Culturally adapted health care

Culturally adapted health care tailors care to patients’ norms, beliefs, values, language, and literacy skills (Pottie 2013*, Hodge 2010*). Care may delve more deeply into cultural considerations such as social, psychological, and economic factors (Hodge 2010*). Culturally adapted care can include: matching specialists to patients by race or ethnicity (Chowdhary 2014); adapting patient materials to reflect patients’ culture, language, or literacy skills (Pottie 2013*); offering education via community-based health advocates (Cochrane-Attridge 2014*); incorporating norms about faith, food, family, or self-image into patient care; and implementing patient involvement strategies (Kong 2014).

Expected Beneficial Outcomes (Rated)

  • Improved health outcomes

  • Improved mental health

  • Improved health-related knowledge

  • Improved chronic disease management

  • Increased cancer screening

Other Potential Beneficial Outcomes

  • Increased patient satisfaction

  • Reduced hospital utilization

  • Improved quality of life

  • Improved adherence to treatment

  • Increased tobacco cessation

  • Improved dietary habits

  • Improved weight status

  • Improved patient-provider communication

  • Improved prenatal care

  • Reduced drug and alcohol use

Evidence of Effectiveness

There is strong evidence that culturally adapted health care improves health outcomes (Cochrane-McCallum 2017*, Shommu 2016, Cochrane-Attridge 2014*, Benish 2011*, Pottie 2013*, Hodge 2010*), mental health (Healey 2017, Benish 2011*, Chowdhary 2014, Fuentes 2012, Kalibatseva 2014, Pearson 2019), health-related knowledge (Cochrane-McCallum 2017*, Cochrane-Attridge 2014*, Pottie 2013*, Hawthorne 2010, Howie-Esquivel 2014), and chronic disease management (Cochrane-McCallum 2017*, Benish 2011*, Cochrane-Attridge 2014*, Masi 2007, Press 2012, Shommu 2016), and increases cancer screening (Healey 2017, Shommu 2016, Masi 2007) for culturally and linguistically diverse (CALD) patients. There are many types of culturally adapted care, with approaches such as culturally appropriate health education programs (Cochrane-McCallum 2017*, Cochrane-Attridge 2014*), culturally tailored life style interventions (Nierkens 2013, Pottie 2013*), and culturally trained or bilingual health workers (Truong 2014, Pottie 2013*) appearing especially effective. 

Evidence of improved outcomes is strongest for asthma, mental health, and diabetes treatment, cancer screening, and smoking cessation (Cochrane-McCallum 2017*, Benish 2011*, Nierkens 2013, Cochrane-Attridge 2014*, Shommu 2016, Masi 2007). Culturally adapted care for children with asthma improves caregiver and patient understanding of asthma more than usual care. It can also lead to improvements in symptom control and reductions in hospitalization and emergency room visits (Cochrane-McCallum 2017*). For asthmatic adults, culturally adapted care improves self-reported quality of life (Cochrane-McCallum 2017*) and disease management (Press 2012).

Psychotherapy adapted to a patient’s cultural understanding of illness improves psychological functioning more than standard psychotherapy (Benish 2011*). Treatment built on patient understanding may improve patient satisfaction (Benish 2011*, Healey 2017), expectations, adherence to treatment, and willingness to consider alternate illness explanations (Benish 2011*). Addressing values, customs, language, and culturally relevant metaphors can also improve mental health among patients with depression (Chowdhary 2014, Fuentes 2012, Kalibatseva 2014). A rural Washington-based study of Native American women exposed to trauma found that culturally-adapted Cognitive Processing Therapy reduced symptoms of post-traumatic stress disorder (PTSD), risky sexual behavior, and frequency of alcohol consumption (Pearson 2019).

For patients with limited English proficiency (LEP), professionally trained medical interpreters improve patient-provider communication and are associated with improved quality of care (Campbell-Wollscheid 2015, Flores 2005*). Culturally appropriate, individualized education for Spanish‐speaking heart failure patients improved self‐care and heart failure knowledge more than usual care (Howie-Esquivel 2014). Culturally and gender-sensitive programs show promise for treating alcohol and substance abuse in Latino men (Valdez 2018*). A New Haven, CT-based study of Spanish-speaking individuals found that culturally adapted web-based cognitive behavior therapy (CBT) reduced drug and alcohol use and increased completion of substance use disorder treatment (Paris 2018*). Culturally-adapted motivational interviewing can reduce the number of heavy drinking days and physical harm related to alcohol use for Latinos (Healey 2017).

Telephone-based cessation counseling adapted to patients’ linguistic and cultural needs increases smoking cessation more than standard telephone counseling (Nierkens 2013). Interventions that include more counselor contacts and address familial influences can yield stronger effects than less intense interventions (Nierkens 2013).

Culturally adapted diabetes care improves glycemic control and diabetes knowledge more than usual care (Cochrane-Attridge 2014*, Pottie 2013*, Hawthorne 2010), especially when interventions include: appropriately adapted education materials; flexible implementation; local health worker support; affordable, culturally acceptable food choices; and less intense patient time requirements (Pottie 2013*). Incentives such as cash, glucose monitors, or healthy snacks can also improve patient retention and short-term glycemic control (Pottie 2013*). Effects appear strongest in communities with limited access to diabetes education and services (Pottie 2013*, Joo 2014*).

Culturally adapted obesity interventions can improve diet and weight status for black women, especially when patients are involved in the planning and recruitment phases of these interventions (Kong 2014). However, additional evidence is needed to determine whether such interventions outperform usual care (Nierkens 2013). A culturally congruent counseling program for HIV-positive black women and men was shown to increased long-term adherence to HIV treatment (Bogart 2017).

Adapting care to patient linguistic and cultural needs can improve breast cancer knowledge and increase screening rates more than usual care, especially among women with lower incomes. Addressing financial and transportation barriers, language, and literacy skills can yield stronger effects (Masi 2007); offering vouchers for the cost of service can increase the number of low income Latina women receiving mammograms (Healey 2017). Coordinating culturally-appropriate maternity care within the broader continuum of care can increase the use of skilled maternity care (Jones 2017a, Coast 2016*).

The cost of culturally adapted care varies by intervention and condition; additional research is needed to determine the cost‐effectiveness of culture‐specific programs (Cochrane-McCallum 2017*). Diabetes care interventions have demonstrated costs per patient between $150 over six months and $384 over one year, and appear cost-effective in terms of quality adjusted life years (QALYs) saved (Cochrane-Attridge 2014*, Hawthorne 2010).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

In 2019, the Centers for Disease Control and Prevention (CDC) expanded their $98 million program, Good Health and Wellness in Indian Country, to fund 27 awards over five years for American Indian and Alaska Native communities to implement culturally adapted care initiatives in support of healthy living and chronic disease prevention (CDC-GHWIC). The CDC also offers guidance and tools on cross-cultural communication and health literacy for organizations to use (CDC-Cross-cultural tools).

The US Department of Health and Human Services’ Office of Population Affairs provides numerous resources on cultural competence principles and how to apply them in specific settings (US DHHS-OPA CC). The National Research Center on Hispanic Children & Families offers cultural competency resources including guidelines, fact sheets, and a webinar for community-based service organizations (Hispanic Research Center, Lopez 2017).

Implementation Resources

Finding Answers-Responding to culture - Finding Answers: Disparities Research for Change. Responding to culture: Beyond cultural competence training.

US DHHS-Think cultural health - US Department of Health and Human Services (US DHHS). Think cultural health.

US DHHS-Cultural competence - US Department of Health and Human Services (US DHHS). Health Resources and Services Administration (HRSA). Culture, language and health literacy.

AHRQ HCIE-Trihn Shevrin - Trihn-Shevrin C. Community health workers offer culturally tailored interactive workshops and counseling to Filipino Americans, leading to improvements in medication adherence and cardiovascular risk factors. Rockville: AHRQ Health Care Innovations Exchange.

CDC-Cross-cultural tools - Centers for Disease Control and Prevention (CDC). Tools for cross-cultural communication and language access can help organizations address health literacy and improve communication effectiveness.

CDC-CC evaluation - Centers for Disease Control and Prevention (CDC). Practical strategies for culturally competent evaluation.

US DHHS-OPA CC - US Department of Health and Human Services (US DHHS), Office of Population Affairs (OPA). Cultural competence.

Citations - Evidence

* Journal subscription may be required for access.

Cochrane-McCallum 2017* - McCallum G, Morris P, Brown N, Chang A. Culture‐specific programs for children and adults from minority groups who have asthma. Cochrane Database of Systematic Reviews. 2017;(8):CD006580.

Shommu 2016 - Shommu NS, Ahmed S, Rumana N, et al. What is the scope of improving immigrant and ethnic minority healthcare using community navigators: A systematic scoping review. International Journal for Equity in Health. 2016;15(6).

Cochrane-Attridge 2014* - Attridge M, Creamer J, Ramsden M, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus: Review. The Cochrane Database of Systematic Reviews. 2014;(9):CD006424.

Benish 2011* - Benish SG, Quintana S, Wampold BE. Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology. 2011;58(3):279-89.

Pottie 2013* - Pottie K, Hadi A, Chen J, Welch V, Hawthorne K. Realist review to understand the efficacy of culturally appropriate diabetes education programmes. Diabetic Medicine. 2013;30(9):1017-25.

Hodge 2010* - Hodge DR, Jackson KF, Vaughn MG. Culturally sensitive interventions and health and behavioral health youth outcomes: A meta-analytic review. Social Work in Health Care. 2010;49(5):401-23.

Healey 2017 - Healey P, Stager ML, Woodmass K, et al. Cultural adaptations to augment health and mental health services: A systematic review. BMC Health Services Research. 2017;17(1):1-26.

Chowdhary 2014 - Chowdhary N, Jotheeswaran AT, Nadkarni A, et al. The methods and outcomes of cultural adaptations of psychological treatments for depressive disorders: A systematic review. Psychological Medicine. 2014;44(6):1131-46.

Fuentes 2012 - Fuentes D, Aranda MP. Depression interventions among racial and ethnic minority older adults: A systematic review across 20 years. American Journal of Geriatric Psychiatry. 2012;20(11):915-931.

Kalibatseva 2014 - Kalibatseva Z, Leong FTL. A critical review of culturally sensitive treatments for depression: Recommendations for intervention and research. Psychological Services. 2014;11(4):433-450.

Pearson 2019 - Pearson CR, Kaysen D, Huh D, Bedard-Gilligan M. Randomized control trial of culturally adapted cognitive processing therapy for PTSD substance misuse and HIV sexual risk behavior for Native American women. AIDS and Behavior. 2019;23(3):695-706.

Hawthorne 2010 - Hawthorne K, Robles Y, Cannings-John R, Edwards AGK. Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: A systematic and narrative review of randomized controlled trials. Diabetic Medicine. 2010;27:613-23.

Howie-Esquivel 2014 - Howie-Esquivel J, Bibbins-Domingo K, Clark R, Evangelista L, Dracup K. Appropriate educational intervention can improve self-care in Hispanic patients with heart failure: A pilot randomized controlled trial. Cardiology Research. 2014;5:91-100.

Masi 2007 - Masi CM, Blackman DJ, Peek ME. Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women. Medical Care Research and Review. 2009;64(5):195S-242S.

Press 2012 - Press VG, Pappalardo AA, Conwell WD, et al. Interventions to improve outcomes for minority adults with asthma: A systematic review. Journal of General Internal Medicine. 2012;27(8):1001-15.

Nierkens 2013 - Nierkens V, Hartman MA, Nicolaou M, et al. Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities: A systematic review. PLOS One. 2013;8(10):e73373.

Truong 2014 - Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: A systematic review of reviews. BMC Health Services Research. 2014;14(1):99.

Campbell-Wollscheid 2015 - Wollscheid S, Munthe-Kaas HM, Hammerstrøm KT, Noonan E. Effect of interventions to facilitate communication between families or single young people with minority language background and public services: A systematic review. Campbell Systematic Reviews. 2015:7.

Flores 2005* - Flores G. The impact of medical interpreter services on the quality of care: A systematic review. Medical Care Research and Review. 2005;62(3):255-299.

Valdez 2018* - Valdez LA, Flores M, Ruiz J, et al. Gender and cultural adaptations for diversity: A systematic review of alcohol and substance abuse interventions for Latino males. Substance Use and Misuse. 2018;53(10):1608-1623.

Paris 2018* - Paris M, Silva M, Añez-Nava L, et al. Culturally adapted, web-based cognitive behavioral therapy for Spanish-speaking individuals with substance use disorders: A randomized clinical trial. American Journal of Public Health. 2018;108(11):1535-1542.

Joo 2014* - Joo JY. Effectiveness of culturally tailored diabetes interventions for Asian immigrants to the United States: A systematic review. The Diabetes Educator. 2014;40(5):605-15.

Kong 2014 - Kong A, Tussing-Humphreys LM, Odoms-Young AM, Stolley MR, Fitzgibbon ML. Systematic review of behavioural interventions with culturally adapted strategies to improve diet and weight outcomes in African American women. Obesity Reviews. 2014;15(S4):62-92.

Bogart 2017 - Bogart LM, Mutchler MG, Wagner GJ. A randomized controlled trial of Rise, a community-based culturally congruent adherence intervention for Black Americans living with HIV. Annals of Behavioral Medicine. 2017;51(6):868-878.

Jones 2017a - Jones E, Lattof SR, Coast E. Interventions to provide culturally-appropriate maternity care services: Factors affecting implementation. BMC Pregnancy and Childbirth. 2017;17(267):1-10.

Coast 2016* - Coast E, Jones E, Lattof SR, Portela A. Effectiveness of interventions to provide culturally appropriate maternity care in increasing uptake of skilled maternity care: A systematic review. Health Policy and Planning. 2016;31(10):1479-1491.

Citations - Implementation Examples

* Journal subscription may be required for access.

CDC-GHWIC - Centers for Disease Control and Prevention (CDC). Good Health and Wellness in Indian Country (GHWIC).

CDC-Cross-cultural tools - Centers for Disease Control and Prevention (CDC). Tools for cross-cultural communication and language access can help organizations address health literacy and improve communication effectiveness.

US DHHS-OPA CC - US Department of Health and Human Services (US DHHS), Office of Population Affairs (OPA). Cultural competence.

Hispanic Research Center - National Research Center on Hispanic Children & Families. Research to help programs and policies better serve low-income Hispanic children and families.

Lopez 2017 - López M, Hofer K, Bumgarner E, Taylor D. Developing culturally responsive approaches to serving diverse populations: A resource guide for community-based organizations. National Research Center on Hispanic Children & Families; 2017.

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