Why we need to look beyond cultural competency to fix the patient diversity challenge

The healthcare industry has work to do. There is a known implicit bias in healthcare, which has been shown to influence treatment decisions, adherence and patient health outcomes. Disparities in health outcomes can be identified across the world, with black women in the United States over three times more likely to die as a result of pregnancy complications than their white counterparts, and older people from ethnic minority groups in the United Kingdom more likely to suffer with multiple long-term conditions.

However, this bias does not exist only in communities of healthcare professionals (HCPs) — it can be found throughout the drug development process too. The lack of diversity in clinical research is a concerning issue, and the debate on how best to improve diversity in clinical trials is not a new one. The industry has been aware of under-representation since the publication of the unequal treatment public health report in 2003, which has since triggered numerous initiatives to rectify under-representation of minority groups in clinical trials.

One such initiative is an increase in cultural competency, where HCPs would undergo training to further develop their understanding of different cultures, improving their ability to deliver care across a wider spectrum of different people.

While this was a good initial step, cultural competency is limited in a few ways. Firstly, its outcome is static. One is either culturally competent, or one is not. This has led to HCPs who have completed such training to being falsely convinced that they are delivering care in a culturally competent manner when, in fact, they aren’t. One study found that over 80% of HCPs often or sometimes found it more difficult to engage with or treat patients from cultures different from their own. And, while 84% of HCPs agreed that disparities affect their practice, just 29% believed that personal biases influenced their level of care. For this reason, cultural competency has been criticised for amplifying the notion that HCPs can, and should, aim to master a certain level of knowledge about other cultures, and that in itself is enough to eliminate bias. Cultural competency has therefore become a tick-box exercise, rather than a solution.

Secondly, cultural competency often fails to address the numerous ways that people differ under the cultural umbrella. Culture doesn’t just mean ethnicity. It encompasses socio-economic status, physical ability, religion, education and gender, among many other influential factors.

Lastly, cultural competency is often framed towards the individual, with no mention of systemic processes, privileges or power. By positioning training on an individual level, this allows for the ‘othering’ of other cultures, almost reinforcing a binary separation, ie, people of a similar culture to oneself, and people of differing cultures. This leads to an oversimplification of cultural understanding which, ironically, can do more harm than good.

In terms of correcting implicit bias in HCP communities and clinical research staff, cultural safety training is a better solution. Whereas cultural competency is the understanding of cultures different from one’s own, cultural safety training requires HCPs to consider aspects of their own culture, individual attitudes, biases, stereotypes and more, and how these can influence their clinical interactions.

Cultural safety training has an element of introspection. It’s expected that by highlighting the importance of HCPs’ cultural identities, they are able to understand the value that patients place on their own cultures, too. HCPs are then encouraged to challenge how their cultural identity may impact the way they deliver care. This, in itself, remedies one of the problems with cultural competency. Whereas cultural competency enables ‘othering’ of cultures, cultural safety forces the focus to be on the culture, and its consequent impact, of the HCP rather than the patient. Due to its reflective approach, cultural safety becomes more than a tick-box exercise, as it promotes an ongoing element of self-reflection on clinical practices.

Furthermore, cultural safety training goes deeper than cultural competency, covering many more defining features of culture than just ethnicity. By encompassing more key elements, cultural safety enables a more inclusive approach to healthcare.

As mentioned above, implicit bias does not begin and end just with HCPs. Implicit bias can be found in clinical trials too, manifesting as a lack of diverse representation among participants.

Fortunately, cultural safety approaches can be applied to clinical trial staff training, too. Whether the training is used to impact study and protocol design, improve patient recruitment activities, or enhance the patient experience, this ongoing practice works to improve diversity in clinical trials, which is imperative in improving healthcare for all.

‘The lack of diversity in clinical research is a concerning issue, and the debate on how best to improve diversity in clinical trials is not a new one’