Building Relationships with People from Different Cultures

Relationships are powerful. Our one-to-one connections with each other are the foundation for change. And building relationships with people from different cultures, often many different cultures, is key in building diverse communities that are powerful enough to achieve significant goals.

Whether you want to make sure your children get a good education, bring quality health care into your communities, or promote economic development, there is a good chance you will need to work with people from several different racial, language, ethnic, or economic groups. And in order to work with people from different cultural groups effectively, you will need to build sturdy and caring relationships based on trust, understanding, and shared goals.

Why? Because trusting relationships are the glue that hold people together as they work on a common problem. As people work on challenging problems, they will have to hang in there together when things get hard. They will have to support each other to stay with an effort, even when it feels discouraging. People will have to resist the efforts of those who use divide-and-conquer techniques--pitting one cultural group against another.

Regardless of your racial, ethnic, religious, or socioeconomic group, you will probably need to establish relationships with people whose group you may know very little about.

Each one of us is like a hub of a wheel. Each one of us can build relationships and friendships around ourselves that provide us with the necessary strength to achieve community goals. If each person builds a network of diverse and strong relationships, we can come together and solve problems that we have in common.

In this section, we are going to talk about:

  • Becoming aware of your own culture as a first step in learning about other people's culture.
  • Building relationships with people from many different cultures.

But first let's talk about what culture is. Culture is a complex concept, with many different definitions. But, simply put, "culture" refers to a group or community with which we share common experiences that shape the way we understand the world. It includes groups that we are born into, such as gender, race, national origin, class, or religion. It can also include groups we join or become part of. For example, we can acquire a new culture by moving to a new region, by a change in our economic status, or by becoming disabled. When we think of culture this broadly we realize we all belong to many cultures at once. Do you agree? How might this apply to you?

How do you learn about people's cultures?

Start by becoming aware of your own culture.

It may seem odd that in order to learn about people in other cultures, we start by becoming more aware of our own culture. But we believe this is true. Why?

If you haven't had a chance to understand how your culture has affected you first hand, it's more difficult to understand how it could affect anyone else or why it might be important to them. If you are comfortable talking about your own culture, then you will become better at listening to others talk about theirs. Or, if you understand how discrimination has affected you, then you may be more aware of how it has affected others.

Here are some tips on how to becoming more aware of your own culture:

What is your culture?

Do you have a culture? Do you have more than one? What is your cultural background?

Even if you don't know who your ancestors are, you have a culture. Even if you are a mix of many cultures, you have one. Culture evolves and changes all the time. It came from your ancestors from many generations ago, and it comes from your family and community today.

In addition to the cultural groups we belong to, we also each have groups we identify with, such as being a parent, an athlete, an immigrant, a small business owner, or a wage worker. These kinds of groups, although not exactly the same as a culture, have similarities to cultural groups. For example, being a parent or and an immigrant may be an identity that influences how you view the world and how the world views you. Becoming aware of your different identities can help you understand what it might be like to belong to a cultural group.


Try listing all the cultures and identities you have: (This is just a list of suggestions to get you started. Add as many as you think describe you.)

What is your:

Sexual identity
Marital status
Geographic region

Are you:

A female
A male
From an urban area
From a rural area
A parent
A student

Have you ever been:

In the military
In prison
In the middle class
In the working class

Did this help you think about your identities and cultures? How have these different cultures and identities affected your life?

How do you build relationships with people from other cultures?

There are many ways that people can learn about other people's cultures and build relationships at the same time. Here are some steps you can take. They are first listed, and then elaborated upon one at a time.

  • Make a conscious decision to establish friendships with people from other cultures.
  • Put yourself in situations where you will meet people of other cultures.
  • Examine your biases about people from other cultures.
  • Ask people questions about their cultures, customs, and views.
  • Read about other people's culture's and histories
  • Listen to people tell their stories
  • Notice differences in communication styles and values; don't assume that the majority's way is the right way
  • Risk making mistakes
  • Learn to be an ally.

Make a conscious decision to establish friendships with people from other cultures

Making a decision is the first step. In order to build relationships with people different from yourself, you have to make a concerted effort to do so. There are societal forces that serve to separate us from each other. People from different economic groups, religions, ethnic groups, and races are often isolated from each other in schools, jobs, and neighborhoods. So, if we want things to be different, we need to take active steps to make them different.

You can join a sports team or club, become active in an organization, choose a job, or move to a neighborhood that puts you in contact with people of cultures different than your own. Also, you may want to take a few minutes to notice the diversity that is presently nearby. If you think about the people you see and interact with every day, you may become more aware of the cultural differences that are around you.

Once you have made the decision to make friends with people different from yourself, you can go ahead and make friends with them in much the same way as with anyone else. You may need to take more time, and you may need to be more persistent. You may need to reach out and take the initiative more than you are used to. People who have been mistreated by society may take more time to trust you than people who haven't. Don't let people discourage you. There are good reasons why people have built up defenses, but it is not impossible to overcome them and make a connection. The effort is totally worth it.

Put yourself in situations where you will meet people of other cultures; especially if you haven't had the experience of being a minority, take the risk.

One of the first and most important steps is to show up in places where you will meet people of cultures other than your own. Go to meetings and celebrations of groups whose members you want to get to know. Or hang out in restaurants and other gathering places that different cultural groups go. You may feel embarrassed or shy at first, but your efforts will pay off. People of a cultural group will notice if you take the risk of coming to one of their events. If it is difficult for you to be the only person like yourself attending, you can bring a buddy with you and support each other in making friends.

Examine your biases about people from other cultures.

We all carry misinformation and stereotypes about people in different cultures. Especially, when we are young, we acquire this information in bits and pieces from TV, from listening to people talk, and from the culture at large. We are not bad people because we acquired this; no one requested to be misinformed. But in order to build relationships with people of different cultures, we have to become aware of the misinformation we acquired.

An excellent way to become aware of your own stereotypes is to pick groups that you generalize about and write down your opinions. Once you have, examine the thoughts that came to your mind and where you acquired them.

Another way to become aware of stereotypes is to talk about them with people who have similar cultures to your own. In such settings you can talk about the misinformation you acquired without being offensive to people from a particular group. You can get together with a friend or two and talk about how you acquired stereotypes or fears of other different people. You can answer these kinds of questions:

  • How did your parents feel about different ethnic, racial, or religious groups?
  • What did your parents communicate to you with their actions and words?
  • Were your parents friends with people from many different groups?
  • What did you learn in school about a particular group?
  • Was there a lack of information about some people?
  • Are there some people you shy away from? Why?

Ask people questions about their cultures, customs, and views

People, for the most part, want to be asked questions about their lives and their cultures. Many of us were told that asking questions was nosy; but if we are thoughtful, asking questions can help you learn about people of different cultures and help build relationships. People are usually pleasantly surprised when others show interest in their cultures. If you are sincere and you can listen, people will tell you a lot.

Read about other people's cultures and histories

It helps to read about and learn about people's cultures and histories. If you know something about the reality of someone's life and history, it shows that you care enough to take the time to find out about it. It also gives you background information that will make it easier to ask questions that make sense.

However, you don't have to be an expert on someone's culture to get to know them or to ask questions. People who are, themselves, from a culture are usually the best experts, anyway.

Don't forget to care and show caring

It is easy to forget that the basis of any relationship is caring. Everyone wants to care and be cared about. Caring about people is what makes a relationship real. Don't let your awkwardness around cultural differences get in the way of caring about people.

Listen to people tell their stories

If you get an opportunity to hear someone tell you her life story first hand, you can learn a lot--and build a strong relationship at the same time. Every person has an important story to tell. Each person's story tells something about their culture.

Listening to people's stories, we can get a fuller picture of what people's lives are like--their feelings, their nuances, and the richness of their lives. Listening to people also helps us get through our numbness-- there is a real person before us, not someone who is reduced to stereotypes in the media.

Additionally, listening to members of groups that have been discriminated against can give us a better understanding of what that experience is like. Listening gives us a picture of discrimination that is more real than what we can get from reading an article or listening to the radio.


You can informally ask people in your neighborhood or organization to tell you a part of their life stories as a member of a particular group. You can also incorporate this activity into a workshop or retreat for your group or organization. Have people each take five or ten minutes to talk about one piece of their life stories. If the group is large, you will probably have to divide into small groups, so everyone gets a chance to speak.

Notice differences in communication styles and values; don't assume that the majority's way is the right way.

We all have a tendency to assume that the way that most people do things is the acceptable, normal, or right way. As community workers, we need to learn about cultural differences in values and communication styles, and not assume that the majority way is the right way to think or behave.


You are in a group discussion. Some group members don't speak up, while others dominate, filling all the silences. The more vocal members of the group become exasperated that others don't talk. It also seems that the more vocal people are those that are members of the more mainstream culture, while those who are less vocal are from minority cultures.

How do we understand this? How can this be resolved?

In some cultures, people feel uncomfortable with silence, so they speak to fill the silences. In other cultures, it is customary to wait for a period of silence before speaking. If there aren't any silences, people from those cultures may not ever speak. Also, members of some groups (women, people of low income, some racial and ethnic minorities, and others) don't speak up because they have received messages from society at large that their contribution is not as important as others; they have gotten into the habit of deferring their thinking to the thinking of others.

When some people don't share their thinking, we all lose out. We all need the opinions and voices of those people who have traditionally been discouraged from contributing.

In situations like the one described above, becoming impatient with people for not speaking is usually counter-productive. However, you can structure a meeting to encourage the quieter people to speak. For example, you can:

  • Have people break into pairs before discussing a topic in the larger group.
  • At certain times have each person in the circle make a comment. (People can pass if they want to.)
  • Follow a guideline that everyone speaks once, before anyone speaks twice.
  • Invite the quieter people to lead part of the meeting.
  • Talk about the problem openly in a meeting, and invite the more vocal people to try to speak less often.
  • Between meetings, ask the quieter people what would help them speak, or ask them for their ideas on how a meeting should be run.

A high school basketball team has to practice and play on many afternoons and evenings. One team member is a recent immigrant whose family requires her to attend the birthday parties of all the relatives in her extended family. The coach is angry with the parents for this requirement, because it takes his player away from the team.

How do we understand this? How can this be resolved?

Families have different values, especially when it comes to family closeness, loyalty, and responsibility. In many immigrant and ethnic families, young people are required to put their family's needs first, before the requirements of extra-curricular activities. Young people from immigrant families who grow up in the U.S. often feel torn between the majority culture and the culture of their families; they feel pressure from each cultures to live according to its values, and they feel they have to choose between the two.

As community workers, we need to support and respect minority and immigrant families and their values. It may already be a huge concession on the part of a family to allow a teenager to participate in extracurricular activities at all. We need to make allowances for the cultural differences and try to help young people feel that they can have both worlds--instead of having to reject one set of values for another.

As community builders, it helps to develop relationships with parents. If a young person sees her parents have relationships with people from the mainstream culture, it can help her feel that their family is accepted. It supports the teen in being more connected to her family and her community--and also, both relationships are critical protective factors for drug and alcohol abuse and other dangerous behaviors. In addition, in building relationships with parents, we develop lines of communication, so when conflicts arise, they can be more easily resolved.

Risk making mistakes

As you are building relationships with people who have different cultural backgrounds than your own, you will probably make mistakes at some point. That happens. Don't let making mistakes of making mistakes keep you from going ahead and building relationships.

If you say or do something that is insensitive, you can learn something from it. Ask the affected person what you bothered or offended them, apologize, and then go on in building the relationship. Don't let guilt bog you down.

Learn to be an ally

One of the best ways to help you build relationships with people of different cultures is to demonstrate that you are willing to take a stand against discrimination when it occurs. People will be much more motivated to get to know you if they see that you are willing to take risks on their behalf.

We also have to educate ourselves and keep informed so that we understand the issues that each group faces and we become involved in their struggles--instead of sitting on the sidelines and watching from a distance.

In Summary

Friendship is powerful. It is our connection to each other that gives meaning to our lives. Our caring for each other is often what motivates us to make change. And establishing connections with people from diverse backgrounds can be key in making significant changes in our communities.

As individuals, and in groups, we can change our communities. We can set up neighborhoods and institutions in which people commit themselves to working to form strong relationships and alliances with people of diverse cultures and backgrounds. We can establish networks and coalitions in which people are knowledgeable about each other's struggles, and are willing to lend a hand. Together, we can do it.

Marya Axner

Online Resources

Brown University Training MaterialsCultural Competence and Community Studies: Concepts and Practices for Cultural Competence The Northeast Education Partnership provides online access to PowerPoint training slides on topics in research ethics and cultural competence in environmental research. These have been created for professionals/students in environmental sciences, health, and policy; and community-based research. If you are interested in receiving an electronic copy of one the presentations, just download their Materials Request Form (found on the main Training Presentations page under "related files"), complete the form, and email it to This email address is being protected from spambots. You need JavaScript enabled to view it..

The Center for Culturally and Linguistically Appropriate Services collects and describes early childhood/early intervention resources and serves as point of exchange for users.

Culture Matters is a cross-cultural training workbook developed by the Peace Corps to help new volunteers acquire the knowledge and skills to work successfully and respectfully in other cultures.

The International & Cross-Cultural Evaluation Topical Interest Group, an organization that is affiliated with the American Evaluation Association, provides evaluators who are interested in cross-cultural issues with opportunities for professional development.

The Multicultural Pavilion offers resources and dialogue for educators, students and activists on all aspects of multicultural education.

The National Center for Cultural Competence at Georgetown University increases the capacity of health care and mental health programs to design, implement and evaluate culturally and linguistically competent service delivery systems. Publications and web links available.

SIL International makes available "The Stranger’s Eyes," an article that speaks to cultural sensitivity with questions that can be strong tools for discussion.

Study, Discussion and Action on Issues of Race, Racism and Inclusion - a partial list of resources utilized and prepared by Yusef Mgeni.

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Cultural competency in health care

Cultural competency in health care


Health disparities are differences in health status between segments of the population due to greater social and/or economic barriers to health. Health disparities are prevalent and, as the U.S. population becomes increasingly diverse, they are likely to increase if not adequately addressed. One way to address them is through cultural competency. Cultural competency in health care is the ability to recognize and understand cultural distinctions, address unconscious/conscious bias, and adapt care delivery and services to meet individuals’ unique social, cultural, and language needs. Cultural competency can increase patient engagement, utilization of preventive services, treatment adherence rates and overall health status. As the population becomes more diverse, it is a business and social justice imperative that health care providers, employers, and health plans recognize the need to deliver culturally competent care and services to improve health outcomes, lower the total cost of care, and improve patient satisfaction.

Diversifying U.S. population

Racial and ethnic minorities currently make up about a third of the U.S. population, and are expected to become a majority by 2055. See figure 1.1 Additionally:

〉 Hispanics will continue to make up the largest

portion of the minority population.2

〉 The Asian population is expected to grow at the fastest

rate between 2015 and 2055.3

〉 The foreign-born population will increase at a higher rate

than the native born population, accounting for

approximately 20% of the U.S. population by 2060.4

As the U.S. becomes more diverse, it is likely that more individuals will have limited English proficiency or will not adhere to Western cultural norms, which may contribute to greater health disparities.

Health disparities

Multiple individual and systemic factors can limit access to care and impact disparities. Individual factors include:

〉 Language barriers

〉 Cultural beliefs and practices

〉 Medical bias, conscious and unconscious, towards specific groups

〉 Variations in care access and quality

〉 Low health literacy

〉 Social determinants, such as socioeconomic status, education, and/or physical environment

〉 Individual characteristics such as age, race, ethnicity, sexual orientation, gender identity/expression, and disability status

Additionally, historical unethical medical practices that targeted minorities still contribute to lack of trust in the health care system. There are multiple historical instances of studies, medical trials, and procedures performed on minorities without informed consent.5 This mistrust, further aggravated by the lack of diversity within the health care workforce, can reduce the likelihood that an individual will proactively seek care.

1. Pew Research Center population projections, “Modern Immigration Wave Brings 59 Million to US, Driving Population Growth and Change Through 2065,” 2015.

2. Pew Research Center population projections, “Modern Immigration Wave Brings 59 Million to US, Driving Population Growth and Change Through 2065,” 2015.

3. Pew Research Center population projections, “Modern Immigration Wave Brings 59 Million to US, Driving Population Growth and Change Through 2065,” 2015.

4. Colby, Sandra L., Ortman, Jennifer M., Current Population Reports, United States Census Bureau, “Projections of the Size and Composition of the U.S. Population: 2014 to 2060,” March 2015.

5. For example: CDC: The Tuskegee Timeline, updated 19 February 2016; U.S. National Library of Medicine, National Institutes of Health, Health & Human Services, ”Native Peoples’ Concepts of Health and Illness: Native Voices Timeline”; Cepko, Roberta, Berkley Journal of Gender, Law & Justice, “Involuntary Sterilization of Mentally Disabled Women,” September 2013.

Cultural competency in health care

Delivering quality care to an increasingly diverse population


Health disparities in accessing medicine8

While there is little variation across populations in face-to-face time spent with physicians, considerable differences exist in time spent traveling to and waiting to receive care.

Clinic time Travel time

(waiting for/obtaining care)

non-Hispanic whites: 80 minutes 36 minutes

non-Hispanic blacks: 99 minutes 45 minutes

Hispanics: 105 minutes 45 minutes

Unemployed: 94 minutes 41 minutes

Highest hourly income: 72 minutes 34 minutes

Impact on cost, quality, and access

Health disparities directly and indirectly cost the U.S. economy $309 billion annually.6 It is estimated that approximately 30% of direct medical costs for Blacks, Hispanics, and Asians are unnecessary costs resulting from health disparities, and indirect costs include lost work productivity and premature death.7 Some examples of current health disparities experienced by minority populations that impact health outcomes include: 8

〉 Adults with disabilities are more likely to be obese, smoke, have high blood pressure, and be inactive than adults without

disabilities. They are also three times more likely to have heart disease, stroke, diabetes, or cancer.9

〉 Bisexual adults are almost twice as likely to fail to obtain needed medical care due to costs compared to straight adults.10

〉 Non-Hispanic black infants are significantly more likely than non-Hispanic white and Hispanic infants to be born pre-term and/or at a low birth weight, the two leading causes of mortality among black infants.11

〉 Less educated, low-income, and minority populations are less likely to have health coverage, negatively impacting their ability to access and afford care.12

Market trends exacerbating health disparities

The health care market is changing rapidly, and there is potential that certain trends will have a more adverse effect on minority populations. These trends include:

〉 Rising health care costs that impact individuals’ ability to afford care, particularly those who are uninsured or underinsured. The Affordable Care Act (ACA) and Medicaid expansion decreased uninsured rates, however coverage disparities remain.13

〉 Localized physician shortages. The physician workforce is unevenly distributed across the U.S. largely affecting rural and low-income households. These localized shortages are further exacerbated if physicians have limited or closed patient panels or lack cultural competency skills.

Regulatory efforts to reduce disparities

In an effort to reduce disparities, the U.S. government has implemented various initiatives, including:

〉 An ACA provision (effective October 2016) prohibiting discrimination based on sex or gender identity and requiring assistance services for individuals with limited English proficiency or with disabilities.14*

〉 The 2011 Department of Health and Human Services (HHS) Disparities Action Plan, which builds on the ACA and is used to assess the impact of policies and programs on health disparities.15

〉 The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS standards), which provide a framework to support health care organizations’ efforts to deliver culturally and linguistically appropriate health care.16

Opportunities to address health disparities through cultural competency

Reducing health disparities is a business and social imperative. Minority populations will likely become an increasing share of providers’ patient panels, employers’ workforces, and health plans’ customers, requiring that all stakeholders seek ways to promote health equity to improve health and access, reduce costs, and improve experience. Moreover, as the health care industry transitions to a provider payment system that rewards providers for the quality and efficiency of services (i.e., fee-for-value) instead of the volume of services, addressing health disparities has the ability to improve health outcomes and efficiency, thereby increasing provider reimbursement. There are several opportunities for providers, employers, and health plans to address disparities by increasing cultural competency to more effectively engage and communicate with consumers and meet their health needs. There are also opportunities to reduce disparities through emerging delivery models by addressing the needs of minority populations.

6. Henry J. Kaiser Family Foundation, “Focus on Health Care Disparities,” December 2012

7. Artiga, Samantha, The Henry J. Kaiser Family Foundation, “Disparities in Health Care and Health Care: Five Key Questions and Answers,” 12 August 2016.

8. JAMA Internal Medicine, “Disparities in Time Spent Seeking Medical Care in the United States,” 5 October 2015.

9. Centers for Disease Control and Prevention: 35 million adults in the US living with a disability, 30 July 2015.

10. Ward, Brian W. et al., National Health Statistics Report ”Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013,” 15 July 2014.

11. March of Dimes, “Racial and Ethnic Disparities in Birth Outcomes,” 27 February 2015.

12. Barnett, Jessica C., Vornovitsky, Marina S., U.S. Census Bureau, Current Population Reports, “Health Insurance Coverage in the United States: 2015,” September 2016.

13. Artiga, Samantha, The Henry J. Kaiser Family Foundation, “Disparities in Health Care and Health Care: Five Key Questions and Answers,” 12 August 2016.

14. HHS “HHS takes next step in advancing health equity through the Affordable Care Act,” 3 September 2015. *Applies to Health Insurance Marketplaces and health programs/activities that receive government funding.

15. HHS Office of Minority Health, “HHS Disparities Action Plan,” 13 September 2016.

16. HHS Office of Minority Health, “The National CLAS Standards,” 1 September 2016.


Views of Mental Health: Vietnamese-Americans20

In Vietnamese culture, there is significant stigma associated with mental health, in part due to low mental health literacy, and a “morality view” of mental health as a reflection of an individual rather than a disease. This has a significant impact on likelihood to seek treatment. For example, a UC Irvine Center for Health Care Policy study found that Vietnamese-Americans report depression and anxiety at more than twice the rate of whites, but are less than half as likely to have discussed mental health with a professional. By not seeking appropriate treatment and disclosing their concerns, overall health may suffer.

Incorporating cultural competency in emerging care delivery models

Non-traditional providers. Non-traditional providers (e.g., retail clinics) can supplement traditional health care providers and help mitigate the negative impacts of localized physician shortages. They are generally more cost-effective, have extended hours, and are conveniently located, increasing accessibility. Despite increased use of non-traditional providers, minority populations still frequently turn to more costly care.17 For example, a survey of parents/caregivers utilizing the emergency department for their children’s non-urgent care needs showed that they were more likely to be Latino and foreign-born and almost half were low-income, and/or lacking health insurance themselves, even though almost all the children had insurance and a primary care physician (PCP).18 Non-traditional providers could increase appropriate use by minority populations through culturally competent outreach and care delivery and serve as a referral source to traditional PCPs for ongoing health care delivery and management.

Integrated care delivery. There are efforts underway to more fully integrate medical, behavioral, and pharmacological care for optimal treatment planning and outcomes. Many cultures have different views of care, particularly when it comes to discussing mental health and accepting treatment, which may make them less likely to seek treatment or disclose critical information to their care provider. Moreover, low health literacy may be one factor that influences whether individuals adhere to medications.19 Therefore, it is important that any integrated care approach has the flexibility to be personalized to offer culturally competent care to individuals.20

What health care providers can do

Health care providers can help eliminate health disparities by recognizing that the best possible care for one population may not be the best option for another. By taking steps to improve their cultural agility, they will be better equipped to serve each of their patients, regardless of race, ethnicity, culture, gender or sexual orientation or other individual factors. Some ways they can do this are to:

〉 Identify training needs by taking a cultural competency assessment and addressing any identified opportunities to reduce personal bias and increase knowledge and cross-cultural communication skills that will help build trust, engagement and positive relationships with patients

〉 Create a welcoming office environment with a culturally diverse staff reflective of the community served or provide staff with cultural competency resources and training

〉 Establish language services policies and procedures to provide professional interpreter services and/or hire bilingual staff certified as medical interpreters; provide frequently-used patient instructions and health education materials at the right level of literacy and in the most common languages of the community served

〉 Indicate in patient records whether a patient requires special services, such as interpreter services, so that each time the patient visits he/she experiences the same seamless experience as any other patient

〉 Collaborate with community-based organizations/other providers on solutions to improve population health

What employers can do

Employers can also take steps to build cultural competency and improve health outcomes for all their employees by:

〉 Expanding their human resources leadership team to include experts in cultural competency and diversity

〉 Instituting multicultural staff representatives to support onsite health services, such as health fairs and open enrollment

〉 Seeking feedback from diverse groups of employees about their experiences as health care customers

〉 Providing materials and benefits information that are culturally competent, e.g., culturally adapted or language-specific

〉 Proactively gathering the demographic data of their workforce to measure and take action on health trends

〉 Collaborating with their health plan to better engage employees in their health

What health plans can do

It is important for health plans to offer culturally competent services to their customers and support health care providers’ efforts to be culturally competent. Health plans can do this by:

〉 Offering multi-lingual health coaching or customer service lines

〉 Offering cultural competency training/resources to educate health care providers and staff

〉 Helping health care providers adhere to Federal and/or State regulations focused on reducing health disparities and providing culturally competent care (e.g., provision of language services)

17. Kubicek, Katrina, et al., NCBI, “A profile of non-urgent emergency department usage in an urban pediatric hospital,” 28 October 2012.

18. Kubicek, Katrina, et al., NCBI, “A profile of non-urgent emergency department usage in an urban pediatric hospital,” 28 October 2012.

19. Zhang, NJ, Terry, A., McHorney, CA, NCBI, The Annals of Pharmacology, “Impact of health literacy on medication adherence: a systematic review and meta-analysis,” 11 March 2014.

20. Kandil, Caitlin Yoshiko, Los Angeles Times, “Mental health literacy may be a roadblock for Vietnamese Americans seeking help, study shows,” 8 July 2016.


Health Advocates In-Reach and Research (HAIR) Campaign: Community-based health interventions

Underutilization of colorectal cancer screening among African Americans is associated with higher mortality rates.21 However, non-traditional settings can be very effective for health intervention outreach. The Cigna Foundation provided a $200K grant to expand the University of Maryland’s HAIR campaign to improve screening rates by partnering with Black barbershops and salons. The program trains barbers, leaders in the community, to become health advocates to promote colorectal screening. The program has been successful at improving community awareness and knowledge.

〉 Passing on interpreter services discounts to in-network health care providers to make these services more affordable

〉 Encouraging culturally competent care in value-based models, such as accountable care organizations (ACOs)

〉 Making translated versions of standard forms available online for physician offices to use

〉 Seeking advice from health care providers to better understand what resources and training they need to be more culturally competent, and their preferred method for that training

Cigna's response

Our goal is to enable optimized relationships that connect the care between our customers and their health care providers to improve health, affordability, and experience. Health equity and cultural competency are essential to meeting this goal. Cigna's Health Equity Council is dedicated to achieving health equity through a coordinated, multidisciplinary strategy, aligned with the HHS’ National Partnership for Action to End Health Disparities. The strategy focuses on:


〉 Increasing awareness of the significance and impact of health disparities, and the necessary actions to improve health outcomes for marginalized and underserved populations

〉 Developing and promoting health equity leadership throughout the organization to address health disparities and

promote health equity solutions at all levels

〉 Improving data utilization to help build and optimize solutions for improved outcomes

〉 Improving health and health outcomes for marginalized and underserved populations

〉 Improving cultural and linguistic competency of our diverse workforce that better reflects and can better serve the needs of our customers

We provide resources to our in-network health care providers to support their efforts to offer culturally competent care, including:

〉 A cultural competency assessment in collaboration with Georgetown University

〉 Discounts for interpreter and translation services to in-network health care providers

〉 Access to CultureVisionTM which provides learning guides and other resources to improve engagement with customers with backgrounds or identities unfamiliar to our staff or our in-network providers

〉 Cultural competency training for the care coordinators in large physician groups with a value-based relationship with Cigna, focusing on cultural agility, unconscious bias, and delivering culturally responsive care to the Hispanic community

In addition to supporting our in-network health care providers to deliver culturally and linguistically appropriate care, Cigna has ongoing efforts to help ensure that Cigna staff is culturally and linguistically competent, including:

〉 Developing and retaining a diverse workforce which better represents our customers and communities

〉 Training customer-facing staff on cultural competency and educating staff on how cultural issues affect health care and its delivery across the world

〉 Providing customers language-specific resources and service lines

〉 Making sure all customer communications are relevant, simple, valuable, engaging, in plain language and follow health literacy best practices

As the U.S. population and health care market evolve, there is an opportunity for health plans, health care providers, and employers to collaborate to support individuals’ increasingly diverse needs. By understanding the cultural, social, and language needs of individuals – in addition to health care needs – health plans and employers can support health care providers to optimize care delivery and better engage customers through a personalized experience to help improve health outcomes.

21. May, FP, et al, NCBI, National Library of Medicine, “Low uptake of colorectal cancer screening among African Americans in an integrated Veterans Affairs health care network,” August 2014.

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Texas’ Amended Data Breach Notification Law Is Expansive

Texas amended its existing data breach notification law which became effective on September 1, 2012. The relevant section of the law is titled “Notification Required Following Breach of Security of Computerized Data” and is found at Section 521.053 of the Texas Business and Commerce Code. This is one of the most expansive state breach notification laws in the country as it applies to not only Texas citizens, but to citizens of other states that do not have a breach notification law.




















The main body of the law provides as follows:










(b)  A person who conducts business in this state and owns or licenses computerized data that includes sensitive personal information shall disclose any breach of system security, after discovering or receiving notification of the breach, to any individual whose sensitive personal information was, or is reasonably believed to have been, acquired by an unauthorized person.  The disclosure shall be made as quickly as possible, except as provided by Subsection (d) or as necessary to determine the scope of the breach and restore the reasonable integrity of the data system.




















What is a “breach of system security”?




















The law defines “breach of system security” as the “unauthorized acquisition of computerized data that compromises the security, confidentiality, or integrity of sensitive personal information maintained by a person, including data that is encrypted if the person accessing the data has the key required to decrypt the data.”




















What is “sensitive personal information”?




















The law has a fairly detailed definition of “sensitive personal information” that should be read carefully. A couple of general points will provide an overview of what is and is not protected:










Information that is lawfully made available to the public from a federal, state, or local governmental body is not considered sensitive personal information










Sensitive personal information does include “an individual’s first name or first initial and last name in combination with any one or more of the following items, if the name in the items are not encrypted:” Social Security number, driver’s license number or other government issued identification number, account or card numbers in combination with the required access or security codes










Also included is information that at that identifies an individual and is related to their health condition, provision of healthcare, or payment for healthcare




















Who does the law apply to?




















The law applies to any person (which includes entities) who conducts business in Texas and owns or licenses computerized data that includes sensitive personal information.




















Who must be notified?




















The law requires notification to “any individual whose sensitive personal information was, or is reasonably believed to have been, acquired by an unauthorized person.” This is an incredibly broad class of individuals that is certainly not limited to only Texas citizens and, quite possibly, is not even limited to citizens of the United States.




















When must the notification be given?




















The notification must be given as quickly as possible after it has been determined that an individual’s sensitive personal information was, or is reasonably believed to have been, acquired by an unauthorized person. However, the notification may be delayed as necessary to determine the scope of the breach and restore the reasonable integrity of the data system or at the request of law enforcement to avoid compromising an investigation.




















What is the penalty for failure notify?




















Section 151.151 of the law provides for a penalty for failing to comply with this notification requirement is a civil penalty of up to $100.00 per individual per day for the delayed time but is not to exceed $250,000 for a single breach.




















If you have any questions about data breaches, breach notification, privacy or data security, please feel free to contact me to discuss.




















Shawn E. Tuma

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HIPAA Privacy and Breach Notification: Recent Enforcement Actions

HIPAA Privacy and Breach Notification: Recent Enforcement Actions


Since the Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted, health care entities have had HIPAA Breach Notification as a major responsibility, in addition to a long list of other privacy-related obligations.  Violation of any of these obligations could result in sanctions or substantial fines for the entities.

As of April 30, 2017, the Office for Civil Rights (OCR) has settled 50 cases in which health care entities were noncompliant with HIPAA, resulting in more than $70 Million in fines and penalties from breaches and other HIPAA violations. This is in addition to more than 25,000 other cases that OCR has resolved more simply by requiring entities to change their privacy practices and apply corrective actions.

Many of these fines and penalties could have been avoided if the entities had established policies and procedures to ensure it met all regulatory requirements, or if the company’s workforce had followed such policies. Where computer theft or loss was involved, for instance, costly notifications and fines related to a breach could have been avoided if proper encryption had occurred.

To this point, the compliance issues OCR investigated most are (in order of frequency):

  • Impermissible uses and disclosures of protected health information
  • Lack of safeguards of protected health information
  • Lack of patient access to their protected health information
  • Use or disclosure of more than the minimum necessary protected health information
  • Lack of administrative safeguards of electronic protected health information.

As an example, some of the more recent federal enforcement actions include: 

 HIPAA Violation


Entity Name

  • Theft by employees of patient data resulting in identify fraud
  • Use by employees of an ex-employee’s login – lack of procedures for terminating employee access
  • Lack of reports investigating employee access to electronic systems

$5.5 Million

Memorial Healthcare System of Florida 

  • Failure to encrypt laptop
  • Lack of appropriate physical safeguards
  • Inadequate risk assessment
  • Lack of a required Business Associate Agreement

$5.5 Million

Advocate Health Care of Illinois

  • Lack of appropriate physical safeguards
  • Failure to encrypt laptop and mobile devices
  • Inadequate management of known risks

$3.2 Million

Children’s Medical Center of Dallas

  • Insufficient management of known risks
  • Insufficient institutional oversight
  • Failure to assign a unique user name or number for accessing electronic systems

$2.75 Million

University of Mississippi Medical Center

  • Insufficient management of known risks
  • Failure to encrypt laptop and mobile devices
  • Lack of a Business Associate Agreement with Google Drive

$2.7 Million

Oregon Health and Science University

  • Loss of two unencrypted laptops
  • Insufficient risk analysis and management
  • Lack of established policies and procedures

$2.5 Million

CardioNet of Pennsylvania (now BioTelemetry, Inc.)

Enforcement actions of this type are expected to continue.  The number of facilities receiving enforcement actions is increasing, and fines are getting higher. With each fine levied, there is the opportunity for OCR to hire more staff and/or expand its scope of investigations and audits.

Nonetheless, there is much that you can do to help avoid similar enforcement actions:

  • Make sure your organization’s policies and procedures are up-to-date. 
  • Make sure that your entire workforce learns and follows the HIPAA policies and procedures specific to your organization.
  • Know and respect the privacy rights of patients served by your organization.
  • Protect the privacy and security of all patient information entrusted to you. This includes taking special care to encrypt all electronic devices, including portable devices, that might contain sensitive or protected health information.
  • Report suspected violations or breaches immediately by calling your privacy official.

To learn more about HIPAA enforcement process or what you can do to avoid HIPAA breaches, contact the University of Louisville Privacy Office at (502) 852-3803 or This email address is being protected from spambots. You need JavaScript enabled to view it.

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Breach Notification Rule

Breach Notification Rule

The HIPAA Breach Notification Rule, 45 CFR §§ 164.400-414, requires HIPAA covered entities and their business associates to provide notification following a breach of unsecured protected health information. Similar breach notification provisions implemented and enforced by the Federal Trade Commission (FTC), apply to vendors of personal health records and their third party service providers, pursuant to section 13407 of the HITECH Act.

Definition of Breach

A breach is, generally, an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information.  An impermissible use or disclosure of protected health information is presumed to be a breach unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the protected health information has been compromised based on a risk assessment of at least the following factors:

  1. The nature and extent of the protected health information involved, including the types of identifiers and the likelihood of re-identification;
  2. The unauthorized person who used the protected health information or to whom the disclosure was made;
  3. Whether the protected health information was actually acquired or viewed; and
  4. The extent to which the risk to the protected health information has been mitigated.

Covered entities and business associates, where applicable, have discretion to provide the required breach notifications following an impermissible use or disclosure without performing a risk assessment to determine the probability that the protected health information has been compromised.

There are three exceptions to the definition of “breach.” The first exception applies to the unintentional acquisition, access, or use of protected health information by a workforce member or person acting under the authority of a covered entity or business associate, if such acquisition, access, or use was made in good faith and within the scope of authority. The second exception applies to the inadvertent disclosure of protected health information by a person authorized to access protected health information at a covered entity or business associate to another person authorized to access protected health information at the covered entity or business associate, or organized health care arrangement in which the covered entity participates. In both cases, the information cannot be further used or disclosed in a manner not permitted by the Privacy Rule. The final exception applies if the covered entity or business associate has a good faith belief that the unauthorized person to whom the impermissible disclosure was made, would not have been able to retain the information.

Unsecured Protected Health Information and Guidance

Covered entities and business associates must only provide the required notifications if the breach involved unsecured protected health information. Unsecured protected health information is protected health information that has not been rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary in guidance. 

This guidance was first issued in April 2009 with a request for public comment. The guidance was reissued after consideration of public comment received and specifies encryption and destruction as the technologies and methodologies for rendering protected health information unusable, unreadable, or indecipherable to unauthorized individuals. Additionally, the guidance also applies to unsecured personal health record identifiable health information under the FTC regulations. Covered entities and business associates, as well as entities regulated by the FTC regulations, that secure information as specified by the guidance are relieved from providing notifications following the breach of such information. 

View the Guidance Specifying the Technologies and Methodologies that Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals.  

Breach Notification Requirements

Following a breach of unsecured protected health information, covered entities must provide notification of the breach to affected individuals, the Secretary, and, in certain circumstances, to the media. In addition, business associates must notify covered entities if a breach occurs at or by the business associate.

Individual Notice

Covered entities must notify affected individuals following the discovery of a breach of unsecured protected health information. Covered entities must provide this individual notice in written form by first-class mail, or alternatively, by e-mail if the affected individual has agreed to receive such notices electronically. If the covered entity has insufficient or out-of-date contact information for 10 or more individuals, the covered entity must provide substitute individual notice by either posting the notice on the home page of its web site for at least 90 days or by providing the notice in major print or broadcast media where the affected individuals likely reside. The covered entity must include a toll-free phone number that remains active for at least 90 days where individuals can learn if their information was involved in the breach. If the covered entity has insufficient or out-of-date contact information for fewer than 10 individuals, the covered entity may provide substitute notice by an alternative form of written notice, by telephone, or other means.  

These individual notifications must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include, to the extent possible, a brief description of the breach, a description of the types of information that were involved in the breach, the steps affected individuals should take to protect themselves from potential harm, a brief description of what the covered entity is doing to investigate the breach, mitigate the harm, and prevent further breaches, as well as contact information for the covered entity (or business associate, as applicable).

With respect to a breach at or by a business associate, while the covered entity is ultimately responsible for ensuring individuals are notified, the covered entity may delegate the responsibility of providing individual notices to the business associate.  Covered entities and business associates should consider which entity is in the best position to provide notice to the individual, which may depend on various circumstances, such as the functions the business associate performs on behalf of the covered entity and which entity has the relationship with the individual.  

Media Notice

Covered entities that experience a breach affecting more than 500 residents of a State or jurisdiction are, in addition to notifying the affected individuals, required to provide notice to prominent media outlets serving the State or jurisdiction.  Covered entities will likely provide this notification in the form of a press release to appropriate media outlets serving the affected area.  Like individual notice, this media notification must be provided without unreasonable delay and in no case later than 60 days following the discovery of a breach and must include the same information required for the individual notice.

Notice to the Secretary

In addition to notifying affected individuals and the media (where appropriate), covered entities must notify the Secretary of breaches of unsecured protected health information. Covered entities will notify the Secretary by visiting the HHS web site and filling out and electronically submitting a breach report form. If a breach affects 500 or more individuals, covered entities must notify the Secretary without unreasonable delay and in no case later than 60 days following a breach. If, however, a breach affects fewer than 500 individuals, the covered entity may notify the Secretary of such breaches on an annual basis. Reports of breaches affecting fewer than 500 individuals are due to the Secretary no later than 60 days after the end of the calendar year in which the breaches are discovered.

Notification by a Business Associate

If a breach of unsecured protected health information occurs at or by a business associate, the business associate must notify the covered entity following the discovery of the breach.  A business associate must provide notice to the covered entity without unreasonable delay and no later than 60 days from the discovery of the breach.  To the extent possible, the business associate should provide the covered entity with the identification of each individual affected by the breach as well as any other available information required to be provided by the covered entity in its notification to affected individuals. 

Administrative Requirements and Burden of Proof

Covered entities and business associates, as applicable, have the burden of demonstrating that all required notifications have been provided or that a use or disclosure of unsecured protected health information did not constitute a breach. Thus, with respect to an impermissible use or disclosure, a covered entity (or business associate) should maintain documentation that all required notifications were made, or, alternatively, documentation to demonstrate that notification was not required: (1) its risk assessment demonstrating a low probability that the protected health information has been compromised by the impermissible use or disclosure; or (2) the application of any other exceptions to the definition of “breach.”

Covered entities are also required to comply with certain administrative requirements with respect to breach notification.  For example, covered entities must have in place written policies and procedures regarding breach notification, must train employees on these policies and procedures, and must develop and apply appropriate sanctions against workforce members who do not comply with these policies and procedures.

Instructions for Covered Entities to Submit Breach Notifications to the Secretary

Submit a Breach Notification to the Secretary

View Breaches Affecting 500 or More Individuals

Breaches of Unsecured Protected Health Information affecting 500 or more individuals.  View a list of these breaches.

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