.

Health-Care Organizations

Culturally and Linguistically Appropriate Standards from HHS.

Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile 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

Interpreters

Texas Health and Human Services Commission, Communication and Interpreting Contractors.

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, that resource should never be used as a substitute for a professional interpreter.

Adolescents: Adolescent Health: A Guide for Providers, from Texas Health Steps.

African Americans: Race Consciousness and the Health of African Americans, from nursingworld.com.

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 Individuals: 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.

LGBTQ Individuals:

Health Care for Lesbians and Bisexual Women. (2021). From the Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (ACOG). 

Human Rights Campaign. (2022). Resources: LGBTQ+ Youth.

LGBTQI+ 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.

Seasonal and Migrant Farmworkers: National Center for Farmworker Health, Inc.

6. Health Literacy Resources

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

Risk Management from the Texas Medical Liability Trust.

9. Motivational Interviewing

Motivational Interviewing from the AAP.