Cultural care delivery: The gateway to promoting greater health equity

By Mark Stephan, MD

The World Health Organization (WHO) defines social determinants of health (SDoH) as “the conditions in which people are born, grow, live, work and age,” which are “shaped by the distribution of money, power and resources at global, national and local levels.” SDoH are “mostly responsible” for causing the health inequities that exist around the world, according to the WHO.

These social and economic factors, such as housing, healthy food, and income, can drive up to 80% of health outcomes, making them critical components in any “whole-person” approach to healthcare. In general, SDoH go a long way in determining both the access and quality of care available to people.

Three levels of clinician cultural preparedness

While it’s fairly easy for clinicians to agree that SDoH have a substantial impact on health, what—if anything—they should do about it is a more challenging question. Some physicians are apprehensive about wading into SDoH, well aware that these issues are not their domain of expertise. Others worry that SDoH are simply too large and all-encompassing of a societal issue for medical professionals to solve. Many recognize that the interventions the healthcare system has identified to address SDoH are inadequate. Adding complexity to the SDoH issues are cultural beliefs, preferences, and practices among ethnic minority groups that influence both health behaviors and the way in which people engage with healthcare services.

It is possible, however, for providers to deliver a positive impact to patients’ SDoH. In some cases, it may be as straightforward as connecting a patient with a smoking cessation program, though many SDoH issues are obviously more complex. Our experience has shown that most medical practices can be grouped into one of the following three levels of cultural competence when it comes to addressing patients’ SDoH:

Cultural awareness: This is the most basic level of SDoH recognition, in which clinicians have a basic understanding of the scope of sociocultural factors and the role they play in medical care. These clinicians appreciate that the world is a heterogenous place and that behavioral and cultural differences exist across different populations.

Cultural competence: At this level, clinicians not only realize that SDoH exist, but they have begun to investigate their own patient panel in attempt to determine how these factors impact well-being. It starts by medical practice personnel asking probing questions of patients without assuming they already know the answers. Culturally competent practices have taken active steps to gain a more intimate understanding of the social and economic factors as well as cultural beliefs and values that are contributing to patient outcomes.

Cultural care delivery: Building on the other two levels of cultural preparedness, cultural care delivery means that clinicians are taking some action to address SDoH. Medical practices that have achieved this level not only collect SDoH information from patients, but they are in a position to act on it, helping patients take steps or create connections to resolve issues related to SDoH.

How medical practices can start addressing SDoH

Admittedly, getting to the point of cultural care delivery can be a heavy lift for practices that are already overwhelmed with administrative burden. Many small, independent practices lack the time and resources necessary to serve as hubs of SDoH activity and may prefer to enlist the help of a partner. For practice leaders who are considering a more proactive approach to SDoH, here is a three-step process to lay the foundation for cultural care delivery:

Conduct SDoH surveys: The first step to alleviating SDoH issues is to recognize which problems are the most acute in the practice’s patient panel. Practices should conduct annual patient surveys, collecting demographic and personal information that will help reveal any challenges patients are facing. Ideally, this information would be collected with the assistance of staff prior to the clinician visit, perhaps via an online form in the waiting room. The goal of this step is to identify barriers that may prevent patients from following through on their care plans, such as a recent job loss compounded by health literacy issues that would make it difficult for a patient to afford a pricey new prescription and understand medications being prescribed.

Analyze the data to develop a full SDoH picture: After identifying via the survey the individual issues confronting each patient, practices should aggregate all individual survey data to create a holistic representation of the SDoH challenges patients face. Whether the most prevalent issues are food insecurity, housing insecurity, or transportation challenges, for example, clinicians can use this information to begin exploring ideas and having conversations about how the community can work together to solve them.

Build a network of vetted community partners: Clinicians certainly can’t do it alone, so it’s critical that practices establish networks of trusted community-based organizations to which they can refer patients for SDoH issues. These partners may include food banks, housing coordinators, job training centers, and similar organizations. All participants in this preferred community network should have a clear set of goals and expectations for the level of service they provide to patients.

Although the myriad societal problems contributing to health inequity can make the problem appear insurmountable, many medical practices can play an important part in improving the underlying social, cultural, or economic issues impacting their patients. By starting with cultural awareness and competence and then graduating to cultural care delivery, clinicians can make a difference in patients’ lives that goes far beyond the four walls of their practice.

Mark Stephan, MD, is chief medical officer at Equality Health, a whole-health delivery system.