Acquiring and integrating knowledge, attitudes, and skills allows a provider to communicate across cultures, address cultural differences in communication, and understand the needs, values, and preferences of their patients. Cultural differences in communication—such as how and when an interaction takes place, tone, eye contact, and other factors must be considered, even when using interpreters (HHS, 2022).
3.1 Promoting Collaboration on Healthcare Decisions
Collaborative decision-making occurs when patients work together with their healthcare providers to make decisions about screening, treatments, and managing chronic conditions. Shared decision-making and information sharing helps people understand the risks and benefits of different treatment options. In fact, shared decision-making has been called the pinnacle of person-centered care. A key feature of shared decision-making is the exploration of patient values and priorities (Jull et al., 2021).
3.2 Developing Good Communication Tools
In the United States, more than 59 million residents speak a language other than English at home. More than 25 million people live in linguistic isolation, a termed coined by the U.S. Census Bureau in which no one in a household over 14 years of age speaks English well (NCCC, 2026).
In Oregon, 15% of residents speak a language other than English. The largest non-English language spoken in Oregon is Spanish, representing 9% of Oregon’s population. The next most-common non-English language is Chinese (Mandarin, Cantonese), followed by Vietnamese (Data USA, 2024).
Executive Order 13166 (Improving Access to Services for Persons with Limited English Proficiency), signed into law in 2000, requires federal agencies to examine the services they provide, identify the need for services for those who have limited English proficiency, and develop and implement a system to provide meaningful access to services (NIH, 2025).
3.2.1 Good Communication is a Two-Way Dialogue
Effective communication is a two-way dialogue between patients and care providers. In that dialogue, both parties speak and are listened to without interrupting; they ask questions for clarity, express their opinions, and exchange information (Kwame and Petrucka, 2021).
Poor communication contributes to an incomplete and inaccurate health history, misdiagnoses, and the failure of a patient to understand their health condition and recommended treatment. This can lead to misuse of medications, repeat visits, and lack of informed consent (NCCC, 2026).
3.2.3 National CLAS Standards
Culturally and Linguistically Appropriate Services (CLAS) standards are intended to advance health equity, improve quality, and help eliminate healthcare disparities by providing a blueprint for individuals and healthcare organizations to implement culturally and linguistically appropriate services (OMH, 2026). CLAS standards can improve the quality of services provided to all individuals, reducing health disparities and improving health equity.
In Oregon, providers and care organizations are encouraged to provide services consistent with National CLAS Standards. This means all health services, including telemedicine services:
- Are culturally responsive.
- Provide meaningful access to language services.
- Are provided in an equitable and inclusive manner.
3.2.4 Language Assistance Services
In the United States, healthcare organizations are required by law to provide interpretation services at no cost. Language assistance services include oral interpretation, translation of written documents, signage, and wayfinding symbols. Healthcare organizations must notify patients that communication and language assistance services are available when scheduling an appointment (HHS, 2022). Providers should never try to “get by” using their own inadequate foreign language skills, or unqualified interpreters, such as a patient’s friend or family member or untrained staff.
3.2.5 Case: Mr. Louis and His Granddaughter
Mr. Louis just celebrated his 70th birthday with his family and neighbors. Soon after his birthday, Mr. Louis visited his doctor for a checkup. He was sent for additional testing, which showed the presence of prostate cancer. Let’s see what happens during Mr. Louis’ appointment with the oncologist, Emily Parker.
The Initial Appointment: Mr. Louis brought his granddaughter, Esther, to his appointment with the oncologist. He knows some English but was worried that he would not understand everything the doctor said and he wanted his granddaughter there for support.
Once the appointment began, Dr. Parker and Esther did all the talking. Mr. Louis did not get a chance to speak, and he did not understand most of what Dr. Parker and Esther were saying. After a few minutes, Esther seemed to be arguing with Dr. Parker. This embarrassed Mr. Louis, and he stayed quiet.
After the Appointment: Esther explained to her grandfather in French that, to treat his cancer, he would undergo a procedure the next week that would implant radioactive seeds. Esther told her grandfather that the procedure was simple, painless, and without side effects. She did not mention what else the doctor said or what they had been arguing about.
Mr. Louis began to worry about the procedure. He researched it online and talked about it with his friends. He learned that the procedure did have side effects, including the possibility of incontinence. Remembering how Esther had argued with the doctor, Mr. Louis wondered if she had told him the truth about her conversation with Dr. Parker.
The Surgical Appointment: The next week, Mr. Louis and his granddaughter arrived at the admissions office at the hospital. “No surgery,” Mr. Louis said firmly. The admissions clerk looked up in surprise, and Esther quickly explained that Mr. Louis did not really understand the issue and that he really did want the surgery.
Esther asked to sign the papers for her grandfather, but the admissions clerk explained that without legal standing Esther was not eligible to do so. Mr. Louis continued to quietly say “No surgery.” The admissions clerk wasn’t sure what to do. The surgical staff called to say that they were waiting for Mr. Louis.
The clerk spent almost half an hour trying to find a hospital staff member who spoke French, but no one was available. The surgery staff called again, saying that if Mr. Louis did not arrive shortly, they would have to reschedule his procedure.
Exasperated, Esther insisted that Mr. Louis undergo the procedure. She said, “The hospital has people ready to do this. You’re wasting their time. Come on, just sign the paper and let’s get you upstairs.” Mr. Louis said again, “No surgery.” Esther had no choice but to take him home.
Mr. Louis responds: “I depended on my granddaughter to help me with my doctor’s appointment. But she did not tell me the truth about the surgery and my options to treat my illness. I am really angry that I came very close to having a surgery I did not want! It was so frustrating to not be able to communicate directly with my doctor. All I wanted was someone who could listen to me and explain my options.”
Dr. Parker responds: “These days, I see a lot of patients who don't speak English very well, or at all. I'm used to communicating with a family member or friend instead of the patient. In fact, I ask patients to bring someone who can interpret for them. It’s so much easier that way!”
“When I heard what happened to Mr. Louis, I was shocked. I had not recommended the procedure Esther scheduled for him; I had suggested watchful waiting instead. During the consultation, Esther insisted that Mr. Louis undergo the procedure.”
“Now that I think about it, I didn't speak much with Mr. Louis because Esther seemed to be in charge. I thought I was doing the right thing by speaking with his family member. Now, knowing that Mr. Louis did not want surgery scares me. I wish I had been able to speak directly with him without his granddaughter interfering.”
Discussion: Providing language assistance services, including a competent medical interpreter, helps patients with limited English proficiency understand and make informed decisions about their medical care. Unfortunately, Mr. Louis almost had a surgery that he did not want, and the surgery could have caused side effects about which he had not been informed.
The doctor should never use a family member or untrained colleague to translate. The hospital had language services available, but the doctor felt it was easier to use the granddaughter to translate. Operating on a patient who did not want surgery or who was not aware of potential adverse effects could have serious liability implications for the doctor and the hospital.
Think About It
- How would you feel if this happened to you or a family member?
- Could this happen at your organization?
- Does your workplace offer language assistance?
3.3 Utilizing Data to Inform Clinical Practice and Health Equity
Improving health equity starts with the collection and analysis of data on patient demographics, disease prevalence, and treatment outcomes. The next step involves collecting data on patient outcomes, patient satisfaction, and changes in health disparities over time. Engaging patients is a critical part of this step. This involves gathering patient feedback and incorporating it into decision-making processes.
Once disparities have been identified, the data is used to develop targeted interventions. For example, a healthcare organization may implement outreach programs to increase access to care for marginalized populations or create targeted treatment plans based on patient data.
In Oregon, the Oregon Health Authority collects and analyzes data on health outcomes and health disparities, including race/ethnicity, language, income, and geographic location. The organization then identifies areas where health disparities exist and prioritizes interventions and initiatives aimed at reducing health disparities and improving health equity.
OHA has used this data to develop a series of culturally and linguistically appropriate outreach and education programs aimed at reducing disparities in chronic disease management among communities of color. They have also worked to increase the availability and use of health data in clinical practice, including implementing health information technology systems and training health providers in the use of data to inform patient care.
3.3.1 Case: Digging into the Data
Data analysts at a regional health system notice their overall population of patients with Type 2 diabetes has an average HbA1c reduction that meets national quality benchmarks. On paper, the clinical practice looks highly successful. However, when the quality improvement team analyzes these clinical outcomes by race, primary language, and zip code, a stark disparity emerges.
Data Analysis: The team notices that Spanish-speaking patients living in three specific zip codes have significantly higher average HbA1c levels and a 40% higher rate of diabetes-related emergency department visits compared to the general patient population. Automated electronic health records show that 65% of patients in the three zip codes screened positive for food insecurity (living in a food desert with limited access to fresh produce) and reported transportation barriers that caused them to miss follow-up clinical appointments.
The data revealed that fewer minority or non-English-speaking patients were being referred to advanced endocrinology clinics or clinical trials for newer cardioprotective diabetes medications. The hospital implemented an electronic health record clinical decision support alert to prompt providers to screen for eligibility, removing implicit referral bias.
Discussion: Instead of continuing with a one-size-fits-all clinical guideline, the organization used this data to overhaul its clinical pathways and deployment of resources. A bilingual certified diabetes care and education specialist was added to the primary care teams serving these specific neighborhoods. Patient education materials and glucose monitor trainings were restructured to be linguistically accurate and culturally relevant.
To address social determinants of health, the facility partnered with a local non-profit to establish a “Food Farmacy” prescription program. Patients with poorly controlled diabetes who screened positive for food insecurity received vouchers for free, fresh, diabetes-friendly groceries delivered to their homes or accessible via a mobile market.
To address transportation, the hospital shifted clinical practice by offering targeted telehealth visits for routine check-ins, backed by a program that provided cell-data stipends or dispatched rides through a health-transit partnership for lab work. By using data to pinpoint exactly where and why clinical outcomes were falling short for a specific sub-population, the medical facility moved health equity from an abstract concept into a tangible, measurable clinical protocol.
3.4 Collaboration with Community Resources
Institutional culture refers to the shared beliefs, values, attitudes, and behaviors that are present within a healthcare organization. Institutional structure shapes how resources, power, opportunities, and healthcare access are distributed across different populations. When institutional policies, practices, or cultural norms disadvantage specific groups, it creates structural inequities that directly impact health outcomes.
Healthcare organizations that prioritize health equity create a culture that emphasizes diversity, values patient-centered care, and supports ongoing training and education for healthcare providers. This type of institutional culture prioritizes community engagement and outreach, and supports policies and initiatives aimed at reducing disparities in health outcomes and access to care.
3.4.1 Working with Interpreters
Interpreters and translation services reduce disparities by bridging the communication gap between providers and patients with limited English proficiency. These services provide a more comfortable and trusting environment for patients and ensure that all parties understand a provider’s medical instructions and diagnoses.
In 2021, the Oregon Legislature passed House Bill 2359, requiring that all publicly funded healthcare providers hire only credentialed healthcare interpreters listed on a state registry. To obtain accreditation and entry into the state’s registry, interpreters must pass language proficiency testing and meet other requirements (Lund Report, 2022).
Language assistance services include oral interpretation, translation of written documents, signage, and wayfinding symbols for patients with limited English proficiency and those who are deaf or hard of hearing.
Interpreters and translators differ in their jobs. A translator works with the written word, translating from one language to another, while an interpreter translates spoken information. Interpreters and translators are required to show respect for all involved, respect confidentiality, interpret accurately, convey cultural information, and remain impartial.
Interpreters are communication professionals who interpret everything that is said, maintain confidentiality, and provide a cultural context. Family members, children, other patients, visitors, or untrained staff should not be used as interpreters. Healthcare providers are responsible for the actions of interpreters and translators, ensuring that they act ethically.
Interpreters can briefly provide essential cultural context to the healthcare provider. For example, the interpreter might explain to an oncologist that a patient's hesitation to sign a DNR form is tied to a cultural belief that speaking of death invites it.
3.4.2 Working with Cultural Brokers
Cultural brokers provide a link between a patient’s traditional health beliefs and practices and the healthcare system. While a cultural broker’s role can vary depending on patient and provider need, cultural brokers must be knowledgeable about the cultural group they serve and be able to successfully navigate the healthcare system. An individual acting as a cultural broker should be a trusted and respected member of the community but does not need to be a healthcare professional (PSNET, 2019).
Incorporation of a cultural broker in the care team embraces the importance of cultural distinctions among patient groups. It also acknowledges that, particularly in very diverse communities, it is unrealistic for providers to have sufficient understanding of all the different cultures present in the patient population they serve (PSNET, 2019).
Test Your Knowledge
Today, I had a patient who I thought might need translation assistance, but the patient declined this service. I assumed her refusal meant she would clearly understand everything we were going to discuss—so I just dropped it. Was this the correct course of action?
Discussion: If a patient refuses language assistance services, ask them to sign a form that says they understand that language assistance is available and have chosen to decline these services. The form must be available and signed in the patient’s native language or completed orally if he or she is unable to read in their native language.
Document that the individual was notified about these rights and make sure your notes include the patient’s preferences for utilizing language services in the future. Written documentation is needed to communicate with other providers and to indicate that language services are available and were offered.
Modified from Think Cultural Health: Working Effectively with an Interpreter
3.4.3 Traditional Health Workers
Traditional Health Workers are individuals from their local communities who provide person- and community-centered care by acting as a bridge between communities and the health systems they serve. They connect people with health systems, advocate for their clients, support adherence to care and treatment, and empower individuals to be agents in improving their own health. As of October 2024, there were more than 6,500 Traditional Health Workers registered and certified in Oregon (Li et al., 2025). In Oregon, six specialty types of Traditional Health Workers are codified in ORS 414.665. They include:
- Community Health Workers (CHWs)
- Peer Support Specialists
- Peer Wellness Specialists
- Birth Doulas
- Personal Health Navigators
- Tribal Traditional Health Workers (TTHW)
Traditional Health Workers are effective because they have similar lived experience or are members of the same community as the patients they serve. They have knowledge of health issues and are able to help patients navigate the health system. Traditional Health Workers provide high-quality, culturally responsive care, which supports Oregon Health Authority’s goal of eliminating health inequities in Oregon by 2030 (Li et al., 2025).
Healthcare providers can collaborate with Traditional Health Workers by including them in interdisciplinary care-planning meetings. THW services are integrated into billing and care-coordination structures and thus often accessible without restrictive prior authorizations. They act as core clinical allies, not supplementary staff.
3.4.4 Working with Traditional Medicine/Healers
Modern, Western-trained healthcare providers receive minimal training and education on traditional healing practices and their application and integration into healthcare settings. Lack of knowledge and practice guidelines on how to navigate these two healthcare perspectives can create difficult treatment uncertainties (Esposito and Kahn-John, 2022).
For Western-oriented healthcare providers, training in traditional medicine/healing is important to providing comprehensive, culturally inclusive, and effective care (Esposito and Kahn-John, 2022). Instead of forcing a patient to forego a traditional remedy, providers and healers should openly discuss the patient’s treatment plan to ensure safety.
For example, a Western-trained provider treating a patient with type 2 diabetes learns the patient is working with a traditional herbalist who uses specific botanical extracts. Rather than dismissing the herbs, the provider reviews the botanical compounds for potential pharmacokinetic interactions.
The provider then works with the traditional healer to adjust the pharmaceutical timing or dosage, while the traditional healer monitors the patient's spiritual and holistic alignment. Both agree to monitor the patient’s blood glucose and renal function together, establishing shared boundaries of safety.
The goal is not to override indigenous practices, but to build a respectful, dual-system framework. These communication practices directly advance health equity. By actively inviting traditional healers into the conversation, the provider reduces the institutional trauma that has alienated some communities from Western care. Patients are no longer forced to hide parts of their identity to receive treatment, resulting in safer care, deeper trust, and better clinical outcomes.
3.5 Implementing Health Equity Interventions
To reduce the impact of implicit bias and increase cultural competence, healthcare organizations must move beyond one-time awareness training toward structural changes that standardize care and increase accountability. When a disparity is identified (e.g., maternal mortality rates), it must be immediately mitigated with a clinical or administrative intervention.
Specific interventions are characterized by a common goal: closing the health equity gap, improving outcomes, and enhancing the patient experience. Department-specific performance goals tied to equity encourage the reduction of health disparities.
3.5.1 Case: Chronic Disease Management and Implicit Bias
Roy is a 54-year-old Black man with a 10-year history of type 2 diabetes presents with an A1C of 9.2% (up from 8.1% six months ago). The chart notes Roy has a history of “frequent missed appointments” and the patient has been labelled as “noncompliant with diet and medication.”
After reviewing Roy’s chart, what is your treatment plan:
- Choice A (the standard compliance path): Review the risks of diabetic retinopathy and neuropathy. Strongly emphasize the importance of medication adherence, increase his metformin dosage, and add a once-daily basal insulin injection. Schedule a 2-month follow-up.
- Choice B (the equity/social determinant of health intervention path): Acknowledge the rising A1C neutrally. Use open-ended questions to explore recent lifestyle or environmental changes, explicitly assessing food insecurity, cost barriers, and scheduling conflicts.
Discussion: If you chose option A, you don’t realize that Roy lost his job six months ago, resulting in severe food insecurity. He is skipping meals to make his food last, causing his blood sugar to spike from stress and poor nutrition. Adding insulin without addressing his lack of consistent food may cause his blood sugar to drop dangerously low on the days he couldn't afford meals. This is as an implicit bias failure: “non-compliance” as a behavioral choice rather than a social determinant of health.
Option B means you understand some of the difficulties facing this patient. You arrange to pair him with a social worker, who enrolls him in a local food pharmacy program. You also switch his prescriptions to generic, low-cost alternatives on the $4 formulary list. Four months later, his A1C drops to 7.8% without a single episode of hypoglycemia.
3.6 Health Disparities and Social Inequities
A health disparity is a quantifiable difference in health outcomes, disease prevalence, or access to care between different populations. A social inequity is an unfair, unjust, and preventable structural difference in society that directly causes health disparities. Inequities are rooted in systemic factors like racism, socioeconomic status, geography, and policy.
A health disparity is the measurable symptom (e.g., higher asthma rates). A social inequity is the root cause (e.g., building a toxic chemical plant next to a low-income housing district).
3.7 Collaborating with Community Resources
Teaching healthcare providers to bridge the gap between clinical care and community resources is one of the most impactful ways to drive health equity. Community organizations provide valuable insights into the needs of marginalized populations and help healthcare providers develop targeted interventions that are effective and sustainable.
Increasing healthcare access and services in underserved communities can be achieved by reducing transportation barriers, increasing affordability, and providing more convenient hours to accommodate different work and family schedules. Programs tailored to the needs and cultures of the community should be designed to address health issues in a culturally appropriate way.
One aspect of health literacy is training providers to communicate health information in a way that is easy for patients to understand by using clear language, avoiding medical jargon, and developing well-designed visuals and written materials to help patients understand their health status and treatment options.
3.7.1 Case: Lorraine
Lorraine, a 62-year-old member of the Burns Paiute Tribe, is diagnosed with stage II breast cancer. The oncologist recommends immediate surgery followed by chemotherapy. Lorraine hesitates and states she needs to return home first to consult with a traditional healer and conduct a specific healing ceremony. How do you respond?
Choice A: You tell Lorraine, "Time is of the essence. Delaying surgery for a ceremony could allow the cancer to spread. We really need to schedule this next week. You can do the ceremony after you recover." This approach shows low cultural competency and creates a forced choice between her culture and her medical care. Lorraine is highly likely to cancel her appointment and not return.
Choice B: You say to Lorraine, "I respect that completely. Your spiritual well-being is a vital part of your healing process. Let's talk about the timeline for your ceremony so we can coordinate your surgery to happen right after, ensuring you get the full strength of both treatments." This approach shows high cultural competency. You have validated her worldview and framed the traditional ceremony as a complementary asset to the surgery, rather than a barrier.