12/11/2019 Access to Health Care: Influential Factors and Cultural Competence

PUBLISHED SEPTEMBER 18, 2013

Access to Health Care: In uential Factors and Cultural

Competence

Mary Ann E. Zagaria, PharmD, MS, CGP

Independent Senior Care Consultant Pharmacist and President of MZ Associates, Inc.,
Norwich, New York
www.mzassociatesinc.com
Recipient of the Excellence in Geriatric
Pharmacy Practice Award from the Commission for Certi cation in Geriatric Pharmacy.

US Pharm. 2013;38(9):20-22.
The United States population is not only aging, but it is also increasing in
diversity. Approximately 13.3 % of the population is now 65 years of age or
older, and approximately 42% of the general population identi es as African
American, Hispanic, Asian, American Indian, Alaskan Native, being of another
race that is not White, or as coming from two or more races.1 

As the age and diversity of our population increases, so does the potential for
patients, including older adults, to experience barriers to health care access.
Therefore, pharmacists and other clinicians must continue to strive for effective
communication with sensitivity toward cultural, socioeconomic, and
sociodemographic factors. Furthermore, seniors who do achieve access to care
need to be fully engaged in the clinician-patient encounter so they are able to
follow instructions and adhere to medication regimens; engaging an aging and
diverse population requires that pharmacists and other health care providers be
culturally competent.

Factors In uencing Access to Health Care in Seniors

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Among nonelderly Americans, disparities in access to health care have been

well documented, with the primary reason being lack of health insurance (i.e.,
either employer-sponsored or public).2-6 Some sociodemographic factors such
as race and income are highly correlated with a lack of insurance in younger
populations.7-9

Sociodemographic factors, socioeconomic status, and type of insurance

coverage have a substantial impact on the elderly population’s access to health
care.10 Among seniors, psychological and physical barriers affect access to
care and may be in uenced by poverty more than by race.11 The issue of
adequate access to health care has attracted the attention of the U.S.
Government, professional associations, and health care providers alike.12 

In one study supporting this concern, Fitzpatrick et al. evaluated self-perceived

access to health care from self-administered questionnaires in a cohort of
Medicare bene ciaries with a mean age of 76 years.11 The researchers
identi ed patterns of use and barriers to health care and found the most
common barriers to seeing a physician were the doctor’s lack of
responsiveness to patient concerns, medical bills, transportation, and street
safety. Independently related to perceptions of barriers to access to health care
were low income, no supplemental insurance, older age, and female gender;
race was not signi cant after adjustment for other factors.11 

Interestingly, there is a perception of greater equality regarding access to health

care in U.S. seniors due to their eligibility for Medicare; however, conclusions
from recent studies show otherwise. Even for Medicare recipients, cost appears
to be one of the signi cant factors associated with lack of access to care.13-18
Since the greatest nancial burden for Medicare recipients involves out-of-
pocket expenses, issues of cost in the elderly are primarily related to insurance
coverage that is supplemental to Medicare coverage.16 This type of insurance
has been reported to be independently related to both the use of health services
and medical outcomes.14,17 Lack of complementary health insurance may
affect the health care services received by individuals aged 65 years and older,
in addition to race, education, age, and gender.13,15-18 

Striving for Cultural Competence

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Numerous studies indicate that satisfaction with provider services may impact
perceptions of access to health care, in addition to clinical outcomes.19-22 As
noted above, lack of responsiveness to patient concerns is commonly perceived
as a barrier to access to care among older adults.11 A factor in patients’
perceptions of clinicians’ responsiveness may be their ability to make patients
feel respected and understood regardless of cultural differences between
them. 

We, as individuals, are de ned by our culture.23 Further, a variety of factors that
mold behavior and values have the potential to in uence cultural values and
beliefs toward health care (TABLE 1).24 The ultimate goal of a health care
provider is to improve patient outcomes; achieving this goal includes
understanding the culture and language of patients.24 To provide quality care to
patients who come from a variety of cultures and backgrounds, health care
providers, including pharmacists, should strive toward cultural competence.
Cultural competence is the ability of individuals and systems to respond
respectfully and effectively to people of all cultures, classes, races, ethnic
backgrounds, sexual orientations, and faiths or religions in a manner that
recognizes, a rms, and values the worth of individuals, families, tribes, and
communities and protects and preserves the dignity of each.23

The underlying reasons for emphasizing cultural competence in the health care
arena are the change in demographics in the U.S., disparities in health, and
patient safety.24 It is important for clinical practitioners and their students alike
to recognize that patients, including seniors, may enter a health care setting
describing their illness with a different explanation than that found in the U.S.

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12/11/2019 Access to Health Care: Influential Factors and Cultural Competence

medical model. Clinicians need not only to be able to truly listen to a patient’s
own perception of health, but also to acknowledge difference and negotiate
treatment options, all while being respectful.

Standards for Cultural Competence

Understanding and interpreting accreditation standards for health care
organizations and Title VI of the Civil Rights Act are some of the regulatory and
legal issues surrounding cultural competence.24 On April 24, 2013, the U.S.
Department of Health & Human Services released enhanced National Standards
for Culturally and Linguistically Appropriate Services (CLAS) in Health and
Health Care—a comprehensive update of the 2000 CLAS Standards—to ensure
an even stronger platform for health equity.25 Considered a blueprint to help
organizations improve health care quality in serving diverse communities, these
enhanced standards are grounded in a broad de nition of culture in which
health is recognized as being in uenced by a range of factors from race and
ethnicity to language, spirituality, disability status, sexual orientation, gender
identity, and geography.25 These standards can be used by stakeholders
including policymakers, purchasers, patients, advocates, educators, and the
health care community in general to advance health and health care in the
U.S.25

There is support for CLAS standards by the primary national accrediting body
for health care organizations and programs, the Joint Commission, which
requires effective communication, cultural competence, and patient-oriented
care (see RESOURCES). Cultural competence, therefore, can be demonstrated
by an organization when that entity has a de ned set of values and principles
(i.e., mission), policies, and the necessary structures for the delivery of services
that incorporate community input and enable persons in the organization to
effectively perform within cultures and cross-culturally.26,27 Although barriers
exist for cross-cultural communication, they can be overcome if clinicians
understand verbal and nonverbal cues in communication.24 Pharmacists and
other clinicians should also recognize and embrace the fact that it is essential
to have quality interpretation in the patient encounter.

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12/11/2019 Access to Health Care: Influential Factors and Cultural Competence

Conclusion
Access to health care has been viewed as a primary concern, particularly
among the elderly population. Ineffective communication may contribute to this
concern, in addition to negatively affecting medication adherence, therapeutic
outcomes, and patient safety. Navigating across cultures requires tools such as
learning how to listen, empathize, and negotiate a treatment and
pharmaceutical plan with patients. Without cultural competence, effective
communication regarding these issues may be compromised.

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