According to the 2000 U.S. census, members of minority groups now represent one-third of the American population and the University of Georgia’s Selig Center estimates minority spending every year on goods and services at more than $2 trillion. This constitutes a huge market for the providers of healthcare products and services, but only if they know how to meet the unique needs of people from Hispanic, African-American, Asian, Native-American, Middle Eastern, and other cultures.

As the U.S. population has become more racially and ethnically diverse, healthcare organizations are beginning to appreciate the importance of ethnic and minority marketing. However, since health marketers are only now refining their skills in marketing to mainstream consumers, redirecting their attention to the nation’s various racial, ethnic, and national subgroups represents a considerable challenge.

While all industries face opportunities and barriers in marketing to multicultural populations, the significance of this challenge is undoubtedly greater in healthcare. The stakes are greater due to growing competitiveness and, more importantly, because the patient’s health and even life is at stake, with no margin for error in marketing communications.

Healthcare organizations that want to effectively market to multicultural people are often hindered by a lack of knowledge about the target groups. Further, a number of U.S. cultural perceptions cause many marketers to develop inaccurate perceptions of the populations they’re cultivating, although some of these beliefs may sometimes be true.

Perceptions and Misperceptions
People from other cultures only want to do business with someone of their own culture. In reality, members from many cultural groups prefer to obtain services from outside their own culture. Some groups are very private about their personal affairs and may be concerned that their private information may be disclosed to their community through someone from their culture. For instance, it’s common knowledge in the real estate industry that Asians often seek out non-Asian banks from which to obtain home loans so their financial affairs are shielded from other Asians. Many Hispanics avoid going to Latin lending institutions for the same reason.

In any case, this is not often an issue in healthcare, since few physicians from racial and minority groups are in practice. According to the American Medical Association, only 3.5% of doctors are Hispanic and 2.6% are African American at a time when 13% of the U.S. population is of Latino/Hispanic descent and 12% are African Americans. As a result, members of ethnic and minority groups must seek out practitioners from other backgrounds out of necessity.

To further complicate matters, Nursing Management reports that less than 2% of healthcare executives are non-white. The situation is not any better in the pharmaceutical industry where few minorities are employed in sales, marketing, and development, or even used as drug-trial participants.

To serve minorities more effectively, healthcare marketers should make an effort to develop the skills for attracting these customers and ensure that the environment in which they are treated is sensitive to their cultural background. There are also advertising agencies across the country that have expertise in attracting Hispanic, African-American, Asian, Middle Eastern, and other specific cultural groups.

Multicultural people have superstitions and beliefs that are incomprehensible to Americans. We must remember that all cultures have beliefs and customs that seem strange to those in other cultures. People in the United States have beliefs that often baffle outsiders, such as our fears of black cats crossing our paths, of walking under ladders, and of the number thirteen.

Many cultural beliefs have implications for healthcare, which may be direct or indirect. The manner in which services are packaged and promoted or the terms used or notions conveyed in promotional materials may create problems in cross-cultural communication. As an example, many Asians believe that the number four is unlucky because when pronounced in Japanese or Chinese it sounds very similar to the word for "death" in those cultures. Thus, items arranged in groups of four, such as pills or syringes, can symbolize bad luck for those people who believe in numerology. Just as there are very few hospitals or hotels in America with a thirteenth floor, the same is true for buildings in Asia where they scrupulously avoid numbering the fourth floor.

Also, beliefs around healthcare can vary widely between cultures. For instance, cupping is very common among Hispanics and Asians. Cupping is placing a cup on the body with a candle inside that form a vacuum when it burns out so that bad spirits are drawn out. Many American physicians, who are unaware of this practice, contact child protective services when they see circular bruising on youngsters from cultures that follow this belief. Many cultures use a wide range of herbal remedies to treat various maladies, and this should be ascertained during the first visit. Otherwise interactions with medications could have deadly results.

It's impossible to get accurate personal information from multicultural people because they're so secretive. This is one of the beliefs about minorities that is a definite reality. Many people who are new to this country are extremely private about medical and other personal data. They may be unfamiliar with the healthcare system in America and may be distrustful of such organizations because of past experiences in their home country. Unfortunately, healthcare organizations are receiving a great deal of publicity lately for their zeal in collecting personal information about patients.

Even asking about the ability to pay for medical services may create an uncomfortable situation for the patient and his or her family. Many new immigrants don’t believe in banks and keep much of their money hidden as cash in their homes. They may feel that to indicate what they have in the way of resources may make them the target of thieves. Asians and Hispanics are often victimized by these types of crimes because members of these groups are known to hide their money at home.

Just because nearly half of all working-age Latinos lack health insurance doesn’t mean they can’t afford healthcare. Members of this and other ethnic groups may be willing and eager to pay cash for the services they receive. Some cultures believe it is unacceptable to owe money and many do not believe in borrowing to pay for purchases. The fact that the multicultural patient does not have insurance doesn’t necessarily mean they’re not paying customers.

People from outside this country insist on negotiating the price for services. There are two types of countries in the world—negotiating and non-negotiating. The United States is a non-negotiating country where we generally pay the price asked by vendors without question. In most other countries around the world, people haggle on everything from groceries to clothing to homes to medical care. To expect someone from one of these places not to bargain is tantamount to asking them not to breathe. While few healthcare organizations would be willing or able to negotiate fees, even if they wanted to, health professionals must be cognizant of the fact that the negotiation of fees is an important aspect of business protocol in many cultures. It should also be recognized that this is not simply a way of getting a better price. It’s also a way to get to know those with whom one is doing business. Often, something as simple as giving a habitual negotiator a free sample can make them feel more comfortable with the relationship because they’re used to getting something extra from a vendor with whom they plan to do business for a long time.

People from other cultures are just too much trouble to bother with. While employees in other industries may be in a position to be choosy about their customers, health professionals don’t have this luxury. Just because sick people can’t be turned away, however, doesn’t mean that the attitudes of health professionals don’t show through. Until recently, we practiced a one-size-fits-all medicine, and it was up to the patient to adapt to that approach. Fortunately, today we realize that different people have different needs and expectations and that the system must adapt to this as much as possible. The growing competitiveness of healthcare has heightened sensitivity to this situation.

For the most part, multicultural customers are potentially more enjoyable to work with than many mainstream customers who have become jaded by the system. Minority patients are likely to place a lot of emphasis on personal interaction and to develop a strong loyalty to a provider if it is earned. In addition, people from other cultures are very good about referring their friends and family if they are served with sensitivity and patience. This also represents an opportunity for American practitioners to gain much-needed insight into other perspectives—if they’re willing to ask.

It is important, however, to get some training on how to efficiently build relationships with people from diverse cultures without taking time away from other patients. Asking the right questions can go a long way toward showing people that you care about them.

People from other lands should do as Americans do when they're in this country. When Americans visit foreign countries, we expect the “natives” to accommodate our whims. We demand that they speak English and provide the amenities that we’re used to. Yet, when confronted by multicultural patients who bring their own perceptions, values, and behaviors from their home countries, we tend to be incensed that they can’t adapt better to American ways of doing things. While it's difficult for us to leave our 200-year-old American culture at the gate when traveling abroad, it's even harder for those coming here from cultures that are thousands of years old to do as we do here. And while research indicates that immigrants do try to assimilate, it’s not easy.

The U.S. healthcare system may be one of the biggest challenges for newcomers to adapt to. After all, even native-born Americans have a very hard time understanding the benefits of their medical plans. A little effort expended in accommodating the perspectives of multicultural customers will go a long way in winning acceptance and loyalty.

It’s too much trouble to customize my product or service for people from other cultures. Making changes to accommodate the needs and perspectives of minority patients doesn’t have to be hard. It does take some thought and an appreciation of the patients’ expectations. A good place to start is with promotional brochures and patient forms. They should be printed in the major languages of the patients who seek services with your organization. Avoid the mistake, however, of carrying out word-for-word translations from English, since many concepts and words in English don’t convert easily to other languages. Marketing lore is replete with stories of gaffes in marketing campaigns that failed to appreciate linguistic and cultural distinctions. Recently, General Motor’s Buick division spent a great deal of time and money coming up with a name for a new model car that they eventually decided to call “LaCrosse.” Unfortunately, GM neglected to check with its French Canadian distributors because, while that is the name of a popular sport, it also turns out to be slang in Canada for masturbation.

Culturally appropriate materials are only the first step. The importance of communication for the patient experience can’t be overemphasized. It goes without saying that cultural miscommunication could result in serious adverse effects on patient care. Ideally, interpreters should be available to intercede in the face of language barriers, and many hospitals today have prerecorded bilingual information available if they don’t have interpreters on site. It is not recommended that family members be used to fulfill this function because patients may not want to divulge their illness to those closest to them. Laypersons are also not aware of the correct anatomical terms or what might be involved in specific conditions, illnesses, treatments, and procedures. When children have been used as interpreters they often become embarrassed, confused, and afraid to discuss adult issues with their parents. Instead, consider using one of several telephonic interpretation services that are available by search the Internet under “medical telephone interpretation.”

The setting in which care is provided should be carefully considered. This may involve hiring a consultant who is familiar with the cultures being served. They may suggest an assessment of the office layout, examining room design, color scheme, signage, and other factors that may represent cultural barriers. Issues to consider include: feng shui (placement of objects for optimum energy flow); good and bad numerology; and the packaging of consumer health products.

Similar attention should be given to the processes that affect the patients. Health professionals need to be sensitive to issues of privacy, personal data confidentiality, restrictions on male/female interaction, and other cultural concerns that may come into play. While it’s impossible to be aware of all of these issues, it’s important to ask the patient about any restrictions during the intake process.

Everyone should be treated equally, regardless of his or her cultural background. While this maxim should be more relevant in healthcare than in any other industry, it’s a goal that we sometimes fail to achieve. Recent research reveals that members of different racial and ethnic groups are often assigned different diagnoses despite having the same symptoms. Further, these patients are likely to be treated differently once diagnosed. This may range from providing limited treatment to members of some minority groups and extensive treatment to others or providing different therapeutic modalities to different groups despite a common diagnosis.

In actuality, the healthcare system has never treated members of different groups equally. The approach to care, the design of facilities, and the processes involved have been implicitly established to accommodate the needs of white, middle-class American patients to the exclusion of those who were “different.” Health professionals are beginning to realize this, and efforts are being made to create culturally sensitive environments that accommodate patients from a variety of cultural backgrounds.

Don’t forget that we should not “lump” cultural groups together. In the Asian culture, Chinese are different from Japanese who are different from Koreans and so on. They speak different languages, have unique beliefs, and may even dislike each other for political, religious, or other reasons. Likewise, Hispanics are not one homogeneous group, and you will see large variations among Mexicans, Puerto Ricans, Cubans, South and Central Americans, and others.

To appropriately treat any patient you must know specifically what cultural group he or she comes from. While it’s important to treat all patients fairly, our goal should not be to treat them equally. Equality would dictate that you simply hand a printed medical booklet to someone who comes into your office with a seeing-eye dog and a white cane. We must customize our services to meet the unique needs of our unique patients.

Patients don't want to talk about their culture; they just want to be treated like everyone else. This is probably the biggest myth when dealing with people from other cultures. Members of ethnic and minority groups know they are different. Unless culture is mentioned early in the relationship between a health professional and a multicultural patient, it will always stand as a barrier to building true rapport. Health professionals should be open to talking about their own cultural background and history as a starting point. Admittedly, there is seldom enough time to delve into the details of a patient’s background, but taking a sincere interest in their cultural backgrounds will go a long way toward developing a trusting relationship and providing more culturally appropriate medical care.

Even this process requires some cultural sensitivity, however. In everyday life, we find that multicultural people are asked about their cultural backgrounds in an accusatory way. (“Where are you from, anyway?”) Thus, it’s important that such information be obtained in an objective but personal manner. Knowing a word or two in the patient’s language is another way to help build rapport.

In addition, it’s crucial that healthcare professionals recognize that ethnicity can play an important role in treatment. For example, Latinos and African Americans have been found to have higher rates of hypertension, diabetes, and asthma. Specifically, studies by the American Diabetes Association show that 13% of African Americans and 10% of Hispanics have diabetes as opposed to only 6% of Americans in general. Similarly, Asian Americans have been shown to face a higher risk for cardiovascular disease, depression, cancer, and diabetes than white Americans.

Becoming culturally competent is essential to adequately serve all patients. For healthcare organizations to be truly successful with people from other cultures and advance the cause of “ethnic medicine,” health professionals must be willing to meet multicultural patients halfway. By opening up American culture to these patients and accepting aspects of their cultures, it’s possible to develop a mutually beneficial relationship that has the potential to create a loyal lifetime customer.