Defining Terms

Cultural competence is a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system or organization or among professionals to enable effective work in cross-cultural situations. The term culture refers to integrated patterns of human behavior that include the thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups. In the health-care setting, cultural competence implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs of patients and their communities.²

Diversity generally refers to the individuals who make up a community and reflects the degree of difference among them. Inclusion refers to the act of encompassing one thing into another, such as including another person's perspective when developing an opinion.

The Importance of Cultural Competence

Demonstrating cultural competence when communicating with clients enables a practitioner to promote inclusion and provide services to a more diverse population of clients, thereby expanding his or her veterinary practice and increasing the number of animals receiving appropriate veterinary medical care.³ Despite the growing recognition of the value of cultural competence in professional service industries, resources currently available to veterinarians for education and training related to cultural competence are limited. Many veterinary medical colleges do not actively integrate the concept of cultural competence into their current curriculum, despite evidence that this gap in communication training may effectively limit their graduates' practice potential following graduation.⁴ Medical education rightly represents the bulk of the veterinary curriculum, but this means that many of the essential nonclinical skills must be developed independently. In this regard, continuing education programs addressing the development of cultural competence are needed. The members of the 2012–2013 AVMA Future Leaders Program are working to develop cultural competency resources for veterinarians and members of the veterinary medical team.

Individual Cultural Competency

Data are difficult to obtain, but it is near certain that many animals in the United States are not receiving routine preventive veterinary medical care.⁵ This may be a reflection of a lack of owner education regarding the importance of preventative health care for their animals, owner concerns about the rising cost of veterinary care, a lack of availability of local veterinary services, or sociocultural barriers to seeking veterinary care. The lack of diversity among veterinary professionals has also surfaced as a potential barrier to the expansion of veterinary care to underserved populations.⁶ Although increasing diversity encourages the development of cultural competence, diversity is distinct from cultural competence. Increasing diversity in the veterinary professional workforce is an important goal, but further discussion is outside the scope of this article, and achieving diversity will likely take many generations. In the short term, it is a more realistic goal to increase cultural competence within the profession as one measurable way to be able to provide better care to underserved members of the animal-owning population.

Embracing cultural competence as a vital component to veterinary clinical practice is important not only on the professional level, but also on the citizen level. The population demographics of the United States continue to change rapidly. Four in ten Americans will belong to a racial or ethnic minority group by 2030; this is predicted to increase to more than five in ten by 2040. Learning how to communicate effectively and to market the value of veterinary medicine to all members of a community is a critical skill for practitioners to remain relevant and meet the needs of an evolving clientele. The AVMA, veterinary medical colleges, and other veterinary organizations have recognized the potential negative impact of failing to understand the importance of cultural competence in veterinary practice.⁶ Although it is not practical to categorize each cultural difference and to assign these differences to individuals on the basis of appearance or perceived racial-ethnic background, it is important to understand that some broad concepts of cultural competence can be applied to the practice of veterinary medicine.

More data on the importance of cultural competence in clinical practice exist for human medical practice than for veterinary medical practice, but at least some of the findings for the human medical profession can be applied to the veterinary medical profession. In 2003, Betancourt et al⁷ defined a culturally competent health-care system as a system that “acknowledges and incorporates at all levels the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaption of services to meet culturally unique needs.” They further defined 3 levels of the health-care system where sociocultural barriers exist: organizational, structural, and clinical. At the organizational level, leadership and workforce do not reflect the racial and ethnic composition of the population. At the structural level, the health-care system is complex and can be difficult for some to access. At the clinical level, communication barriers may exist between health-care providers and patients or their families. The solutions proposed include recruiting more minorities into the health-care professions, developing interpreter services and language-appropriate health education materials, developing specific quality measures for diverse patient populations, and improving health-care provider education on cross-cultural issues.⁷ These ideas may prove useful to veterinarians evaluating methods for incorporating cultural competence into their practices.

Cultural Differences Relevant to Veterinary Medicine

The 2012 AVMA US Pet Ownership and Demographics Sourcebook describes survey data for more than 50,000 households obtained to provide a comprehensive picture of ownership and veterinary care of cats, dogs, and other pets in the United States.⁸ According to the survey, respondents identifying as white were most likely to own pets (65.6%), followed by Spanish/Hispanic respondents (62.5%), Asian Pacific Islander/American Indian/Aleut Eskimo respondents (47.7%), and Black/African American respondents (32.7%).⁸ A majority of respondents viewed pets as family members (66.7% of dogs and 56.1% of cats).⁸ The most common reason for not taking a dog or cat to the veterinarian was that the pet was not sick or injured. The second most common reason pet owners did not seek veterinary care was cost, indicating they could not afford it. As one might expect, mean annual veterinary expenditure per pet-owning household was positively correlated with household income (the higher the income, the more money spent on the pet),⁸ illustrating the impact socioeconomic differences can have on the level of care that companion animals receive in the United States. Even though the factors contributing to the disparities in veterinary care are multifactorial and quite complex, veterinary professionals can begin to bridge some of the social issues that contribute to these disparities by improving their cultural competence.

The Hispanic population is the most rapidly growing minority group in the United States, so information on Hispanic pet owners is important. In a 2010 study,⁹ Hispanic pet owners were found to regard their pets as members of the family but were less likely to have their pets neutered than were non-Hispanic pet owners. These findings are useful for veterinary practitioners looking to have culturally competent conversations about elective neutering with Hispanic pet owners. Because taking care of family is seen as a primary responsibility in many Hispanic cultures, focusing on the long-term health benefits of neutering, rather than the social obligation of avoiding dog and cat overpopulation, would likely be a more effective appeal.⁹

Although studies of cultural differences in attitudes toward companion animals can help veterinarians communicate more effectively with their clients, incorrect assumptions about study results can be damaging. In particular, practitioners should not assume that findings for Hispanic populations apply equally to all Hispanic animal owners. Just as diversity exists within large geographic populations, the same degree of diversity can exist within populations of homogenous ethnicity from disparate geographic origins.

Strategies to Implement Cultural Competence

Identifying communication gaps in client relations, developing cultural competence knowledge and skills, and examining potential client demographics can help practitioners better serve the animals and people in their community. The diversity, or lack thereof, of the practice staff can potentially impact the practice's ability to effectively serve a local population. Bilingual veterinarians and staff would be ideal in certain communities, but maintaining a bilingual staff may not always be realistic or affordable. A more efficient plan to address language barriers may include educating staff members on the basics of communicating with people who do not speak the same language. In addition, veterinarians and staff members could consider taking conversational classes in a second language. Having signage, pamphlets, and client education materials readily available in several languages can help staff members more effectively communicate with a multilingual client base. A large selection of AVMA brochures are currently available to members in Spanish and Serbian,¹⁰ with other translations pending.

Client education is one of the most important obligations for veterinarians. This includes actively educating the local community about services offered by the practice and how those services can benefit the human and animal members of the community. It is important to use appropriate communication methods, respecting language and sociocultural differences. Veterinarians can integrate themselves within the local community by participating in community events or volunteering for local civic organizations. Such activities not only raise the profile of the veterinary practice but also emphasize the importance of veterinary medicine and responsible animal ownership to the community.

Impact of Cultural Competence on Practice Profitability

Making a practice more appealing to an underserved population by becoming more culturally competent can expand an existing client base, thereby improving the practice's profitability.¹¹ Enhancing cultural competence may not completely overcome the barriers to service because economic factors also play a role. However, developing cultural competence is an important first step toward expanding services to diverse populations. If animal owners feel comfortable in the veterinary clinic, they are more likely to seek out care, participate in medical discussions, and follow recommendations. Cultural competence strategies can improve the efficiency and accuracy with which medical information is conveyed, enhance medical decision making, and ultimately improve medical care of animals. When discussions are clearer, client frustration is likely to be reduced and client compliance increased. Positive case outcomes and client experiences certainly have a positive impact on practice revenue. Therefore, improving client communication by increasing cultural competence can result in better veterinary care for animals and positively affect practice income.¹²

Conclusions

Implementing cultural competence in veterinary medical practice is an expansion of concepts previously applied in human health care. More importantly, cultural competence can have direct positive effects on the daily practice of veterinary medicine.

Recognizing the importance of cultural competence, veterinary medical colleges have begun to incorporate cultural awareness and diversity training in their curriculums. For example, the North Carolina State University College of Veterinary Medicine offers between 5 and 8 cultural awareness modules each year covering a variety of subjects and offered in a variety of formats. The goal of these modules is to provide exposure and education for students, faculty, and staff on multicultural issues, populations, and practices. A curriculum in which cultural issues are integrated into clinical courses would be more ideal and may become a reality as the importance of cultural competence gains recognition among practicing veterinarians.

Additional continuing education programs addressing cultural competence for veterinary practitioners are sorely needed. The 2012–2013 AVMA Future Leaders Program is developing a cultural competency training program targeting practitioners. The goal of this project is to provide veterinary practitioners the tools they need to more carefully examine the community around them, create a climate of comfort for those they serve, expand their client base, and increase the numbers of animals receiving veterinary medical care. Ultimately, we believe increasing cultural competence will improve the economics of the veterinary profession and further emphasize the positive impact responsible animal ownership can have in a community.