CULTURAL COMPETENCE

Many companies today are struggling with the proposition of a quickly changing cultural landscape in this country and throughout the world. In some industries, it's simply a matter of product sales. In our industry, culturally competent communications can make the difference between success in clinical interventions or failure. In a marketplace where one in four physicians are trained overseas, more than half of the graduates of U.S. medical schools are women, the baby-boomer workforce soon will be retiring in droves, and new population statistics indicate radically shifting cultural proportions, we must pay attention. We must finally get in sync with who our audiences really are and start marketing to their specific healthcare informational needs in culturally relevant terms.

The increasing diversity in the U.S. means that every day, healthcare providers encounter and must learn to manage complex differences in communication styles, attitudes, expectations and world views. Decades of literature from the social and clinical sciences have documented the issues that arise when different cultures encounter each other. But does cultural competence make a difference to patients and to healthcare delivery and health outcomes?

There have been many attempts to describe and quantify cultural competence in healthcare. These include formal definitions, model programs, regulations, standards, performance measures and other evaluative criteria. For example, the Culturally and Linguistically Appropriate Services (CLAS) project, in a report on the impact of cultural competence interventions on the delivery of healthcare and health outcomes, was guided by the following definition of cultural competence (U.S. Department of Health and Human Services, 2000):

"Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities."

Not just about color or language

Being culturally competent is not about noticing the color of skin or the language spoken; it is about respecting the differences in beliefs, preferences, traditions and values of groups of people whose cultural background is different from our own. America's cultural diversity makes the case much more complex because there is no one representative culture in which we can immerse ourselves. There is, however, a way to become culturally aware and sensitive, and to achieve cultural competence on cross-functional corporate teams.

Moreover, each member of our teams needs to develop an awareness of the differences and a willingness to accept that the differences are not bad or good, just different from what we are used to. Milton Bennett, a scholar of cultural competence, noted a continuum of awareness with discreet stages that people go through in developing sensitivity (see sidebar, right). It seems that the final paradigm shift of integration is the most difficult. Thankfully, it is not necessary for each of us to attain that level of understanding because we can achieve the same result by building diversity into our marketing teams: getting all the members to at least step 4 - acceptance that what seems ordinary in one environment may be offensive or incomprehensible in another - then deferring to individuals with intimate knowledge of the alternate environment to help craft the communications appropriately.

But being culturally competent in global environments is more far reaching than understanding the make-up of the U.S. population. Barbara Pritchard, president of the Pritchard Group and Intermedica, has worked extensively on taking CME events from the U.S. to Latin America. "The actual translation into Spanish or Portuguese is only one aspect of what we do," says Pritchard. "There are situations where drugs are not available there, or certain therapies are too expensive. The prevalence of diseases can differ, as can treatment regimens. But mostly, if a program is case-based, some modification is necessary in the patient examples to be appropriate in Latin America.

"The best advice is to involve local opinion leaders and medical societies in the adaptation process," she adds. "We create joint medical advisory boards from the U.S. and Mexico who determine what topics are most needed and appropriate."

Achieving cultural competence in marketing

For so many Americans, multicultural marketing means translating customer materials into Spanish and adding people of color to the pictures. But that's not the picture of America that the healthcare system sees. Because it's a matter of beliefs and values, not color and language, achieving cultural competence in marketing is not simply a matter of substituting pictures and translating words, though language does come into play.

For example, certain cultures faithfully follow the instruction of their healthcare practitioners, and then combine those directives with spiritual and holistic approaches. If those two collide, they must choose the spiritual path, as that is the path for all time, not just this moment. They may stop taking the drug, even if it means risking their lives. Recognizing that your instructions may be colliding with the spiritual and changing them to work in concert may be necessary, particularly if the audience affected is a primary audience for your product.

Then it's a matter of creating in-culture (rather than in-language) communications. Walter Arenzon, president and creative director of Farmacopea and an expert in marketing to Hispanic cultures, recounts a case about a prominent pharma company that had a patient brochure translated into Spanish. The literal translation by an educated "student of Spanish" suggested to patients that they must perform tests on their own livers at specified intervals. So translation without comprehension of the sense and cultural nuances can be problematic.

It is difficult to create a "multicultural program" because one size does not fit all. So if you don't have the resources for a full-blown multicultural effort, is there nothing else you can do? Of course there is. You can and must create respect for the cultural diversity of the audiences with whom you interact and build that into your marketing environment.

Sensitivity to cultural differences that drive healthcare decision making - including cultural roots, age, gender, education and life stage - can, at a minimum, avoid offending major segments of your population and, at best, drive preference and enhance compliance for your brand. But how can we do that in a country as diverse as ours? How can we make it a cost-effective proposition?

According to the most recent census, the U.S. population is projected to increase nearly 50 percent from 282.1 million in 2000 to 419.9 million in 2050. The total population is expected to become older, with child-bearing rates remaining low. Females are expected to continue to out-number males, rising from 5.3 million more in 2000 to 6.9 million more in 2050. Non-Hispanic whites are expected to drop to half of the total, while Hispanic and Asian populations will triple and the black population is projected to rise by 71 percent.

How will this affect our marketing needs? If the population is becoming older and retiring, the young people stepping up need to appreciate the special needs of an aging population with disabilities. In some cases, it may be as simple as using larger type and college-level programming for an educated, aging population so they don't get frustrated. Women are the "chief purchasing officers" for Healthcare, reported to make 80 percent of the decisions for their household, yet they are seldom marketed to directly for products other than "women's health products." Why not expand your thinking there? If only half the population is white, then half of your target audience is not - do your promotional materials reflect that? These are all factors we need to become recognize in our daily routines when considering our audience.

Cultural upbringing affects how we access and process information; it should also affect how we deliver it, speaking to each group of individuals with similar interests on their own terms and in their own voice. Take their communication preferences into account. Are they visual, verbal or experiential? Do they like print or interactive? Do they watch TV or listen to the radio? It sounds complex but it's not. It's really about knowing your audience's preferences and respecting the cultural influences that dictate them. It makes simple business sense to market to people where, when and how they choose.

One of the easiest ways to hone your cultural competence in marketing is by building a diverse marketing team. If you have a mix of people from different cultural backgrounds, the team is likely to become much more efficient and effective by taking into account cultural differences up front. What this team will do for you immediately is save your company and product from mistakes that can alienate a good portion of your audience. To be truly representational may be difficult at first, but a focus that reflects the interests of your primary audiences is achievable. If 75 percent of the audience is female, 40 percent is Hispanic and 30 percent is Mediterranean, then you have a pretty good idea of whom you need to represent on the team.

Diversity on your marketing team will produce other benefits as well. The creativity of the team is likely to increase if not everyone is thinking the same; the efficiency of reaching audiences with effective messages is likely to increase because the team will waste less time off track, and the budgets may be more appropriately allocated for maximum ROI.

"Our market, customer base and patient pool are becoming more multicultural," says Debbie Freire, vice president, diversity and workforce potential, at Novartis. "The more we understand emerging healthcare needs and can effectively satisfy them, the better our competitive position will be. Teams with a diverse set of skills, experiences and perspectives will provide the greatest foundation to deliver innovative, customer-focused and best-in-class products and services."

The importance of sales training

Because one of every four physicians in America is now a foreign graduate, sales reps need to be sensitive to differences in customs that may be irrelevant, or worse, may offend their key customers. "Two of the major hurdles reps face are not being able to identify the culture or geographical origin of their physicians correctly and a lack of knowledge about international medical graduates' backgrounds, cultures and business philosophies," explains Kimberly Farrell, founder of Unlimited Performance Training.

Improving the cultural competence of your sales team can have a profound influence on the marketing of your products. Developing customer-oriented cultural competence training for your sales force can be the start of a strong corporate focus on the changing dynamics of cultural influence on healthcare in America.

Delivering that same training to your marketing professionals and healthcare delivery partners can't hurt either. If you just think about the fact that Europeans think differently than Americans, you'll appreciate how cultural sensitivity has to permeate everything we do. For example, Americans rush into projects, reporting their progress at every major goal achieved. Europeans tend to encourage people to absorb information and internalize it before delivering the final product in one fell swoop. Both deliver on the project within the deadline, but with very different styles. This too is cultural competence, and appreciation of these differences needs to be a part of a diverse team structure.

When your organization has shown an awareness of the importance of culture, get a cultural audit to help evaluate your organization's awareness and progress in continuous quality improvement in cultural proficiency. There are specialists who can help you. You can start as simply as circulating a self-assessment quiz. It can start to open people's eyes and minds to different possibilities, and every little bit will help. Here's a sample quiz. Along with that, consider an online cultural competence training program. What's great is that it will enhance employee behavior on the job and help them develop as individuals as well.