Is CRC the new standard of care?

The data is clear: Racial disparities plague the US healthcare system.

COVID-19 has brought this issue into sharp relief. According to data released by the US Department of Health and Human Services (HHS) in March, racial and ethnic minorities not only experienced higher rates of coronavirus infection but also higher rates of hospitalization and death from COVID-19. And now that vaccinations are rolling out, early evidence suggests that minority groups are being vaccinated at a proportionally lower rate compared with White Americans, as well, according to the HHS.

With systemic solutions lacking, some physicians are taking it upon themselves to try to overcome health disparities using a concept known as “culturally relevant care” or CRC. But many doctors don’t know what CRC is or what it entails. Here’s an overview of CRC, how it can help doctors provide care that respects patients’ unique cultural needs, and how this strategy can benefit patient outcomes.

What is CRC?

In short, culturally relevant care is a tool physicians can use to build greater connections with diverse and underserved Americans, with the goal of overcoming systemic challenges that lead to worse outcomes in these groups. Other monikers for this concept in the past have included “culturally competent care” or “culturally sensitive care.”

In a blog post, physician Vik Bakhru, MD, COO/CFO at ConsejoSano, explained the value of CRC. The US healthcare system, he said, tends to apply a “one-size-fits-all” approach to care delivery, which doesn’t meet the needs of America’s diverse multicultural population. “When we treat people like this (and also make it difficult to access care in the first place), it’s not surprising that [patients] don’t trust or engage with the system," he wrote.

Dr. Bakhru believes CRC is the solution. It represents the antithesis of this one-size-fits-all approach and should be implemented broadly as a new standard of care, he suggested. CRC integrates a deep understanding of cultural and socioeconomic differences into doctor-patient interactions. “It dictates whether you stand or sit, what you say and how you say it, the breadth of knowledge you bring to the conversation, and more,” he wrote. “Its value lies in acknowledging and engaging with the social determinants of health and barriers to access that the healthcare system often overlooks.”

One review, published in PLoS One, buttresses Bakhru’s argument, examining healthcare inequalities and mitigation techniques that fall under the banner of CRC. The authors highlight several barriers that prevent minority groups from accessing healthcare services, including “the organization and complexity of healthcare systems, legal restrictions on access to certain health services, linguistic and cultural barriers, discrimination and limited competencies or unawareness of providers.” Such challenges are exacerbated by low health literacy, fear of stigma, employment or immigration status, or differences in health beliefs. 

Deficiencies within healthcare systems—like the lack of interpreter services or the absence of culturally and linguistically adapted information materials—lead to mistrust, decreased adherence to medical advice, and poorer health outcomes, the authors wrote.

Evidence for CRC’s efficacy

Examples of CRC can be found in the aforementioned PLoS One review. The researchers examined 67 articles, which outlined several approaches implemented in different healthcare settings, measuring their effectiveness. 

One article showed that the availability of a bilingual Russian internist at the Denver Medical Center resulted in a reduction in diastolic blood pressure and cholesterol among Russian diabetes patients. The authors also cited a study carried out at Boston’s Martha Eliot Health Center, which focused on the outcomes for Latinx patients with anxiety participating in an allocentric relaxation intervention, a culturally relevant therapy in Latin culture. The study found that long-term rates of major depression in these patients decreased from 25% to 14%.

Other articles cited found that providing an avenue for more involvement from patients’ family members resulted in patients from African American, Latinx, or Asian backgrounds feeling that they were better able to treat their disease, more comfortable talking about their diabetes with their families and friends, and more confident and in control of their lives. 

Other studies in the review arrived at similarly encouraging results. The installment of a sweat lodge at one hospital saw admissions from Native American patients increase from 4.7% to 7.5%. In another study, the implementation of community health workers (who would educate patients during home or clinic visits) led to increases in rates of cancer screenings among Chinese and Hispanic patients. Another study found that the employment of Black or Latinx “health navigators” at a breast cancer clinic helped lower stress for patients and providers “through improved communication, increased safety of treatment, improved understanding, trust and connectedness, which in turn [led] to higher efficacy of treatment and greater improvements in applying health recommendations.”

Study authors concluded that some, but not all, of these strategies, appeared to result in “moderate effects on patient outcomes.” More research is needed because the efficacy of many strategies could not be confirmed due to a lack of a control group and other study limitations. Researchers also pointed to several outstanding strategies that weren’t implemented in any of the studies analyzed, including the use of telemedicine, other outreach methods, and the creation of community health networks.

Putting CRC in practice

In his blog post, Bakhru cites two real-world examples where the method proves vital in proper care delivery. “In primary care settings, physicians often emphasize the importance of cervical cancer screening for female patients. For most women, this is a simple subject to discuss. But for trans men, such conversations require a high degree of cultural sensitivity and mutual understanding. Get it right, and you can build trust with a diverse American that ripples out into the local community. Neglect cultural sensitivity, and the opposite effect occurs,” Bakhru explained. 

Here’s the second example: “In late April, a Muslim patient whose chart shows a long history of healthy blood pressure presents with hypertension. Cultural sensitivity in this scenario requires an awareness that Ramadan occurs in the spring, meaning your patient’s vitals may be affected by their religious observation of that holiday, which can include fasting. It’s important to acknowledge that a patient may have short-term elevated blood pressure before pursuing therapeutic strategies for a reading that amounts to a brief anomaly in their chart,” Bakhru said.

While further research is required to establish clinically proven strategies for the implementation of CRC, physicians should nonetheless explore ways to adopt the approach as a first step to addressing America’s healthcare inequities. After all, as Bakhru argues, it could become the new standard of care.