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Cross-cultural care and communication

Joseph R Betancourt, MD, MPH
Alexander R Green, MD, MPH
J Emilio Carrillo, MD, MPH
Section Editor
Mark D Aronson, MD
Deputy Editor
Howard Libman, MD, FACP


The impact of sociocultural factors, race, ethnicity, and limited English proficiency (LEP) on clinical care is increasingly important in the delivery of quality health care and is the focus of a growing body of literature [1-9]. Sociocultural background influences a patient's perspectives, values, beliefs, and behaviors regarding health and wellbeing. These factors give rise to variation in recognition of symptoms, thresholds for seeking care, comprehension of management strategies, expectations of care (including preferences for or against diagnostic and therapeutic procedures), and adherence to preventive measures and medications.

Sociocultural differences between patients and providers influence communication and clinical decision-making. Evidence clearly links clinician-patient communication to patient satisfaction, adherence, and health outcomes [10-12]. Lower-quality care may result when clinicians fail to recognize and understand sociocultural differences between their patients and themselves [13].

The field of cross-cultural care focuses on the ability to communicate effectively and provide quality health care to patients from diverse sociocultural backgrounds. There is no empirical literature comparing the effectiveness of different models of cross-cultural care and communication. There is excellent empirical evidence showing that efforts to educate health care clinicians in cross-cultural care improve knowledge and good evidence that they improve attitudes and skills [14,15]. Accreditation groups for undergraduate and graduate medical education in the United States require training in cultural competency and racial/ethnic disparities and a curriculum guide has been developed for trainees and practitioners in primary care [16]. The Joint Commission introduced cultural competency guidelines and standards, which include training of clinical staff practicing in the hospital environment [17]. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) will impact hospital Medicare reimbursements by measuring clinician-patient communication as a major determinant of satisfaction scores [18]. The development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence Item Set promotes efforts to study the impact of cultural competency on patient satisfaction [19].

This topic will identify the key issues faced when caring for patients from diverse backgrounds and provide a framework for an effective clinical encounter. These recommendations are based on a combination of expert opinion and, when possible, evidence from related literature such as the field of clinician-patient communication. Other issues related to the patient-provider relationship are discussed separately. (See "A patient-centered view of the clinician-patient relationship".)


Culture is a system of beliefs, values, rules, and customs that is shared by a group and is used to interpret experiences and direct patterns of behavior. Culture plays a large role in shaping each individual's health-related values, beliefs, and behaviors, and clearly impacts clinical care.

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Literature review current through: Nov 2017. | This topic last updated: May 17, 2016.
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  1. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978; 88:251.
  2. Hill RF, Fortenberry JD, Stein HF. Culture in clinical medicine. South Med J 1990; 83:1071.
  3. Berger JT. Culture and ethnicity in clinical care. Arch Intern Med 1998; 158:2085.
  4. Pachter LM. Culture and clinical care. Folk illness beliefs and behaviors and their implications for health care delivery. JAMA 1994; 271:690.
  5. Einbinder LC, Schulman KA. The effect of race on the referral process for invasive cardiac procedures. Med Care Res Rev 2000; 57 Suppl 1:162.
  6. Flores G. Culture and the patient-physician relationship: achieving cultural competency in health care. J Pediatr 2000; 136:14.
  7. Epner DE, Baile WF. Patient-centered care: the key to cultural competence. Ann Oncol 2012; 23 Suppl 3:33.
  8. Vidaeff AC, Kerrigan AJ, Monga M. Cross-cultural barriers to health care. South Med J 2015; 108:1.
  9. Koh HK, Gracia JN, Alvarez ME. Culturally and Linguistically Appropriate Services--advancing health with CLAS. N Engl J Med 2014; 371:198.
  10. Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Intern Med 1979; 90:957.
  11. Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control 1999; 3:25.
  12. Paez KA, Allen JK, Beach MC, et al. Physician cultural competence and patient ratings of the patient-physician relationship. J Gen Intern Med 2009; 24:495.
  13. Betancourt JR, Carrillo JE, Green AR. Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep 1999; 1:482.
  14. Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care 2005; 43:356.
  15. Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database Syst Rev 2014; :CD009405.
  16. Smith WR, Betancourt JR, Wynia MK, et al. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007; 147:654.
  17. http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf (Accessed on August 23, 2011).
  18. https://www.cms.gov/hospitalqualityinits/30_hospitalhcahps.asp (Accessed on August 23, 2011).
  19. Clancy C, Brach C, Abrams M. Assessing patient experiences of providers' cultural competence and health literacy practices: CAHPS Item Sets. Med Care 2012; 50:S1.
  20. Weissman JS, Betancourt J, Campbell EG, et al. Resident physicians' preparedness to provide cross-cultural care. JAMA 2005; 294:1058.
  21. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999; 130:829.
  22. Commonwealth Fund Health Care Quality survey, 2001. Available at: www.cmwf.org/surveys (Accessed on March 15, 2006).
  23. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. National Academies Press; Washington, CT 2001.
  24. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academy Press; Washington, DC 2002.
  25. Chen J, Rathore SS, Radford MJ, et al. Racial differences in the use of cardiac catheterization after acute myocardial infarction. N Engl J Med 2001; 344:1443.
  26. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993; 269:1537.
  27. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA 2008; 299:70.
  28. Epstein AM, Ayanian JZ, Keogh JH, et al. Racial disparities in access to renal transplantation--clinically appropriate or due to underuse or overuse? N Engl J Med 2000; 343:1537.
  29. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients' preferences on racial differences in access to renal transplantation. N Engl J Med 1999; 341:1661.
  30. Clark LT, Maki KC, Galant R, et al. Ethnic differences in achievement of cholesterol treatment goals. Results from the National Cholesterol Education Program Evaluation Project Utilizing Novel E-Technology II. J Gen Intern Med 2006; 21:320.
  31. Kandula NR, Wen M, Jacobs EA, Lauderdale DS. Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites: Cultural influences or access to care? Cancer 2006; 107:184.
  32. Miranda J, McGuire TG, Williams DR, Wang P. Mental health in the context of health disparities. Am J Psychiatry 2008; 165:1102.
  33. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007; 22:1231.
  34. Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med 2008; 168:1317.
  35. National Quality Forum. Endorsing a framework and preferred practices for measuring and reporting cultural competency (ongoing Project). Accessed at: www.qualityforum.org/projects/ongoing/cultural-comp/ (Accessed on March 15, 2006).
  36. Wilson-Stronks A, Galvez E. Exploring Cultural and Linguistic Services in the Nation's Hospitals: A Report of Findings. The Joint Commission; Oakbrook Terrace, IL 2007.
  37. Wilson-Stronks A, Lee KK, Cordero C, et al. One size does not fit all: Diverse populations pose special health needs. The Joint Commission and California Endowment; 2008.
  38. U.S. Department of Health & Human Services. https://www.thinkculturalhealth.hhs.gov/content/clas.asp (Accessed on July 28, 2014).
  39. Donini-Lenhoff FG, Hedrick HL. Increasing awareness and implementation of cultural competence principles in health professions education. J Allied Health 2000; 29:241.
  40. Paniagua FA. and Treating Culturally Diverse Clients: A Practical Guide, Sage Publications, Thousand Oaks, CA 1994.
  41. Blackhall LJ, Murphy ST, Frank G, et al. Ethnicity and attitudes toward patient autonomy. JAMA 1995; 274:820.
  42. Petersen LA. Racial differences in trust: reaping what we have sown? Med Care 2002; 40:81.
  43. Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract 1997; 44:169.
  44. Safran DG, Taira DA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract 1998; 47:213.
  45. Race, Ethnicity and Medical Care, A Survey of Public Perceptions and Experiences (KFF) Kaiser Family Foundation. Available at: www.kff.org (Accessed on March 11, 2005).
  46. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 1997; 87:1773.
  47. Corbie-Smith G. The continuing legacy of the Tuskegee Syphilis Study: considerations for clinical investigation. Am J Med Sci 1999; 317:5.
  48. Brandt AM. Racism and research: the case of the Tuskegee Syphilis Study. Hastings Cent Rep 1978; 8:21.
  49. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001; 14:352.
  50. Institute of Medicine. Complementary and Alternative Medicine in the US. National Academies Press; Washington, DC 2005.
  51. Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med 1998; 129:406.
  52. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q 1993; 71:279.
  53. Behforouz HL, Drain PK, Rhatigan JJ. Rethinking the social history. N Engl J Med 2014; 371:1277.
  54. Green AR, Betancourt JR, Carrillo JE. Integrating social factors into cross-cultural medical education. Acad Med 2002; 77:193.
  55. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997; 15:1.
  56. Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med 1999; 14:82.
  57. Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med 2007; 22 Suppl 2:283.
  58. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care 2007; 19:60.
  59. Schyve PM. Language differences as a barrier to quality and safety in health care: the Joint Commission perspective. J Gen Intern Med 2007; 22 Suppl 2:360.
  60. Flores G, Ngui E. Racial/ethnic disparities and patient safety. Pediatr Clin North Am 2006; 53:1197.
  61. Flores G. Language barriers to health care in the United States. N Engl J Med 2006; 355:229.
  62. Lee KC, Winickoff JP, Kim MK, et al. Resident physicians' use of professional and nonprofessional interpreters: a national survey. JAMA 2006; 296:1050.
  63. Schenker Y, Lo B, Ettinger KM, Fernandez A. Navigating language barriers under difficult circumstances. Ann Intern Med 2008; 149:264.
  64. Institute of Medicine. Report brief. Health literacy: a prescription to end confusion. Available at: www.iom.edu/CMS/3775/3827/19723/19726.aspx (Accessed on June 12, 2006).
  65. Karliner LS, Napoles-Springer AM, Schillinger D, et al. Identification of limited English proficient patients in clinical care. J Gen Intern Med 2008; 23:1555.
  66. Botelho RJ. A negotiation model for the doctor-patient relationship. Fam Pract 1992; 9:210.
  67. Katon W, Kleinman A. Doctor-patient negotiation and other social science strategies in patient care. In: The Relevance of Social Science for Medicine, Eisenberg L, Kleinman A (Eds), D Reidel Publishing Company, 1980.
  68. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality; Rockford, MD 2010.