Ethnic minority populations are growing at a tremendous rate in the United States. Unfortunately, the growth of health care professionals from some minority groups (e.g., African Americans, Latinos, and Native Americans) is not commensurate with their representation in the general population (2). As the primary care patient population becomes increasingly diverse, it is essential that clinicians better prepare themselves to work with patients from different cultural and linguistic backgrounds. Primary care providers face daunting challenges in providing culturally and linguistically competent care to diverse patient populations. The failure to consider a patient’s cultural, spiritual, and linguistic issues can result in a variety of adverse consequences, including miscommunication, poor continuity of care, less preventive screening, difficulties with informed consent, reduced access to care, use of harmful remedies, delayed immunizations, and fewer necessary prescriptions (3).

The Institute of Medicine’s (IOM) groundbreaking report, Unequal Treatment, found that racial and ethnic minorities—even those with equivalent access to health services—receive lower quality of care than nonminorities for several medical conditions (4). These disparities in health care are associated with worse outcomes and increased mortality. In the area of mental health, the Surgeon General’s Supplement to the Report on Mental Health, entitled Mental Health: Culture, Race and Ethnicity, identified striking disparities in mental health care for racial and ethnic minorities (5). It reported that minorities have less access, availability, and quality of mental health services. The report further states that a consequence of this disparity is that racial and ethnic minorities bear a disproportionate burden of disability from untreated and
inadequately treated mental health problems. The key message of the report is that culture counts!

Culture influences many aspects of health care, including how patients recognize, acknowledge, and cope with their symptoms; communicate with their providers; accept treatment; and access support systems. A new report by The Joint Commission titled Hospitals, Language, and Culture: A Snapshot of the Nation recommends that providers make efforts to address language and cultural issues that create challenges to delivering safe and effective care to diverse populations in the United States (6). Additionally, spirituality is an often overlooked aspect of culture. Spiritual beliefs and practices are important to most patients, yet physicians are often unsure how to address these issues in the context of primary care. This chapter aims to help providers assess spirituality in medical settings, understand the importance of language access in medical care, and provides the OCF as a way to incorporate culture into clinical practice.

The United States is home to a number of diverse religious faiths (7). Surveys have found that 95% of people in the United States believe in God and 84% of Americans claim that religion is important in their lives (8). In the last two decades, the importance of religious faith and spirituality in medicine has been increasingly recognized, such that addressing spirituality in medical education and care is mandated by numerous institutions (9).

Several studies suggest that many patients prefer a clinician who is accepting and attentive to their religious or spiritual beliefs (10). Most patients seem to want their providers to inquire into coping and means of social support and, when indicated, be willing to participate in a spiritually oriented discussion. Patient preferences regarding different spiritual interventions vary depending on the severity of the medical illness as well as the medical setting. For example, studies indicate that most patients do not want a clinician to inquire about their religious beliefs during a routine office visit, but in the context of dying, most would welcome such a discussion (7). In addition, patients’ spiritual or religious faith may play a role in their medical decision making, such as consideration of blood transfusions, planning an advance directive, or considering do not resuscitate (DNR) status.

The Census 2000 revealed that nearly 20% of U.S. residents speak a language other than English when at home. Within this group, nearly 45% speak English “less than very well” (12). This means that persons with limited English proficiency (LEP) are not able to speak, read, write, or understand the English language at a level that allows them to interact effectively with health care providers (13). Limited or lack of communication in health care is associated with disparities in access to services as well as in diagnosis and treatment (4). Research has repeatedly shown that language barriers impede access, compromise quality of care, and increase the risk of adverse health outcomes among patients with LEP. Title VI of the Civil Rights Act of 1964 requires health systems that are recipients of federal financial assistance to provide persons with LEP meaningful access to programs and free language services. Despite this, language barriers continue to be an important obstacle to appropriate care and wide gaps persist due to extra costs and limited availability of interpreters.