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Cultural Competence

Viewpoint: Cultural Competence and the
African American Experience with Health
Care: The Case for Specific Content in Cross-
Cultural Education
Arnold R. Eiser, MD, FACP, and Glenn Ellis

Abstract

Achieving cultural competence in the
care of a patient who is a member of an
ethnic or racial minority is a multifaceted
project involving specific cultural
knowledge as well as more general skills
and attitude adjustments to advance
cross-cultural communication in the
clinical encounter. Using the important
example of the African American patient,
the authors examine relevant historical
and cultural information as it relates to
providing culturally competent health
care. The authors identify key influences,
including the legacy of slavery, Jim Crow
discrimination, the Tuskegee syphilis

study, religion’s interaction with health
care, the use of home remedies, distrust,
racial concordance and discordance, and
health literacy. The authors propose that
the awareness of specific information
pertaining to ethnicity and race enhances
cross-cultural communication and ways
to improve the cultural competence
of physicians and other health care
providers by providing a historical and
social context for illness in another
culture. Cultural education, modular in
nature, can be geared to the specific
populations served by groups of
physicians and provider organizations.

Educational methods should include both
information about relevant social group
history as well as some experiential
component to emotively communicate
particular cultural needs. The authors
describe particular techniques that
help bridge the cross-cultural clinical
communication gaps that are created
by patients’ mistrust, lack of cultural
understanding, differing paradigms for
illness, and health illiteracy.

Acad Med. 2007; 82:176–183.

There has been much interest recently
in preparing physicians to care for
patients from a variety of cultural and
ethnic backgrounds.1–3 Despite this
interest, recent studies suggest that this
area of medical education is the still
most lacking.4,5 The population seeking
primary care consists of people from
varying racial and ethnic backgrounds,
with approximately 40% belonging to
racial and ethnic minorities; by 2015, this
number will likely be over 50%.6 New
Jersey is the first state to mandate cultural
competence as a medical licensure
requirement, but others will soon follow
this trend.7 The Institute of Medicine
has stated, on a national level, that cross-
cultural training should have a significant
role in improving quality of care for
minorities and eliminating racial and
ethnic disparities.8

One approach to improving the cultural
competence of physicians focuses on
general attitudinal and organizational
shifts and the application of general
methods for communicating across
different cultures.9,10 Kleinman et al9

pioneered this approach with the use of
open-ended ethnographic-type questions
in cross-cultural physician–patient
encounters. Others have advocated an
approach to cross-cultural education
based on using specific background
information about patients.11

Although both of these approaches
have definite merit, we emphasize the
importance of the specific cultural and
historical factors that influence the nature
and outcomes of the clinical encounter.
We also assert that specific knowledge of
these factors is necessary for the optimal
cross-cultural clinical encounter. In this
article we focus on the African American
experience as a paradigmatic example of
minority interaction with the American
health care system. The fact that
physicians themselves are increasingly
coming from varied ethnic backgrounds
adds emphasis to the need for greater
cultural education, as both patients and
providers are often ethnically distinct.
Twenty-five percent of physicians

practicing in the United States are
international medical graduates (IMGs),
and many of them come from a variety of
countries.12 In New York and New Jersey,
IMGs comprise 40% of the physician
workforce. Clinical communication
between patients and physicians
necessarily crosses many different
cultural contexts, and effective
communication in a cross-cultural
clinical encounter hinges on a physician’s
ability to bridge cultural divides. IMGs
who were raised in other countries will
not generally be familiar with American
history or cultural aspects, and therefore
may have some difficulty communicating
with American patients. This, if anything,
raises the need for cross-cultural
communication education, even as
American medical graduates are
surely in need of it as well.

As just one example of health care
disparities between African Americans
and Caucasians, recent studies indicate
that differences persist between these
two racial groups in terms of coronary
refusion therapy and coronary
angiography.13,14 Caucasian patients
were more likely than African American
patients to undergo the potentially
lifesaving procedures such as coronary

Dr. Eiser is vice president, Department of Medical
Education, Mercy Health System of Southeastern
Pennsylvania, and professor of medicine and
associate dean, Drexel University College of
Medicine, Philadelphia, Pennsylvania.

Mr. Ellis is president, Strategies for Well-Being LLC,
Yeadon, Pennsylvania.

Correspondence should be addressed to Dr. Eiser,
1500 Lansdowne Ave., Darby, PA 19023; telephone:
(610) 237-5620; fax: (610) 237-4762; e-mail:
([email protected]).

Academic Medicine, Vol. 82, No. 2 / February 2007176

revascularization or reperfusion. Several
factors can influence such treatment
differences: physician bias, patient
mistrust of physicians, reluctance
to undergo invasive procedures or
preventive testing, fundamentalist
religious beliefs, and insurance coverage
and other economic influences.

The role of mistrust is one important
aspect in the African American
experience of medical care. African
American history in the United States
includes a protracted period of slavery,
post-Emancipation “Jim Crow”
discrimination and persecution in the
South, and an extended period of
socioeconomic disadvantages during
ghettoization in northern cities.15 Health
care during these periods was often
unavailable to African Americans, or
the quality and quantity of the care was
deficient. Specific medically related
discrimination included hospital ward
segregation, which at one time was
common,16 and the well-known U.S.
Public Health Service–sponsored
Tuskegee syphilis study in which
informed consent was not used and
indicated treatment was withheld without
the patients’ knowledge.17 This event was
revealed through an investigative report
by the Atlanta Constitution Journal
and was followed decades later with a
presidential apology.18 Today, the study is
widely known in the African American
community. The cumulative effect of
many negative clinical and clinical
research experiences, of which Tuskegee
is only the best known, continues to
foster distrust of health care providers
and the health care system within the
African American community.19,20 Many
African Americans today, regardless of
socioeconomic status, still carry lingering
mistrust as the result of this legacy of
mistreatment and lack of informed
consent.

The historical and cultural legacy of
discrimination against African Americans
influences their socioeconomic status and
affects their health care interactions and
clinical outcomes. African Americans
receive disparate care for a number of
conditions, including cardiac care,21,22

and most caregivers are oblivious to such
disparate care differences.23 In addition
to the discrimination that is prominent in
African American history, certain aspects
of the African American cultural
historical experience are unique to this

particular group. Understanding these
cultural aspects is necessary in achieving
the optimal cross-cultural clinical
encounter between an African American
patient and a physician from a different
racial or ethnic background.

Religion and African Americans

Many African Americans have either a
religious orientation or a viewpoint
grounded in African American social and
cultural history, which may emphasize a
holistic approach to health and health
care.24 Religion is a source of enormous
emotional support for African
Americans, and religious observance or
religiosity can, in many regards, correlate
with improved health outcomes.25

Religious and medical perspectives are,
of course, different and could come into
conflict, though in general they need not
be contradictory. Furthermore, religious
belief and practices may vary widely
among individuals, even within the
same religion or specific denomination.
Although most, if not all, religious
denominations have memberships that
span the racial spectrum, the African
American religious experience brings a
particular intensity borne of the powerful
role that Christian churches played in the
African American communities during
and after slavery, as well as in the civil
rights movement.26 The church became
the source of salvation for both body and
soul when often there was no other
institution available.27

Within the African American
community, several distinctive groups
of churches can be identified,28,29

including mainstream Baptist or
Methodist churches, messianic or
nationalistic churches, conversionist (e.g.,
Pentecostal) churches, and “spiritual”
churches that emphasize magical contact
with the spirit world to improve physical
as well as spiritual states.29 As a
prominent component of African
American history and culture, religion
has a strong role in establishing African
Americans’ health care attitudes and
practices. The spiritual churches also
relate to African American faith healers
who provide consultations in individual
as well as group settings as an alternative
to mainstream health care.30 The
mainstream churches are less likely to
encourage a fundamentalist religious
belief. For African American women,

faith-based institutions provide a social
context whereby a new awareness of
health promotion can be possible.31,32

In addition to Christianity, Islam has had
an impact on African American history
and culture. It is estimated that 10% to
20% of the slaves brought over from
Africa were Muslims, and Islam has
had a growing presence in the African
American community since the 1960s.33

Individuals who embrace the Islamic
faith are likely to define a good physician
as one who addresses issues of faith and
spirituality as well as biological needs.
It is reasonable to expect that African
American Islamic patients expect some
of these broader issues of faith and
belief—not merely biological issues—to
be addressed in the clinical encounter.34

If these issues are not addressed or
acknowledged by the clinician, the result
can be the patient’s mistrust of the
physician and noncompliance in the
medical regimen. In our opinion, this
is likely to be true for patients of other
religions as well.

A scientific medical approach does not
preclude a religious perspective, but it
does qualify the domain of religion to
some extent with regard to some health
care matters. Many health care providers
as well as many hospitals have an overtly
religious perspective or mission, yet they
deliver evidence-based medical care. In
general, it should not be difficult for
physicians and other care providers to
show courtesy to patients’ religious
beliefs without compromising evidence-
based health care. In rare circumstances
of extreme belief, there may be direct
conflict between evidence-based
medicine (EBM) and religious belief, and
this should be approached with tact as
well as community resources.

Many African Americans have a
deep sense of spirituality, and this
spiritualism is intertwined with
other aspects of their lives, including
health.29,30 Traditional African
American folk beliefs concerning health
and illness focus on herbal remedies
and magical aspects of illnesses that
invoke spiritual components, including
hexes, roots, and divine displeasure
of people or their offspring.35 The
humoral theory of illness that dates
back to antiquity and was codified by
Galen found its way to the Americas
and persists in Hispanic folk medicine

Cultural Competence

Academic Medicine, Vol. 82, No. 2 / February 2007 177

culture.36 It also entered the African
American health practices of the
antebellum South.37 In this spiritual–
magical schema, the allopathic
physician may have been viewed as
inferior to an evangelist or spiritualist
“gifted in the healing arts.”37,38 These
beliefs and practices were strongest
in the South but made their way
to northern cities, including
Philadelphia.39,40 This phenomenon
is analogous with the burgeoning
complementary medicine movement
in the general population in recent
decades.41,42 The urge to have a
theurgical or magicoreligious cure to
illness perennially supersedes the
emotionally colder approach that
scientific medical practice tends to
entail.

However, a fundamentalist religious
belief that God will cure illness without
medical treatment is associated with a
greater than fourfold increased likelihood
of presentation with late stage of breast
cancer among breast cancer patients.43,44

Similarly, the belief that “roots or spells”
will cause or cure cancer has a fivefold
increase in the likelihood of a patient
presenting with an advanced stage of
cancer.43 This study found that African
American patients are more likely to have
such a perspective. Another study showed
that African American women who
believed in God as a controlling agent
over health were less likely to obtain
mammography and clinical breast
examination.44 These particular aspects of
religiosity can complicate health care by
delaying appropriate interventions and
may contribute to presentation at a late
stage of disease.

African American women were also more
likely than Caucasian women to consider
breast self-examination an effective form
of early detection of breast cancer;
however, self-examination is insufficient
in this role because mammography and
physician examination are required
for appropriate screening.45 Such an
information gap must be closed if clinical
outcomes are to improve.

Religious beliefs and practices can affect
patients’ attitudes toward health care in a
number of ways. On one hand, patients’
spiritual and religious participation tends
to correlate with better blood pressure
control in some studies of African
Americans.46 Conversely, patients with

folk beliefs that “high-pertension” (as
some of those surveyed referred to the
condition) is causally related to stress and
a negative emotional state were less
likely to comply with a regimen of
antihypertensives among African
American outpatients in New Orleans.47

The president of the National Medical
Association when this article was
written, Sandra Lynn Gadson, MD, a
nephrologist, related that in one case she
needed a court order to dialyze a patient
with kidney failure, who was being
confined by an alternative “minister”
practicing faith healing.48 Dr. Gadson,
herself an African American, noted that
her own spirituality was a powerful
influence in her own life, yet it was
compatible with biomedical practice.
Clearly, religious beliefs can vary greatly,
and some improve health practices
whereas others may delay important
medical interventions.

At times, belief in God may be
accompanied by a reduction in
medication compliance. For example,
Polzer and Miles49 found that strong
spirituality in African American diabetic
patients was correlated with self-
management of the disease and greater
noncompliance with a diabetic regimen.
Religious beliefs may at different times
exert differing effects, positive or
negative, on the delivery of effective
health care. The challenge in realizing
improved health outcomes among
African Americans is to maximize
the positive influence of faith while
minimizing the negative influence.

Delay in diagnosis of breast cancer is an
example of correlation between religiosity
and an increased probability of late
diagnosis. A “true believer” who is
awaiting divine intervention may have a
worse outcome than a patient who seeks
allopathic medical attention at the first
signs of disease. Clinicians must be
attuned to this possibility and
recommend an approach that permits
faith to support the patient without
impeding evidence-based evaluation and
treatment. Physicians can explain to their
patients who adhere to African American
religious and cultural traditions that faith
can be compatible with timely medical
interventions. Physicians can refer to
the many examples wherein faith and
medical approaches are pursued
concurrently, such as by the many faith-
based medical institutions, as well as by

medical practitioners like Dr. Gadson,
the president of the National Medical
Association, and many other clinicians
who embrace religious faith while
practicing EBM. Physicians who express
respect for patients’ religious beliefs while
providing the latest in EBM are likely to
be most positively received in cross-
cultural clinical encounters. In one
author’s (ARE) practice, a rare,
previously invariably fatal infection
(cryptococcemia) was effectively treated
when the patient’s faith group was
permitted to pray at the bedside and the
latest medical management was applied.50

This act of respect and acknowledgement
of the religious and cultural beliefs of the
patient facilitated the cooperation that
was necessary for the application of the
complicated and difficult medical
technology that the patient required.
One cannot state that the praying at the
bedside altered the clinical outcome,
but it did improve mutual respect and
communication between the physician
and the patient, and it may have
improved the patient’s frame of mind.
Physicians can also demonstrate respect
of their patients’ cultural and religious
needs by permitting them to discuss
treatment options with their clergy and
family before making decisions about
treatment.

Home or Natural Remedies

Home or natural remedies are commonly
known and are used by African
Americans, particularly among the
elderly. Turning to an herbalist for
remedies is a part of the African
American cultural history dating back to
the time of slavery, and in Africa before
slavery.51 Indeed, it is difficult to separate
African herbal medicinal usage from
African religions, including those of Igbo,
Yoruba, and other traditions.52 African
Americans were often deprived of
standard medical treatments during
slavery and for some time thereafter. As
a result, a common practice in the past
among African Americans was to try the
home herbal remedies before accessing
medical institutions that were often
inhospitable or, in many instances,
unavailable. For example, an ailing
person may have tried Epsom salt
ingestion and apple vinegar for a
cathartic effect to “cleanse” the body of
illness. Root or faith healing is a tradition
dating back to African origins that was
nurtured during slavery and has endured

Cultural Competence

Academic Medicine, Vol. 82, No. 2 / February 2007178

to current times. It is not uncommon
that an African American today has tried
a home remedy before seeking medical
treatment. Traditionally, the family
matriarch was the source of knowledge
of roots and home remedies, and this
knowledge was considered part of
domestic expertise and was passed down
from the matriarch to her daughters.53

One study reveals that elderly African
Americans with osteoarthritis are more
likely than elderly Caucasian patients to
perceive that traditional remedies are
efficacious and are less likely to seek
joint-replacement therapy.54

One author (GE) was the proprietor
of a health food and herbal store located
near the hospital of the University of
Pennsylvania during the 1990s. It was
his personal experience that African
American patients routinely went to the
store directly from a physician’s office
or clinic to seek an herbal remedy
alternative to the physician’s prescribed
treatment. Often, the patients would not
inform the physician that they were
taking the herbal remedy instead of or in
addition to the prescribed medication. A
clinical study in North Carolina found
that African Americans and American
Indians were 81% and 76%, respectively,
more likely to use food home remedies
than Caucasian study participants.55

Health care providers, physicians, and
others need to understand the role of
home remedies in the social history of
African Americans and how that role
influences the current context of a
clinical counter today. If the providers
show some understanding and respect for
these traditions, even without endorsing
them, it can help in caring for African
Americans by gaining their respect and
trust. Minority groups’ skepticism about
evidence-based medicine can be bridged
by creating trusting relationships
grounded in physicians’ understanding of
particular aspects of the minority culture.

Distrust and Race

We note that distrust of institutions
and authority figures is rooted in the
African American history of racial
discrimination, including slavery, post-
Emancipation persecution, and persistent
racial discrimination.56 Boulware et al57

have demonstrated that African
Americans were less likely to trust their
physicians and hospitals than Caucasians

were. The Tuskegee syphilis study is
frequently cited for this distrust and
undoubtedly contributes to it, as do more
recent instances of racial bias in health
care.19,20 Distrust itself contributes to
racial disparity in health outcomes. Trust
in a physician has been shown to increase
the likelihood of compliance with a
medical regimen, despite cost pressures
and other influences.58,59 Patients with
lower levels of trust were less likely to
comply with a medical regimen for
diabetes.60 Furthermore, the quality of
patient–physician communication may
be lower when Caucasian physicians treat
African American patients. According to
Johnson et al,61 physicians were more
verbally dominant and less engaged in
patient-centered communications when
dealing with African Americans. In
another study, African Americans were
less trusting of Caucasians regarding
medical research participation.62 This
distrust of medical intervention,
illustrated by African Americans’ unease
with cross-cultural physician–patient
communication and medical research
participation, also applies to invasive
but effective clinical practices. African
American veterans were significantly less
likely to accept a recommendation for
carotid endarterectomy in VA system
hospitals.63 In this study, African
American patients were more likely
to express a high aversion to such an
intervention and fewer African American
patients received the intervention,
though all patients had a carotid stenosis
of at least 50%.

Within the African American
community, a patient’s distrust of
institutions and physicians may act
synergistically with fundamentalist
religious beliefs to cause him or her to
delay seeking medical treatments in favor
of trying faith healing or herbal remedies
first. Clearly, there exists an opportunity
for African American religious and
community leaders to affirm to their
community members the value of
evidence-based medical care and its
concordance with religious beliefs.
Although there may be some religious
beliefs that are incompatible with
evidenced-based medical practice, most
are not. We suggest in this regard the
perspective that “God helps those who
help themselves to preventive care and
timely medical intervention,” though we
recognize that all religious leaders may
not agree with this proposition.

Distrust of physicians occurs among
Caucasians and African Americans as
well as other ethnic groups. Surveys
reveal a somewhat higher rate of
distrust of physicians among African
Americans.64 Physicians can mediate
racial differences by showing emotional
support for their patients and involving
other health care providers (nurses,
social workers, therapists, dietitians) of
various ethnicities in the patient’s care.
Respectful, emotionally supportive
dialogue can help overcome racial
barriers.

Racial Concordance

African American patients rated their
encounters with physicians more
rewarding and participatory when the
physician was also African American.
However, only 22% of respondents
expressed a preference for an African
American physician, but those who did
were more likely to express satisfaction
with a racially concordant physician.65

The Commonwealth Fund’s Health
Care Quality Survey found that African
Americans were more likely to rate their
physicians as excellent if the physician
was also African American.66 Racially
discordant clinical dyads were found to
be less likely to engage in a participatory
communication process.61 It is unlikely in
the foreseeable future that most minority
patients will be treated by racially
concordant physicians, given the differing
patient and physician demographics.
African American physicians account for
less than 4% of the medical profession,
whereas African Americans account for
approximately 13% of the population,67 so
the majority of African Americans will see
non-African American physicians. The
ability to cross cultural and ethnic divides
is an essential component of the 21st-
century physicians’ “toolkit.” Moreover,
today physicians themselves come from
diverse ethnic backgrounds, making
cross-cultural clinical dialogue inevitable,
and all physicians should work to
improve their cultural competence.

Bridging the Gulf

Cultural competence in the clinical
setting indicates that the physician is
sensitive to the individual patient’s needs
and establishes rapport across ethnic
differences. Establishing interpersonal
rapport with a patient by identifying and
relating to his or her personal humanity

Cultural Competence

Academic Medicine, Vol. 82, No. 2 / February 2007 179

has been described in the context of
narrative ethics.68,69 Physicians needs to
comprehend the “patient’s story,” not
merely detect the disease and treat it.
Such a more narrative approach can also
help bridge cultural differences and
improve clinical communications in
general.

Demonstrating humility and mutual
concern can also be effective in this
regard, although the former is not a
common physician characteristic.
Bridging the cultural gap requires the
non–African American physician to reach
out to the African American patient to
establish an individual rapport that
transcends historical distrust of medical
institutions. The physician can establish
such a rapport by making an effort
to observe, learn, and practice
the techniques of cross-cultural
communication. For example, although it
may be necessary, referring to insurance
coverage does not build trust between the
physician and the patient. When possible,
it is preferable for the physician to leave
this aspect of interaction to his or her
support staff to avoid the appearance that
self-interest is guiding the physician–
patient interactions. A patient’s
perception of a physician’s self-interest
can also be one of the causes for mistrust.

List 1 summarizes techniques we suggest
in this article for bridging the gulf in
cross-cultural clinical communication.

Health Illiteracy

The prohibition against educating
African American slaves has seriously
impacted on the long-term literacy of
certain components of the African
American population.24 Health illiteracy
is a common hindrance to optimal
health care and is more frequent in lower
socioeconomic groups.70 Among
ethnically and racial diverse patients,
43% report difficulty understanding
information in the clinical encounter.
Among patient with chronic illness, three
quarters have limited literacy. Low
literacy in diabetic patients was associated
with worse glycemic control and
increased rates of retinopathy and
blindness.

One of the authors (ARE) was part
of an Agency for Healthcare Research
and Quality–sponsored research
collaboration that developed and
evaluated a multimedia computer
program for diabetes education in low-
literacy minority populations.71 This
program was developed with the concept
that racial and ethnic concordance
enhance communication of information.
The study demonstrated that the
program increased perceived
awareness of susceptibility to diabetic
complications, especially among those
with low literacy. Other studies reveal
that health illiteracy increases medical
costs and reduced efficiency of services.72

Thus, improving health literacy can

conceivably improve outcomes and
reduce costs if it is culturally sensitive.

Certified health educators are
infrequently African American (10%)
and only a minority (34%) of health
educators are community based.73 Hence,
there are relatively few African American
health educators to provide racially
concordant health education. Health
educators can educate patients about
self-care, communicate with health care
providers, and advocate for patients with
reduced health literacy.74 Federal
funding of community-based ethnically
similar health educators may be
efficacious and cost-effective if …