It is (an individual’s) health views, needs, and experiences that matter when making an informed decision, not a patient’s ethnicity, race, or social status.

Togioka et al, 2024
Diversity and Discrimination in Healthcare

Cultural competence is a lifelong process that encourages healthcare providers to integrate knowledge into standards, policies, and practices. The goal being to improve the quality of services, thereby producing better outcomes. With practice and awareness, cultural competency can evolve over time, allowing providers to work effectively in cross-cultural situations (NPIN, 2024).

Providing culturally appropriate care creates a healthcare system and workforce that delivers accessible and effective healthcare regardless of a person’s background. It recognizes that health is inseparable from cultural perceptions of wellbeing (Liu, Miles, and Li, 2022).

In 2002, the National Academies published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which analyzed barriers to accessing care, historic and contemporary inequities, and pressures for cost-containment. They looked at clinical encounters and found evidence that stereotyping, biases, and uncertainty on the part of healthcare providers contributed to unequal treatment (IOM, 2003).

The report found that people in racial and ethnic minority groups received lower-quality healthcare than whites received, even when they were insured to the same degree and when other healthcare access-related factors, such as the ability to pay for care, were the same. The IOM report was a primary impetus for the cultural competence movement in healthcare (Stubbe, 2020).

Providing culturally responsive healthcare services means that clinical staff and organizations are aware of their own attitudes, beliefs, biases, and assumptions about others. In some circumstances, patients whose providers completed training had better opinions of their clinicians and participated longer in mental health counseling than patients whose providers did not (UW, 2020).

2.1 Cultural Sensitivity, Awareness, and Humility

Cultural sensitivity is an ongoing process of self-assessment that helps healthcare workers better understand people from cultural backgrounds that differ from their own. It helps us understand that a person’s cultural background and personal beliefs affect their perceptions of health, illness, and death, beliefs about causes of disease, and approaches to health promotion. It can help us understand that culture influences how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer.

Cultural awareness means you strive to improve your understanding of the norms and customs of multi-cultural groups. Self-awareness of cultural influences is closely related to health equity, helping us understand that values often assumed to be universal can be relative in nature. Awareness of our own cultural beliefs can help us understand the influences of diverse but interrelated determinants of health, offering new models of care that account for more than just biology and medicine.

Cultural humility means you keep an open mind and a non-judgmental approach to patient care (Shepherd et al., 2019). Practicing cultural humility means you keep an open mind and a non-judgmental approach to patient care. It means understanding that you are not an expert in all cultural matters.

2.2 Cultural Diversity

Broadly defined, diversity is the inclusion of varied attributes or characteristics. Diversity education encourages providers to understand their position of power and privilege in society, develop a critical consciousness*, and recognize their own implicit biases and those of the institutions and systems in which they work (Togioka et al., 2024).

*Critical consciousness: a reflective awareness of the self, others, and the world and a commitment to addressing issues of societal relevance in healthcare.

Diversity training encourages providers to consider the unique, individual context of each patient and to remember that a situation may be experienced differently by different patients (Togioka et al., 2024). There are five key principles associated with diversity training (Ogrin et al., 2020):

1. Awareness: understanding unconscious bias and prejudice, self-identifying biases.
2. Promotion: focusing on similarities between people rather than differences.
3. Embedding: ensuring access and equity in policy and practice.
4. Identifying: uncovering individual characteristics that promote participation, sharing decision-making, trust-building, and rapport.
5. Understanding: acknowledging the intersectionality of people’s various characteristics.

Efforts to diversify the healthcare workforce have largely centered on individuals designated as underrepresented in medicine relative to their numbers in the general population. Studies examining race and ethnicity at the undergraduate, graduate, and faculty level have reported modest improvements in the proportions of underrepresented racial, ethnic, and sex groups within medicine over time.

Although diversity in the medical workforce has increased, it has not yet accounted for the shifting demographics of the U.S. population. This despite mounting evidence that diversifying the workforce to reflect the population served is key to providing high-quality, high-value, culturally effective care (Lett et al., 2019).

A lack of gender diversity is evident in healthcare management positions. For example, more than half the pediatricians and gynecologists in the U.S. are now female, yet department leaders remain predominantly male. Men are more likely to be selected for editorial board membership and achieve status as an associate or full professor, department chair, or medical school dean. Men also earn more at each academic rank (Togioka et al., 2024).

In nursing, men are put on a fast track and pushed to achieve positions that include greater responsibility, higher salary, and more organizational benefits. While diversity is necessary and important, equity is also needed to decrease disparities and mitigate the impact of discrimination (Togioka et al., 2024).

2.3 Indirect Discrimination

Indirect discrimination happens when a policy applies in the same way for everyone but disadvantages a group of people who share a protected characteristic. If this occurs, the person or organization applying the policy must show that it is in place for a good reason. A "policy" can include a specific practice, rule, or arrangement. It makes no difference whether anyone intended the policy to disadvantage you or not (EHRC, 2019).

Indirect discrimination often operates under the guise of legitimacy and fairness. It can be related to sex, gender reassignment, sexual orientation, race, belief, age, disability, marriage or civil partnership, or religion. While direct discrimination is often clearly evident, indirect discrimination can be subtle and difficult to prove.

To prove that indirect discrimination is happening or has happened, a person must be able to show that the policy has disadvantaged them personally or that it will disadvantage them. Additionally, indirect discrimination can occur if the organization is unable to show there is a good reason for applying the policy despite the level of disadvantage to people with a protected characteristic (EHRC, 2019).

Examples of indirect discrimination include prohibiting certain types of hairstyles, requiring patients to be given care by someone of the same gender, or providing protective clothing that is too small or large for an employee. Establishing height requirements for jobs where height is irrelevant or refusing a job to someone because the company’s equipment is not designed for people of a certain height are also examples of indirect discrimination.

In hospital organizations owned by religious organizations, indirect discrimination—although well intentioned, can include:

• Refusing to pay for an employee’s required training on Saturday because of the employer’s religious beliefs.
• Requiring prayer at the start of staff meetings.
• Promoting only employees who share the religious beliefs of the hospital’s owners or managers.

A number of tools have been developed to help an organization prevent policies and assumptions that can lead to indirect discrimination. For example, the Equality Pay Act of 1963 requires employers to pay each employee equally for the same role regardless of gender identity and disability.

If enacted, the Equality Act, introduced by Congresswoman Nancy Pelosi, would amend existing civil rights laws—including the Civil Rights Act of 1964, the Fair Housing Act, the Equal Credit Opportunity Act, the Jury Selection and Services Act, and several laws regarding employment with the federal government—to explicitly include sexual orientation and gender identity as protected characteristics. The legislation also amends the Civil Rights Act of 1964 to prohibit discrimination in public spaces and services and federally funded programs on the basis of sex (HRC, 2023).

2.4 Intersectionality

An individual’s cultural background is not merely a matter of race or language, but is at the intersection of heritage, language, beliefs, knowledge, behavior, common experience, and self-identity. A culturally sensitive assessment must consider all the aspects that make up cultural diversity, as well as their complex interactions (Mortaz Hejri, Ivan, and Jama, 2022).

Intersectionality is a social theory that explains how different forms of oppression, such as racism, sexism, and classism, intersect and compound to create marginalization and privilege. It highlights the interconnected nature of social identities and the ways in which systems of power interact and overlap to shape individual experiences.

Because individuals belong to more than one group and have overlapping health and social inequities, as well as overlapping strengths and assets, health equity is intersectional. Understanding how social identities overlap can help a provider better understand, interpret, and communicate health outcomes.

2.5 Gender and Culture

[This section is taken from Global Health 50/50, 2020]

Gender refers to the roles, behaviors, activities, and attributes that a given society at a given time considers appropriate for men and women and people with nonbinary gender identities. These attributes, opportunities, and relationships are socially constructed and are learned through socialization. They are context and time-specific and changeable.

Gender determines what is expected, allowed, and valued in a woman or a man. In most societies there are differences and inequalities between women and men in responsibilities, activities, access to—and control over—power and resources, as well as decision-making opportunities. Gender is part of the broader context of sociocultural power dynamics, as are class, disability status, race, poverty level, ethnic group, sexual orientation, and age.

Gender equality means having the same opportunities, rights, and potential to be healthy and benefit from the results. Inclusion means actively building a culture of belonging, inviting the contribution and participation of all people, and creating balance in the face of power differences.

2.6 Older Adults, Person-Centered Care, and Ageism

For older adults, culturally competent care is essential to meet the needs of what is becoming a larger and more diverse population. Older adults from culturally diverse backgrounds are often miscategorized as a homogenous group despite prominent sociocultural differences. Person-centered care encourages providers to tailor care to a patient’s specific sociocultural backgrounds (Chowisdhury et al., 2022).

To support older adults, healthcare providers must learn to be responsive to the many diverse characteristics influencing the health and care needs of older people. It is important to move away from viewing people through a single lens, towards understanding the intersection of their various characteristics.

For older adults, many complex and interacting factors underly disparities in health risk and disease burden (NIA, 2023 June 27):

• Unequal access to healthcare services.
• Availability of social support.
• Neighborhood and workplace environments.
• Food availability and accessibility.
• Wealth and income gaps.
• Racism, sexism, and other forms of discrimination.

A lack of geriatrics specialists, insurance issues, ageism, hearing and visual changes, chronic diseases, cognitive changes, limited English proficiency, and health literacy add to these disparities. Stigma and misunderstandings can contribute to inaccurate diagnoses, lack of follow-up care, and poor health outcomes.

Including a patient’s perspective on the quality of healthcare delivery is becoming an increasingly important aspect of culturally competent care. This approach prioritizes viewing older adults as partners in their care (Chowdhury et al., 2022).

Five key principles of culturally competent include:

1. awareness of unconscious bias and prejudice
2. promotion of inclusion
3. access and equity
4. appropriate engagement
5. intersectionality (Ogrin et al., 2020)

For older adults, ageism is an often underrecognized form of discrimination that includes stereotypes and prejudices directed toward people on the basis of their age. Ageism has serious implications for the health of older people. Age-based discrimination has been associated with poorer physical and mental health, reduced quality of life, and even earlier death (NIA, 2023 June 27).

Effective communication builds satisfying relationships with older patients. It strengthens the patient-provider relationship, leads to improved health outcomes, reduces medical errors, and makes the most of limited interaction time (NIH, 2023 January 25).

Additional recommendations (NIH, 2023 January 25):

1. Make older patients comfortable.
2. Avoid hurrying older patients.
3. Speak plainly.
4. Write down or print out takeaway points.